Clare Hughes

Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups

BackgroundThis study aims to review the literature regarding the barriers to sampling, recruitment, participation, and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups.MethodsA systematic review with narrative synthesis was conducted. Searches of electronic databases Medline, PsychInfo, EMBASE, Social Science Index via Web of Knowledge and CINHAL were conducted for English language articles published up to May 2013. Qualitative and quantitative studies as well as literature reviews were included. Articles were included if they reported attempts to increase disadvantaged group participation in research, or the barriers to research with disadvantaged groups. Groups of interest were those described as socially, culturally or financially disadvantaged compared to the majority of society. Eligible articles were categorised according to five phases of research: 1) sampling, 2) recruitment and gaining consent, 3) data collection and measurement, 4) intervention delivery and uptake, and 5) retention and attrition.ResultsIn total, 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included. A comprehensive summation of the major barriers to working with various disadvantaged groups is provided, along with proposed strategies for addressing each of the identified types of barriers. Most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials.ConclusionsTo tackle the challenges of research with socially disadvantaged groups, and increase their representation in health and medical research, researchers and research institutions need to acknowledge extended timeframes, plan for higher resourcing costs and operate via community partnerships.

The effect of energy and traffic light labelling on parent and child fast food selection: a randomised controlled trial

OBJECTIVES Labelling of food from fast food restaurants at point-of-purchase has been suggested as one strategy to reduce population energy consumption and contribute to reductions in obesity prevalence. The aim of this study was to examine the effects of energy and single traffic light labelling systems on the energy content of child and adult intended food purchases. PARTICIPANTS AND METHODS The study employed a randomised controlled trial design. English speaking parents of children aged between three and 12 years were recruited from an existing research cohort. Participants were mailed one of three hypothetical fast food menus. Menus differed in their labelling technique- either energy labels, single traffic light labels, or a no-label control. Participants then completed a telephone survey which assessed intended food purchases for both adult and child. The primary trial outcome was total energy of intended food purchase. RESULTS A total of 329 participants completed the follow-up telephone interview. Eighty-two percent of the energy labelling group and 96% of the single traffic light labelling group reported noticing labelling information on their menu. There were no significant differences in total energy of intended purchases of parents, or intended purchases made by parents for children, between the menu labelling groups, or between menu labelling groups by socio-demographic subgroups. CONCLUSIONS This study provided no evidence to suggest that energy labelling or single traffic light labelling alone were effective in reducing the energy of fast food items selected from hypothetical fast food menus for purchase. Additional complementary public health initiatives promoting the consumption of healthier foods identified by labelling, and which target other key drivers of menu item selection in this setting may be required.OBJECTIVES Labelling of food from fast food restaurants at point-of-purchase has been suggested as one strategy to reduce population energy consumption and contribute to reductions in obesity prevalence. The aim of this study was to examine the effects of energy and single traffic light labelling systems on the energy content of child and adult intended food purchases. PARTICIPANTS AND METHODS The study employed a randomised controlled trial design. English speaking parents of children aged between three and 12 years were recruited from an existing research cohort. Participants were mailed one of three hypothetical fast food menus. Menus differed in their labelling technique – either energy labels, single traffic light labels, or a no-label control. Participants then completed a telephone survey which assessed intended food purchases for both adult and child. The primary trial outcome was total energy of intended food purchase. RESULTS A total of 329 participants completed the follow-up telephone interview. Eighty-two percent of the energy labelling group and 96% of the single traffic light labelling group reported noticing labelling information on their menu. There were no significant differences in total energy of intended purchases of parents, or intended purchases made by parents for children, between the menu labelling groups, or between menu labelling groups by socio-demographic subgroups. CONCLUSIONS This study provided no evidence to suggest that energy labelling or single traffic light labelling alone were effective in reducing the energy of fast food items selected from hypothetical fast food menus for purchase. Additional complementary public health initiatives promoting the consumption of healthier foods identified by labelling, and which target other key drivers of menu item selection in this setting may be required.

Regulating health claims on food labels using nutrient profiling: what will the proposed standard mean in the Australian supermarket?

OBJECTIVE Proposed Australian regulation of claims on food labels includes requirements for products carrying a health claim to meet nutrient profiling criteria. This would not apply to nutrition content claims. The present study investigated the number and healthiness of products carrying claims and the impact of the proposed regulation. DESIGN Observational survey of claims on food packages across three categories: non-alcoholic beverages, breakfast cereals and cereal bars. Nutrient profiling was applied to products carrying claims to determine their eligibility to carry health claims under the proposed regulation. SETTING Three large metropolitan stores from the three major supermarket chains in Sydney, Australia were surveyed in August 2011. SUBJECTS All claims on 1028 products were recorded. Nutrition composition and ingredients were collected from the packaging, enabling nutrient profiling. The proportion of products in each category carrying claims and the proportion of these that did not meet the nutrient profiling criteria were calculated. RESULTS Two-thirds of products in the three categories (ranging from 18 to 78 %) carried at least one claim. Of those carrying health claims, 31 % did not meet the nutrient profiling criteria. These would be ineligible to carry these claims under the proposed regulation. Additionally, 29 % of products carrying nutrition content claims did not meet the nutrient profiling criteria. CONCLUSIONS The number of products carrying nutrition content claims that did not meet the nutrient profiling criteria suggests that comprehensive regulation is warranted. Promotion of unhealthy foods using claims is potentially misleading for consumers and hinders their ability to select healthier foods. Implementation of the proposed regulation represents an improvement to current practice.

Increased exposure to community-based education and ‘below the line’ social marketing results in increased fruit and vegetable consumption

OBJECTIVE To determine if localised programmes that are successful in engaging the community can add value to larger fruit and vegetable mass-media campaigns by evaluating the results of the Eat It To Beat It programme. DESIGN The Eat It To Beat It programme is a multi-strategy intervention that uses community-based education and ‘below the line’ social marketing to increase fruit and vegetable consumption in parents. This programme was evaluated by a controlled before-and-after study with repeat cross-sectional data collected via computer-assisted telephone interviews with 1403 parents before the intervention (2008) and 1401 following intervention delivery (2011). SETTING The intervention area was the Hunter region and the control area was the New England region of New South Wales, Australia. SUBJECTS Parents of primary school-aged children (Kindergarten to Year 6). RESULTS The programme achieved improvements in knowledge of recommended intakes for fruit and vegetables and some positive changes in knowledge of serving size for vegetables. Exposure to the programme resulted in a net increase of 0.5 servings of fruit and vegetables daily for those who recalled the programme compared with those who did not (P = 0.004). Increased intake of fruit and vegetables was significantly associated with increasing exposure to programme strategies. CONCLUSIONS The Eat It To Beat It programme demonstrates that an increase in consumption of fruit and vegetables can be achieved by programmes that build on the successes of larger mass-media and social-marketing campaigns.This suggests that funding for localised, community-based programmes should be increased.

Do Health Claims and Front-of-Pack Labels Lead to a Positivity Bias in Unhealthy Foods?

Health claims and front-of-pack labels (FoPLs) may lead consumers to hold more positive attitudes and show a greater willingness to buy food products, regardless of their actual healthiness. A potential negative consequence of this positivity bias is the increased consumption of unhealthy foods. This study investigated whether a positivity bias would occur in unhealthy variations of four products (cookies, corn flakes, pizzas and yoghurts) that featured different health claim conditions (no claim, nutrient claim, general level health claim, and higher level health claim) and FoPL conditions (no FoPL, the Daily Intake Guide (DIG), Multiple Traffic Lights (MTL), and the Health Star Rating (HSR)). Positivity bias was assessed via measures of perceived healthiness, global evaluations (incorporating taste, quality, convenience, etc.) and willingness to buy. On the whole, health claims did not produce a positivity bias, while FoPLs did, with the DIG being the most likely to elicit this bias. The HSR most frequently led to lower ratings of unhealthy foods than the DIG and MTL, suggesting that this FoPL has the lowest risk of creating an inaccurate positivity bias in unhealthy foods.

Investigating fruit and vegetable claims on Australian food packages

OBJECTIVES Fruit and vegetable claims on food packages are not regulated under Australian food standards. The present study aimed to: (i) investigate the number and healthiness of products carrying fruit and vegetable claims in Australia; and (ii) compare the nutrition composition of these products with fresh fruit and/or vegetables. DESIGN Content analysis of fruit and vegetable claims on food packages. The Australian food standards nutrient profiling model was used to determine the proportion of products not meeting nutrient profiling criteria. The nutrient composition of products carrying claims referencing the servings of fruit and vegetables in the product were compared with that of the dominant fruit and/or vegetables in each product. SETTING The five largest supermarket chains in Australia. SUBJECTS All available products in the fruit snacks, soups and fruit and vegetable juices/fruit drinks categories (n 762) were surveyed. Nutrition composition, ingredients and claims were recorded for each product. RESULTS Of the products surveyed, 48 % (n 366) carried at least one claim, of which 34 % (n 124) did not meet nutrient profiling. Products carrying claims referencing the number of servings of fruit and vegetables had more energy, sodium, saturated fat and sugar, and less fibre, than fresh fruit and/or vegetables (all P<0·001). CONCLUSIONS Many products carried fruit and vegetable claims and were significantly higher in energy, saturated fat, sugars and sodium than fresh fruit and vegetables. Marketing these products as a way of meeting fruit and vegetable intake is inaccurate and potentially misleading. Fruit and vegetable claims should be regulated using nutrient profiling.

Who is responsible for selecting children's fast food meals, and what impact does this have on energy content of the selected meals?

Aim The present study aimed to: (i) document the role of parents in childrens fast food meal selection; (ii) determine whether parental demographics, weight status or fast food consumption frequency were associated with who selects childrens fast food meals; and (iii) determine whether the total energy content of childrens meals selected from a hypothetical fast food menu was associated with selection responsibility. Methods A cross-sectional survey of 477 parents of children aged 3–12 years in New South Wales, Australia, was conducted. Participants completed two computer-assisted telephone interviews. The first collected demographic and anthropometric data including height and weight. Participants were subsequently mailed a hypothetical fast food menu. The second interview asked who was responsible for selecting their childrens fast food meals, and what items would be chosen. Energy content of the selections was examined. Results Most parents (60%) stated that they shared meal selection responsibility with their children. Parents with higher education levels (P < 0.01) or younger children (P < 0.01) were more likely to take responsibility for meal selection. When parents stated that children were responsible, they chose fast food meals with significantly higher energy content than when responsibility was shared (P < 0.01). Conclusions The present study shows that parents are influential in childrens fast food intake. Parents should be encouraged to play an active role in assisting children to make healthier fast food choices, to reduce the impact of high-energy meals on their overall diets.

Advertising to children initiatives have not reduced unhealthy food advertising on Australian television.

Background In response to rising childhood obesity rates, the Australian food industry implemented two initiatives in 2009 to reduce the marketing of unhealthy food to children. This study evaluated the efficacy of these initiatives on the rate of unhealthy food advertising to children on Australian television. Methods The rates of food advertisements on three free‐to‐air commercial television channels and a youth‐oriented digital channel in Sydney, Australia were analysed over 2 weekdays (16 h) and two weekend days (22 h). Advertisements were categorized according to the healthiness of foods advertised (non‐core, core, miscellaneous) and signatory status to the food industry advertising initiatives. Results Total food advertising rates for the three channels increased from 5.5/h in 2011 to 7.3/h in 2015, due to an increase of 0.8/h for both core and miscellaneous foods. The rate of non‐core food advertisements in 2015 (3.1/h) was similar to 2011 (3.0/h). The youth‐oriented channel had fewer total food advertisements (3.7/h versus 7.3/h) but similar fast‐food advertisement rates (1.3/h versus 1.3/h). Conclusions There was no change in the rate of unhealthy food advertising since 2011, suggesting minimal impact of the current food industry initiatives on reducing childrens exposure to unhealthy food advertising.

Energy-dense fast food products cost less: an observational study of the energy density and energy cost of Australian fast foods.

Objective: To examine the association between energy cost and energy density of fast food products.

Protocol for a Randomized Trial Assessing Consumer Evaluations of Pre-Packaged Foods that Systematically Vary by Nutrition Information and Product Attributes

BackgroundNutrition information is increasingly provided on pre-packaged foods as a public health measure to help consumers make healthier food choices. Many studies have looked at the independent effects of three main sources of nutrition information: the Nutrition Information Panel (NIP), front-of-pack labels and health claims. However, few studies have considered their interactive effects. A better understanding of how these different sources of nutrition information interact with each other is important given they frequently appear together on food packs. There are also policy implications since many countries specifically mandate the provision of an NIP whenever a health claim is made.MethodsThis paper outlines a protocol for an experimental study assessing how nutrition information (FoPLs, health claims and NIP), in combination with food type, price and product healthiness interact to affect consumers’ product evaluations. Consumers’ global impressions, perceptions of healthiness, purchase intentions and assumptions relating to the amount of the product that is appropriate/desirable to consume will be assessed. The nutrition information presented will include NIPs, front-of-pack labels (Daily Intake Guide, Multiple Traffic Light system, Health Star Rating system) and health claims (nutrient content, general level, higher level). A diverse sample of approximately 2000 Australians will be recruited to complete an online survey that will require them to evaluate a range of hypothetical products with varying nutrition and price attributes. All attribute levels will be fully crossed with each other, resulting in a full factorial design. This design has not been used in past studies and offers a higher level of control than achieved previously due to the ability to explore interactions between all attribute levels.DiscussionStudy results will indicate (1) the independent and combined effects of each attribute on consumer evaluations, (2) which front-of-pack labels are more effective at helping consumers distinguish between healthier and less healthy foods and (3) how health claims affect perceptions of healthiness. The study will also provide crucial information on the effectiveness of the new Health Star Rating system, for which quantitative research is currently lacking.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12616000626460. Retrospectively registered: 16 May, 2016.