Lindsay McLaren

Ecological perspectives in health research

An ecological perspective on health emphasises both individual and contextual systems and the interdependent relations between the two. Origins of this approach have emanated from multiple disciplines over the past century or more. This article provides a glossary of perspectives, processes, and settings that pertain to an ecological approach in health research.

Rose's population strategy of prevention need not increase social inequalities in health

Geoffrey Roses 1985 paper, Sick individuals and sick populations, continues to spark debate and discussion. Since this original publication, there have been two notable challenges to Roses population strategy of prevention. First, identification of high-risk individuals has improved considerably in accuracy, which some believe obviates the need for population-wide prevention strategies. Secondly, and more recently, it has been suggested that population strategies of prevention may inadvertently worsen social inequalities in health. We argue that population prevention will not necessarily worsen social inequalities in health, and the likelihood of it doing so will depend on whether the prevention strategy is more structural (targets conditions in which behaviours occur) or agentic (targets behaviour change among individuals) in nature. Also, there are potential drawbacks of approaches that focus on discrete populations (i.e. high risk or vulnerable) that need to be considered when selecting a strategy. Although Roses ideas need to be continually scrutinized, his population strategy of prevention still holds considerable merit for improving population health and narrowing social inequalities in health.

Women's body dissatisfaction, social class, and social mobility.

Several studies indicate that socially advantaged women are more dissatisfied with their bodies than socially disadvantaged women. These findings have been based on womens current social class, and no attention has been paid to the social class of her family of origin or to intergenerational social mobility. In the present research 912 54-year-old women from a prospective birth cohort study provided self-report data on current body esteem (appearance and weight dimensions). Childhood and adult social class (manual versus non-manual) were defined based on fathers occupation and own or partners occupation, respectively. This information and the highest educational qualifications recorded by age 26 were gathered prospectively. Indicators of current and adolescent body mass index (BMI) were computed from height and weight values collected at ages 15 (or 11) and 53-54 years. Multiple regression was used to examine the relationship between midlife body esteem and childhood social class, adult social class, educational qualifications, and social mobility, unadjusted and adjusted for BMI. Women from the non-manual classes as adults were more dissatisfied with their weight than women from the manual classes as adults, for a given BMI. Adjusting for BMI, downwardly mobile women were more satisfied with their appearance than stable non-manual women. Adjusting for BMI, higher educational qualifications were associated with more dissatisfaction with weight and with appearance, and education appears to be more important than occupationally defined social class in explaining body dissatisfaction. A clearer understanding of the relationship between socio-economic position and body dissatisfaction demands that the following distinctions are made: weight versus appearance satisfaction, education versus occupation, and current social class versus intergenerational social mobility.

Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target

Objective To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025. Methods A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework. Results A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt. Conclusion The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

Body Dissatisfaction in Midlife Women

ABSTRACT We examined the extent and correlates of body dissatisfaction among 1026 54-year-old women from the MRC National Survey of Health and Development. Weight dissatisfaction was reported by nearly 80% of the sample and by over 50% of ‘normal weight” women (BMI < 25). Women indicated being most dissatisfied with their bodies currently, relative to their younger years, including their forties. Adjusting for BMI, dissatisfaction was highest in higher social class women and in those who rated themselves in poorer health. Women with poor body esteem, regardless of body size, were likely to avoid various everyday situations because of how they felt about their bodies. Adjusting for BMI, women who were happy with their weight were more likely to report distress about other aspects of their appearance. We suggest that body dissatisfaction in women of this age group merits further attention.

Is there an association between spatial access to parks/green space and childhood overweight/obesity in Calgary, Canada?

BackgroundThe recent increase in childhood obesity is expected to add significantly to the prevalence of chronic diseases. We used multivariate multilevel analysis to examine associations between parks/green space and childhood overweight/obesity across communities in Calgary, Canada, a city characterized by intensified urban sprawl and high car use.MethodsBody Mass Index was calculated from measured height and weight data obtained from 6,772 children (mean age = 4.95 years) attending public health clinics for pre-school vaccinations. Each childs home postal code was geocoded using ESRI ArcGIS 9.2. We examined four measures of spatial access to parks/green space (based on Geographic Information Systems): 1) the number of parks/green spaces per 10,000 residents, 2) the area of parks/green space as a proportion of the total area within a community, 3) average distance to a park/green space, and 4) the proportion of parks/green space service area as a proportion of the total area within a community. Analyses were adjusted for dissemination area median family income (as a proxy for an individual childs family income) community-level education, and community-level proportion of visible minorities.ResultsIn general, parks/green space at the community level was not associated with overweight/obesity in Calgary, with the exception of a marginally significant effect whereby a moderate number of parks/green spaces per 10,000 residents was associated with lower odds of overweight/obesity. This effect was non-significant in adjusted analyses.ConclusionOur null findings may reflect the popularity of car travel in Calgary, Canada and suggest that the role built environment characteristics play in explaining health outcomes may differ depending on the type of urban environment being studied.

Positive and negative body-related comments and their relationship with body dissatisfaction in middle-aged women

We examined the relationship between body-related comments recalled across the life span and current body esteem among 898 54-year-old female participants from the MRC National Survey of Health and Development. A significant effect of negative comments while growing up, which was independent of comments from partner, suggests an enduring adverse impact of these early comments on midlife body esteem. There was no evidence that the detrimental effect of negative comments recalled while growing up could be reversed by compliments from one’s partner. Partner comments (positive or negative) had a greater impact on the body esteem of thinner women and of women who had received positive comments while growing up. Results suggest that an impact of social feedback on body esteem is not restricted to young samples, and that comments received in adulthood (and not just during childhood or adolescence) should be taken into account.

Individual-level and neighborhood-level income measures: agreement and association with outcomes in a cardiac disease cohort.

Background:Census-based measures of income often are used as proxies for individual-level income. Yet, the validity of such area-based measures relative to ‘true’ individual-level income has not been fully characterized. Objectives:The objectives of this study were (1) to determine whether area-based measures of household income are a suitable proxy for self-reported household income and (2) to assess whether these measures are associated with outcomes in a cardiac disease cohort. Research Design:We used a prospective cohort from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH©) cardiac catheterization registry. Subjects:A total of 4372 patients having undergone cardiac catheterization and who also completed a 1-year follow-up questionnaire on self-reported income level were studied. Measures:Our measurements were survival to 2.5 years after catheterization and health-related quality of life (EuroQoL). Results:Agreement between the 2 income measures generally was poor (unweighted Kappa = 0.07), particularly for the low-income patients. Despite this poor agreement, both income measures were positively associated with survival and EuroQoL scores. An outcome analysis that simultaneously considered individual level income and area-based income revealed that low-income individuals have poorer survival and lower quality of life scores if they live in low income neighborhoods, but not if they live in high income neighborhoods. Conclusions:The area-based estimates of household income in these data demonstrate poor agreement with self-reported household income at the level of individual patients, particularly for low-income patients. Despite this, both income measures appear to be prognostically relevant, perhaps because individual and neighborhood income measure different constructs.

Women's body satisfaction at midlife and lifetime body size: A prospective study

The relationship between past body size and current body dissatisfaction among 933 middle-aged women from a prospective birth cohort study was examined. Women provided self-report data on weight esteem at age 54. Height and weight data were collected at ages 7, 11, 15, 20, 26, 36, 43, and 54. Data on reproductive variables were also collected prospectively. Hierarchical linear modeling and multiple regression analyses were used. Women who were dissatisfied at midlife were heavier at age 7 and showed a more rapid increase in body mass index with age. A late menarche, being postmenopausal, and having started hormone replacement therapy before menopause were associated with less dissatisfaction. Attention to these factors across the life span is necessary to understand body dissatisfaction in women at midlife.

Appropriateness of healthcare interventions: Concepts and scoping of the published literature

OBJECTIVES This report is a scoping review of the literature with the objective of identifying definitions, conceptual models and frameworks, as well as the methods and range of perspectives, for determining appropriateness in the context of healthcare delivery. METHODS To lay groundwork for future, intervention-specific research on appropriateness, this work was carried out as a scoping review of published literature since 1966. Two reviewers, with two screens using inclusion/exclusion criteria based on the objective, focused the research and articles chosen for review. RESULTS The first screen examined 2,829 abstracts/titles, with the second screen examining 124 full articles, leaving 37 articles deemed highly relevant for data extraction and interpretation. Appropriateness is defined largely in terms of net clinical benefit to the average patient and varies by service and setting. The most widely used method to assess appropriateness of healthcare services is the RAND/UCLA Model. There are many related concepts such as medical necessity and small-areas variation. CONCLUSIONS A broader approach to determining appropriateness for healthcare interventions is possible and would involve clinical, patient and societal perspectives.