M Moonan

Barriers to partnership working in public health: a qualitative study.

Background Public health provision in England is undergoing dramatic changes. Currently established partnerships are thus likely to be significantly disrupted by the radical reforms outlined in the Public Health White Paper. We therefore explored the process of partnership working in public health, in order to better understand the potential opportunities and threats associated with the proposed changes. Methodology/Principal Findings 70 participants took part in an in-depth qualitative study involving 40 semi-structured interviews and three focus group discussions. Participants were senior and middle grade public health decision makers working in Primary Care Trusts, Local Authorities, Department of Health, academia, General Practice and Hospital Trusts and the third sector in England. Despite mature arrangements for partnership working in many areas, and much support for joint working in principle, many important barriers exist. These include cultural issues such as a lack of shared values and language, the inherent complexity of intersectoral collaboration for public health, and macro issues including political and resource constraints. There is particular uncertainty and anxiety about the future of joint working relating to the availability and distribution of scarce and diminishing financial resources. There is also the concern that existing effective collaborative networks may be completely disrupted as the proposed changes unfold. The extent to which the proposed reforms might mitigate or potentiate these issues remains unclear. However the threats currently remain more salient than opportunities. Conclusions The current re-organisation of public health offers real opportunity to address some of the barriers to partnership working identified in this study. However, significant threats exist. These include the breakup of established networks, and the risk of cost cutting on effective public health interventions.

Public health nutrition actions across 14 EU countries: a qualitative study to elicit the views of policy makers and thought leaders

Abstract Background Cardiovascular disease (CVD) is the main cause of death in Europe. EuroHeart II is a research programme led by the European Heart Network and European Society of Cardiology to address the burden of CVD in Europe and to determine interventions for prevention of avoidable deaths and disability. One aspect identifies the most effective public health nutrition policies, to inform future evidence-based strategies to promote cardiovascular health. Methods We mapped national nutrition policies across 30 European countries, then contacted and recruited potential participants in 14 of those countries. Participants were identified through various sources; for example, the European Heart Network, via national Heart Foundations, via published work, the internet, and the snowballing technique. Before interview, participants were emailed information about the project, the interview questions (developed and piloted with senior stakeholders in the UK), and a summary of public health nutrition policies in their country. Policy makers, academics, and other public health nutrition experts at the national level shared their views on a range of possible approaches to public health nutrition strategies, covering the entire policy spectrum. The interviews were done in English, either by person, telephone, or Skype. The interviews typically lasted 45–60 min. The interview questions were open ended and used as a topic guide. This structure enabled the interviews to be led by the interviewees, not the interviewers. Also, the interviews were flexible with no maximum time limit. Interviews were transcribed and entered into NVivo software. The Framework approach was used to analyse transcripts. Cross checking of coding and interpretation of data was done by three researchers from the research team. Findings We did 70 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 regarded as an early part of the policy process). Voluntary reformulation of foods is also common, especially for salt, sugar, and total fat. 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 that they were more effective than voluntary measures and information-based interventions, albeit politically more challenging. Conversely, information-based interventions were often seen as being more politically feasible than regulation and fiscal measures. Interpretation Public health nutrition policies in Europe represent a complex, dynamic, and rapidly changing arena. Encouragingly, most countries are engaged in activities intended to increase consumption of health food and decrease the intake of junk food and sugary drinks. Exemplar countries showing notable progress might include Finland, Norway, Iceland, Hungary, the UK, and Portugal. However, most countries fall well short of optimum activities. Implementation of potentially powerful nutrition policies remains frustratingly patchy across Europe. This study provides only a snapshot of activities up until 2012; developments are ongoing, and data may not be complete and will require regular updating. We propose future work to identify and assess population-based policy actions across the WHO European Region to expand and refine the evidence base. This information could support development of a nutrition policy assessment method for each country to use to promote—and implement—healthier food strategies. Funding European Union Health Programme.

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.

PS15 Policy Actions to Reduce Dietary Salt Intake: Price, Product, Place or Promotion? A Review of the Evidence

Background A range of policies aim to reduce salt intake; however, their relative effects remain unclear. We undertook a narrative synthesis of existing evidence to determine the most promising approaches. Methods We searched for systematic reviews, then empirical and modelling studies of salt reduction policies in six electronic databases. Reference lists of retrieved articles were screened and key informants were asked to identify further reviews and empirical/modelling studies. Items were assessed for inclusion and data were extracted into predesigned forms. Results were categorised using a modified version of the marketing four P’s framework: Price, Product, Place and Promotion. Results Price: A US sodium excise tax may reduce sodium intake (by 6%), systolic blood pressure (by 0.9mmHg), stroke (by 10%) and myocardial infarction (by 5%) over the lifetime of those aged 40 – 85 years. (One modelling study) Product: Voluntary US salt limits might achieve lifetime reductions in sodium intake (-9.5%), blood pressure (-1.25mmHg), myocardial infarction (-5%) and stroke (-10%). In Australia, mandatory salt limits could reduce cardiovascular disease (by 18%) but only by 1% with voluntary intervention. (Two modelling studies) Promotion: Intensive advice, support and encouragement to restrict dietary sodium intake led to significant long term reductions in urinary sodium excretion, systolic blood pressure (-1.1mmHg) and disease burden (-0.5%.) Interventions involving advertising/marketing/labelling have only been evaluated within multi-component interventions. (One systematic review.) Place: Place-based interventions (targeting schools, workplaces and community settings) have only been evaluated within multi-component interventions. Multi-component interventions: The UK FSA product and promotion-based initiatives reduced salt intake by approximately 10%. Two modelling studies estimate that similar interventions in low- and middle-income countries might achieve a 15% reduction in salt consumption, globally averting perhaps 1 million deaths and 21 million disability-adjusted life years annually. Modelling estimates from Norway suggest that combining taxes and subsidies with product and price interventions might reduce daily salt intake by 6g. Survey data reveal that in Finland between 1979 – 2002, a comprehensive and mandatory nutrition intervention (using regulations targeting price, product, place and promotion) reduced urinary sodium excretion from 13 to 10 g/day in men and from 10.5 to 7.5g/day in women. (Two empirical studies and three modelling studies) Conclusion There is patchy evidence on the effectiveness of policy actions to reduce dietary salt intake. Dietary advice can achieve modest benefits. Modelling suggests taxes and reformulation may be effective (particularly when mandatory). Empirical and modelling studies indicate multi-component interventions could be particularly powerful.