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Background This study was conducted to assess the national prevalence of different grades of nutritional status (underweight, normal weight, overweight and obesity) among Iranian school-students and to compare the prevalence of overweight and obesity using three different sets of criteria. Methods This cross-sectional national survey was conducted on a representative sample of 21 111 school students including 10 253 boys (48.6%) and 10 858 girls (51.4%) aged 6–18 years, selected by multistage random cluster sampling from urban (84.6%) and rural (15.4%) areas of 23 provinces in Iran The percentage of subjects in the corresponding body mass index (BMI) categories of the Centers of Disease Control and Prevention (CDC), the International Obesity Task Force (IOTF) and the obtained national percentiles were assessed and compared. Results There was no gender differences in BMI, but was higher in boys living in urban than in rural areas (18.4 ± 3.88 vs. 17.86 ± 3.66 kg/m2 respectively, P

Background Alcohol policy in England is determined at local government level, and as a result differences between local authorities in priorities around how best to reduce the effects of alcohol consumption have led to variability in local composition of alcohol control policies and interventions. An important policy area is that of regulating the physical availability of alcohol and modifying the commercial drinking environment. We evaluated whether the intensity with which local licensing policies, including specifically cumulative impact zones, were implemented and enforced has resulted in measurable differences in local population health. Methods Alcohol and late night refreshment licensing data (2007–12) from the Home Office were linked to alcohol-related hospital admissions from the Local Alcohol Profiles for England, and to population size and area deprivation at local area level. Cumulative policy and enforcement intensity was coded as passive, medium, or high on the basis of presence of cumulative impact zones, whether any new licence applications were successfully challenged, or both. Changes in directly age-standardised rates of people admitted to hospital with alcohol-related conditions in 2009 to quarter one of 2015 were analysed with mixed-effects log-rate models adjusted for seasonality, population size, deprivation, and alcohol-related crime rate. Findings Data were obtained for all 326 lower tier local authority areas in England, of which 319 provided licensing activity data. Spatial autocorrelation in licensing policy intensity was negligible (Moran's I=0·02). An exposure-response association was observed, with an additional average decrease in alcohol-related hospital admission rates in the areas with the highest intensity policies compared with passive areas of 2% annually (95% CI −3 to −2, p=0·006). Accounting for other population changes, this equated to a modest additional 5% reduction, or about eight unique admissions per 100 000 people, in 2015 compared with what would have been expected had these areas not had active policies in place. Interpretation Although these analyses do not directly prove causality, they add to the available evidence about the efficacy of alcohol licensing policies specifically for England. Despite the fairly modest average effect, the intensity of alcohol licensing policies implementation and enforcement is related to measurable health gain. Funding This work was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR).

Background Policy makers are increasingly interested in how changes in local neighbourhood environments can affect health behaviours, especially physical activity, but individual studies rarely consider multiple environmental dimensions. Although older people can be particularly at risk of physical challenges in their local environment, few studies have focused on this age group. Methods We developed a local environment audit instrument to capture multiple dimensions of the built environment that could affect the physical activity of older people; we linked the environmental data to physical activity behaviour collected in two nationally representative cohorts: the British Regional Heart Study and British Women's Heart and Health Study. Comprehensive foot-based audits were conducted by trained field staff in 20 towns across England and Scotland covering 590 lower super output areas and data zones; interobserver reliability of the instrument was high. The primary outcome was time spent in moderate-to-vigorous physical activity measured in participants for 1 week during 2010–12 with GT3X accelerometers (Actigraph, Pensacola, FL, USA). Using multilevel regression analysis, we assessed the association between aspects of the built environment and physical activity adjusted for individual-level confounders and area-level population density. Findings 686 men and 638 women aged 69–92 years participated in the accelerometer study and were included in the analysis. Geometric mean time in moderate-to-vigorous physical activity was 26·3 min/day (geometric SD 2·7) in men and 23·8 min/day (SD 2·5) in women. There was no evidence of associations between any of the domains studied (quality of the built environment defined by latent class analysis; number of bus stops; area aesthetics; density of shops and services; amount of green space) and moderate-to-vigorous physical activity. Relative to areas with the worst quality walking environment, people living in areas with the best walking environments spent 2% more time in moderate-to-vigorous physical activity (95% CI −11 to 17, p=0·78 for overall trend). Interpretation Although small effect sizes cannot be discounted, this study suggests that older individuals might be less affected by their local neighbourhood environment than is often presumed in the scientific literature, reflecting both the heterogeneous functionality of this age group and the varying nature of their activity spaces. Funding This study was funded by a grant from the Medical Research Council (MR/J007145/1). The collection and extraction of data on physical activity in these cohorts was supported by grants from the British Heart Foundation (PG/09/024 and PG/13/66/304422) and National Institute for Health Research (PDF 2010-03-23).

Objectives Local government services and policies affect health determinants across many sectors such as planning, transportation, housing and leisure. Researchers and policymakers have argued that decisions affecting wider determinants of health, well-being and inequalities should be informed by evidence. This study explores how information and evidence are defined, assessed and utilised by local professionals situated beyond the health sector, but whose decisions potentially affect health: in this case, practitioners working in design, planning and maintenance of the built environment. Design A qualitative study using three focus groups. A thematic analysis was undertaken. Setting The focus groups were held in UK localities and involved local practitioners working in two UK regions, as well as in Brazil, USA and Canada. Participants UK and international practitioners working in the design and management of the built environment at a local government level. Results Participants described a range of data and information that constitutes evidence, of which academic research is only one part. Built environment decision-makers value empirical evidence, but also emphasise the legitimacy and relevance of less empirical ways of thinking through narratives that associate their work to art and philosophy. Participants prioritised evidence on the acceptability, deliverability and sustainability of interventions over evidence of longer term outcomes (including many health outcomes). Participants generally privileged local information, including personal experiences and local data, but were less willing to accept evidence from contexts perceived to be different from their own. Conclusions Local-level built environment practitioners utilise evidence to make decisions, but their view of ‘best evidence’ appears to prioritise local relevance over academic rigour. Academics can facilitate evidence-informed local decisions affecting social determinants of health by working with relevant practitioners to improve the quality of local data and evaluations, and by advancing approaches to improve the external validity of academic research.

Este articulo de revision sistematica de literatura, discute las implicancias de politicas futuras y de investigacion cientifica sobre la efectividad de las intervenciones y programas promoviendo el consumo de frutas y verduras en ambos adultos y ninos a lo largo del mundo, realizadas en 2004. Los resultados indican que pequenos aumentos en el consumo de frutas y verduras son posibles en subgrupos poblacionales y que estos cambios pueden ser alcanzados desde varios acercamientos (a niveles individual, poblacional y desarrollo de politicas macro e intervenciones ambientales) tanto en ninos como en adultos. Mientras muchos programas de promocion de frutas y verduras han sido conducidos o iniciados en todas las regiones del mundo, nuestro articulo muestra que los disenos de estudio utilizados han sido frecuentemente sub-optimos para evaluar efectividad, particularmente en paises menos desarrollados. Aunque es necesario mayor esfuerzo para mejorar el diseno y la evaluacion de dichas intervenciones a lo largo del mundo, estos resultados son estimulantes y sugieren que los gobiernos deben seguir desarrollando politicas para mejorar la nutricion que tengan un enfasis fuerte en el consumo de frutas y verduras

Twelve cases of community acquired legionnaires’ disease have been associated with south east London in July and August 2005

International recommendations advise increasing intakes of fruit and vegetables to help reduce the burden of chronic diseases worldwide. This project systematically reviewed evidence on the effectiveness of interventions and programs promoting fruit and/or vegetable intake in adults. In April 2004, we contacted experts in the field and searched 14 publication databases. We considered all papers published in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish, and reporting on interventions and promotion programs encouraging higher intakes of fruit and/or vegetables in free-living not acutely ill adults, with follow-up periods > or = 3 mo, that measured change in intake and had a control group. Forty-four studies (mainly from developed countries) were included in the review and stratified by study setting. Larger effects were generally observed in individuals with preexisting health disorders. In primary prevention interventions in healthy adults, fruit and vegetable intake was increased by approximately 0.1-1.4 serving/d. Consistent positive effects were seen in studies involving face-to-face education or counseling, but interventions using telephone contacts or computer-tailored information appeared to be a reasonable alternative. Community-based multicomponent interventions also had positive findings. This literature review suggests that small increases in fruit and vegetable intake are possible in population subgroups, and that these can be achieved by a variety of approaches. More research is required to examine the effectiveness of specific components of interventions in different populations, particularly less developed countries. There is also a need for a better assessment of the effectiveness and cost-effectiveness of large community-based interventions.

Trends in cardiovascular disease in Europe have shown an east-west divide for over 30 years. Rapid declines in the European Union contrast with stagnant or rising trends in Russia and central and eastern Europe, with some notable exceptions, such as Poland and the Czech Republic, where rates have fallen since the 1990s.1 2 These improvements are attributed primarily to improved nutrition,1 2 which can be traced to the economic transition that followed political change in the late 1980s. In Poland many food subsidies, in particular for animal fats, were abolished. Wider availability and lower prices for unsaturated fats and fruits caused rapid dietary changes. Zatonski and Willett explore the impact of these changes, suggesting …

Background. There is growing recognition of the need to increase consumption of currently suboptimal levels of fruit and vegetables by children, given their known beneficial effects for health. There is, however, a need for a synthesis of the evidence on interventions that might achieve this policy goal. Methods. A systematic review of published and unpublished studies was carried out by searching 14 publication databases and contacting experts in the fields. All papers in eight languages were considered if they described individual- and population-based interventions and promotion programmes that encouraged the consumption of a diet relatively higher in fruit and/or vegetables in free-living, not acutely ill children of both genders, with follow-up periods of at least 3 months, measurement of change in intake and a control group. Results. Fifteen studies focusing on children met the criteria for inclusion in the systematic review. None of the studies reviewed had a detrimental effect on fruit and vegetable consumption. Ten studies had a significant effect, ranging from +0.3 to +0.99 servings/day. Conclusions. More research is needed to examine in more depth, for longer follow-up periods, the effectiveness of interventions promoting fruit and vegetable consumption. The evidence is strongest in favor of multi-component interventions to increase fruit and vegetable consumption in children.

On 1 May 2004 the European Union (EU) underwent unprecedented enlargement, from 15 to 25 countries, increasing its population by 20% to over 450 million. Although EU law has limited specific competence in the area of health, its influence on other policy sectors such as agriculture, trade, and employment has wide ranging implications for health. Yet with the exception of provisions on communicable disease control and food safety, public health considerations have played little part in negotiations on EU accession. This paper argues for an intersectoral public health approach in the expanded EU. It reviews the legal basis for assessing the health impacts of policy in the EU and, using health impact assessment as a case study, it examines how well the new member states may be prepared to tackle intersectoral public health action within the constraints imposed by EU policy.

Although food supply statistics are commonly used in ecological studies of diet and disease, little information is available on how they compare with reported intakes of foods. The objective of the present study was to compare fruit and vegetable availability with estimates of national mean intakes derived from national food consumption surveys. Food availability statistics from the FAO were used. For each country, mean national supply, based on at least 3 years of FAO data, was calculated. National estimates of mean fruit and vegetable intakes were derived from population-based surveys from fifteen countries, gathered for the World Health Organization Global Burden of Disease Study revision for 2000. Extrapolations were made when survey data did not cover all age groups. For each country, the FAO:survey estimate ratio was calculated. This ratio ranged from 0·93 to 2·70 (median value=1·39). Although there was a tendency for FAO data to overestimate intakes (fourteen out of fifteen countries), the degree of overestimation varied greatly among the countries included in this study (5–270 %). As food supply statistics are the only source of information on dietary patterns in most countries of the world, further information on how they reflect food intakes is needed. Obtaining detailed and valid estimates of dietary intakes in more countries around the world will be essential for such comparisons.

BACKGROUND: The OECD countries and the United Nations have agreed to co-ordinate their work around a series of International Development Targets. The targets for health are based on improvements in infant, child and maternal mortality. Progress towards these goals will be used to assess the effectiveness of development policies. OBJECTIVES: To assess the potential impact of achievement of the International Development Targets on health in Russia, and to identify possible alternatives that may be more relevant to transition countries. DESIGN: The study covered the population of the Russian Federation from 1995-99.The effects of reducing infant, child and maternal mortality on Russian life expectancy at birth were modelled using construction of life tables. Three scenarios were modelled, reducing rates to those of the best performing regions in Russia, those required to achieve the International Development Targets and current UK rates. The results were compared with the effect on life expectancy at birth of policies to reduce adult mortality in different ways. RESULTS: Achieving the International Development Targets for infant, child and maternal mortality (66.7 and 75% reductions) will contribute very little to improving life expectancy in Russia (0.96 years). In contrast, even a 20% reduction in adult mortality would give rise to an increase in male life expectancy at birth of 1.86 years. CONCLUSION: Targets for health improvement in transition countries such as Russia should take account of adult mortality as well as the indicators contained in the International Development Targets.

Background In the context of population ageing and urbanisation, a growing number of cities are adopting the WHO's Age-Friendly Cities (AFC) framework, which incorporates eight interlinking domains. This study set out to design an evidence-based instrument to assess interventions intended to make urban settings more age-friendly. Methods Fieldwork is taking place in Liverpool, UK. A needs assessment used census, Hospital Episode Statistics, and Ambulance Service data and highlighted falls as a local health priority for older people (65 years or older). Health, environmental, and social science databases (including PubMed, Scopus, and Web of Science) were systematically searched to identify systematic reviews from Jan 1, 2000, to July 31, 2014, in English that described effective falls-related interventions. Examples of keywords for age were old* people* OR old person* OR age* 65* OR elder*. Examples for review were systematic review* OR narrative review* OR integrated review* OR review*. Examples for falls were fall* OR outdoor safety OR trip hazard*. Interviews with key informants (n=12) from different sectors as well as interviews (n=20) and focus groups (n=2, 10 participants each) with older people on falls-related provision are proceeding. The research is informing the development of an evidence-based evaluation instrument that can be applied to settings and interventions more widely. The instrument will be pilot-tested for usability, with in-depth validation planned for a further project phase. Findings Analysis of available data has shown a high incidence of and case fatality from falls, and it has revealed common causes and locations of falls in Liverpool. The effective falls-related interventions identified were mapped onto the WHO domains to highlight important areas of provision. Strongly represented were interventions that relate well to the domains of Community Support and Health Services and Housing (eg, home modifications). The domains of Outdoor Spaces and Buildings and Transportation were identified as important areas for provision, although the evidence base was more limited. Analysis of qualitative data is exploring whether this pattern is reflected in Liverpool's falls-related provision. The evidence mapping, together with the primary data, allows presentation of a picture of strengths and gaps in falls-related provision in Liverpool in relation to the AFC domains. Interpretation Data collection has highlighted key dimensions to be incorporated in the evaluation instrument. These dimensions include consideration of the extent to which AFC initiatives are informed by a needs assessment and robust research evidence, political will, availability of resources, attention to target group perspectives, and plans for evaluation. Funding This project is funded by the National Institute for Health Research School for Public Health Research (SPHR) as part of SPHR's Ageing Well programme of research.

Background The recent transfer of public health teams to local authorities in England offers opportunities for new policy approaches to tackling alcohol harm. The new responsible authority status of directors of public health, for example with regard to licensing applications, raises the prospect of reducing excessive alcohol consumption through local availability measures. Local authorities are also responsible for the commissioning of community-based treatment services. We used a case study approach to identify the major drivers and characteristics of local alcohol policies and services in two contrasting local authorities. Methods The many sources used were semi-structured interviews with key informants, including two in public health, two in licensing and trading standards, one in the police, and one information specialist; documentary analysis, including two alcohol strategies; two statements of licensing policy; and field observation (attending a licensing committee hearing). Focusing on alcohol harm prevention programmes and their underlying objectives, we used storyboards and constant comparative methods to describe and explain differences in the alcohol policy landscape between the two local authorities. Ethics approval was obtained from the University of Sheffield Ethics Committee. Findings Substantial differences in the stated priorities of alcohol harm prevention strategies were shown in the contrasting policy responses of the two local authorities. Concern about how best to reduce high rates of alcohol-related hospital admissions in local authority 1 led to an emphasis on health-service approaches, such as screening and brief intervention, whereas a public disorder focus in local authority 2 resulted in policies aimed at reducing availability through licensing measures. Perceived tensions were apparent for local authority 1 between maintaining a supportive environment for local businesses at a time of economic recession and introducing policy measures with a regulatory focus. Field observations highlighted the underlying importance of well-functioning working relationships between licensees and all responsible authorities, for achieving acceptable implementation plans for novel policies. Resource constraints and a lack of clear policy champions were also barriers to more preventive measures in local authority 1. Interpretation Devolved responsibility for alcohol harm prevention clearly presents the potential for local authorities to tailor policies closely to their identified population needs. The exercising of responsible authority status in reducing availability through licensing approaches is best achieved however when fully integrated into the full spectrum of alcohol harm reduction activities, from prevention through to treatment-based interventions. Funding JDM's post is fully funded by the National Institute for Health Research School for Public Health Research School-wide Programme on Alcohol.

Background The Licensing Act (2003) gives English local authorities the power to implement Cumulative Impact Policies (CIPs), which are intended to strengthen licensing powers and limit the growth of on-premise and off-premise alcohol outlet density. Local authorities can now implement CIPs by designating boundaries within their borough as cumulative impact zones (CIZs) if adverse social effects of alcohol market saturation can be demonstrated. We are evaluating this intervention in a London borough, which as of January, 2013, had seven CIZs. Methods The qualitative arm of our study is informed by institutional ethnography. This sociological research tradition has had limited application in public health sciences despite obvious applicability to understanding processes of multilevel institutional regulation. We conducted semi-structured individual and group interviews with stakeholders (eg, licensing officers, councillors, police, trade), documentary analysis, and ethnographic data collection. Research participants were purposively selected to include diverse stakeholders from within our case study area as well as neighbouring boroughs with CIPs. We developed a detailed map to account for the ways in which different texts (eg, laws, policies, licensing forms) coordinate sequences of action related to alcohol licensing (eg, the work of granting or rejecting a licence application). Findings CIPs are an example of multilevel governance where national and local alcohol licensing priorities, interests, and legal powers interface. CIPs informed how some licensed premises conducted their business, including terms and conditions voluntarily adopted to minimise alcohol-related harms (eg, willingness to stop selling high-strength, inexpensive beer and cider). With newfound regulatory powers at the local level, came complex forms of work that local authorities had to negotiate, including assembling evidence and contesting licensing claims of applicants who sought to be granted new or modified licences. Interpretation Understanding the social and public health effects of CIPs requires innovative research strategies. Institutional ethnography offers important opportunities for methodological innovation in public health science. The map we developed reveals that CIPs must be viewed in relation to other alcohol initiatives. This qualitative research also generated nuanced questions about the social and public health effects of this alcohol intervention to which our ongoing quantitative analysis will contribute. Funding This work was supported by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR).

Background Retailers routinely collect data about people's purchasing behaviours and access to consumer products associated with health and wellbeing. Here we discuss how retail data can be used in public health research and consider potential strengths and limitations to such research. To illustrate the discussion we refer to an evaluation of an intervention called Reducing the Strength, whereby off-licence shops and supermarkets voluntarily stopped selling inexpensive superstrength (≥6·5% alcohol by volume) beers and ciders. Methods Monthly data from a large retail chain (East of England Co-operative Society) were obtained for three UK counties (141 stores). In one county the intervention started 12 months earlier than the others, allowing for a pre–post study design with a delayed implementation comparator. Difference-in-differences analysis of unit alcohol sales controlled for socioenvironmental confounders and shop-level characteristics including shop size, parking facilities, cash machines, opening hours, and other factors. Findings The retail data detailed shop-level characteristics and sales data such as prices, quantities, product brands, alcohol content, sales, and factors affecting sales. The wide geographical coverage, shop-level data, including data for potential confounding factors, and frequent timepoints made the retail data well-suited for a quasi-experimental evaluation capitalising on temporal and spatial variations in intervention exposure. Limitations of this study include a lack of longitudinal data for individual customers, and shops that are not covered by the data. Qualitative interviews with shop workers and customers, and triangulation using alternative data sources can help to address limitations. Alternative sources of retail data such as private sector consultants who specialise in collecting shop-level and sales data for a range of companies might also address some limitations; however, there are potential barriers of expense, accessibility, and coverage associated with the use of such consultants. Interpretation Increasingly, researchers recognise the potential of retail data for evaluating interventions affecting social determinants of health and inequalities, such as local access to alcohol. However, shop-level data have frequently proved difficult for researchers to obtain. By obtaining such data we have been able to assess, using a quasi-experimental design, the effects of removing strong, cheap beers and ciders from shops. We have also been able to explore in more detail how to optimise the strengths and address some limitations of the data in ways that could potentially assist others planning to use this important data source in their research. Funding The study is funded as part of the School of Public Health Research by NHS National Institute of Health Research. AJ, SA, and JW contributed as employees of Public Health Suffolk, Suffolk County Council.

Background Despite growing consumer demand for organically produced foods, information based on a systematic review of their nutritional quality is lacking. Objective We sought to quantitatively assess the differences in reported nutrient content between organically and conventionally produced foodstuffs. Design We systematically searched PubMed, Web of Science, and CAB Abstracts for a Period of 50 y from 1 January 1958 to 29 February 2008, contacted subjects experts, and hand-searched bibliographies. We included peer-reviewed articles with English abstracts in the analysis if they reported nutrient content comparisons between organic and conventional foodstuffs. Two reviewers extracted study characteristics, quality, and data. The analysis were restricted to the most commonly reported nutrients. Results From a total of 52471 articles, we identified 162 studies (137 crops and 25 livestock products); 55 were of satisfactory quality. In an analysis that included only satisfactory quality studies, conventionally produced crops had a significantly higher content of nitrogen, and organically produced crops had a significantly higher content of phosphorus and titratable acidity. No evidence of a difference was detected for the remaining 8 of 11 crop nutrient categories analyzed. Analysis of the more limited database on livestock products found no evidence of a difference in nutrient content between organically and conventionally produced livestock products. Conclusions On the basis of a systematic review of studies of satisfactory quality, there is no evidence of a difference in nutrient quality between organically and conventionally produced foodstuffs. The small differences in nutrient content detected are biologically plausible and mostly relate to differences in production methods.

It is widely accepted that the health of a population is determined by a range of factors and that the greatest scope for improving the public's health lies outside the control of the NHS. Health impact assessment (HIA) has emerged to identify those activities and policies likely to have major impacts on the health of a population. #### Summary points Health impact assessment is a structured method for assessing and improving the health consequences of projects and policies in the non-health sector It is a multidisciplinary process combining a range of qualitative and quantitative evidence in a decision making framework Applications include national policy appraisal, local urban planning, transport, and water and agricultural projects Benefits include improved interagency collaboration and public participation Limitations include a lack of agreed methods and gaps in the evidence base for health impacts Health impact assessment is a means of evidence based policy making for improvement in health. It is a combination of methods whose aim is to assess the health consequences to a population of a policy, project, or programme that does not necessarily have health as its primary objective.1 Health impact assessment is a multidisciplinary process within which a range of evidence about the health effects of a proposal is considered in a structured framework. It takes into account the opinions and expectations of those who may be affected by a proposed policy. Potential health impacts of a proposal are analysed and used to influence the decision making process. A health impact assessment is based on a broad model of health, which proposes that economic, political, social, psychological, and environmental factors determine population health (box B1). For the first time these wider determinants of health have been acknowledged by the UK government in the white paper Saving Lives : Our Healthier Nation .2 This …

Background Alcohol-related ill health is estimated to cost the UK National Health Service £3 billion per year, and there were over 1 million alcohol-related admissions to hospital in England (primary or secondary diagnosis) in 2010–11. Although liver disease mortality (for which the principle cause is alcohol consumption) has been falling in other northern European countries, rates in the UK continue to rise. Correspondingly, alcohol is now prominent on the UK policy agenda, and a range of new control and prevention measures have been proposed, including new powers for local authorities, as part of a focus on localism in English public health. Although many local alcohol policy interventions are supported by published evidence, there has been little exploration locally of the contextual factors that determine the optimum mix of policies for a particular area. As part of the National Institute for Health Research School for Public Health Research, we aim to localise the Sheffield alcohol policy model (SAPM) to enable appraisals of policy interventions (particularly pricing, licensing, and protocols for screening and brief intervention policies) that are specific to local population characteristics, alcohol consumption patterns, rates of harm, and existing policy frameworks. Methods A key challenge will be obtaining estimates of key model indices from local authorities. Baseline alcohol consumption for local authorities will be estimated by pooling multiple national datasets (eg, the General Lifestyle Survey) to create sufficiently large samples for local authorities (or clusters of authorities) and by identifying local consumption surveys. Estimates of alcohol consumption derived from different survey years will need to be rebased to the latest available year before pooling with age-period cohort models that infer projected trends in alcohol consumption. Data might also need to be adjusted to account for differences in survey method. Estimates will be cross-validated with the local alcohol profiles for England (LAPE) produced by the North West Public Health Observatory. Data-pooling methods will also be used to explore whether local estimates of alcohol prices and spending, grouped by age, sex, and ethnic origin, can be derived. For alcohol availability, spatial analyses of full postcode data for all English alcohol outlets in 2003, 2007, 2010, and 2013 will be used to characterise local authorities by availability measures. After cross-validation with established local datasets on health harms and other societal effects by regression techniques, the predictive capacity of the locally adapted SAPM (SAPM-LA) to estimate localised harms corresponding to different local consumptions will be tested. When validated, SAPM-LA should help to facilitate the comparative appraisal and optimisation of a wide range of policies aimed at local reduction of alcohol harms from licensing and promotion restrictions through to targeted brief intervention strategies. Any reduction in harms will therefore be modelled on the projected reductions in consumption resulting from licensing and planning approaches to restricting alcohol supply, as well as more overtly behavioural approaches such as screening and brief interventions. Although LAPE identifies local authorities with high rates of alcohol harms (eg, Bradford and Rotherham in the Yorkshire and Humber region), most have little additional detail on accompanying local consumption patterns. A few local authorities with which we already have strong working links have undertaken dedicated surveys locally, which will provide a comparison for our baseline estimates. Interpretation The work outlined here is a methods-only presentation and is intended to stimulate discussion and interest with front-line public health practitioners within local authorities to enable discussion of the types of intervention mixes that will be the most useful, feasible, and practicable. The locally adapted model could then be used to build the evidence case for implementation, as has been most persuasive at both national and devolved government levels. Funding Multicentre National Institute for Health Research School of Public Health Research.

Background Many non-health public policy sectors might have effects on population health outcomes. Views of decision makers about research evidence are less well understood in these sectors than in health care or public health. With the recent move of public health in England to local authorities, there is a need to investigate the cultures of evidence in other policy sectors. Methods We undertook a systematic review of qualitative evidence. 28 database sources were searched for both published and unpublished work: Applied Social Sciences Index and Abstracts, Campbell Library, CENTRAL, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Conference Proceedings Citation Index—Science, Conference Proceedings Citation Index—Social Science and Humanities, Copac, Criminal Justice Abstracts, Database of Abstracts of Reviews of Effects, EconLit, Enviroline, Health Technology Assessment, Medline, Medline In-Process, National Criminal Justice Reference Service, National Health Service Economic Evaluation Database, OAIster, OpenGrey, PAIS International, PsycINFO, Science Citation Index, Social Care Online, Social Policy and Practice, Social Science Citation Index, Social Services Abstracts, Transportation Research Information Services Database, and Zetoc. The searches were done in October, 2012, and were not limited by date. The searches located 13 131 records. Studies were included if they encompassed local policy makers or practitioners in transport, housing, urban planning and regeneration, crime and policing, or licensing; and reported qualitative data on views, beliefs, or experiences of research evidence. Study quality was assessed with the instrument in the National Institute for Health and Care Excellence Public Health methods manual. Study findings were synthesised with a thematic analysis approach with EPPI-Reviewer 4 software. The protocol for this review can be found on the School for Public Health Research website: http://sphr.lshtm.ac.uk/our-research/publications/projects/. Findings 16 studies were included. Decision makers use many different sources of information to inform decisions, many of which are not research evidence, as traditionally conceived. Several factors affect decision makers' use of evidence, including practical issues such as capacity and organisational factors. However, the relevance and usefulness of research studies seem to be more important; much research is seen as unable to show the complexity of practice and as preoccupied with theoretical concerns to the exclusion of practical applicability. The credibility of evidence is also important, but often derives mainly from the personal or institutional authority of those producing it. The scope of decision making is often constrained by political feasibility or acceptability, or by legislation or guidance, which means that the use of evidence may not be practicable. Local decision makers seem to mainly use evidence tactically to support policy choices and are often sceptical about the evidence-based policy agenda. Interpretation Compared with health care or public health, cultures of evidence in non-health sectors present different issues, which may lead to problems for public health decision makers working with colleagues in other sectors or advocating for policy-level interventions to promote health. Health practitioners and policy makers should take into account the differing ecologies of information in other sectors. Researchers may also benefit from taking a broader perspective on evidence use, which takes into account the whole decision-making process, and the interaction of academic research with more informal and situated forms of knowledge. Linear models of knowledge translation may not capture the complexity of potential relations between knowledge and practice and the wide variation in the understanding of decision makers of the concept of evidence. The findings call into question the assumption that increasing the uptake of research evidence is likely to lead to better decisions. Funding This work was supported by the National Institute for Health Research (NIHR)'s School for Public Health Research. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.

Background Many non-health public policy sectors which form part of local government may have impacts on population health outcomes. Decision-makers’ views about research evidence, and their practices of evidence use, are less well understood in these sectors than in healthcare or public health. Methods Systematic review (PRISMA) of qualitative evidence. A range of sources were searched. Studies were included if: they included local policy-makers or practitioners in transport, housing, urban planning and regeneration, crime and policing, or licensing; and reported substantive data on views, beliefs or experiences regarding research evidence. Study findings were synthesised using a grounded-theory thematic analysis approach. Results A range of contextual factors impact on evidence use, including personal contacts, institutional structures and power relationships, and national legal or policy constraints. Academic research evidence is often a relatively small part of the overall knowledge base for decision-making. The types of evidence used vary considerably across sectors: evaluations of effectiveness are generally a secondary concern, with descriptive evidence on contexts being more highly valued. General messages about the value of evidence-based policy and practice have been widely disseminated, and some sectors report relatively high rates of evidence use. However, decision-makers’ understandings of these messages are highly divergent, and the ways evidence is used in practice often do not conform to academic researchers’ preconceptions. Discussion Compared to healthcare or public health, cultures of evidence in non-health sectors present distinct issues. The findings of this review indicate the need for a broader perspective on evidence use, which takes into account the whole decision-making process, and the interaction of academic research with more informal and situated forms of knowledge. Linear models of ‘knowledge translation’ may not capture the complexity of potential relations between knowledge and practice, and the wide variation in decision-makers’ understandings of the concept of evidence.

A failure to acknowledge uncertainty about the effectiveness of social interventions is a major barrier to evidence based public policy making. M Petticrew and colleagues argue that we need to develop and apply the concept of social equipoise

Background Few public health interventions combining modification of the social and built environment with individual-level health promotion have been robustly evaluated in the UK. Well London is an assets-based community development programme designed to improve physical activity, healthy eating and mental wellbeing in highly deprived inner-city communities. The programme, delivered between 2007 and 2011, comprised a mix of projects delivering traditional health promotion, community development and changes to the physical neighbourhood environment. The objectives of the study are to: (i) determine the effectiveness of Well London for improving healthy eating, physical activity and mental wellbeing in deprived inner-city communities; (ii) examine the effects in population subgroups linked to health inequalities in the UK. Methods We used a pair-matched, cluster-randomised trial with 20 control neighbourhoods matched within London boroughs to 20 programme delivery neighbourhoods. The trial outcomes in adult residents (aged ≥16 years) were collected using a structured electronic household survey, administered by fieldworkers to 100 randomly sampled residents in each intervention and control neighbourhood. The main outcome measures were: physical activity: meeting UK Chief Medical Officer-recommended five sessions of 30 minutes moderate intensity activity per week (self-report International Physical Activity Questionnaire); healthy eating: eating at least five portions of fruit/vegetables per day (food frequency questionnaire from the Health Survey for England); and mental wellbeing: abnormal score on 12-item General Health Questionnaire; Warwick Edinburgh Mental Wellbeing Scale score. Results The baseline survey in 2008 showed that the intervention and control populations are comparable on socio-demographic/economic characteristics and primary trial outcomes. At baseline, 37% of adults met the five-a-day (healthy eating), 60% met the five-a-week (physical activity), and 18% reported experiencing anxiety or depression. Results from the follow-up survey will be available in April 2012. We will present the effects of Well London on the primary outcomes and subgroup analyses by gender, age, ethnicity and level of education. Conclusion In a health system where less than 1% of the research budget is spent on primary preventive interventions for non-communicable diseases, robust evidence about the effectiveness and cost-effectiveness of upstream interventions is essential for action on health inequalities and reductions in healthcare spending recommended by the Marmot Review (2010) and the Wanless report (2004).

Background The benefits of regular physical activity are well known. Few adults in the UK meet the recommended levels. There is growing evidence suggesting that neighbourhood characteristics interact with individual characteristics to determine physical activity levels. Objective Examine relationships between neighbourhood-level and individual-level characteristics and physical activity. Setting 40 of the most deprived neighbourhoods in London (census lower super output areas (LSOA) ranked in the top 11% of LSOAs in London by Index of Multiple Deprivation). Design Cross-sectional, interviewer-administered survey with households in the 40 neighbourhoods (n=4107 adults aged >=16 years); fieldworker-completed neighbourhood audit tool to measure area characteristics. Methods Physical activity was measured using the International Physical Activity Questionnaire in the household survey. The outcome measure was meeting the minimum recommended levels of physical activity (5 x 30 min moderate activity per week). Multilevel modelling in Stata 11 was used to examine the effects of individual and neighbourhood characteristics on achieving the recommended weekly physical activity levels. Multiple imputation was used to account for missing data. Results 70% of respondents reported physical activity equivalent to the recommended 5x30 min per week; the intra-neighbourhood correlation coefficient was 0.15. Preliminary results (adjusted for socio-demographic characteristics) indicate that women were less likely than men to meet the recommended physical activity levels (OR=0.6; 95% CI 0.4 to 0.7); individuals with positive mental health were more likely to meet the recommended levels (OR for 1 point increase in Hope Scale=1.2; 95% CI 1.0 to 1.3). After adjusting for individual characteristics, 9% of the residual variance in propensity to meet recommended physical activity was attributable to neighbourhood differences. Neighbourhood levels of incivilities, proximity and quality of parks/green space, walkability and cyclability were not associated with meeting recommended physical activity levels. Further results for other neighbourhood characteristics will be presented and social inequalities in the effects of neighbourhoods on health will be examined. Conclusion The level of physical activity in low income communities in London is higher than the national average measured in the Health Survey for England. In preliminary analyses we found no evidence of neighbourhood effects on physical activity levels in deprived London neighbourhoods. These observations may be due to: (i) limited clustering of physical activity levels across the most deprived neighbourhoods in London; (ii) limited variability in neighbourhood environments in these communities; (iii) individual level characteristics are stronger determinants of physical activity in these communities; (iv) complex and contingent causal pathways of physical activity, not captured in our models.

Background Poor mental health is more common in deprived communities in the UK. Individual characteristics (employment, financial security, significant life events, social networks) are key proximal determinants of mental health. It is important to examine the upstream effects of the neighbourhood environment on mental health because it may be easier to modify in the context of public health interventions that aim to reduce health inequalities. Objective To identify the influence of the local neighbourhood environment on positive mental health in low income communities in London. Methods Individual-level characteristics were collected by interviewers using structured questionnaires from 4107 adults (aged ≥ 16 years) living in 40 of the most deprived neighbourhoods in London (neighbourhoods defined as census lower super output areas(LSOA); ranked in the top 11% of LSOAs in London by Index of Multiple Deprivation). Physical and social characteristics of the neighbourhoods were captured using a fieldworker-completed environmental audit tool. Statistics Multiple imputation to account for missing individual-level data; multilevel modelling to examine the individual and neighbourhood determinants of positive mental health (the Hope Scale – higher value indicates positive mental health). Results Preliminary results indicate (after adjusting for socio-demographic characteristics): individuals who find it more difficult to manage on their household income have lower Hope Scale scores (test for trend p=0.001); unemployed individuals had lower Hope Scale scores than those in employment or education (coefficient=−4.2; p Conclusions Preliminary analyses indicate no neighbourhood effects on positive mental health in low income communities in London; this may be due to the limited clustering of positive mental health in the sampled communities. Further work is needed to understand the complex causal pathways by which neighbourhood environments and other structural determinants may affect mental health in deprived communities.

A growing body of literature explores the relationship between the built environment and health, and the methodological challenges of understanding these complex interactions across the lifecourse. The impact of the neighbourhood environment on health and behaviour amongst older adults has received less attention, despite this age group being potentially more vulnerable to barriers in their surrounding social and physical environment. A qualitative geographical information systems (QGIS) approach was taken to facilitate the understanding of how older people over 70 in 5 UK towns interact with their local neighbourhood. The concept of neighbourhood changed seasonally and over the lifecourse, and was associated with social factors such as friends, family, or community activities, rather than places. Spaces stretched further than the local, which is problematic for older people who rely on variable public transport provision. QGIS techniques prompted rich discussions on interactions with and the meanings of ‘place’ in older people., Highlights • Neighbourhoods become increasingly important to older people's wellbeing. • Older people associate neighbourhood with people and activities rather than places. • Neighbourhoods are dynamic; change seasonally and over the lifecourse. • Qualitative GIS produces rich data on older people's interactions with place and space.

The WHO recently conducted, within its Global Burden of Disease 2000 Study, a Comparative Risk Assessment (CRA) to estimate the global health effect of low fruit and vegetable intake. This paper summarizes the methods used to obtain exposure data for the CRA and provides estimates of worldwide fruit and vegetable intakes. Intakes were derived from 26 national population-based surveys, complemented with food supply statistics. Estimates were stratified by 14 subregions, 8 age groups, and gender. Subregions were categorized on the bases of child mortality under age 5 y and 15- to 59-y-old male mortality (A: very low child and adult mortality; B: low child and adult mortality; C: low child, high adult mortality; D: high child and adult mortality; E: high child, very high adult mortality). Mean intakes were highest in Europe A [median = 449 g/(person.d)] and the Western Pacific Region A. They were lowest in America B [median = 192 g/(person.d)], and low in Europe C, the South East Asian Regions B and D, and Africa E. Children and elderly individuals generally had lower intakes than middle-aged adults. SDs varied considerably by region, gender, and age [overall median = 223 g/(person.d)]. Assessing exposure levels for the CRA had major methodological limitations, particularly due to the lack of nationally representative intake data. The results showed mean intakes generally lower than current recommendations, with large variations among subregions. If the burden of disease attributable to dietary factors is to be assessed more accurately, more countries will have to assess the dietary intake of their populations using comparable methods.

OBJECTIVE: To describe the food environment in rural villages and an urban slum setting in India with reference to commercially available unbranded packaged snacks and street foods sold by vendors, and to analyze the type and quantity of fat in these foods. DESIGN: Cross-sectional. SETTING: Two low-income villages in Haryana and an urban slum in Delhi. PARTICIPANTS: Street vendors (n = 44) were surveyed and the nutritional content of snacks (n = 49) sold by vendors was analyzed. MAIN OUTCOME MEASURES: Vendors' awareness and perception of fats and oils, as well as the type of snacks sold, along with the content and quality of fat present in the snacks. ANALYSIS: Descriptive statistics of vendor survey and gas chromatography to measure fatty acid content in snacks. RESULTS: A variety of snacks were sold, including those in unlabeled transparent packages and open glass jars. Mean fat content in snacks was 28.8 g per 100-g serving in rural settings and 29.6 g per 100-g serving in urban settings. Sampled oils contained high levels of saturated fats (25% to 69% total fatty acids) and trans fats (0.1% to 30% of total fatty acids). CONCLUSIONS AND IMPLICATIONS: Interventions need to target the manufacturers of oils and fats used in freshly prepared products to improve the quality of foods available in the food environment of low-socioeconomic groups in India.