The Moray Food & Health Project
Working together to improve health in Moray
1 Contents
Executive Summary 4
1. Introduction 6
2. Background 7 2.1 Diet and Health in Moray 7 2.2 Obesity and overweight 11 2.3 Food Access 12 2.4 Children and young people 13 2.5 Health Inequalities 15
3. Project Methodology & Results 16 3.1 Research Sites 16 3.2 Community Profiles 16
4. Objective One – Food Access 20 4.1 Methodology 20 4.2 Results 22 4.2.1 Food Mapping 22 4.2.2 Consultation with Retailers, Tomintoul 27 4.2.3 Community Consultation – Behavioural Data 29 A Full Adult Questionnaire 29 Lhanbryde & Tomintoul 29 A.1 Quantative Data 29 Lhanbryde 31 Tomintoul 35 A.2 Qualitative Data 39 Lhanbryde 39 Tomintoul 40 B Young Peoples’ Health Profiles 43 B.1 Quantative Data 43 Tomintoul & Lhanbryde Youth Clubs 43 Craigellachie, Dufftown, Aberlour & Rothes Primary Schools 46 C Revised Parental Questionnaires 51 C.1 Quantative Data 51 Craigellachie , Dufftown, Aberlour & Rothes 51 C.2 Qualitative Data 56 Craigellachie, Dufftown, Aberlour & Rothes 56 4.3 Key Themes 58 4.4 Recommendations 60
5. Objective Two – Cooking Skills 61 5.1 Methodology 61 5.2 Results 62 5.3 Key Themes 64 5.4 Recommendations 65
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6. Objective Three – Weight Management & Obesity Services 66 6.1 Methodology 66 A. General Practice Health Profile Framework 66 B. Weight Management Training Questionnaire 67 6.2 Results 68 6.2.1 General Practice Health Profiles 69 6.2.2 General Practice Obesity & Weight Management Service Profiles 77 6.2.3 Weight Management & Training Questionnaires 79 A. Weight Management Questionnaire 79 B. Training Questionnaire 80 6.3 Key Themes 81 6.4 Recommendations 83
7. Objective Four – Schools 84 7.1 Methodology 84 7.2 Results 85 7.2.1 Primary Schools 86 7.2.2 Speyside High 89 7.3 Key Themes 90 7.4 Recommendations 90
8. Conclusion 91 Acknowledgements 91
9. Appendices 92
Appendix 1 Transport costs and services in Speyside and Lhanbryde 92 Appendix 2 Food Mapping – checklist of products 93 Appendix 3 Full Adult Questionnaire 94 Appendix 4 Young People’s Health Profiles 98 Appendix 5 Revised Parental Questionnaire 102 Appendix 6 Shop survey – all results 104 Appendix 7 General Practice Health Profile 107 Appendix 8 Obesity Management / Training 109 Appendix 9 Lesson Plan Speyside Primary Schools 110 Appendix 10 Lesson Plan Speyside High School 112
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Executive Summary
Section 1 – Introduction
The aims and objectives of the Moray Food and Health Project are introduced in this section. Supported by Quality of Life Funding, the project team has worked in consultation with communities in Speyside and Lhanbryde to establish what food and health issues exist and to offer health improvement initiatives that are designed to improve long term health and well being in these areas.
Section 2 – Overview of Diet & Health in Moray
A profile of food and health issues for the Moray area is offered, highlighting areas of concern for communities and agencies in relation to health improvement relevant to the aims and objectives of the Moray Food and Health Project. Although by no means comprehensive, due to a dearth of local data on this topic overall, it is clear that as much as there is clear cause for concern there is considerable scope for improvement.
Section 3 – Community Profiles
The methodology and results for the broad community profiling of the target areas covered by the report is outlined. Local healthcare services are also described.
Section 4 – Food Access
An extensive part of the project has been community food mapping and consultations with both adults and children to determine what issues exist within the target areas regarding accessing healthy food. This section reports on the methodology and results of this in- depth piece of work. The outcomes of discussions with local retailers in Tomintoul are also reported. Key themes are drawn together and recommendations for future action offered.
Section 5 – Food Skills
The impact and success of two specific pieces of community food skills work are assessed in this section – a community based food skills course and a locally delivered training for trainers food skills course for youth workers, both in Speyside. Key issues are identified and approaches for the future suggested.
Section 6 – Obesity & Weight Management Services
In this part of the project, more detailed local information was gathered to address issues around the increasing local and national prevalence of overweight/obesity; chronic diseases for which overweight/obesity is a significant predisposing factor and chronic disease-related complications, which may primarily occur due to overweight/obesity and poor diet. A detailed account of the methodology and results of this key exercise are described and future actions proposed.
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Section 7 – Schools
In the early stages of the project it had been planned to formulate health profiles of school children that would include information on height, weight and eating habits. However, due to difficulties in accessing this information and the time constraints alternative ways of obtaining similar information were pursued. Workshops were run in both primary and secondary schools in the Speyside area based on the Balance of Good Health. Baseline information on expected nutrition competencies were used to enable the dietitian to assess the levels of knowledge of the participants. The results and potential developments of this part of the project are reported.
Section 8 – Conclusion
The considerable extent of the work covered by the first phase of the project is acknowledged. Phase 1 has established baseline data on which to build the second phase of the project which will be community focussed and delivering health improvement projects that will tackle key issues identified previously.
Section 9 - Appendices
Here copies of relevant data and documents developed, gathered and used in the course of Phase 1 of the project are reproduced for reference.
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1. Introduction
The Moray Food and Health Project (MFHP) aims to design a framework for the development of inter-linked local food initiatives that will raise the profile of the role food plays in developing a healthier lifestyle and preventing a range of non-communicable diseases including cancer, cardiovascular disease (CVD) and obesity. Specifically, it aims to encourage better access to healthy food choices, to provide training and skills, to support and encourage lifestyle changes, particularly in children and young people and to reduce inequalities in health.
These aims are being achieved in partnership through four key objectives:
Food Access
• To make better food choices more available to more people in Speyside and Lhanbryde during and beyond the funding period, particularly fruit and vegetables.
Cooking Skills
• To encourage the development of food skills such as purchasing, preparation, handling, budgeting and creating a balanced diet in the community.
Obesity & Weight Management Services
• To provide improved and accessible community based weight management support delivering key food and weight management messages.
Schools
• To work with schools to further develop the Health Promoting Schools initiative within the formal and informal curriculum.
The project has drawn on a range of skills and experience from the community, nursing, dietetics and public health to form its core team. Over a period of nine months a considerable amount of data was gathered to provide a picture of what the real issues are in relation to the key objectives of the project in the target communities.
Supported by funding for the year 2003/04 by Quality of Life Funding through the Moray Council and local Moray Health Improvement Funding through the Moray Local Healthcare Co-operative (LHCC). The project team worked with Lhanbryde and communities in Speyside to establish what food and health issues exist. In consultation with these communities MFHP will offer initiatives that will improve long term health and well being.
The methodology developed and used in this project and described in this report is owned by the Moray Food and Health Project. It is available for wider use upon request from the Moray Food and Health Group.
Judith Catherwood Nutrition and Dietetic Services Manager, Moray CHP, Dr Gray's Hospital, Elgin, IV30 1SN [email protected] Elaine Brown Public Health Lead, Moray CHP, Spynie Hospital, Duffus Road, Elgin, IV30 5PW [email protected]
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2. Background
A balanced diet providing sufficient energy but not excess can enhance health and fitness and is an investment in future good health. In contrast, a poor diet can predispose to a variety of serious illnesses, including diabetes, cardiovascular disease and some cancers. A poorer quality of life is a significant factor in many premature deaths from coronary heart disease, cancer and stroke. Diet thus considerably affects health1.
The Moray Health Improvement Action Plan2 sets out a clear vision for Moray stating that “the people of Moray deserve the best health possible”. It urges that in Moray:
• health services are developed to maximise opportunities for health gain
• the promotion of health is sponsored and supported
• partners work effectively together to improve the wider factors that influence health
The Moray Food and Health Project was set up by the Moray Food and Health Group with a vision to tackle food and health improvement within six specific communities of Moray:
• Tomintoul including Glenlivet • Aberlour • Rothes • Craigellachie • Dufftown • Lhanbryde
Funding for the initial pilot phase of the project for the year 2003/04 is from Quality of Life Funding through the Moray Council and local Moray Health Improvement Funding through the Moray Local Healthcare Co-operative (LHCC).
2.1 Diet & Health in Moray
This section offers a profile of food and health issues for the Moray area, highlighting areas of concern for communities and agencies in relation to health improvement relevant to the aims and objectives of the Moray Food and Health Project. Although by no means comprehensive, due to a dearth of local data on this topic overall, it is clear that as much as there is clear cause for concern there is considerable scope for improvement.
The total population of the target areas of the project (6435) comprises 7.4% of the total Moray population (86,940)3.
A national constituency profile of Moray in 20014 stated that “A rounded view of this constituency would suggest that it has an average population structure, a lower than average educational attainment amongst school leavers, and levels of unemployment and
1 www.phis.org.uk/evid/sub.asp?p=cca9 2 Joint Health Improvement Plan 2003/05, Moray Community Planning Partnership 2003 3 Source; 2001 Population Census 4 Office for Public Health in Scotland for the Public Health Institute of Scotland Moray Constituency Report 2001 7 household income that are close to the Scottish average. All the health indicators compare favourably with the Scottish average”
Moray constituency health and well being statistics in 20045 indicate that life expectancy is 74.8 years, 1.9 years less than the highest in Grampian and 10.8 years higher than the worst in Scotland.
Taking social class as an indicator of health the profiles show that 64% of the Moray constituency are in the middle social grades and 19% in the lower social grades (third highest proportion in Grampian though 17% less than the average for Scotland.
However, average gross household income is the lowest in Grampian and over 2% lower than the Scottish average. Levels of unemployment are the second highest in Grampian, though 40% lower than Scotland. There are more part time employees than the average for Scotland, and this trend has increased over time.
Prescribing for cardiovascular disease is the second highest in Grampian and 2% above the rest of Scotland. Death from cardiovascular disease is 14% lower than the Scottish average. Cancer mortality is the second highest in Grampian and 0.3% over the Scottish average.
The Standardised mortality ratio6 for Moray is 103, which is just above the standard ratio of 100 for Grampian7.
Diet is poorer, especially men’s diets in Moray than in Grampian overall8.
Breastfeeding data9 shows lower breastfeeding rates for Dr Gray’s Hospital, Elgin (49.3%) than at Aberdeen Maternity Hospital (50.1%). These figures are slightly above the Scottish national average of 45.5%.
Within a national context Moray’s health status would seem positive. It is important, however, to bear in mind Scotland’s health in a wider international context to highlight the broader overall position of Moray.
Leon et al.10 recently stated that ‘if the countries of the UK were regarded as separate entities, then life expectancy in Scotland would, for women, be the lowest in the European Union, and for men, the second lowest after Portugal. Scotland is now achieving levels of life expectancy seen in the best performing European countries in 1970.’
In seeking clues to the causes for this position after noting first widespread smoking related lung cancer prominence, the report notes that ‘the Scottish diet has traditionally been low in fresh fruit and vegetables and there is now growing evidence that this can exacerbate the contribution of smoking to both lung cancer and cardiovascular disease’. It also exhorts that despite the fact that ‘to some extent the script for the future is already
5 NHS Health Scotland, Health and Well Being Constituency Profiles 2004 6 The ratio of the number of deaths observed in the study group or population to the number that would be expected if the study population had the same specific rates as the standard population, multiplied by 100. Usually expressed as a percentage. 7 Assessment of Health Needs – Moray LHCC 2002 8 Grampian Adult Lifestyle Survey 1999 9 Guthrie Data 2002 10 Understanding the Health of Scotland’s Population in an International Context. Leon D., Morton S., Cannegieter S. and McKee M. PHIS 2003 8 written, as many causes of death have their origins in circumstances earlier in life’ that ‘more can, and must, be done’.
In 2003–04 a local poverty action group “Moray against Poverty” carried out research11 into poverty issues in Moray. Data was gathered from 100 separate questionnaires and 5 focus groups covering a number of distinct groups within the community including disabled, unemployed, students, lone parents, young people, pensioners, low waged and the homeless.
Access to food and services were among the topics discussed and a number of clear issues emerged.
Food
“Paying for food and fuel is a real problem proper food, eating a balanced diet. Although you get cheap food it is not necessarily good for you. I live in a homeless hostel the food’s provided and its good, it makes a big difference to me”. Student, Keith
“It’s a huge expense for healthy food. I buy it for about two days a week, then we’re eating crap. My mum brings around fruit when she comes to visit us instead of sweets for the kids”. Lone Parent Focus Group
”Yes its nice to do but I can’t afford to. I regulate the fruit to so much a day. It’s awful to say no to fruit”. Lone Parent Focus Group
School Dinners
“I grudge paying £1.65 for a slice of pizza and two chips. They’re not very good. I’d rather give £1.75 a day for a packed lunch” Lone Parent Focus Group
“There is a stigma about getting school dinners. My son went to West End and he was the only kid to get them. He stuck out like a sore thumb” Lone parent, Elgin
Shops
“Food prices are high in Aberlour”. Low wage, Aberlour
“The co-op is expensive and has nae a wide range of stuff”. Low wage, Aberlour
11 ‘Voices from the Edge’ – Moray Against Poverty 2004 9
“The co-op is here and that’s a lot better - cheaper food than the old store. Old folks save a lot of money (they don’t go into Elgin) not as cheap as ASDA but cheaper than before”. Low wage, Craigellachie
“Local shops are not fully stocked so I have to go to Elgin”. Pensioner Tomintoul
“Shops in the area are only just managing to stay open” Low wage, Portknockie
“We need shops in Clochan – all the services have died away” Unemployed, Clochan/Buckie
“The town lacks a real market.” Pensioner, Elgin
“Lossie there’s only a butchers, no clothes or shoes shops. I would like to see better shops” Pensioner, Lossie
Another local study aiming to develop an innovative model for identifying the key factors that contribute to health and ill health in Moray, focussing on rural areas12, has identified through information gathering and analysis a wide range of themes and issues including:
Mental health Community spirit Alcohol/drugs (isolation/stress/anxiety)
Access to services and facilities Confidentiality and anonymity Disability (including food)
Housing Crime and safety Diet and nutrition
Tensions between Environmental issues Cost of rural living indigenous/incomer populations
Illness (asthma/cancers/poor Communication Perceptions that this is the land quality of water and risks to health) that time forgot
Transport Employment
12 Strathisla Rapid Appraisal 1998 10
2.2 Obesity & Overweight
Obesity is now a major public health problem across the UK. It is estimated that at present, 38% of people are overweight and a further 20% are obese Body Mass Index (BMI) over 30. A BMI over 30 is a serious risk to health and can increase an individual's changes of suffering coronary heart disease, diabetes, high blood pressure, cancer, joint and back problems, infertility and mental health problems. Diabetes is also a major cause of morbidity and mortality in Scotland and the prevalence of diabetes is increasing, partly due to a reduced threshold on diagnosis but almost certainly due to lifestyle issues such as obesity and lack of activity.
Outpatient services for obesity
Dietetic services
Dietetic outpatient services for obesity are provided in Dr Gray's Hospital and in many GP practices across Moray. Significant proportions of the patients referred to dietetic out patient clinics are referred for obesity management (either for dietary treatment alone or diet and drug treatment for treatment associated with diabetes and other conditions). Out waiting lists are long, dietetic referral rates are high and patient needs are not being met.
Table 1 provides a snapshot of the amount of dietetic time that was being used in treating obesity in early 2003.
Diabetes Weight Reduction Other Total N R N R N R N R
Secondary 10 95 5 3 14 14 29 112 Care (34%) (85%) (17%) (3%) (48%) (12%)
Primary 30 92 15 43 27 29 72 164 Care (42%) (56%) (21%) (26%) (37%) (18%)
Total 40 187 20 46 41 43 101 276 (40%) (68%) (20%) (17%) (40%) (15%)
Table 1 - Average Monthly Outpatient Appointments in Moray (N=new, R=review)
This table indicates that 40% of new dietetic appointments in out patient services for Nutrition and Dietetics across Primary and Secondary Care are provided for diabetic patients. Of review appointments 68% are also used to manage the diabetic caseload. Diabetes is a chronic disease and diet is the cornerstone of treatment. Dietitians are key to the Primary Care and Secondary Care Teams delivering diabetes services and it is therefore not surprising that the vast majority of out patient based services are provided to this client group.
However, it is also clear that patients referred for weight management are using large proportions of the additional out patient services. Of all new patient appointments 20% are allocated to people with this diagnosis. However, this is 33% of the available out patient 11 appointments when diabetes services are excluded. Of review appointments 17% are provided to patients requiring weight reduction advice, however this is almost 50% of all review out patient appointments once diabetes patients are excluded.
Obesity is therefore the second most common diagnosis resulting in an out patient appointment with the dietician. While obesity is clearly a priority and that effective weight management could help prevent diseases such as diabetes. Dietetic services do not have the capacity to continue to allocate this proportion of out patient services to patients with a diagnosis of obesity alone.
A previous audit undertaken by the Nutrition & Dietetic Department in 2003 identified that the vast majority of DNA appointments are attributable to patients referred for obesity management advice. It could be argued that one of the reasons for this is that the waiting time is significant and patients lose motivation to attend.
These measures alone, however, are unlikely to be sufficient to meet the growing need for effective obesity management services across the Moray locality. Primary and Secondary Care Services are increasingly protocol driven and clinician’s awareness of the importance of effective obesity management has increased demand considerably in this area in recent years. There is a requirement to redesign the way which obesity management services are provided, particularly in Primary Care settings. This may require increased training for primary health care practitioners at GP practice level together with partnership approaches with the private sector.
GP services
GP practices have a key role to play in obesity prevention and are uniquely placed to act opportunistically in promoting health. Moray practices are already working to achieve this.
95% of the population see their GP over a three-year period13. It is suggested that practices can contribute by:
• developing local health profiles to target those who can benefit most • work with local neighbourhood renewal programmes to support key groups in improving their health • develop outreach services and community development programmes • develop facilities jointly with other agencies and service providers
2.3 Food Access
Food access is part of a wider set of issues raised by the demise of local shops and services and the current crises in farming which impact on both rural and urban areas. In many cases people are living nowhere near the everyday services on which they depend including shops.
Food access is also about addressing the main barriers to achieving a healthy diet within the context of daily lives. These include:
• economic access - the affordability of healthier food choices in relation to the proportion of total disposable income available to spend on food and travel.
13 National Service Frameworks. A practical aid to implementation in primary care. www.nelh.nhs.uk 2002 12
• physical access - the accessibility of healthier food choices namely the range and quality (availability) of food within reach by foot, public transport or private car.
• attitudes, motivation and skills - the food which is chosen to eat is influenced by knowledge about what constitutes a healthy diet, the skills which are present to cook a healthy diet, the demands on time and by cultural practice.
These issues are also linked to other key local agendas such as local transport networks, environmental considerations (e.g. food miles) and support for local enterprise (local shops). They highlight the importance of improved access to healthy food choices as relevant to local planning and policy and as a cross-cutting issue. Crucially, issues around access to healthy food choices need to sit at the heart of the developing local community planning process.
Elgin is the main retail centre within Moray. It offers a wide range of retail outlets including a number of major supermarkets. Past research of shops in Moray14 has noted:
• a considerable diversity of price between the larger centres of population (cheaper) and the outlying areas (expensive).
• cheaper, less healthy brand prices in Elgin and Forres comparable to those of the Aberdeen supermarkets. For the healthy options whether quality or cheaper brand, the prices in Elgin and Forres were cheaper overall than those in Aberdeen.
• the availability of fruit and vegetables to be good but with some instances of considerably reduced availability in some outlying areas. Elgin again emerged as significantly cheaper in a number of instances.
• good availability of less healthy, quality options throughout but with less choice of cheaper brands particularly in the more outlying areas.
• apart from Elgin and Forres, a very limited availability of healthy options. This includes quality brands and to an even greater extent, cheaper, healthy brands. The shopper is, therefore, not able to purchase healthy options whatever price they are willing or able to pay.
2.4 Children & Young People
A varied diet containing enough energy and nutrients combined with physical activity is essential for normal growth and development, which at times can be very rapid in children and young people.
Detailed measurement of diet, nutritional status, physical activity, oral health, lifestyle and socio-demographic characteristics nationally15 has found that, with the exception of the youngest children (4-6 years), children in Britain are largely inactive. About 40% of boys and 60% of girls spend, on average, less than 1 hour a day in activities of at least moderate intensity and, therefore, fail to meet the Health Education Authority’s
14 Grampian Shopping Basket Survey, Grampian Heart Campaign (2000) 15 The National Diet and Nutrition Survey: Young People aged 4-18 years: UK DoH, 2000 13 recommendation for young people’s participation in physical activity. For boys and girls in the oldest age group (15-18 years) this proportion increases to 56% and 69% respectively. The most commonly consumed foods were white bread, savoury snacks, chips, biscuits, potatoes and chocolate confectionery. Fizzy soft drinks are the most popular beverage. On average, British children are eating less than half the recommended five portions of fruit and vegetables per day. One in five 4-18 year olds ate no fruit at all during the week of the study.
Young people’s diet was found to be relatively high in saturated fat, the main sources being cakes, biscuits, buns and pastries. Other important sources of saturated fat include meat and meat products, potatoes chips and savoury snacks. The consumption of non- milk extrinsic sugars which have been shown to be harmful to oral health and found in foods such as soft drinks, sugars, preserves and confectionery was also high.
Children over five years of age are beginning to take responsibility for their own food intake and it is vital that they understand the need for a healthy diet. However, the family earlier in life will have influenced their eating habits and it is difficult to change these once they are established. It is, therefore, important that the whole family has a healthy lifestyle. School meals can make an important contribution to the energy and nutrient intake of children. They are thought to be the best option when compared with food brought from other sources such as cafés and takeaways. Children whose parents receive Income Support or Income-based Jobseeker’s Allowance are eligible for free school meals.
Some schools now offer parents guidance on the content of packed lunches, which are becoming more popular. This advice is offered as part of a ‘whole school approach’ to healthy eating through which the food consumed at school is in harmony with the principles of healthy eating taught in the classroom.
The majority of schools in Moray are working towards becoming Health Promoting Schools. Many are currently focussing on food and health as one of nine priority health topics. In addition, the national initiative “Hungry for Success – a whole school approach to school meals in Scotland” is driving forward the food and health agenda in schools.
“Hungry for Success” sets out a vision for a revitalised school meals service in Scotland and presents a number of far-reaching recommendations connecting school meals with the curriculum as a key aspect of health education and health promotion. For the first time in the UK, national nutrient-based standards for school lunches are proposed and detailed mechanisms for monitoring these standards are set out. The key agents of success in implementing these standards are local authorities working in partnership with catering professionals, schools and the school communities including teachers, parents and pupils themselves.
“Kids in Condition” (KIC) is an interactive health club throughout Primary Schools in Moray. KIC encourages children to adopt a healthy lifestyle by increasing their uptake of physical activity, encouraging them to make healthier choices and discourages them from smoking, with the long-term aim of reducing coronary heart disease, stroke and cancer. KIC does not replace gym time in schools but is designed to be part of the whole school approach to becoming a “Health Promoting School”.
14 2.5 Health Inequalities
The health of individuals and communities can be disadvantaged in a number of ways. Research into indicators of rural disadvantage has established a number of key factors that have an impact on health16:
• access to employment • quality of employment • vulnerability of employment • low incomes • access and affordability of housing • quality of housing • physical isolation
Genetic predisposition and individual choice also influence health. Health inequalities exist when unacceptable variations in health occur when these type of factors combine.
Accessing health care services can also be a problem, particularly in some of the more remote and rural areas in Moray. People who do not present to health care services are missed from routine data collection and, therefore, do contribute to published healthcare statistics.
16 Dunn J, Hodge I, Monk S, Kiddle C (1998) ‘Developing indicators of rural disadvantage’ The Rural Development Commission
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3. Project Methodology & Results - General
The Moray Food and Health Project focuses both on the target communities as a whole and individuals within them with a view to improving health and well being. Phase 1 of the project has focused primarily on needs assessment with a view to establishing food and health priorities in the target areas. This information will inform resource allocation and provides baseline information for improving food and health services. A number of specific health improvement interventions have also taken place in response to local need.
3.1 Research Sites
The two broad target areas were selected as contrasting localities in Moray. Lhanbryde is relatively urban and close to Elgin. Speyside is more rural, dispersed and remote. The suitability of these areas for more detailed needs assessment and health improvement activity had also been highlighted by partner agencies within the wider Moray Food and Health Group. Previous studies10, 11 have also identified key food and health issues for these areas and local organisations considered these areas to merit further in-depth study from their knowledge of the needs of these communities.
Each objective within the project required a different approach to data collection depending on the type of data needed and the appropriateness of particular approaches to different settings within the target communities.
3.2 Community Profiles
Community profiles were drawn up for all areas identifying population sizes, retail/commercial outlets, transport costs and availability and active community groups. This was a desk based exercise that also served to identify local key gatekeepers and organisations which were subsequently approached to explain about and seek support for the project.
Speyside
The localities targeted for this part of the project are situated along the valley of the River Spey. The River Spey stretches for 98 miles and is fed by the surrounding area of some 1300sq. miles from its source to the Spey Bay in the Moray Firth. The six communities vary in population size between the large centres of Dufftown (1730) and Aberlour (1730) and the smaller communities of Craigellachie (420) and Tomintoul incorporating Glenlivet (330).
Employment throughout the Speyside area is mainly public service, farming, forestry, game keeping, whisky distilling and tourism. Each community has a health centre and general practice.
Tomintoul
Tomintoul which is the highest village in the Highlands at over 1000’ above sea level and lies just to the west of the Lecht pass and is always the first to be blocked by snow in the winter months. The community is widely spread through a rural area with small settlements
16 and farms, with the town of Tomintoul the main population centre and Glenlivet a remote rural glen.
A direct bus service runs to Elgin once a week, the return service leaves Elgin within three hours of arrival leaving only a relatively short time for shopping. Elgin can also be reached three times daily during school term with a change of bus in Aberlour. Tomintoul is served by three general stores including a general grocer located on the main shopping street. This retailer carries a fair range of fruit and vegetables displayed in a recently installed chilled cabinet facility. There are also a number of hotels and guest houses.
The new SYHA Youth Hostel has increased the local demand for fresh fruit and vegetables. However, due to its location and climatic factors, Tomintoul has a very short growing season. The SYHA is seasonal so the imbalance in produce availability is greater in the winter months.
Fresh meat is available by ordering in advance with deliveries on a Monday and Friday. Fresh fish and bakery deliveries are on Tuesday and Thursday. A fresh fish delivery van visits the area alternative Monday’s. At the time of survey, one of the hotels and coffee shop owned by the same person were both up for sale creating uncertainty for local residents.
Tomintoul has an active Community Association with a wide range of local groups.
Dufftown
Although technically a rural locality, Dufftown residents are served by numerous, high quality facilities. Situated at the confluence of the Fiddich and Dullan Rivers, the community relies on the quality of the water for the survival of the local distilleries that are the lifeblood of the community and a magnet for tourists.
Access to Elgin is hourly by bus between 7am and 6pm with a journey time of 40 minutes. A change of bus is necessary in Elgin to access the major supermarket. The community has two general and four specialist retail outlets, together with a number of hotels, pubs and tearooms.
The Cabrach and Mortlach Community Association is one of a wide range of community based organisations which enhance the quality of life in the area for both visitors and residents.
Craigellachie
Essentially Victorian in character, Craigellachie is situated at the junction of roads to Keith, Elgin, Dufftown and Grantown-on-Spey. Craigellachie itself is a village relying on the whisky industry and is home to the Speyside Cooperage.
The community is served by a combined shop and filling station, a hotel and restaurant plus a number of community based organisations.
17 Aberlour
A small bakery founded in 1909 has grown to become the famous Walker's Shortbread factory which employs around 200 people in this community. The village has one general store.
Speyside High School, the only secondary school for the Speyside area into which eight outlying primary schools feed, is situated in Aberlour within which is also located Speyside Community Centre. As well as meals provided on site the school is also served by a nearby chip shop. A large number of community associations, Speyside Swimming Pool and the Fleming Cottage Hospital are also in Aberlour.
Rothes
Rothes is situated further north in Speyside than the other localities and closer to Elgin. Many of the working population commute to neighbouring Speyside towns and Elgin with a core employed in local services. In common with other communities in Speyside Rothes is served by a wide range of community organisations and has two general and two food shops stocking a narrower range of goods.
The main bus route to Elgin passes through the area and this and other transport services are summarised in Appendix 2.
Lhanbryde
Lhanbryde village is located four miles from Elgin and has a mix of rural and urban style housing. It is situated on the main bus route to Elgin with buses every half hour to the main bus depot where a change of bus is required to access the main supermarket.
Some Lhanbryde residents travel to Elgin to work whilst others find employment at factories such as Baxter’s of Speyside at Mosstodloch and Walkers of Aberlour.
The Lhanbryde Community Challenge is active within the community supporting a range of community activities and initiatives which are often led by volunteers.
The village has two shops one on the main street and the other located within a housing scheme. The general grocer and Post Office, although located away from the main residential area, is well stocked with fruit, vegetables and staples. The other outlet, by contrast, appeared to be struggling for business at time of survey. The owner informed the project researcher that the shop has suffered from competition, has been on the market for some years and that it is intended that the business will close in the very near future.
Whytes Butchers from Keith supply ready made meals and use beef and vegetables from Fraserburgh. A fish van with bakery visits the village on Tuesday and Thursday.
Healthcare Services in Speyside
The A95 is the main access route to all GP practice areas within Speyside. Adverse weather can affect the accessibility of services with roads regularly blocked by snow over the winter period and sometimes in autumn and spring. Power failures can result and communities are cut off. There has also been severe flooding in recent years. Social isolation can be an issue generally in rural Speyside. 18
GP services are being influenced by the new General Medical Services Contract arrangements for practices. As a result, re-organisation of unscheduled care and out of hours services are currently being planned.
There are prescribing and dispensary issues for rural practices; some practices dispense medications on site. Community Hospital Management / Services, including accident and emergency, telemedicine and health centre with day care / lunch club are located at Stephen Hospital, Dufftown and at the Flemming Hospital in Aberlour.
At present the area of Speyside receives the following dietetic outpatient services:
• monthly General clinics at Dufftown HC and Aberlour HC
• monthly Diabetes clinics at Dufftown HC and Aberlour HC, every second month at Rothes HC and Tomintoul HC (joint diabetes and general clinic)
The monthly clinics at Dufftown and Aberlour have to take in the population from all of the surrounding areas such as Craigellachie, Rothes and Knockando.
During a general clinic there are 3-4 new appointments and 4-6 review appointments. Each new appointment is allocated 30 minutes and reviews are allocated 15 minutes. In some clinics there are only 3 new slots due to a need for more review places for patients.
Therefore, at present, the maximum number of new patients the Dietetic Service is able to see in a year is 48 for a monthly clinic. This does not take into account holiday periods and non-attendance by patients.
The Service also has to consider other types of patient referred for dietary intervention other than weight reduction. At present obesity is not prioritised for treatment due to its chronic nature. Dietary priorities at present include malnutrition (and more specifically under nutrition), GI conditions and palliative care.
It would, therefore, be impossible for the Dietetic Service to be responsible for all of the weight management patients within the practice.
Dietetic services in Lhanbryde
The Lhanbryde population is served mainly via Elgin clinics. At present there are four clinics per month (one clinic per week) at Dr. Gray’s hospital. This clinic accepts referrals from all Elgin and Lossiemouth GP practices. Presently the template allows for 3 new patients slots and 6 review slots per clinic of 30 and 15 minutes respectively.
Those patients with a Fochabers GP can be seen at Fochabers Health Centre. Here there is one clinic per month with 4 new and 4 review slots per clinic.
This totals 16 new patients for the population of Fochabers, Elgin, Lossiemouth, Hopeman, Lhanbryde, Burghead, Duffus and Miltonduff and comprises the total capacity per month.
19
4. Objective One – Food Access, Methodology & Results
To make better food choices more available to more people in Speyside and Lhanbryde during and beyond the funding period, particularly fruit and vegetables
4.1 Methodology
Food Access work has been developed using a theoretical Food Access Model17. This model suggests that peoples’ choices about the foods they eat are the result of a broad combination of factors (see 2.3 Food Access). A mapping exercise was carried out in the target areas in order to obtain an accurate picture of services, current eating and purchasing patterns and barriers to food choice and to provide accurate and high quality information about each community. The scope of this exercise went beyond food in order to provide a picture of a wide range of factors with the potential to impact on health.
Food Mapping
Thirteen retail outlets (2 in Lhanbryde, 10 in Speyside and 1 in Elgin) were visited and surveyed between September 2003 and February 2004 to identify the range of food on sale against a pre-selected checklist of healthy food products (Appendix 2: Food Mapping - checklist of products). The purpose of this exercise was to provide a broad picture of the cost, availability and quality of healthier food options in the target areas. Shop prices in the Speyside area were surveyed in late 2003 and in Lhanbryde in the early months of 2004. Although not within the target areas, a major supermarket in Elgin was surveyed to give a baseline comparison. Shop opening and deliveries times were also recorded.
Initial data gathering resulted in some inconsistency in data recording, so some information had to be resurveyed. The data from one outlet had to be abandoned due to difficulties obtaining consent from the retailer for recording the necessary information.
Volumes and weights of individual items varied between shops. To achieve comparable standardised results the data was manipulated as follows:
• where fruit and vegetable prices were recorded per individual item or in packs of a specified number, an average weight was assumed per item and the notional price per kg calculated (oranges 200g, apples 150g, bananas 150g, turnip 700g and onion 250g).
• where volumes/quantities varied, prices were standardised to a common value. For example milk was recorded in a range of volumes therefore all types were standardised to 2 litres assuming that in a shop where only 1 litre is available the shopper would need to purchase 2 x 1 litre and incur double the cost; fruit juice varied in price per litre according to type so a mean value was assumed within the price range supplied. One outlet required an imperial/metric conversion. The same principle was applied when standardising tinned/frozen fruit and vegetables, as the shops surveyed stocked a diverse range of product weights.
17 Dowler E, Dobson B. 1997. Nutrition and poverty in Europe: an overview. Proceeding of the Nutrition Society; 56: 51 - 62 20
The quality of the fresh fruit and vegetables was ranked:
• high would last a week and looks fresh • average best used that day or within 2 days or • poor bruised, mouldy, green/black or sprouting
A range of foods fresh, frozen and tinned were sampled as these are all deemed acceptable and considered to count towards a portion of fruit and vegetables. Tinned fruit and vegetables were recorded tinned in fruit juice, rather than syrup and without added salt or sugar where possible.
Final results were recorded and interrogated in an Access 2000 database and grouped into the following categories:
1. fruit and vegetables (fresh, tinned and frozen) 2. bread, cereal and pulses 3. fats, including milk
Retailer Consultation – Tomintoul
Retailers in the Speyside area were approached to follow up initial comments emerging from the detailed behavioural data gathered by questionnaire. A focus group was held with the owners of the three shops in the Tomintoul area.
Community Consultation
The community consultation element of the food access strand of the project gathered both quantitative and qualitative behavioural data.
Adult & Youth Consultations – Lhanbryde & Tomintoul
In depth consultations with a large element of outreach work were carried out in the Tomintoul & Glenlivet areas of Speyside and Lhanbryde.
Initially, a detailed questionnaire (Appendix 3: Full adult questionnaire) was developed to capture demographic information around individual and family eating patterns, food purchasing patterns, individual perceptions of health, basic physical activity levels and to gather anecdotal information on food access issues in the target communities. The questionnaire also sought to gain baseline information on the extent to which general health messages have been taken on board by the general public.
Self reported information was gathered through in depth community consultations with adults using a semi-structured interview carried out with local residents to identify perspectives of key stakeholder groups. These included sessions with pre-identified groups, street work and door knocking.
The questionnaire was then reviewed, reworded and the format altered. A version was developed for use with young people (Appendix 4: Young people’s health profiles) using a less formal interview approach and sessions were run in youth clubs to develop personal health profiles with young people. 21 Community Planning Open Day - Aberlour
Members of the research team were present at the community planning open day held in Aberlour in November 2003. This was more of an opportunity to publicise the aims of the Food and Health project rather than a consultation process, although a number of questionnaires were completed on the day.
Adult & Youth Consultations – Craigellachie, Dufftown, Aberlour & Rothes
In these areas of Speyside the consultation methodology was deliberately less intensive and did not include the same level of outreach work. The initial questionnaire used in Part 1 above was distilled and refocused and used in these four remaining Speyside localities (Appendix 5: Revised questionnaire). Respondents were parents targeted through four local primary schools.
Workshops were run in with P5 pupils in 4 primary schools in this area. The lead input on these sessions was by the project Dietitian (see 3.2.4 Schools) with REAP staff working with pupils to develop individual health profiles. The questionnaire was then sent home via the school for one per household, returned through the school.
4.2 Results
4.2.1 Food Mapping
The data collected is detailed in Appendix 6. Some entries are blank because the product in question was not available at the time of survey.
Shops surveyed in the target areas outside Elgin generally sold smaller quantities of products, for example frozen vegetables, although this is not shown in the tables as the results have been standardised to enable price comparison across the board. The food in these areas has, therefore, the double disadvantage of being more expensive and offering no economy of scale (bulk buys).
Fruit and vegetables - fresh
It is clear from the data (see Table 3) that there is good general availability of basic fruit and vegetables in the target areas. Price comparisons with Elgin are reasonable, with the majority more but some less expensive. The price of apples for example (in Elgin £1.28) ranging from £1.20 to £2.00 per kilo. Only bananas were considerably more expensive by comparison overall with little availability of satsumas and grapes. Fruit juice was consistently more expensive to buy.
Vegetables also compared favourably although the range available does not extend much beyond basic root vegetables to salad vegetables (tomatoes being the exception here). Good prices in Speyside may indicate more locally sourced produce. Average prices calculated indicate more expensive fresh produce overall with the exception of onions.
The one specialist fruit and vegetable shop (No 6) stocked a good range of high quality fruit and vegetables that were sometimes cheaper than Elgin, so worth shopping around here if an option for consumers. However, quality of produce in the more remote areas of Speyside was average to poor. 22 Filling stations and larger retail outlets (No’s 4, 5, 7 & 10) stocked a reasonable range although more remote areas again scored lower on quality by comparison. Prices here were sometimes but not consistently competitive.
Comparisons between shops in Lhanbryde indicated that shop No 2 is more reasonably priced with a greater availability of produce that is of a better quality.
Fruit and vegetables – tinned and frozen
Availability of basic tinned vegetables is good but prices are consistently higher. Only one outlet offered tinned tomatoes, a good store cupboard stand by. Availability of tinned fruit is patchy and all items were again more expensive than the Elgin shop.
Frozen vegetables were considerably more expensive overall and availability was inconsistent with some outlets stocking none at all (perhaps due to a lack of required cold storage). This was an important product to look for due to the travelling time encountered by customers going to Elgin for shopping, frozen foods are not always possible to purchase due to spoilage. It makes greater sense to purchase these locally.
Bread
Types other than wholemeal or white were not available in the target areas. Bread, of whatever type, was consistently more expensive overall by comparison with Elgin although availability of both white and wholemeal bread was good. Wholemeal is more expensive to buy than white bread in all outlets, including Elgin.
Pulses
Pulses are an excellent store cupboard ingredient providing good quality fibre to the diet and a cheap source of protein. Arguably essential for vegetarian diets and recommend for more regularly inclusion within everyone’s daily diet. Reasonable availability although with wide price variations and all more expensive than Elgin. Broth mix was most commonly stocked. Few outlets stocked tinned kidney beans. Even in the more remote areas availability was maintained with occasional prices standing out as significantly more expensive from others in the Speyside area.
Cereals
Availability of breakfast cereals was good overall but prices were high in the target areas. Some types of cereal (shredded wheat and branflakes) were stocked less overall. These foods provide high carbohydrate to the diet and are considered to be a good source of iron in a population consuming decreasing amounts of red meat.
Fats and oils
Dietary recommendations are for increased proportions of poly and monounsaturated fats. Blended vegetable oils are not as healthy a choice as individual types of oils. Although much of their content tends to be rapeseed oil (monounsaturated) this cannot be guaranteed).
23 In all shops surveyed butter was widely available but expensive to buy. Healthier choices were less readily available and more expensive even in the larger outlets. Other than vegetable oil, options here were limited and expensive. Sunflower oil was not found and olive oil, when available, averaged out at £5.45 per litre (£1.08 in Elgin).
Milk
Semi-skimmed milk would be considered the healthier choice in this instance. Alternatives were looked for again to consider those individuals choosing a vegan way of life or needing to avoid cow’s milk for any reason.
Full and semi-skimmed milk were equally and widely available. Prices averaged higher overall but varied considerably within that some were competitively priced. Alternatives were few and Soya milk in particular was rare.
Opening times
All outlets open between 7 and 9 am in the morning except for the supermarket in Elgin, which is open 24 hours, 7 days a week. Shop 2 (Lhanbryde) and the shop in Aberlour are open until 10 pm daily. All others close between 5 and 7 pm in the evening. Shops in the Tomintoul area have more limited opening hours than other outlets surveyed.
Sample healthy shopping baskets – selected outlets
To further illustrate the price comparisons between project areas, a table has been compiled (see Table 2) showing the prices of a range of healthy items extracted from the main shop survey data. These figures represent:
1. the actual cost of available items 2. the notional prices of non-available items based on average overall increased price of available items compared with Elgin prices
Two outlets were not selected for this particular exercise because of the reduced stock carried making meaningful comparisons difficult.
The table illustrates the increased cost of food in shops outside Elgin. The greatest average increase is in area 5 (Dufftown) although it should be noted that one of the outlets excluded from this exercise is a specialist fruit and vegetable shop in Dufftown that offers a good selection of reasonably priced, high quality fruit and vegetables, extending choice for shoppers in this area.
24 Table 2: Sample healthy shopping basket – selected outlets
Total cost at time of survey of: 1. Available items (non-shaded) 2. Notional prices of non-available items based on average overall increased price of available items compared with Elgin prices (shaded) Shop Shop Shop Shop 1 2 3 4 5 6 7 8 9 Elgin Lhanbryde Craigellachie Aberlour Dufftown Distance from Elgin (miles) 4 12 15 17 27 31 37 37 Average price increase at time of survey x1.56 x1.64 x1.63 x1.98 x1.59 x1.82 x1.91 x1.54 Apples (1kg) 128 133 120 169 129 167 133 167 200 Oranges (1kg) 138 145 140 89 165 135 75 150 140 Bananas (1kg) 74 139 150 99 159 140 143 150 175 Fruit Juice (1ltr) 62 112 112 165 85 113 118 89 Onions (1kg) 130 49 60 65 99 40 236 95 45 Carrots (1kg) 49 70 105 55 99 35 80 95 59 Potatoes (1kg) 30 64 36 34 84 25 120 57 49 Broccoli (1kg) 119 186 195 193 236 189 216 227 183 Tomatoes (1kg) 127 199 150 185 252 178 231 260 189 Lettuce 59 92 97 96 117 94 107 113 91 Sweetcorn (340g tin) 57 84 47 59 89 91 104 64 88 Tomatoes (400g tin) 35 55 57 59 69 56 64 67 54 Fruit Cocktail (415g tin) 75 117 123 122 149 119 85 143 116 Peas (907g frozen) 78 178 278 216 138 124 142 312 120 Wholemeal bread (800g) 43 92 101 61 109 97 78 75 78 Broth Mix (500g) 39 79 58 52 75 63 71 85 65 Lentils (500g) 55 119 89 85 95 87 100 104 92 Kidney Beans (420g tin) 79 124 129 77 156 45 144 45 122 Porridge (1kg) 53 85 119 258 98 80 198 238 178 Weetabix (24) 109 172 184 137 159 151 153 174 125 Low/reduced fat spread (500g) 83 95 134 127 119 132 151 158 128 Olive Oil (1ltr) 108 169 177 339 598 698 196 206 167 Semi-skimmed milk (2ltr) 92 105 152 151 123 114 87 177 81 Total cost £18.22 £25.51 £28.13 £28.40 £34.82 £29.45 £30.27 £32.80 £26.34
25 Added transport costs to shopping in Elgin from outlying areas
Comparisons have also been drawn (see Table 3) between the added transport costs of travelling by car/bus/taxi and combinations thereof from outlying areas for those choosing to shop in Elgin. The cost of a sample healthy shopping basket in Elgin was used as a constant in all calculations.
Total cost of shopping in Elgin by bus Elgin Lhanbryde Craigellachie Aberlour Dufftown Tomintoul
Cost of Elgin shop 18.22 18.22 18.22 18.22 18.22 18.22 Return bus fare to Elgin 3.80 5.60 6.00 6.40 9.60
£18.22 £22.02 £23.82 £24.22 £24.62 £27.82 Total cost of shopping in Elgin bus out / taxi back
Elgin Lhanbryde Craigellachie Aberlour Dufftown Tomintoul
Cost of Elgin shop 18.22 18.22 18.22 18.22 18.22 18.22 Single bus fare to Elgin 1.95 2.90 3.15 3.33 4.80 Single taxi from Elgin 6.50 18.00 25.00 25.00 36.00
£18.22 £26.67 £39.12 £46.37 £46.55 £59.02 Total cost of shopping in Elgin by car
Elgin Lhanbryde Craigellachie Aberlour Dufftown Tomintoul
Cost of Elgin shop 18.22 18.22 18.22 18.22 18.22 18.22 Cost by car (return)* 0.82 2.47 3.09 3.50 7.02
£18.22 £19.04 £20.69 £21.31 £21.72 £25.24 *See community profiles for mileage and petrol costs *Calculations based on average fuel consumption of 35 mpg
Table 3: Added transport costs to shopping in Elgin from outlying areas
26 4.2.2 Consultation with Retailers in Tomintoul
Prior to and during the community consultations, contact had been made with local retailers regarding their perceptions around access to healthy foodstuffs. In recognition of the key role that local shops have as service providers, it was agreed from the outset that the project would seek to work in partnership with local retailers and attempt to improve access through them where possible. The session was structured around four discussion points.
What additional services do you think you provide to the local community?
Deliveries
By arrangement some include hot food – almost a “meals on wheels” service. Home deliveries provide an element of social contact for some isolated individuals. Newspaper deliveries – by hand in village and by post in more rural areas.
Community focus
Shops are a real community meeting place. Act as an unofficial tourist information service and provide toilet facilities.
Flexibility
Flexible working hours – which locals and visitors alike can sometimes take advantage of. People can shop on account and pay later.
During the community consultation people said things like “we understand how difficult it is to run a local shop and we want to support it “ and “ I mainly use it as a back-up when I run out of things like milk and bread”. They also said things like they “would like to see a wider range of fruit and vegetables available”. What do you think about this?
Changing Retail Environment
“The world has changed – that is the reality”. “We don’t try to compete with the supermarkets – our niche is different” “People shopping in Elgin – there is a large social element to this as it is also a ‘day out’ for them as well”. “Don’t expect people to buy everything from us, but need people to buy more than milk, bread and cigarettes”. “People think there are big margins on things like cigarettes – there aren’t”.
Filling gaps and finding a niche
“Our niche is as providers of a good service”.
Making a living
Anecdotal information received made it clear that retailers are finding it hard as economically all of the 3 retailers have other income streams – two as holiday providers and one through spouse taking external employment.
In the last five years the staffing levels in the shops have gradually dropped. Reduced staffing levels mean longer working hours and limited holiday opportunities for retailers. Things like the increase in water charges in recent years have had a big negative impact – so has increased legislation.
27
Aware of being a local employer – when things were tight spouse went to work outside of the shop rather than paying off local employee.
Tourism
Retailers had mixed views on tourism with both concerns and hopes for the future. Hope that “in the next five years there will be benefits from the National Park status – increased tourism and that more facilities would open locally to cater for tourists – particularly local hotels”.
Concerns were raised around the Tourist Board who “operate a shop in the high tourist season which seems very unfair – they only operate at the peak time and don’t provide a year round service. They are also subsidised from the public purse”.
What is your view on the range of healthy food choices you are able to stock?
Stocking the basics
Stock staples such as apples, bananas, lemons, sprouts, grapes, broccoli, leeks, cabbages and so on.
Delivery and distribution
What we stock depends on what is available in deliveries and how it is priced. Deliveries varied between 1 and 2 a week for individual retailers. Retailers supplement local deliveries with visits to the cash and carry.
Viability of healthy food
The unfortunate reality is that food is a very marginal item in terms of the profit margin – this particularly applies to fruit and vegetables.
Examples were given of when things were sold on at cost price and the delivery note shown to customers to make them aware of this fact – this shows how tight the margins are and the fact that some things are actually stocked as a service to the community.
If something of good quality comes in it sells out really quickly because people know it will not be available long (e.g. happened with mushrooms the previous week which were of a good quality and sold out immediately).
Storage
There is a problem in that many of the products available now come in bigger packs, which can’t be split –for example flour now comes in packs of 48. Things like flour and spices tend not to be carried because they don’t sell quickly enough and end up out of code and have to be discarded. Increased legislation has affected what people stock and would consider stocking particularly in relation to meat
28 Any final comments/possible ways to improve things?
Delivery and distribution
It would be desirable to increase the frequency of deliveries to 3 per week. There may be opportunities for retailers to co-operate more around deliveries and splitting large packs to increase availability.
Marketing and awareness raising
All would be happy to have sponsored healthy shelves especially if there were marketing and educational materials to go with them. Wider education all of the retailers commented on how overseas tourists all support local shops and come from a culture where they believe in shopping locally.
4.2.3 Community Consultation – Behavioural Data
A. Full Adult Questionnaire
LHANBRYDE & TOMINTOUL
The full adult questionnaire was used in two target areas, Tomintoul (including Glenlivet) and Lhanbryde. A team of three researchers from REAP visited Tomintoul/Glenlivet in November 2003 and interviewed a total of 100 adults. A semi structured interview format was used with each consultation lasting approximately 7-8 minutes.
Consultations were carried out with individuals meeting in groups such as mother and toddlers, with parents at the school gates, in shops, local hotels, on the street, by door knocking and in workplaces.
The interviewers carried out the research in the morning, afternoon, evenings and at weekends in order to reach as representative a sample of residents as possible. Weekend work, particularly the Sunday morning slot at the local Post Office, was particularly effective in reaching the male population.
In February 2004, the consultation focus moved to Lhanbryde. The same format and outreach methods were used with a total of 117 people being interviewed. These interviews took place in groups, on the street, at a local Health Fair and outside the main shop / Post Office.
A.1 Quantative Data
Age range of participants – Tomintoul & Lhanbryde
100 adults in Tomintoul and 117 in Lhanbryde were interviewed.
• The age range of those consulted in Lhanbryde was markedly different from the age range in Tomintoul. Lhanbryde had a greater number in the 19 -30 age range with 36 in Lhanbryde and only 6 in Tomintoul. Several factors could influence this including the high number of 2 bedroom council houses located in Lhanbryde as opposed to Tomintoul and a sheltered housing complex in Tomintoul where there is no similar complex in Lhanbryde. As a consequence Lhanbryde had significantly
29 fewer pensioners over the age of 66, only 6 interviewed compared to 12 in Tomintoul.
• Of those interviewed the number of single parent families was 41 in Lhanbryde and 20 in Tomintoul forming a total of 35% of those interviewed in Lhanbryde and 20% in Tomintoul.
• Tomintoul had a significantly higher number of residents in the age range of 31-50 and retired residents over 66 than Lhanbryde.
• Of the 116 adults interviewed in Lhanbryde the majority were parents with households reporting a total of 123 children under the age of 16.
• Of the 100 adults interviewed in Tomintoul the majority were parents with households reporting a total of 112 children under the age of 16.
Physical activity
How many days a week do you build up at least 30 minutes of moderate physical activity18?
Activity Level (days) Lhanbryde Tomintoul
0 – 2 28% 37%
3 – 4 36% 25%
5 – 7 36% 38%
Table 4: Activity Levels
18 Adults should accumulate at least 30 minutes of moderate activity on most days of the week Let’s make Scotland more active - Scottish Executive 2002
30
Lhanbryde
Annual household income
• 3.5% declined to give this information • 9.5% had an annual income below £5,200 • 38% had an annual income of £5,200 to10,000 • 35% had an annual income of £10,000 to 20,000 • 14% had annual incomes over £20,000+
Adults in household
200 Adults
Under 16’s in household
126 Under 16 years
Which foods were consumed in the last 24 hours?
Carbohydrates
• Everyone interviewed indicated that they had eaten at least one carbohydrate during the previous 24 hours
• Of those who had eaten bread 72.5% had eaten white whilst 52% had eaten brown/wholemeal. (It should be noted some individuals had eaten both types of bread)
• The top 3 carbohydrates consumed were bread/toast, potatoes and breakfast cereal
Cereals
When asked what kind of cereal they bought some interviewees indicated that they purchased more than one cereal, however:
• 62% of adults purchased medium fibre cereals • 22.5% purchased high fibre high sugar cereals • 61% purchased low fibre low sugar cereals • 33.5% low fibre high sugar cereals • 14.5% of those surveyed who said that they purchased low fibre/high sugar cereals were aged 19-30 and parents of young children
It should be noted that researchers may have spoken to both parents on different occasions and therefore the children’s figures cannot be regarded as entirely accurate.
31
Low fat spreads
Interviewees were asked if they used spreads or oil in any form for cooking.
• 71% said that they used vegetable or sunflower oil • 37% said that they used butter or margarine • 7.5% said that they used olive oil or an olive based spread • It was found that no interviewees used lard.
Many respondents also indicated that they used several different spreads.
How many portions∗ of fruit and vegetables, including fruit juice, respondents consume each day compared with how respondents rated their own health: *No guidance was given on portion sizes
This question was on a scale of 1-10, 10 being very healthy and 1 being very unhealthy.
Health Rating Respondents 0 Portions 0 – 3 Portions 4+ Portions
10 4 0 1 3
9 9 0 2 7
8 13 0 4 9
7 9 0 4 5
6 18 0 6 12
5 29 1 10 18
4 22 1 11 10
3 10 0 9 1
2 2 0 1 1
1 0 0 0 0
Table 5: Health Rating & Portion Comparison
32
What kind of milk do you usually drink?
Type of milk %
45 Full fat
52 Semi-skimmed
3 Other
Table 6: Consumption of Milk
11% of respondents indicated that they purchased more than one type of milk they were in households with 19 children.
Which factors most influence your choice when purchasing fruit and vegetables?
Fresh Top three factors - • Quality • Availability • Price
Tinned Top three factors - • Branded labels were the most important factor • Price • Liquid used in canning
Frozen Top three factors - • Storage facilities at home • Availability • Travel time
What do you buy locally? (Lhanbryde is 4 miles from Elgin)
• Over 50% of the respondents indicated that they only purchased emergency shopping • Only 9.5% purchased their full shop from local businesses • 7% of those interviewed indicated that they bought fruit and vegetables locally
How often do you go shopping to the supermarket?
• 78% went to a supermarket weekly
How do you get to the supermarket?
33 • 53% used cars
• 16.5% use taxis to access supermarkets
• 16.5% use public transport to access supermarkets and 6% got a lift
Example:
The bus fare from Lhanbryde to Elgin is £3.80 (adult) for a return journey to the bus station. For a family of four travelling from Lhanbryde to Elgin the bus fares alone would be £11.52. The bus only goes to the bus station where a connecting bus would then take them to the supermarket. The price of a taxi from Lhanbryde door to door of a supermarket in Elgin is £6.50 (£13.00 return).
Anecdotal information received in Lhanbryde found that many residents took the bus or got a lift into Elgin and a taxi back with their shopping. It was also noted that several people shared the cost of the taxi fares. Given the high cost of bus fares it makes economic sense to take a taxi if you are shopping as a family.
Total household income including benefits / pensions:
The interviewers were aware that some interviewees may have felt uncomfortable giving details of personal income. The interviewees were under no pressure to divulge this information.
Rating how healthy interviewees felt their diet was in relation to income range and portions of fruit and vegetables consumed:
Income range Average Health % Average portions consumed Rating
Declined information 3.5 5 5
Under £100 per week 9.5 7 4
£100-200 per week 38 6.5 4
£200-400 per week 35 6.5 6
£400+ per week 14 7 7
Table 7: Income, Health Rating & Portion Comparison
Do you feel you have enough money for food?
70% of interviewees indicated that they felt they had enough money for food, 30% felt they did not have enough money for food
34 Tomintoul
Annual household income
• 15% declined to give this information • 7% had an annual income below £5,200 • 22% had an annual income of £5,200 to10,000 • 32% had an annual income of £10,000 to 20,000 • 24% had annual incomes over £20,000+
Adults in household
194 Adults
Under 16’s in household
112 Under 16’s
Which foods were consumed in the last 24 hours?
Carbohydrates
• Everyone interviewed indicated that they had eaten at least one carbohydrate during the previous 24 hours
• Of those who had eaten bread 61% had eaten white whilst 73% had eaten brown/wholemeal. (It should be noted that 34% had eaten both types of bread)
• In Tomintoul the top 3 carbohydrates consumed were bread/toast, potatoes and breakfast cereal
Cereals
When asked what kind of cereal they bought some interviewees indicated that they purchased more than one cereal, however:
• 51% of adults purchased medium fibre cereals • 21% purchased high fibre high sugar cereals • 35% purchased low fibre low sugar cereals • 24% low fibre high sugar cereals • 16% of those surveyed who said that they purchased low fibre/high sugar cereals were aged 19-30 and parents of young children
It should be noted that researchers may have spoken to both parents on different occasions and therefore the children’s figures cannot be regarded as entirely accurate
35 Low fat spreads
Interviewees were asked if they used spreads or oil in any form for cooking.
• 75% said that they used vegetable or sunflower oil • 52% said that they used butter or margarine • 12% said that they used olive oil or an olive based spread • 12% used lard
Many respondents also indicated that they used several different spreads/oils.
How many portions∗ of fruit and vegetables, including fruit juice, respondents consume each day compared with how respondents rated their own health: *No guidance was given on portion size
This question was on a scale of 1-10, 10 being very healthy and 1 being very unhealthy.
Health Rating Respondents 0 Portions 0 – 3 Portions 4+ Portions
10 9 0 6 4
9 4 0 0 4
8 12 0 2 10
7 26 0 4 22
6 24 0 9 15
5 17 0 5 12
4 5 0 1 4
3 3 0 1 2
2 0 0 0 0
1 0 0 0 0
Table 8: Health Rating & Portion Comparison
36 What kind of milk do you usually drink?
Type of milk %
Full fat 35
Semi-skimmed 63
Other 2
Table 9: Consumption of Milk
14% of respondents indicated that they purchased more than one type of milk; they were in households with 30 children.
Which factors most influence your choice when purchasing fruit and vegetables?
Fresh Top three factors - • quality was the main factor for people • availability • price
Tinned Top three factors - • branded labels were the most important factor • price • liquid used in canning
Frozen Top three factors - • storage facilities at home • availability • travel time •
What do you buy locally?
• 27% purchased emergency shopping from local businesses • on average 25% used local businesses for to purchase milk, bread, fruit and vegetables and non food items • 9.5% purchased their full shop from local businesses • 28% bought fruit and vegetables locally
How often do you go shopping to the supermarket?
• 52% went to the supermarket every week
37 How do you get to the supermarket?
• 86% used cars
Total household income including benefits / pensions:
It was realised by the interviewers that interviewees may have felt uncomfortable giving out this information therefore it was not pushed as being absolutely necessary.
Rating how healthy interviewees felt their diet was in relation to income range and portions of fruit and vegetables consumed:
Average Health Income range % Average portions consumed Rating
Declined information 15 7 4
Under £100 per week 7 7.5 4
£100-200 per week 22 6.5 4
£200-400 per week 32 5.5 5
£400+ per week 24 6.5 5
Table 10: Income, Health Rating & Portions Comparison
Do you feel you have enough money for food?
84 % of interviewees indicated that they felt they had enough money for food, 16% felt they did not have enough
38
A.2 Qualitative Data
Lhanbryde
What would you like to see happen locally to improve your food choices?
Comments received in response to this question from Lhanbryde fall into the following categories:
• satisfaction • transport • cost • choice and availability • quality • local food
Satisfaction
Some positive views emerged on access to food in Lhanbryde ranging from “OK” “Fine” to “Fantastic”! “Lhanbryde is good – gets orders”.
Some respondents provided a more personal interpretation of these feelings “I’m OK, but I think prices are high for anyone that wants fruit and vegetables but can’t afford. I know I’m not healthy but that’s my choice!” “It has enough for me – I buy what I like”
Transport
Transport was not a major issue although a number of suggestions for improvement were made “Cheap local transport for people without cars or special rates on taxi’s” “Free Asda bus”
Cost
The higher cost of food in local shops is a concern with comments like:
“Local prices need to come down” “Cheaper fruit and vegetables” “Prices for low fat, caffeine free, healthy eating goods lowered to eat healthy you have to pay for it” “Fruit and vegetables are expensive, lower prices, make the displays more appetising”
Choice and availability
A large number of respondents highlighted issues here, often linked to cost:
“More different fruit and vegetables like sweet potatoes/mangoes etc. As soon as you want anything other than apples and pears the prices are really high locally” “More choice in local shops, nothing looks that good!” “More fresh fruit and vegetables – to improve quality of fruit and vegetables” “Lower prices, better advertising of what they do stock”
39 “More choice, lower prices. I choose to use my money on buying healthy food, but it doesn’t leave much for anything else” “Fresh produce cheaper and perhaps more choice in fruit and vegetable sections. I wish food in general was cheaper because my family are eating me out of house and home!” “Better fruit and vegetables in shop, sandwiches, no pot noodles”
Quality
A number of respondents wanted better quality food products “Fruit and vegetables – better selection, quality is variable”
Local food
Local food was an issue in Lhanbryde with comments such as: “Kinloss farm shop very good” “More locally grown products available” “Fresh vegetables, locally, Speyfruits are OK, but Kinloss farm shop is much fresher” “More local produce e.g. farmers vegetables in local shops, and in summer more fruit in local shops e.g. strawberries and raspberries etc.” “Less supermarkets, fruit and vegetables locally”
Tomintoul
What would you like to see happen locally to improve your food choices?
Comments received in response to this question from Tomintoul/Glenlivet fall into the following categories:
• satisfaction • transport • cost • choice and availability • quality • delivery • local food • take away food
Satisfaction
A number of respondents expressed clear satisfaction with access to food in the area.
“Quite happy – knew what it would be like when I moved here” One person felt that it would not be possible to change anything and expressed a resignation with the current situation. Another commented that “Supermarket choices & prices hardly possible in a small village”
Transport
Transport was a minority issue amongst respondents with one concern expressed about the cost of petrol. “Price (of local food) means supermarkets make travelling for large
40 shopping”. Car ownership can not be assumed as one respondent replied that I “Would go to supermarket if I could get a lift” Another requested “Better transport”
Cost
The cost of food was an issue although not a major one. Links were made to the higher cost of organic choices. The increased cost of local food choices in comparison with Elgin supermarkets, which are also relatively far away, is a significant issue. “Prices fixed and everything then everybody would use local shops” “Cheaper food nearer”
Choice and availability
Choice and availability were important issues particularly with regard to fruit and vegetables although it was acknowledged that this is a challenge for the local shops. “Suppliers veg and fruit could be better – selection and quality” Other foods highlighted were fish, meat, baby/young children foods, baby milk, fresh yoghurts (not UHT) and organic.
Quality
“Better fruit & veg selection and quality” was requested. “Fresh produce with a good selection. I feel the produce locally is poor in quality and choice – except meats” “Better fresh fruit and veg quality and choice (supplier not fresh”) “More fresh stuff available, quality not good”
Delivery
This was a specific issue raised by a number of respondents that fell into three categories:
Internet home delivery
“Tesco home delivery or local shops at a reasonable price” “Like Morrison stores same prices from city to remote areas” “Internet shopping to deliver to Glenlivet”
Mobile, home delivery
“Mobile unit, more choice locally” “Fresh meat, bakery delivery” “Delivery service reasonably priced)” “Fresh veg from van”
Deliveries to local shops
“More fresh fruit and veg delivered more often than once a week to the local shops” “Fresher produce – bigger variety, delivery”
41
Local food
Interest and enthusiasm was expressed for greater availability of locally sourced food.
“Locally grown produce at a price we can all afford i.e. farm shop or farm produce priced and sold in local shops” “Legislation makes the selling of fresh farm foods difficult i.e. farm shops (milk, butter, eggs and veg)” “Development of community association co-operatives sourcing local produce” “Local veg/fruit farm shop” “More farm- gate sales and PYO” “More choice of fresh fruit and veg i.e. from local markets” “As I live on an organic farm, I have often thought of having an organic shop but with many regulations it is quite off putting”
Eating out
A number of respondents expressed the view that there is a lack of alternatives to cooking at home in the area. “Please get someone to open a café or coffee shop or restaurant so I don’t have to cook *every* night!!!” “McDonalds/Pizza Hut” and “Decent hotel to eat out in, takeaway”
42 B. Young Peoples’ Health Profiles
B.1 Quantative Data
TOMINTOUL & LHANBRYDE YOUTH CLUBS
The project team felt that the semi-structured interview was too detailed for work with young people. A new method which was more rooted in participatory appraisal techniques was developed and used with 17 young people who attended Tomintoul Youth Club.
The young people were asked to build up an individual health profile which identified things such as how they got to school, what they had eaten in the course of the day and how much exercise they took. The profile was built up using a pool of pictures which were then placed onto large sheets of papers. The answers given by the young people were recorded on a tally sheet and a photograph taken of the completed profile, which was then cleared for use by another young person.
Picture 1: Health Profiles
A total of 37 young people at the youth club in Lhanbryde completed a personal health profile. The questions were the same as in the Tomintoul consultation, although the method was simplified so that the pictures to make up the profile were produced on sticky labels and these were stuck directly onto a sheet of A3 paper folded into a booklet. These changes meant that more young people could work on their profiles at the same time and there was no longer a need to complete a tally sheet or photograph the finished profile.
54 children under the age of 16 were interviewed at youth clubs in both areas. The children were asked a variety of questions relating to their normal routine. Of the children spoken to, 58.5% attended primary school and 41.5% attended high school.
When asked how they got to school the children responded that:
• 48% travelled to school by bus • 44% walked • 2% cycled • 6% other including car
43 Traffic and distance to primary schools and secondary schools are the most obvious factors as to why children do not cycle. For children attending secondary schools distance for a child in Tomintoul travelling to Speyside High in Aberlour is 21.5 miles and from Lhanbryde to Milne’s High in Fochabers the journey is 5 miles on the A96 Inverness/Aberdeen. As the primary school is based Tomintoul many rural children travel by bus or car due to distance and road safety
When asked what they had eaten in the previous 24 hours the results showed that:
Breakfast
• Of the children who indicated that they had eaten cereal / toast / bread in Lhanbryde, 62% had one portion whilst 16% had eaten two portions. This was compared to 76% eating one portion and 12% eating two portions in Tomintoul.
• In Lhanbryde, 65% said that they had consumed no dairy products whilst 35% had consumed one portion. This was compared to 59% in Tomintoul consuming one portion and 18% consuming 2 portions
% Children over the Area % Eaten Breakfast % no Breakfast age of 12
Lhanbryde 54 30 24
Tomintoul 12 12 0
Table 11: Breakfast by Area
When asked what they had drunk at breakfast the children responded that:
• 26% drank fruit juice • 7.5% drank water • 4% drank squash
Lunch
The range of food available from the school menu will influence what young people eat.
• 46.5% overall took school dinners, 59% in Tomintoul and 40.5% in Lhanbryde • 44% overall had a packed lunch • 9.5% overall went home for lunch, 35% in Tomintoul and 49% in Lhanbryde
• overall 26% had one portion of bread • 30% had one portion of a dairy product • 9% had eaten a portion of chips
• 22% had one portion of fruit or vegetables whilst 7.5% had 2 portions • 28% had eaten either chocolate a biscuit or crisps
44 • 7.5% had eaten at least two potions of chocolate, biscuit or crisps
• 15% drank a fizzy drink • 24% drank fruit juice • 9% drank squash
Evening meal
• 35% had chips or a chip shop supper • 45% had starch through other products • 30% had eaten one portion of vegetables • 9% had one portion of fruit
• 7.5% had a fizzy drink • 5.5% had fruit juice • 11% drank squash • 4% drank milk
• 4% had eaten either chocolate a biscuit or crisps
Supper
• 2% had cereal • 6% had a yoghurt • 4% had a sandwich • 20% had one portion of fruit and none of these were children in Tomintoul • 37% had eaten one of either chocolate, a biscuit or crisps • 18.5% had eaten two of either chocolate, a biscuit or crisps • 4% had eaten three of either chocolate, a biscuit or crisps • 18.5% had a drink
45 CRAIGELLACHIE, DUFFTOWN, ABERLOUR & ROTHES PRIMARY SCHOOLS
137 individual health profiles were created using the ‘stickers’ method, which was developed with young people in Lhanbryde in Part 1 of this project. The 137 children came from local primary schools and were asked a variety of questions relating to their normal routine.
How do you get to school?
No of Children % Bus % Walk % Car % Cycled
Craigellachie 16 31 38 31 0
Dufftown 43 16 75 9 0
Aberlour 38 10.5 52.5 37 0
Rothes 39 15.5 61.5 7.5 15.5
Table 12: Method of travel to school
Traffic and distance to primary schools are the most obvious factors as to why children do not cycle. Although in some areas there could be issues around taking bikes to school.
What have you eaten in the past 24 hours?
% % % % %
Cereal Bread(W) Bread(B) Fruit None
Craigellachie 62.5 31 0 0 0
Dufftown 74 18.5 2 2 9
Aberlour 81.5 24 8 15 0
Rothes 43 36 5 2.5 5
Table 13: Breakfast Foods
46
What did you drink at breakfast?
% % % % % Fizzy %
Fruit juice Water Squash *Milk juice Caffeine
Craigellachie 25 6 0 62.5 0 0
Dufftown 28 0 21 37 2 0
Aberlour 31.5 2.5 26 45 5 0
Rothes 10 0 13 54 0 13
Table 14: Breakfast Drinks *It should be noted that some children may have included the milk from their cereal as a drink
Where did you go for lunch?
% School % Packed % Home
Craigellachie 50 44 6
Dufftown 42 42 16
Aberlour 60.5 31.5 18
Rothes 43.5 46 10.5
Table 15: Where did you have Lunch
47 What did you have for lunch?
% 1 % 2 % % % % % % Fruit Fruit Bread Sandwich Yoghurt Cheese Chips Pasta Veg Veg
Craigellachie 12 44 12 12 6 12 31 0
Dufftown 9 0 30 0 0 0 28 0
Aberlour 13 0 13 13 18.5 0 26 0
Rothes 12 46 38 5 18 0 28 0
Table 16: Food Consumed for Lunch
What did you have to drink at lunch time?
% Fruit % % % Fizzy % % % Squash juice Water Milk juice Caffeine Nothing
Craigellachie 19 31 25 6 12.5 0 6.5
Dufftown 21 25 16 9 4.5 0 24.5
Aberlour 34 18 23.5 13 2.5 0 9
Rothes 33 5 36 10 10 0 6
Table 17: Drink Consumed at Lunch
What did you have for your evening meal?
% % % % % 0 % 0 % % % 1 % 2
Bread Pasta Potatoes Chips Veg Fruit 1Fruit 2Fruit Veg Veg
Craigellachie 12 6 37.5 19 57 94 0 6 37 6
Dufftown 4.5 28 25.5 26 70 96 2 2 16 14
Aberlour 5 13 31.5 36 72 90 5 2.5 18 5
Rothes 18 13 15 46 57 85 15 0 23 10
Table 18: Food Consumed for Evening Meal
48 What did you have to drink with your evening meal?
% Fruit % % % % Fizzy % %
juice Water Squash Milk juice Caffeine Nothing
Craigellachie 6 19 19 0 12.5 0 43.5
Dufftown 11.5 7 30 9 18.5 0 24
Aberlour 13 2.5 31.5 13 23.5 0 16.5
Rothes 5 0 25.5 10 23 0 36.5
Table 19: Drink Consumed with Evening Meal
What snacks have you consumed during the previous 24 hours?
% % % 1 Choc, 2+ Choc, % % % % % 3+ % bisc, bisc, Cereal Yoghurt Sandwich Fruit 2Fruit Fruit Sweets crisps crisps
Craigellachie 12.5 6 6 50 6 6 19 44 6
Dufftown 0 0 7 30 2 6 42 37 11.5
Aberlour 10.5 23.5 10.5 16 16 10 31.5 39 0
Rothes 0 10 13 28 10 10 33 46 0
Table 20: Snacks Consumed Within 24 Hours
What drinks have you had in between meals?
% Fruit % % % % Fizzy % %
juice Water Squash Milk juice Caffeine Nothing
Craigellachie 19 0 6 31 6 0 38
Dufftown 23 0 21 16 14 0 26
Aberlour 10 0 10 18 13 0 59
Rothes 25.5 0 15 15 15 0 29.5
Table 21: Drinks Consumed between meals
49 What about regular exercise?
% % % Activity % Craigellachie Dufftown Aberlour Rothes
Cycling 44 26 26 49
Football 25 23 60 43.5
Playing outside 37.5 44 79 31
Roller skating 19 11.5 13 10
Running 25 40 37 61.5
Skateboarding 6 7 21 8
Swimming 31 30 87 33
Tennis 0 28 18 18
Table 22: Regular exercise by type
50 C Revised Parental Questionnaires
C.1 Quantative Data
CRAIGELLACHIE, DUFFTOWN, ABERLOUR & ROTHES
A total of 172 questionnaires were returned from parents of children from the four primary schools targeted in Aberlour, Dufftown, Rothes and Craigellachie. These questionnaires contained information on households with 697 people in them. This was an excellent response rate, although difficult to exactly quantify. 500 questionnaires were given out (as per the school roll) but as many families will have had more than one child in the school, there was only one questionnaire per household. This provided a response rate of at the very minimum 35% but probably significantly higher.
What is your Annual Household Income?
less than £5,200 to £10,000 to more than Area declined £5,200 10,000 20,000 £20,000
Craigellachie 10.5% 5.5% 5.5% 10.5% 68%
Dufftown 18% 4% 4% 10% 64%
Aberlour 25% 7% 24% 0% 44%
Rothes 7.5% 0% 15.5% 50% 27%
Table 23: Income by Area
How many are in your household?
Area Adults in Household Under 16 years in Household
Craigellachie 40 130
Dufftown 127 146
Aberlour 58 87
Rothes 95 60
Table 24: Persons living in Household by Area
51 How many portions of fruit and vegetables does your household consume per day?
Adults
Area % 0 Fruit or Vegetables % 3 or less % 4 or more
Craigellachie 2.5 20 77.5
Dufftown 4 29 67
Aberlour 7 26 67
Rothes 6.5 27 66.5
Table 25: Portion of Fruit consumed by adults by Area
Under 16 years of age
Area % 0 Fruit or Vegetables % 3 or less % 4 or more
Craigellachie 12 37 51
Dufftown 6.5 46.5 47
Aberlour 11 36 53
Rothes 15 41.5 43.5
Table 26: Portion of Fruit consumed by Under 16s by Area
Where do you do your main food shop?
% Shop % 3+ miles % Several Area % Tesco % Asda locally away locations
Craigellachie 5 95 37 63 20
Dufftown 20 61 23.5 75 20
Aberlour 13 98 12.5 82.5 33
Rothes 23 92 4 96 27
Table 27: Shopping Preferences by Area
52
How often do you food shop?
Area % Weekly % Fortnightly
Craigellachie 58 21
Dufftown 83 6.5
Aberlour 68.5 13
Rothes 85 4
Table 28: Shopping Frequency by Area
When buying fruit and vegetables do you tend to purchase:
Area Weekly Fortnightly
Craigellachie Check this figure 84% 5%
Dufftown 84% 5%
Aberlour 24% 66.5%
Rothes 92% 4%
Table 29: Frequency of Purchasing Fruit & Vegetables by Area
If you run out of fruit and vegetables do you tend to:
Area Next shopping trip Buy more locally
Craigellachie 26% 73%
Dufftown Check this figure26% 73%
Aberlour 7% 73%
Rothes 20% 74%
Table 30: Alternative Place/Frequency of Purchasing Fruit & Vegetables by Area
53 When asked to agree or disagree with the following three statements:
1. There is a good choice of produce available locally throughout the week 2. The price of fruit and vegetables available locally was competitive 3. The quality of fruit and vegetables available locally was good
Agree
% % % Question % Craigellachie Dufftown Aberlour Rothes
1 73.5 53 73 46
2 52.5 34 44 38
3 63 55 80 50
Table 31: Agreement with Statements by Area
Disagree
% % % % Question Craigellachie Dufftown Aberlour Rothes
1 26.5 47 27 54
2 47.5 66 56 62
3 37 45 20 50
Table 32: Disagreement with Statements by Area
How healthy do you think your household is on a scale of 1-10, 10 being healthy?
Area % No indication % 0 – 4 % 5+
Craigellachie 21 0 79
Dufftown 22 3 75
Aberlour 15 10 75
Rothes 7.5 15.5 77
Table 33: Health Rating by Area
54 Are you happy with the amount of fruit and vegetables consumed in your household?
Area % Happy % Unhappy
Craigellachie 84 16
Dufftown 62.5 37.5
Aberlour 60 40
Rothes 62.5 37.5
Table 34: Level of Satisfaction with Number of Portions Consumed by Area
If more money was available for food would your diet be healthier?
Area % Yes % No
Craigellachie 26 74
Dufftown Check this figure26 74
Aberlour 37 63
Rothes 37.5 67.5
Table 35: Satisfied with Income Available for Food by Area
55
C.2 Qualitative Data
CRAIGELLACHIE, DUFFTOWN, ABERLOUR & ROTHES
What would you like to see happen locally to improve your food choices?
Comments received in response to this question fall into the following categories:
• Cost • Choice and availability • Quality • Issues for local retailers • Local food • Children and young people
Cost
“I would like to see local prices come down as not all families are in a situation that they can afford fruit and vegetables every day. Especially people on benefits. And also it is very hard to get your children to adapt to 5 portions of fruit and vegetables every day unless you disguise, which we have to do – like mashing the carrots and turnip and onions into the mince and mixing it through the potatoes. Lots of children just don’t like vegetables until they get older. It’s a fact that they tend to eat more fruit”
“Take down the prices of fresh produce. Chicken fillets can make a good healthy meal – but are far too expensive. Fruit and vegetables bought in Aberlour are too expensive and don’t keep long”
“I buy 90% of fresh food locally using supermarkets only for store cupboard foods, I think what is provided locally is great, although sometimes the price can put you off buying anything other than the ordinary ingredients”
Respondents wished to be able to go into a local shop and buy good fresh fruit and vegetables at a reasonable price and recognised that most people are going to buy at large supermarkets because it is cheaper. Local supermarket prices are extremely high for fruit and vegetables unless on special offer. Cost was also linked to the desire for more variety and a better quality of food in local shops.
Choice and Availability
“Definitely bigger choice of fresh fruit & vegetables. All shops in Rothes have a very unappealing selection in terms of quality and freshness. A deli or fruit and vegetable shop would be great – the one that opened in Aberlour is too specialised and expensive”
“It’s family choice really. A family can live healthy on a lower budget if they really want to. The good foods are always available”
More variety of fresh produce locally was a common theme. “Although the choice of fruit and vegetables can be quite good, I would like to see it a bit more consistent and occasionally something different”
56 A local fruit and vegetable van was suggested “like the fishmonger’s who come to your door” “Government subsidised fruit & vegetable van to visit local communities twice a week. This would improve the selection and quality of foods available.” One respondent highlighted the lack of organic produce available locally and another raised the problem posed by the limited opening hours of local shops for working parents. Another respondent reflected that “I think I will always shop out with town”
Quality
“Smaller shops need to stock fresher fruit and vegetables and a better variety at a more competitive price. There is nothing more off putting than rotten food”
“Shops to rotate their stock more frequently especially in the summer – where last year I would go into a certain shop and their fruit and vegetables were just left to go mouldy for days on end”
“Shelves to be full of good quality fruit and vegetables. Hardly any choice and you are extremely lucky to find a decent (un-rotten) lettuce! A lot of fruit is mouldy and the potatoes are green! No chance of any squashes at all!”
“There does not necessarily need to be more choice, but the produce available should be as fresh as possible”
Issues for local retailers
“Having that at all would be a bonus. The Co-op in Aberlour is limited to the classic Scots’ stuff – carrots, spuds, leeks, cabbage (inferior salad). Fruit is very limited. There’s no contest with Tesco in Elgin. The Co-op should see what Tesco do and test the market some more adventurous produce”
At the same time it was acknowledged that there are broader issues for local retailers. Local towns are too small to allow competitive prices and smaller shops can’t compete with bigger supermarkets, “we have enough choice for the size of the shop that the town has”. However choice and price need to be addressed by local smaller retailers to keep them in favour with local customers.
One respondent commented I “do not want a large commercial store in Dufftown as it would spoil the area” but another suggested a solution would be to “open a supermarket nearby not as far out as Elgin. Our household doesn’t have a car, to get bulk shopping which would benefit my budget to get better bargains and more shopping for my money”
Local food
A number of respondents highlighted the need for more and a greater variety of local produce to be available for sale locally.
“Would like to see equivalent of farm shop to buy fresh fruit and vegetables”
“More local less imported goods. More local vegetable box schemes, organic meat”
“Would like to see the price of fruit and vegetables reduced in local shops, locally grown should be cheaper to buy at the moment you can obtain double the value at any supermarket”
57 “Local farmers/gardeners could get together to deliver home-grown produce in season to people who made a commitment to purchase regularly whatever they had available”
Children and young people
Some respondents also had concerns regarding food issues for children requesting “Sweets banned from schools and healthy snacks (melon, grapes, dried fruit, muesli etc) available for pupils to buy” “Schools do not offer sweets, sweet drinks from tuck shop” Schools have key role and school meals needed to be improved.
A parent requested that local shops have “a variety of fresh fruit on offer at lower prices and have less sweets shown on display. To make fruit display more colourful for children”
4.3 Key Themes
Environmental Issues
The availability of healthier options is variable within the target areas. Shops surveyed generally sold smaller quantities of products which do not offer economies of scale to larger families but will have advantages for those purchasing for only on or two.
There is good general availability of basic fruit and vegetables with prices comparing reasonably with Elgin. However, quality of these products, particularly in the more remote areas, is less good.
Staples such as bread and cereal were more expensive with healthier options less available. Full and semi-skimmed were equally available but with considerable variation in price.
Overall, it is more expensive to shop locally, and to shop in Elgin from outlying areas when additional costs are added in for travel. For some this is a lifestyle choice, for others it is an additional barrier to opting for a healthier diet.
Retailers
There is a clear understanding by retailers of the issues faced in Speyside and a willingness to try to address these issues and to explore the potential for developing the niche service that local shops can provide. Local shops have a valuable role within communities and local people recognise this.
There is scope for local outlets to work together to look at reducing costs by rationalising distribution thereby tackling some of the financial pressures which retailers face.
Retailers were interested in promoting healthier products at the same time recognising that food sales overall deliver only marginal profit margins.
Behavioural issues
It is clear that healthy eating messages about reducing fat consumption from dairy food and saturated fats from lard/butter are being acted upon. Consumption of full milk as compared with semi-skimmed was markedly different between Speyside and Lhanbryde with fewer respondents drinking full milk in Tomintoul. Also within the youth data there is a notable difference between those children having dairy produce (especially at breakfast time) between respondents in both areas. This suggests that those having breakfast will 58 not be having a breakfast cereal and that the overall nutritional quality of their diet may be affected, due to the provision of vitamins, minerals and fibre from this food.
Interestingly the greatest consumers of lard and butter are in the workforce age group, rather than the oldest age group as originally envisaged. This has possible implications for the ongoing health of the workforce. There may be a perception that the messages around saturated fat are being confused by conflicting messages in the media around trans fatty acids and hydrogenated fats. Families are choosing to buy butter as the “natural” choice rather than obtaining the “harmful” hydrogenated fats. However, they are missing the message that many processed products are rich hydrogenated fats.
The health messages around hidden fats and the saturated fat contents of biscuits, crisps and other snack foods have obviously not been acted upon, with a significant consumption, especially by children, as both snack foods and part of their main meals.
The Scottish dietary target19 of non-milk extrinsic sugars to reduce to less than 10% of total energy for children looks far from being achieved. Chips are also highly consumed at both lunch and supper. This is for both primary and secondary school age children. The concept of balanced meals and variety does not seem to translate into everyday meals.
Fruit and vegetable consumption interestingly, looks to be quite positive in the interviewed group, although there is still a large proportion not consuming any fruit or vegetables throughout the day in both the adults and especially the children interviewed. It should be realised also that if adults within a household are not consuming fruit and vegetables, they are less likely to be available for the children within that household.
Fluid intake is the other notable dietary aspect that is being overlooked. Water has been described as an essential nutrient for life as it is needed in greater amounts than the body is able to produce, and mild dehydration has been linked to symptoms of thirst, headache, lethargy, irritability, poor concentration and diminished mental performance20. Many of the children interviewed did not have any fluids at breakfast (6 - 62%), at lunch (up to 24%) and at evening meals (up to 43%).
Income ranges contrasted overall, with lower ranges recorded in Lhanbryde than in Speyside, with the exception of Rothes.
Quality was a key issue determining food purchase with price less important. Lhanbryde and lower Speyside residents expressed more concern in anecdotal comments about the cost of food than those interviewed in Tomintoul. Availability and the limited range of products on offer were highlighted as important.
The greater majority of families shop weekly at the supermarket but local shops are still important for top up / emergency shopping and staples such as milk. Cars are the main mode of transport although public transport is used by some.
In Tomintoul transport was a key issue, but unsurprisingly not in Lhanbryde. Tomintoul residents expressed a wish to see improved local delivery services.
For young people in Speyside considerable distances to school can preclude more active methods of transport such as cycling.
19 Outlined in the Scottish Diet Action Plan (SDAP), Eating for Health (1996) 20 Kleiner, S.M (1999) Water: An essential but overlooked nutrient. Journal of American Dietetic Association. 99 (2), 200-206 59 4.4 Recommendations
1. Work with local target communities to address issues of availability, accessibility and cost of healthier food for those with limited income and with particular needs such as older people and those with young families.
2. Work with retailers in Speyside to improve availability, quality and price of healthier choices locally through a range of solutions such as delivery options, reassessing of distribution systems and exploring the potential for working co-operatively.
3. Work with young people in a range of settings to address the need to improve the balance of foods consumed with a view to maintaining good health in the longer term.
60
5. Objective Two – Cooking Skills, Methodology & Results
To encourage the development of food skills such as purchasing, preparation, handling, budgeting and creating a balanced diet in the community
5.1 Methodology
Training for Trainers
Following identification of gatekeeper organisations within Speyside and a meeting with Community Learning to discuss local food and health issues it became evident that a need existed for locally based food hygiene/cooking skills training for youth workers. Training courses delivered by Moray College had taken place in Elgin in the past but a major obstacle to running the course in outlying rural areas had been the barrier posed by the distance of Speyside from the course providers. It was agreed that the Moray Food and Health Project would fund a 12 week course for 2 hours a week using the kitchen facilities at Speyside High School, Aberlour.
Food skills “Training for Trainers” aims to equip youth workers with the skills and knowledge to facilitate practical food skills within community settings through the provision of:
• food preparation, cooking and demonstration skills • food hygiene and safety training in the form of the REHIS (Royal Environmental Health Institute of Scotland) Elementary Food Hygiene Certificate • basic preparation and cooking equipment • information on aspects of healthy eating
Food Skills Training
Cooking skills courses in Grampian are provided by NHS Grampian through the ‘Now You’re Cooking’ (NYC) programme. Now You're Cooking is a food skills and nutrition education project working with low-income and excluded groups in Grampian. The course comprises eight, two-hour, predominantly practical, participatory sessions, covering healthy eating, food hygiene, food labelling and hands on practical cooking guidance. The project aims to build confidence and skills in order to enable individuals to achieve a healthier diet.
Courses had run in Moray before although most of these had been Elgin based. Sessions had also run in Rothes in summer 2002 and a further request was received by the NYC programme co-ordinator in Aberdeen on behalf of Speyside Parents Support Group through the local Health Visitor in autumn 2003. It was agreed that the Moray Food and Health Project would fund sessions based in Rothes delivered by a trained facilitator employed on a sessional basis by NHS Grampian.
Enquiries were subsequently received through Health Visitors for two further courses. Sessions were planned for the Weight Management Reduction Group in Dufftown. These had to be postponed due to a drop in potential participants. Following discussions between mums in Aberlour/Archieston and the local Health Visitor it was decided that a full cookery skills course would not address the group’s needs and a further meeting to discuss options was planned for April 2004. 61
5.2 Results
Training for Trainers – Speyside
Following a meeting with Moray College, project team members and a member of Public Health staff working with young people in Moray 10 x 2.5 hour sessions facilitated by Moray College were run on Thursday evenings in Speyside High School commencing February 2004.
11 local youth workers attended the course. Consensus evaluation was carried out at the end of the course in order to establish how valuable the course had been.
Positive aspects of the course
Delivery
• Fun, practical, well organised and presented, informal, hands on, imaginative, easy learning • Well delivered with lots of opportunities to ask questions • Very local/delivered at Speyside
Content
• Lots of good information/knowledge passed on • Learnt a lot and changed the way I eat • Loads of tips on presentation • Loads of very good tasters/sampling and practical/good tasting food • Varied recipes
Positive aspects of the course resources
• Very useful utensils/equipment/everyone had their own set of equipment • Easy to read and understand recipe books • Good venue • Good sources for useful aids and posters • All ingredients were always there • Videos • Handouts
Negative aspects of the course
Delivery
• Time 7 – 9 pm – harder to retain information when tired • Venue
Content
• Course presumed some knowledge of cooking • Instructions in the book not always clear • Rushing cooking preparation • Demonstrations by participants – stressful experience • Didn’t like some foods
62 Resources
• Photocopied book • No washing up liquid in box
Possible solutions to negative aspects
Content and delivery
• Increase available budget • Daytime preferred or childcare required • Held over shorter period
How do you intend to utilise your skills/resources?
• Teaching/help other persons/young persons to cook and eat sensibly/cook and try new foods • Holding cooking/hygiene evenings with young people • Use equipment and skills with mixed group of kids • Working with young people in a variety of settings • Working with kids through Out Of School Club/any groups including young mums and youth groups • Within our youth club setting and on youth club residential
This evaluation will be further followed through with participants six months after completion of the course to establish whether the skills and knowledge gained have continued to be applicable, relevant and incorporated into the work setting. Results from this will be added to this report when available.
The course tutor was also asked to comment on positive and negative aspects of the course and the course resources. She felt that all participants were very enthusiastic, that the accommodation was good and that the community staff were very welcoming. As far as the course resources were concerned the tutor felt that a good range of equipment was provided for students, that all resources ordered were supplied and that there was good support from Health Improvement staff.
Negative aspects of the course were the distance of the venue from the Elgin base and that, as a consequence, it was often a long working day for the course tutor. From a practical perspective the storage areas for the equipment at the venue were a long distance from the room in which the course was held and the tutor also felt that more support was needed for moving resources for the course in general.
63 “Now You’re Cooking” – Speyside
Initial interest in three cookery skills courses led to the MFHP running one course in this area within Phase 1 of the project. Young mothers attended the sessions and the food skills facilitator, a member of NHS Grampian sessional staff and experienced cookery skills facilitator was supported by a member of social work staff. In addition to opportunities to prepare food and reinforce key food and health messages the sessions also incorporated basic food hygiene awareness. At time of writing, feedback from the sessions in Rothes were not available as the course was still in progress. This information will be added to this report when available.
The project team felt it was important that courses should meet the needs of the participants in order to be of maximum benefit. As a result, a considerable amount of time was spent by the project nurse in early 2004 following up the initial enquiries from Rothes and Dufftown. Meetings proved time consuming to arrange and facilitate, venues needed to be visited and approved, equipment found and the course content, which included the identification of appropriate food groups and recipes, specifically tailored to meet the needs of the individual groups.
Although the Dufftown group was postponed, the GP surgery was encouraged to identify a group of patients with specific food and health needs/issues who may wish to meet in the future and discuss the possibility of taking part in a food skills sessions funded by the MFHP.
5.3 Key Themes
The MFHP has established an interest in and demand for food skills work within the Speyside area at both an individual learning and skills development level and at Training for Trainers level. There is clear potential for extending this area of work.
The importance of healthy eating awareness and basic food skills need to be integrated within the health consciousness of both professionals and individuals in order to improve health.
To date the project has scratched at the surface of potential networks and individuals that could be supported to develop food skills work. These networks require further development and the project marketed in order to make the service more widely known and available within local communities.
Training for Trainers
The Training for Trainers initiative has the potential to reach a wide range of individuals in the local community by giving skills and knowledge to those who have influence over and regular contact with groups and individuals. The course run in Phase 1 of the project was received with considerable enthusiasm and opportunities for running further courses should be explored.
As is being explored elsewhere in Grampian the courses would be of added value to participants if accredited through the Scottish Qualifications Authority.
Practical issues that have been raised through the course evaluations need to be addressed and resolved.
64 Food Skills Courses
Food skills courses are most effective and relevant to participants when tailored as far as is possible to local need. It would be useful for the MFHP to link into food skills work elsewhere in Grampian in order to develop a clear but flexible framework of delivery and evaluation for future sessions.
In order to take the work forward it will be necessary to map in a more systematic way what facilities and venues exist for facilitating food skills work in Speyside.
The work should also take into account the changing roles of health professional such as health visitors and practice nurses and would benefit from links into work that addresses weight management issues of which having the skills to cook a healthy diet form a key part.
Local sponsorship of initiatives could be explored and links to local food and retailing issues developed, for example, setting up a mobile/dedicated community kitchen facility.
5.4 Recommendations
1. Further development and marketing of food skills network in order to make the service more widely known and available within local communities.
2. Address and resolve practical issues that have been raised through the Training for Trainers course evaluations.
3. Develop accreditation of food skills Training for Trainers courses in partnership with Moray College.
4. Map existing suitable facilities and venues for food skills work in MFHP target areas.
5. Explore possibilities for local sponsor ship of initiatives and links to local food and retailing issues.
65
6. Objective Three – Weight Management & Obesity Services
To provide improved and accessible community based weight management support delivering key food and weight management
6.1 Methodology
The general health status of the Moray population has been outlined in Section 2 of this report. This data has been amplified in Phase 1 of the project through work with individual General Practices in Speyside.
In order to effectively achieve the overall objective for this part of the project more detailed local information was gathered to address issues around the increasing national prevalence of:
• overweight/obesity • chronic diseases for which overweight/obesity is a significant predisposing factor • chronic disease-related complications, which may primarily occur due to overweight/obesity and poor diet
Specifically the following information was needed:
• the current provision of weight management services in primary care/communities • the current provision of weight management training for key primary care and community staff groups • the current provision of community based projects addressing and managing overweight/obesity
A total of five general practices in Speyside participated in the weight management project which aimed to gather baseline data within two broad areas for each practice.
A. General Practice Health Profile Framework
The general practice health profile framework (Appendix 7: General Practice Health Profile) was developed following the:
• identification of the type of information required by the MFHP • review of the Counterweight21 clinical audit framework, which was recently implemented via the Improving Obesity Management in Primary Care through Support and Facilitation Audit • identification of the accredited information technology management system most commonly used by General Practitioners in Speyside, GPASS, which encompasses the Scottish Programmes for Improving Clinical Effectiveness in Primary Care (SPICE-PC). SPICE-PC is favoured by the Scottish Executive, via the Clinical Resource and Audit Group (CRAG)22
21 Counterweight: Improving Obesity Management in Primary Care through Facilitation and Support. Audit Framework. 1999.
22 General practices receive quarterly practice and other Scottish comparative data, based upon chronic disease management and performance, thus providing a benchmark for Phase One general practices chronic disease data 66 • input of knowledge, skills, practice and experience gained by the Project Nurse, whilst working as a Practice Nurse in Speyside prior to working on this project
It was also felt that the general practitioners taking part in the weight management project could also, at their own discretion, identify ways in which they could use the general practice health profile to their own professional advantage e.g. to provide credible evidence-based information in the application and process of skill mix review(s), staff development bid(s) and General Practice service review and development thus making the general practice health profile a multi-faceted clinical audit tool.
The GPASS system was chosen to ensure data standardisation and the General Practice Health Profile framework was be used for all general practices taking part in the project, whether or not they had the GPASS IT database in place.
Although an accredited clinical management IT database, GPASS is considered `basic` by many primary care professionals, including, general practitioners and practice managers. However, it is one of the more economical clinical management IT database systems available, and this is likely to be the reason why, due to present budgetary and service control and restrictions, it is considered and chosen by the majority of general practice teams.
Due to database/software restrictions, GPASS has unfortunately been unable to provide all data requested by the MFHP. The first draft of the General Practice Health Profile, Chronic Disease Practice Population Framework initially included dyslipidaemia; however, several practices encountered search problems and were unable to access the relevant data. Dyslipidaemia was subsequently withdrawn from the Framework.
Other database issues that have had an impact on the General Practice Health Profile data results for Speyside are that not all of the general practices taking part in the project have recorded all of their patient details on to GPASS. In these practices, patient details are only available in paper format, which unfortunately, due to manpower, time and service constraints are impossible to access and record, thus there are a few areas where data is incomplete.
In addition, it must be noted that practices that do have their entire patient details on GPASS and that are also proactive in regards of patient screening are more likely to have higher percentages within the data than practices that do not - this can be clearly identified in the results.
B. Weight Management Training Questionnaire
A weight management training questionnaire (See Appendix 8) for key primary care staff including General Practitioner, Practice Nurse and Health Visitor was developed.
The questionnaire was designed to collect information about the level and standard of weight management services and also the level of weight management knowledge /training held by key primary care staff groups responsible for the facilitation and clinical management of obesity/weight within the primary care sector.
Pre-arranged facilitated interviews with pre-identified key primary care staff were held in each of the participating general practices and questionnaire responses recorded during interviews. Interviews were recorded and typed to provide Phase 1 results and for future reference.
67
The questionnaire provided data about the level and quality of weight management provision within each practice and about the level of weight management knowledge/ training held by key primary care staff groups responsible for the facilitation and clinical management of weight management.
The original questionnaire was based on an individual with a BMI>2523. However, it was felt by a significant number of the interviewees, that it was unlikely that any action to directly address weight management issues would take place, unless the patient/client clinically presented a secondary factor/problem, i.e. painful joints, impaired glucose level, thus giving the interviewee, opportunity to introduce and discuss weight management.
It was therefore decided by the project dietitian and nurse to increase the BMI>25 in the questionnaire to BMI>30, as it was unlikely that any action to address weight management would be taken unless a patient/client with a BMI>25 presented a secondary factor OR had a BMI>30.
Interview sample:
A total of 9 key primary care staff were interviewed:
4 General Practitioners 2 Practice Nurses 3 Health Visitors 1 GP and 1 Practice Nurse declined interview due to current workload.
6.2 Results
Because of the potential sensitivity of the data, results for this objective of the project are presented anonymously. Comparisons are nevertheless evident between areas and where applicable, are offered with Scottish comparative data.
Note that results are expressed as a percentage of the recorded total practice population and not as a percentage of the overall area population.
23 BMI Classification; Human Nutrition and Dietetics. 10th Edition. Ed Garrow J.S., James W.P.T., Ralph A. Chapter 34 page 529. Table 34.1 Classification of Overweight in Adults According to Body Mass Index (BMI) (World Health Organisation, 1998) 68
6.2.1 GENERAL PRACTICES HEALTH PROFILES
Age Distribution by Practice
25
20
15
10 Percentage 5
0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
0-17 18-25 26-35 36-45 46-55 56-65 66-75 76+
Graph 1: Age distribution by practice
• High population percentages of 0-17yr olds, minimum 19% maximum 23% • Project results helped identify a need for future profiles to include further in depth data regarding 0- 17 yrs age group i.e. Age distribution AND Weight/BMI: 0-1yrs, 2-4yrs, 5-10yrs and 11-17yrs. This will offer an evidence base for service providers for children/young families and for initiatives looking at childhood development and obesity
Age Distribution by Age Grouping
25 20 15 10 5
% Practice Population Practice % 0 0-17 18-25 26-35 36-45 46-55 56-65 66-75 76+
Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Graph 2 Age distribution by Age Grouping
69 % Patient's Weight/BMI Recorded
150
100
50
% Practice Population Practice % 0 18-25 26-35 36-45 46-55 56-65 66-75 76+
Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 No Data
Graph 3: % Patient’s Weight and BMI Recorded
• Data relates only to the number of patients who have a weight recorded • No data available practice 3, patient details had not been recorded onto GPASS database (ref section 3.2.3 A) • Data recording discrepancies (ref section 3.2.3 A)
.
% Patient's BMI Recorded >25
150 100 50 Percentage 0 18-25 26-35 36-45 46-55 56-65 66-75 76+
Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 No Data
Graph 4: % Patients BMI recorded > 25
• Data forms a subset of the data in the previous graph • No data available practice 3, patient details had not been recorded onto GPASS database (ref section 3.2.3 A) • Possible data recording issues practice 1
70 % CHD Patients Per Practice
7 6 5 4 3
Percentage 2 1 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
CHD Scottish Comparative Data
Graph 5: % CHD patients per practice
• Some general practices within Moray are in the process of planning and implementing CHD clinics. This may suggest that future local CHD data collections may be more accurate.
% Stroke/TIA Patients per Practice
2.5 2 1.5 1 Percentage 0.5 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Stroke/TIA Scottish Comparative Data
Graph 6: % Stroke/TIA patients per practice
71
% Hypertension Patients per Practice
12 10 8 6 4 Percentage 2 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Hypertension Scottish Comparative Data
Graph 7: % Hypertension patients per practice
• Practice 2 and 5 have no patients recorded in this particular group.
% Hypertension (Age>35) Patients per Practice
25 20 15 10
Percentage 5 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Hypertension (Age>35) Scottish Comparative Data
Graph 8: % Hypertension (age > 35) patients per practice
72
% Diabetes Patients per Practice
5 4 3 2 Percentage 1 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Diabetes Scottish Comparative Data
Graph 9: % Diabetes patients per practice
• Generic, encompassing types 1 and 2.
% Diabetes Patients (Age>=17) per Practice
6
4
2 Percentage 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Diabetes (Age>=17) Scottish Comparative Data
Graph 9: % Diabetes patients (age > = 17) per practice
73 % COPD Patients per Practice
2
1.5
1
Percentage 0.5
0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
COPD Scottish Comparative Data
Graph 11: % Chronic Obstructive Pulmonary Disease patients per practice
• Local COPD data may be substantially lower than Scottish comparative data due to the high number of recorded COPD patients in central Scotland. • Some local COPD patients may have been recorded on the GPASS asthma database.
% Asthma Patients per Practice
7 6 5 4 3
Percentage 2 1 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Asthma Scottish Comparative Data
Graph 12: % Asthma patients per practice
74
% Hypothyroid Patients per Practice
5 4 3 2 Percentage 1 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5
Hypothyroid Scottish Comparative Data
Graph 13: % Hypothyroid patients per practice
% Cancer Patients per Practice (diagnosed since 01.04.03) 3 2.5 2 1.5 1 0.5 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 No Data
Cancer (diagnosed since 1.4.03) Scottish Comparative Data
Graph 14: % Cancer patients per practice (diagnosed since 01.04.03)
• Practice 5, no patients diagnosed since 01/04/03.
75 % Mental Health Patients on Register per Practice
1.5 1 0.5 0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 No Data
Mental Health Problems Scottish Comparative Data
Graph 15: Mental health patients on register
• Practice 1, no mental health patients on register
76 6.2.2 GENERAL PRACTICE OBESITY & WEIGHT MANAGEMENT SERVICES PROFILES
1. Obesity / weight management clinics Practice Clinic Frequency Facilitator 1 Weight Reduction Weekly HV supported by Nursing Auxiliary & Community Nursing Services 2 Nil N/A N/A 3 Health Promotion (20-60 years) Weekly PN, attended by GP 4 Nil N/A N/A 5 Nil N/A N/A 2. Mechanism / appointment when weight / BMI is recorded Primary care staff available Range of appointments available GP (General Practitioner) Registration medical, well person clinic, 75 plus appointment PN (Practice Nurse / clinic, chronic disease review, baby clinic, child health HV (Health Visitor) surveillance screening programme (pre-school) DN (District Nurse) CN (Community Nurse) 1 GP, PN, HV, DN, CN All 2 GP, HV, DN, CN All, except well persons clinic 3 GP, PN, HV, DN, CN All 4 GP, PN, HV, DN, CN All 5 GP, HV, DN, CN All, except well persons clinic; 75 plus appointment only 3. Weight management equipment available * Criteria for appropriate level and standard of weight management equipment based on Counterweight17 Equipment held Checking Servicing Weighing scales, height measures, large blood pressure cuffs, tape measures, BMI charts and wheels, height / weight conversion charts 1 *All, appropriate level and standard Regular Sporadic 2 *All, appropriate level and standard Sporadic Sporadic 3 *All, appropriate level and standard Regular Annually 4 *All, appropriate level and standard Regular Annually 5 *All, appropriate level and standard Regular Sporadic
77 4. Method of data collection (Paper, electronic (prescriptions), I.T. Database, GPASS) 1 All 2 All 3 All 4 All 5 All 5. Skill mix GP PN HV MW (Midwife) Nursing Team 1 2 2 (P/T) 1 (P/T) 1 (P/T) District / Community 1 trainee 1 assistant (P/T) 2 2 (1 P/T) 1 (P/T) 1 (P/T) District / Community 3 2 (1 P/T) 1 (P/T) 1 1 (P/T) District / Community 1 assistant (P/T) 4 3 1 (P/T) 1 (30 hours) 1 (P/T) District / Community 1 assistant (P/T) 5 2 1 (P/T) 1 (P/T) District / Community 1 (P/T)
78 6.2.3 WEIGHT MANAGEMENT & TRAINING QUESTIONNAIRES
A. Weight Management Questionnaire
NO OF QUESTION RESPONSE RESPONDENTS How do you broach After noting that the individual required Q1 the subject of weight 8 assistance would weigh the individual loss? and calculate and explain their BMI Do you consider Q2 8 Yes, quite important to consider motivation? 1 No, would not initially consider motivation Do you use any tools or questions to Q3 assess and 3 Q & A session encourage motivation? 2 Weighing scales and BMI calculator 1 Basic advice 2 No tools or questions Know patients well, probably would 3 already know what level of motivation patient would have All about education - would provide individual with appropriate information If yes, what if they (only one participant suggested specific Q4 are not motivated to 5 patient information/literature) and change? encourage the individual to think about it and come back at any time If the individual was not that motivated 1 would not push it Would not nag a patient because it is counterproductive, however one of the 2 participants later added that it depended upon the level of severity (weight/BMI) 1 No comment Do you make Q5 recommendations for: a) Making changes? 9 Yes 2 Yes b) Target goal / 6 No weight? 7 No Yes - most people did not exercise enough; it was not always practical; Do you discuss patients can be referred to the Moray Q6 exercise, physical 9 Leisure Centre through the GP Referral activity? Scheme; should start small, no great changes to current lifestyle
79
Do you offer any 7 Yes Q7 literature? 2 No 7 Yes - British Heart Foundation and HEBS Is it evidence based? 1 No Is it produced in- house, or is it 2 Company information company information? Does it contain any One participant said that they would be 0 advertising? reluctant (to use it) if it did No Do you offer any 2 In the past Q8 anecdotal experience 1 e.g. Food diary, other successful or tips? 6 patients/clients/husband(anonymously) Aim to keep within the individual’s 7 financial limitation Do you make any ‘Hassle Free Food’ booklet special 1 Do not have many low-income Q9 considerations for 1 individuals/families at their practice individuals on a low Had made special considerations in the income? 1 past
B. Training questionnaire
QUESTION RESPONSES Have you undertaken any Yes No obesity Q1 management training? 6 3
Part of a If yes was it in Company Q2 Tutorial Study day certified Certified course the form of: presentation course 1 2 2 1 0 If certified was Q3 Certificate Diploma Degree Other it: 1 (post 0 1 0 graduate) How long ago did you attend Under 12 3 – 4 4 – 5 years Q4 obesity/weight 1 – 2 years 2 – 3 years months years management training? 2 1 1 0 0
80 Anecdotal comments recorded:
“Most of our population, (practice) is greater than 25 (BMI)” (GP)
“People with a BMI>30, I think we have a medical duty to discuss it” (GP)
“I would like to refer anybody with a BMI>30 to the dietitian as a standard, but there just aren’t the facilities to do that” (GP)
“The dietitian comes for two hours and we have only been given four slots for the year. So, it really won’t cope with the need” (GP)
“GP referral to the Moray Leisure Centre, nobody goes, because it is 70 miles there and back” (GP)
“It can be very difficult getting appointments with me; sometimes it is faster getting appointments with GP” (Practice Nurse)
“You feel you could be doing more with someone, but time means you are restricted” (Practice Nurse)
“Knowing the individuals in this practice really well plays a great part” (GP)
“I think there is more of a problem with social isolation in a sense than low-income. I think there is certainly the kind of younger mums, who have got nothing else to do all day, but to sit and eat in the evenings, because they can’t get any babysitters to look after the three kids and the husband has dashed off with someone younger, smarter and slimmer” (GP, male)
Community Obesity / Weight Management Groups / Services.
None were found, only physical activity (walking) groups.
Private / Industry Obesity / Weight Management Services.
Weight Watchers: Aberlour Parish Hall. High Street, Aberlour. Monday 7 pm
Counterweight: Dufftown Medical Group; Control Group Audit ‘Improving Obesity Management in Primary Care through Support and Facilitation. November 1999 – May 2001’
6.3 Key Themes
Weight Management for Patient/Client with BMI 25-30
Due to the nature of existing and changing primary care services, individual practice skills mix and time constraints, it is unlikely that any action will be taken in respect of the identified gap in the management of patients with a BMI between 25-30 unless a patient/client directly requests assistance or presents a secondary medical factor/problem, i.e. painful joints, impaired glucose level. There is a missed opportunity here for primary health care staff to introduce and discuss weight management issues with patients.
81 Local/In-House Weight Management Training
Six out of nine interviewees had undertaken some level of obesity management training. Only two interviewees had undertaken training in the past twelve months, the remaining four interviewees had undertaken training within the last one to twelve years.
Access to local, in-house obesity/weight management training for primary health care personnel in Moray is poor. Currently, requests can only be made directly to the Department of Dietetics at Dr Gray’s Hospital on order to access tutorial sessions on various aspects of nutritional management. There is no other local, in-house weight management training available.
Weight Management Resources
The majority of interviewees use a number of resources, including patient information / literature, from a variety of sources, some of which are out of date. Since the inception of the Moray Food and Health Project numerous enquiries have been received from primary health care personnel regarding accessing appropriate weight management resources / tools.
Multi-agency and multi-disciplinary weight management integrated care pathway
Responsibility for tackling weight management issues is shared by primary care, dietetic services, the individual and local communities. Inevitably, individuals will turn to their GP, Practice Nurse, Health Visitor and other related Community Nursing Services for help or for a referral to dietetic services.
In order to improve local weight management services and also to reduce waiting lists for dietetic services there is a specific need for the development and implementation of multi- agency and multi-disciplinary weight management care pathway within the local community.
Local obesity/weight management evidence base
Local general practice health profile and obesity/weight management services data needs to continue to be collected and analysed to improve local evidence-based obesity/weight training, services and management in other areas of Moray.
82 6.4 Recommendations
The development, implementation and where appropriate the facilitation of:
1. A local integrated care pathway for weight management, encompassing both community and private/industry services, in Speyside and Elgin.
2. An approved directory of weight management resources for primary health care personnel.
3. An approved directory of weight management training for primary health care personnel.
4. Local, in-house weight management training for primary health care personnel.
5. Local, in-house weight management training for community based workers (e.g. community development workers, youth workers, after school carers, local sports co- ordinators, Rainbows/Brownie/Guide/Cub and Scout groups).
6. Collection and analysis of further local general practice health profile and obesity/weight management services data (Phase Two Lhanbryde, Phase Three Buckie and satellite villages) including more specific data relating to 0 -17 year age group thereby expanding and maintaining an up to date obesity/weight management evidence base in Moray.
83 7. Objective Four - Schools
To work with schools to further develop the Health Promoting Schools initiative within the formal and informal curriculum.
7.1 Methodology
A clear path did not immediately emerge for the work of the project in schools. It was initially envisaged that the project would add value to the work locally developing the Hungry for Success initiative. However, the timescale of Phase 1 of the Moray Food and Health (July 2003 – March 2004) in relation to the slower progress of local implementation of the national initiative prompted a rethink. Four Primary Schools in Speyside (Aberlour, Rothes, Dufftown and Craigellachie) and Speyside High were individually approached and opportunities for engaging with food and health issues explored in conjunction with the community consultation taking place in these areas.
Initially it had been planned to formulate health profiles of school children that would include information on height, weight and eating habits and so on, but due to difficulties in accessing this information and time constraints alternative ways of obtaining similar information were pursued.
Workshops were run with pupils from Primaries 4 and 5 in Speyside (Appendix 9: Lesson Plan Speyside Primary Schools). Baseline information on expected nutrition competencies24 for primary aged children was used to enable the Dietitian to assess the levels of knowledge of the participants. Sessions focussed on the Balance of Good Health25 using pictorial representations of the functions of key nutrients and the Balance of Good Health mat resource to generate discussion.
A meeting with the Head Teacher of Speyside High late on in the later stages of the first phase of the project identified a number of opportunities for the project to become involved with school based food related activities. A session was held in school time with 19 participants studying standard grade home economics aiming to improve their knowledge of food groups, nutrients, their sources and functions and the relevance of these to different groups of the population (Appendix 10: Lesson Plan Speyside High). Relating directly to the curriculum this initiative took place in response to a request from the teacher to see if additional external teaching would help to get the message across. Again the Balance of Good Health and associated resource was used and the nutrient content of food models discussed. Pictorial nutrient function cards were matched to component food groups of example menus. Group work followed with case studies looking at nutritional needs of specific population groups.
Further baseline information on expected nutrition competencies has brought together by a cross government group via The Food Standards Agency26. These guidelines were
24 http://www.nutrition.org.uk/education/healthyschools/competencies/5to7.htm 25 The Balance of Good Health is a nationally endorsed pictorial representation of the recommended balance of foods in the diet that aims to help people understand and enjoy healthy eating. 26 The suggested competencies for 14-16 year olds identify a minimum level of understanding and skill for young people to be gained from within and outside curricula activities. They represent a view of what young people need to know and should be able to do in order to live a healthy diet both now and in the future. ‘Getting to Grips with Grub’ Food and Nutrition Competencies of 14-16 year olds, Food Standards Agency 2003
84 considered but not used as a possible way of enabling the Dietitian to assess the levels of knowledge of the participants in this age group. The proposed key competencies for 14 - 16 year olds in relation to food and nutrition measure the knowledge and skills of young people in being able to provide themselves with a healthy diet within limited budgets, using good food and hygiene practices.
Food Preparation and Food hygiene and Diet and health Consumer awareness handling skills safety An understanding of the The capacity to make relationship between Knowledge and informed choices about Skills to plan a varied food, good health, understanding of the food in relation to a and healthy diet growth and energy principles of food safety healthy diet balance throughout life Knowledge about the The need to achieve a Practical capability to be Awareness of hygienic components of, and balanced and varied diet able to prepare and cook procedures to follow proportions in a healthy through wise choice of a variety of dishes/meals when preparing, cooking diet foods to achieve a healthy diet and storing food Knowledge about what Knowledge of how constitutes a healthy Awareness of cooking methods can weight, how it relates to seasonality, and affect the nutritional and diet, health and implication of food miles sensory qualities of physical activity. food ingredients Knowledge of costs of Application of food foods and hygiene principles to
preparation/cooking food preparation, methods cooking and storage. Understanding of food labelling information from manufacturers Awareness of the influence of food
advertising and promotion
Table 36: Food and Nutrition Competencies of 14-16 year olds, Food Standards Agency 2003
The nutrition competencies were not utilised in the preparation and evaluation of the session as it was built around the key messages that were required to be learned for the exam. The group involved was a mixed group of foundation and credit level students and their knowledge was difficult to assess. In addition, it was not appropriate to divide the group. This was a one off teaching session with pupils prior to their exams.
7.2 Results
Workshops were run with primary pupils in Speyside. Baseline information on expected nutrition competencies27 for primary aged children was used to enable the Dietitian to assess the levels of knowledge of the participants. The results of these observations are outlined in Table 33.
Competencies 7-11 Competencies 5-7 years Actual observations in Actual observations in years study group study group
Clearly the children Understand that a All children understood from Enjoy their food appeared to enjoy their variety of food is the plate that a variety of
foods needed in a healthy foods were recommended
27 http://www.nutrition.org.uk/education/healthyschools/competencies/5to7.htm 85 diet Understand that food is a Identify and classify This was the main basic requirement of life foods and composite assessment and as reported and that a variety of food is All children had an dishes according to some struggled more than needed to grow, be active understanding of this. the 5 food groups in others with certain concepts and maintain health. the BOGH model. and combination foods brought debate. Recognise the 5 food groups from the BOGH They generally knew Understand that food I would say this may have model and convey basic the basics of what was provides energy and been too advanced a healthy eating messages, and was not healthy but nutrients (in different concept for the age group e.g. we are all encouraged in a very black and amounts). involved. to eat more form some white way. groups than from others. Understand that eating at Some of the children Understand that food least 5 portions of fruit and would have struggled to is needed to be vegetables every day report the number of active for health and Good understanding of this. contributes to a healthy portions necessary to maintain diet. eat. health/wellbeing. Make healthy choices in improve All children in the group Talk about which foods they No problems in doing their diet, explaining were able to suggest and others eat and like this. what they have healthier alternatives for the /dislike with reasons. changed and why. lunch box.
Understand that we eat Apply dental health different foods depending This arose when and personal hygiene on the time of day, discussion focussed on Not assessed. practices. occasion and lifestyle. breakfasts.
Understand that people around the world choose food according to This competency was
availability, need and not really assessed. preference.
Table 37 - Summary of assessed nutrition competencies
7.2.1 Workshops with pupils from Primaries 4 and 5 in Speyside
The focus of these sessions was the introduction of The Balance of Good Health (BOGH)19 model explaining that foods divide into groups depending on what nutrients they give us.
Summary of discussions and observations – all schools
Milk and Dairy
In all schools visited the children knew about calcium and that it was important for building good bones. There was some confusion in one group where one child suggested that it kept the teeth white in colour. A good method of remembering was put forward by Dufftown teacher in that bones and teeth are white and so is milk and that might be a good method of associating the fact that milk and dairy foods often contain calcium and are, therefore, good for our teeth and bones.
Meat, Fish and Alternatives
This was a food group of which there was generally poor knowledge about why it is eaten and what foods would be associated with this group. Even when trying to place the fish on
86 the Balance of Good Health mat, it was often mistakenly placed into the dairy section by pupils.
The project dietitian questions whether the children had heard of iron because of advertising about fortified foods. “I felt that it may be a reflection of the power of advertising as breakfast cereals are often heavily marketed at children and most breakfast cereals will comment that they are fortified with vitamins and iron. I thought this might be why they had heard of iron.” Very few pupils could tell the function of iron or of protein. They did catch on quickly to the strength aspect. This could have been because they liked the picture that was used to associate strength with foods.
Bread Cereals and Potatoes
There was some confusion around this group. Many of the children were able to say that this group contained carbohydrate, although, none would really have known what that means. A common misconception was that we get wheat from this group and there was confusion that this was not the required answer. When explained along with the function cards, there was good understanding that these foods helped you to play sports and give you energy. This point was taken on board very quickly and easily
Fruit and vegetables
Practically every child could respond “To keep us/make us healthy!” When asked for what it is in fruit and vegetables that make us healthy, at least one child from every group came up with vitamins or most commonly vitamin C. Many had never heard of the ACE28 vitamins and looked quite interested in this concept as it sounded quite “cool”.
The question “Why do we need vitamins?” prompted a limited response. The majority of children did not know the answers other than, again, “To keep us healthy!!” When quizzed further about how we would feel without vitamins answers varied – tired, weak, ill, and sleepy. Mostly they could say that vitamins would keep them in good health. Only a few children from each group could say they were good for your heart. This did seem to be well remembered later on in the session when they were asked to associate functions with individual food groups
Foods containing fats and sugars
The children easily recognised the foods in the picture and acknowledged that these were “yummy” foods.
To the question “What does this food group give us?”. The response was - sugar and fat. What do we get if we eat too many of these foods? Mostly all the children knew that they would get bad teeth. Very few answers came out around the fact that they might put on weight or get too fat. This particular issue was not emphasised. It did not seem appropriate to expand on the issue of overweight, especially as most groups appeared to have at least one child who appeared overweight, (subjectively). Also the fact that on occasions there was no teacher present and this could have resulted in some teasing to the children that were overweight and therefore it was felt inappropriate to expand on this. Time was also a factor.
28 Vitamins A, C and E contain antioxidants that have been shown to protect against free radical damage which is linked to the development of cancer 87 When asking which food groups the models went into there was some confusion at points around certain things like doughnuts, some children wanted to put them into the bread and cereals group. The project dietician wondered if these answers were associated with the link of wheat containing foods. One young pupil commented when asked where to put the “Smarties” responded “Into the pit of despair”. He had grasped the concept of fats and sugars very well!
Responses and observations – by school
Schools sampled have been listed within the corresponding GP practice areas in the obesity / weight management section. This enables cross objective comparisons of data.
School One
These children were enthusiastic, but did not have a good prior knowledge of food groups. They had mostly not heard of protein and the group relied on a few of the more vocal children to provide correct answers. There was confusion around calcium and vitamins. Most groups did not offer the correct answers when asked why we need to eat fruit and vegetables.
There was confusion over placing foods from the meat group into the dairy group, especially fish - one group did not know at all.
Mostly those that ate packed lunches agreed they should have a sandwich in the box. The issue of keeping the lunch cool until lunchtime was discussed as was the order to eat lunch in and about eating fruit before or after sweeties. (Do they clean your teeth if you have them afterwards or should you eat your fruit before sweeties to ensure you have the space for them?)
Breakfast was mostly taken by pupils but their knowledge of energy was not so good; recognition of fruit and vegetables was good. Actual numbers for this were not recorded.
School Two
This group was taken in the games hall and it was very noisy. The consultation group finished very quickly as the groups needed to be moved around. The knowledge of this group was very different to the other schools. There was poor understanding of the functions of nutrients by the children and their ability to recall points they had just been told was relatively poorer. There was limited understanding about which food should be in which group. However, the completion of the word searches was done in record time.
The children appeared generally more excitable as there was no teacher present and they were out of the classroom. This may have been a further reason that their answers were not as good. The final group from P5 composite with the P6 class had an excellent level of knowledge and appeared more settled.
School Three
There was a very noticeable difference between the two years in their knowledge base. The P4 teacher informed us that they were just about to do a project on healthy eating for health week. P5 also very willingly contributed that they had done this the year before but as the food pyramid29. Many of the children reported taking packed lunches in this school.
29 American equivalent nutritional model to the Balance of Good Health 88 Mostly children especially in P4 had never heard of protein. One P5 pupil commented about protein “My sister doesn’t eat enough protein and that is why she is short".
P4 really needed to be led through much of the work but this is understandable if they have never come across it before. They were able to make appropriate suggestions on ways to alter the packed lunch to make it more balanced. The project dietitian was informed by one child at the end that she had missed out a very important aspect of health. In order to be healthy you must be happy!
School Four
Pupils were very enthusiastic with a good amount of knowledge. The majority of children reported eating school dinners and mostly eating breakfasts. There was some confusion over why breakfast may be important. The children appeared to take on board the issue of the small proportion of food from the fatty and sugary group, in fact better than an adult appears to understand. This is again a subjective comment and there would be no specific reference to back it up.
7.2.2 Session at Speyside High School
The project dietitian personally evaluated this session and concluded that effective learning took place and that the objectives of the session were achieved.
The dietitian concluded further that the strong points of the lesson were achieved in getting the pupils to communicate the answers to questions and getting them asking questions themselves about food and nutrition.
There was a definite turning point in the session when the pupils appeared to catch on to what was required began to be able to specify which nutrients came from which food group. One of the biggest learning points was making the associations between nutrients. The majority of the class did not know about links between nutrients for example:
• Iron and vitamin C • Calcium and Vitamin D and phosphate • Fibre and its functions in both blood lipid and glucose reduction as well as roughage
The session emphasised the need to eat fruit and vegetables rather than taking a vitamin pill due to all the other non-nutrient properties available.
The pupils found that when the problem solving exercise were completed after the BOGH exercise and they realised that changes could be made to improve the nutrition offered, they discovered that they did know about foods and could try to think through logically about the sources of different nutrients.
The weak point of the lesson was that the session allowed those that were more confident or intelligent to provide the answers, at the same time allowing those less so to stay quiet.
Future improvements to the lesson plan could be the inclusion of some written work or a later input to see what messages have been taken in and which messages were missed.
This was an interesting way to be involved with young people. This particular group, by choosing to take home economics to standard grade level, are obviously showing an interest in the subject of food and nutrition. However, the course curriculum does cover aspects other that just food: Including 89 • safe working practices • design features – including clothes, equipment • cleanliness in relation to health • physical need of individuals and families including consumer rights • management of expenditure
It would be useful in the future to examine how different our population is to the key competencies described previously22.
7.3 Key Themes
The developing partnership work between local schools and the MFHP throughout phase 1 has highlighted the added value the project can offer to existing food and health work within the curriculum. As it progressed, this objective has nurtured relationships with schools, accommodated the considerable time demands on teaching staff and worked alongside the developing Hungry for Success initiative.
An important part of the approach for this initiative has been the consideration of comparisons with established competencies in food and health knowledge of primary and secondary aged pupils. It has been demonstrated that overall, children in the sample group, whilst having some broad knowledge of the Balance of Good Health, lack a more in depth understanding of the concepts involved. Although not appropriate for use in this instance in the secondary setting, it would be useful to find ways in the future of examining how children’s knowledge squares with the relevant expected competency levels.
Future work would also benefit from drawing together appropriate resources suitable for use with children in the school setting in order to broaden pupil’s knowledge of food and health issues.
7.4 Recommendations
1. Continue to work in partnership with schools and health improvement staff to identify and implement initiatives that add value to existing food and health initiatives such as Health Promoting School and Hungry for Success.
2. Develop work to raise food and health knowledge of school pupils using established nutrition competencies as a baseline measurement.
3. Identify and recommend resources appropriate for use in schools.
90
8. Conclusion
Throughout this phase of the project a considerable amount of data has been gathered and learning has taken place at a range of levels in order to raise the profile of the role food plays in developing a healthier lifestyle and preventing disease.
For the project team, working in partnership has been a positive experience and this process and an assessment of what the project has achieved in relation to its overall objectives will be set out in a separate evaluation paper.
Further funding has been secured to continue the project for the next financial year and recommendations from this report will form the basis of project planning for Phase 2 of the project over the next year.
Having established a framework for food and health work in Speyside and Lhanbryde a priority of the project will now be to take the results back to the communities and local agencies to develop local action plans.
Community planning has a crucial role to play in improving the health and well being of communities in Moray and offers an opportunity for issues raised by the project to be incorporated into wider strategic work to address health improvement issues and reduce health disadvantage.
This phase of the project has provided clear guidance to enable this process and a firm basis for future work to improve health and well being in Moray.
Acknowledgements
The MFHP project team would like to thank the communities, agencies, GPs and staff, schools, retailers and local agencies for their help and co-operation with this piece of work.
91 9. Appendices
Appendix 1 – Transport costs and services in Speyside and Lhanbryde
Miles Food Petrol cost Eating Secondary Area Pop. to Bus Freq. Sun. Taxi retail Primary Cost - A/S, (per ltr) places School Elgin A/R, C/S, C/R outlets 305 2 Aberdeen general Milnes High, 1971 4 323 Spey Hourly £6.50 - £8 2 hotels Lhanbryde 1 Fochabers Bay 315 £1.95 £3.80 specialist Lhanbryde Elgin £0.97 £1.96 2 2 take general Speyside 1330 10 336 Hourly No £15 - £18 79.9 away 3 Rothes 2 High £2.70 £5.20 hotels Rothes £1.35 £2.70 specialist
Speyside 420 12 336 Hourly No £18 - £21 79.9 1 Craigellachie £2.90 £5.60 1 hotel 1 High Craigellachie £1.45 £2.90 restaurant 1 1 café 2 Aberlour Speyside 1730 15 336 Hourly No £25 - £26 79.9 general £3.15 £6.00 3 pubs Inveravon High Aberlour £1.57 £3.14 specialist 2 5 hotels 3 general Mortlach Speyside 1730 17 336 Hourly No £25 - £26 79.9 restaurants £3.33 £6.40 4 / cafes & 2 Cabrach High Dufftown £1.67 £3.34 specialist takeaway
3 77.9 3 6 hotels Tomintoul Speyside Tomintoul 330 35 363 times No £36 - £62 (Ballindaloch) general /pubs Glenlivet High (incorporating a day £4.80 £9.60 Glenlivet) £2.40 £4.60
92 Appendix 2: Food Mapping – checklist of products
Study Area Fats Weight Price Store Name Butter/Margarine Business Hours Poly/monounsaturated spread Product Availability Weight Price Low/reduced fat spread Fruit - Fresh Pure veg oil - sunflower/olive Apples Oranges Full fat Banana Semi-skimmed Pears Skimmed milk powder Pure Fruit Juice Soya or alternative Vegetables - Fresh Skimmed Onions Pulses Carrots Lentils Turnips Split Peas Potatoes Broth Mix Fresh Salad Veg. Tomatoes Kidney Beans Tinned Peas Cereals Sweetcorn High Fibre style Carrots Porridge Potatoes Weetabix Tinned Fruit (Natural) Shredded Wheat Branflakes or mix Frozen Frozen veg Fresh fruit/vegetable quality Frozen veg High Frozen fruit Average Poor Breads White Mobile Vans/ Delivery Whole/Granary
93 Appendix 3: Full Adult Questionnaire
1. Gender M F
2. Age Range
0-12 13-18 19-30 31-50 51-65 66+
3. Where do you live?
IV30 AB55 AB37 AB38
4. How many in your household?
Adults Under 16 16+ FT Ed
5. Over the last 24 hours….Taking what you ate yesterday as an example?
Did you eat any Bread /Toast Potatoes Pasta Rice Breakfast cereal
What kind of bread do you buy? Wholemeal White Granary Other
What kind of cereal do you buy?
Do you use any spread/oil for your bread/cooking/tatties? Butter/margarine Low fat spread
Cooking oil Lard
What kinds do you buy?
Have you eaten any fruit? Yes No
If yes would you mind telling us what you have had?
Have you had any vegetables, fresh, frozen or tinned?
94 Have you drunk pure fruit juice/unsweetened juice not squash? Yes No
What kind of milk do you usually drink?
Full fat semi skimmed skimmed milk powder Other e.g. Soya
6. On average how many portions of vegetables do you eat each day? Not including potatoes
On average how many portions of fruit do you eat each day?
7. When buying fruit and vegetables which are the factors that have most influence on your choices? Please rank in order of importance to you TOP 3 Fresh What shop has available?
Quality of produce/freshness?
Ease of preparation i.e. pre-washed
Price
Availability of Organic produce
Do not buy fresh produce
Other
95 Tinned Branded labels
Price
Liquid used for canning i.e. salt/ sugar added
How heavy shopping is to carry
What shop has available
Other
Frozen What shop has available
Storage facilities at home
Price
Length of time taken to travel home
Do not buy frozen produce
Other
8. Do you shop for food locally?
Never Sometimes Always
9. What do you buy locally?
10. How often do you go shopping to a supermarket?
Never Weekly Monthly Occasionally
11. How do you get to the supermarket?
Car Lift Taxi Public Walk Other
96 12. Household income including benefits/pensions Please circle one
Per week -£100 £100-£200 £200-£400 £400+ Per month -435 £435-£867 £867-£1,735 £1,735 Per year -£5,200 £5,200- £10,400- £20,000 + £10,400 £20,800
13. Please indicate where you feel you are on the graph below in relation to how healthy your diet is. Unhealthy diet being 0 and healthy being 10
☺
Unhealthy Healthy
Please indicate where you feel you are on this graph in relation to: not enough money for food /as much money as I want for food
☺
Not enough As much as I want
14. On how many days per week do you build up at least 30 minutes of moderate physical activity (equivalent to brisk walking)?
0-2 3-4 5 or more
15. What would you like to see happen locally to improve your food choices?
97 Appendix 4: Young People’s Health Profiles
MORAY FOOD & HEALTH PROJECT UNDER 16 PROFILES AGE GENDER LOCATION BREAKFAST Bread Toast Cereal Margarine Butter Flora Yoghurt Fruit Egg Milk Fruit Juice Water Sugar DINNER HOME SCHOOL PACKED Potatoes Chips Pasta Rice B Bread W Bread Sandwich filling Crackers Carrots Onions Broccoli Sprouts Cauliflower Salad Turnip Peas Oranges Apples Grapes Pear Banana Strawberries Milk Fruit Juice Squash Fizzy drink Tea
98 Coffee Crisps Milkshake Chocolate Sweets Biscuits Fish Supper Dried Fruit Cheese Egg Chicken Pie Margarine Roll Yoghurt TEA - TIME Potatoes Chips Pasta Rice B Bread W Bread Sandwich filling Crackers Carrots Onions Broccoli Sprouts Cauliflower Salad Turnip Peas Oranges Apples Grapes Pear Banana Strawberries Milk Fruit Juice Squash Fizzy drink Tea Coffee Crisps Milkshake Chocolate Sweets Biscuits Fish Supper Dried Fruit Cheese
99 Egg Steak mince Water/Ice cream Pickle Yoghurt Pot Noodle SNACKS Biscuit C Biscuit P Crisps Fruit Cheese Cake Squash Fizzy Juice Yoghurt Sweets Chocolate HOW DO YOU GET TO SCHOOL? Walk Bus Cycle Car Other Other Other WHAT ACTIVITIES CAN YOU DO? Walking Cycling Dancing Ice skating Rollerblading hockey Swimming Rugby Horse riding Running Skate boarding Play park Disco Walking Basketball Football Bowling Tennis Cricket Other WHICH OF THESE WOULD YOU USUALLY DO IN A WEEK? Walking Cycling Dancing
100 Ice skating Rollerblading Hockey Swimming Rugby Horse riding Running Skate boarding Play park Disco Walking Basketball Football Bowling Cricket Other Other
101 Appendix 5: Revised Parental Questionnaire
The Moray Food and Health Project is led by NHS Grampian. We are carrying out a number of community based research exercises to find out what people think about healthy eating and how accessible they feel healthy food is to them. Thank you very much for taking the time to complete this short questionnaire, which should be returned to the school.
1. What is your postcode? ______
2. How many people live in your in your household?
Adults Under 16 years
3. On average how many portions of fruit and vegetables does your household consume each day?
Example Adult 1 Adult 2 Adult 3 Adult 4 Adult 5 Fruit 2 Veg 1 Child 1 Child 2 Child 3 Child 4 Child 5 Fruit 2 Veg 1 • Refer to table on leaflet for guidance on portions
4. Where do you do your main food shop?
Local shops within walking distance / three miles
Local shops outwith 3 miles
Supermarkets - Asda Tesco Co-op Safeway Farmfoods
Other
Please specify
5. How often do you do a food shop?
Every day Every Week Fortnightly Monthly
Other Please specify
6. When you are buying fruit and vegetables do you tend to do it…
Every day Every Week Fortnightly Monthly
102 7. If you run out of fruit and vegetables do you tend to:
buy more locally wait until your next shop neither
8. Please indicate whether you agree or disagree with the following statements Agree Disagree
There is a good choice of produce available locally throughout the week?
The price of fruit and vegetables available locally are competitive?
The quality of fruit and vegetables available locally is generally good?
9. Please indicate on the line below where you feel your household is in relation to how healthy you think your diet is with 0 being unhealthy and 10, healthy.
0 10 Unhealthy Healthy
10. Are you happy with the amount of fruit and vegetables consumed in your household? No Yes
11. If you had more money available for food shopping, do you think you would eat a healthier diet No Yes
12. What is your total household income including benefits/pensions? Tick one box only
Weekly income Monthly income Yearly income
£100 £435 £5,200
£100-£200 £435-£867 £5,200-10,000
£200-£400 £867-£1,735 £10,000-£20,000
£400+ £1735-£20,800 £20,000+
Do you have any suggestions about what you would like to see happening to improve your food choices locally?
Thank you for taking the time to complete this questionnaire
103 Appendix 6 - Shop survey – all results
Average
(selection) AREA Elgin Lhanbryde Craigellachie Aberlour Dufftown Tomintoul STORE 1 2 3 4 5 6 7 8 9 10 11 Fruit - Fresh (1 kg) Apples 128 133 145 120 169 108 129 133 167 167 200 147 Oranges 138 145 145 140 89 165 165 75 150 135 140 135 Satsumas 128 15 159 Banana 74 139 150 99 107 159 143 150 140 175 140 Pears 118 139 158 189 189 108 152 150 160 Grapes 218 Pure Fruit Juice (1ltr) 62 99 112 112 165 85 99
Vegetables - Fresh (1 kg) Onions 130 49 60 65 95 99 95 40 45 69 Carrots 49 70 105 55 130 99 80 95 35 59 81 Turnips 59 114 60 105 98 84 57 49 81 Potatoes 30 64 36 34 65 84 120 25 49 60 Lettuce (each) 59 89 Tomatoes 127 158 150 185 98 260 178 189 Cucumber (each) 54 Mushrooms 240 445 Broccoli 119 58 Cauliflower (each) 68 98
Quality H - high A - average P - poor H A P H H H A P A A A
Fruit/Vegetables - Tinned Peas (300g) 23 52 39 37 46 32 115 54 Sweetcorn (340g) 57 84 47 59 62 89 64 68 Carrots (300g) 15 52 38 37 38 55 56 52 Potatoes (300g) 54 36 71 92 Tomatoes (400g) 35 59
104 Appendix 6 - Shop survey – all results (cont) STORE 1 2 3 4 5 6 7 8 9 10 11
Fruit cocktail (415g) 75 85 Peaches (415g) 75 79 Pineapple (425g) 60 72 114 81 Mandarin (298g) 21 45 49
Vegetables - Frozen Sweetcorn (907g) 96 120 159 Peas (907g) 78 178 278 216 138 312 224 Broccoli (907g) 112 159 199 252 Cauliflower (907g) 48 120 Beans (907g) 98 135 179 Sprouts (907g) 83 144 162 145 Mixed (907g) 77 261 158 192 237
Bread White (800g) 23 89 49 81 75 75 94 75 88 69 77 Wholemeal (800g) 43 92 101 61 109 75 97 78 88 Soft Grain (800g) 72
Pulses Lentils (500g) 55 119 89 85 95 104 92 Split Peas (500g) 34 62 45 59 104 59 90 59 Broth Mix (500g) 39 79 63 58 52 75 85 63 65 Kidney Beans (500g) 79 77 57 58 Tinned Kidney Beans (420g) 35 60 45 45
Cereals High Fibre style (500g) 69 179 229 65 174 253 109 161 Porridge (1 kg) 53 85 110 119 258 98 198 238 80 178 152 Weetabix (24) 109 172 149 184 137 159 153 174 151 125 156 Shredded Wheat (18) 148 169 135 Branflakes or mix (500g) 119 175 185 179 165 177 165
105
Appendix 6 - Shop survey – all results (cont) STORE 1 2 3 4 5 6 7 8 9 10 11
Fats and oils Butter/Margarine (500g) 34 158 178 184 48* 178 178 90 49* Poly/monounsaturated spread (500g) 84 109 130 128 109 107 68 109 Low/reduced fat spread (500g) 83 95 127 119 114 Vegetable oil (1 ltr) 52 118 78 119 133 139 Sunflower (1 ltr) 66 Olive oil (1 ltr) 108 339 598 698 545
Milk Full fat (2 ltr) 92 109 126 110 151 144 99 87 81 113 Semi-skimmed (2 ltr) 92 105 180 152 151 123 87 114 81 124 Skimmed (2 ltr) 92 158 114 Skimmed milk powder (198g) 120 185 169 159 139 168 179
Soya or alternative (500ml) 115 (1ltr)
106 Appendix 7: General Practice Health Profile
1. Total practice population
2. Age distribution of practice population
0-17yrs 18-25yrs 26-35yrs 36-45 46-55yrs 56-65yrs 66-75yrs 76yrs plus
3. Age distribution of practice population with Weight/BMI recorded
18-25yrs 26-35yrs 36-45yrs 46-55yrs 56-65yrs 66-75yrs 76yrs plus
4. Age distribution of practice population with BMI>25
18-25yrs 26-35yrs 36-45yrs 46-55yrs 56-65yrs 66-75yrs 76yrs plus
5. Number / % of chronic disease within practice population
Chronic disease list: I. Coronary heart disease. II. Stroke or TIA. III. Hypertension. IV. Hypertension (Age>35) V. Diabetes. VI. Diabetes (Age>17) VII. Chronic Obstructive Pulmonary Disease VIII. Asthma IX. Hypothyroid X. Cancer XI. Mental Health XII. Dyslipidaemia (subsequently withdrawn see section 3.2.3 A.)
© 2004 by Tracey Gervaise
107 List mainly based on GPASS/Spice-Pc Chronic Disease Populations
6. Obesity management services
• Number and description of obesity/weight management clinics currently held within the practice
• Description of mechanisms/appointments when Weight / BMI is recorded e.g registration medical, well person clinic, chronic disease review
• The current availability of: - Weighing scales - Height measures - Large BP cuffs - Retractable tape measures - BMI Chart - Height/weight conversion chart - Other
• How often is equipment checked / serviced?
7. Practice population data
Practice medical records - Paper - Electronic - IT database - identify.
8. Practice skill mix.
No. of working hours per week:
GP; HV; PN; Other e.g. HV assistant
© 2004 by Tracey Gervaise
108 Appendix 8: Obesity Management / Training
Interviews to be recorded so that information given is correctly scribed.
1. Obesity management.
An individual requires assistance with weight reduction, either by request or has been identified through screening. BMI>30.
1) How do you broach the subject of weight loss? 2) Do you consider their motivation? 3) Do you use any tools or questions to assess and encourage motivation? 4) If yes, what if they are not motivated to change? 5) Do you make recommendations, or targets for, i) making changes ii) target / goal weight. 6) Do you discuss exercise/physical activity? 7) Do you offer any literature? i) Is the literature evidence based? ii) Is it produced in-house or is it company information? iii) Does it contain any advertising? 8) Do you offer any anecdotal experience or tips? 9) Do you make any special considerations for individuals on a low income?
2. Obesity training
1) Have you undertaken any obesity management training? 2) If yes, was it in the format of : a) Company presentation b) Tutorial c) Study day d) Part of a certified course e) Certified course 3) If a certified course, what level was it? a) Certificate b) Diploma c) Degree d) Other, describe. 4) How long ago did you attend obesity management training? a) 12 months or less b) 1-2 years c) 2-3 years d) 3-4 years e) 4-5 years f) Can’t remember
© 2004 by Tracey Gervaise and Natalie Vicca
109 Appendix 9: Lesson Plan Speyside Primary Schools
Pupil Numbers: Various 12-33 per class Year group: P4 & P5
Lesson aims: To familiarise the pupils with the Balance of Good Health (BOGH) and the correct proportions of foods to be eating throughout the day. Leave pupils with an understanding of the nutrients we gain from each food group and their primary functions.
Objectives: To be able to identify which foods fall into each food group To identify which function is associated with each food group To identify the proportions of foods we should aim to eat at meal times To understand why one example of a packed lunch is unhealthy and be able to make appropriate suggestions to make it healthier and balanced.
Stage of Time Student Activities Tutor Activities Lesson Aids lesson Introduction 5 minutes After initial introduction Introduction by dietitian of what the divide into groups plan is for the session. Asking the pupils to think hard about what they had to eat yesterday and also to be able to tell what they know. Development 5 minutes Identify the foods in each Briefly what is a dietitian and what Poster of BOGH group of the BOGH does a dietitian do? Source (‘Eat to be Fit’ campaign BOGH which foods are in each pack) group 15 minutes Students identify which Why do we need to eat the foods Use Picture cards as prompts to food groups provide the from each group? What do we get remind pupils why we need this body with which nutrient from them? food group. Place around the and the basic function of BOGH poster that nutrient 5 minutes Identify reasons example Unhealthy packed lunch, why is it Use food models to give example lunch is unhealthy. unhealthy? How can it be of 2 lunches, use BOGH mat to put Which food groups foods improved? models onto correct section of the are from. Make plate.
110 suggestions on alternative foods and which food groups they Improved lunch, food models to are in. Discuss how to correct food groups. store lunch and order of consumption Info on storage If have to fill in 3-5 minutes Put food model onto Discuss healthy breakfasts with Food models of breakfast foods. time whilst correct section of mat the group and how they balance Balance of good health ma REAP staff are with the plate model still completing task Conclusion 3 minutes Children allowed to taste Bring Class together and thank Fruit tasters of different fruits such the fruits if they wish to them for time. as melon, mango, papaya Ask if they have learned anything. Children asked to identify different fruits and offered tastes.
111 Appendix 10: Lesson Plan Speyside High School
Student Numbers: 19 Subject: Standard Grade Home Economics
Lesson Aims: To improve knowledge of food groups, nutrients, their sources and functions and the relevance of these to different groups of the population.
Objectives: To be able to identify the 5 main food groups. To associate nutrients with food groups. To state the functions of nutrients. To know the sources of nutrients. To know the differing dietary requirements of specific groups of the population.
Stage of lesson Time Student Activities Tutor Activities Lesson Aids Introduction 10 mins Introductions. Discuss the role of a dietitian. Discuss the aims of today’s session. Development 1 hour Split into 2 groups. Discuss the balance of good BOGH mat and (20 mins G1 – use mat to put food models in place. health and how it is used. food models. for each Discuss nutrient content of food models. Look Discuss the nutrients. Pizza and of the at function cards and match to food groups. Work with groups and use to additions. activities) G2 – Look at basic meal i.e. cheese pizza and discuss the various nutrients. what food groups it contains and how to Move groups between the balance it further. Use function cards when food different activities. groups are decided upon. Split into 4 groups. Discuss with the groups the Each given a case study for pregnancy, requirements of the group then adolescents, elderly or vegetarians. hand out case study and menu to be altered. Keep discussion going re nutrients and their sources. Conclusion 20 mins Questions. Question time – answers. Fill out evaluation tool. Evaluation tool.
112