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Barrett M, Spires M, Vogel C. The Healthy Start scheme in England "is a lifeline for families but many are missing out": a rapid qualitative analysis. BMC Med 2024; 22:177. [PMID: 38715000 PMCID: PMC11077836 DOI: 10.1186/s12916-024-03380-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Healthy Start (HS) is a government scheme in England, Wales and Northern Ireland that offers a financial payment card and free vitamins to families experiencing low income. Pregnant women and families with children < 4 years can use the HS card to buy fruit, vegetables, cow's milk, infant formula and pulses. HS was fully digitalised in March 2022. While digitalisation has improved the user experience for many families, in the context of the cost-of-living crisis and increasing dietary inequalities, it is important to understand why HS is not reaching more families. This study aimed to (i) assess the perceptions and experiences of HS from stakeholders across the system including those who promote, implement and are eligible for HS, and (ii) identify recommendations to improve the scheme's effectiveness and uptake. METHODS The study design was a post-implementation rapid qualitative evaluation using stakeholder interviews. Data were collected between January and June 2023 via semi-structured interviews (50% online; 50% in person) with 112 stakeholders, including parents (n = 59), non-government organisations (n = 13), retailers (n = 11) and health and community professionals (n = 29) at national and local levels. Findings were confirmed by a sub-sample of participants. RESULTS Six core themes cut across stakeholders' perceptions and experiences, and stakeholders collectively outlined seven recommendations they felt could be acted upon to maximise uptake and efficiency of HS, with actions at both national and local levels. A novel finding from this study is that raising awareness about HS alone is unlikely to result automatically or universally in higher uptake rate. Recommendations include: continuing to provide this scheme that is universally valued; the need for many families to be provided with a helping hand to successfully complete the application; reframing of the scheme as a child's right to food and development to ensure inclusivity; improved leadership, coordination and accountability at both national and local levels. CONCLUSIONS HS provides benefits for child development and family wellbeing. The study's recommendations should be actioned by national and local governments to enable all families eligible for the scheme to benefit from this nutritional safety net.
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Affiliation(s)
- Millie Barrett
- Centre for Food Policy, City, University of London, London, UK.
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, UK.
| | - Mark Spires
- Centre for Food Policy, City, University of London, London, UK
| | - Christina Vogel
- Centre for Food Policy, City, University of London, London, UK
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, UK
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
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Escher NA, Andrade GC, Ghosh-Jerath S, Millett C, Seferidi P. The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review. Lancet Glob Health 2024; 12:e419-e432. [PMID: 38301666 PMCID: PMC7616050 DOI: 10.1016/s2214-109x(23)00562-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Low-income and middle-income countries (LMICs) experiencing nutrition transition face an increasing double burden of malnutrition (DBM). WHO has urged the identification of risks and opportunities in nutrition interventions to mitigate the DBM, but robust evidence is missing. This review summarises the effect of nutrition-specific and nutrition-sensitive interventions on undernutrition and overnutrition in LMICs. METHODS We searched four major databases and grey literature for publications in English, French, Portuguese, and Spanish from Jan 1, 2000, to Aug 14, 2023. Eligible studies evaluated nutrition-specific or nutrition-sensitive interventions on both undernutrition and overnutrition, employing robust study designs (individually randomised, cluster randomised, and non-randomised trials; interrupted time series; controlled before-after; and prospective cohort studies). Studies were synthesised narratively, and classified as DBM-beneficial, potentially DBM-beneficial, DBM-neutral, potentially DBM-harmful, and DBM-harmful, using vote counting. This review is registered with PROSPERO (CRD42022320131). FINDINGS We identified 26 studies evaluating 20 nutrition-specific (maternal and child health [MCH] and school-based programmes) and six nutrition-sensitive (conditional cash transfers and other social policies) interventions. Seven of eight MCH interventions providing food-based or nutritional supplements indicated possible DBM-harmful effects, associated with increased maternal or child overweight. Most school-based programmes and MCH interventions that target behavioural change were considered potentially DBM-beneficial. Two studies of conditional cash transfers suggested DBM-beneficial effects in children, whereas one indicated potentially harmful effects on maternal overweight. A study on a family planning service and one on an education reform revealed possible long-term harmful effects on obesity. INTERPRETATION There is considerable scope to repurpose existing nutrition interventions to reduce the growing burden of the DBM in LMICs. In settings undergoing rapid nutrition transition, specific policy attention is required to ensure that food-based or supplement-based MCH programmes do not unintentionally increase maternal or child overweight. Consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is essential to expand the evidence base to identify and promote interventions maximising benefits and minimising harms on the DBM. FUNDING President's Scholarship (Imperial College London) and National Institute for Health and Care Research. TRANSLATIONS For the Portuguese, Spanish and French translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nora A Escher
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.
| | - Giovanna C Andrade
- Centre for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil
| | | | - Christopher Millett
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal; Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil
| | - Paraskevi Seferidi
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
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Thomas M, Moore JB, Onuselogu DA, Dalton A, Rains T, Lowry E, Sritharan N, Morris MA. Supermarket top-up of Healthy Start vouchers increases fruit and vegetable purchases in low-income households. NUTR BULL 2023; 48:353-364. [PMID: 37501220 DOI: 10.1111/nbu.12627] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023]
Abstract
Stark, widening health and income inequalities in the United Kingdom underpin the need for increased support for low-income families to access affordable and nutritious foods. Using anonymised supermarket loyalty card transaction records, this study aimed to assess how an additional Healthy Start voucher (HSV) top-up of £2, redeemable only against fruit and vegetables (FVs), was associated with FV purchases among at-risk households. Transaction and redemption records from 150 loyalty card-holding households, living in northern England, who had engaged with the top-up scheme, were analysed to assess the potential overall population impact. Using a pre-post study design, 133 of these households' records from 2021 were compared with equivalent time periods in 2019 and 2020. Records were linked to product, customer and store data, permitting comparisons using Wilcoxon matched-pairs sign-ranked tests and relationships assessed with Spearman's Rho. These analyses demonstrated that 0.9 more portions of FV per day per household were purchased during the scheme compared to the 2019 baseline (p = 0.0017). The percentage of FV weight within total baskets also increased by 1.6 percentage points (p = 0.0242), although the proportional spend on FV did not change. During the scheme period, FV purchased was higher by 0.4 percentage points (p = 0.0012) and 1.6 percentage points (p = 0.0062) according to spend and weight, respectively, in top-up redeeming baskets compared to non-top-up redeeming baskets with at least one FV item and was associated with 5.5 more HSV 'Suggested' FV portions (p < 0.0001). The median weight of FV purchased increased from 41.83 kg in 2019 to 54.14 kg in 2021 (p = 0.0017). However, top-up vouchers were only redeemed on 9.1% of occasions where FV were purchased. In summary, this study provides novel data showing that safeguarding funds exclusively for FV can help to increase access to FV in low-income households. These results yield important insights to inform public policy aimed at levelling up health inequalities.
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Affiliation(s)
- Madeleine Thomas
- School of Food Sciences and Nutrition, University of Leeds, Leeds, UK
| | | | | | - Alexandra Dalton
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | | | | | | | - Michelle A Morris
- School of Food Sciences and Nutrition, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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Miguel-Berges ML, Jimeno-Martínez A, Larruy-García A, Moreno LA, Rodríguez G, Iguacel I. The Effect of Food Vouchers and an Educational Intervention on Promoting Healthy Eating in Vulnerable Families: A Pilot Study. Nutrients 2022; 14:nu14234980. [PMID: 36501009 PMCID: PMC9739317 DOI: 10.3390/nu14234980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Cost has been reported as the main barrier to healthy eating in vulnerable groups. We aimed to evaluate the effect of a nutrition education intervention on adherence to Mediterranean Diet and health when providing food vouchers. This pilot study has a randomized control trial design. We included 66 vulnerable users from the Red Cross of Zaragoza (Spain). Intervention and control group individuals received 120 euros/month of food vouchers over 3 months to be spent in supermarkets (60 euros/month if under 12 y) plus a 10-week nutrition education program for the intervention group. Family food purchases were assessed using electronically recorded supermarket-obtained transactions. During and at the end of the intervention the percentage of healthy food was higher in the intervention than in the control group. Once the nutrition education was over, differences between groups dissipated. In the intervention group, health parameters improved, particularly weight-status, lipids, and liver enzymes. Control participants gained weight, although lipid and liver enzymes improved. Blood pressure and HbA1c did not improve in either the intervention or the control group. In conclusion, providing unrestricted food vouchers to vulnerable groups to increase healthy food consumption appears to be insufficient and should be accompanied by medium-long term nutrition education.
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Affiliation(s)
- María L. Miguel-Berges
- Growth, Exercise, Nutrition and Development (GENUD) Research Group, University of Zaragoza, C/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón, 50013 Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), 50009 Zaragoza, Spain
| | - Andrea Jimeno-Martínez
- Growth, Exercise, Nutrition and Development (GENUD) Research Group, University of Zaragoza, C/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón, 50013 Zaragoza, Spain
| | - Alicia Larruy-García
- Growth, Exercise, Nutrition and Development (GENUD) Research Group, University of Zaragoza, C/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón, 50013 Zaragoza, Spain
| | - Luis A. Moreno
- Growth, Exercise, Nutrition and Development (GENUD) Research Group, University of Zaragoza, C/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón, 50013 Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), 50009 Zaragoza, Spain
| | - Gerardo Rodríguez
- Growth, Exercise, Nutrition and Development (GENUD) Research Group, University of Zaragoza, C/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón, 50013 Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
| | - Isabel Iguacel
- Growth, Exercise, Nutrition and Development (GENUD) Research Group, University of Zaragoza, C/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón, 50013 Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), 50009 Zaragoza, Spain
- Correspondence: ; Tel.:+34-(97)-6761749
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van der Gulden R, Timmerman A, Muris JWM, Thoonen BPA, Heeneman S, Scherpbier-de Haan ND. How does portfolio use affect self-regulated learning in clinical workplace learning: What works, for whom, and in what contexts? PERSPECTIVES ON MEDICAL EDUCATION 2022; 11:247-257. [PMID: 36136233 PMCID: PMC9582105 DOI: 10.1007/s40037-022-00727-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Portfolio use to support self-regulated learning (SRL) during clinical workplace learning is widespread, but much is still unknown regarding its effectiveness. This review aimed to gain insight in the extent to which portfolio use supports SRL and under what circumstances. METHODS A realist review was conducted in two phases. First, stakeholder interviews and a scoping search were used to formulate a program theory that explains how portfolio use could support SRL. Second, an in-depth literature search was conducted. The included papers were coded to extract context-mechanism-outcome configurations (CMOs). These were synthesized to answer the research question. RESULTS Sixteen papers were included (four fulfilled all qualitative rigor criteria). Two primary portfolio mechanisms were established: documenting as a moment of contemplation (learners analyze experiences while writing portfolio reports) and documentation as a reminder of past events (previous portfolio reports aid recall). These mechanisms may explain the positive relationship between portfolio use and self-assessment, reflection, and feedback. However, other SRL outcomes were only supported to a limited extent: formulation of learning objectives and plans, and monitoring. The partial support of the program theory can be explained by interference of contextual factors (e.g., system of assessment) and portfolio-related mechanisms (e.g., mentoring). DISCUSSION Portfolio research is falling short both theoretically-in defining and conceptualizing SRL-and methodologically. Nevertheless, this review indicates that portfolio use has potential to support SRL. However, the working mechanisms of portfolio use are easily disrupted. These disruptions seem to relate to tensions between different portfolio purposes, which may undermine learners' motivation.
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Affiliation(s)
- Rozemarijn van der Gulden
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Angelique Timmerman
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Jean W M Muris
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Bart P A Thoonen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sylvia Heeneman
- Department of Pathology, Maastricht University, Maastricht, The Netherlands
| | - Nynke D Scherpbier-de Haan
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, Groningen, The Netherlands
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Carbonneau E, Dumas A, Brodeur-Doucet A, Fontaine-Bisson B. A Community Prenatal Intervention in Social Nutrition: Evaluating the Impact on Pregnancy and Birthweight Outcomes. Nutrients 2022; 14:nu14061151. [PMID: 35334807 PMCID: PMC8951613 DOI: 10.3390/nu14061151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 02/04/2023] Open
Abstract
This study aims to assess the associations between structural features of the Montreal Diet Dispensary’s social nutrition intervention and pregnancy (i.e., anemia, gestational diabetes mellitus (GDM), gestational weight gain (GWG), hypertension) and birthweight outcomes (i.e., small- or large-for-gestational-age) among pregnant women, most of them recent immigrants. The study consists of a secondary analysis of the digital client database of the Montreal Diet Dispensary (n = 2925). Logistic regressions were used to estimate the odds of pregnancy and birthweight outcomes, depending on structural features of the intervention. Pregnant women who attended a welcoming group session presented lower odds of GDM and anemia compared to those who did not attend. A longer duration of intervention was also associated with lower odds of GDM and anemia. Each additional appointment with a dietitian was associated with higher odds of excessive GWG and lower odds of insufficient GWG only among women with a pre-pregnancy BMI lower than 25 kg/m2. This study emphasizes the importance of providing nutritional services early in pregnancy to reduce the risk of GDM and anemia. It also stresses the importance of using appropriate nutritional guidelines to avoid increasing the risk of excessive GWG.
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Affiliation(s)
- Elise Carbonneau
- School of Nutrition Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
- Centre NUTRISS—Nutrition, Santé et Société, Institut sur la Nutrition et les Aliments Fonctionnels, Université Laval, Quebec, QC G1V 0A6, Canada
- School of Nutrition, Université Laval, Quebec, QC G1V 0A6, Canada
- Correspondence:
| | - Alex Dumas
- School of Human Kinetics, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
- Institut du Savoir Montfort, Montfort Hospital, Ottawa, ON K1K 0T2, Canada
| | | | - Bénédicte Fontaine-Bisson
- School of Nutrition Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
- Institut du Savoir Montfort, Montfort Hospital, Ottawa, ON K1K 0T2, Canada
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7
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Moonan M, Maudsley G, Hanratty B, Whitehead M. An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England. BMC Public Health 2022; 22:392. [PMID: 35209874 PMCID: PMC8869346 DOI: 10.1186/s12889-022-12704-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Government nutritional welfare support from the English 'Healthy Start' scheme is targeted at low-income pregnant women and preschool children, but take-up of its free food vouchers is much better than its free vitamin vouchers. While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children's centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins. METHODS Informed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children's centres in a similarly deprived universal and a targeted implementation-area of North West England. RESULTS While good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families' resilience. CONCLUSION Higher 'universal' vitamin take-up may well have reflected fewer barriers when it became everyone's business to be vitamin-aware. Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that 'policy, politics, and problem' should be aligned to reach considerable unmet need.
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Affiliation(s)
- May Moonan
- Department of Public Health and Policy, The University of Liverpool, Liverpool, UK.,Present Address: Warrington Hospital (Kendrick Wing), Warrington, UK
| | - Gillian Maudsley
- Department of Public Health, Policy, and Systems, The University of Liverpool, Liverpool, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Margaret Whitehead
- Department of Public Health, Policy, and Systems, The University of Liverpool, Liverpool, UK.
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South E, Rodgers M, Wright K, Whitehead M, Sowden A. Reducing lifestyle risk behaviours in disadvantaged groups in high-income countries: A scoping review of systematic reviews. Prev Med 2022; 154:106916. [PMID: 34922995 PMCID: PMC8803546 DOI: 10.1016/j.ypmed.2021.106916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/06/2021] [Accepted: 12/12/2021] [Indexed: 11/20/2022]
Abstract
High prevalence of risk behaviours may exacerbate existing poor health in disadvantaged groups. We aimed to identify and bring together systematic reviews with a focus on reducing risk behaviours in disadvantaged groups and highlight where evidence is lacking. We searched MEDLINE and Embase up to October 2020, with supplementary searching in Epistemonikos and Health Systems Evidence. We included systematic reviews that reported behavioural outcomes and targeted smoking, excessive alcohol use, unhealthy diet, or physical inactivity in groups with the following characteristics: low income or low socio-economic status (SES), unemployed people, homeless people, care leavers, prisoners, refugees or asylum seeker, Gypsies, Travellers, or Roma, people with learning disabilities and people living in disadvantaged areas. Reviews that included primary studies from any high-income country were eligible. Reviews were mapped based on the disadvantaged group(s) and behaviour(s) targeted. Ninety-two reviews were included, with the majority (n = 63) focusing on people with low income or low SES. We identified gaps in the evidence for care leavers; Gypsies, Travellers, and Roma and limited evidence for refugees and unemployed people. Few reviews targeted alcohol use. There was limited evidence on barriers and facilitators to behaviour change. This suggests there is insufficient evidence to inform policy and practice and new reviews or primary studies may be required.
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Affiliation(s)
- Emily South
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.
| | - Mark Rodgers
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Margaret Whitehead
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, United Kingdom
| | - Amanda Sowden
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
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Sawyer ADM, van Lenthe F, Kamphuis CBM, Terragni L, Roos G, Poelman MP, Nicolaou M, Waterlander W, Djojosoeparto SK, Scheidmeir M, Neumann-Podczaska A, Stronks K. Dynamics of the complex food environment underlying dietary intake in low-income groups: a systems map of associations extracted from a systematic umbrella literature review. Int J Behav Nutr Phys Act 2021; 18:96. [PMID: 34256794 PMCID: PMC8276221 DOI: 10.1186/s12966-021-01164-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/25/2021] [Indexed: 02/08/2023] Open
Abstract
Background Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups. Methods A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals. Results Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake. Conclusions Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health. Supplementary Information The online version contains supplementary material available at 10.1186/s12966-021-01164-1.
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Affiliation(s)
- Alexia D M Sawyer
- Department of Public and Occupational Health, Amsterdam University Medical Centres, University of Amsterdam, Room J2-211, Meibergdreef 15, Amsterdam, 1105 AZ, The Netherlands.
| | - Frank van Lenthe
- Department of Public Health, Erasmus Medical Centre, Rotterdam, 3000 CA, The Netherlands
| | - Carlijn B M Kamphuis
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, 3584 CH, The Netherlands
| | - Laura Terragni
- Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Gun Roos
- Consumer Research Institute, Oslo Metropolitan University, 0170, Oslo, Norway
| | - Maartje P Poelman
- Department of Social Sciences, Wageningen University, Wageningen, 6706 KN, The Netherlands
| | - Mary Nicolaou
- Department of Public and Occupational Health, Amsterdam University Medical Centres, University of Amsterdam, Room J2-211, Meibergdreef 15, Amsterdam, 1105 AZ, The Netherlands
| | - Wilma Waterlander
- Department of Public and Occupational Health, Amsterdam University Medical Centres, University of Amsterdam, Room J2-211, Meibergdreef 15, Amsterdam, 1105 AZ, The Netherlands
| | - Sanne K Djojosoeparto
- Department of Human Geography and Spatial Planning, Faculty of Geosciences, Utrecht University, Utrecht, 3584 CB, The Netherlands
| | - Marie Scheidmeir
- Psychology Institute, Johannes Gutenberg University Mainz, D-55122, Mainz, Germany
| | | | - Karien Stronks
- Department of Public and Occupational Health, Amsterdam University Medical Centres, University of Amsterdam, Room J2-211, Meibergdreef 15, Amsterdam, 1105 AZ, The Netherlands
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10
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Jenkins G, Maugeri I, Palermo C, Hardwick R. Using realist approaches in nutrition and dietetics research. Nutr Diet 2021; 78:238-251. [PMID: 34155774 PMCID: PMC8361699 DOI: 10.1111/1747-0080.12675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 01/14/2023]
Abstract
AIM The aim of this study was to explore the use and future potential of realist approaches to research in nutrition and dietetics. METHODS A targeted literature review was used to search key journals (n = 7) in nutrition and dietetics to identify existing research using a realist approach. A narrative synthesis was conducted to explore findings in relation to the research aim. RESULTS Nine research papers (four realist evaluations, five realist reviews) describing seven nutrition interventions were found, which revealed the application of realist research in nutrition and dietetics has focused on public health interventions. Realist research provided a deeper, more nuanced understanding of varied outcomes including the role of context, and contributed to the development of theory about how and why interventions work. As a theory-driven research method, realist research was able to assist in overcoming methodological shortcomings to contribute to meaningful, transferable findings. CONCLUSION The results highlight the potential contribution of the realist research in nutrition and dietetics to evaluate interventions and inform future practice.
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Affiliation(s)
- Gemma Jenkins
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Isabella Maugeri
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Claire Palermo
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia.,Monash Centre for Scholarship in Health Education, Monash University, Melbourne, Victoria, Australia
| | - Rebecca Hardwick
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, England
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11
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Woodside JV, Mullan KR. Iodine status in UK-An accidental public health triumph gone sour. Clin Endocrinol (Oxf) 2021; 94:692-699. [PMID: 33249610 DOI: 10.1111/cen.14368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/16/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022]
Abstract
The improvement in iodine status among the UK population from the 1930s onwards has been described as an 'accidental public health triumph' despite the lack of any iodine fortification program. However, iodine deficiency in the UK has re-emerged in vulnerable groups and is likely due to a combination of changing farming practices, dietary preferences and public health priorities. The UK is now among only a minority of European countries with no legislative framework for iodine fortification. The experience of folic acid fortification and the 28-year delay in its implementation lays bare the political difficulties of introducing any fortification program in the UK. If iodine fortification is not an imminent possibility, then it is important to explore other options: how to change farming practice especially on organic farms; encourage dairy intake; protect and expand our public health programs of milk provision for vulnerable groups and embark on education programs for women of childbearing potential and healthcare professionals. This review explores how the UK may have arrived at this juncture and how the iodine status of the nation may be improved at this time of major political and public health upheaval.
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Affiliation(s)
- Jayne V Woodside
- School of Medicine, Dentistry and Biomedical Sciences, Institute for Global Food Security, Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Karen R Mullan
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, BHSCT, Belfast, UK
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12
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Relton C, Crowder M, Blake M, Strong M. Fresh street: the development and feasibility of a place-based, subsidy for fresh fruit and vegetables. J Public Health (Oxf) 2020; 44:184-191. [PMID: 33164095 PMCID: PMC8904189 DOI: 10.1093/pubmed/fdaa190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/10/2020] [Accepted: 09/25/2020] [Indexed: 11/26/2022] Open
Abstract
Background Many UK communities experience food insecurity, and consume diets high in energy-dense, nutrient poor, processed foods and low in fruit and vegetables (FV). We explored a novel area-based approach to promote FV consumption and healthy eating in one such community. Methods We developed a weekly subsidy scheme for fresh FV with key local stakeholders in an area of socioeconomic deprivation in Northern England. The scheme (Fresh Street) offered five £1 vouchers to every household, regardless of income or household type. Vouchers were redeemable with local suppliers of fresh FV (not supermarkets). The feasibility of the scheme was assessed in four streets using rapid ethnographic assessment and voucher redemption information. Results Local councillors and public health teams were supportive of the scheme. Most eligible households joined the scheme (n = 80/97, 83%), and 89.3% (17 849/19 982) of vouchers issued were redeemed. Householders reported that the scheme made them think about what they were eating, and prompted them to buy and eat more FV. Conclusions This feasibility study reported high levels of acceptance for a place-based, household-level weekly FV subsidy scheme. Further research is required to evaluate the effectiveness of this approach to creating healthy diets, eating behaviours and food systems.
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Affiliation(s)
- C Relton
- Institute of Population Health Sciences, Queen Mary University of London, London E1 2AB, UK.,School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - M Crowder
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - M Blake
- Department of Geography, University of Sheffield, Sheffield, UK
| | - M Strong
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
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Abrams R, Park S, Wong G, Rastogi J, Boylan AM, Tierney S, Petrova M, Dawson S, Roberts N. Lost in reviews: Looking for the involvement of stakeholders, patients, public and other non-researcher contributors in realist reviews. Res Synth Methods 2020; 12:239-247. [PMID: 32985074 DOI: 10.1002/jrsm.1459] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 09/07/2020] [Accepted: 09/24/2020] [Indexed: 12/31/2022]
Abstract
The involvement of non-researcher contributors (eg, stakeholders, patients and the public, decision and policy makers, experts, lay contributors) has taken a variety of forms within evidence syntheses. Realist reviews are a form of evidence synthesis that involves non-researcher contributors yet this practice has received little attention. In particular, the role of patient and public involvement (PPI) has not been clearly documented. This review of reviews describes the ways in which contributor involvement, including PPI, is documented within healthcare realist reviews published over the last five years. A total of 448 papers published between 2014 and 2019 were screened, yielding 71 full-text papers included in this review. Statements about contributor involvement were synthesized across each review using framework analysis. Three themes are described in this article including nomenclature, nature of involvement, and reporting impact. Papers indicate that contributor involvement in realist reviews refers to stakeholders, experts, or advisory groups (ie, professionals, clinicians, or academics). Patients and the public are occasionally subsumed into these groups and in doing so, the nature and impact of their involvement become challenging to identify and at times, is lost completely. Our review findings indicate a need for the realist review community to develop guidance to support researchers in their future collaboration with contributors, including patients and the public.
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Affiliation(s)
- Ruth Abrams
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, England
| | - Sophie Park
- Department of Primary care and population health, UCL, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Juhi Rastogi
- Department of Primary care and population health, UCL, London, UK
| | - Anne-Marie Boylan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephanie Tierney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mila Petrova
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Shoba Dawson
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
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14
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Babovič M, Fu RH, Monrouxe LV. Understanding how to enhance efficacy and effectiveness of feedback via e-portfolio: a realist synthesis protocol. BMJ Open 2019; 9:e029173. [PMID: 31076477 PMCID: PMC6528049 DOI: 10.1136/bmjopen-2019-029173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The validity of feedback as one of the defining components for electronic portfolios (e-portfolios) to be effective and efficacious has yet to be demonstrated. While the literature has shown individual beneficial features of e-portfolios and feedback per se, evidence of feedback as mediated through technology directly resulting in improved educational practice is scarce. The explanation of how feedback via e-portfolio improves educational practice is particularly vague. METHODS AND ANALYSIS The aim of this research is to unpack how and why feedback via e-portfolio is likely to flourish or wither in its path. Given the complexity of intervention, we will apply a theory-driven approach for evidence synthesis called realist synthesis. Informed by realist philosophy of science, it seems the most appropriate method because it explores observed outcomes (O) in terms of causal relationship between relevant contexts (C) and generating mechanisms (M). Initial programme theory will be developed through literature scoping. Later on it will be tested against purposively gathered evidence (through database and journal search), which simultaneously will be evaluated for rigour and relevance (whether method used are trustworthy and whether data contributes to theory building). We strive to (1) uncover 'context sensitive' mechanisms that generate feedback via e-portfolio to be (in) effective and (2) define in what circumstances is this mostly likely to occur. ETHICS AND DISSEMINATION The synthesis report will be written according to the RAMESES guidelines and its findings will be published in peer reviewed articles and presented at relevant conferences. The aim is to inform: (1) policy and decision makers for future-course design; (2) medical educators/clinical supervisors and learners for improved educational use. No formal ethical approval is required. PROSPERO REGISTRATION NUMBER 120863.
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Affiliation(s)
- Mojca Babovič
- Chang Gung Medical Education Research Centre (CG-MERC), Chang Gung Memorial Hospital Linkou Branch, Taoyuan City, Taiwan
| | - Ren-Huei Fu
- Chang Gung Medical Education Research Centre (CG-MERC), Chang Gung Memorial Hospital Linkou Branch, Taoyuan City, Taiwan
| | - Lynn V Monrouxe
- Faculty of Health Sciences, The University of Sydney, Sydney, NSW, Australia
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Ohly H, Crossland N, Dykes F, Lowe N, Moran VH. A realist qualitative study to explore how low-income pregnant women use Healthy Start food vouchers. MATERNAL AND CHILD NUTRITION 2018; 15:e12632. [PMID: 29956890 DOI: 10.1111/mcn.12632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/09/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Abstract
Healthy Start is the UK government's food voucher programme for low-income pregnant women and young children. It was introduced in 2006, but the impact of the programme on nutritional outcomes remains understudied. This study sought to explore potential outcomes of the Healthy Start programme (including intended and unintended outcomes) and develop explanations for how and why these outcomes might occur. A realist review preceded this study, in which programme theories were developed and tested using existing evidence. This qualitative study aimed to further refine and consolidate the programme theories from the realist review while remaining open to new and emerging theories (or hypotheses) about how low-income pregnant women use Healthy Start vouchers. Semistructured interviews were conducted with 11 low-income women from North West England, who received Healthy Start vouchers during pregnancy. A realist logic of analysis was applied to generate clear and transparent linkages between outcomes and explanations. The findings suggested that some women used the vouchers to improve their diets during pregnancy (intended outcome), whereas some women were diverted towards alternative or unintended outcomes. Women's circumstances, values, beliefs, and motivations influenced how they perceived and responded to the vouchers. This paper presents four evidence-based programme theories to explain four contrasting (and potentially overlapping) outcomes: dietary improvements (theory refined from review), shared benefits (new theory), financial assistance (theory refined from review), and stockpiling formula (new theory). It considers how the Healthy Start programme could be improved, to increase the possibilities for low-income women to experience the intended outcome of dietary improvements.
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Affiliation(s)
- Heather Ohly
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Nicola Crossland
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Fiona Dykes
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Nicola Lowe
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Victoria Hall Moran
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
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