'McDonalds and KFC, it's never going to happen': the challenges of working with food outlets to tackle the obesogenic environment.

BACKGROUND: Food outlets may make an important contribution to an obesogenic environment. This study investigated barriers and facilitators to public health work with food outlets in disadvantaged areas. METHODS: In-depth qualitative interviews with 36 directors, managers and public health service delivery staff in a coterminous primary care trust and local authority in northwest England. Data were analysed using the constant comparative method. RESULTS: Three interventions were available to engage with businesses; awards for premises that welcomed breastfeeding mothers or offered healthy menu options and local authority planning powers. Sensitivity to the potential conflict between activities that generate profit and those that promote health, led to compromises, such as awards for cafés that offer only one healthy option on an otherwise unhealthy menu. An absence of existing relationships with businesses and limited time were powerful disincentives to action, leading to greater engagement with public rather than private sector organizations. Hiring staff with commercial experience and incentives for businesses were identified as useful strategies, but seldom used. CONCLUSIONS: Encouraging food outlets to contribute to tackling the obesogenic environment is a major challenge for local public health teams that requires supportive national policies. Commitment to engage with the local public health service should be part of any national voluntary agreements with industry.

The experience of community engagement for individuals: a rapid review of evidence.

Community engagement is central to strategies to promote health and well-being and reduce health inequalities in many countries, particularly interventions which focus on improving health in disadvantaged populations. Despite the widespread use of community engagement approaches, however, there have been relatively few attempts to review the evidence on the impact that participation has on the lives of individuals involved. Drawing on a wider review of evidence carried out on behalf of the National Institute for Health and Clinical Excellence (NICE), this article reports on a rapid review of evidence of the effectiveness of initiatives which seek to engage communities in action to address the wider social determinants of health, to explore individuals' subjective experiences of engagement. The rapid review process was guided by NICE's public health methods manual, adapted to suit the diversity of the evidence. A total of 22 studies were identified containing empirical data on subjective experiences of community engagement for individuals. The findings of the rapid review suggest that the majority of 'engaged' individuals perceived benefits for their physical and psychological health, self-confidence, self-esteem, sense of personal empowerment and social relationships. Set against these positive outcomes, however, the evidence suggests that there are unintended negative consequences of community engagement for some individuals, which may pose a risk to well-being. These consequences included exhaustion and stress, as involvement drained participants' energy levels as well as time and financial resources. The physical demands of engagement were reported as particularly onerous by individuals with disabilities. Consultation fatigue and disappointment were negative consequences for some participants who had experienced successive waves of engagement initiatives. For some individuals, engagement may involve a process of negotiation between gains and losses. This complexity needs to be more widely recognised among those who seek to engage communities.

How can the health equity impact of universal policies be evaluated?: Insights into approaches and next steps: synthesis of discussions from an Expert Group Meeting held at the University of Liverpool, 2–4 November 2010

Taking population level action on the wider social determinants of health in efforts to reduce health inequities is an international public health imperative. However, an important barrier to action is the perceived lack of evidence about what works to reduce health inequities. This is particularly evident in relation to universal welfare policies, which can have profound effects on health inequities, both positive and negative in nature. Because universal policies are usually applied to whole populations, and are often complex in nature with long causal chains, this precludes a true experimental design, and other approaches to evaluation are required. This report presents arguments and case studies from an expert group meeting convened to clarify the importance and challenges of evaluating universal policies, and to outline potential approaches to assessing the impact of universal policies on health inequities. The report also identifies key research and policy questions that need evaluating as a matter of priority, and sets the agenda for partnership working to develop these methods further.

Students' attitudes to the communications employed during an outbreak of meningococcal disease in a UK school: a qualitative study.

BACKGROUND: Following an outbreak of meningococcal disease in a school in the North West of England, the communication methods employed by the Health Protection Agency (HPA) were evaluated in order to explore ways of improving communication with the public. METHODS: Qualitative questionnaires were distributed to Year 12 (sixth form) students. The Framework approach was used to analyse the data, which were coded, and emergent themes identified. RESULTS: In the absence of clear communication from official sources, many participants suggested that circulating rumours caused confusion and anxiety in the student population. Rumours were spread through informal networks in person or through text and MSN messaging. It was generally perceived that accurate information in this period would have been useful to allay potentially unfounded anxiety. Most students surveyed reported that they were sufficiently aware of the situation prior to receiving official announcements. The information provided by the HPA through the school was generally perceived as being useful, but it came too late. CONCLUSION: In outbreak situations, rumours will spread rapidly in the absence of early communication, and this can be a significant cause of anxiety. The use of digital communication strategies should be considered, since they can seed dependable information that will disseminate rapidly through peer groups.

Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making.

BACKGROUND: In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making. METHODS: Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified. RESULTS: Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established. CONCLUSION: Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.

Policy-makers' attitudes to decision support models for coronary heart disease: a qualitative study.

OBJECTIVES: To explore attitudes to the use of models for coronary heart disease to support decision-making for policy and service planning. METHODS: Qualitative study using semi-structured interviews with 33 policy- and decision-makers purposively sampled from the UK National Health Service (NHS) (national, regional and local levels), academia and voluntary organizations. Interviews were transcribed, coded and emergent themes identified using framework analysis aided by NVivo software. RESULTS: Policy-makers and planners were generally enthusiastic about models to assist in decision-making through: predicting trends; assessing the effect of interventions on health inequalities; quantifying the impact of population level and targeted interventions, and facilitating economic evaluation. The perceived advantages of using models included: more rational commissioning; the facility for scenario testing; advocacy for population level interventions and off-the-shelf synthesis to aid real time decision-making. However, although participants were aware of models to support decision-making, these were not being used routinely. Some participants felt that models oversimplify complex situations and that there is a lack of shared understanding as to how models work. Factors that increase confidence in decision support models included: rigorous validation and peer review, the availability of user-support and increased transparency. CONCLUSION: Policy-makers and planners were generally enthusiastic about the use of models to support decision-making, illustrating the potential uses for models and the factors that improve confidence in them. However, existing models are often not being used in practice. So new models that are fit for practice need to be developed.

Starting young? Children's experiences of trying smoking during pre-adolescence.

Although the risks smoking poses to health are now well known, many young people continue to take up the habit. While numerous cross-sectional studies of adolescents have identified correlates of smoking initiation, much less prospective, longitudinal research has been conducted with young children to gather their accounts of early experiences of smoking, and this study fills that significant gap. Quantitative and qualitative data, collected using questionnaires, interviews and focus groups, are presented from the pre-adolescent phase of the Liverpool Longitudinal Study of Smoking. By age 11, 27% of the cohort had tried smoking, 13% had smoked repeatedly and 3% were smoking regularly. Rates of experimentation increased over time. Qualitative data revealed that curiosity and the role of peers were central to children's accounts of early smoking. By pre-adolescence, children are at different stages in their smoking careers, therefore interventions must be targeted to their varied experiences. Current prevention strategies often focus on restricting access to cigarettes, but a broad range of intervention measures is required which take account of the multifactorial nature of smoking onset. To be effective, policies that aim to prevent smoking must be grounded in children's lived experiences.

Lies, damned lies and statistics? Reliability and personal accounts of smoking among young people.

Smoking remains a major problem among young people in Europe. However, within the research community examining the issue, debate continues about the best way of assessing the extent of that problem. Questions have been raised about the extent to which existing techniques for generating statistical representations of patterns of youth smoking can address a range of problems connected with identifying, accounting for and correcting unreliable self-report smoking data. Using empirical data from the UK Liverpool Longitudinal Smoking Study (LLSS), this paper argues that self-report measures of smoking, treated in isolation from participants' personal accounts, can disguise problems with the reliability and validity of a given study. Using longitudinal qualitative and quantitative data in dialogue, two main factors contributing to unreliable data are discussed: (a) participants' access to and familiarity with frameworks of everyday cultural knowledge about the practice of smoking, and (b) participants' retrospective revision of events in line with their current goals, aspirations and self-understandings. The conclusion drawn is that research has to employ multiple methods, minimally incorporating some personal contribution from participants, to explore the complex character of the problem of smoking and to avoid the difficulties posed by the models of smoking behaviour embodied within stand-alone statistical research.