Elspeth Anwar

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.

Return on investment of public health interventions: a systematic review

Background Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions. Methods We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries. Results We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5. Conclusions This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy.

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.

Poverty and child health in the UK: using evidence for action

There are currently high levels of child poverty in the UK, and for the first time in almost two decades child poverty has started to rise in absolute terms. Child poverty is associated with a wide range of health-damaging impacts, negative educational outcomes and adverse long-term social and psychological outcomes. The poor health associated with child poverty limits childrens potential and development, leading to poor health and life chances in adulthood. This article outlines some key definitions with regard to child poverty, reviews the links between child poverty and a range of health, developmental, behavioural and social outcomes for children, describes gaps in the evidence base and provides an overview of current policies relevant to child poverty in the UK. Finally, the article outlines how child health professionals can take action by (1) supporting policies to reduce child poverty, (2) providing services that reduce the health consequences of child poverty and (3) measuring and understanding the problem and assessing the impact of action.

‘It has not ruined my life; it has made my life better’: a qualitative investigation of the experiences and future aspirations of young mothers from the North West of England

BACKGROUND Teenage pregnancy has been portrayed as problematic and leading to negative long-term health outcomes. However, this assumption has been questioned. This qualitative study explores the experiences and future aspirations of teenage mothers in North West England. METHODS Ten in-depth qualitative interviews were conducted with teenage mothers recruited from childrens centres located in deprived areas. RESULTS The young mothers felt motherhood was a positive experience, which provided them with a valued social role. Within the communities they lived, they felt well supported. For many of the young mothers, dislike of school had occurred pre-pregnancy and becoming a mother had led the young women to reassess the value of education and employment. However, in common with many older mothers, while their child is young they choose to prioritize motherhood. The young women relied heavily upon family and the support of trusted professionals. CONCLUSIONS Motherhood can be a positive experience that makes sense in the lives of young women from disadvantaged backgrounds. To be effective, policy must recognize the valued social role motherhood provides for these young women. The negative long-term outcomes observed may largely be a result of their disadvantaged position within society and this should be the focus of interventions.

Erratum: The health equity and effectiveness of policy options to reduce dietary salt intake in England: Policy forecast (PLoS ONE (2015) 10:7 (e0127927) DOI: 10.1371/journal.pone.0127927)

There is information missing from funding section of this paper. The funding section should read: This article presents independent research funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR) through a grant (SPHR-LIL-PH1-MCD) to the LiLaC collaboration between the University of Liverpool and Lancaster University. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

P97 Quantifying the Return on Investment of Public Health Interventions: A systematic review

Background Benjamin Franklin once famously stated that “an ounce of prevention is worth a pound of cure”. Despite this concept, the Treasury recently announced substantial cuts to the public health budget. Ignoring previous assurances that no service cuts would be made. A number of organisations have suggested that cuts to public health budgets are a short sighted false economy, and will likely lead to considerable harms. To help inform the potential impact of cuts to public health budgets, we set out to determine the return on investment (ROI) and opportunity cost for a range of public health interventions. We further hypothesised a “public health Effectiveness Hierarchy”: that the median ROI of interventions delivered at a national level is at least a twofold greater than those delivered at regional or local level. Methods We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED) to identify studies that calculated or reported a return on investment for public health interventions in the UK and other countries where relevant. Interventions were stratified by national, regional and local level to test the effectiveness hierarchy hypothesis. Results We identified 5020 potentially relevant titles, and finally included 52. Many studies examined ‘health protection’ interventions such as vaccination, few reported ‘wider determinants’ interventions. Median ROI results were 14.3 for every 1 unit invested. Studies reporting a cost benefit ratio (CBR) produced a very similar median of 14.1: 1. Stratification by level revealed an effectiveness hierarchy whereby national programmes tended to provide larger returns compared to regional or local interventions, median ROI of 28.6 versus 4.0, median CBR 17.5 versus 10.3. The quality and analysis of ROI values ranged widely, but was generally better in studies reporting a CBR. Conclusion Extensive evidence suggests that Benjamin Franklin was correct – public health interventions offer substantial returns on investment. Nation-wide programmes typically achieved returns on investment averaging 14:1 compared with 4:1 returns for local interventions, consistent with a public health effectiveness hierarchy. The proposed Treasury cuts to local public health budgets in England might therefore be a false economy. The so-called “efficiency savings” will paradoxically result in substantial additional costs to the NHS and the wider economy.

OP16 Utilising a Novel Framework to Assess Public Health Nutrition Actions Across 30 European Countries (EuroHeart II Project)

Background EuroHeart II is a European programme designed to inform cardiovascular health strategies across Europe. Our project examines the role of food policies in cardiovascular disease prevention, including the development and piloting of a novel conceptual framework for categorising public health nutrition policies. Methods We conducted a mapping exercise to identify and categorise public health nutrition policy actions across 30 European countries using a novel framework. The framework was based on the traditional marketing “4Ps” approach: Price, Product, Promotion and Place (the “marketing mix”). A database was created to summarise public health nutrition policy for 30 European countries (EU 27 plus Iceland, Norway and Switzerland). National policies were classified according to Price (taxes, subsidises, other economic incentives); Product (reformulation, new healthier products); Place (schools, workplaces, community settings); and Promotion (advertising to children/general population, food labelling and health education initiatives). Results Dialogue, recommendations and nutrition guidelines are now widespread across Europe. Information and education campaigns are also widespread. These include campaigns covering the general population, and campaigns targeting schools, the workplace or communities. Subsidies for fruit in schools are almost universal through the EU School Fruit Scheme, but implementation differs across the 30 countries. New EU legislation supports limited, back of pack food labelling. Some countries have also implemented national legislation requiring more detailed label information about the nutritional value of foods (e.g. Finland). However, the presentation and information vary widely. Voluntary reformulation of foods is common, especially for salt, sugar and total fat (e.g. salt reduction in the UK). However, mandatory reformulation of products to reduce saturated fat and salt are still limited to trans fat bans in Austria, Denmark, Iceland and Switzerland. Legislation/regulation affecting salt, sugar, fat and fruit and vegetable consumption is uncommon, although several countries have legal requirements regarding the maximum salt content in certain foods (Belgium, Bulgaria, Finland, Greece, Latvia, Lithuania, Netherlands, Portugal, Romania, Slovak Republic, Slovenia and Wales). Taxes to promote healthy nutrition are currently used infrequently. However, Finland, France, Hungary and Portugal have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Hungary and Portugal also tax salty products. Conclusion The diverse public health nutrition activities across 30 European countries might initially appear complex and bewildering. However, the “4Ps” framework offers a potentially structured and comprehensive categorisation of these diverse interventions. National food policies in Europe are currently at very different stages of development and implementation. However, exemplar countries might include Denmark, Finland, Hungary, Iceland, the UK and Portugal.

OP15 Identifying the most effective public health nutrition policies: The views of policy-makers and thought-leaders across 14 EU countries

Background EuroHeart 2 is a European research programme led by the European Heart Network and European Society of Cardiology (http://www.ehnheart.org/euroheart-ii.html). One aspect of the project aimed to identify the most effective public health nutrition policies, in order to inform future evidence-based strategies to promote cardiovascular health. We interviewed senior policy-makers and thought-leaders in 14 diverse EU countries to elicit their views on a very wide range of possible nutrition strategies covering the entire public health policy spectrum aimed at improving approaches to public health nutrition. Methods We first mapped national nutrition policies across 30 European countries. We then identified contacted and recruited potential participants in 14 diverse countries. Policy-makers, thought-leaders and others active in the field of public health nutrition at the national level were interviewed. Questions were first developed and piloted with senior stakeholders in the UK. The interviews were conducted in English, either by person, telephone or Skype. The interviews typically lasted between 45 and 60 minutes. The interviews were transcribed and entered into NVIVO software. The Framework approach was used to analyse the transcripts. Results We conducted 66 interviews in 14 countries across Europe. The interviews enabled more up to date and accurate information than was provided on websites or in reports. Responses revealed important differences between official lists of food policies and their actual implementation “on the ground”. European countries are at very different stages of addressing public health nutrition issues. Most are promoting dialogue, recommendations and guidelines (often considered an early part of the policy process). Voluntary reformulation of foods is also common, especially for salt, sugar and total fat. However, legislation regulation or fiscal interventions targeting salt, sugar, fat or fruit and vegetable consumption are still uncommon. Many interviewees expressed a preference for regulation and fiscal interventions and generally believed they were more effective, albeit politically more challenging. Conversely, information-based interventions were often seen as being more politically feasible. Conclusion Public health nutrition policies in Europe represent a complex, dynamic and rapidly changing arena. Encouragingly, the majority of countries are engaged in activities intended to increase consumption of health food, and decrease the intake of junk food and sugary drinks. Exemplar countries demonstrating notable progress might include Finland, Norway, Iceland, Hungary, the UK and Portugal. However, most countries fall well short of optimal activities. Implementation of potentially powerful nutrition policies remains frustratingly patchy across Europe.

PP09 Assessing the Potential Effect of Healthy Eating Policy Interventions on Socioeconomic Inequalities: Systematic Review

Background Cardiovascular disease (CVD) is one of the main contributors to health inequalities. CVD primary prevention includes potentially powerful interventions to promote healthy eating. However, might some dietary interventions actually widen the heath gap between rich and poor, thus leading to intervention-generated inequalities? Objective To systematically review the evidence for differential socio-economic effects associated with healthy eating policy interventions. Methods We initially searched two bibliographic databases (MEDLINE & Psycinfo) using a piloted search strategy. Results from further databases and additional sources will be reported in the final review. Search results were screened independently by two reviewers. We included evaluations of policy interventions to promote healthier diets, (defined as the reduced intake of salt, sugar, trans fats, saturated fat, total fat, or total calories, or increased consumption of fruit and vegetables). All quantitative studies were eligible for inclusion. Studies were only included if quantitative results were presented by socio-economic group (SEG), defined by income, education level, ethnicity, or occupational status. Extracted data were categorised with a modified version of the 4Ps marketing framework: Price, Product, Place and Promotion, with a 5th “P” labelled “Personal”, relating to person-based health education. Based on preliminary findings included studies were synthesised as a narrative review due to their heterogeneous nature. Results We identified 14,449 studies in the initial search and reviewed 47 full text papers. Following screening, only 14 articles met the inclusion criteria. Preliminary results analysed using the “5 P’s” framework suggest that some food policy interventions may generate socio-economic differentials. Price interventions showed the greatest potential to reduce health inequalities (3 of 5 studies). Conversely, Personal interventions tended to widen inequalities (3 of 4 studies showed preferential outcomes in higher SEGs). Results relating to Place interventions were mixed, with 2 school-based studies reporting a preferential outcome in higher SEGs, and 1 work-based study reporting a preferential outcome in lower SEGs. Evidence for Product and Promotion interventions appears sparse, with only 1 study found for each category. However, both reporting preferential outcomes in higher SEGs. Conclusion Interventions categorised by the “5 P’s” show differential effects on healthy eating outcomes by SEG, with interventions categorised as Personal appearing the most likely to increase health inequalities. However the vast majority of studies retrieved did not explore differential effects by socio-economic group. Future policies aimed at improving population health should be routinely evaluated for their potential impact on health inequalities.