Has the European Union created a healthy food environment for its citizens? Application of the Food Environment Policy Index (Food-EPI)

Background

European Union (EU) Member states' food environments are shaped by both national and EU policies. To date however, studies assessing food environment policies developed and set by the EU are scarce. The aim of this study was to assess the strength of EU policies to improve food environments as well as to assess the extent these policies could lead to a decrease or widening of socio-economic inequalities in dietary intake.

Methods

We compiled evidence on the EU policies for each of the Food-EPI 47 indicators. A European panel of independent, non-government experts (N = 30) specialized in nutrition, obesity or chronic diseases, using the Food-EPI evidence, rated the strength of EU policies to improve food environments during an online survey in February-March 2020. The experts also rated to which extent policies could lead to a decrease or widening of socio-economic inequalities in dietary intake. In addition, experts formulated actions to improve EU food environment policies, which were prioritized during a follow-up online survey.

Results

The overview of EU-level policies resulted in a 79-pages document, describing policies (or the lack thereof) for each of the 47 Food-EPI indicators. This document has been verified for completeness and accuracy by EU governmental officials. The evidence document shows that the EU has mainly binding legislation on the food labelling whereas policies on the other Food-EPI domains are mostly voluntary. Results from the online survey and the formulated prioritized actions will be presented during the conference. The results will reflect the experts' ratings supported by documented evidence and will provide meaningful guidance to EU officials and public health advocates in their efforts to improve the food environment policies set by the EU.

Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis

OBJECTIVES

To describe, from the perspective of patients, distinguishing features of doctors' attempts to explain the symptoms of somatisation disorders.

DESIGN

Qualitative analysis of verbatim records of interviews in which patients recounted doctors' explanations of their symptoms.

SETTING

Patients with persistent somatising symptoms referred from general practices in Liverpool and St Helens and Knowsley were interviewed before entry into a treatment programme.

SUBJECTS

228 of 324 patients referred were interviewed. Initial interviews were used to develop the process and technique, and the final analysis was based on a subsample of 68 records, randomly chosen from the transcripts of 188 subjects who were interviewed subsequently.

RESULTS

Doctors' explanations were often at odds with the patients' own thinking. Analysis showed that medical explanations could be grouped into one of three categories, defined by the patients' perceptions. Most explanations were experienced as rejecting the reality of the symptoms. An intermediate category comprised explanations that were viewed as colluding, in which the doctor acquiesced with the patients' own biomedical theories. However, a few explanations were perceived by patients as tangible, exculpating, and involving. These explanations were experienced by patients as satisfying and empowering.

CONCLUSIONS

Patients with somatisation disorders feel satisfied and empowered by medical explanations that are tangible, exculpating, and involving. Empowering explanations could improve these patients' wellbeing and help to reduce the high demands they make on health services.

Motivation and continuation of professional development

Variations in levels of motivation to learn among established general practitioners (GPs) have received scant attention. Building on previous work, we present an analysis of factors contributing to the development of motivation to learn in those who are entering and already established in practice. This approach suggests that individual motivation is both complex and unstable in response to external factors. We draw attention to the possibility of motivational immaturity in recruits to general practice, the contribution of values, and the presence of demotivators. The implications of our analysis are explored in relation to individual professional development and continuing education provision. We suggest that motivational audit will identify individual and contextual factors that are reducing the capacity of GPs to continue learning. A number of approaches addressing these factors are proposed.

Patients with medically unexplained symptoms: sources of patients' authority and implications for demands on medical care

Lay and medical beliefs are not separate systems. The beliefs of somatizing patients, in particular, incorporate medical understanding and it has been argued that this increases the power that such patients exert in seeking treatment from doctors. To understand the nature and use of this power requires investigation of (i) how patients use medical ideas and language to explain their symptoms and (ii) how this process influences patients' expectations and evaluations of their doctors. We interviewed 68 patients, in whom no physical cause had been found for persistent physical symptoms. Their accounts of symptoms and of their experience of doctors were subjected to qualitative thematic analysis. As expected, patients used medical terms to explain their symptoms. However, these depicted explanatory themes which have long been familiar in traditional lay models: disease as a malign entity and imbalance between bodily forces. Patients' sense of authority over doctors derived, not from facility with medical language and ideas but from contrasting their own sensory, and therefore infallible, experience of symptoms with doctors' indirect and fallible knowledge. By providing explanations that questioned the reality of symptoms, doctors were perceived as incompetent and inexpert. Patients used their authority, not to seek treatment, but to secure naming of, and collaboration against, the disorder. Although these patients saw the doctors' role as limited and inexpert by comparison with their own, our analysis suggests ways in which doctors might more effectively engage with persistent somatizing patients.

Detection of depression in primary care: comparison of two self-administered scales

Two self-rated questionnaires, SELFCARE (D) and Hospital Anxiety Depression (HAD) Scale, were compared in relation to their efficacy in detecting depression in 72 elderly patients attending general practitioners at a health centre in Liverpool, England. The sensitivity, specificity and overall misclassification rates of both the scales were assessed against a diagnosis arrived at by using a standardized interview schedule, Geriatric Mental State (community version), and a computerized diagnostic scheme, AGECAT. In this preliminary study, SELFCARE (D) was found to be superior to HAD as a screening instrument for depression in the elderly population in primary care.

The quality of hospital discharge: a survey of discharge arrangements for the over-65s

A three-phase study comprising semi-structured interviews with patients and/or their carers, follow-up postal questionnaires, and a postal survey of the views of professionals involved in the discharge of participating patients was conducted to assess the quality of arrangements for patients over 65 years of age, discharged from hospitals in Chester and Ellesmere Port in the United Kingdom. A large majority of patients (80%) felt they had been adequately consulted about arrangements for their discharge, but less than 2% of health and social care professionals considered all discharges satisfactory. This apparent disparity between patient and professional views may be explained by low levels of expectation among patients in this aspect of their care and their reluctance to express views which they fear may compromise future care. Continuing difficulties with interprofessional communication and liaison suggest that further attention to discharge management is required if improvements are to be effected.

Tissue factor expression in human leukemic cells

Patients with acute leukemia are at increased risk for thrombotic and hemorrhagic complications, particularly those patients with acute promyelocytic leukemia (APL) undergoing induction chemotherapy. These serious complications have been attributed by some authors to the release of tissue factor (TF) procoagulant activity (PCA), particularly during cytotoxic chemotherapy. In previous studies of normal peripheral blood cells, only cells of the monocyte lineage have been found to express TF PCA. Therefore, several questions remain regarding the origin and characterization of the PCA in malignant leukemic cells, particularly those thought to be derived from granulocyte progenitor cells. We utilized a full-length cDNA probe, several monoclonal antibodies (MAbs) and a sensitive one-stage PCA assay to study the expression of TF in the human cell line, HL-60, in human peripheral blood monocytes/macrophages (Mo/Mø) and in highly purified populations of human polymorphonuclear leukocytes (PMN). In the HL-60 cells we detected low but significant levels of TF mRNA and TF antigen (TF:Ag). In unstimulated cells, coordinate increased levels of TF mRNA, TF:Ag and TF PCA expression were noted following phorbol-ester-induced macrophage differentiation of the cells, but a decreased level of TF mRNA with no change in the basal level of TF:Ag expression occurred following retinoic acid-induced granulocyte differentiation of this cell line. Long-term cultures of stimulated mature Mo/Mø demonstrated initial coordinate expression of TF mRNA, TF:Ag and TF PCA, but TF:Ag expression persisted even after 7 days (when TF PCA was undetectable). No TF PCA, TF:Ag or TF mRNA was demonstrated in highly purified populations of human PMN, regardless of culture conditions. Discordant expression of TF mRNA, TF:Ag and TF PCA in HL-60 cells suggests the possibility of novel, post-synthetic mechanisms for the regulation of TF PCA expression, which might be dependent on the phenotypic differentiation level of the cell. Such mechanisms (yet to be defined) might account for the ability of some leukemic cells, which frequently express characteristics of more than one cell line (e.g. monocytes and granulocytes), to express a TF gene product capable of activating blood coagulation.

Reaccreditation: the why, what and how questions

Currently, reaccreditation is the subject of debate within general practice in the United Kingdom, largely in terms of medico-political expediency. In an attempt to broaden the basis of the debate, this paper explores reaccreditation in relation to its purpose in shaping the future of general practice (the why question); the qualities it might appropriately seek to assess (what?); and, whether such qualities can be measured (how?). It is argued that reaccreditation has far-reaching educational and service implications for general practice in the UK and should only be adopted after careful consideration of the issues involved for the profession, for patients and for the National Health Service. Providing that these issues can be resolved satisfactorily, it is proposed that the ability of general practitioners to learn from experience, rather than competence or performance, represents an appropriate and feasible yardstick for reaccreditation. Both general criteria and specific characteristics of assessment methods suitable for measuring experiential learning are identified. The feasibility and acceptability of applying such methods to the reaccreditation of general practitioners are considered. It is concluded that once such methods have been successfully refined and field-tested the way would be open for the profession's negotiators to offer the implementation of reaccreditation in return for certain safeguards designed to protect the future role of the generalist doctor in the community.

Developing organisational vision in general practice

Vision is a fashionable but ill defined term in management circles. Nevertheless, it embodies a significant concept related to guiding an organisation from present realities, through opportunities and hazards, to a viable future. Until recently a typical general practice could assume a stable external environment, but now it is caught up in the uncertainties stemming from the NHS reforms. For such a practice to undertake effective strategic planning it will have to develop a vision connecting the present with aspirations for the future. While vision is usually considered to be an individual talent, it is possible to develop a collective organisational vision within a general practice, and the small size of general practices makes this relatively easy. The vision needs to be broad; it needs to be continuous; and its capacity to predict the future needs to be monitored.

Continuing education for general practice. 2. Systematic learning from experience

Prompted by evidence that the recently-adopted arrangements for ongoing education among established general practitioners are unsatisfactory, the first of a pair of papers examined the theoretical basis of continuing education for general practice and proposed a model of self-directed learning in which the experience of established practitioners is connected, through the media of reading, reflection and audit, with competence for the role. In this paper a practical, systematic approach to self-directed learning by general practitioners is described based on the model. The contribution which appropriate participation in continuing medical education can make to enhancing learning from experience is outlined.

Continuing education for general practice. 1. Experience, competence and the media of self-directed learning for established general practitioners

The arrangements under which continuing education for general practice is provided and attendance by general practitioners is rewarded have now been in operation for three years. More recently, reaccreditation has emerged as a significant issue for the profession. For these reasons it appears timely to review the whole basis of ongoing learning by established general practitioners. In this the first of two papers, learning by established professionals is considered in relation to the educational development of the learner, the role of experience and the goals of competence and performance. It is concluded that self-directed learning based on experience should form the centre-piece of continuing education for general practice and that educational provision should adopt a complementary role in sustaining motivation to learn and by enabling learning from experience to be shared and enriched. A model of self-directed learning, connecting experience and competence through systematic application of three learning media, reading, reflection and audit, is proposed and related to appropriate educational participation by established general practitioners.

Audit in general practice: students and practitioners learning together

OBJECTIVES

To describe and evaluate the use of medical audit in general practice as an educational activity shared by undergraduate medical students and general practitioners.

DESIGN

A descriptive study, evaluated by a questionnaire survey of all participating practices and by results of completed student projects on general practice audit topics during three weeks in the first year of completed projects (1990-1).

SETTING

One university department of general practice, collaborating with 18 general practices in contract with Liverpool Family Health Services Authority.

PARTICIPANTS

150 medical students, working in groups of two to six, and the general practitioners with whom they worked in 18 practices.

MAIN MEASURES

The nature of topics proposed by practices and chosen by the students; methods of audit used by students; reported effects of the audits on the practices; general practitioners' opinions of the projects' usefulness to the practice.

RESULTS

The range of topics was wide, and both quantitative and qualitative methods were used. Fifteen of the 18 questionnaires sent out were completed. Six practices reported that the final project had changed substantially after joint planning with the students. Two thirds (10) attached high value to the audits and were making changes in the delivery of care as a result.

CONCLUSIONS

Medical audit "project work" by medical undergraduates is an effective tool for motivating students to learn and can lead to change in the clinical setting in which it occurs.

IMPLICATIONS

By meeting the learning needs of both undergraduates and established practitioners audit project work has wider application within medical education.

Providing information and detecting concerns about health in general practice populations using a computer system in the waiting area

Theoretical and practical problems for general practice exist following the increased emphasis placed upon preventive care in the 1990 contract for general practitioners. In particular, the risk that questionable systematic activity is encouraged while opportunistic prevention is discouraged, suggests the need for better targeted and more efficient methods of health promotion. This paper describes computer software which provides a broad range of information about health on a patient-dedicated terminal in general practice waiting areas. The software is interactive and monitors both the level of use of the component parts of the database and specific information sought but not found. In this way the system generates an indicator of 'health concerns' in the practice population. Experience of the system at four contrasting sites in Merseyside is reported. Data from the first year suggest that site-specific differences in use and perceived need are emerging, and could lead to an information source which evolves in response to local demand. In addition, the system should provide a resource for opportunistic prevention in primary care and a way of monitoring the emergence of new concerns about health.

Teaching problem handling in general practice: a computer assisted learning software package for medical students

A computer assisted learning software package for medical students, EnMesh, designed to increase understanding of the problem-handling skills needed in general practice has been developed at the University of Liverpool. Users access the system anonymously and respond in sequence to problems in the form of clinical vignettes. Responses to each problem, in the form of up to six two-line text statements, are generated by the user with a simple word processing facility. Users compare their responses with those of established general practitioners, searching for similar or matching ideas. After completing not less than four problems users are provided with feedback on their performance in relation to the physical, psychological and social dimensions of the problems. The frequency with which the system is being used and the results of self scoring are monitored by a parallel teacher programme. The programmes are designed to run on a wide range of microcomputers. EnMesh was designed to provide an informal learning resource within an established clinical course. The challenge of valid problems, the option to respond anonymously, self scoring and feedback on performance are features designed to attract student participation in computer assisted learning. Although in EnMesh the expert data is categorized in three dimensions, in designing such software the number of categories is limited solely by the range of responses which feedback is required to reflect.

A video-based information system for patients

This paper describes a video-based information system (VISP) for general practice waiting areas, and considers its potential for broadening the range of information which might be made available to patients.

Ectopic expression of the erythrocyte band 3 anion exchange protein, using a new avian retrovirus vector

A retrovirus vector was constructed from the genome of avian erythroblastosis virus ES4. The v-erbA sequences of avian erythroblastosis virus were replaced by those coding for neomycin phosphotransferase, creating a gag-neo fusion protein which provides G418 resistance as a selectable marker. The v-erbB sequences following the splice acceptor were replaced by a cloning linker allowing insertion of foreign genes. The vector has been tested in conjunction with several helper viruses for the transmission of G418 resistance, titer, stability, transcription, and the transduction and expression of foreign genes in both chicken embryo fibroblasts and the QT6 quail cell line. The results show that the vector is capable of producing high titers of Neor virus from stably integrated proviruses. These proviruses express a balanced ratio of genome length to spliced transcripts which are efficiently translated into protein. Using the Escherichia coli beta-galactosidase gene cloned into the vector as a test construct, expression of enzyme activity could be detected in 90 to 95% of transfected target cells and in 80 to 85% of subsequently infected cells. In addition, a cDNA encoding the avian erythrocyte band 3 anion exchange protein has been expressed from the vector in both chicken embryo fibroblasts and QT6 cells and appears to function as an active, plasma membrane-based anion transporter. The ectopic expression of band 3 protein provides a visual marker for vector function in these cells.

Self-help in primary care: preliminary findings of a study in Liverpool

Self-help groups are an important, but often neglected, resource in primary care. This paper reports the preliminary findings of a study of the origins and natural history of self-help groups in Liverpool, and considers the role for general practitioners in mobilizing resources to facilitate community participation in health through this diverse, and informal, sector of the health care system.

v-erbA cooperates with sarcoma oncogenes in leukemic cell transformation

The v-erbB, v-src, v-fps, v-sea, and v-Ha-ras oncogenes induce avian erythroid progenitor cells to self-renew in an erythropoietin-independent manner. These transformed erythroblasts retain both their capacity to differentiate into erythrocytes and their requirement for complex growth media. However, previous studies showed that erythroblasts transformed by v-erbB plus v-erbA (which by itself is not oncogenic) are blocked in differentiation and grow in standard media. Here we show that the introduction of v-erbA into erythroblasts transformed with v-src, v-fps, v-sea, or v-Ha-ras likewise induces a fully transformed phenotype. It also reduces the capacity of ts sea- and ts erbB-transformed erythroblasts to differentiate terminally in an erythropoietin-dependent manner after a temperature shift. Cooperativity involving v-erbA also occurs in vivo since chicks infected with a retroviral construct encoding v-erbA and v-src develop both acute erythroblastosis and sarcomas.