Duika Burges Watson

Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study.

Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. ‘Drip feeding’ information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation.

The Change4Life convenience store programme to increase retail access to fresh fruit and vegetables: a mixed methods process evaluation.

Background Consumption of fruit and vegetables is important for health, but is often lower than recommended and tends to be socio-economically patterned with lower consumption in more deprived groups. In 2008, the English Department of Health introduced the Change4Life convenience store programme. This aimed to increase retail access to fresh fruit and vegetables in deprived, urban areas by providing existing convenience stores with a range of support and branded point-of-sale materials and equipment. Methods We undertook a mixed-methods study of the Change4Life convenience store programme in the North East of England around two years after initial implementation. Store mapping (n = 87; 100% stores) and systematic in-store observations (n = 74; 85% stores) provided information on intervention fidelity; the variety, purchase price and quality of fresh fruit and vegetables on sale; and purchase price compared to a major supermarket. Ten qualitative interviews with a purposive sample of retailers and other professionals explored experiences of the intervention and provided further insight on quantitative results. Results Intervention stores were primarily located in socio-economically disadvantaged areas. Fidelity, in terms of presence of branded materials and equipment, was low and much was not being used as intended. Fresh fruit and vegetables on sale were of high quality and had a purchase price around 10% more than comparable products at a major supermarket. Interviewees were supportive of the health improvement aim of the intervention. Retailers were appreciative of part-funding for chill cabinets and free point-of-sale materials. The intervention suffered from: poor initial and on-going communication between the intervention delivery team and retailers; poor availability of replacement point-of-sale materials; and failure to cement intended links with health workers and community organisations. Conclusions Overall, intervention fidelity was low and the intervention is unlikely to have had a substantial or long-term effect on customers’ consumption of fruit and vegetables.

Public health and carrageenan regulation: a review and analysis

The status of carrageenan in the regulatory sphere influences how and where it may be used, with implications for seaweed farmers, carrageenan manufacturers and consumers. Over the period 1935 to the present the status of carrageenan has been effected by changes in the regulatory environment that reflect new understandings about carrageenan, health and health risks as well as broader trade, social and political changes. This paper reviews regulatory progress from the 1930s to the present. It reflects, in particular, the shifting priorities in public health and their effects on the regulatory status of carrageenan. Four case studies of public controversies about carrageenan safety are discussed in relation to regulatory responses and their public health significance. It is concluded that current assessments of risk associated with carrageenan have, in some contexts, failed to take into account the full spectrum of safety assessments that have been carried out and the maturing of food additive regulations thereby allowing a myth of risk to continue.The status of carrageenan in the regulatory sphere influences how and where it may be used, with implications for seaweed farmers, carrageenan manufacturers and consumers. Over the period 1935 to the present the status of carrageenan has been effected by changes in the regulatory environment that reflect new understandings about carrageenan, health and health risks as well as broader trade, social and political changes. This paper reviews regulatory progress from the 1930s to the present. It reflects, in particular, the shifting priorities in public health and their effects on the regulatory status of carrageenan. Four case studies of public controversies about carrageenan safety are discussed in relation to regulatory responses and their public health significance. It is concluded that current assessments of risk associated with carrageenan have, in some contexts, failed to take into account the full spectrum of safety assessments that have been carried out and the maturing of food additive regulations thereby allowing a myth of risk to continue.

Politics for food security and climate changes

In the global governance of climate change, the impact on food security remains a contested policy arena with multiple obstacles to resolution. The article begins by considering how conventional indicators understate the extent off food insecurity and diet-related inequalities. While there may be scientific consensus that climate change will affect food systems provision, a range of issues arise involving agricultural and marine environments, and the ‘double inequity’ of climate change. A further dimension involves the proliferation of ‘land grabs’ – large-scale purchases or leases by foreign actors of agricultural land for export production. Debates about food security must be opened up to scrutiny from voices outside the mainstream – in particular highlighting critiques of ‘productivist’ solutions and raising issues around purchasing power, access, and entitlement to food for low-income communities, and threats to the urban poor. Political concerns are the focus of the final section, drawing attention inter alia to debates about carbon pricing and vested interests of fossil fuel companies and codependent industries.

Book Review: Van Loon, J. (2003) Risk and Technological Culture: Towards a Sociology of Virulence, Routledge, London, New York

Once more tuberculosis stalks the globe, with one third of the world’s population infected and two million dying each year. Just thirty years ago, many believed that by the millennium, vaccination and antibiotics would eradicate a disease, which, during the nineteenth century, had been the principal cause of death in Europe and North America, with infection rates nearing 100 per cent in London and Paris. Yet, on the back of HIV, drug resistance and global social and economic change, the White Plague has returned with a vengeance, making Hippocrates’ description of this ‘greatest and most terrible disease’ as apt today as it was two thousand years ago. The essays in this edited collection by a number of distinguished authors provide a global survey of the historical, social, political and medical aspects of the re-emergence of TB. Early chapters chart the development of medical knowledge, and social attitudes towards the disease, during the 19th and 20th centuries. The major protagonists of this story are familiar with the signatures of poverty, war, gender and social upheaval evident in past records of TB infection rates from war-torn 19 century Havana to the tenements of Glasgow in the 1940s. Indeed, the history of TB reads as social history, with debates about its cause and cure reflecting the anxieties and concerns of the day. In the nineteenth century, TB became a potent but contradictory symbol for society’s ills. Social reformers in Europe and the US argued that the structural causes of this disease, known as ‘poverty’s penalty’, provided convincing evidence for the need for social change. But others used TB to stigmatise socially marginal groups and reinforce racial and ethnic divisions. In the US at the end of the 19th century, the disease was variously known as ‘negro consumption’ and the ‘Jewish disease’, the latter despite lower rates of TB amongst Jewish immigrants than native-born Americans. Science played an ambiguous role in these debates, and was enlisted to support entirely opposing policy prescriptions. As one chapter observes, the rise of germ theory provided a powerful argument for social reform, but also gave TB a new menacing aspect, namely the threat of infection from the poor, immigrants and socially excluded. The resurgence of TB in the developed world has served to heighten similar contemporary anxieties, with sometimes paradoxical consequences. For example, immigrants to the UK from countries where TB is common are subject to compulsory screening at ports of entry. Yet may end up living in parts of London where rates of disease are twice as high as in their countries of origin. Plus ça change . . . The book’s middle chapters move on to describe the causes and consequences of contemporary global patterns of the disease, especially drug resistant TB, from Sub-Saharan Africa to contemporary outbreaks in New York and London. Just a few years ago, for example, TB rates in the USSR had reached an historic low, and even the prisons of Stalin’s gulag had had TB control programmes. But the collapse in health care after the fall of Health, Risk & Society, March 2005; 7(1): 93 – 100