Assessing chronic disease management in European health systems. Country reports

Many countries are exploring innovative approaches to redesign delivery systems to provide appropriate support to people with long-standing health problems. Central to these efforts to enhance chronic care are approaches that seek to better bridge the boundaries between professions, providers and institutions, but, as this study clearly demonstrates, countries have adopted differing strategies to design and implement such approaches. This book systematically examines experiences of 12 countries in Europe, using an explicit comparative approach and a unified framework for assessment to better understand the diverse range of contexts in which new approaches to chronic care are being implemented, and to evaluate the outcomes of these initiatives. The study focuses in on the content of these new models, which are frequently applied from different disciplinary and professional perspectives and associated with different goals and does so through analyzing approaches to self-management support, service delivery design and decision-support strategies, financing, availability and access. Significantly, it also illustrates the challenges faced by individual patients as they pass through the system. This book complements the earlier published study Assessing Chronic Disease Management in European Health Systems; it builds on the findings of the DISMEVAL project (Developing and validating DISease Management EVALuation methods for European health care systems), led by RAND Europe and funded under the European Union’s (EU) Seventh Framework Programme (FP7) (Agreement no. 223277)

An obesogenic island in the Mediterranean: mapping potential drivers of obesity in Malta.

OBJECTIVE: The prevalence of childhood and adult obesity in Malta is among the highest in the world. Although increasingly recognised as a public health problem with substantial future economic implications for the national health and social care systems, understanding the context underlying the burden of obesity is necessary for the development of appropriate counter-strategies. DESIGN: We conducted a contextual analysis to explore factors that may have potentially contributed to the establishment of an obesogenic environment in Malta. A search of the literature published between 1990 and 2013 was conducted in MEDLINE and EMBASE. Twenty-two full-text articles were retrieved. Additional publications were identified following recommendations by Maltese public health experts; a review of relevant websites; and thorough hand searching of back issues of the Malta Medical Journal since 1990. SETTING: Malta. SUBJECTS: Whole population, with a focus on children. RESULTS: Results are organised and presented using the ANalysis Grid for Elements Linked to Obesity (ANGELO) framework. Physical, economic, policy and socio-cultural dimensions of the Maltese obesogenic environment are explored. CONCLUSIONS: Malta's obesity rates may be the result of an obesogenic environment characterised by limited infrastructure for active living combined with an energy-dense food supply. Further research is required to identify and quantify the strength of interactions between these potential environmental drivers of obesity in order to enable appropriate countermeasures to be developed

Assessing chronic disease management in European health systems. Concepts and approaches

This book comprises two volumes and builds on the findings of the DISMEVAL project (Developing and validating DISease Management EVALuation methods for European health care systems), funded under the European Union’s (EU) Seventh Framework Programme (FP7) (Agreement no. 223277). DISMEVAL was a three-year European collaborative project conducted between 2009 and 2011. It contributed to developing new research methods and generating the evidence base to inform decision-making in the field of chronic disease management evaluation (www.dismeval.eu). In this book, we report on the findings of the project’s first phase, capturing the diverse range of contexts in which new approaches to chronic care are being implemented and evaluating the outcomes of these initiatives using an explicit comparative approach and a unified assessment framework. In this first volume, we describe the range of approaches to chronic care adopted in 12 European countries. By reflecting on the facilitators and barriers to implementation, we aim to provide policy-makers and practitioners with a portfolio of options to advance chronic care approaches in a given policy context. In volume II (available online at http://www.euro.who.int/en/about-us/ partners/observatory/studies), we present detailed overviews of each of the 12 countries reviewed for this work and which informed the overview presented in the first volume of the book

Environmental components of childhood obesity prevention interventions: an overview of systematic reviews.

Childhood obesity has a complex multi-factorial aetiology grounded in environmental and individual level factors that affect behaviour and outcomes. An ecological, systems-based approach to addressing childhood obesity is increasingly being advocated. The primary aim of this review is to summarize the evidence reported in systematic reviews on the effectiveness of population-level childhood obesity prevention interventions that have an environmental component. We conducted a systematic review of reviews published since 1995, employing a standardized search strategy in nine databases. Inclusion criteria required that reviews be systematic and evaluated at least one population-level, environmental intervention in any setting aimed at preventing or reducing obesity in children (5-18 years). Sixty-three reviews were included, ten of which were of high quality. Results show modest impact of a broad range of environmental strategies on anthropometric outcomes. Systematic reviews vary in methodological quality, and not all relevant primary studies may be included in each review. To ensure relevance of our findings to practice, we also report on relevant underlying primary studies, providing policy-relevant recommendations based on the evidence reviewed. Greater standardization of review methods and reporting structures will benefit policymakers and public health professionals seeking informed decision-making

The strategies of alcohol industry SAPROs : Inaccurate information, misleading language and the use of confounders to downplay and misrepresent the risk of cancer

Peer reviewe

The future of environmental sustainability labelling on food products.

If each of us were to consider the food we had for lunch, we can probably estimate whether it was relatively healthy (e.g., did we go hungry, did it add to the variety of our diet, or consumption of five fruits and vegetables a day?). How easy is to make a similar judgement on whether our lunch contributed to a sustainable diet? For example, the carbon emissions associated with a simple sandwich can more than double, depending on the filling, where it is made, the packaging used and many more factors.1 Drawing on the past experiences of nutrition labelling on food products, we consider whether sustainability labelling can provide a practical route to encourage sustainable food choices, sustainable market changes, and a move towards sustainable and healthy food systems. Sustainability labelling on food products is most commonly associated with social and ecological certification schemes (e.g., USDA Organic Seal; Fairtrade mark; Friend of the Sea).2 More recently, an increasing number of labels have emerged which estimate the impact of a product on one or more environmental factor e.g., carbon foot-printing as a marker of greenhouse gas emissions or climate change.3 Research suggests there is a demand for these different types of sustainability labels; yet, it is uncertain if these labels will affect our everyday selections and purchases of food.4 Price, taste, brand, appearance, product familiarity and habits are still dominant reasons for our food choices; however, over 20 years’ of research indicates nutrition labelling can drive healthy food choices and incentivise product reformulation.5 In 2019, a meta-analysis investigated the impact of nutrition labels on food products and menus (including a variety of nutrient content labels, claims, logos, or indices, such as warning labels and traffic light labels). They concluded a small impact of labels, which can reduce total energy and total fat consumption, increase vegetable intake, and positively impact industry reformulation for sodium and trans fat content.5 Further research is on-going regarding whether these impacts follow a social gradient and compound diet-related health inequalities (e.g., reformulated ‘healthier’ products are added to a range at a higher price point/available only in higher income countries; or numeracy skills are required to interpret health indicating labels).6 Food labelling has become part of the food system infrastructure, yet there are challenges with governing this sector. Voluntary recommendations and mandatory regulations are used to facilitate inter-/national trade (e.g., country of origin requirements by the FAO/WHO Codex Alimentarius food labelling standards), and signify quality assurance, safety and traceability standards (e.g., declaration of trans fatty acids content). Ensuring compliance with regulation requires considerable resources from those responsible for governing the food system. For example, the European Food Safety Authority (EFSA) has been harmonising and adapting food labelling regulation since 2006 to keep pace with a proliferation of food labels in the market. EFSA now require a portfolio of evidence from each manufacturer to authorise the use of a health or nutrient claim on their food product. This is to protect fair competition within the food industry and also to monitor the validity of claims to protect the public from being misled. Producing and reviewing these portfolios has taken considerable resources for both EFSA and the food industry. It is worthwhile to consider whether existing regulation and regulatory resources are sufficient to monitor sustainability claims if they were to become more widespread. Trust and transparency in any labelling scheme is essential for it to be meaningful and motivate change in individuals or industries. We have seen confusion surrounding the use of the term ‘organic’ on food products. These products can be ascribed a ‘health halo’, yet there are limitations in the evidence indicating a superior nutrition quality of organic products and health benefits may be more associated with the social values attributed to organic production. The use of certification schemes can encourage transparent standards; however, this is less clear with schemes (e.g., Fair Trade) which have been brought in-house: where products are self-certified rather than part of an ‘independent’ certification scheme. It is difficult to discern the sustainability of a product at point of purchase and maintaining the trust and transparency of different sustainability indices or metrics, across inconsistent product categories, will be paramount to ensuring accountability for food fraud or the use of exploitative marketing techniques.7 A major challenge with sustainability labelling of food products is the complexity of the sustainability concept itself, as well as the food system within which it operates. Sustainability is multi-faceted and sustainable food systems represent not only environmental factors (ecology), they are also sensitive to the health of the population today and in the future (nutrition, food security), and society as a whole (ethics and social welfare). Food systems themselves are also dynamic and complex: involving a multitude of changeable and inter-related activities, actors, and infrastructure from the production to the consumption, recycling and/or disposal of food. At every point there can be multiple environmental impacts, related to biodiversity, green house gas emissions (carbon dioxide, methane etc.), land, water or other resource use (e.g., nitrogen or phosphorous management). All these factors complicate the ability to create a metric or index that can trace a product as it journeys through the food system in order to assess its environmental, health or social impacts. Creating food systems that provide healthy food to everyone today and in future generations without exploiting human or planetary resources is one of the greatest challenges of this century. The development and use of sustainability labelling has the potential to play a role in moving towards sustainable and healthy food systems and a sustainable future, as outlined in the aims of the United Nations Sustainable Development Goals. The reach of food labelling is considerable and could increase public awareness of how food is produced and consumed. Nutrient labelling remains a popular public health intervention, with mandatory nutrition labelling in at least 50 countries worldwide, with highly processed and packaged foods making an ever greater contribution to the global diet (e.g., in a sample of sixteen countries approximately 85 % of packaged food carried a nutrient label, health/nutrition claim, or a health/nutrition marketing claim).8 9 Past experiences of nutrition labelling provide a number of cautions to the rise in sustainability labelling. First, sustainability labelling is unlikely to be a panacea for behaviour change in consumers. Instead it can target small incremental changes at different levels and actors in the food system, within both individuals and organisations. Second, there is the potential for confusion with sustainability concepts, which can be exploited for commercial or political use, particularly where competing interests are present. The media and public attention on climate change and rise in sustainability labelling of food products provides an opportunity to develop food system analytics and sustainability metrics. Using these metrics, actors within the food system will be better equipped to communicate the nuances and evaluate the risks and trade-offs of system-wide interventions, and ultimately contribute to the evolution of sustainable and healthy food systems. The authors declare no competing interests. KAB, FH, CK contributed substantially to the conception and drafting of this work; KAB, FH, FH, CK, CP revised the work critically for important intellectual content; all authors approved the final version to be published and agree to be accountable for the work. All authors receive funding from the Wellcome Trust’s Our Planet, Our Health programme: KAB, FH, CK via the Sustainable and Healthy Food Systems (SHEFS) programme [grant number 205200/Z/16/Z], and CP via the Livestock, Environment and People (LEAP) project [grant number 205212/Z/16/Z]. This commentary does not necessarily reflect the views of the Wellcome Trust or its future policy in this area

Voluntary agreements between government and business - a scoping review of the literature with specific reference to the Public Health Responsibility Deal.

OBJECTIVES: A scoping review was conducted to synthesise the findings of evaluations of voluntary agreements between business and government. It aimed to summarise the types of agreements that exist, how they work in practice, the conditions for their success and how they had been evaluated. METHODS: Voluntary agreements were included if they involved a transparent signing-up process and where businesses agreed to carry out specific actions or to achieve specific outcomes. Studies of any design published in English were included. RESULTS: 47 studies were identified. Voluntary agreements may help to improve relationships between government and business, and can help both parties agree on target-setting and data-sharing. Governments may also use the experience to help develop subsequent legislation. For voluntary agreements to be successful, targets should be ambitious and clearly defined, with robust independent monitoring. Public knowledge of agreements can help encourage participation and ensure compliance. CONCLUSIONS: If properly implemented and monitored, voluntary agreements can be an effective policy approach, though there is little evidence on whether they are more effective than compulsory approaches. Some of the most effective voluntary agreements include substantial disincentives for non-participation and sanctions for non-compliance. Many countries are moving towards these more formal approaches to voluntary agreements

Issues arising when crossing a border to give birth: an exploratory study on the French-Belgian border.

BACKGROUND: Anecdotal evidence suggests that many organised initiatives for cross-border collaboration in healthcare in border regions originate from the need for women to give birth close to home. Despite this, there is remarkably little research on these practices and the specific modes of collaboration between providers and experiences and needs of these women. In this paper we describe the experiences of French women who choose to give birth in Belgium. STUDY DESIGN: We conducted semi-structured interviews with 14 key informants and captured the experiences of 14 French mothers using a 40-item questionnaire. RESULTS: The chief motivations for French mothers to cross the border to deliver a baby in Belgium were geographical proximity as well as perceived better quality of care. Several procedural differences between France and Belgium were highlighted as possibly affecting the quality of follow-up care, including the absence, in some cases, of a contact person in France, and communication problems between providers. CONCLUSION: There is a tension between the testimony of patients who are clearly satisfied and evidence of problems in communication and weak collaboration between providers on either side of this cross border collaboration. This paradox requires more research efforts to generate clear evidence of the added value of these cross-border collaborations for patients