Power, control, communities and health inequalities III: participatory spaces—an English case

This article—third in a series of three—uses theoretical frameworks described in Part 1, and empirical markers reported in Part 2, to present evidence on how power dynamics shifted during the early years of a major English community empowerment initiative. We demonstrate how the capabilities disadvantaged communities require to exercise collective control over decisions/actions impacting on their lives and health (conceptualized as emancipatory power) and the exercise of power over these communities (conceptualized as limiting power) were shaped by the characteristics of participatory spaces created by and/or associated with this initiative. Two main types of participatory spaces were identified: governance and sense-making. Though all forms of emancipatory power emerged in all spaces, some were more evident in particular spaces. In governance spaces, the development and enactment of ‘power to’ emerged as residents made formal decisions on action, allocated resources and managed accountability. Capabilities for alliance building—power with—were more likely to emerge in these spaces, as was residents’ resistance to the exercise of institutional power over them. In contrast, in sense-making spaces residents met informally and ‘made sense’ of local issues and their ability to influence these. These processes led to the development of power within capabilities and power to resist stigmatizing forms of productive power. The findings highlight the importance of designing community initiatives that: nurture diverse participatory spaces; attend to connectivity between spaces; and identify and act on existing power dynamics undermining capabilities for collective control in disadvantaged communities.

Systematic review of dietary salt reduction policies: Evidence for an effectiveness hierarchy?

BACKGROUND

Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake remains much higher than recommended, increasing blood pressure, cardiovascular disease and stomach cancer. Substantial reductions in salt intake are therefore urgently needed. However, the debate continues about the most effective approaches. To inform future prevention programmes, we systematically reviewed the evidence on the effectiveness of possible salt reduction interventions. We further compared "downstream, agentic" approaches targeting individuals with "upstream, structural" policy-based population strategies.

METHODS

We searched six electronic databases (CDSR, CRD, MEDLINE, SCI, SCOPUS and the Campbell Library) using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were independently screened, appraised and graded for quality by two researchers. To facilitate comparisons between the interventions, the extracted data were categorised using nine stages along the agentic/structural continuum, from "downstream": dietary counselling (for individuals, worksites or communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most "upstream" regulatory and fiscal interventions, and comprehensive strategies involving multiple components.

RESULTS

After screening 2,526 candidate papers, 70 were included in this systematic review (49 empirical studies and 21 modelling studies). Some papers described several interventions. Quality was variable. Multi-component strategies involving both upstream and downstream interventions, generally achieved the biggest reductions in salt consumption across an entire population, most notably 4g/day in Finland and Japan, 3g/day in Turkey and 1.3g/day recently in the UK. Mandatory reformulation alone could achieve a reduction of approximately 1.45g/day (three separate studies), followed by voluntary reformulation (-0.8g/day), school interventions (-0.7g/day), short term dietary advice (-0.6g/day) and nutrition labelling (-0.4g/day), but each with a wide range. Tax and community based counselling could, each typically reduce salt intake by 0.3g/day, whilst even smaller population benefits were derived from health education media campaigns (-0.1g/day). Worksite interventions achieved an increase in intake (+0.5g/day), however, with a very wide range. Long term dietary advice could achieve a -2g/day reduction under optimal research trial conditions; however, smaller reductions might be anticipated in unselected individuals.

CONCLUSIONS

Comprehensive strategies involving multiple components (reformulation, food labelling and media campaigns) and "upstream" population-wide policies such as mandatory reformulation generally appear to achieve larger reductions in population-wide salt consumption than "downstream", individually focussed interventions. This 'effectiveness hierarchy' might deserve greater emphasis in future NCD prevention strategies.

The Health Equity and Effectiveness of Policy Options to Reduce Dietary Salt Intake in England: Policy Forecast

BACKGROUND

Public health action to reduce dietary salt intake has driven substantial reductions in coronary heart disease (CHD) over the past decade, but avoidable socio-economic differentials remain. We therefore forecast how further intervention to reduce dietary salt intake might affect the overall level and inequality of CHD mortality.

METHODS

We considered English adults, with socio-economic circumstances (SEC) stratified by quintiles of the Index of Multiple Deprivation. We used IMPACTSEC, a validated CHD policy model, to link policy implementation to salt intake, systolic blood pressure and CHD mortality. We forecast the effects of mandatory and voluntary product reformulation, nutrition labelling and social marketing (e.g., health promotion, education). To inform our forecasts, we elicited experts' predictions on further policy implementation up to 2020. We then modelled the effects on CHD mortality up to 2025 and simultaneously assessed the socio-economic differentials of effect.

RESULTS

Mandatory reformulation might prevent or postpone 4,500 (2,900-6,100) CHD deaths in total, with the effect greater by 500 (300-700) deaths or 85% in the most deprived than in the most affluent. Further voluntary reformulation was predicted to be less effective and inequality-reducing, preventing or postponing 1,500 (200-5,000) CHD deaths in total, with the effect greater by 100 (-100-600) deaths or 49% in the most deprived than in the most affluent. Further social marketing and improvements to labelling might each prevent or postpone 400-500 CHD deaths, but minimally affect inequality.

CONCLUSIONS

Mandatory engagement with industry to limit salt in processed-foods appears a promising and inequality-reducing option. For other policy options, our expert-driven forecast warns that future policy implementation might reach more deprived individuals less well, limiting inequality reduction. We therefore encourage planners to prioritise equity.

Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact

BACKGROUND

Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP).

METHODS

We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the "4Ps" marketing mix, expanded to 6 "Ps": "Price, Place, Product, Prescriptive, Promotion, and Person".

RESULTS

Our search identified 31,887 articles. Following screening, 36 studies were included: 18 "Price" interventions, 6 "Place" interventions, 1 "Product" intervention, zero "Prescriptive" interventions, 4 "Promotion" interventions, and 18 "Person" interventions. "Price" interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as "Person" had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any "Prescriptive" interventions and only one "Product" intervention that presented differential results and had no impact by SEP. More "Place" interventions were identified and none of these interventions were judged as likely to widen inequalities.

CONCLUSIONS

Interventions categorised by a "6 Ps" framework show differential effects on healthy eating outcomes by SEP. "Upstream" interventions categorised as "Price" appeared to decrease inequalities, and "downstream" "Person" interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.

Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework

Background

Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions represents a potentially bewildering smorgasbord.

We aimed to map existing public health nutrition policies, and examine their perceived effectiveness, in order to inform future evidence-based diet strategies.

Methods

We created a public health nutrition policy database for 30 European countries . National nutrition policies were classified and assigned using the marketing "4Ps" approach Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling, health education) and Place (schools, workplaces, etc.).

We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies.

Results

Product Voluntary reformulation of foods is widespread but has variable and often modest impact. Twelve countries regulate maximum salt content in specific foods.

Denmark, Austria, Iceland and Switzerland have effective trans fats bans.

Price EU School Fruit Scheme subsidies are almost universal, but with variable implementation.

Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products.

Promotion Dialogue, recommendations, nutrition guidelines, labelling, information and education campaigns are widespread. Restrictions on marketing to children are widespread but mostly voluntary.

Place Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens.

Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but also politically more challenging.

Conclusions

Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. The "4Ps" framework potentially offers a structured and comprehensive categorisation.

Encouragingly, the majority of European countries are engaged in activities intended to increase consumption of healthy food and decrease the intake of "junk" food and sugary drinks. Leading countries include Finland, Norway, Iceland, Denmark, Hungary, Portugal and perhaps the UK. However, all countries fall short of optimal activities. More needs to be done across Europe to implement the most potentially powerful fiscal and regulatory nutrition policies.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1195) contains supplementary material, which is available to authorized users.

Critical and anticipated recovery paths: only the beginning

Multidisciplinary outcome-based care plans are a powerful aid to clinicians in managed care and case management situations. After several years of using Anticipated Recovery Paths, a committee designed a Professional Practice Symposium focusing on the skills needed by nursing personnel to provide effective outcome-based practice. Results of this educational effort are reported.

Statistical analysis of Salmonella test data and comparison to results of animal cancer tests

A quantitative framework for the analysis of results of the Salmonella (Ames) test is presented, and the relationship between mutagenesis and carcinogenesis is examined. Color graphics are used for the Salmonella data to describe variability, and trends across multiple chemicals and test conditions. Positivity in the Salmonella test, using statistical criteria to classify results, is compared to positivity in carcinogenesis bioassays for 48 chemicals tested in NCI/NTP-sponsored programs. Sensitivity of the Salmonella test across 5 tester strains was 91% (21/23), while specificity was only 36% (9/25). Results were most concordant for TA100 Aroclor-induced rat S9: sensitivity was 87%, specificity 64%. The correlation of mutagenic potency and carcinogenic potency was 0.41 (p less than 0.001) for 80 chemicals, using results from both the general published literature and the NCI/NTP-sponsored programs. After removal of 3 extreme values, the correlation was 0.24 (p = 0.04).

Graphical Perception and Graphical Methods for Analyzing Scientific Data

Graphical perception is the visual decoding of the quantitative and qualitative information encoded on graphs. Recent investigations have uncovered basic principles of human graphical perception that have important implications for the display of data. The computer graphics revolution has stimulated the invention of many graphical methods for analyzing and presenting scientific data, such as box plots, two-tiered error bars, scatterplot smoothing, dot charts, and graphing on a log base 2 scale.

Variables on Scatterplots Look More Highly Correlated When the Scales Are Increased

Judged association between two variables represented on scatterplots increased when the scales on the horizontal and vertical axes were simultaneously increased so that the size of the point cloud within the frame of the plot decreased. Judged association was very different from the correlation coefficient, r, which is the most widely used measure of association.

Graphical Presentation of Results from Scientific Computer Models

The graphical presentation of the results of complex computer model calculations is frequently as important as the computation, since it is generally through such presentations that the modeler and the modeler's audience derive the maximum amount of information. In this article graphical techniques for presenting multidimensional model results are reviewed and examples are given of the most useful forms of presentation. Color graphics is used increasingly for the presentation of model results, and three types of color displays are discussed here: the chromatic plot, the binary chromatic plot, and the ternary chromatic plot. Their use is illustrated with examples from computer modeling of air quality in the urban atmosphere.

Gross composition and fatty acid constitution of blackbuck antelope (Antilope cervicapra) milk

Milk collected from three blackbuck antelope in Texas contained an average of 6.9% protein, 9.3% fat, and 4.3% lactose. The fatty acid constitution of the lipid fraction resembled that found in domestic cows' milk.