The effect of a behaviour change intervention on the diets and physical activity levels of women attending Sure Start Children's Centres: results from a complex public health intervention

A Healthy Conversation Skills intervention to support changes to physical activity and dietary behaviours in community-dwelling older adults during the COVID-19 pandemic

AIMS

Physical activity (PA) and nutrition are important determinants of health in late adulthood. However, low levels of PA and poor nutrition are common in older adults and have become more prevalent during the COVID-19 pandemic. We hypothesised that Healthy Conversation Skills could be used to support health behaviour changes beneficial for health in older adults and thus conducted a study nested within the UK Hertfordshire Cohort Study.

METHODS

Between November 2019 and March 2020, 176 participants were visited at home. A trained researcher administered a questionnaire and undertook anthropometric and physical performance tests. A total of 89 participants were randomised to the control group and received a healthy living leaflet; 87 participants in the intervention group were interviewed using Healthy Conversation Skills at the initial visit with follow-up telephone calls at 1, 3, 6 and 9 months. Follow-up at 1 year by postal questionnaire assessed change in PA and diet. In total, 155 participants (79 control and 76 intervention) completed the baseline and 1-year follow-up.

RESULTS

At baseline, median (lower quartile, upper quartile) age (years) was 83.1 (81.5, 85.5) and median PA time (min/day) from walking, cycling and sports was 30.0 (15.0, 60.0). In total, 95% of participants completed the intervention; the total response rate for postal questionnaires was 94%. There were no statistically significant differences in outcomes between the trial arms. In women, there was a tendency for greater increases in diet quality in the intervention group compared to the control group (p = 0.075), while among men, there was a tendency for reduced decline in self-reported physical function in the intervention group compared to the control group (p = 0.081).

CONCLUSION

We have shown that it is viable to utilise Healthy Conversation Skills via telephone to promote healthier lifestyles in older adults. Larger appropriately powered studies to determine the efficacy of such an intervention are now warranted.

Enhancing making every contact count (MECC) training and delivery for the third and social economy (TSE) sector: a strategic behavioural analysis

OBJECTIVE

To enhance Making Every Contact Count (MECC, an opportunistic approach to health promotion), training in the Third and Social Economy (TSE, all groups and organisations primarily working towards social justice, outside of the government or household) by examining the degree to which the behavioural content of MECC training tackled significant factors influencing MECC delivery.

METHODS AND MEASURES

A strategic behavioural analysis design. Semi-structured interviews with service providers (n = 15) and users (n = 5) were coded for barriers and facilitators of MECC delivery using the Theoretical Domains Framework (TDF). Existing MECC training was coded for behaviour change techniques (BCTs) and intervention functions (IFs). The degree to which BCTs and IFs addressed the key TDF domains of influences on MECC delivery in the TSE were examined using prespecified tools.

RESULTS

Seven key TDF domains of influences in MECC delivery were identified. Overall, only 9/31 linked BCTs were utilised within MECC training, with percentage utilisation of relevant BCTs for each domain ranging from 0% to 66.7%. Training adequately addressed 2/7 key domains.

CONCLUSION

The TSE and healthcare share many common key TDF domains, although there are differences in how each are relevant. Limitations and recommendations for MECC training are discussed.

Barriers and facilitators to healthy eating in disadvantaged adults living in the UK: a scoping review

In the UK people living in disadvantaged communities are less likely than those with higher socio-economic status to have a healthy diet. To address this inequality, it is crucial scientists, practitioners and policy makers understand the factors that hinder and assist healthy food choice in these individuals. In this scoping review, we aimed to identify barriers and facilitators to healthy eating among disadvantaged individuals living in the UK. Additionally, we used the Theoretical Domains Framework (TDF) to synthesise results and provide a guide for the development of theory-informed behaviour change interventions. Five databases were searched, (CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science) for articles assessing healthy dietary intake of disadvantaged adults living in the UK. A total of 50 papers (34 quantitative; 16 qualitative) were included in this review. Across all studies we identified 78 barriers and 49 facilitators found to either impede and/or encourage healthy eating. Both barriers and facilitators were more commonly classified under the Environmental, Context and Resources TDF domain, with 74% of studies assessing at least one factor pertaining to this domain. Results thus indicate that context related factors such as high cost and accessibility of healthy food, rather than personal factors, such as lack of efficiency in healthy lifestyle drive unhealthy eating in disadvantaged individuals in the UK. We discuss how such factors are largely overlooked in current interventions and propose that more effort should be directed towards implementing interventions that specifically target infrastructures rather than individuals.

Establishing an updated consensus on the conceptual and operational definitions of Making Every Contact Count (MECC) across experts within research and practice: an international Delphi Study

OBJECTIVES

The Making Every Contact Count (MECC) initiative is broadly defined as an opportunistic approach to prevention by making use of the thousands of conversations service providers have with service users every day. However, since its conception, the application of MECC has diverged and developed considerably. Thus, the current study aimed to revise the definition according to current research and practice to better describe what is and is not included.

STUDY DESIGN

A consensus building classic Delphi methodology, completed by an expert panel.

METHODS

Round 1 asked open questions around the definition of MECC. Content analysis of round 1 identified statements that were rated for agreement in round 2. Statements achieving ≥80% agreement were included in a short, long, or operational definition of MECC that were rated for agreement in round 3 (the minimum number required). An agreement of ≥80% indicated consensus.

RESULTS

Forty out of 100 contacted experts completed three rounds. Experts in practice and research were recruited internationally although most were from England. From round 1, 274 statements were generated, of which 96 achieved consensus and were included within round 3. The short and long definition received consensus in round 3, the operational definition required four rounds to reach consensus.

CONCLUSIONS

MECC is a person-centred approach to health behaviour change that, provided an individual possesses the relevant skills, can be delivered by anyone and anywhere. The distinguishing feature of MECC is not in its duration, target behaviour, or conditions for delivery, but rather in the approach taken and the mechanisms applied to conversations. Implications for research and practice are discussed, and the limits for applicability acknowledged.

Growth phase estimation for abundant bacterial populations sampled longitudinally from human stool metagenomes

Longitudinal sampling of the stool has yielded important insights into the ecological dynamics of the human gut microbiome. However, human stool samples are available approximately once per day, while commensal population doubling times are likely on the order of minutes-to-hours. Despite this mismatch in timescales, much of the prior work on human gut microbiome time series modeling has assumed that day-to-day fluctuations in taxon abundances are related to population growth or death rates, which is likely not the case. Here, we propose an alternative model of the human gut as a stationary system, where population dynamics occur internally and the bacterial population sizes measured in a bolus of stool represent a steady-state endpoint of these dynamics. We formalize this idea as stochastic logistic growth. We show how this model provides a path toward estimating the growth phases of gut bacterial populations in situ. We validate our model predictions using an in vitro Escherichia coli growth experiment. Finally, we show how this method can be applied to densely-sampled human stool metagenomic time series data. We discuss how these growth phase estimates may be used to better inform metabolic modeling in flow-through ecosystems, like animal guts or industrial bioreactors.

How useful is the Making Every Contact Count Healthy Conversation Skills approach for supporting people with musculoskeletal conditions?

Aim

To explore the current use and perceptions of the Wessex model of Making Every Contact Count (MECC), incorporating Healthy Conversation Skills (HCS), focussing specifically on physiotherapists supporting people living with musculoskeletal conditions.

Methods

A mixed method, sequential explanatory design was employed. This article reports the first phase of the study, in which an online questionnaire was administered, consisting of items relating to perceived acceptability, appropriateness, feasibility, sustainability, and uptake of MECC HCS. Barriers and facilitators to MECC HCS delivery were additionally explored and mapped to the Theoretical Domains Framework.

Results

Seventy-one professionals responded, including 15 physiotherapists supporting people with MSK conditions. Across professional groups, MECC HCS was found to be highly acceptable, appropriate, and feasible. A significant interaction between perceived sustainability of MECC HCS and the location in which professionals worked was observed. Physiotherapists reported using their MECC HCS at least daily; however, there were discrepancies between the number of their patients they believed could benefit from behaviour change intervention, and the number to whom they reported actually delivering MECC HCS. Perceived barriers and facilitators to MECC HCS implementation mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework.

Conclusions

The Wessex model of MECC is a promising brief or very brief intervention for physiotherapists supporting individuals with musculoskeletal conditions. Barriers associated with the sustainability of the intervention within organisations must be addressed in order to enhance future implementation. Further rollout of this intervention may be beneficial for meeting the goals of the NHS and Public Health England in prevention of chronic MSK conditions and promotion of musculoskeletal health.

Making Every Contact Count and Healthy Conversation Skills as very brief or brief behaviour change interventions: a scoping review

Aim

To identify and map the available evidence regarding the implementation of Making Every Contact Count and/or Healthy Conversation Skills for both staff delivering and service users receiving the brief or very brief intervention/s.

Methods

A scoping review approach was used to rapidly map and provide an overview of the relevant literature, identify gaps in knowledge, and inform further, related research. Articles investigating experiences, perceptions and impact of Making Every Contact Count and/or Healthy Conversation Skills were included. Quantitative, qualitative, and mixed methods studies were eligible for inclusion, as were reviews and reports.

Results

Twenty-two articles were included in total. Healthy Conversation Skills training was found to be acceptable, and had a positive impact on staff confidence and competence in supporting behaviour change, across studies. Some positive effects of intervention exposure on the sedentary behaviour and dietary quality of service users were evidenced. Changes in confidence following Making Every Contact Count training were varied, as was perceived acceptability of the intervention for staff. Two studies highlighted positive impacts of the intervention on service user health; however, statistical significance was not reported. The perceived barriers and facilitators of implementation for both interventions mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework.

Conclusion

Healthy Conversation Skills is an acceptable and effective behaviour change intervention that could provide a consistent approach to Making Every Contact Count training and evaluation. Further research is warranted to evaluate this approach for more staff and service user groups.

Young women's and midwives' perspectives on improving nutritional support in pregnancy: The babies, eating, and LifestyLe in adolescence (BELLA) study

RATIONALE

Teenage pregnancy has a high risk of poor outcomes for both mother and baby. Teenage girls have the poorest diets of any population group in the UK, which compounds the risk of poor pregnancy outcomes. Pregnant teenagers trust advice from their midwives, but midwives feel they do not have time, confidence, or knowledge to discuss nutrition.

OBJECTIVE

This study examined how the relationship between pregnant teenagers and their midwives could be utilised to deliver support to improve diet quality.

METHOD

Qualitative interviews were conducted across three urban sites in the UK: Manchester, Doncaster, and Southampton with adolescent mothers and their midwives regarding diet and lifestyle, and what form of support would be helpful. In total, 106 young women and 20 midwives were interviewed. Most of the young mothers were 19 or younger (67%). Half had had their first child in the past year (52%) and 21% were pregnant during the study. Thematic analysis was used to identify ways to better support young mothers to eat well.

RESULTS

Young women found it difficult to prioritise healthy eating; they often felt isolated and not in control of their own lives and wanted support from their midwife. Midwives felt that it was their role to support young mothers with diet in pregnancy but were anxious about initiating conversations and felt they lacked clear guidance.

CONCLUSIONS

Pregnant teenagers and their midwives lack reliable resources and strategies for healthy eating support. An effective intervention to improve pregnant teenagers' diet quality must empower, inform, and motivate young mothers and their midwives, and enable connections between young mothers.

Typology of drug discontinuation trials - Methodological recommendations

OBJECTIVE

Due to the increasing concerns about polypharmacy, there is a growing need for clinical recommendations for drug discontinuation. This requires studies investigating the process on several levels. This paper addresses the methodological problems of drug discontinuation trials (DDTs). To that end, we offer a new typology of research aims and corresponding methodological recommendations for trials evaluating drug discontinuation.

STUDY DESIGN AND SETTING

Multi-stage development process, including literature search and expert panels.

RESULTS

Clinical trials are only required in cases of scientific uncertainty. We identified three situations of uncertainty associated with drug discontinuation from which we derived three study types: 1) Uncertainty regarding the effectiveness and/or safety of a drug; 2) Uncertainty regarding the procedure of discontinuing a previously taken drug; 3) Uncertainty regarding the effectiveness of complex strategies used to discontinue one or more drugs. We developed specific methodological recommendations for each study type.

CONCLUSION

We offer a comprehensive definition of research aims, study designs, and methodological recommendations regarding DDTs. The typology we propose can help investigators clarify their research aims and study design. The type-specific methodological recommendation should improve the quality of future drug discontinuation trials.

Translating new evidence into clinical practice: a quasi-experimental controlled before-after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa

OBJECTIVES

We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding.

DESIGN

Quasi-experimental controlled before-after study.

SETTING

Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa.

PARTICIPANTS

All HWs providing infant feeding counselling in selected facilities were invited.

INTERVENTIONS

Three 1-2 hours, on-site workshops over 3-6 weeks.

PRIMARY OUTCOME MEASURES

Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level.

RESULTS

In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups.

CONCLUSION

A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale.

Engaging adolescents in changing behaviour (EACH-B): a study protocol for a cluster randomised controlled trial to improve dietary quality and physical activity

BACKGROUND

Poor diet and lack of physical activity are strongly linked to non-communicable disease risk, but modifying them is challenging. There is increasing recognition that adolescence is an important time to intervene; habits formed during this period tend to last, and physical and psychological changes during adolescence make it an important time to help individuals form healthier habits. Improving adolescents' health behaviours is important not only for their own health now and in adulthood, but also for the health of any future children. Building on LifeLab-an existing, purpose-built educational facility at the University of Southampton-we have developed a multi-component intervention for secondary school students called Engaging Adolescents in Changing Behaviour (EACH-B) that aims to motivate and support adolescents to eat better and be more physically active.

METHODS

A cluster randomised controlled trial is being conducted to evaluate the effectiveness of the EACH-B intervention. The primary outcomes of the intervention are self-reported dietary quality and objectively measured physical activity (PA) levels, both assessed at baseline and at 12-month follow-up. The EACH-B intervention consists of three linked elements: professional development for teachers including training in communication skills to support health behaviour change; the LifeLab educational module comprising in-school teaching of nine science lessons linked to the English National Curriculum and a practical day visit to the LifeLab facility; and a personalised digital intervention that involves social support and game features that promote eating better and being more active. Both the taught module and the LifeLab day are designed with a focus on the science behind the messages about positive health behaviours, such as diet and PA, for the adolescents now, in adulthood and their future offspring, with the aim of promoting personal plans for change. The EACH-B research trial aims to recruit approximately 2300 secondary school students aged 12-13 years from 50 schools (the clusters) from Hampshire and neighbouring counties. Participating schools will be randomised to either the control or intervention arm. The intervention will be run during two academic years, with continual recruitment of schools throughout the school year until the sample size is reached. The schools allocated to the control arm will receive normal schooling but will be offered the intervention after data collection for the trial is complete. An economic model will be developed to assess the cost-effectiveness of the EACH-B intervention compared with usual schooling.

DISCUSSION

Adolescents' health needs are often ignored and they can be difficult to engage in behaviour change. Building a cheap, sustainable way of engaging them in making healthier choices will benefit their long-term health and that of their future children.

TRIAL REGISTRATION

ISRCTN 74109264 . Registered on 30 August 2019. EACH-B is a cluster randomised controlled trial, funded by the National Institute for Health Research (RP-PG-0216-20004).

Addressing embodied inequities in health: how do we enable improvement in women's diet in pregnancy?

OBJECTIVE

To disrupt cycles of health inequity, traceable to dietary inequities in the earliest stages of life, public health interventions should target improving nutritional wellbeing in preconception/pregnancy environments. This requires a deep engagement with pregnant/postpartum people (PPP) and their communities (including their health and social care providers, HSCP). We sought to understand the factors that influence diet during pregnancy from the perspectives of PPP and HSCP, and to outline intervention priorities.

DESIGN

We carried out thematic network analyses of transcripts from ten focus group discussions (FGD) and one stakeholder engagement meeting with PPP and HSCP in a Canadian city. Identified themes were developed into conceptual maps, highlighting local priorities for pregnancy nutrition and intervention development.

SETTING

FGD and the stakeholder meeting were run in predominantly lower socioeconomic position (SEP) neighbourhoods in the sociodemographically diverse city of Hamilton, Canada.

PARTICIPANTS

All local, comprising twenty-two lower SEP PPP and forty-three HSCP.

RESULTS

Salient themes were resilience, resources, relationships and the embodied experience of pregnancy. Both PPP and HSCP underscored that socioeconomic-political forces operating at multiple levels largely determined the availability of individual and relational resources constraining diet during pregnancy. Intervention proposals focused on cultivating individual and community resilience to improve early-life nutritional environments. Participants called for better-integrated services, greater income supports and strengthened support programmes.

CONCLUSIONS

Hamilton stakeholders foregrounded social determinants of inequity as main factors influencing pregnancy diet. They further indicated a need to develop interventions that build resilience and redistribute resources at multiple levels, from the household to the state.

Use of healthy conversation skills to promote healthy diets, physical activity and gestational weight gain: Results from a pilot randomised controlled trial

OBJECTIVES

This study evaluated the use of Healthy Conversation Skills (a client-centered communication approach to behaviour change) in supporting women to achieve optimal gestational-weight-gain and health behaviours.

METHODS

Seventy pregnant women were randomised to the control or intervention group. Study visits and phone calls were delivered by Registered Dietitians (RDs) to women in the intervention and control groups. The intervention RD was trained in Healthy Conversation Skills while the control RD was not. Diet, physical activity and gestational-weight-gain were assessed at baseline and again at follow-up in the intervention and control groups.

RESULTS

Women in the intervention group improved their diet score between baseline and visit 2, while the control group did not. At 34 weeks, women in the control group reported being sedentary for longer than women in the intervention group. There were no differences in total gestational-weight-gain between the groups.

CONCLUSIONS

Pregnant women who interacted with an RD using Healthy Conversation Skills reported positive outcomes in health behaviours.

PRACTICE IMPLICATIONS

Healthy Conversation Skills shows promise as an approach to initiate, and maintain discussions promoting health behaviour change in pregnancy.

Knowledge about the Developmental Origins of Health and Disease is independently associated with variation in diet quality during pregnancy

Environmental factors affecting development through embryogenesis, pregnancy, and infancy impact health through all subsequent stages of life. Known as the Developmental Origins of Health and Disease (DOHaD) hypothesis, this concept is widely accepted among health and social scientists. However, it is unclear whether DOHaD-based ideas are reaching the general public and/or influencing behaviour. This study thus investigated whether and under what circumstances pregnant people in Canada are familiar with DOHaD, and if DOHaD familiarity relates to eating behaviour. Survey responses from pregnant people from Hamilton, Canada, were used to assess respondents' knowledge of DOHaD (hereafter, DOHaDKNOWLEDGE ) compared with their knowledge of more general pregnancy health recommendations (Pregnancy GuidelineKNOWLEDGE ). The survey also characterized respondents' pregnancy diet quality and sociodemographic profiles. We fit two multiple, linear, mixed regression models to the data, one with DOHaDKNOWLEDGE score as the dependent variable and the other with diet quality score as the dependent. In both models, responses were clustered by respondents' neighbourhoods. Complete, internally consistent responses were available for 330 study-eligible respondents. Relative to Pregnancy GuidelineKNOWLEDGE , respondents had lower, more variable DOHaDKNOWLEDGE scores. Additionally, higher DOHaDKNOWLEDGE was associated with higher socio-economic position, older age, and lower parity, independent of Pregnancy GuidelineKNOWLEDGE . Diet quality during pregnancy was positively associated with DOHaDKNOWLEDGE , adjusting for sociodemographic factors. A subset of relatively high socio-economic position respondents was familiar with DOHaD. Greater familiarity with DOHaD was associated with better pregnancy diet quality, hinting that translating DOHaD knowledge to pregnant people may motivate improved pregnancy nutrition and thus later-life health for developing babies.

Mobile phone short message service (SMS) as a malaria control tool: a quasi-experimental study

BACKGROUND

Despite the extensive implementation of control measures and achievements in morbidity reductions, malaria continues to contribute to substantial morbidity and mortality in children under-five. Innovative approaches involving the use of mobile phones have been suggested to improve health outcomes. However, evidence of its effect on reducing the prevalence of malaria is limited. This study, therefore, aimed to assess the effect of a theory-driven mHealth intervention on the prevalence of malaria among children under-five living in rural districts of Ghana.

METHODS

We conducted a quasi-experimental study of a 12-month intervention using a random sample of 332 caregivers with children under-five from two rural districts, assigned to either an intervention or a control group. Caregivers in the intervention group received voice short message service (SMS) on malaria prevention based on a behavior change theory to improve their health behaviors and practice, once a week for twelve months, while caregivers in the control group received none. Pre- and post-intervention assessment of the treatment effect (ATT) on malaria in children under-five was conducted using propensity score and difference-in-difference (DiD) analyses.

RESULTS

Among children whose caregivers received the intervention, the prevalence of malaria decreased from 58.4% at baseline to 37.8% at endline (difference: -20.6%; 95% CI: - 31.1, - 10.1) compared with children in the control group, where a reduction of 65.0 to 59.9% (difference - 5.1%; 95% CI: - 15.5, 5.4) was observed. The treatment effect at endline revealed a statistically significant reduction in malaria prevalence (ATT: -0.214; 95% CI: - 0.36, - 0.07) compared with the baseline (ATT: -0.035; 95% CI: - 0.16, 0.09). Overall, the intervention effect showed a significant reduction in the prevalence of malaria among children under-five was positive (DiD: - 0.154; p = 0.043).

CONCLUSION

The results of the study indicate the effectiveness of mobile phone SMS as a control tool for reducing the burden of malaria in children under-five.

Examination of how food environment and psychological factors interact in their relationship with dietary behaviours: test of a cross-sectional model

BACKGROUND

To improve population diet environmental strategies have been hailed the panacea because they require little agency or investment of personal resources; this contrasts with conventional strategies that rely on individuals to engage high levels of agency and make deliberate choices. There is an immediate need to improve understanding of the synergy between the psychological and environmental determinants of diet in order to optimise allocation of precious public health resources. This study examined the synergistic and relative association between a number of food environment and psychological factors and the dietary behaviours of a population sample of women with young children.

METHODS

Women in Hampshire were recruited from children's centres and asked about their demographic characteristics, psychological resources, dietary behaviours (food frequency questionnaire) and perceptions of healthy food access and affordability. Three local food environment factors were objectively assessed: i) spatial access to food outlets using activity spaces; ii) healthfulness of the supermarket where women did their main food shop, (based on nine in-store factors including price, placement and promotion on seven healthy and five less healthy foods); iii) nutrition environment of children's centres visited frequently by the women, assessed via staff-administered questionnaire. A theoretical model linking environmental factors to dietary behaviours, both directly and indirectly through three factors representing individual agency (psychological resources, perceived food affordability, perceived food accessibility), was tested using Structural Equation Modelling.

RESULTS

Complete data were available for 753 women. The environment of women's main supermarket was indirectly related to their dietary behaviours through psychological resources and perceived food affordability. Shopping at supermarkets classified as having a healthier in-store environment was associated with having greater psychological resources associated with healthy eating (standardised regression weight β = 0.14SD, p = 0.03) and fewer food affordability concerns (β = - 0.14SD, p = 0.01), which in turn related to healthier dietary behaviours (β = 0.55SD, < 0.001 and β = - 0.15, p = 0.01 respectively). The three food environment factors were not directly associated with dietary behaviour (p > 0.3). The overall model fit was good (CFI = 0.91, RMSEA = 0.05 [0.05, 0.06]).

CONCLUSIONS

This pathway analysis identified three focal points for intervention and suggests that high-agency interventions targeting individual psychological resources when combined with low-agency supermarket environment interventions may confer greater benefits on dietary behaviours than either intervention alone.

How well do national and local policies in England relevant to maternal and child health meet the international standard for non-communicable disease prevention? A policy analysis

OBJECTIVES

(1) To identify national policies for England and local policies for Southampton City that are relevant to maternal and child health. (2) To quantify the extent to which these policies meet the international standards for nutrition and physical activity initiatives set out in the WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases (WHO Action Plan).

DESIGN

The policy appraisal process involved three steps: (1) identifying policy documents relevant to maternal and infant health, (2) developing a policy appraisal framework from the WHO Action Plan, and (3) analysing the policies using the framework.

SETTING

England and Southampton City.

PARTICIPANTS

57 national and 10 local policies.

RESULTS

Across both national and local policies, priority areas supporting public health processes, such as evidence-based practice, were adopted more frequently than the action-oriented areas targeting maternal and child dietary and physical activity behaviours. However, the policy option managing conflicts of interest was rarely considered in the national policies (12%), particularly in white papers or evidence-based guidelines. For the action-oriented priority areas, maternal health policy options were more frequently considered than those related to child health or strengthening health systems. Complementary feeding guidance (9%) and workforce training in empowerment skills (14%) were the least frequent action-oriented policy options adopted among the national policies. The maternal nutrition-focused and workforce development policy options were least frequent among local policies adopted in 10% or fewer. Macroenvironmental policy options tended to have a lower priority than organisational or individual options among national policies (p=0.1) but had higher priority among local policies (p=0.02).

CONCLUSIONS

Further action is needed to manage conflicts of interest and adopt policy options that promote a system-wide approach to address non-communicable diseases caused by poor diet and physical inactivity.

Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative

Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.

Global Health Education and Advocacy: Using BMJ Case Reports to Tackle the Social Determinants of Health

Since 2013, BMJ Case Reports (http://casereports.bmj.com/) has published over 70 global health case reports from five continents, written by doctors, nurses, students, and allied health professionals. These cases, a burgeoning repository of evidence of how real patients are affected by disease, trauma, violence, sexual assault, conflict, migration, adverse living and working conditions, and poor access to health care, discuss, in addition to clinicopathological findings, the global health problems affecting each patient. The global health problem analysis examines the problems of individual patients, critically appraises the literature, and describes actual and potential solutions for the patient, the local community, and patients affected by similar issues across the world. At present global health literature and learning materials lack a patient focus and real-life context in the analysis of global health problems. BMJ Case Reports global health case reports are a unique and important tool to learn about and advocate for change in the social, political, cultural, and financial determinants of health as they affect real patients. This growing evidence base brings together clinicians, local service providers, policy makers, and government and non-governmental institutions to effect real change in patients' lives toward improving health. Each global health case report is an excellent resource for learning, and together, these case reports provide essential reading for anyone embarking on a career in global health, and writing their own case report. The online course (http://casereports.bmj.com/site/misc/GHMA_Mar_2017.pptx) at BMJ Case Reports uses these cases and is free to access.

Intervention strategies to improve nutrition and health behaviours before conception

The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.

Improving recruitment to clinical trials during pregnancy: A mixed methods investigation

OBJECTIVE

To identify reasons underlying women's refusal to participate in a pregnancy trial and to identify ways of increasing recruitment.

DESIGN

Mixed methods study using a questionnaire and qualitative interviews.

SAMPLE

A questionnaire asking them to indicate reasons for their decision was completed by 296 pregnant women who declined to participate in one of two trials of nutritional supplementation in a large teaching hospital in southern England. Qualitative interview data were collected from two samples of pregnant women: 1) 30 women who declined to participate in a trial but completed the questionnaire; and 2) 44 women who participated in a trial.

RESULTS

Questionnaire data from pregnant women who declined to participate suggested the major barriers to participation were study requirements, including taking study medication, having a bone scan or blood tests, or being too busy. Thematic analysis of interview data identified differences in self-efficacy and levels of trust in medical research between participants and decliners. Participants believed that the research would cause no harm, while decliners felt they or their unborn child would be at risk. When faced with potential obstacles, participants found ways around them while decliners felt they were insurmountable.

CONCLUSIONS

Recruitment methods for pregnancy trials should focus on building women's trust in the trial, and on enhancing women's self-efficacy so they feel able to meet trial requirements. Suggestions for building trust include investing time in open, honest discussion of the risks and benefits of participation, improving visibility of the research team, testimonials from previous participants and advertising study safety and ethical conduct. Self-efficacy can be enhanced by training research staff in empowering styles of communication enabling women to feel heard and supported to problem-solve. These strategies could be implemented relatively easily into pregnancy trial protocols, and their effectiveness tested through their impact on recruitment rates.

The relationship between dietary quality and the local food environment differs according to level of educational attainment: A cross-sectional study

There is evidence that food outlet access differs according to level of neighbourhood deprivation but little is known about how individual circumstances affect associations between food outlet access and diet. This study explored the relationship between dietary quality and a measure of overall food environment, representing the balance between healthy and unhealthy food outlet access in individualised activity spaces. Furthermore, this study is the first to assess effect modification of level of educational attainment on this relationship. A total of 839 mothers with young children from Hampshire, United Kingdom (UK) completed a cross-sectional survey including a 20-item food frequency questionnaire to measure diet and questions about demographic characteristics and frequently visited locations including home, children’s centre, general practitioner, work, main food shop and physical activity location. Dietary information was used to calculate a standardised dietary quality score for each mother. Individualised activity spaces were produced by creating a 1000m buffer around frequently visited locations using ArcGIS. Cross-sectional observational food outlet data were overlaid onto activity spaces to derive an overall food environment score for each mother. These scores represented the balance between healthy and unhealthy food outlets using weightings to characterise the proportion of healthy or unhealthy foods sold in each outlet type. Food outlet access was dominated by the presence of unhealthy food outlets; only 1% of mothers were exposed to a healthy overall food environment in their daily activities. Level of educational attainment moderated the relationship between overall food environment and diet (mid vs low, p = 0.06; high vs low, p = 0.04). Adjusted stratified linear regression analyses showed poorer food environments were associated with better dietary quality among mothers with degrees (β = -0.02; 95%CI: -0.03, -0.001) and a tendency toward poorer dietary quality among mothers with low educational attainment, however this relationship was not statistically significant (β = 0.01; 95%CI: -0.01, 0.02). This study showed that unhealthy food outlets, like takeaways and convenience stores, dominated mothers’ food outlet access, and provides some empirical evidence to support the concept that individual characteristics, particularly educational attainment, are protective against exposure to unhealthy food environments. Improvements to the imbalance of healthy and unhealthy food outlets through planning restrictions could be important to reduce dietary inequalities.

Translating Developmental Origins: Improving the Health of Women and Their Children Using a Sustainable Approach to Behaviour Change

Theories of the developmental origins of health and disease imply that optimising the growth and development of babies is an essential route to improving the health of populations. A key factor in the growth of babies is the nutritional status of their mothers. Since women from more disadvantaged backgrounds have poorer quality diets and the worst pregnancy outcomes, they need to be a particular focus. The behavioural sciences have made a substantial contribution to the development of interventions to support dietary changes in disadvantaged women. Translation of such interventions into routine practice is an ideal that is rarely achieved, however. This paper illustrates how re-orientating health and social care services towards an empowerment approach to behaviour change might underpin a new developmental focus to improving long-term health, using learning from a community-based intervention to improve the diets and lifestyles of disadvantaged women. The Southampton Initiative for Health aimed to improve the diets and lifestyles of women of child-bearing age through training health and social care practitioners in skills to support behaviour change. Analysis illustrates the necessary steps in mounting such an intervention: building trust; matching agendas and changing culture. The Southampton Initiative for Health demonstrates that developing sustainable; workable interventions and effective community partnerships; requires commitment beginning long before intervention delivery but is key to the translation of developmental origins research into improvements in human health.

Developmental Origins of Health and Disease: A Lifecourse Approach to the Prevention of Non-Communicable Diseases

Non-communicable diseases (NCDs), such as cardiovascular disease and osteoporosis, affect individuals in all countries worldwide. Given the very high worldwide prevalence of NCDs across a range of human pathology, it is clear that traditional approaches targeting those at most risk in older adulthood will not efficiently ameliorate this growing burden. It will thus be essential to robustly identify determinants of NCDs across the entire lifecourse and, subsequently, appropriate interventions at every stage to reduce an individual's risk of developing these conditions. A lifecourse approach has the potential to prevent NCDs, from before conception through fetal life, infancy, childhood, adolescence, adulthood and into older age. In this paper, we describe the origins of the lifecourse concept, the importance of early life influences, for example during pregnancy, examine potential underlying mechanisms in both cell biology and behavior change, and finally describe current efforts to develop interventions that take a lifecourse approach to NCD prevention. Two principal approaches to improving women's nutritional status are outlined: nutritional supplementation and behavior change.

Interventions to prevent maternal obesity before conception, during pregnancy, and post partum

Prevention of obesity in women of reproductive age is widely recognised to be important both for their health and for that of their offspring. Weight-control interventions, including drug treatment, in pregnant women who are obese or overweight have not had sufficient impact on pregnancy and birth outcomes, which suggests that the focus for intervention should include preconception or post-partum periods. Further research is needed into the long-term effects of nutritional and lifestyle interventions before conception. To improve preconception health, an integrated approach, including pregnancy prevention, planning, and preparation is needed, involving more than the primary health-care sector and adopting an ecological approach to risk reduction that addresses personal, societal, and cultural influences. Raising awareness of the importance of good health in the period before pregnancy will require a new social movement: combining bottom-up mobilisation of individuals and communities with a top-down approach from policy initiatives. Interventions to reduce or prevent obesity before conception and during pregnancy could contribute substantially to achievement of the global Sustainable Development Goals, in terms of health, wellbeing, productivity, and equity in current and future generations.

Southampton PRegnancy Intervention for the Next Generation (SPRING): protocol for a randomised controlled trial

Background

The nutritional status and health of mothers influence the growth and development of infants during pregnancy and postnatal life. Interventions that focus on improving the nutritional status and lifestyle of mothers have the potential to optimise the development of the fetus as well as improve the health of mothers themselves. Improving the diets of women of childbearing age is likely to require complex interventions that are delivered in a socially and culturally appropriate context. In this study we aim to test the efficacy of two interventions: behaviour change (Healthy Conversation Skills) and vitamin D supplementation, and to explore the efficacy of an intervention that combines both, in improving the diet quality and nutritional status of pregnant women.

Methods/design

Women attending the maternity hospital in Southampton are recruited at between 8 and 12 weeks gestation. They are randomised to one of four groups following a factorial design: Healthy Conversation Skills support plus vitamin D supplementation (1000 IU cholecalciferol) (n = 150); Healthy Conversation Skills support plus placebo (n = 150); usual care plus vitamin D supplementation (n = 150); usual care plus placebo (n = 150). Questionnaire data include parity, sunlight exposure, diet assessment allowing assessment of diet quality, cigarette and alcohol consumption, well-being, self-efficacy and food involvement. At 19 and 34 weeks maternal anthropometry is assessed and blood samples taken to measure 25(OH) vitamin D. Maternal diet quality and 25(OH) vitamin D are the primary outcomes. Secondary outcomes are women’s level of self-efficacy at 34 weeks, pregnancy weight gain, women’s self-efficacy and breastfeeding status at one month after birth and neonatal bone mineral content, assessed by DXA within the first 14 days after birth.

Discussion

This trial is evaluating two approaches to improving maternal diet: a behaviour change intervention and vitamin D supplementation. The factorial design of this trial has the advantage of enabling each intervention to be tested separately as well as allowing exploration of the synergistic effect of both interventions on women’s diets and vitamin D levels.

Trial registration

ISRCTN07227232. Registered on 13 September 2013.

Measuring young women’s self-efficacy for healthy eating: Initial development and validation of a new questionnaire

Healthy eating in women of childbearing age is critical to the health of future generations. Interventions that increase women’s dietary self-efficacy may be particularly effective at improving healthy eating. However, no validated tool exists to measure self-efficacy for healthy eating in this specific population. We therefore designed a new questionnaire (the 8-Item Self-Efficacy for Healthy Diet Scale) using a think-aloud study and expert panel consultation. We then pilot-tested the 8-Item Self-Efficacy for Healthy Diet Scale in an interviewer-administered survey of 94 women recruited primarily from community settings. The 8-Item Self-Efficacy for Healthy Diet Scale is an 8-item measure of self-efficacy for healthy eating with promising psychometric properties including internal consistency, convergent, criterion and divergent validity.

Preconception and pregnancy: opportunities to intervene to improve women's diets and lifestyles

Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a 'teachable moment' for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.

Why is changing health-related behaviour so difficult?

OBJECTIVE

To demonstrate that six common errors made in attempts to change behaviour have prevented the implementation of the scientific evidence base derived from psychology and sociology; to suggest a new approach which incorporates recent developments in the behavioural sciences.

STUDY DESIGN

The role of health behaviours in the origin of the current epidemic of non-communicable disease is observed to have driven attempts to change behaviour. It is noted that most efforts to change health behaviours have had limited success. This paper suggests that in policy-making, discussions about behaviour change are subject to six common errors and that these errors have made the business of health-related behaviour change much more difficult than it needs to be.

METHODS

Overview of policy and practice attempts to change health-related behaviour.

RESULTS

The reasons why knowledge and learning about behaviour have made so little progress in alcohol, dietary and physical inactivity-related disease prevention are considered, and an alternative way of thinking about the behaviours involved is suggested. This model harnesses recent developments in the behavioural sciences.

CONCLUSION

It is important to understand the conditions preceding behaviour psychologically and sociologically and to combine psychological ideas about the automatic and reflective systems with sociological ideas about social practice.

'Making every contact count': Evaluation of the impact of an intervention to train health and social care practitioners in skills to support health behaviour change

A total of 148 health and social care practitioners were trained in skills to support behaviour change: creating opportunities to discuss health behaviours, using open discovery questions, listening, reflecting and goal-setting. At three time points post-training, use of the skills was evaluated and compared with use of skills by untrained practitioners. Trained practitioners demonstrated significantly greater use of these client-centred skills to support behaviour change compared to their untrained peers up to 1 year post-training. Because it uses existing services to deliver support for behaviour change, this training intervention has the potential to improve public health at relatively low cost.

How do mothers manage their preschool children's eating habits and does this change as children grow older? A longitudinal analysis

The practices mothers adopt in relation to feeding their children have been identified as important predictors of children's quality of diet. However, most studies of the impact of these practices on quality of children's diets have been cross-sectional in design, limiting conclusions about change and causality. Previous research has called for qualitative exploration of the way these practices are used in a real-life setting. This study set out to address these gaps in knowledge. At baseline, mothers recruited to a community-based intervention study and who had a preschool child, completed a questionnaire about their use of covert and overt control practices, child food neophobia and demographics. The quality of children's diets was assessed using a validated food frequency questionnaire. Both questionnaires were repeated with the mothers two years later. Complete data at both time points were available for 228 mother-child pairs. Four focus group discussions were conducted with 29 mothers of preschool children to explore their experiences of feeding young children. Mothers who increased their use of overt control had children whose level of food neophobia also increased (P = 0.02). Mothers who used more covert control had children with better quality diets at both time points (P = <0.01) and mothers who increased their use of covert control over the two year follow-up had children whose diet quality improved (P = 0.003). These associations were independent of confounders such as mother's level of education. In the focus groups, mothers suggested that feeding young children was stressful and that control was often relinquished in order to reduce conflict at mealtimes. Supporting parents to adopt more covert techniques to control their children's eating habits may be an effective way of improving the quality of young children's diets.

Developmental origins, behaviour change and the new public health

A developmental approach to public health focuses attention on better nourishing girls and young women, especially those of low socio-economic status, to improve mothers' nutrition and thereby the health of future generations. There have been significant advances in the behavioural sciences that may allow us to understand and support dietary change in young women and their children in ways that have not previously been possible. This paper describes some of these advances and aims to show how they inform this new approach to public health. The first of these has been to work out what is effective in supporting behaviour change, which has been achieved by careful and detailed analysis of behaviour change techniques used by practitioners in intervention, and of the effectiveness of these in supporting change. There is also a new understanding of the role that social and physical environments play in shaping our behaviours, and that behaviour is influenced by automatic processes and 'habits' as much as by reflective processes and rational decisions. To be maximally effective, interventions therefore have to address both influences on behaviour. An approach developed in Southampton aims to motivate, support and empower young women to make better food choices, but also to change the culture in which those choices are being made. Empowerment is the basis of the new public health. An empowered public demand for better access to better food can go a long way towards improving maternal, infant and family nutrition, and therefore the health of generations to come.