With the remarkable improvement in people’s socioeconomic living standards around the world, adolescent obesity has increasingly become an important public health issue that cannot be ignored. Thus, we have implemented its use in an attempt to explore the viability of scenario-based simulations through the use of a data mining approach. In doing so, we wanted to explore the merits of using a General Bayesian Network (GBN) with What-If analysis while exploring how it can be utilized in other areas of public health. We analyzed data from the 2017 Korean Youth Health Behavior Survey conducted directly by the Korea Centers for Disease Control & Prevention, including 19 attributes and 11,206 individual data points. Our simulations found that by manipulating the amount of pocket money-between $60 and $80-coupled with a low-income background, it has a high potential to increase obesity compared with other simulated factors. Additionally, when we manipulated an increase in studying time with a mediocre academic performance, it was found to potentially increase pressure on adolescents, which subsequently led to an increased obesity outcome. Lastly, we found that when we manipulated an increase in a father’s education level while manipulating a decrease in mother’s education level, this had a large effect on the potential adolescent obesity level. Although obesity was the chosen case, this paper acts more as a proof of concept in analyzing public health through GBN and What-If analysis. Therefore, it aims to guide health professionals into potentially expanding their ability to simulate certain outcomes based on predicted changes in certain factors concerning future public health issues.  Due to changes in our lifestyle and eating habits, the world’s obese population has more than doubled from 0.857 billion to 2.1 billion since 1980. Additionally, according to World Health Organization (WHO), it is believed that by 2025, a total of 260 million children worldwide will be overweight, with more than 90 million categorized as obese or worse .With this rise in obesity, being able to identify potential causes can help to find preventive measures. Several studies have been conducted in order to explain the factors that cause obesity , citing Prior research has focused on the use of a GBN in health informatics , includiAdolescence is a pivotal period of one’s life, in which habits are difficult to shake off once learned. Habits such as eating and exercise are ones that adolescent adults struggle with the most . In part disease . In addi disease . Studies disease .Lee et al. found an association between BMI and a mothers’ education level (low) and a lower age of adolescents (middle school). Also, it was found in urban areas for boys who’s fathers’ education level was low . A lack Predicting obesity is a social challenge and, therefore, researchers have been studying obesity from various perspectives ,18,19,20P(B|A), then we can use a Bayesian network to find out P(A|B). Overfitting often happens in GBN when the parameters of datasets reach the extents that the computer can cope with. Feature selection (FS) can be applied to solve the above problem through the removal of redundant and irrelevant features. For this reason, we implemented the use of the Markov Blanket, which has been used for this feature in previous papers [GBN is a directed acyclic graph in which nodes represent domain variables, and arcs between nodes represent probabilistic dependencies . GBN is s papers ,33,34. . More prith input of x = {x1, ..., xn}, and (η(∙), and it can be fully written in the following [What-If analysis recalculates variables using substituted presumption to discover another consequence. What-If analysis can be represented by ollowing :(2)y=(X)In this research, GBN MB with What-If analysis was implemented in obesity to suggest the impact of various parameter changes on the incidence of obesity. Note that the parameters that we have selected for this paper are for the purposes of demonstration, rather than for the purposes of providing an overall medical solution for obesity.https://www.cs.waikato.ac.nz/ml/weka/.First, we compared the GBN classifier with some common algorithms known for high accuracy in solving complex datasets. Next, accuracy, AUC, and F-measure were performed in order to test the performance of the GBN models against the other chosen classification models. Furthermore, in order to provide a practical implication for predicting adolescent obesity from this paper, What-If analysis was simulated using the result from the GBN models derived from the given dataset on obesity. The open source tool WEKA was used to implement classifiers on the dataset and can be found at the following URL: This paper uses the raw data of the 2017 Korean Youth Health Behavior Survey conducted by the Korean Centers for Disease Control & Prevention. The target collection group of the 13th Adolescent Health Form Online Survey  had a participation of 62,276 in April 2016. The online survey of youth health behaviors was based on and approved by the government approval statistics committee  and the National Health Promotion Act (Article 19). The 2017 Korean Youth Health Behavior Survey surveyed 123 questions in 15 areas, including smoking, drinking, and physical activity, and calculated 216 indicators. This paper used the sociological characteristics of the population, health morphological characteristics, smartphone use characteristics, obesity, and other related projects.First, we deleted responses that had missing values and also removed the irrelevant attributes that could not help in evaluating obesity. Second, we removed the data for respondents that had no prior smartphone use, as well as data from respondents who answered as “don’t know” to the smartphone usage section. Third, we calculated the degree of obesity by the following steps: (1) the BMI is calculated by dividing the body weight by the square of the height , which are commonly used to evaluate the performance of machine learning techniques ,40,41, oIn order to find interesting relationships in the obesity data, we attempted to shift the lens in which previous research has viewed obesity. Although there are many common factors that could be used to explain the cause of obesity, this study focused more on unique factors that were not dealt with in previous research. Hence, we chose the following features for further analysis: “Obesity_Level”, “Pocket_Money (KRW)”, “Wealth”, “Pressure”, “Sitting_Time_Study (min)”, “Sleeping_Quality”, “Education_Mother”, “Education_Father”, “Academic_Performance”, “Smartphone_Time (min)”, and “Smartphone_Service”.As What-If analysis can be used to solve several complicated problems, especially for highly complex research models. For example, to determine the factors that affect adolescent obesity, we needed to manipulate the maximum and minimum output of the models. Therefore, in this study, we have generated 13 scenarios for obesity, as shown in When scenario 1 is applied see , the medWhen scenario 2 is applied see , which sWhen we apply scenario 3 see , time spFor scenario 4, we selected a medium budget for ‘Pocket_Money’ and also set the ‘Wealth’ to ‘Low’ see . As can In By maximizing the level of ‘Smartphone_Time’ and setting the ‘Smartphone_Service’ configuration to “study”, we applied scenario 6 to the obesity dataset see . The resIn our final scenario, we wanted to investigate the relationship between adolescent obesity and their parents’ education level. To the best of our knowledge, this has not been explored in previous research and, thus, could shed light on an unknown area within the obesity debate. To achieve this supposition, we adjusted the value of the father’s education data point to the maximum value as well as that of the of the mother’s education data point to the minimum value to see if the educational backgrounds of parents in general could influence the obesity levels of their children, as shown in scenario 7, see . In doinWith the remarkable improvement in people’s socioeconomic living standards, the obesity of adolescents has become a serious social problem in the developed world. Over the past 30 years, the rate of adolescent obesity has quadrupled, increasing health care and their associated costs, as well as increasing the risk of disease. Although obesity rates have been halting in countries like the United States , more reThis paper focused on predicting the influencing factors of adolescent obesity by using a GBN with an embedded MB. Chung et al. (2013) made recommendations on the use of a GBN within health informatics, and previous research done on data from the UK showed the power of using a GBN for understanding obesity . The resBased on the seven scenarios poised in the What-If analyses, we can reach the following implications. First, in scenario one, adolescents with a reasonable pocket money budget were seen to have a higher chance of obesity. This is also cited in prior research, which suggested that children in China who had more pocket money would more likely consume sugary drinks and eat fast food . AlthougFrom scenario two, it shows that as poor quality of sleep increases the chance of being obese, agreeing with prior research that also links body aches with these two factors . AnotherFinally, smartphone use was implied to increase the chances of obesity, when used for studying purposes in scenario six. Although smartphone use has been linked to obesity in prior work , it has  and it is very plausible that this effect could spill over into adolescents too.Korea is still a society largely driven by male dominance and a mother and father household. Therefore, some of the scenarios might be unique whereby men are the so-called ‘breadwinners’, and women are expected to be ‘stay-at-home’ mothers. Although some of the scenarios shed potentially new implications on the causes of obesity, the Korean culture may be playing a more dominant factor in these results. This implies that these results may not cross boundaries into countries whereby women play a more liberal or dominant role in the workplace and whereby women are the ‘breadwinners’, and it is instead, the father who stays at home. Furthermore, this result ignores the fact that there is growing evidence that divorced households, i.e., single mothers or fathers, have been shown to have an effect on obesity in preadolescent children , and it Another limitation of this study is that we did not consider the effects of factors such as posttraumatic stress disorders, lack of exercise, and a direct reference to diet choices within our scenario building. Recent research has started to make direct links between these factors and obesity , and theBecause our GBN-MB research model is based on cross sectional data, the relationships are not causal, while they are more associative. In addition, it is difficult to represent the characteristics of all situations within the globe as the dataset used was limited to the case of Korea. Thus, future research should look to study a selection of various data samples from several nations who are suffering from this rise in obesity. This would help to find more meaningful results that have not been derived in this study and could potentially contribute even more by providing a more fruitful solution from the perspective of public health concerns on obesity. In line with this, another limitation is in the ability to translate informatic-based models into real-world health informatics. Therefore, in order to examine the findings within this paper, we suggest that future research should look to employ longitudinal epidemiological data to help support the findings from this paper.


Over the turn of the 21st century, the use of data from large electronic corpora has changed research on Spanish historical syntax, spurring interest in long-range evolutions, and the shape of the correspondent diachronic curves. However, general reflections on diffusion and the factors that drive and influence it are still pretty much lacking. In this paper, I reflect on the research possibilities laid open by the availability of such large masses of data, focusing particularly on new knowledge on syntactic change brought about by the study of low-frequency phenomena and of recessive changes, as well as on the exploration of changes conditioned by dialect contact, and textual traditions. I conclude with some remarks on the general typology of diffusion in syntactic change. Asociación de Historia de la Lengua Española1), a meeting held since 19872. Looking at the contributions to the Historical Morphology and Syntax section in AHLE proceedings and taking only those in which primary data are used , it is possible to group those contributions according to the time period studied, as shown in It is widely recognized that the field of historical morphosyntax in Spanish has been gaining ground in the last four decades to the extent that it now occupies a position of clear dominance in the area of diachronic linguistic research on that language (cf. holochronic studies) have increased dramatically in frequency – the largest increase occurring around the time of the 6th Conference . This parallel and complementary change in focus may have numerous causes, of which two are, in my opinion, clearly prevailing: a growing tendency to carry out  studies dealing with very long timescales based on very few sources for the individual historical periods studied – these sources being considered representative due to their iconic literary or cultural status – and, above all, the increasing ease of access to large databases of digitized resources. A few years ago, Rolf Eberenz made a timely observation on both these trends, adding a warning concerning the implications of both:From We have at our disposal a body of texts, the majority of which are “literary,” from which we select two or three works for each century to extract the data that interests us […]. The digital corpus and the tools provided by information technology permit both statistical and linguistic analysis of increasing precision. However, the plethora of information stored on computer brings with it a certain danger, that is, the data tend to become a shapeless mass in which the differences between texts and within individual texts become lost from view ..., thus becoming increasingly analogs to the so-called “analytic future” of the type cantarlo he “I will sing it,” literally “to sing it (I) have,” which obligatorily includes a clitic and has no linking preposition. Furthermore, and in concert with these formal changes, a distributional change also took place as the construction came to be more often found toward the beginning of main clauses, further converging with “analytic futures,” which are almost exclusively found in that position9.The evolution of the use of this syntactic schema is shown in haber “to have” had to a large extent lost its possessive meaning and was being lexically replaced by tener “to hold, to possess.” This substitution had reached modal deontic periprases such as haber de + INF, which was losing ground to tener de + INF  {must/can/want}”). After 1600, the whole set of constructions using the infinitive followed by an inflected modal verb practically disappears  seems to have occurred almost catastrophically  come directly from the very rare group of schemas illustrated in (1), the systematic study of which would not have been possible without the resources of an immense digitized corpus. Thus, the analysis of low frequency phenomena can have an impact that reaches far beyond the merely descriptive and, on occasion, may go on to open doors to the formulation of new hypotheses concerning the evolution of much larger groups of constructions.In early Classical Spanish,  INF cf. . Since aears cf. . This maally cf. , 2011, pally cf. . Be it aCorpus del Español), CODEA+, CORDIAM or the search engine provided by the Biblioteca Virtual Miguel de Cervantes (BVMC), to mention only the major corpora available that allow exploring not only Medieval Spanish but also later periods10. In such situations, researchers may become increasingly inclined to search through databases that are open – i.e., constantly growing in number – and not mediated, in the sense that the works they hold are not selected according to philological criteria, but if anything, rather on bibliological grounds, and contain versions in substantially original format (untouched by a modern editor), like Google Books11. It is possible to find on this platform, for example, dozens of examples which confirm the exclusively eastern12 character of the prepositional use of bajo + NP  in Pre-classical and Classical Spanish  an S-curve, no matter how it [is] propagated through grammatical contexts, words, speakers, texts, geographical regions, or social classes. This overall trajectory appears to be determined by differential weighting of variants (replicator selection) : 294.hemos at the expense of the older form habemos (both meaning “we have”), which unfolds along another sinuous S-curve principally during the Classical Spanish period  construction: cantarlo hemos “we will sing it”) to the formally and, most importantly, semantically related deontic periphrasis haber de + INF “have to + INF,” and there from, in successive waves, to the perfect tenses with haber + Past Participle “have PP,” less related to the source constructions both in form and meaning. This is suggested by the data in hemos saw its initial boom. In global terms, hemos and habemos occur with similar frequencies  within the corpus; however, the variant hemos shows the greatest affiliation to haber de + INF , whereas the variant habemos is shown to be largely preferred in non-auxiliary contexts (where haber is used as a verb of possession), clearly more distant from the periphrastic futurate construction where short hemos originated.Besides lexical diffusion , these authors explicitly mention a further mode of diffusion via syntactic patterns . The latter would appear to be in action in the expansion of the shorter variant h period . The proser + PP and haber+ PP with reflexive predicates15. As 16. The reason for this may lie in the fact that the S-curve is a natural feature of lexical diffusion: initially, very few words will adopt a change; then, during the intermediate phase, given that the semantic connections between lexical elements form a complex network, groups of interconnected words will add together in a cascade with a cumulative, snow-balling effect; finally, only a few isolated areas of resistance remain, which explains the slow trailing off of the last phase. However, purely syntactic context expansion + INF “must, ought to,” a fact which suggests that haber de+ INF became engaged in Classical Spanish in a competition to express not only deontic, but also epistemic values, since deber (de) + INF could convey both  tengo  and becomes attracted to analogous sequences using the auxiliaries deber “must, ought to,” poder “can, be able to” and querer “want to,” in which the clitic can be used but is not obligatory .However, not only the recessive phases create doubts about the generalizability of S-curvese “that”  shows a To our knowledge there are no clearly documented cases of a change going toward completion that follows […] an exponential curve  : 280.que “that” occurred when its use with the infinitive clause was at its height  to becoming a corrective adversative linking sequence  could have buttressed,  characterization of linguistic changesenon Map , the larenon Map , and tha22, but it can also provide the key for explaining the propagation of a given phenomenon. Such is the case with the schema in which the negative qualifier nada “nothing” is placed before the main verb, as in nada sé “nothing I know,” rather than the more common negative agreement construction, no sé nada “NEG I know nothing.” This schema expands and declines in use in accordance with the degree of acceptance of a syntactic rule imported into cultivated Spanish prose from the written tradition and grammar of Latin – a language with no negative agreement and typically preverbal negative quantifiers (nihil scio “Nothing I know”). As discussed elsewhere  characteristic morphosyntactic features.Now, the study of how a change is adopted across discursive traditions is not only a methodological requirement of any investigation that seeks to take a non-trivial historical perspectivelsewhere , the adolsewhere . This phínterin “while,” which from its first appearance replaces, at an ever-increasing rate, its competitor ínterin que “meanwhile that,” which in turn had previously ousted the equivalent conjunctive phrases en (el) ínterin que “in (the) meantime that”  universality of S-curve trajectories in cases of competing minimal pairs, which, as we expect to have illustrated, fall short of accounting for all the interesting ups and downs observed during propagation, and are in addition neither well suited to describe the final phases (regressive or otherwise) of trajectories, nor allow us to correlate types of change and modes of diffusionThe author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


N = 29, 1012 observations) filled out questions on momentary experiences at semi-random intervals, five times a day, over a period of 7 to 10 days. Predictors of within-person variations in awareness of Present Moment Experience (PME) and non-reactivity to PME were examined using multilevel analyses. Participants were more aware of PME when they had an activated intention to be mindful and when they felt good, and not very busy or hurried, and were not involved in social interaction. They were more reactive to PME when they experienced unpleasant affect, and when they were hurried or tired. An activated intention to be mindful was also associated with an increased tendency to analyse PME. Experiencing threat was associated with increased reactivity, but not with decreased awareness. Our study generally supports the idea that competition for attention can be a fruitful framework to describe mechanisms behind being or not being mindful.Despite the apparent benefits of being mindful, people are often not very mindful. There seem to be forces that drive people toward as well as away from mindfulness. These forces are conceptualised in terms of competition for scarce attentional resources. To explore these forces and to test this framework, an experience sampling study was performed among people with an explicit intention to be mindful and an ongoing practice to examine concurrent associations between state mindfulness and daily life experiences that may affect it. Participants ( Why are people, even people having an explicit intention to be mindful, not always mindful? The benefits of mindfulness and mindfulness training have received ample attention in present-day psychological research  and non-reactivity, the latter representing the non-elaborative nature of awareness and an open and accepting orientation. Thus conceptualised, these two aspects of mindfulness are states, not traits.In their operational definition of mindfulness, Bishop et al.  define mState non-reactivity should then not be confused with trait acceptance. The latter, as conceptualised by Cardaciotto et al. , has beeAs the concept of attention is crucial to mindfulness, theoretical models of attention may help understand why and when people are mindful or not. The theoretical framework presented below was inspired by Desimone and Duncan’s  biased ccontent of thought (i.e. thinking) and attending to the experience of thought, the former does not qualify as mindfulness, the latter does.) The strongest competitor “wins” the competition. It follows that one’s degree of mindfulness critically depends on the strength of PME in that competition. This does not imply that mindfulness is incompatible with attending to things like work or socialising. Yet, it does seem to imply that, for example, attending to a deadline can attract attention so completely that the connection with PME is lost.Principle 1 is the existence of a competition for attention. As it is impossible to attend to everything simultaneously  is associated with decreased awareness. After all, resources needed to attend to PME are not available when one is very busy with other tasks that require attention. Furthermore, the intention to be mindful may be rapidly forgotten in demanding situations, just like the intention to perform some action may be rapidly forgotten in such circumstances  control Knudsen . An acticonceptualization of mindfulness, rather than identify intention as a variable affecting mindfulness.)One may thus consciously aim to be mindful. A general intention to be mindful will not always be on the top of one’s mind. The level of its activation varies between situations and will affect one’s degree of mindfulness. The importance of intention for being mindful has been stressed before by Shapiro et al. .  instantaneous. Therefore, the focus was on examining concurrent associations among state mindfulness and daily life experiences that may affect it. The hypotheses to be tested were that (1) individuals are less aware of PME when they are busy; (2) there is (a) more awareness and (b) less reactivity when there is an activated intention to be mindful; (3) there is (a) more awareness and (b) less reactivity when one’s affect is perceived pleasant; (4) more fatigue is associated with (a) less awareness and (b) more reactivity; (5) in situations involving loss potential, there is (a) less awareness and (b) more reactivity; and (6) during social interaction, there is less awareness.general intention to be mindful are unlikely to have the activated intention to be mindful that figures in hypothesis 2. Participants were recruited using sign-up lists , direct participation requests  and snowballing (N = 8). Two additional individuals who did not meet the inclusion criteria were excluded before data were gathered. One other participant was dropped from the data analyses after data gathering  with meditation experience in traditions related to and valuing mindfulness, such as vipassana and Mindfulness-Based Stress Reduction  received messages from the SurveySignal software (Hofmann and Patel N = 3) received SMSs (following semi-random schedules similar to those of the smartphone group), prompting the answering of the questions in a paper-and-pencil format.The experience sampling schedule involved a period of 7 to 10 days, depending on participant preference and willingness. Five times a day, at semi-random intervals, between 8.45 AM and 9.45 PM, participants received a signal prompting them to answer the questions. Participants could either fill out the questions online on their smartphone or by paper and pencil, depending on their own preferences and (phone) hardware possession. Participants in the smartphone group , some items proved very sensitive to circumstances not directly related to mindfulness. For example, an item intended to measure noticing of bodily sensations proved very sensitive to the To construct a new questionnaire, a preliminary set of eight items was created. Because of our conceptualisation of mindfulness, the questionnaire covered questions measuring both awareness and non-reactivity. Two items assessing awareness were formulated, reflecting awareness of PME and attending to PME. Six preliminary items were formulated to assess non-reactivity, reflecting the non-elaborative, open and accepting orientation to PME. They included various ways of being reactive (e.g. seeking distraction). Because the items effectively assessed ways of not being mindful, they were all reverse-coded. The way in which participants comprehend and respond to these items was examined using a method inspired by Belzer et al. . A conveSome modifications were made at this stage. The noun “experience” (Dutch: “ervaring”) was sometimes interpreted as “past experience”, and was therefore eliminated from the wordings of some items. The item “I am interested in what I experience” was dropped because it tended to be interpreted in terms of active analysis of PME. The item “I am attending more to my experience itself than to my reactions to that experience” was dropped because it led to confusion, especially among experienced meditators, who felt that this distinction could not be made. One item was rephrased: “I know what’s going on inside me” was replaced by “I am aware of what’s going on inside me”. The resulting six items were found to be comprehensible and unambiguous, and were interpreted as intended.To investigate the items in an experience sampling setting, a subsequent second small pilot study  was performed, which focused on the mindfulness items. The items were found to have good interpretability and applicability to real-life situations, and no further changes were made.analysis item  cross-loaded somewhat on the awareness scale, which makes sense, as will be discussed below. The final set of items is listed in the “In the final analysis, the item assessing absorption (“I'm so consumed by one thing that everything else passes me by”) was dropped because it did not fit well into the factor structure of the mindfulness scales. The final set of five items see the “” sectionBecause the participants had to fill out the same questionnaire many times, the questionnaire had to be short in order to promote compliance , α = 0.87. Non-reactivity was measured with three items , α = 0.75 . Example: “I am trying to be mindful right now”.Three items were constructed to measure loss potential. As discussed below, analyses showed that the three items had quite different correlation patterns. Consequently, the scale was split into two scales, named “hurry” , α = 0.76.Social interaction was measured with two items, assessing being with others and communicating with others, respectively, α = 0.80. Fatigue was measured with a single item: “I am tired”.Affect valence was measured with a single item: “I feel good”.Busyness was measured with a single item: “I am very busy”.Except for the items assessing social interaction, 5-point Likert scales were used, ranging from 1  to 5 (fully). The items assessing social interaction were rated on a three-point scale, anchored “No”, “More or less” and “Yes”, scored 1, 3 and 5, respectively, to have consistent ranges for all items in the questionnaire. Scale scores were computed by averaging item scores. The items that were used in the questionnaire were in Dutch and are listed in the “The data have a hierarchical structure, with reports (level 1) clustered within participants (level 2). Multilevel regression analysis takes this structure into account .Standard deviations, correlation coefficients and Cronbach alphas were computed after centring around participant means. This ensures that between-participant variance is removed.Because we expected that all hypothesised effects are (near-) instantaneous, only concurrent and no time-lagged associations were examined. We expected mindfulness levels to vary rather quickly, and computed lagged correlations to verify this.Random effects were initially included for all independent variables, thus allowing the relationships between variables to vary between participants. The purpose of this was to ensure accurate prediction of average effects. The random effect of hurry on non-reactivity was omitted because it caused convergence problems, because the effect was small and because adding the random effect did not improve model fit according to Akaike’s  informatα = 0.05. All reported p values are one-tailed, unless stated otherwise. If, in a report, a single item was missing from a scale consisting of more than two items, the scale score was still computed as the mean of the available items. All analyses were then performed on an available-case basis and missing data were not imputed.All planned hypothesis tests were one-tailed, The multilevel analyses are based on maximum likelihood methods that rely on normality and homoscedasticity assumptions .χ2(14) = 12.1, p = 0.60.Median response time was 3 min; 69% of the answered (smartphone) signals were answered within 15 min. A comparison of quick answers (within 15 min) with slow answers (not within 15 min) yielded no statistically significant differences in the correlation coefficients of both mindfulness dimensions with their predictors, The means and standard deviations of the variables under study are presented in Table The results of the univariable multilevel analyses predicting either awareness or non-reactivity are presented in Table As hypothesised (Hypothesis 1), people were less aware when they were very busy. This was shown both in the univariable analysis and in the multivariable analysis.As predicted (Hypothesis 2a), people were more aware of PME when they had an activated intention to be mindful. In terms of regression coefficients, this is the strongest relationship that was found.B = 0.189, SE = 0.059, p < 0.01 in a univariable multilevel regression; for the other two non-reactivity items, no significant relationship was found. To explore the possibility that the increased analysis of PME was associated with increased awareness of PME, the analysis was repeated, including awareness as an additional predictor. This indeed reduced the association between activated intention to be mindful and increased analysis of PME to being statistically non-significant, B = 0.089, SE = 0.056, p (two-tailed) = 0.12.In contrast with our expectations (Hypothesis 2b), having an activated intention was not associated with non-reactivity. To examine this further, separate regression analyses of the individual items of non-reactivity were performed. Activated intention to be mindful was associated with increased analysis of PME, As predicted (Hypothesis 3), people tended to be more aware and less reactive when feeling good. Both effects are evident in the univariable analysis and the multivariable analysis.In the univariable as well as the multivariable analyses, the association between fatigue and awareness was negative, as expected (Hypothesis 4a), but did not reach statistical significance. As predicted, fatigue was associated with increased reactivity to PME (Hypothesis 4b).The associations of hurry and threat were not as simple as suggested by Hypothesis 5. Hurry and threat were differently associated with awareness and non-reactivity. Being in a hurry was associated with lower levels of awareness of PME, but the association with non-reactivity to PME was rather weak , controlling for other predictors Fig. . The uniThe bootstrap analyses, each keeping 10,000 resampled datasets with good convergence, yielded results similar to the original multilevel analyses. The same regression coefficients were significant as in the multilevel regression analyses. This was true for the multiple regression analyses of awareness as well as non-reactivity.Additional multilevel analyses were performed to examine relationships between predictors. The results are included in Fig. Furthermore, a regression analysis with busyness as predictor and activated intention to be mindful as outcome was performed. The expected negative association was indeed found.B = 0.162, SE 0.045, p < 0.01) compared with less experienced meditators . The difference is statistically significant .The predicted relationship between affect valence and awareness, though in the expected direction and statistically significant, was somewhat smaller than expected. This raised the suspicion that it may be smaller because participants who are avoiding an unpleasant feeling are unlikely to report (or even notice) that feeling. To explore this possibility, a subset of the data was created, containing the data of only the experienced meditators. “Experienced” was operationalised as having at least 3 years of meditation experience, having a current practice of at least 3 h a week and having silent retreat experience. The reasoning behind this was that these indicators signal intensive practice, associated with a more developed ability to detect “hidden” feelings. Eighteen participants fulfilled these criteria. The hypothesis was that experienced meditators would be more able to detect repressed unpleasant affect while filling out the questionnaire, thus avoiding the attenuation of the relationship between affect valence and awareness. Indeed, for experienced meditators, there was a considerably stronger association between affect valence and awareness , This study focused on explaining within-person variations in awareness of Present Moment Experiences (PME) and non-reactivity to PME. Associations between variations in momentary mindfulness and other variables throughout the day were examined. Generally speaking, real-life momentary mindfulness levels indeed varied in a way that is consistent with the proposed principles.Our results support the prediction that people would be less aware of PME when they are very busy (Hypothesis 1). This was the most direct prediction following from competition for attention (Principle 1); it therefore provides a direct corroboration of our theoretical framework.Having an activated intention to be mindful was associated with increased awareness of PME (Hypothesis 2a), corresponding with the principle that attention is partially under conscious control. In contrast with our expectations, an activated intention to be mindful is associated with increased analysis of PME, which is a form of reactivity to PME. A plausible explanation for this finding is that awareness of PME is necessary in order to analyse it. If the intention to be mindful increases awareness, it thereby facilitates analysis of PME, a possibility also suggested by the cross-loading of the analysis item  on the awareness factor. This explanation is supported by the finding that the association between having an activated intention to be mindful and non-reactivity is non-significant in the multivariable analysis, where awareness is also included as a predictor.Third, pleasant feelings were hypothesised to increase awareness and decrease reactivity. The results showed that participants were indeed more aware and less reactive when they felt good (Hypotheses 3a and 3b). This is consistent with the results of Brown and Ryan , who fouParticipants were less aware when they were tired (Hypothesis 4a). However, the relationship between fatigue and awareness was only marginally statistically significant. Participants also reported higher levels of reactivity to PME when they were more tired, as expected (Hypothesis 4b). Considering the strong relationship between fatigue and affect valence, it seems plausible that individuals react to fatigue because it they experience it as being unpleasant.Regarding Hypothesis 5 , the results suggest that hurry and threat have markedly different effects. Being in a hurry was associated with reduced present moment awareness. This association may arise because hurry, which is often associated with a need for immediate action, reduces mindfulness by competing for attention. Threat, on the other hand, was mainly associated with increased reactivity. This may be caused by threat being an unpleasant experience. The difference in the effects of hurry and threat is consistent with our finding that affect valence has a stronger relationship with threat than with hurry. The difference is also consistent with the examples participants gave of typical situations in which they experienced hurry or threat. These examples mostly implied that hurry required immediate action, such as needing to arrive in time or getting a job done quickly. For threat, participants mostly described unpleasant situations beyond their immediate control, such as interpersonal issues or impending lack of income.Threat, by itself, was not associated with awareness. However, when analysed alongside our other predictors, it was associated with increased awareness, instead of decreased awareness. The difference between the univariable and multivariable analyses may arise because when threat and affect valence are entered into the same regression analysis, any effect of threat mediated by affect valence is absorbed into the regression coefficient of affect valence, and only a direct effect remains. It is possible that our participants, intending to be mindful and practicing to that end, may have developed a “reflex” to be aware of PME when difficulties arise. Unfortunately, this speculation could not be tested with our dataset. Our findings do not imply that threat increases mindfulness; on the contrary, threat is strongly associated with increased reactivity to PME.Participants were less aware when they were involved in social interaction (Hypothesis 6). This corroborates the prediction that, because social interaction is demanding and associated with considerable reward/loss potential, it claims scarce attentional resources, diminishing awareness of PME. The effect was, however, rather weak. It is not clear to what extent our participants’ social interactions differ from those of the general population or how this effect size generalises to the general population. Plausibly, our selected group may have more “mindful” contacts, reducing the tendency of their social interactions to decrease mindfulness.An interesting question is whether the statistical relationships reflect causal effects on awareness and reactivity. Our findings corroborate the hypothesised causal effects in a limited sense, as they generally support the testable hypotheses derived from them, but the possibility that mindfulness affected the predictors under study, rather than the other way around, cannot be excluded. The associations under study were concurrent associations, and therefore do not contain information on the direction of the effects.The question of causality is especially pertinent with respect to the effect of affect valence on mindfulness. Previous findings suggest that mindfulness and affect valence influence one another mutually  mindfulness scales have been criticised because of issues regarding differential understanding of items (e.g. Grossman A limitation inextricably connected with experience sampling is that what remains unconscious tends to go unnoticed (and unreported). The decision to specifically study participants practicing to be mindful, supposedly being relatively aware, was intended to counter that limitation.Another limitation of the study is, as touched upon earlier, that inferences about the direction of the associations cannot be made, as concurrent associations were examined. However, as the hypotheses suggest that the experiences would have an almost instant effect on mindfulness, examining time-lagged associations would not solve this issue.Furthermore, our data on threat may have mainly reflected situations in which the threat was relatively obvious, hence the low average of loss potential, though the latter could also be explained by threat (and hurry) being relatively rare). However, the items had sufficient within-person variance to be able to find relationships.trait mindfulness (viewed as time-averaged state mindfulness) could not be detected. Given the propensity of the human brain to learn by forming habits  10 days. Thus, factors such as long-term learning and habit formation could not be detected, nor have they been elaborated on in the proposed theoretical framework. Put differently, changes in activated intention to be mindful demonstrates the importance of intention to be mindful per se. Therefore, in-depth research on the determinants of intention to be mindful is warranted. The Theory of Planned Behavior . Yet, affect has been found to have two  are especially challenging for someone trying to be mindful. This suggests that specifically practising under these difficult circumstances could optimise transfer of what has been learned to daily life.To remind participants of their intention to be mindful and to practice at moments that being mindful is especially challenging, the “Stop, Breathe and Be” exercise of the .b (“dot-be”) MBI for adolescents (Burnett et al.


Supporting the implementation of school food and nutrition policies (SFNPs) is an international priority to encourage healthier eating among children and youth. Such policies can improve equitable access, resources, and supports for healthy eating. However, despite the potential impact of SFNPs, several implementation barriers have been reported. This study sought to examine the system-level intervention points within a school food system using a complex systems framework. We conducted semi-structured interviews with various stakeholders working to influence the school food system in Nova Scotia, Canada. We sought to understand their roles and experiences with the SFNP by applying the Intervention Level Framework (ILF), a novel, solutions-oriented approach to better understand how complex systems function. Participants (n = 33) included teachers, parents, cafeteria workers, public health staff and non-profit organizations. Interview transcripts were first coded, then themed and finally analyzed using the ILF, resulting in three intervention points within the school food system. These were defined as: (1) Actors and Elements, (2) System Regulation and Interconnections and (3) Purpose and Values. We concluded that understanding the interactions between these system levels and stakeholder roles can help to inform the development of relevant policy strategies that better support healthier school food environments in this jurisdiction. Strategies that encourage healthy eating are an international priority to address diet quality among children and youth ,2. Over Systems-thinking recognizes the interrelationships and interactions across stakeholders, structures, processes, and contexts ,7 and isa set of elements or parts that is coherently organized and interconnected in a pattern or structure that produces a characteristic set of behaviours, often classified as its function or purpose” and proposed 12 leverage points for effective intervention in systems [Multiple frameworks have been developed to support the application of complex systems science approaches to promote health or prevent chronic disease ,17. Typi systems . To furt systems . In the  systems  and obes systems , allows The province of Nova Scotia (NS) in Canada offers a unique case to explore system-level intervention points within the school food system because it has a rich history of research, policy, and grass-roots efforts to create healthy school environments . Of noteStep one of this study involved collecting data through interviews with cafeteria workers, teachers, and parents of school-aged children in NS, and relevant employees of the provincial health authority. The purpose of these interviews, conducted in 2016–2017, was to gather more in-depth information about stakeholder roles and perspectives on healthy school food environments, including factors that may obstruct or enable actions to create them. Participants were purposively recruited via multiple recruitment strategies that included posters, social media, word of mouth, and snowball recruitment strategies, and included internal and external stakeholders, such as food distributors and relevant non-profit organizations. Initial contact with individuals was made by e-mail and phone, whereby participants could review the study details and respond confirming interest, date and location for the interview. A small number of individuals did not respond to invitations for interviews or were unable to confirm a time. One individual declined to participate due to illness. Ethical approval was provided by the Dalhousie University Research Ethics Board. Informed consent was achieved verbally for each phone participant and written or verbally for in-person interviews. Semi-structured interviews were conducted using an interview guide including broad questions designed by the research team to facilitate the interview, that was untested prior to this study see . Twenty-In total, 34 interviews were conducted, of which 9 were teachers, 8 were staff working with the provincial public health system that has the responsibility for food and nutrition policy implementation within the school system, 8 were parents of students within the public school system, 5 were school cafeteria staff and 4 were external stakeholders involved in aspects of food distribution or resource provision in schools, as noted above. There was one repeat interview where the same individual was interviewed twice, once as a public health staff member during the first wave of interviews in 2016 and again as a parent in 2017, resulting in 33 total participants. Of the 33 participants, there was representation across all four public health regions that are operational in Nova Scotia, and half of the seven provincial school boards, which represent the administrative structure for school operations in the province. A small number of participants had a prior relationship with some members of the research team, particularly those in the external stakeholder group. In these cases, the interviewer with the least amount of association with the participant conducted the interview. In-person interviews were conducted at locations selected by the participant and included their homes, offices or rooms at the office of the researcher. Most interviews were private conversations between the participant and interviewer, however some participants completed interviews with children, students or co-workers within audible proximity. Proximity of others, especially co-workers, may have influenced what participants shared, however allowing participants to participate at times and locations convenient to them was important in making the study more accessible to busy and hard to reach populations .Step two of the study involved the application of Qualitative Description (QD) methodology to better understand the interaction between system levels and stakeholder roles in the complex school food environment. Being less interpretative than other designs, QD has the purpose of understanding and richly describing participant experience, particularly in understudied areas, and allows research to remain close to the data, permitting description of phenomena and events “in the everyday terms of those events ,25. AudiStep three of this study applied the ILF framework to the themed data so that participant experience could be understood with a view to elucidating potential system-level intervention points to inform future policy implementation, based on the definitions provided by Johnston et al. (2014) see . Given tWhen mapped to the ILF, the qualitative data generated in this research resulted in three themes that could be considered as system-level intervention points see . The firThis theme relates to the structural elements and pieces of the school food system, aligned with the lowest level of the ILF framework, and characterized by the physical elements and the presence (or absence) of different actors within a system. Actors identified in this study consisted of students, families, teachers, principals, cafeteria workers, food distributors, school boards, government, and a variety of external stakeholders like community organizations and retail or fast food outlets. At this level of the ILF, actors were seen to be either present or absent from discussions related to school food policy implementation, or to have specific roles and responsibilities related to it. The majority of these discussions related to the actors’ impact on the creation and maintenance of school food systems. The interactions, perceptions, and mechanisms for communication among actors represent a higher level of the ILF and are therefore further discussed in the themes below.when you’re serving that many kids, you can’t probably make your muffins from scratch every day. It’s got to be something that can be prepared quickly”. This closely connected to the availability of staff and volunteer capacity. A teacher said, for example, in reference to expanding a breakfast program, “I just, I’m the only one who does it, so just no human power, there’s no manpower to do it, I just don’t know if it’s feasible”, while a public health employee described the school food policy as “something else added to their (the school’s) plate and it’s a plate that’s already full”. Other resources discussed by stakeholders as necessary were related to education and training, for food providers and distributors, cafeteria staff, and teachers. One external stakeholder summarized this by listing opportunities needed to increase the capacity for supporting a healthy school food environment, including, “sharing best practices, creating a community of practice, supporting stories, reimagining budgets, tools, training sessions”.In relation to system elements, two subthemes emerged, which were Resources and Finances and Funding , which fhow are you supposed to feed anywhere between 100 and 400 kids if you don’t have the space to hold the food?”, as well as family experience, as parents discussed the challenges of not being able to send food that required refrigerating or being heated. Finally, participants described local community organizations as a positive resource for schools by helping with breakfast programs and developing school gardens, for example. Valuable community resources included local farmers, which was felt to facilitate, “a different tone around food - kids know those farmers in their community”, as well as local organizations like clubs and churches, that hosted breakfast and lunches.Kitchen space and equipment also emerged as important resources, relating to the ability to serve and store healthy food items. This connected both to school operations, demonstrated by an external stakeholder asking, “…you know, have the funds available from the government whether it be local level or federal level to be able to put some type of lunch program in place for all of our kids, not only for the kids who would be able to afford it but for all the kids in Canada”. Fundraising was also discussed, noting the historical tendencies of schools to sell unhealthy foods to raise money, and the limited alternative options. Others highlighted the need for increased cost savings within school cafeterias that move toward healthier foods, noting staff hours might be cut to save money, and the impact of healthy food on operating budgets. One cafeteria employee said, “like before the profits were high but it wasn’t healthy food because as you know, when you buy healthy you spend more, but I find that it’s not as important to make a profit as it is to provide the service”. Finally, stakeholders connected funding to human resources, with one external stakeholder saying, “the funding piece will go hand-in-hand with more human resources, there’s only two boards in our province that have actual dietitians working for them - we could use a lot more”.As part of this theme, and closely connected to resources, was the subtheme related to finances and funding. Finances, money, and funding were described as important structural elements in various ways and from a variety of perspectives, though frequently as a challenge or constraint. Stakeholders broadly discussed the overall amount of available funding as limited, with some emphasizing the lack of federal funding for a national school food strategy. One parent noted: “This theme aligns with the middle levels of the ILF framework, connecting to feedback and delays, or system regulation, and system structures, or the interconnections between system elements. This theme is also illustrated through several subthemes including first, interacting roles and responsibilities, second, food access, and third, communication, collaboration, and direction .I think you should talk to the students themselves - they would definitely have opinions on food at their school”. Student preference was also highlighted by stakeholders. In some participants there existed a perception that youth do not like healthy food. Other participants identified this as misperception. One cafeteria employee noted that: “the kids nowadays like the healthy food, before it was a struggle. they know what they want now and they want healthy”.The first subtheme related to system interconnections and regulation illustrates the interacting roles and responsibilities of the various system stakeholders and their interdependence with other system elements. Families were discussed by most stakeholders as having the biggest influence on students through their roles as primary food providers and role models for healthy or unhealthy food behaviours. Parents that participated in this research demonstrated varying degrees of understanding of school food systems and nutrition policies but they unanimously supported creating healthier school food environments. Students were also identified as having an important role in system regulation as consumers of school food and potential agents of change, although stakeholders noted that they were often overlooked. A teacher said, for example, “there’s some schools where the principal was very involved and very concerned about the food and there’s other schools where they’re not. And so that’s what creates the challenges”. Teachers saw their responsibility primarily around role modelling, with one surmising, “Practice what you preach. I’ve always allowed my kids if they want to have a snack in class, it’s no problem, but it has to be a healthy snack”. Cafeteria staff also played an important role in the regulation of school food systems; participants discussed their role in what food is served and sold, how it is prepared, and how their knowledge, skills, and relationships with students influence cafeteria operations, although many participants noted that cafeteria staff are typically undervalued and underfunded. One cafeteria employee described their relationship with students, saying, “I really get to know the kids really well and so I ask them you know how was that today, did you like that, do you think I should do this again?”.The role of school staff was also discussed in relation to system regulation. Principals were highlighted as having a particularly important role in school leadership, related to setting direction and tone. One stakeholder said, for example, “some schools are a little more lax then others—we’re just here to give them what they’re asking for, they order it, we supply it”. This was furthered by a public health employee who noted challenges around distributors’ “interpretation of the policy and the advice they give to schools”. As previously mentioned, community assets and organizations, like farms and non-profit organizations were seen as valuable connections by several stakeholders, though challenges around “red tape” in accessing schools were also noted, such as by one parent, who said, “I get the sense though that the schools aren’t necessarily as open to support from the broader community, or that there’s barriers to them doing that”. This also relates to the below sub-theme of access in reference to the bureaucracy that limits partnerships with schools. Finally, many discussed the availability of unhealthy food from retail and fast food establishments, noting that while healthy food may be available in schools, students could choose to eat in their communities instead. This competition between school cafeterias and retail outlets was highlighted by a public health employee who said, “with zoning bylaws, I think we could really see an increase in school food if we could decrease the amount of fast food restaurants that are around schools”.Beyond schools, further interconnections and system regulations involved school boards/districts, government, communities, and other external stakeholders. Participants noted that the role of the school board was complex, and that more collaboration with government was required to facilitate healthy school food environments. Food distributors and suppliers were highlighted as an important interconnection for school food systems. One external stakeholder noted: “I also have worked with kids of so many different socio-economic, various backgrounds and there’s so many different factors that come into play. Food security is a huge issue and fresh fruits and vegetables for some people is just not an option all the time”. Broader regulatory changes in the school food system over time also connected to access, with one cafeteria staff member saying, about students, “they know that they’re not going to get hotdogs at school”, and another stakeholder saying, “we no longer have deep fat fryers or pop machines, and those types of things in schools”. Similarly, access was connected to cost, with one parent saying, “I don’t know if there’s anything that can be done to lower food prices but—it’s shocking how expensive food is”. Proximity to retail food environments was also discussed as facilitating access to unhealthy food. Convenience was further discussed by most stakeholders, regarding fast food chains, in addition to packaged foods that are easy to store, and have long shelf lives, making them easy for students to access.The second subtheme within system interconnections and regulation relates to food access which was discussed in a variety of ways by stakeholders, particularly given the role of the school food and nutrition policy in shaping food access. Some stakeholders discussed the challenges of food access in relation to socioeconomic factors. This was seen to be more influential on students’ health than the system elements previously discussed. One teacher noted how, “it’s really a multi-pronged approach. You know, it’s really collaboration and partnerships because again, the schools have a lot on their plate”. The idea of communication was also closely tied to collaboration, such that it is a necessary part of relationship building and maintenance. A teacher described a challenge presented by communication, saying, “the functionality of the cafeteria is completely unknown to the staff. And I’ve gone in, ‘how do you decide that chicken fingers are going to be served on Thursday?’ The workers there are also not too sure, and I’m wondering if it’s more of a, you know, coming from a head office”.The final subtheme related to interconnections and system regulation was communication, collaboration and direction. All stakeholders discussed the idea of collaboration being required to support healthy school food environments, noting that stakeholders, such as boards, principals, school staff, and families need to work together or toward the same ideas in order to see the most impact. That said, many also discussed challenges in role clarity, responsibility, and resources, which limited their ability to work collaboratively. A public health employee said, “supportive leadership, working as a team, and being really kind of positive and open to talking. I always find connecting like being able to talk or dispel any kind of notions - so more ways to connect”. Participants indicated that, in order to collaborate, there needs to be communication, and with communication comes clarity in direction. The idea of direction was discussed by many stakeholders, often in terms of waiting for or needing instruction or clarity, and also in relation to ideas around autonomy and flexibility in their roles. A cafeteria employee said for example, “I sort of do my own thing. I don’t, like nobody comes down and says you should do this, you should do that, they know that I know what we should do”. This autonomy was generally preferred by cafeteria employees but they also identified the need for support from others, particularly related to their budgets and resources. Several stakeholders noted that changes to school food environments, including the nutrition policy, required more direction and leadership, with one parent illustrating this by saying, “I could be pleasantly surprised, maybe they (the school) do talk about the policy and promote it, that would be great but I would guess that they don’t do it much”.A parent further highlighted the role of communication in discussing elements that make it easier for schools to provide healthier food environments, saying, “The theme of purpose and values aligns with the highest levels of the ILF framework, relating to goals and paradigms, and illustrates a system’s philosophies, commitment, and beliefs. This level offers the most in terms of potential for impact but is typically the most challenging to influence. This theme was also illustrated by several subthemes, including control, disconnect and misalignment, competing priorities, and food culture .we’re educators, you know, we need to inform kids on proper choices, healthy choices but at the same time they need to be able to be given that, the choice to make that choice”. A parent illustrated these competing ideological challenges saying, “I know that one of the people on the (Parent Teacher Association) said, ‘well it’s not for us to be the role models for these kids, it’s the parents to do that’, which I disagree with, I think the school should be a role model. I think there’s a lot of that; that people are free to choose what they want to do, you know, it’s a free society”.The concept of control emerged frequently through the exploration of the multiple levels of the school food system. Ideas around who can and should control the food choices of children, who controls how and where funding is spent, and how school food policies should be managed and implemented were commonly discussed by stakeholders. Alongside the idea of control, was that of accountability, where participants discussed whose responsibility it might, or should, be to ensure a healthy school food environment. Further to this, was the concept of individual versus collective responsibility and having a balance between individual control and autonomy and caring for our children societally. A teacher said, for example, “it’s about more than just what happens at lunch time - I think it needs to be more holistic. Ideally there would be pieces of curriculum that would reflect what they’re seeing at the cafeteria level and then what they’re being role modelled by staff and then there would be a policy that also supports that and the environment physically would be one that’s free of harmful influences and then the social environment would then follow suit and you know people would have those positive feelings about food”. Another parent noted the autonomy of individual schools, “I think we’re siloed still too much, each school doing its own thing which makes it just subject to the people that are there”.A second subtheme, disconnect and misalignment, illustrated the wide variety of perspectives and priorities relating to food and food environments that were held by various stakeholders. Participants discussed how priorities, mandates and perceptions map onto divided jurisdictions with varying capacity and resources, creating a challenging context in which to support healthy food environments consistently. A parent described this complex context saying, “our principals, with everything else, they’re concerned about keeping their food service workers employed. Not everyone has a business degree, the message around healthy school food environment, (it) can get lost in the management of the food service”, while another echoed, “it’s kind of a catch 22, it would be really nice to figure out what is the amount of time that’s required to provide, to prepare quality healthy foods that kids will eat and that you can make money”.Ideas around disconnect and misalignment were also closely connected to the third subtheme of competing priorities. Stakeholders discussed challenges around cafeterias operating as for-profit businesses, and teachers and principals having workloads such that supporting a healthy food environment was perceived to be in direct competition of other priorities. A public health employee described one such challenge, “I know that a lot of companies market directly to kids and that’s kind of, there’s some ethical questions about that, I think some pretty dodgy marketing going on and, it would be nice if that was addressed and regulated”. Others discussed the concept of “treats” and special occasions, which become so frequent in the school environment that they are no longer occasional or special; one stakeholder said, “broadly there is more of a movement toward healthy eating and valuing healthy food but there is this kind of counter balance ‘but like oh this is a special occasion’, and it’s just when the special treats become everyday things”. There were also many examples of food culture connected to how food is treated in schools, such as one parent, who described eating at school to be perceived as, “a nuisance to the school culture, it’s disruptive, it’s you know it’s something that, it’s only done at a certain time of day. I think the whole culture is just so backwards”. Others discussed the lunch time at schools, which has several activities, priorities, and circumstances happening simultaneously, speaking to whether, or how time for nutrition was valued. A public health employee illustrated this perspective, saying, “the culture of lunch time at the schools is an issue. Students are leaving for many reasons, I don’t think it’s necessarily to get unhealthy food, I think it’s like the social pressure of being cool enough to leave school. It’s the culture of what’s in a cafeteria and what the cafeteria looks like, and it’s the culture that schools are starting to lose intramurals which is what is keeping them at school”. Several participants also discussed food culture from an employment perspective, in that those who work in food service tend to be societally undervalued, with one stakeholder saying, “if we’re going to talk about health, we have to talk about equity, like when I think about what food service workers make in comparison to teachers—I don’t know why we would value the people who feed us so much less”. Some stakeholders discussed education as a potential solution to many of these issues, and while others thought that would be sufficient, others highlighted that education should be paired with resources, salaries, time, and broader commitments to valuing and supporting healthy food environments.As a final subtheme relating to purpose and values, food culture emerged as an important concept that illustrated participants’ understanding of the deeply held beliefs, perspectives, and norms relating to food and how we interact with it both societally and in the school food context. Many stakeholders discussed the important influence of advertising and marketing, and how media influences youth. One parent summarized by saying, “This study examined system level intervention points across the school food system, derived from interviews with key stakeholder groups in NS, Canada. Using the ILF, we aimed to go beyond a conceptual consideration of the complexity within school food environments that suggest simple solutions and that assume rationality and linearity ,30. RathThe theme that related to the highest leverage point in the system, goals and paradigms, highlighted the importance of alignment in priorities and food culture in the creation of a healthier school food system. Conflicting goals related to nutrition in schools is commonly reported as a barrier to improving school food environments ,35,36,37The second theme focused on interconnections and system regulation, specifically on roles and responsibilities, access and convenience, and communication, collaboration and direction. This theme aligns with feedback and delays and system structures, highlighting the complexities of the school food system and the communications gaps among stakeholders. As highlighted in our results, stakeholders at each level of the system had their own perceptions of who was responsible for supporting healthy school food environments and who should be connecting with whom to make it happen. Almost all cafeteria staff interviewed spoke about positive relationships with their school principals and nutrition-related support but felt isolated from board-level decisions. Though they are tasked with delivering many elements of the policy and making budgets work, cafeteria workers expressed instances of not feeling supported, often spending extra time to find the best deals to source food. These challenges for cafeteria staff are noted in recent research exploring their perceptions, which highlights challenges around support and communication . This ofMany participants spoke about their experiences with contracted distributors, suppliers and food service management contracts, highlighting the influence they have on the school food environment and tensions that exists among some stakeholders. The role of distributors in farm-to-school programs has been explored by some authors, revealing structural limitations in the types of foods that can be provided, the locality of the food and the packaging in which it is distributed . To our Finally, the physical elements in a system, including resources, funding and time was identified as the lowest leverage point within the system, but are often the most frequently acted upon. Although these elements are closely connected to larger influences related to values and priorities, solely focusing on action at this level would offer a simple solution to a complex problem. Specific resources noted in other studies as being critically important for supporting a healthy school food environment include lesson plans, materials and expert assistance for nutrition education ,51,52,53The strengths of this study include the use of a complex system lens and the variety of stakeholder roles that were included. We also connected system aspects to stakeholders, which is an important contribution to the literature. A key limitation is that some perspectives may have been missing from the data. We sought to gather a variety of perspectives of stakeholders involved with supporting school food in NS, with participants recruited through multiple recruitment strategies, but they may still represent a selected group of those that are interested in the issue. It is important to note that several attempts were made to involve a greater number of food distributors and service providers. However, these perspectives were under-represented and further study is needed with this stakeholder group. In addition, student voices were not part of this study, although as noted above, they are engaged in additional aspects of the broader research project. Qualitative work is inherently biased, and as health researchers, the interviewers were personally interested in promoting healthier school food environments. These biases were mitigated through regular meetings to discuss observations, biases, challenges and whether data saturation was being reached.Creating a healthy school food environment means targeting features of the school that may support healthier eating among students, such as access to healthy foods, programs or initiatives and creating a culture where healthy eating is modeled and supported throughout the school day. This paper examined the system level intervention points across the school food system in the province of NS and from the perspective of key stakeholder groups . We used


The prevalence of diabetes in Sub-Saharan Africa (SSA) is growing rapidly. Qualitative research on experiences of type 2 diabetes in SSA is emerging, but no qualitative synthesis has been attempted. This scoping review aims to redress this lack of synthesis and to extract policy-relevant suggestions from the literature.Scoping review methodology was employed. Eleven online databases were searched , using terms designed to identify qualitative studies of experiences of diabetes in SSA. Findings from records identified in the search were analysed inductively in NVivo 10 in three stages, to produce an analytical synthesis of studies of diabetes experiences in SSA.Searches were conducted in 2017 and identified 2743 records, which were reduced to 21 after screening. The earliest identified record was published in 2003 and there was a clustering of records published between 2014 and 2016. The 21 records were based in eight SSA countries: Cameroon, Ethiopia, Ghana, Senegal, South Africa, Tanzania, Uganda, and Zimbabwe. A majority of the studies were conducted in Ghana (5) and South Africa (5), limiting the generalisability of our findings.identifying type 2 diabetes ; hybridity of diabetes care (how multiple forms of care are often blended and/or pursued concurrently); impediments, improvisation and diabetes management ; sources of support (who supports participants and how); and diabetes and HIV/AIDs (the ways in which the two conditions are sometimes confused and how stigma is often experienced).The analytical synthesis produced five themes: The experiences of people with type 2 diabetes in SSA are under-researched across the region, pointing to a gap in knowledge. Interpreting our analytical synthesis, we suggest three priority areas for policy makers and implementers. Firstly, uncertainties relating to access to diabetes treatment need to be reduced. Secondly, more needs to be done to acknowledge and alleviate the economic struggles that those with diabetes face. Finally, high-quality information and education would improve recognition and management of the condition. The number of adults estimated to be living with diabetes in sub-Saharan Africa (SSA) in 2017 was 15.5 (9.8–27.8) million, with a regional prevalence of ~ 6%, and associated healthcare costs of USD 3.3 billion. By 2045, this number is expected to increase by 162.5%, with an estimated 40.7 million adults suffering from type 2 diabetes and costs rising to USD 6 billion  three days!’ That is why I went to the traditional healer. I was afraid because I had changed a lot; it was a big change for just three days. I thought I was bewitched…” However, witchcraft and appeals to the supernatural were not simple replacements for biomedical explanations. Rather, biomedicine and traditional medicine are not mutually exclusive. , 19, 21:“I will just finish these[…] drugs because I bought them. But tomorrow, I will go for more protection and tell the native doctor that he is a man. He knows his job. I must not joke at my workplace because there is a lot of witchcraft and jealousy there; they have put this diabetes into my body. My family told me in the village that I should be careful… My man will cure me and that enemy will be ashamed” As this Cameroonian exemplifies, the two discourses can become entangled.Thirteen studies focused on how people with diabetes employed both biomedical and non-biomedical services in the management of their type 2 diabetes , 31, 35.“I want to be healed so I will follow up whenever I hear of somebody who can help.” Some searches for cures were directly linked to a perceived failure of biomedical practitioners to provide a cure.“I was never at ease when the doctor told me that I had diabetes. I tried to be cured in the hospital and my diabetes could not finish. The doctor kept telling me that I was not complying with treatment. A friend of mine also, sick with diabetes, told me that some unperformed ritual might be holding back the treatment. She advised me to consult a traditional healer. The healer advised me on the ritual to perform to my ancestors. After the ritual, I felt well and my blood sugar returned to normal six months afterwards. I believe that the doctor did not know this other cause of my diabetes and how I could be cured.” Informants such as this Cameroonian spoke of frustration at the lack of a cure and continued suffering as reasons for engaging non-biomedical healers. When informants assessed their treatment regimens to be of low efficacy, they looked to other forms of treatment.The financial pressures that biomedical treatments often place on households was another reason offered for consulting non-biomedical services. Non-biomedical services cost less than biomedical services, providing a cheaper alternative to those struggling to afford to pay for biomedical services, as represented by this Senegalese narrative , 19–22:“The main problem we have with diabetes is the diet and the medications are extremely expensive. The cheapest drugs are between 60 to 100 dollars a month. For a third world country like Senegal, it is almost impossible for most of us to be able to afford it. Most of the diabetic patients are living in misery or dying. The situation is that extreme. A money issue is the main reason why most of us try traditional plants because it is more economical” Even though non-biomedical services are routinely utilized, biomedicine was often reported to be both preferred and the first source of diagnosis , 26, 35.“I just follow instructions as the doctor said to me. I decided ok, the doctor told me this and this, which is why I have to follow it, because they know what I don’t know. They saw it in my body…so I just carry on..” Moreover, when symptoms worsened, non-biomedical explanations and treatments for diabetes tended to be downplayed by participants in favour of biomedical alternatives.A number of studies described a situation where both biomedical and non-biomedical services were used interchangeably , 26, 30.‘Let health care providers do their part, the traditional healers will complete the treatment’ As described by this Cameroonian, hybridising multiple systems is not uncommon. Participants often take multiple forms of medication, mix advice from a variety of healers, and deploy variegated conceptual frameworks in their accounts of how they care for themselves.Alongside traditional healers and biomedical healthcare professionals, religious beliefs also contribute to treatment discourse. Many informants attributed any potential success in treating their diabetes to God’s will. Those who went to faith-based healers or engaged in prayer as a form treatment considered God to be the ultimate healer , 31, 33.“It is only God who can intervene. It is only God who can let you meet a doctor who can cure you of the disease.”“If God doesn’t bless the drugs you take it might not be effective even though it is efficacious.” Christian healing manifested itself in many practices including special diabetes prayers, taking communion, being anointed with holy water, and visiting dedicated faith healers. In combination with biomedical services, the inclusion of religion was seen as an effective method to find a cure , 27, 29.All 21 studies in the review reported narratives relating to the impediments people with diabetes face when managing their diabetes. The high costs of medication was a major concern for people held by people with diabetes studie , 34, 35.“. . .The drugs are not affordable. . .besides diabetes doesn’t come alone. There’s the cholesterol and hypertension that come along. I struggle to cover all that with my government salary.” Another cost identified in three studies was the cost of diabetes monitoring equipment, with participants in Uganda reporting that managing treatment is made more difficult by an inability to afford monitoring equipment to test their blood sugar levels , 18, 27.One study reported that informants would sometimes buy their medication directly from local pharmacies without attending clinics to obtain an appropriate prescription, to avoid healthcare and transportation costs . Other m“…Medicines are very important for treating this disease…That is why you find people using a half of the dose and saving the rest for the days ahead, because you do not know how it is going to be tomorrow… [Have you experienced that situation?] Yes…sometimes instead of injecting myself twice in a day I inject myself only once… At least when I do this the medicine for a month can last me two months.” Improvisations in treatment practices were not just related to medication, but also occurred as a response to a lack of blood glucose testing equipment. One participant described testing sugar levels by tasting urine for sweetness or looking to see if ants are attracted to it .Accessing clinics, hospitals and other biomedical facilities was a significant impediment for some. In four studies, informants reported that biomedical facilities were too far away to reach easily, often due to the cost of transport. This was especially true for those who lived in remote villages in rural or semi-rural areas , 30–32.“I need to have enough money for a return transport, accommodation, and food before I can think about going to the clinic—and that doesn’t include the money for laboratory tests and medicines… my financial resources are low….I just leave it to God—if I have money I go to get the medicines, and if I don’t, I stay home and go without….” In addition to the high cost of transportation, participants such as this Tanzanian woman required money for accommodation and food in order to make the journey to her nearest diabetes clinic. During rainy seasons, clinics also become unreachable for some:“….During the rains it is very difficult to come to the clinic because our roads are impassable, and cars are unable to reach the village….. This is why even I could not come to the clinic last month…” Even when clinics were accessible, the treatment and care described in the literature was often inadequate , 31, 32.“…For instance, last year diabetes medications disappeared for almost three weeks … I could not find them anywhere in Ifakara … and during that time I didn’t have a single medicine from the hospital…. That it is when you find us in these other places .” Alongside disruptions to the supply of medicines, informants also described long delays at health clinics. These delays often entailed losing wages or labour time, and some reported fainting as a consequence of waiting for fasting blood glucose tests , 31, 32.Informants reported how diabetes also impacted their incomes. Six studies recounted the impacts that diabetes had on informants’ ability to work , 28, 29.Complications such as decreased mobility, or poor eyesight were contributing reason for people having to retire early . One Sen“I am blind and cannot support my family.” Earnings were also lost due to time spent seeking treatment. Kagee, Le Roux and Dick found that participant in South Africa reported losing their wages when they had to go to and travel to biomedical facilities:“You miss a day’s wages. So you see money plays a role whether or not I go to the clinic. What do you think?” In some instances, informants described living with diabetes as stressful , 29, 34,“It is frightening when you don’t have money to buy drugs, but if you have money then your mind is at ease.” As well as financial stresses, participants were concerned about managing their conditions. Specifically, the inability to monitor glucose levels and struggles to keep diabetes under control were both described as sources of stress by South African participants , 29. FinExercise as a way to manage diabetes was discussed in eleven studies , 33–35. Another impediment to self-care reported in the literature related to the foods that participantshad access to. Eleven studies focused on how informants found sustaining an appropriate diet a pressure on finances , 29, 32.Twelve studies reported on the sources of support that people with diabetes were able to draw on , 32–35. “I get a lot of support from my family and from my friends thank God. I cannot complain and I am very grateful. My son who was born in 1974 is a grown man and he helps me a lot financially. The rest of my family supports me mentally. My wife and my daughter-in-law cook my food.” Care informants reported receiving from family often included reminders to take medicines , 32, 33,“When I’m in bed and my granddaughter has prepared food, she wakes me up and says, ‘Food is ready, take your medicine.” Metta et al. found that when initially confronted with diabetes symptoms, informants turned to friends (as well as family) for assistance . Like fa“People have been supportive [of my diabetes]. My neighbour now also has it and we are always talking about it together and I enjoy being around her. We usually share a laugh about it sometimes”. While many participants described living in supportive environments, with helpful family and friends, some narrated feeling unsupported in caring for their diabetes , 29, 35.“...My daughter-in-law knows that I am diabetic but she cooks rice a lot because she doesn’t want me to do well.” Similarly, tensions over diet could also occur between friends. One study from Ethiopia found that during social events, refusal to eat from a common dish was considered inappropriate, forcing people with diabetes to choose between adhering to their diet or maintaining good relations .Some participants felt that they did not get the necessary levels of support from their health care providers , 33, 35.“At the hospital they don’t tell the numbers—just write them. If they [the nurses] write large I can read them myself, but if they write too small, I have to ask my brother’s granddaughter or the neighbor’s child to read them because I do not see well.” The lack of education on managing diabetes was mentioned in eight studies , 33, 35.The HIV/AIDS epidemic in SSA has had an impact on the ways in which diabetes has been understood and its symptoms interpreted. Eight studies explored aspects of this relationship , 30, 32.“Initially, I used to urinate a lot; also drank water a lot… When my condition further worsened and I continued to lose weight and couldn’t even go to the toilet by myself, I wondered if I might have contracted AIDS.” The assumption, in this Ethiopian context, that diabetes symptoms such as weight loss were attributable to HIV/Aids was not only held by those experiencing such symptoms them , 26, 31.“My weight was 90 kg when I was less than 35 years old. I have lost more than 10 kg as part of my treatment. People now perceive me as someone that is suffering from AIDS. This is affecting my personality. I have to gain some weight to remove that stigma and show them I am well...” [One study found that participants had to continually explain their diagnosis, as family and community members thought that the person with diabetes was actually HIV positive.“Why is your health so unstable… have you been tested (for HIV)?’ Even when you say I have been tested and I am just fine, you still hear: ‘You had better get another test at another place because sometimes they can miss it, if the second test shows you are ok, then you can be completely sure’” Stigma, as narrated by this Tanzanian person, also impacted the ways in which people with diabetes engaged with their treatment. From the four studies, paricipants detailed how they adjusted treatment regimens to avoid the stigma of the presumption of having HIV/AIDS. This was done by avoiding weight loss, or in the case of one Ghanian woman, ending treatment , 21.This review found 21 studies relating to type 2 diabetes illness experiences in 8 of 48 SSA countries, published between 2003 and 2017. Interviews (mostly semi-structured) were the most common form of data collection (20/21) and focus groups were also popular (6/21). Studies in Ghana and South Africa accounted for nearly half of the records included in the review (10/21). At this very basic level of analysis, and as encouraged by scoping methodology , our worWith these geographical and cultural limitations in mind, we were nonetheless able to identify five areas of convergence in the literature from the 8 countries represented in the literature. Most studies (20/21) offered data on how people came to identify their diabetes, how they reacted to being diagnosed and how they located the condition using multiple pre-existing cultural frameworks. A majority of studies (13/21) described how biomedical, ethnomedical and faith treatments are often hybridised by people with diabetes in SSA, who locate their condition in multiple socio-cultural frameworks, are sometimes in pursuit of a cure, and often face financial and/or access issues that shape the treatment providers they can consult. All 21 studies included in the review reported on the various impediments people living in SSA face when pursuing care. These included issues of cost, access, interruptions to drug supplies and stress. Sources of support were described in 13/21 studies, with family and friends featuring heavily and some comment being made on levels of support received from medical professionals. Finally, intersection between HIV/AIDS and diabetes were described in 8/21 articles. Participants in these studies reported initially interpreting diabetes symptoms, such as weight loss, as signs of HIV/AIDS, and that this interpretation was often shared by others in their community, leading to stigma.Uncertainty is arguably one of the leading challenges: supplies of medicine are interrupted [economic resources shape patient experiences: treatments (including travelling to obtain them) are unaffordable for many, especially when multiple drugs are prescribed [quality information and education about diabetes is not easy in SSA: healthcare services are stretched, often leaving little time for education [Taken together, the 21 studies paint living with type 2 diabetes in SSA as a complex and multifaceted experience, often characterised by considerable challenge. Our interpretation of the five themes synthesis that we have presented suggests that three major challenges can be identified in the literature. errupted ; incomeserrupted ; visits errupted ; and, aberrupted . Similarescribed ; diabeteescribed ; and resescribed . Finallyducation ; informaducation .uncertainty, economic resource, and quality information/education) are a useful starting point for focussed, collective action to improve the lives of those living with type 2 diabetes in SSA and could be addressed by a range of stakeholders. Policy makers could consider how they might reduce the uncertainties experienced by people with type 2 diabetes; how they might enhance the economic affordances offered to people with the condition; and how they may provide high-quality prevention and self-management education at both a population and localised (community) level. Health care professionals could develop explicit protocols for managing uncertainty, economic instability and access to quality information. Pharmaceutical companies could make greater efforts to ensure that cheap, first-line treatments such as metformin, are readily available. Finally, a range of civil society organisations, including national diabetes foundations, faith-based congregations/organisations, sports clubs, educational establishments and other socio-political collectives offer potential channels through which type 2 diabetes prevention and management strategies/programmes could be pursued.While stemming from work in 8/48 countries, and with a limit on generalisability (10/21 were from 2 countries), these three challenges (A primary limitation of this scoping review is that it only admitted peer-reviewed articles from the databases that we searched. ‘Grey literature’ studies were omitted by design, which means that this review does not contain findings from non-peer reviewed studies, such as those produced by non-governmental organisations. This is a departure from the Arksey and O’Malley framework and resulted from time and resource constrains. However, the broad terms of our search offer the study a strength. Rather than narrowing our concern to specific aspects of the experiences of people with type 2 diabetes, our scoping review had no pre-conceived vision of what these experiences might be. An equally important limitation of the review is that it covers only 8/48 SSA territories, limiting generalisability. That said, this work has clearly identified a gap in knowledge that needs redressing if SSA countries are to improve the illness experiences of those with type 2 diabetes. Limiting our searches to studies in English is a further limitation, but one that was unavoidable due to the language skills present in the team. Finally, our consultations could have been broader, which may have resulted in additional literature being identified.uncertainties, economic resources and quality information and education as key concerns for people living with diabetes in SSA. Governments, civil society organisations, culturally-sensitised public health practitioners and diabetes specialists could work collaboratively to produce interdisciplinary and pragmatic approaches to management and care for those living with type 2 diabetes, as well as prevention for those who are at risk of developing the condition.Research focussed on exploring the illness experiences of people living with type 2 diabetes is yet to cover the broad territory that is SSA. Based on an analytical synthesis of the evidence presented in 21 studies from 8/48 SSA countries, this scoping review has identified