Do councils have what they need to help tackle obesity?

Guest post by Michael Chang, Project and Policy Manager, Town & Country Planning Association

The new revised National Planning Policy Framework (NPPF) is published by the Ministry for Housing, Communities and Local Government this week (24 July). It now provides the policy basis for planning healthy communities (Section 8 Paragraphs 91 and 92). In this context, here I want to explore whether there are enough planning powers to successfully tackle fast food outlets. At a Fuse event earlier this year on ‘Planning for Healthier diets: restricting hot food takeaway proliferation’, I also highlighted interesting results of recent planning policy developments and planning appeal decisions.
 

Back to the future… again?

Firstly it should be stated that concerns about the physical built environment and food environment in relation to people’s health and wellbeing are not a new trend. There has long been an understanding (with increasing supporting academic evidence) of the negative implications of food deserts and extant planning policies to tackle the negative environmental impacts from food outlets such as smells, noise, opening hours, litter and traffic generation.

The Foresight Tackling Obesities report was published in 2007 which, in the context of addressing the issue through a whole system approach, suggested two actions in which urban planners can effect change in the living environment, one of which refers to food and drink access and availability[1]. But a year earlier, the Royal Commission on Environmental Pollution, an independent standing body established in 1970 to advise the Queen, the Government, Parliament and the public on environmental issues, had already highlighted availability and cost of healthy food as an environmental determinant to cardiovascular risk in its seminal 26th report on The Urban Environment[2].

Is there an enabling policy environment to tackle obesity?

Given the weight of evidence, research and high-level recommendations in the last decade, in 2018, do planning practitioners working in local authorities have the right policy tools to do something about it? The main indicator is whether local plans, which each local authority across England have created, have the right policies? Local plans are powerful because in addition to setting out the council’s long-term vision and pathway for creating sustainable local communities, they are the basis with which decisions on planning applications are made from extensions to your house, to opening new shops on the high street to the creation of a complete new neighbourhood.

CEDAR (Centre for Diet and Activity Research) will publish more extensive results on local plans and fast food outlet policies so I will focus on the wider issue of tackling obesity. As part of the Planning Healthy Weight Environment work in 2014[3], the Town & Country Planning Association (TCPA) undertook an extensive policy review of local plans in England. Forty-one percent (41%) did reference obesity but generally only in the introductory paragraphs where they identified that obesity was a problem in the area. Only 17% followed through to the policy sections, but always in the supporting text rather than in the policy text. In statutory Joint Health and Wellbeing Strategies, only 31% make specific links to the built environment as one of the wider determinants of obesity. 

There is no reason, if supported by evidence and needs assessment, for councils not to have relevant policies such as on active travel, open space and food environment with a specific objective to help reduce local obesity rates. Recent planning inspector reports on draft local plans, before they are approved by councils, indicate a growing positive picture of a more welcoming stance on restricting fast food outlet policies including greater acceptance of the exclusion zone approach.

Have planning appeal decisions been favourable?

How are councils actually faring when they apply these policies in defending their decisions to refuse planning permission for new fast food outlets? The picture is more mixed with some councils successfully defending their decisions while many others have their decisions overturned by planning inspectors. The justifications by planning inspectors are not as you might expect.

"...this is politics, it's not medicine..." - 24 TV series

To illustrate the way planning appeals have been decided for and against planning applications for new fast food takeaways, take for example a scene from the hit American drama ‘24’. President Palmer’s advisor Wayne Palmer said to the President’s doctor Anne Packard: “It’s he said, she said, you see this is politics, it’s not medicine, so do me a favour and stay out of it”. 

Most, if not all the recent judgements I have seen (but there would need to be a more systematic review), do reference national guidance and support the obesity crisis as a valid planning reason. The health and medical arguments appear to have been won, but other wider considerations including local ‘political’ issues come into play and only evidence presented on the day are valid. This scene underlies the tension in planning decisions, which is why in its three reports into the government’s Childhood Obesity Plan in the last three years, the Health and Social Care Select Committee[4] has consistently called for health to be a material planning consideration in an arena of competing considerations from economic to employment.

What does this all means?

There needs to be more research done in the area to better understand the implications of proliferation of fast food outlets on population health from the health inequalities lens. There also needs to be more applied research to understand why practitioners could not effectively implement policies and what the real barriers are. Evidence and aspiration can only go so far. It is time we all take a breather from pursuing perfect evidence to properly supporting practitioners at the coal-face.


Michael Chang is a Chartered Town Planner at the Town and Country Planning Association (TCPA), leads on TCPA’s Reuniting Health with Planning Initiative and currently undertaking a part time Master by Research at Leeds Beckett University on using planning powers to promote healthy weight environments.


References:

1. Foresight, 2007, Tackling Obesities: Future Choices: https://www.gov.uk/government/publications/reducing-obesity-future-choices  
2. Royal Commission on Environmental Pollution (RCEP), 2006, The Urban Environment: http://webarchive.nationalarchives.gov.uk/20110322144101/http://www.rcep.org.uk/reports/26-urban/documents/urban-environment.pdf
3. Town & Country Planning Association (TCPA), 2014, Planning Healthy-weight environments: https://www.tcpa.org.uk/Handlers/Download.ashx?IDMF=7166d749-288a-4306-bb74-10b6c4ffd460
4. Health and Social Care Select Committee, Childhood obesity inquiries reports 2015, 2017 and 2018: 

• https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/inquiries/parliament-2015/inquiry/publications/, 
• https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/inquiries/parliament-2015/childhood-obesity-16-17/publications/, 
• https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/inquiries/parliament-2017/childhood-obesity-inquiry-17-19/

Images:

1. "318-365 Year3 On Our Way Home" by John Garghan via Flickr.com, copyright © 2011: https://www.flickr.com/photos/johngarghan/6351566649
2. By The original uploader was Tuxo at German Wikipedia. [Public domain], via Wikimedia Commons: https://commons.wikimedia.org/wiki/File:24-Logo.svg

How can governments reduce health inequalities in high-income countries?

Guest post by Dr Katie Thomson, Institute of Health and Society, Newcastle University

In recent months, there have been high profile stories of how governments can influence public health. The Scottish minimum unit price for alcohol introduced on the 1 May 2018, and more recently the publication of Chapter 2 of the Government’s Childhood Obesity Plan. This update proposed measures to address children’s exposure to junk food advertising on television and online, and called for a ban of price promotions on products that are high in fat, salt or sugar.

20mph zones were shown to increase inequalities in cycle accidents and

 rates of death between more and less deprived neighbourhoods

Such policies have great potential to improve public health, by shifting the distribution of health risk and addressing the underlying social, economic and environmental conditions (Hawe and Potvin, 2009)1. However, it is imperative to understand the impact of these policies on health across the entire social gradient. Thereby ensuring the most marginalised, are not adversely effected by policies which aim to improve health overall.

I have been part of a group of academics which recently completed an umbrella systematic review (‘review of reviews’) which aimed to understand the effects of public health policies in high-income countries. You can read about the research in a handy two-page Fuse research brief. As part of the Health inequalities in European welfare states (HiNews) project, we found evidence of 29 reviews (comprising 150 unique primary studies) which detailed the evidence of how fiscal (government revenue), regulatory, education, preventative treatment and screening approaches can be used by governments to influence health inequalities across eight key domains.

Conceptual framework of population-level preventative public health policies to reduce health inequalities

Our review highlighted 13 key interventions which were demonstrated to reduce health inequalities. These include taxes on unhealthy food and drinks; food subsidy programmes for low-income families; incentive schemes linked to immunisation status; proof of immunisation for school admission; tobacco advertising control measures; traffic calming measures; oral health (water fluoridation and tooth brushing campaigns); some nutritional and cancer education programmes; universal and targeted vaccinations for indigenous populations; and targeted and population screening interventions.

Worryingly, we also found evidence of interventions that were shown to increase health inequalities – potentially leading to so-called 'intervention generated inequalities’ (Lorenc et al., 2013)2. For instance, lowering alcohol tax by 33% was shown to increase inequalities in rates of death amongst disadvantaged groups in Finland. Environmental interventions, including 20mph and low emission zones, were also shown to increase inequalities in cycle accidents and rates of death between more and less deprived neighbourhoods.

Our research also demonstrates that for some potentially important interventions, such as for policies to control alcohol, there is a lack of robust evaluations highlighting the effects on different groups of people.

Given the volume of literature we found on the effects of government-led policies on health overall, it was disappointing that we could only identify 29 reviews that reported data on health inequalities. Going forward, those tasked with evaluating such policies must report how health outcomes differ for specific interventions by subgroup as standard. Furthermore, reviews should incorporate sufficient information on how the intervention was implemented and enforced to be useful for policy makers thinking of adopting such approaches. We also found many of the reviews and their primary studies were US-based, which could potentially limit the transferability of interventions from one country to another.

Undertaking a systematic review is not without its challenges. When published, the article reads like a definitive narrative when in reality it comprises a multitude of subjectivities – which reviews to include? Which primary studies are relevant? Which outcomes are most appropriate? And how to summarise the state of evidence in a particular field given multiple studies/reviews? The methodology is designed to be systematic, but as it uses human interpretation there is always an element of judgement. Umbrella reviews assess the state of the evidence across a wide area of interest, and are therefore worth the blood, sweat and tears which goes into producing them.

Upstream public health interventions involving state or institutional control offer great hope to improve health for all. However, a comprehensive understanding on the effects of different interventions is a necessary first step to ensure policies have an equitable benefit for all members of society and therefore are worthy tools at the disposal of governments tasked with improving health.


The Health inequalities in European welfare states (HiNews) project is a collaboration between the universities of Newcastle, York, Trondheim, Siegen and Harvard and funded by the New Opportunities for Research Funding Agency Cooperation in Europe (NORFACE).

References:

1. Hawe, P., Potvin, L., 2009. What is population health intervention research? 100, I8-I14.
2. Lorenc, T., Petticrew, M., Welch, V., Tugwell, P., 2013. What types of interventions generate inequalities? Evidence from systematic reviews. Journal of Epidemiology and Community Health 67, 190-193.

Photo: © Albert Bridge (cc-by-sa/2.0)

Putting the 'occupation' in Occupational Therapy and debating its role in Public Health

Guest post by Andrew Graham, Registered Occupational Therapist and PhD Candidate, Teesside University

Having recently made the move from NHS clinician into academia (I started my PhD at Teesside University in December 2017), I arrived in Belfast for the Royal College of Occupational Therapy Annual Conference with an appetite to hear new and interesting research in the profession.

In my welcome pack, I received a copy of the RCOT’s Strategic Intentions which represent the leadership response to the challenges of the changing landscape of health and social care. The principle that stood out for me was to ‘position the Profession, and our members, for the 21st century’.

With my background in amputee rehabilitation I have seen first-hand the impact of socio-economic inequalities and lifestyle trends on amputation rate in North East England. For example, the amount of amputations due to diabetes, and more shockingly intra-venous drug use, has spiked in the past 10 years or so. As an Occupational Therapist (OT), I view the person holistically and always try to take into account the social and psychological not just physical barriers they will need to overcome post amputation. My focus will always be on what the person needs and wants to do. The person’s meaningful activities (occupations).


The pledge tree

During the conference, we were asked to make a pledge about how we would do our part to ensure the new strategic intentions are met. The pledge tree seemed to have a recurring theme of ‘ensuring occupation is central to my work’.

My own pledge was to better explain ‘occupation’ and its meaning within occupational therapy to a range of audiences.

So, my attempt at articulating ‘occupation’? I’ll go with ‘doing things that we need to do and want to do (meaningful activities), which enable a sense of self-meaning and improved health and well-being.

I feel as a profession we are experts in using occupation as a goal (top down approach) and/or a means (bottom up approach) to ensure provision of high-quality, client centred services. Utilising the OT process from information gathering to evaluation we strive to enable growth, confidence and self-meaning.

Despite OTs generally being able to better define what they do and what the outcomes can be, it was a bit of a shock to see that the debate at the conference highlighted that the profession is still unsure about its stakeholders. The topic up for discussion was ‘This house believes that Occupational Therapy needs to be predominately based in public health, not in secondary or tertiary services’.

From my experience, this issue had been debated and answered years ago. My pre-registration training saw me working in the NHS, community mental health teams, a special needs school and a charity. The OTs all had a prominent and effective role in these sectors, so as intrigued as I was to hear the debate, I knew which way I would be voting!

For the purpose of this blog I’d like to highlight the case for OTs working in Public Health. A starting point would be the statement by the professional body, which points out that the Public Health Agenda has been of increasing importance and relevance for occupational therapists, who facilitate health promotion through working with people of all ages to enable their participation in meaningful occupations (RCOT 2004).

The evidence base is also pretty strong. A systematic review of Allied Health Professions and Health Promotion (Needle et al 2011) reviewed 28 studies related to occupational therapy and Public Health, and found related interventions in the areas of mental health, arthritis, pain and fatigue, pulmonary rehabilitation, stroke, drug and alcohol problems, and falls prevention.

Not only are OTs already working with people on aspects of Public Health and health promotion activity, but there is an expectation that this focus will form part of the delivery of all occupational therapy interventions in the future. For example, I remember reading about the ‘make every contact count’ campaign when working on an acute stroke ward and making sure I asked about smoking and drinking habits as part of my OT assessment.

So, it was with no surprise that the result swung against the motion at the conference. A particularly convincing rebuttal speech was given by Professor Diane Cox and Dr Jenny Preston, clearly showing the professions ability to address Public Health matters but also reach a wider audience through demonstrating outcomes in secondary and tertiary services.

Overall, I left the conference with a sense that the profession has strategically positioned itself to demonstrate that it is making a difference and will continue to make a difference to the health and well-being of people in the 21st century. It is time for OTs working in Public Health and other services to be proud. In my favourite quote of the conference….‘we are not the jack of all trades, rather we are the masters of human occupation’.


Andrew Graham is investigating ‘Sensory Discriminating Training for Phantom Limb Pain’, as a PhD candidate in the School of Health and Social Care at Teesside University.

Game of Thrones: King in the NoRTH… Workshop is coming… but has anyone actually read the books?

Dr Sonia Dalkin, Senior Lecturer in Public Health and Wellbeing, Northumbria University

Unless you’ve been living in a box since 2011, it’s likely that you will have heard of the series Game of Thrones. For those of you still in your boxes – Game of Thrones is fantasy drama television series created by David Benioff and D. B. Weiss. It is an adaptation of A Song of Ice and Fire, George R. R. Martin's series of fantasy novels, the first of which is called A Game of Thrones. The series has been acclaimed for many things including its acting, complex characters, story, scope, and production values. Notably, it has also received praise from both The Guardian and The Times for what is perceived as a sort of medieval realism. Here, I want to talk about a different type of Realism, that of Scientific Realism, or more specifically Realist Approaches to Research.

What is realist research?

Just as Martin’s novels rely on believable characterisation and relatable motivation to create enough suspension of disbelief to enter a world of dragons and sorcery, realist research focuses on social interventions to explain not only whether an intervention works or not, but for whom and under which circumstances. The focus therefore embraces and explains the complexity of social interventions. It aims to understand the responses people have to programme resources, therefore understanding the reasoning and motivations behind their actions. In order to do this, we focus on programme theory and utilise context, mechanism and outcome configurations. It provides rich findings, explaining why interventions work in some contexts, but not in others. For example – why is Daenerys impervious to fire when others are burnt? Because she’s a decedent of House Targaryen. Context is important, people! Alongside context is its trusty friend mechanism – similar to Ghost (an albino dire wolf) and Jon Snow – they go hand in paw. Mechanisms can be referred to as a combination of intervention resources and participant reasoning. More information is available on mechanisms here.

Altogether, the analytical tools of realist evaluation described above are used in the following way: Intervention resources are introduced in a context, in a way that enhances a change in reasoning. This alters the behaviour of participants, which leads to outcomes.

The methodology is not without its difficulties. Often realist researchers describe feeling that they are in a ‘realist swamp’; going down different alleyways, trying to understand and explain how a programme works, for whom and in which circumstances, but not getting too far. Often in this phase, realist researchers are similar to the White Walkers (an ancient race of humanoid ice creatures who really aren’t too friendly), in both looks and temperament. This phase can be frustrating, but like Arya against The Waif (acolyte of the Faceless Men), in most projects there is a sudden moment of clarity, where the dark alley becomes your friend, it all comes together, and you come out fighting.

Here at Northumbria University we have engaged in many projects using realist methods and want to help other realist researchers beat The Waif as quickly as possible, where possible. In order to do this, we’ve engaged a three-pronged approach as sharp as Arya’s sword, ‘Needle’:

1. Realist research Team Hub (NoRTH)

We felt it was time to highlight ourselves as key players in the realist game and to create a hub of realist research. What does every hub need? An acronym! We are now the Northern Realist research Team Hub (NoRTH).

NoRTH’s priorities will be to: advance the implementation of the methodology; collaborate with others focusing on realist research; contribute to and host realist education platforms; support PhD students in realist research; and continue to offer methodological expertise to those who seek it.

One thing of importance to note here is that we don’t feel we are the only big players in the North in terms of realist research – The Starks (University of Leeds) are obviously the long term true Kings of the North, with Professor Ray Pawson at the helm (our Jon Snow) for many years, and Nick Emmel, Joanne Greenhalgh, and Ana Manzano (Bran, Sansa and Arya) now fighting strong. But being ‘Northumbria University’, the acronym NoRTH seemed too good to resist… please take this blog as a token of our affection and don’t give us a fate like that of the Red Wedding!

2. Winter’s coming… along with a workshop in realist approaches

Winter is coming and soon we’ll have dark nights and frosty mornings, but never fear; alongside winter we have a brilliant offer of a Realist Approaches Workshop. Like Daenerys, mother of dragons, we wanted to educate others and decided one way to do this would be to provide a workshop. Whilst we can’t promise dragons, rebirths in blood and fire, or steamy scenes with Jon Snow, we can offer a fantastic line up of realist researchers, ready to take you on an exciting methodological journey.

Day 1 of the workshop will focus on Basic Principles of Realist Research, whilst day two will focus on contemporary developments such as realist ethnography and realist economic evaluation. To find out more and to book, check out the website.

3. ‘Doing Realist Research’ – a new book

As much as a lot of people claim to be Game of Thrones fans, how many of them have actually read the original books? TV series and films can bring whole worlds to life before our eyes, make characters into living people, but books take you into the detail, the nooks and crannies of the story. For example, the maps in Martin’s book displaying the geography of the mythical Kingdom aren’t as well portrayed in the TV series, despite efforts in the opening titles. Books provide the details that are often overlooked yet important in really understanding the overall story or the characters. Thus, if interested in realist research, I would like to suggest you read the new book ‘Doing Realist Research’, available to pre-order now), which provides much more detail on realist approaches, covering topics such as: realist review problem-solving, literature searching for realist reviews and mechanisms at higher levels of abstraction.

Edited by Nick Emmel, Joanne Greenhalgh, Ana Manzano (The Starks), Mark Monaghan and myself, this book celebrates the possible ways in which realism can contribute to researching complex social puzzles, providing practical advice on the ‘how to’ of realist methods.

Similar to Game of Thrones, so far, it’s received rave reviews, like that from Professor Kieran Walshe, (University of Manchester): “I wish all social science researchers would read this book”. Best of all, it has absolutely no Game of Thrones references – and that’s a promise (similar to that of Ned Starks to Lynna Stark in the infamous Tower of Joy Scene)…



Acknowledgements

Many thanks to Dr Phil Hodgson (Northumbria University) for helping me in identifying so many obvious Game of Thrones parallels with realist research…


Image: "Game of Thrones. Xbox One. 1080.P. 😁 Gameplay Part.04.-06. On my YouTube Channel 😁 https://youtube.com/playlist?list=PLwsjII0MclEGZnmdii3LZb9FZLby_iP4Q 😁 by Rob Obsidian via Flickr.com, copyright © 2015: https://www.flickr.com/photos/65092514@N08/18679295525