Asha Kaur

A systematic review of outcome measures used in forensic mental health research with consensus panel opinion.

OBJECTIVE To describe and assess outcome measures in forensic mental health research, through a structured review and a consensus panel. DATA SOURCES A search of eight electronic databases, including CINAHL, EMBASE and MEDLINE, was conducted for the period 1990-2006. REVIEW METHODS In the structured review, search and medical subject heading terms focused upon two factors: the use of a forensic participant sample and the experimental designs likely to be used for outcome measurement. Data extraction included general information about the identity of the reference, specific information regarding the study and information pertaining to the outcome measures used. The consensus exercise was implemented in two stages. At the first stage, participants were asked to complete ratings about the importance of various potential areas of outcome measurement in a written consultation. At the second stage, they were asked to attend a consensus meeting to review and agree results relating to the domains, to consider and rate specific outcome instruments identified as commonly used from the structured review and to discuss strengths, weaknesses and future priorities for outcome measurement in forensic mental health research. RESULTS The final sample of eligible studies for inclusion in the review consisted of 308 separate studies obtained from 302 references. The consensus group agreed on 11 domains of forensic mental health outcome measurement, all of which were considered important. Nine different outcome measure instruments were used in more than four different studies. The most frequently used outcome measure was used in 15 studies. According to the consensus group, many domains beyond recidivism and mental health were important but under-represented in the review of outcomes. Current instruments that may show future promise in outcome measurement included risk assessment tools. The outcome measure of repeat offending behaviour was by far the most frequently used, occurring in 72% of the studies included in the review. Its measurement varied with position in the criminal justice system, offence specification and method of measurement. The consensus group believed that recidivism is only an indication of the amount of antisocial acts that are committed. CONCLUSIONS A wide range of domains are relevant to assessing outcomes of interventions in forensic mental health services. Evaluations need to take account of public safety, but also clinical, rehabilitation and humanitarian outcomes. Recidivism is a very high priority; the public expects interventions that will reduce future criminal behaviour. Greater attention needs to be given to validity of measurement, given the enormous variety of approaches to measurement. More research is needed on methods to take account of the heterogeneity of seriousness of forms of recidivism in outcome measurement. Validity of self-report instruments regarding recidivism also needs examination by further research. Mental health is clearly also an important dimension of outcome. The review provides clear support for the view that domains such as quality of life, social function and psychosocial adjustment have not been extensively employed in forensic mental health research, but are relevant and important issues. The role of such instruments needs more consideration.

Outcome measures used in forensic mental health research: a structured review

BACKGROUND The evidence base for forensic mental health (FMH) services has been developing since the late 1990s. Are outcome measures sound enough for the evaluation tasks? AIMS To identify, from published literature, outcome measures used in FMH research and, where feasible, assess their quality. METHOD A structured review was undertaken of trials and intervention studies published between 1990 and 2006. Details of outcome variables and measures were abstracted. Evidence regarding most frequently occurring outcome measures was assessed. RESULTS Four hundred and fifty different instruments were used to assess outcomes, incorporating 1038 distinct variables. Very little evidence could be found to support the measurement properties of commonly used instruments. CONCLUSIONS and implications for practice There is little consistency in the use of outcome measure in FMH research. Effort is required to reach consensus on validated outcome measures in this field in order to better inform practice.

Should nutrient profile models be 'category specific' or 'across-the-board'? A comparison of the two systems using diets of British adults.

Background/Objectives:Nutrient profile models have the potential to help promote healthier diets. Some models treat all foods equally (across-the-board), some consider different categories of foods separately (category specific). This paper assesses whether across-the-board or category-specific nutrient profile models are more appropriate tools for improving diets.Subjects/Methods:Adult respondents to a British dietary survey were split into four groups using a diet quality index. Fifteen food categories were identified. A nutrient profile model provided a measure of the healthiness of all foods consumed. The four diet quality groups were compared for differences in (a) the calories consumed from each food category and (b) the healthiness of foods consumed in each category. Evidence of healthier diet quality groups consuming more of healthy food categories than unhealthy diet quality groups supported the adoption of across-the-board nutrient profile models. Evidence of healthier diet quality groups consuming healthier versions of foods within food categories supported adoption of category-specific nutrient profile models.Results:A significantly greater percentage of the healthiest diet quality groups diet consisted of fruit and vegetables (21 vs 16%), fish (3 vs 2%) and breakfast cereals (7 vs 2%), and significantly less meat and meat products (7 vs 14%) than the least healthy diet quality group. The foods from the meat, dairy and cereals categories consumed by the healthy diet quality groups were healthier versions than those consumed by the unhealthy diet quality groups.Conclusions:All other things being equal, nutrient profile models designed to promote an achievable healthy diet should be category specific but with a limited number of categories. However models which use a large number of categories are unhelpful for promoting a healthy diet.

Quantifying the Association Between Physical Activity and Cardiovascular Disease and Diabetes: A Systematic Review and Meta‐Analysis

Background The relationships between physical activity (PA) and both cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) have predominantly been estimated using categorical measures of PA, masking the shape of the dose‐response relationship. In this systematic review and meta‐analysis, for the very first time we are able to derive a single continuous PA metric to compare the association between PA and CVD/T2DM, both before and after adjustment for a measure of body weight. Methods and Results The search was applied to MEDLINE and EMBASE electronic databases for all studies published from January 1981 to March 2014. A total of 36 studies (3 439 874 participants and 179 393 events, during an average follow‐up period of 12.3 years) were included in the analysis (33 pertaining to CVD and 3 to T2DM). An increase from being inactive to achieving recommended PA levels (150 minutes of moderate‐intensity aerobic activity per week) was associated with lower risk of CVD mortality by 23%, CVD incidence by 17%, and T2DM incidence by 26% (relative risk [RR], 0.77 [0.71–0.84]), (RR, 0.83 [0.77–0.89]), and (RR, 0.74 [0.72–0.77]), respectively, after adjustment for body weight. Conclusions By using a single continuous metric for PA levels, we were able to make a comparison of the effect of PA on CVD incidence and mortality including myocardial infarct (MI), stroke, and heart failure, as well as T2DM. Effect sizes were generally similar for CVD and T2DM, and suggested that the greatest gain in health is associated with moving from inactivity to small amounts of PA.

How important is the choice of the nutrient profile model used to regulate broadcast advertising of foods to children? A comparison using a targeted data set

Background/Objective:The World Health Assembly recommends that children’s exposure to marketing of unhealthy foods should be reduced. Nutrient profile models have been developed that define ‘unhealthy’ to support regulation of broadcast advertising of foods to children. The level of agreement between these models is not clear. The objective of this study was to measure the agreement between eight nutrient profile models that have been proposed for the regulation of marketing to children over (a) how many and (b) what kind of foods should be permitted to be advertised during television viewed by children.Subjects/Methods:A representative data set of commercials for foods broadcast during television viewed by children in the UK was collected in 2008. The data set consisted of 11 763 commercials for 336 different products or brands. This data set was supplemented with nutrition data from company web sites, food packaging and a food composition table, and the nutrient profile models were applied.Results:The percentage of commercials that would be permitted by the different nutrient profile models ranged from 2.1% (0.4%, 3.7%) to 47.4% (42.1%, 52.6%). Half of the pairwise comparisons between models yielded kappa statistics less than 0.2, indicating that there was little agreement between models.Conclusions:Policy makers considering the regulation of broadcast advertising to children should carefully consider the choice of nutrient profile model to support the regulation, as this choice will have considerable influence on the outcome of the regulation.

The role of health-related claims and health-related symbols in consumer behaviour: Design and conceptual framework of the CLYMBOL project and initial results

Health claims and symbols are potential aids to help consumers identify foods that are healthier options. However, little is known as to how health claims and symbols are used by consumers in real-world shopping situations, thus making the science-based formulation of new labelling policies and the evaluation of existing ones difficult. The objective of the European Union-funded project Role of health-related CLaims and sYMBOLs in consumer behaviour (CLYMBOL) is to determine how health-related information provided through claims and symbols, in their context, can affect consumer understanding, purchase and consumption. To do this, a wide range of qualitative and quantitative consumer research methods are being used, including product sampling, sorting studies (i.e. how consumers categorise claims and symbols according to concepts such as familiarity and relevance), cross-country surveys, eye-tracking (i.e. what consumers look at and for how long), laboratory and in-store experiments, structured interviews, as well as analysis of population panel data. EU Member States differ with regard to their history of use and regulation of health claims and symbols prior to the harmonisation of 2006. Findings to date indicate the need for more structured and harmonised research on the effects of health claims and symbols on consumer behaviour, particularly taking into account country-wide differences and individual characteristics such as motivation and ability to process health-related information. Based on the studies within CLYMBOL, implications and recommendations for stakeholders such as policymakers will be provided.

Prevalence of Nutrition and Health-Related Claims on Pre-Packaged Foods: A Five-Country Study in Europe

This study is part of the research undertaken in the EU funded project CLYMBOL (“Role of health-related CLaims and sYMBOLs in consumer behaviour”). The first phase of this project consisted of mapping the prevalence of symbolic and non-symbolic nutrition and health-related claims (NHC) on foods and non-alcoholic beverages in five European countries. Pre-packaged foods and drinks were sampled based on a standardized sampling protocol, using store lists or a store floor plan. Data collection took place across five countries, in three types of stores. A total of 2034 foods and drinks were sampled and packaging information was analyzed. At least one claim was identified for 26% (95% CI (24.0%–27.9%)) of all foods and drinks sampled. Six percent of these claims were symbolic. The majority of the claims were nutrition claims (64%), followed by health claims (29%) and health-related ingredient claims (6%). The most common health claims were nutrient and other function claims (47% of all claims), followed by disease risk reduction claims (5%). Eight percent of the health claims were children’s development and health claims but these were only observed on less than 1% (0.4%–1.1%) of the foods. The category of foods for specific dietary use had the highest proportion of NHC (70% of foods carried a claim). The prevalence of symbolic and non-symbolic NHC varies across European countries and between different food categories. This study provides baseline data for policy makers and the food industry to monitor and evaluate the use of claims on food packaging.

How many foods in the UK carry health and nutrition claims, and are they healthier than those that do not?

Objective The present study aimed to measure the prevalence of different types of health and nutrition claims on foods and non-alcoholic beverages in a UK sample and to assess the nutritional quality of such products carrying health or nutrition claims. Design A survey of health and nutrition claims on food packaging using a newly defined taxonomy of claims and internationally agreed definitions of claim types. Setting A national UK food retailer: Tesco. Subjects Three hundred and eighty-two products randomly sampled from those available through the retailer’s website. Results Of the products, 32 % (95 % CI 28, 37 %) carried either a health or nutrition claim; 15 % (95 % CI 11, 18 %) of products carried at least one health claim and 29 % (95 % CI 25, 34 %) carried at least one nutrition claim. When adjusted for product category, products carrying health claims tended to be lower in total fat and saturated fat than those that did not, but there was no significant difference in sugar or sodium levels. Products carrying health claims had slightly higher fibre levels than products without. Results were similar for comparisons between products that carry nutrition claims and those that do not. Conclusions Health and nutrition claims appear frequently on food and beverage products in the UK. The nutrient profile of products carrying claims is marginally healthier than for similar products without claims, suggesting that claims may have some but limited informational value. The implication of these findings for guiding policy is unclear; future research should investigate the ‘clinical relevance’ of these differences in nutritional quality.

Outcome measurement in forensic mental health research: an evaluation

Abstract Measuring change resulting from healthcare interventions is critical to evaluating their usefulness. The choice of outcome measure is an important part of such evaluations and is driven by assumptions about what is likely to change and how best to capture this. Despite its importance, forensic mental health has paid little attention to determining which are the best measures of outcome. This study used a panel of relevant professionals to (i) assess the relative importance of different areas of potential outcome measurement and (ii) evaluate specific instruments used currently as outcome measures in forensic mental health research. Although a wide range of potential outcomes were endorsed as appropriate, few corresponding instruments have been used consistently. Only three psychiatric instruments deemed by our panel as feasible, relevant and psychometrically adequate have been used in five or more studies (the Beck Depression Inventory; the Brief Psychiatric Rating Scale, and the Symptom Checklist-90–Revised). Significant measurement gaps were noted in areas such as social and emotional functioning. Although instruments exist that could capture most areas, none were sufficiently developed for routine use as outcomes. Further research to develop robust, sensitive and diverse outcome measures is needed. This is an essential precursor to extending the evidence base for forensic mental health interventions.

The nutritional quality of foods carrying health-related claims in Germany, the Netherlands, Spain, Slovenia, and the United Kingdom

Backgroung/Objectives:Compares the nutritional quality of pre-packaged foods carrying health-related claims with foods that do not carry health-related claims.Subject/Methods:Cross-sectional survey of pre-packaged foods available in Germany, The Netherlands, Spain, Slovenia and the United Kingdom in 2013. A total of 2034 foods were randomly sampled from three food store types (a supermarket, a neighbourhood store and a discounter). Nutritional information was taken from nutrient declarations present on food labels and assessed through a comparison of mean levels, regression analyses and the application of a nutrient profile model currently used to regulate health claims in Australia and New Zealand (Food Standards Australia New Zealand’s Nutrient Profiling Scoring Criterion, FSANZ NPSC).Results:Foods carrying health claims had, on average, lower levels, per 100 g, of the following nutrients, energy—29.3 kcal (P<0.05), protein—1.2 g (P<0.01), total sugars—3.1 g (P<0.05), saturated fat—2.4 g (P<0.001), and sodium—842 mg (P<0.001), and higher levels of fibre—0.8 g (P<0.001). A similar pattern was observed for foods carrying nutrition claims. Forty-three percent (confidence interval (CI) 41%, 45%) of foods passed the FSANZ NPSC, with foods carrying health claims more likely to pass (70%, CI 64%, 76%) than foods carrying nutrition claims (61%, CI 57%, 66%) or foods that did not carry either type of claim (36%, CI 34%, 38%).Conclusions:Foods carrying health-related claims have marginally better nutrition profiles than those that do not carry claims; these differences would be increased if the FSANZ NPSC was used to regulate health-related claims. It is unclear whether these relatively small differences have significant impacts on health.