Alizon Draper

Chasing the dragon: Developing indicators for the assessment of community participation in health programmes

Community participation was identified as one of the key components of Primary Health Care as articulated in the Alma Ata declaration of 1978 and is enjoying a renewal of interest in both low and high income countries. There remains, however, an on-going challenge in how to assess its role in achieving health improvements. This is largely due to the multiplicity of definitions of community participation, which has made it difficult to evaluate its impact on desired programme outcomes, such as uptake and sustainability, as well as broader health improvements. This paper addresses this challenge by first defining a continuum of community participation that captures its many forms, and then incorporates this into an evaluation framework that enables an analysis of the process of participation and links this with health and programme outcomes. The continuum of participation and framework is based upon the spidergram of Rifkin, Muller, and Bichmann (1988), but modified in the light of the growing literature on community participation and also in relation to our original requirements to evaluate the role of community participation in nutrition-related child survival programmes. A case-study is presented to provide a worked example of the evaluation framework and its utility in the evaluation of community participation. While this is a literature-based and retrospective analysis, it demonstrates how the evaluation tool enables a nuanced analysis of the different ways in which communities can participate in the delivery of health-related interventions. It could be used prospectively by those involved in programme design and implementation to further our understanding of community participation and its relationship with health outcomes, as well as key programme outcomes, such as sustainability.

The principles and application of qualitative research

The present paper provides an overview of the methodological principles that underpin qualitative research and how these principles differ from those of quantitative research. It is intended to set the scene for the following papers that outline two specific approaches to the analysis of qualitative data. Within the tradition of qualitative research there are many different theoretical perspectives, of which these approaches are only two examples, but they need to be set within this broader tradition in order to highlight their specific features. Qualitative and quantitative research differ from each other in far more than their methods and data. They are each based on very different premises about both the nature of the world and the nature of our knowledge of it and how this information is generated. These approaches have implications for all aspects of research strategy, including the assessment of the quality of research findings and their wider utility or application. In relation to the latter, lack of detail in the reporting of qualitative research and small sample sizes has tended to create the impression that the findings of qualitative research have little application outside the particular research setting. While there is need for more rigor in reporting, it needs to be recognized that qualitative research can offer insights and understandings with wider relevance, although these outcomes are of a different type from those provided by quantitative research.

Climate change and food security: health impacts in developed countries.

Background: Anthropogenic climate change will affect global food production, with uncertain consequences for human health in developed countries. Objectives: We investigated the potential impact of climate change on food security (nutrition and food safety) and the implications for human health in developed countries. Methods: Expert input and structured literature searches were conducted and synthesized to produce overall assessments of the likely impacts of climate change on global food production and recommendations for future research and policy changes. Results: Increasing food prices may lower the nutritional quality of dietary intakes, exacerbate obesity, and amplify health inequalities. Altered conditions for food production may result in emerging pathogens, new crop and livestock species, and altered use of pesticides and veterinary medicines, and affect the main transfer mechanisms through which contaminants move from the environment into food. All these have implications for food safety and the nutritional content of food. Climate change mitigation may increase consumption of foods whose production reduces greenhouse gas emissions. Impacts may include reduced red meat consumption (with positive effects on saturated fat, but negative impacts on zinc and iron intake) and reduced winter fruit and vegetable consumption. Developed countries have complex structures in place that may be used to adapt to the food safety consequences of climate change, although their effectiveness will vary between countries, and the ability to respond to nutritional challenges is less certain. Conclusions: Climate change will have notable impacts upon nutrition and food safety in developed countries, but further research is necessary to accurately quantify these impacts. Uncertainty about future impacts, coupled with evidence that climate change may lead to more variable food quality, emphasizes the need to maintain and strengthen existing structures and policies to regulate food production, monitor food quality and safety, and respond to nutritional and safety issues that arise.

Front-of-pack nutrition labelling: are multiple formats a problem for consumers?

Background: Nutrition labels are a potentially valuable tool to assist consumers in making healthy food choices. Front-of-pack labels are a relatively new format and are now widely used across many European countries, but it is unclear which of the many formats in use are best understood by consumers. It is also unclear whether the existence of multiple formats impedes understanding and use. This article addresses this question with findings from a study commissioned by the UK Food Standards Agency to provide evidence to inform policy decisions in this area. Methods: In-depth qualitative interviews were used to explore consumers’ decision-making processes when using two different front-of-pack label formats to judge the relative healthiness of a pair of products. Participants were presented with product pairs differently labelled and a series of structured prompts were used to access their internal dialogues and to identify any difficulties encountered. Results: The interviews revealed that making product comparisons using different label formats was challenging for participants and particularly for those product pairs where there was not an obvious answer. When the label formats on the product pairs lacked a common element, such as text, this also caused difficulties and misinterpretation. The comparisons also took time and effort that would be a deterrent in real-life situations. Conclusions: These findings indicate that the existence of multiple front-of-pack label formats in the marketplace may impede consumer comprehension and discourage use. They suggest that a single format may encourage consumers to use front-of-pack labels in making healthy food choices.

A compilation of energy costs of physical activities.

OBJECTIVES There were two objectives: first, to review the existing data on energy costs of specified activities in the light of the recommendations made by the Joint Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU) Expert Consultation of 1985. Second, to compile existing data on the energy costs of physical activities for an updated annexure of the current Expert Consultation on Energy and Protein Requirements. DESIGN Electronic and manual search of the literature (predominantly English) to obtain published data on the energy costs of physical activities. The majority of the data prior to 1955 were obtained using an earlier compilation of Passmore and Durnin. Energy costs were expressed as physical activity ratio (PAR); the energy cost of the activity divided by either the measured or predicted basal metabolic rate (BMR). RESULTS The compilation provides PARs for an expanded range of activities that include general personal activities, transport, domestic chores, occupational activities, sports and other recreational activities for men and women, separately, where available. The present compilation is largely in agreement with the 1985 compilation, for activities that are common to both compilations. CONCLUSIONS The present compilation has been based on the need to provide data on adults for a wide spectrum of human activity. There are, however, lacunae in the available data for many activities, between genders, across age groups and in various physiological states.

Well London Phase-1: results among adults of a cluster-randomised trial of a community engagement approach to improving health behaviours and mental well-being in deprived inner-city neighbourhoods

Background We report the main results, among adults, of a cluster-randomised-trial of Well London, a community-engagement programme promoting healthy eating, physical activity and mental well-being in deprived neighbourhoods. The hypothesis was that benefits would be neighbourhood-wide, and not restricted to intervention participants. The trial was part of a multicomponent process/outcome evaluation which included non-experimental components (self-reported behaviour change amongst participants, case studies and evaluations of individual projects) which suggested health, well-being and social benefits to participants. Methods Twenty matched pairs of neighbourhoods in London were randomised to intervention/control condition. Primary outcomes (five portions fruit/vegetables/day; 5×30 m of moderate intensity physical activity/week, abnormal General Health Questionnaire (GHQ)-12 score and Warwick–Edinburgh Mental Well-being Scale (WEMWBS) score) were measured by postintervention questionnaire survey, among 3986 adults in a random sample of households across neighbourhoods. Results There was no evidence of impact on primary outcomes: healthy eating (relative risk [RR] 1.04, 95% CI 0.93 to 1.17); physical activity (RR:1.01, 95% CI 0.88 to 1.16); abnormal GHQ12 (RR:1.15, 95% CI 0.84 to 1.61); WEMWBS (mean difference [MD]: −1.52, 95% CI −3.93 to 0.88). There was evidence of impact on some secondary outcomes: reducing unhealthy eating-score (MD: −0.14, 95% CI −0.02 to 0.27) and increased perception that people in the neighbourhood pulled together (RR: 1.92, 95% CI 1.12 to 3.29). Conclusions The trial findings do not provide evidence supporting the conclusion of non-experimental components of the evaluation that intervention improved health behaviours, well-being and social outcomes. Low participation rates and population churn likely compromised any impact of the intervention. Imprecise estimation of outcomes and sampling bias may also have influenced findings. There is a need for greater investment in refining such programmes before implementation; new methods to understand, longitudinally different pathways residents take through such interventions and their outcomes, and new theories of change that apply to each pathway.

Complaints about dog faeces as a symbolic representation of incivility in London, UK: a qualitative study

During a ‘Well London’ study, residents were asked about their neighbourhood and its environment. Above all other complaints, ‘dog poo’ was mentioned as a key concern. Despite low rates of infection and disease among the human population resulting from contact with canine faecal matter, the concerns of the public continue to rate it as a serious public health issue. Most public health studies, therefore, seek to identify processes of transmission and disease pathology as a method of addressing the problem. This study approaches the issue through a contextualised analysis of residents’ complaints, using anthropological theory to examine the symbolic representation of ‘dog poo’. Analysis of the interviews shows that these specific complaints were located among less easily defined or articulated experiences of social and environmental neglect, where neighbours were estranged from one another and local authorities seen as negligent. This approach has important implications for public health, as it provides not only a strong indicator of the level of dissatisfaction within some of Londons more disadvantaged neighbourhoods, but also identifies a need for policies that are grounded in cross-disciplinary research into the relationship between health, ‘wellbeing’ and experiences of marginalisation among urban populations.

A qualitative study exploring parental accounts of feeding pre-school children in two low-income populations in the UK

Good nutrition in the early years of life is essential, yet the diets of many pre-school children in the UK are known to be poor. Understanding the decisions parents make when feeding young children is very important in determining what type and nature of interventional support may be developed to promote good nutrition. The aim of this study was to explore using qualitative methods, parental perceptions of feeding their children in order to inform the development of a nutrition intervention. Focus groups (n = 33) and individual interviews (n = 6) were undertaken with parents, most of whom were attending childrens centres in two deprived populations from one urban (Islington, north London) and one rural (Cornwall) location in England. Accounts of feeding pre-school children were primarily concerned with dealing with the practicalities of modern life, in particular the cost of food and the need to manage on a restricted household budget. Time pressures, a lack of perceived knowledge and confidence in preparing food and managing conflict over food choices between family members were also strong themes. Parents commonly reported differences between how they would like to feed their children and the reality of what they were able to do in their circumstances. These findings suggest that the poor eating habits of many pre-school children may be less a case of parental ignorance but rather the product of a range of coping strategies. Designing an intervention, which helps parents to build their confidence and self-efficacy, may enable them to make positive changes to their childrens diets.

Measures of exposure to the Well London Phase-1 intervention and their association with health well-being and social outcomes

In this paper, we describe the measures of intervention exposure used in the cluster randomised trial of the Well London programme, a public health intervention using community engagement and community-based projects to increase physical activity, healthy eating and mental health and well-being in 20 of the most deprived neighbourhoods in London.10 No earmarked resources to support the development of these measures and associated data collection were provided to either the research team or to those delivering the interventions on the ground. Instead, these were derived from contractually specified performance management information reported quarterly by partners and by inclusion of questions seeking information about participation in the follow-up questionnaires used to measure the main trial outcomes. The exposure measures are consequently considerably less sophisticated than those used in the US studies, where earmarked funding was available.

'Well London' and the benefits of participation: results of a qualitative study nested in a cluster randomised trial

Background Well London is a multicomponent community engagement and coproduction programme designed to improve the health of Londoners living in socioeconomically deprived neighbourhoods. To evaluate outcomes of the Well London interventions, a cluster randomised trial (CRT) was conducted that included a longitudinal qualitative component, which is reported here. The aim is to explore in depth the nature of the benefits to residents and the processes by which these were achieved. Methods The 1-year longitudinal qualitative study was nested within the CRT. Purposive sampling was used to select three intervention neighbourhoods in London and 61 individuals within these neighbourhoods. The interventions comprised activities focused on: healthy eating, physical exercise and mental health and well-being. Interviews were conducted at the inception and following completion of the Well London interventions to establish both if and how they had participated. Transcripts of the interviews were coded and analysed using Nvivo. Results Positive benefits relating to the formal outcomes of the CRT were reported, but only among those who participated in project activities. The extent of benefits experienced was influenced by factors relating to the physical and social characteristics of each neighbourhood. The highest levels of change occurred in the presence of: (1) social cohesion, not only pre-existing but also as facilitated by Well London activities; (2) personal and collective agency; (3) involvement and support of external organisations. Where the physical and social environment remained unchanged, there was less participation and fewer benefits. Conclusions These findings show interaction between participation, well-being and agency, social interactions and cohesion and that this modulated any benefits described. Pathways to change were thus complex and variable, but personal well-being and local social cohesion emerged as important mediators of change.