An early-phase process evaluation of a whole-systems approach to healthy weight among children and families in Wales

Background: Childhood obesity in Wales is a significant public health issue, with prevalence rates particularly high among socioeconomically disadvantaged communities. The Welsh Government has responded to this issue by launching the Healthy Weight: Healthy Wales strategy, which includes the Children and Families Programme. The Children and Families Programme takes a whole-systems approach to increase the proportion of children leaving the school foundation phase (aged between three and seven years) at a healthy weight. This study presents a process evaluation of the early-phase implementation of a childhood obesity-focused evaluation, the Children and Families Programme, across three contrasting localities in Wales: Anglesey, Cardiff, and Merthyr Tydfil. Methods: Thirteen stakeholders involved in the Children and Families Programme were recruited through purposive sampling. The participants represented key roles in public health, dietetics, and community engagement. Semi-structured interviews were co-produced with public health leads and conducted online. Reflexive thematic analysis was used to analyse the interview data. Results: Four key themes were identified: (1) development of the whole-systems approach, (2) partnership working, (3) systemic challenges, and (4) recommendations for future implementation. The findings emphasised the importance of strong leadership, co-production, and cross-sector collaboration. Challenges emerged around system maturity, siloed working, cultural perceptions of weight, and limited time for embedding systemic change. Conclusion: This process evaluation not only highlights the potential of whole-systems approaches in tackling childhood obesity as a complex public health issue, but also underscores the need for time, trust-building, and deeper community engagement. These findings offer actionable guidance for future whole-systems approach initiatives, particularly in the early stages, aimed at reducing health inequalities and improving childhood health outcomes in and beyond Wales.