Rachel Skinner: [00:00:03] Hello, everybody. I'm Professor Rachel Skinner and I'm the Deputy Director of the Wellbeing, Health & Youth NHMRC Centre of Research Excellence in Adolescent Health, and I'm very pleased to be hosting this webinar this week while Kate [Steinbeck] is away on leave. We've got a very interesting presentation for you, and I note that we have quite a number of audience members already online, so I might just get started.

Rachel Skinner: [00:00:58] First of all, I want to acknowledge the funding support that we have received for the establishment of our Centre of Research Excellence, Wellbeing, Health & Youth, and there are all our funders on the screen. And before we start, I'd like to acknowledge the traditional owners of country throughout Australia and recognise their continuing connection to land, waters and cultures. We pay our respects to their elders past, present and emerging.

Rachel Skinner: [00:01:37] Now, just letting people know who may not be aware that the WH&Y Community of Practice is a place you can go to where researchers, clinicians, policy makers and young people come together to share ideas and exchange information, and there you can find resources and publications of interest that we post there of relevance to youth health and wellbeing, and also all of our past webinars are on this site. So, please, anybody who hasn't had a look, go there and see what is there of interest, there's a lot there. 

Rachel Skinner: [00:02:22] Just a bit of housekeeping. If you'd like to make any comments, just put them into that chat box at the bottom right-hand section of your screen. Also, if you want to pose a question to the speaker, you can put it in there and we will field the questions and have a Q&A at about 12.45pm. Your microphone will be muted and your video will be switched off throughout, so just communicate through that chat function. 

Rachel Skinner:[00:03:05] I'd now like to introduce Dr. Stephanie Partridge. Stephanie is a dietitian and senior research fellow at the School of Health Sciences at the University of Sydney, and her research is focused on improving nutrition and physical activity behaviours in young people using digital technology. I'm now going to hand it over to Stephanie. 

Stephanie Partridge: [00:03:29] Thank you so much, Rachel, and thank you to the WH&Y for inviting me to present today. I'm really excited to be here. I'd also like to acknowledge the traditional owners of the land that I'm presenting on today, which is the Gadigal People, and pay my respects to elders past, present and emerging.

Stephanie Partridge: [00:03:50] Now, I usually start my talks going into some negative things around health behaviours, but I thought I'd start off this webinar with some positive news. I really like this quote that was in one of the World Health Organization reports, which is that young people are not 'beings in becoming' but rather are 'the citizens of today' with the right to be respected and heard during their teenage years, and then during that transition into adulthood. And I think this has been exemplified lately in the digital space, particularly with these two examples. Here's an example of a news site run on Instagram by young people. I heard about this news site recently when we were doing some focus groups with young people.They're able to consume news just in a few Instagram tiles and find out the latest that's happening, I guess with the COVID pandemic and other news that's relevant to young people. And I guess this other news story on the right- hand side really made my day on Friday. I had been using this website to get statistics on the COVID 19 pandemic and vaccine rates, and it was run by three teenagers from Melbourne and they were able to identify themselves after they got their first vaccine shot on Friday. So I thought that was a really good news story for young people. 

Stephanie Partridge: [00:05:06] Today, I'll take you through my research, which is focused mostly on obesity prevention in young people using digital technologies. I will briefly go over what we know about the digital environment, touch on some risk factors for Australian young people, go over the overweight and obesity rates for young people in New South Wales, briefly go over what we know about the National Obesity Strategy and the consultation that's underway with that at the moment. I'll also talk you through some evaluation that we've done around the current overweight and obesity prevention and weight-management strategies for adolescents in New South Wales. I'll take you through the two digital health studies that we're currently running and, if I have time, I'll briefly touch on some of the work that we're doing in the online food delivery space. 

Stephanie Partridge: [00:05:57] I guess our digital environment is becoming more and more a part of our everyday life and over the last few decades, but more so really over the last two years during the Covid-19 pandemic, we've really become reliant on digital environments and digital services to help keep our lives going. And it is the environment, both in utero and throughout life, which determines whether an individual's genetic predisposition to obesity will manifest or not. 

Stephanie Partridge: [00:06:28] I really like this diagram that was published in the Medical Journal of Australia in 20018. It really gives a good oversight of all the different influences determining whether someone will have an energy imbalance and then potentially develop obesity. And we know from the emerging research that it's definitely not a lack of willpower that we're seeing in the population, there are all these external influences, which are increasing the overweight and obesity that we are seeing. And I guess the area that I'm particularly interested in is around societal and political influences, particularly the media, public health and practices as well as social norms and social media. 

Stephanie Partridge:[00:07:19] Looking at our digital environment, this data is from the e-Safety Commission, which was a survey done about the digital lives of Australian teenagers published around this time last year. I think the data was collected pre-pandemic. So, excluding virtual learning and online learning, young people are spending roughly 14 hours a week online, nine out of 10 are going online to research, to watch videos, chat with friends and they're using upwards of four social media services. At the time, the most popular ones were YouTube and Instagram, and Tick-Tock was on the rise, and I wouldn't be surprised if Tick-Tock has now come up into that top two position. They are spending a lot of time on social media, and then by the time they're 16 years of age, over 80 percent of young people in Australia have access to a debit card in their name. So they are becoming consumers and they have the opportunity to purchase products and services online as well. 

Stephanie Partridge: [00:08:22] And then this is what they're exposed to online. From our recent cross-sectional study with over 300 young people in Australia, this was the top influencer that they reported following here, which is Chloë Ting. They're being shown this against the ideal body image and potentially purchasing workout videos from these influencers. They're being advertised to by big global companies such as food delivery services, who have a lot of money to be able to get big celebrities to help promote their services. They're being exposed to documentaries with What the Health being another one that was reported as being really popular on our cross-sectional survey, so getting a very biased view of health and health issues across the globe. And then when they tune in and watch the Olympics, they're seeing great displays of athleticism and strength and power and then the advertising that they're seeing with that is from Cadbury and McDonald's. So I guess it's becoming a very complex space online and this is really becoming our cultural e-wallpaper. Traditionally, advertising would usually be at the bus stop or on the train station as a young person's coming home from school, but with spending less time out and about and more time at home, we're seeing a lot more advertising online. And here's another example of Michael Klin, who was a major sponsor, with McDonald's for the Olympics. And as you can see here, it was McDelivery. So, again, promoting their home delivery service and increasing the accessibility to junk food to young people.

Stephanie Partridge: [00:10:07] I think this next statistic was most concerning to me, which is from a report on the Human Rights website of Australia, which shows that it's estimated that by a child's 13th birthday, advertisers will have gathered an average of 72 million data points about them. So by the time they enter that critical period of high school, they're really an advertiser's dream because they already know so much about them from all of the different devices that we have. 

Stephanie Partridge: [00:10:37] It's really no wonder that we're seeing these increasing risk factors for overweight and obesity within this population and other populations in Australia. The data I'm presenting here is from the Australian Health Survey in 2011 and 2012. This data is now over a decade old, so it's likely that these numbers are potentially higher. But over 40 percent of energy intake for adolescents is coming from discretionary foods, junk foods as well as sugar-sweetened beverages. And only one in eight meet physical activity targets and less than one percent of adolescents are eating enough vegetables. And we know that 70 percent of preventable adult deaths from chronic diseases are linked to risk factors that start in adolescence. It's no wonder that we're seeing increasing rates of overweight and obesity within these populations. 

Stephanie Partridge: [00:11:31] This is data from the New South Wales Students Health Behaviours Survey, which was last collected in 2017, a bit outdated as well, but as you can see with the blue line, with young people from 12 to 17 years, the overweight and obesity rates are plateauing but when you break it down by young people who are 12 to 15 years, we're seeing a slight decrease. But concerningly for older adolescents, 16 and 17 years, we are seeing an increase in the incidence of obesity. We can hypothesise that's because there has been a large investment in prevention and management of childhood obesity, but we haven't seen that same investment in the adolescent population.

Stephanie Partridge: [00:12:15] And this is some of the latest data from the New South Wales Population Health Survey looking at young people five to 16 years and then again 16 to 24 years. The latest data that we have from 2019 shows that 23 percent of young people, five to 16 years old, were overweight or had obesity. And then this increases substantially in that 16 to 24 year age group where we're seeing nearly 32 percent of young people being overweight or obese. And we know that the young adult time period is the steepest trajectory of weight gain than any other time during adulthood. And actually, the national data paints a bit of a different picture, it shows a higher rate, so the data that we have from the National Health Survey in 2017 and 2018 shows 41 percent of young people aged 15 to 20 years at risk of being overweight and obese. And we know from research from the University of Sydney, as well as other institutions, that the life-long trajectory of obesity is difficult to reverse and does result in poorer health outcomes. And there was recently a study from the US, which was a 24-year prospective cohort study, and it found that regardless of adult BMI, if a young person had a higher BMI during adolescence they had a higher likelihood of a premature heart attack. And we also know that obesity can negatively impact on quality of life, and the effects are greater in adolescents than at any other time during childhood. 

Stephanie Partridge: [00:13:53] It’s really welcome news that the Federal Government has invested in developing a National Obesity Strategy. This strategy has been out for consultation with the community and now they will be doing I think I read it on the website in the next month or two, another consultation with a draft strategy. But I thought I'd just take you through some of the findings that they had from the first consultation. They consulted with over 620 people across Australia using community forums as well as community discussions and a webinar, and they also received responses from nearly 1,500 people, individuals and organisations. And it was really positive within this strategy that they did identify young people as a priority group. And they consulted with the Consumer Health Forum of Australia, and they engaged with seven young people through focus groups. They were a bit older, between 21 and 26, but they did participate in some long focus groups. And these were the core things that emerged from these consultations. It's really positive that there was a strong emphasis on prevention to achieve population-level change. There was a strong theme of a systems approach, particularly addressing the food systems as being a first priority. There needs to be a strong focus on equity, which is really important to not exacerbate any further inequalities, particularly in priority population groups, with one of those being young people. And there needs to be sustained and collective action. And it is really important that  action goes beyond a political cycle. 

Stephanie Partridge: [00:15:37] I thought I'd just briefly take you through what young people reported within this consultation and what their thoughts were on what needs to be included in a national approach. It was good to see that it had been noted that there was a strong focus on younger children in current strategies and that there were gaps in strategies for older children - it's good that that was recognised within this consultation. And I think some other really important points came out of this consultation. Young people noted that if they are living on a Centrelink payment, it's really not possible to pay for gym memberships and sports fees. So there really does need to be alternate ways for young people to be physically active within the community. They suggested developing targeted programs to continue the participation of sport and exercise beyond high school and into TAFE and university. There's a need to invest in low- or no-cost programs relating to improving cooking skills with a particular focus on schools and low-income groups. I think, interestingly, they said there needs to be improved referral pathways for young people with mental health. I think it's really important that it is emerging that there needs to be more holistic approaches to health services for young people incorporating mental health as a focus. There needs to be a focus on the mental health of young people in all of the programs and interventions. We need to ensure that information and programs are tailored to the needs of young people in partnership with them. And we really need to more clearly articulate the strategies and links between the environment and sustainability. So young people are obviously really interested in this space and that needs to be considered in the strategy. 

Stephanie Partridge: [00:17:28] Next, I thought I'd take you through some of the current strategies that are happening in New South Wales. We've done a review, where we've evaluated and identified all the strategies that are relevant to adolescents and then applied best practice recommendations. Obesity prevention and weight management are mainly the responsibility of state and territory governments, and through federally funded primary health-care networks. It's really welcome that there will potentially be a national strategy for obesity, because at the moment it is very different between all of the different states, and it often hinders our approach because of the lack of coordination across different sectors. In New South Wales, reducing overweight and obesity rates have really been focused on five to 16 year olds. So this has been a key priority of the NSW Government over the last decade, and that was identified in the New South Wales Healthy Eating and Active Living Strategy, which ended in 2018, and it's now being recognised in the New South Wales Youth Health Framework from 2017-2024.

Stephanie Partridge: [00:18:42] A piece of work that we've done recently is comparing all of the current government-led obesity prevention and management initiatives, guidelines and policies, which I'll term strategies moving forward for adolescents in New South Wales against best practice recommendations. I put all of the best practice recommendations from key documents, some of them are pictured here, but not all of them. Key documents include policy frameworks like the New South Wales Youth Health Framework, the National Action Plan for the Health of Children and Young People, the National Strategic Framework for Chronic Conditions, as well as the data we had from the National Consultation Report for the Obesity Strategy. We also used key evidence reviews in the Australian context for adolescents.

Stephanie Partridge: [00:19:37] We identified that there are currently 42 strategies, from really small things up to big statewide guidelines and policies. SIxteen were operating in metropolitan areas, there were 11 regional initiatives, nine state-wide initiatives, two state-wide guidelines, and five policy directives. Ten initiatives were from primary health-care networks, we identified four secondary prevention weight-management services specifically for adolescents, and five tertiary prevention weight management initiatives. Eight of the nine services were located within metropolitan Sydney and only one was located outside of that, and that was in the Hunter New England area. And there were publicly available nutrition and dietetics services available at 11 locations, and ten of those were through Headspace services that were scattered across the state, and a lot of those were in regional areas, which was encouraging. And there were three high-school programs, and two online or telehealth strategies. 

Stephanie Partridge: [00:20:47] We identified best practice domains from those documents that I mentioned before for obesity prevention and weight management, specifically for adolescents. So these were the domains that we recognise: adolescents need to be supported to optimise their health, they should have accessible health services, the health system needs to respond to their needs, they need supportive environments, there needs to be a strong focus on monitoring and evaluation of all of the different strategies, and there needs to be a strong focus on health equity. 

Stephanie Partridge: [00:21:19] I'll take you through some of the gaps that we identified, but I should also mention that across all of the different domains we identified there was action happening, which is really encouraging to see. But I think there are definite ways to improve this for young people. The first one was that adolescents are supported to optimise their health. One of the recommendations was public education campaigns on nutrition and physical activity, and we didn't identify any that were specific to young people. A lot of the campaigns that are available are usually targeted at younger families with younger children, not specifically to young people. We found limited online access to youth-specific and trustworthy health information. A lot of the information that is online is usually written about young people not written for them. And this is actually confirmed - we just finished a series of focus groups with young people and a lot of them do try to go to government-based websites because they know that they're reputable, but when they get there, they find that the information really isn't relevant to them, therefore they're forced to go elsewhere to access information. We found that there was limited evidence that adolescents who are at risk are actually directed to opportunities for health promotion and early intervention. So there is a policy within NSW that young people should have their height and weight recorded every time they encounter a NSW public health facility. But it's only a KPI for that number to be recorded, they don't have to be referred. So within public services across New South Wales, there is a guideline that they can actually be provided with some intervention related to their diet or nutrition behaviours. But we're really identifying that they're not being referred on if they've been identified as high risk. And then a lot of the public health services that are available are mostly only available to young people after comorbidities are established. So with a lot of those weight management clinics that are available, in order to be able to access the service, people have to have an established comorbidity such as insulin resistance or hypertension, for example. 

Stephanie Partridge:[00:23:37] Looking at accessible health services, there was limited secondary and tertiary services for adolescents, particularly those who are 16 to 17 years. Some of the services stopped at 15 years, and as I mentioned, they are all clustered within the metropolitan areas. And there was only one service in the Hunter New England area, but there were no other services outside of that. And we know during Covid-19 that a lot of services potentially did offer some telehealth during that time, but that information wasn't available online. There's also limited access to specialists and counselling services related to this. So young people who are above 16 years within New South Wales can access the Get Healthy Service, which is a telephone counselling service, but there's really no other youth-specific services that are available. And there's really no promotion to increase the uptake of programs for adolescents. This is one of the recommendations that we identified. So only one of the services that we found actually had an Instagram page or any sort of presence online that described their service to young people. And we know from the New South Wales Youth Health Framework that young people really do want to know about health services and read about them online before they attend. Also, the health system needs to respond to the needs of young people. We did identify limited consumer participation and community engagement. The New South Wales Youth Health Framework did consult and engage young people in the design of that Framework, which was very encouraging, but we didn't find evidence of that with many of the other services and strategies that were available. 

Stephanie Partridge:[00:25:20] As well, we identified limited holistic support to optimise quality of life. So these can be things like community gardens, which as we've seen from the National Obesity Consultation, young people are very engaged around sustainability and climate change. So initiatives like this potentially would have a really good uptake from young people. We also saw gaps across the other domains, so supportive environments, there was limited evidence of physical education and nutrition education interventions in schools. We also saw that there are regulations around the food and drink that needs to be sold at New South Wales health facilities, but these hadn't been extended to other areas where we know there's a higher proportion of young people attending like recreation facilities and sporting clubs. There was really limited evidence of any sort of evaluation or monitoring, particularly of long-term evaluation, which is really critical to understand the sustainability of these strategies and if they're having the effect that we intend them to have. And I think most concernly, there was a real lack of priority on the priority populations. So only a handful of the 41 strategies specifically mentioned targeting young people who are potentially more at risk than other young people. 

Stephanie Partridge: [00:26:45] I'll now quickly take you through some of the digital health studies that we're currently undertaking to hopefully address some of the gaps within the system, such as young people not having access to trustworthy and youth friendly information online, and also providing young people in regional areas the opportunity to access prevention services. 

Stephanie Partridge:[00:27:09] One of the studies that we're currently working on is the Textbites Study. This is a text message intervention that has been developed with young people. We know that over 90 percent of young people in Australia own a mobile phone, they can send upwards of 50 text messages per day and these do remain the primary form of communication for young people. And we know that text message programs for chronic disease are effective, and we've seen that in people with heart disease, as well as people with type-two diabetes. These kinds of programs offer flexible delivery, they're simple and they're scalable. Most mobile phones can receive them and they don't cost anything to receive, and you don't require an Internet connection. I think it's really important to consider this within the digital health space, because obviously we often think of the latest technologies and advancements, but for young people we really need technology that's not going to exacerbate that digital divide. There was a recent statistic that came up during the pandemic that I think was 68 percent of young people from low socio-economic backgrounds had the Internet at home, whereas 91 percent of young people from higher socio-economic backgrounds had the Internet at home. So if we're developing really complex digital interventions that require the use of a lot of data, it potentially won't be equitable to all young people, and interventions like this can easily be scaled at a population level. 

Stephanie Partridge: [00:28:41] We've co-designed this program with 25 young people, as well as 15 health professionals, parents and teachers. And we also employed a young person as a research assistant to work with us during the development process of this study. We developed a bank of 107 messages, and this is a program targeted at young people who are at risk of obesity so they are above the healthy weight but they don't have any other comorbidities. It's focused on building on behaviour change, improving nutrition and physical activity behaviours, as well as embedding a focus on mental health and wellbeing and sleep, and similar to what they found in the National Obesity Strategy, we also weaved in sustainability and indigenous issues related to that because we knew that those issues are really important to young people.

Stephanie Partridge: [00:29:31] We have a message bank now with more than 100 messages relating to the four different behaviours that I mentioned and six of the messages encourage young people to text back and communicate with a health counsellor, so that's me at the other of the line talking to young people. They can either have a phone call with me or they can text back and we can communicate and I can answer any of the questions that they have and support them that way. Another 25 percent of messages encourage two-way communications, a quiz or a short question, and some of our messages do differ based on age, some messages are more targeted at a younger age group and then other messages are targeted at a bit of an older age group. And we deliver this program through a commercial platform that we can easily monitor on a Web browser and respond to the different messages every day. 

Stephanie Partridge:[00:30:30] We're currently testing this program in a randomised control trial. We're recruiting 150 young people. I hoped by this date I would have more data to share with you, but we have had some challenges, which I'll take you through in a moment. We've recruited about one third of all participants so far. So 75 would be randomised to the intervention group and another 75 to the control group. And then we follow them up at six months and then again 12 months. And the young people who are randomised to the control group will have the opportunity to receive the program at the end of the 12 months. Our primary outcome is BMI score and our secondary outcomes are related to diet, physical activity, sleep quality, as well as depression risk and eating disorder risk. We screen for depression risk and eating disorders, which I will take you through later.

Stephanie Partridge: [00:31:05] We're about one-third of the way through our recruitment. We started recruitment at the beginning of last year before the Covid 19 pandemic. At that time, I guess digital consent was not as prolific as it is now, so that's one of the really positive things about the pandemic that it has sort of pushed that switch. At that time we were still capturing young people coming to sign the consent form with their parents and as well we were capturing their measured height and weight. And so we had to change our approach when the pandemic hit and it's actually been a really positive aspect because we were able to offer this service to a lot more people. We do screen for eating disorders and depression risk because obviously these are two big health issues within these populations. But I guess one of the challenges that we had was that there wasn't really a screening tool developed for this population or the tools that have been developed for young people with cut-off points who were well above the healthy weight. So I think there's a lot more to explore within this space, particularly as a community intervention. I guess, more intensive interventions, potentially have a medical practitioner or someone on site, so if someone screens high they can easily be seen by that person and then cleared or referred on. But within our setting we have to screen them and then we send them back out to the community to deal with this with their parents, see a GP and get clearance to come back. So I guess that's an area that does require a lot more research within this space. 

Stephanie Partridge: [00:33:37] So far, we've had over 1,200 EOIs (Expressions of Interest) for this study and one-third of them have been eligible, so young people who are a bit more at risk. I think that number has really shown us that there is a demand for these kinds of services for young people. We didn't expect to have that many EOIs. But from all of the young people that have been eligible, getting them onboard with the study has been really challenging. So as soon they find out that there's a phone call with us to do the screening, many of them drop off. And maybe it's because it's a bit too difficult, you know, it's burdensome or they're a bit worried about what we're going to ask them. But there is that challenge. So I guess that's something that we're looking to explore in the next study that we do and hopefully have a more streamlined onboarding process for young people. 

Stephanie Partridge: [00:34:31] Some of the positives of the study so far is that we've had a really high retention rate of the young people that we have, I think we have only lost around two people so far. We're getting really positive qualitative feedback during the interviews that Rebecca's doing with the study. And as well, there's been different levels of engagement. So some young people are really engaged with the messages, which is great, but other young people are more passive consumers. We're really understanding who those young people are and how we can best support them. 

Stephanie Partridge: [00:35:04] I thought I'd share with you some of the things that we've received back. We don't encourage any photos to come back, but young people can send them back. Here's some examples. Some of the messages are focused on time management, for example, and we asked them for the best time-management strategies that they're using, maybe for their study or to balance their work and social life. And some young people have sent back photos, so that was really exciting to see photos that they're sending back of some of the healthy snacks that they've been having during their study breaks and different things like that. And this was a lovely quote that we received from a young person who participated in the intervention group. He was saying that he hoped to see the program becoming mainstream for all young people across Australia, to be as healthy and as happy as they can be. We're really hoping to have the recruitment complete for this study by the end of the year and then be able to share data around the findings for the Textbites Study next year. 

Stephanie Partridge: [00:36:04] But this has really led to our latest study, which is building on a lot of the lessons that we've learned from the Textbites interventions so far. As we've seen, there's been a strong demand for this program with the increased amount of EOIs. I guess young people really want to onboard themselves into the study and consent themselves. So that's something we're going to explore with this study and it's going to be open to all young people with the primary outcome being improving physical activity and nutrition. And I guess with this study as well, we have the opportunity to keep it simple in terms of two-way communication through text message. But we also have the option to include picture messages, as well as include videos within the program. This program will have young people at the centre using frameworks such as the World Health Organization Digital Health Framework for Young People. We're also really excited that we've nearly finished recruitment for our Youth Advisory Group, which will support this Healthy Me study so they'll be the driving force behind all of the content that we put in the program and providing a lot of advice and co-design of the new message bank that we develop for the study so if you know young people, the Youth Advisory Group applications close tomorrow and I can share with you the link. They'll be recruiting 12 young people and they'll be paid for their time and they'll be part of a year-long program. We're also going to evaluate that Youth Advisory Group as well, to really understand what young people got out of the experience as obviously we will develop a really positive intervention and we see positive health outcomes in the intervention. But we also want to see positive outcomes for young people in terms of improved leadership skills, improved confidence and improved knowledge around research as well. So for this study were looking to recruit 330 young people with the primary outcomes being physical activity, and vegetable intake as the other co-primary outcome.

Stephanie Partridge: [00:38:14] I think I have five minutes left so I will briefly just touch on the work that we're doing in the online food delivery space. Obviously creating a supportive digital environment so young people can access health-care support is really important. But it's also important to note that in this space there are so many commercial influencers coming in with a lot of money to be able to advertise to young people. So this is a space we were particularly interested in last year. 

Stephanie Partridge:[00:38:42] Briefly, unhealthy diets are really well established in adolescence. And as I mentioned before, this increases the rates of obesity, and over 60 percent of young people with overweight or obesity actually have at least one risk factor for cardiovascular disease and 20 percent have over two or more. And we know that data from the Cardia Study, which had over 3,000 young adults, found that a healthy diet during young adulthood is strongly associated with lower cardiovascular risk in middle age.To implement effective preventative measures, we need to really understand the environmental influences of food choice on young people. This was a really interesting photo series that was published, I think, in Time Magazine, which showed young people's diets from all over the world. There wasn't anyone from Australia, but I guess the similar dietary pattern that we have is that of America. And this just shows that young people in Australia and in America are really exposed to a lot of fast food. Obviously our food environment is defined as the collective physical, economic policy and social cultural surroundings that influence our food choices. Here's an example of this, it's a photo I took at the University of Sydney of a medical student event. This was the food that they were being provided with, pizzas and Coke. Sometimes if that's the only food that is available, it's the food you're going to eat because it's the easiest choice. 

Stephanie Partridge: [00:40:14] Our digital food environment is the online setting which influences people's food choice and their behaviour, and that can include social media as well as the digital health promotion interventions that I mentioned before. But it also includes digital food marketing and online food retail. If you're living in a metropolitan area, you might have used an online food delivery service during the pandemic. Now obviously they were able to offer a really important service during the pandemic - you were able to order food on your phone, and that is then sent to the restaurant or the fast food outlet of your choice, and then a freelance courier will pick up your food and drop it off to your home, you don't even have to get off the couch really. In Australia, there are three main operators and they have an estimated 9-16,000 food outlet partners. But some of the data that we've captured recently is showing that that's now at nearly 37,000 unique food outlet partners, because a lot of food outlets were forced to join these services during the pandemic to be able to stay in business. And they're increasingly operating out of major capital cities, but they're really trying to expand into regional areas. And it is really a booming global industry. 

Stephanie Partridge: [00:41:39] As I mentioned before, obviously online advertising is huge and here are just some of the examples of the advertising of these services that is happening, particularly during the pandemic. Here you can see they're using KFC buckets to measure out the 1.5m social distancing rule. and they're offering things like free delivery during the pandemic. Even before the pandemic, this photo here was something that I received at Central Station in Sydney as I was getting the bus home one afternoon and there were a lot of university and high school students. They are paying people to hand out these vouchers to get people to sign up. Once they sign up they are a customer and they can be sent advertising. So there's so many different strategies to get young people on board with these services. And of course now they've moved into alcohol delivery, which is another major issue to keep an eye on, particularly for young people. And young people are the highest users of these services from the data that we have available at the moment. We know that young people who use these services tend to have a higher BMI as well as higher levels of education and income, and they may consume fast food and sugary drinks more frequently. 

Stephanie Partridge:[00:42:56] So just quickly, we have done three pieces of work in this space. We've looked at a multi-country study where we've looked at the healthiness of food outlets and the geographical reach of the food outlets; we've looked at the nutritional quality of many items; and we've also done a study where we've looked at the advertising and promotion of these services on Instagram. This is what we found from our study in Sydney and in Auckland. The most popular food outlets on these services are actually fast food chains, McDonald's and KFC, and they have a lot of buy in, a lot of sway with these delivery companies because they can offer so many deals for consumers, free delivery etc. And it just really extends the reach of where that food outlet is because they can now deliver food three to five kilometers away, and you might have driven or walked there before, but now you can easily get it delivered. And a lot of the most popular menu items are actually unhealthy foods. These are the foods that people are seeing first when they look at these platforms. 

Stephanie Partridge:[00:44:04] A second study we did was looking at independent food outlets, things like a kebab shop, a fish and chip shop, and we looked at the marketing strategies that they use within the app to promote food products. We found that a lot more of the unhealthy foods were the foods that you'd see first when you look at that food outlet compared to a healthier food. Unhealthy foods were also more likely to have a photo and they were also more likely to be part of the family meal deal. 

Stephanie Partridge: [00:44:33] And in the third study that we've done so far, we've looked at the advertising and promotion of these services on Instagram, Instagram being a very popular social media site for young people. And particularly we looked at during the Covid-19 pandemic and we found that one third of all of the posts in 2020 - we looked at three different countries and three different services within those countries so there was was a total of nine accounts that we looked at - and a lot of the posts we're referring to Covid-19 and of those posts, a lot of the foods that were pictured, over 85 percent, were actually discretionary or junk food items. So it was associated with the pandemic and then promoting unhealthy foods as well. They use strategies such as combating the pandemic, appropriating front line workers and providing them with vouchers, which is fine but we know a lot of the foods that they have available are unhealthy foods. As mentioned before, they're using strategies around selling social distancing and they're helping to accelerate digitalisation. 

Stephanie Partridge: [00:45:44] Just wrapping everything up, I guess there is digital disruption and acceleration occurring. We really need to make sure that we don't exacerbate any of the digital divide, any of the priority population groups, particularly young people. We need to understand the effectiveness of simple digital interventions with a focus on implementation and scale up. It's really great to understand all of the latest apps and technologies, but we really need to get them out there and get young people involved and support them to improve their health behaviours. Our findings suggest that online food delivery might facilitate the purchase of poor nutritional quality foods, so junk foods. And this area really does require a serious and immediate consideration in public health strategies and policies.

Stephanie Partridge: [00:46:33] I'd just like to thank all the different people that have been involved in the studies that I've mentioned in this webinar. So thank you. 

Rachel Skinner: [00:46:51] Thank you, Stephanie. We do have some questions. Not sure which study this was referring to, but the question's from Christine: "Are young people [who are] diagnosed with type-two diabetes eligible to participate in your study?" 

Stephanie Partridge: [00:47:19] No, so we are supporting young people before they have established any comorbidities, because we know that there are services available for young people. They do require obviously more specialised care than what this program offers. This program is a population program to support young people in positive small behaviour change, whereas a condition like that does require more management. So they are not eligible. 

Rachel Skinner: [00:47:46] And this one: "Thanks for the great talk. Of the 107 messages, for example physical activity, can you please give an example of what the message was in relation to that?" 

Stephanie Partridge:: [00:48:04] Yes. Here’s one referring to the Active Kids's Voucher. So that message often gets a lot of attention, some young people don't know that they're actually eligible for it, so that gives them and their family a small voucher to spend on sporting equipment or fees for the sport they want to participate in. Other ones are around podcasts for things that they can do, if they want to go for a walk and what they can listen to. Or sometimes we ask them to text back what they are listening to and I've actually heard a few really interesting podcasts that I hadn't heard of before. Or going to the park for a walk. I was talking to a young guy in the study the other day and he said he got that message and it was quite a simple message, but he was like, oh, it was so great, I went and got my basketball and I called up my friend and we both headed down to the park and I haven't played basketball in a while so it's a really good reminder for me to get out of the house and stop studying and go play basketball. So they can seem quite simple but it's really interesting to see that they are having a positive effect on young people.

Rachel Skinner: [00:49:19] This question is related, it's about how you manage and automate the sending of text messages. How do you do that? And do you have to be online all the time? 

Stephanie Partridge: [00:49:39] Yes. So we use a commercial program which has a sequencer software, so the messages are all programed within that and all we have to do is once Rebecca enroll's somebody in the study, she just enters their mobile phone and their preferred name into that and then that will feed into the full program of messages that they get. Then they're automatically sent out based on the date that they enroll. And we've scheduled them also to be appropriate for a certain day. So if it's a message around fast food it will go on a weekend or Friday, as opposed to going mid-week when we know most people eat fast food on the weekend. It is all pre-programmed and then in terms of responding to the messages, it's like a Web browser. I'm the person that responds to the messages and monitors that. I actually monitor quite a few different studies, one with women with breast cancer as well, which is quite different. You're getting a lot of different messages back, but it's quite simple. You can respond to them as they come in online. We tell young people that it is monitored all the time, but that you may not be guaranteed a response straight away. Obviously, we have safety protocols in place, but we haven't had any incident. It is quite straightforward. I think it's nice to have a quick chat and a conversation and help someone in that way.

Rachel Skinner: [00:51:04] All right. Thank you. It does sound like it might be quite time consuming, I have to say. 

Stephanie Partridge: [00:51:15] I don't think it's that time consuming. The one I was managing, which was Empower SMS, which was the one for women after breast cancer treatment, that one was actually a bit more active, particularly, I think because a lot of the people write back just thanking you for each of the messages, which was really nice, we didn't have to respond to all of those ones, but a lot of the inbox was people saying ‘thanks, that message made my day’ or ‘I hope you have a nice day, Stephanie’. So it's really nice that they did not associate it with being automated, that they recognised that there was someone behind the messages, which is nice. 

Rachel Skinner: [00:51:55] That must make a big difference. We have a question from Smeeta: "Thank you, Stephanie, for an excellent presentation. How do you see existing programs such as Salsa Youth Voices, programmes that are currently being offered to schools in western Sydney, working with your services and programs? 

Stephanie Partridge: [00:52:17] I think there can't be one program to solve this. We need a collection of different services available. It’s so important to have programs like the Salsa programme in schools, with positive messages where young people can sign up and they can get some support outside of the school setting as well. So I see them hopefully working to really synergise and support each other. Obviously, I know that they both have similar messages around positive behaviours. So you are constantly just reinforcing those messages. And if they're able to get that support at school and then at home and in the community, I think it's very beneficial for young people as well. 

Rachel Skinner: [00:53:01] Excellent. So a couple of other questions, one in relation to the Youth Advisory for Co-Design, how did you go about recruiting and setting that up, we'd be interested to know. 

Stephanie Partridge: [00:53:17] This is through the MRFF (Medical Research Futures Fund) grant that we recently got, which was quite exciting. We have funding within that to be able to pay them for a little bit of their time. We set up an application form and we sent it out to all different networks and we're just sharing it that way and we're asking young people two questions about why do they want to join and then what sort of experience can they bring to that. And that can just be their life experience, we're not expecting them to have a skill set. And then we have a quota where it will be gender balanced, also hoping to get some representation from young people who speak another language at home to get a mix of ethnicity and also people from regional areas. It’s been really exciting to see all the applicants come in and we're going to be going through those tomorrow and then selecting young people. And we already have the Chair recruited for that as well who is someone I've been working with for a little bit. We want to get that established and then to start to work with them to develop the new program.

Rachel Skinner: [00:54:24] Excellent. Great to see that you've got that youth co-deisgn given that you identified a huge gap in the policies and programs with respect to that aspect. So we've got some more questions. “Thanks, Stephanie. Very exciting study. I was wondering what the uptake of the one-on-one chat is with young people.” 

Stephanie Partridge: [00:54:49] They get offered up to six phone calls over the six-month period, so one per month and they get a message every month to remind them that they can just text back and we'll pick a time that suits them. I can do those phone calls with them up until 7pm at night and then on Saturday mornings as well. I think we are getting around probably 50 percent of people taking part in that. And then it's really sporadic how they actually engage with the calls. I don't think I've had anyone do all six of them. And sometimes I get a bit worried, I didn't hear from them, I hope they’re okay. And then they text back and say I had exams or something, I’ve been busy. I hope you're doing okay, Stephanie, which is really nice. I think they want something that is tailored to their life. And they might let me know that they have exams coming up so they're not going to be able to respond or can we push it back two weeks because of what is coming up. Some young people who I've done a few phone calls with, you can maybe sense that it's not really their thing and then they don't respond to the rest and they just enjoy texting back. Whereas other young people are super chatty, some people respond to it, some people don't. But we're capturing the data on the goals that we set during those phone calls and then we'll have all the data on the types. You know, maybe there are certain types of people that prefer this overall. 

Rachel Skinner: [00:56:18] Fantastic. And Louise has asked: "Would you please comment on any social differential in accessing and responding to and being influenced by the messages?”

Stephanie Partridge: [00:56:31] I couldn't give you that information at the moment because I'm only going off their first name in the program and their age. But we will explore that more when we analyse the data. 

Rachel Skinner: [00:56:47] What's your sense or hunch about that? 

Stephanie Partridge: [00:56:50] Well, I am thinking there is quite a variety and I guess I think a lot of potentially older adolescents I'm speaking to during exams,17 or 18 years, they're the ones who are more engaging with the phone calls, whereas the younger ones are a bit more apprehensive about it and more comfortable with the messages. So I guess age is potentially something that's coming up. I'd have to look whether there is anything else later on with the data. 

Rachel Skinner: [00:57:24] Well, hopefully that bodes well for that older adolescent age group, which are the ones that are at risk which you showed us early on. Danielle says: "A wonderful presentation. Could you please confirm the data source and source of information of users of online food service delivery? Will you be unpacking this work further, given the high levels of youth using these services?" 

Stephanie Partridge:[00:57:49] Yes, so the data that we have at the moment, it's only from that one cross-sectional study that was conducted in Perth, which was pre pandemic, to identify who the people are and their behaviours. And then the rest of the data that we know at the moment is from industry reports or consumer organisations like Macquarie Morgan was the one that published some of the data. Rebecca Raeside is working with me. She is doing her PhD in this topic and she's going to be doing an excellent study looking at who are the main users and what are the reasons they are using these services. Are they just receiving food delivery or are they really busy? And what are the factors associated with that? We will definitely be exploring that further and sort of understanding who that population is, particularly as these services grow and try to build their customer base, because we also know that before the latest lockdown in Sydney, UberEats reported that people had returned to normal restaurants or eating out at pre-pandemic levels, but they were still consuming high levels of takeaway food. So obviously it has changed our behaviours during this time and they are probably wanting to retain all of those customers, which is something we'll definitely be exploring in the future.

Rachel Skinner: [00:59:11] From what you've suggested, it indicates that probably there has been an increase over Covid in the consumption of fast food compared to before. 

Stephanie Partridge:[00:59:29] Potentially, but there's also been reports of more home cooking as well. So I guess it would depend, I think there needs to be a little bit more unpacked, I know we have been doing a lot more home cooking, but these services have been available. There are some really good studies coming out in this space. I've seen a lot of multi-country studies that have explored this where their results are coming out. So it would be good to review those when they do publish their findings. 

Rachel Skinner: [00:59:58] Excellent. Well, thank you, Stephanie, that was such a great presentation. We've come right to the end of our time, so really well done. And thanks also to the audience today for all of your great questions. It was an absolutely excellent presentation and all the best for those amazing studies. It's really pleasing to see how you're engaging with young people and really targeting young people for these programs, given the gaps that you've identified and how much they have to gain. So thanks to everyone. We'll see you again for our next webinar, which I don't have the information on yet, but we will get it sent out to you in a forthcoming email.