Organisational priorities for health care focus on efficiency as the health and care needs of populations increase. But evidence suggests that excessive planning can be counterproductive, leading to resistance from staff and patients, particularly those living with cognitive impairment. The current paper adds to this debate reporting an Institutional Ethnography of staff delivering care for older patients with cognitive impairment on acute orthopaedic wards in three National Health Service hospitals in the United Kingdom. A key problematic identified in this study is the point of disjuncture seen between the actualities of staff experience and intentions of protocols and policies. We identified three forms of disjuncture typified as: ‘disruptions’, where sequenced care was interrupted by patient events; ‘discontinuities’, where divisions in professional culture, space or time interrupted sequenced tasks; and ‘dispersions’, where displaced objects or people interrupted sequenced care flow. Arguably disruption is an integral characteristic of care work; it follows that to enable staff to flourish, organisations need to confer staff the autonomy to address systemic disruptions rather than attempt to eradicate them. Ultimately, organisational representations of ‘good practice’ as readily joined up, impose a care standard ‘stereotype’ that obscures rather than clarifies the interactional problems encountered by staff.

Within health and social care, academic attention is increasingly paid to understanding the nature and centrality of body work. Relatively little is known about how and where body work specifically fits into the wider work relations that produce it in healthcare settings. We draw on ethnographic observations of staff practice in three National Health Service acute hospital wards in the United Kingdom to make visible the micro-processes of patient care sequences including both body work and the work contextualising and supporting it. Our data, produced in 2015, show body work interactions in acute care to be critically embedded within a context of initiating, preparing, moving and restoring and proceeding. Shades of privacy and objectification of the body are present throughout these sequences. While accomplishing tasks away from the physical body, staff members must also maintain physical and cognitive work focussed on producing body work. Thus, patient care is necessarily complex, requiring much staff time and energy to deliver it. We argue that by making visible the micro-processes that hospital patient care depends on, including both body work and the work sequences supporting it, the complex physical and cognitive workload required to deliver care can be better recognised. (A virtual version of this abstract is available at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

The global shift in demographics towards aging populations is leading to a commensurate increase in age-related disease and frailty. It is essential to optimise health services to meet current needs and prepare for anticipated future demands. This paper explores issues impacting on people living with cognitive impairment and/or dementia who experience a hip fracture and are cared for in acute settings. This is important given the high mortality and morbidity associated with this population. Given the current insufficiency of clear evidence on optimum rehabilitation of this patient group, this paper explored three key themes namely: recognition of cognitive impairment, response by way of training and education of staff to optimise care for this patient group and review of the importance of outcomes measures. Whilst there is currently insufficient evidence to draw conclusions about the optimal ways of caring for patients living with dementia following hip fracture, this paper concludes that future research should improve understanding of healthcare staff education to improve the outcomes for this important group of patients.

Older people and their families consistently place high value on hospital care that promotes personalised relationships between staff and patients, often termed Person-Centred Care (PCC). PCC features in care guidelines from across Europe, North America and the Asia-Pacific region, demonstrating the value increasingly placed by policymakers on methods emphasising ‘personhood’-in care practices. However, as many secondary care settings such as acute trauma wards become highly rationalised and task driven, PCC orientations can be given less priority. This paper reports on an ethnographic study undertaken within an international research programme exploring ways of delivering care to people living with dementia and admitted to secondary care with hip fracture. Observations were undertaken by five academic and three trained ‘lay’ researchers in Emergency Departments and Trauma wards in three hospitals from across the United Kingdom, generating a data set of 192 hours of observations (48 observations, approximately 4 hours each). Fieldnotes collected from the differing spaces were thematically analysed and further analysed applying Kitwood's (1997) person centred care framework. Data illuminated staff creativity in identifying and responding to opportunities to maintain patient personhood while performing the routine care tasks prioritised within settings. Staff in acute care environments can bring an integrated awareness both of policies prioritising PCC opportunities and policies prioritising task performance, to moderate their practice in creative ways. We conclude that skilled practice responses can ensure task-orientated routines and providing PPC need not be mutually exclusive.

BACKGROUND:Health and social care provision for an ageing population is a global priority. Provision for those with dementia and hip fracture has specific and growing importance. Older people who break their hip are recognised as exceptionally vulnerable to experiencing confusion (including but not exclusively, dementia and/or delirium and/or cognitive impairment(s)) before, during or after acute admissions. Older people experiencing hip fracture and confusion risk serious complications, linked to delayed recovery and higher mortality post-operatively. Specific care pathways acknowledging the differences in patient presentation and care needs are proposed to improve clinical and process outcomes. METHODS:This protocol describes a multi-centre, feasibility, cluster-randomised, controlled trial (CRCT) to be undertaken across ten National Health Service hospital trusts in the UK. The trial will explore the feasibility of undertaking a CRCT comparing the multicomponent PERFECTED enhanced recovery intervention (PERFECT-ER), which acknowledges the differences in care needs of confused older patients experiencing hip fracture, with standard care. The trial will also have an integrated process evaluation to explore how PERFECT-ER is implemented and interacts with the local context. The study will recruit 400 hip fracture patients identified as experiencing confusion and will also recruit "suitable informants" (individuals in regular contact with participants who will complete proxy measures). We will also recruit NHS professionals for the process evaluation. This mixed methods design will produce data to inform a definitive evaluation of the intervention via a large-scale pragmatic randomised controlled trial (RCT). DISCUSSION:The trial will provide a preliminary estimate of potential efficacy of PERFECT-ER versus standard care; assess service delivery variation, inform primary and secondary outcome selection, generate estimates of recruitment and retention rates, data collection difficulties, and completeness of outcome data and provide an indication of potential economic benefits. The process evaluation will enhance knowledge of implementation delivery and receipt. TRIAL REGISTRATION:ISRCTN, 99336264 . Registered on 5 September 2016.

ABSTRACTMany older women reduce the amount of cooking and food preparation they do in later life. While cooking may be seen as traditionally associated with women's family roles, little is known about the impact of such reduced engagement with food on their lives. This paper presents the findings from a one-year qualitative study (Changes Around Food Experience, CAFE) of the impact of reduced contact with preparing and cooking meals from scratch for 40 women, aged 65–95 years, living in Norfolk, United Kingdom. Data were collected through semi-structured interviews, focus groups and observations. Women's reasons for reducing food-related activities included changes in health, loss of a partner or a caring role, and new patterns of socialising. Disengagement from cooking and shopping was not found to entail predominantly negative feelings, passive acceptance or searching for forms of support to re-enable more cooking from scratch. Accounts evidenced the dynamic adaptability of older women in actively managing changed relationships with food. In exploring new meal options, older women were not simply disengaging from their environments. CAFE findings linked women's engagement with their environments to how they were using formal services and, even more, to the value they placed on social engagement and being out and about. Through the connections they fostered with friends, family and community, older women actively enabled their continued involvement in their social, public and family spheres. Reduced contact with preparing and cooking meals from scratch, therefore, did not induce or imply passivity or debility in the CAFE cohort. By contrast, it involved their exploring new means of retaining what was important to them about food in the context of their lived situation and social connections with friends, family, the community and public spheres.

Purpose– The purpose of this paper is to underpin a scoping study commissioned by community leaders to assess the potential for creating a “health café” in the centre of Boston, in eastern England, UK, to facilitate healthier lifestyles.Design/methodology/approach– A mixed methods and framework analytic approach was adopted, using documentary, focus group, interview and survey data. The paper drew on social marketing principles to enhance the community relevance of findings.Findings– Community stakeholders and public were generally supportive of a “health café” facility in the town centre. Accessibility and a welcoming environment were seen as key factors. A wide range of health-related services in addition to providing healthy foods were proposed. Key issues identified were: a wider role of the facility as a community “health hub”; appropriate marketing approaches; food provision issues and sustainability. All groups contacted saw the word “health” as off-putting.Research limitations/implications– As with many commissioned scoping studies, the timetable for delivery was very short, just three months, significantly influencing the choices of methodological approaches taken up. This made it important to provide a multi-disciplinary multi-methods design to enhance triangulation and a research team with extensive community research experience including previous research in this region. It was also important to specify and locate any knowledge claims from the findings.Practical implications– The research helped engage community stakeholders to tap a diversity of views which could be adopted by community leaders into their ongoing health strategies and development plans for a “health hub” for Boston.Originality/value– The paper provides important information for those embarking on community health education projects and particularly in how to tailor health research methods to real-world timescales and stakeholder perspectives. Insights are also provided into community attitudes, understandings and behaviours towards healthy living in a part of the UK with a well-documented history of poor health.

BACKGROUND:There is recognition of the importance of measuring patients' experiences, expectations and satisfaction.OBJECTIVES:To assess the literature on the concept and measurement of patients' expectations for health care, and to develop and test a measure of patients' expectations, using adult patients in community, general practice and hospital outpatient departments in Greater London, Norwich and Essex, UK.DATA SOURCES:Major electronic databases including the British Nursing Index, EMBASE, MEDLINE, PsycINFO and the Applied Social Sciences Index and Abstracts were searched between 2000 and 2009.REVIEW METHODS:Narrative review, semi-structured exploratory study and surveys of GP patients and hospital outpatients immediately before and after their surgery/clinic visit to measure their pre-visit expectations for their health care and their post-visit experiences (expectations met and satisfaction with visit) (site specific).RESULTS:A total of 20,439 titles and 266 abstracts were identified, of which 211 were included in the review. Most research designs were weak, with small or selected samples, and a theoretical frame of reference was rarely stated. The origin of questions about expectations was often absent, questions were frequently untested and those with reported reliability or validity data had generally mixed results. In the survey data the expectations measures met acceptability criteria for reliability; all exceeded the threshold of α = 0.70, in each mode of administration and sample type. Items and subscales also correlated at least moderately with those variables that they were expected to be associated with, supporting their validity. The item means within subscales were generally similar between samples and all-item-total correlations exceeded the acceptability threshold. Descriptive findings revealed that most patients ideally expected cleanliness, information about where to go, convenient and punctual appointments and helpful reception staff, the doctor to be knowledgeable, clear and easy to understand, to be involved in treatment decisions and to experience a reduction in symptoms/problems. Expectations least likely to be met included being seen on time and choice of hospital/doctor (items requested by the ethics committee). Other items that had low met expectations included helpfulness of reception staff, doctor being respectful and treating with dignity (hospital sample), doctor knowledgeable (hospital), being given reassurance, receiving advice about health/condition, information about cause and management of condition and information about benefits/side effects of treatment, being given an opportunity to discuss problems, and the three items on outcome expectancies. Previous consultations/experiences of health services and health-care staff/professionals most commonly influenced expectations. Overall, pre-visit realistic expectations were lower than patients' ideals or hopes. Most post-visit experiences indicated some unmet expectations (e.g. cause and management of health/condition, benefits/side effects of treatments) and some expectations that were exceeded. Generally, GP patients reported higher pre-visit expectations and post-visit met expectations. Correlations between subscale domains were strongest between the structure and process of health care, doctor-patient communication style and doctor's approach to giving information, all common indicators of the quality of health care, supporting the validity of the measures. The post-visit experiences subscale significantly predicted single-item summary ratings of overall met expectations and satisfaction. GP rather than hospital patients were also independently predictive of expectations met. Other predictors were having no/little anxiety/depression, older age (satisfaction) and fewer effects of health on quality of life (met expectations).LIMITATIONS:The surveys in clinics were based on convenience, not random sampling methods.CONCLUSIONS:These findings have implications for establishing the quality of health services and informing their improvement. Awareness of the patient's met and unmet expectations should enable staff to understand the patient's perspective and improve communication. This study examined the perspective of the patient only; it is not possible to examine the extent to which any expectations might have been unrealistically too high or too low. This is a challenge for future research.FUNDING:The National Institute for Health Research Health Technology Assessment programme and the National Co-ordinating Centre for Research Methodology (NCCRM).

OBJECTIVE:To use semi-structured interviews to ascertain patterns in patients' expectations of health care and the extent to which these expectations were met or not.BACKGROUND:In health policy it is important to evaluate health services from varying perspectives including consumers'. One concept of emerging importance in this regard is that of patient expectations. Whether expectations are met or not have been found to be related to general patient satisfaction with treatment and treatment compliance. However, there is conceptual and methodological uncertainty and little informing empirical work regarding what is an 'expectation' and how it should be measured.DESIGN:A qualitative study using semi-structured interviews to elicit 20 GP patients' expectations prior to their consultation. A post consultation interview gauged the extent to which these expectations had been met. SETTING AND PARTICIPANT: Twenty patients of a GP practice in Norfolk (UK).RESULTS:Results suggest several different expectations, concerned with the doctor-patient interaction, the specific processes of the consultation, outcomes, and issues to do with time and space.CONCLUSIONS:This research has used an innovative exploratory approach to address the expectations of GP patients and has implications for how doctors ought to manage their consultations. These results will be used to inform the development of a quantitative expectations questionnaire so as to develop a validated measure of expectations. Such an instrument has great potential to aid in health care research and practice.

Objective The aim of the study was to test the abilities of the newly created smart card system to track the nutrient contents of foods chosen over several months by individual diners in a school cafeteria.Methods From the food choice and composition of food data sets, an Access database was created encompassing 30 diners (aged 8-11 years), 78 days and eight nutrients. Data were available for a total of 1909 meals.Results Based upon population mean values the cohort were clearly choosing meals containing higher than the recommended maximum amounts for sugar and lower than the recommended minimum amounts of fibre, iron and vitamin A. Protein and vitamin C contents of meals chosen were well above minimum requirements. Over the 1909 meals, nutrient requirements were met 41% of the time.Conclusions The system created was very effective at continually monitoring food choices of individual diners over limitless time. The data generated raised questions on the common practice of presenting nutrient intakes as population mean values calculated over a few days. The impact of heavily fortified foods on such studies in general is discussed.

Objective The aim of the study was to test the feasibility of using smart card technology to track the eating behaviours of nearly a thousand children in a school cafeteria.Methods Within a large boys' school a smart card based system was developed that was capable of providing a full electronic audit of all the individual transactions that occurred within the cafeteria. This dataset was interfaced to an electronic version of the McCance and Widdowson composition of foods dataset. The accuracy of the smart card generated data and the influence of portion size and wastage were determined empirically during two 5-day trials.Results The smart card system created succeeded in generating precise data on the food choices made by hundreds of children over an indefinite time period. The data was expanded to include a full nutrient analysis of all the foods chosen. The accuracy of this information was only constrained by the limitations facing all food composition research, e.g. variations in recipes, portion sizes, cooking practices, etc. Although technically possible to introduce wastage correction factors into the software, thereby providing information upon foods consumed, this was not seen as universally practical.Conclusion The study demonstrated the power of smart card technology for monitoring food/nutrient choice over limitless time in environments such as school cafeterias. The strengths, limitations and applications of such technology are discussed.

Purpose“Male” and “low‐income” are both risk factors for eating a nutritionally sub‐standard diet. The aim of the study was to explore the attitudes and experiences of typical low‐income males towards food and health. Information would build upon that previously obtained from a matched group of women, providing the opportunity to explore possible gender issues.Design/methodology/approachA qualitative approach was used to meet the study aims. Face‐to‐face, in‐depth interviews were conducted in 2001 with eleven middle‐aged men who were typical of a substantial low‐income sub‐group. Interviews focussed upon the issues of cancer prevention and fruits and vegetables. Transcripts were analysed using an established interpretative phenomenological approach.FindingsPrevious life‐experiences and control beliefs concerning personal health were key themes influencing dietary attitudes and behaviours. Lack of food/health information and access to healthy foods were not significant factors. Although money was limiting, this in itself, did not prevent the men from eating appropriately. Core findings were similar (with certain exceptions) to those reported previously for a comparable group of women.Research limitations/implicationsFurther studies are needed to test the transferability of these findings to low‐income men of different age, region and ethnicity, as well as to more affluent men.Practical implicationsGreater emphasis on sociological frameworks is needed in both the setting of public health nutrition policies and in how food and nutrition is taught in schools. The potential dangers of stigmatising “the poor” as consumers of “bad” diets should be considered.Originality/valueSimplistic statistical correlations do not adequately explain the complex causes of unhealthy diets and a greater emphasis upon social and cultural dynamics is required.

OBJECTIVE:The consumption patterns of beverages and desserts features highly in the current debate surrounding children's nutrition. The aim of this study was to continuously monitor the choice of beverages and desserts made by nearly 1000 children in a school cafeteria.METHODS:A newly developed smart card system was used to monitor the food choices of diners (7-16-year-old boys) in a school cafeteria over 89 days. A wide variety of beverages and desserts were on offer daily.RESULTS:Despite coming from an affluent, well-educated demographic group, the boys' choices of beverages and desserts mirrored those of children in general. Buns and cookies were over 10 times more popular than fresh fruits and yogurts. Sugary soft-drinks were over 20 times more popular than fresh fruit drinks and milk combined. Appropriate choices could, over a month, reduce intake of added sugar by over 800 g and fat by over 200 g.CONCLUSION:The smart card system was very effective at monitoring total product choices for nearly 1000 diners. In agreement with a recent national school meal survey, where choice is extensive, children show a preference for products high in fat and/or sugar. The consequences of these preferences are discussed.

A current popular theme in medicine concerns whether and how patients should be involved in treatment choice. Assuming patient involvement is desirable, how should one go about eliciting preferences? A variety of quantitative and qualitative methods exist that may be used for this purpose, one of which is the repertory grid method. This method involves eliciting constructs (reasons) for preferences through comparing sets of three options. This method allows the structured elicitation of the reasons behind individual preferences, but also, when used with generalised procrustes analysis (GPA), allows aggregation of individual data to reveal general preference patterns. In this study the repertory grid method was used to examine patient preferences for angina treatments with the goal of, first, gaining some understanding of general patterns of patient preference, and second, examining the likely utility of the technique in this setting. A sample of 21 patients with mild and stable angina from two general practices in Norfolk, UK was interviewed using the repertory grid method to elicit the constructs underlying their preferences amongst seven angina treatments (including 'no treatment'). Individualised questionnaires were then produced and sent to the patients for self-completion, which required rating the extent to which each construct was relevant for each treatment (scored on visual analogue rating scales). Analysis of the ratings, using GPA, showed that the constructs clustered around two dimensions: 'some treatment' versus 'no treatment', and drug treatment versus surgical treatment. While some treatment was generally preferred to no treatment, individuals varied in preference for drug treatments or surgical treatments. Although the latter were generally perceived as 'effective' they were also perceived, for example, as 'invasive', 'frightening', related to 'negative experiences', and being more appropriate for when symptoms are severe ('proportionate'). We consider the implications of these results for involving patients in choosing amongst treatments.

Science & Society1 October 2004free access The risks of eating and drinking Consumer perceptions and ‘reality’ Susan B T Wilkinson Corresponding Author Susan B T Wilkinson Institute of Food Research in Norwich, Norfolk, UK Search for more papers by this author Gene Rowe Gene Rowe Institute of Food Research in Norwich, Norfolk, UK Search for more papers by this author Nigel Lambert Nigel Lambert Institute of Food Research in Norwich, Norfolk, UK Search for more papers by this author Susan B T Wilkinson Corresponding Author Susan B T Wilkinson Institute of Food Research in Norwich, Norfolk, UK Search for more papers by this author Gene Rowe Gene Rowe Institute of Food Research in Norwich, Norfolk, UK Search for more papers by this author Nigel Lambert Nigel Lambert Institute of Food Research in Norwich, Norfolk, UK Search for more papers by this author Author Information Susan B T Wilkinson 1, Gene Rowe1 and Nigel Lambert1 1Institute of Food Research in Norwich, Norfolk, UK *Corresponding author. E-mail: [email protected] EMBO Reports (2004)5:S27-S31https://doi.org/10.1038/sj.embor.7400225 PDFDownload PDF of article text and main figures. ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinked InMendeleyWechatReddit Figures & Info Life is full of risk—everyday we encounter all sorts of hazards, some of which are unavoidable. Eating and drinking are paramount to maintaining life, but unfortunately, are also coupled with a multitude of potential and sometimes fatal health risks. These risks are not to be taken lightly, which is highlighted by the current increase in obesity and related diseases in the developed world, a trend that has the World Health Organization worrying about a growing epidemic of obesity (WHO/FAO, 2003). Similarly, public health officials are increasingly concerned about a dramatic increase in diabetes and coronary heart diseases that are caused by an inappropriate and ultimately hazardous diet. But food holds many more health risks, and recognizing these would greatly benefit human health. …obesity has become a leading cause of death in the USA, second only to smoking The extent to which consumers identify and appreciate food-related risks, and allow this knowledge to direct their eating and drinking behaviour, is therefore of great research interest. In this article, we first detail the most significant sources of food and drink health risks and discuss the implications of consumers’ perceptions of these hazards. This discussion touches on generic research on how people perceive risks and considers the reasons behind apparent ‘misperceptions’ of risks. We also want to emphasize that, in the face of limited scientific knowledge, consumer concerns may be well grounded, and that scientists and policy makers would do well to consider the basis for consumer beliefs in order to preempt future food- and drink-related health and policy crises. A comprehensive list of all hazards associated with eating and drinking would clearly be beyond the scope of this article. Furthermore, the nature and degree of the different food and drink hazards is often specific for both time and culture. For instance, the lack of clean drinking water without microbial contamination is no longer a serious public health problem in the UK. But it was a problem as recently as 150 years ago and it continues to be so today for large parts of the developing world. We therefore concentrate on the most prevalent hazards in today's food supply, focusing on UK examples, although they are liable to be pertinent to other developed countries too. According to the UK Food Standards Agency (2000), most cases of microbial food contamination are caused by five types of bacteria: Salmonella, Campylobacter, Escherichia coli O157, Listeria monocytogenes and Clostridium perfringens. There were at least 81,000 cases of microbial food poisoning in the UK in 2000, with Campylobacter and Salmonella responsible for 63,000 and 17,000 cases, respectively. Symptoms usually develop within 12–36 hours and commonly include abdominal pain, diarrhoea, fever and vomiting. Microbial contamination typically causes 100–200 fatalities per year, mostly in young children and the elderly. However, the real number of food-borne illnesses may be higher as many cases go unnoticed and/or unreported. One of the most serious food contaminations is the infection of cattle with bovine spongiform encephalopathy (BSE) and the resulting risks of developing variant Creutzfeldt–Jakob disease (vCJD), a fatal human illness with no known cure that has caused more than 100 deaths in the UK so far. Recent examples of chemical contaminations of food include high amounts of mercury in fish and elevated levels of the known carcinogen acrylamide, introduced through the cooking process into some popular foods such as chips and crisps. Similarly, barbecuing certain foods creates carcinogenic dioxins and nitroso-compounds. Finally, the contamination of foods with physical objects, such as glass, metal, wood, insects and other objects, remains a major concern especially for food processors and packagers. Many foods contain colourants, flavourings, preservatives and antioxidants, some of which have been associated with adverse health consequences. The common sweetener aspartame has been linked to such conditions as brain tumours, multiple sclerosis, Parkinson's disease, Alzheimer's disease, arthritis and attention deficit disorder (Chivers, 2000). The preservative sulphite can cause asthmas and urticaria (Allergy Clinic, 2003). Another preservative, butylated hydroxytoluene (BHT), although not toxic itself, may interact with other substances to increase cancer risk (Magnuson, 1997). …barbecuing certain foods creates carcinogenic dioxins and nitroso-compounds A food allergy is an immune response to a food that the body mistakenly believes to be harmful. Symptoms are usually quick to develop and can range from mild itching and rashes to more severe swelling of the mouth and throat through to anaphylaxis, circulatory collapse and death within a few minutes. In theory, any food can cause an allergy, but in the UK 90% of all allergic reactions are due to milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat. Although relatively uncommon, the incidence of food allergies is increasing; hospital admissions due to anaphylaxis have increased sevenfold over the past decade and food allergy is one of the most common causes. At present, there is no cure for food allergies other than avoidance. Food intolerances are due to enzyme deficiencies and other mechanisms that mimic allergic reactions. These reactions are rarely life-threatening. Intolerances to wheat (gluten intolerance or coeliac disease) and milk (intolerances to lactose or milk proteins) are the most common in the UK. In Asia and Africa, most adults are lactose intolerant. Sufferers of various conditions also need to avoid specific foods. For example, individuals with diabetes must closely regulate their glucose intake to avoid hypo- and hyperglycaemia, which can have both severe acute and chronic adverse effects. Sufferers of the genetic disorder phenylketonuria must avoid phenylalanine in their food, and individuals with coronary heart disease (CHD) are strongly advised to limit their cholesterol intake to reduce the risk of heart attacks. Public health policies linked to food are increasingly focusing on the hazards from eating a nutritionally substandard diet (Department of Health, 2000). Current ‘Western diets’ with their relatively high amounts of fat, sugar and salt and low amounts of fruits and vegetables, are risk factors for the development of numerous cancers and heart diseases; as many as 1 in 3 of all cancers may be diet-related. Furthermore, such diets have contributed to the astonishing threefold rise in obesity over the past 20 years. At present, nearly half of the UK population is either overweight or obese, which is a major risk factor for both CHD and diabetes. In March this year, Secretary Tommy G. Thompson of the US Department of Health and Human Services warned that obesity has become a leading cause of death in the USA, second only to smoking (The New York Times, 2004). This situation is chronic in that it is the continual consumption of an inappropriate diet over decades that leads to these health hazards. There are further risks, perhaps of less immediate severity, associated with consuming such a diet; for example, an increased level of tooth decay. This list is by no means comprehensive; it does not include risks from drinking alcoholic beverages for instance. Indeed, any ingested substance, even water, is potentially harmful if consumed in large enough quantities. Furthermore, there are about 16,000 cases of choking per year in the UK that are serious enough for a hospital visit. These most commonly involve children (under four years of age) and the elderly, and are caused mostly by food. Nevertheless, what the list does reveal is how diverse the potential risks from eating and drinking are, with consequences varying from the mild (nausea) to the extreme (death from anaphylactic shock), and manifested either immediately (for example choking on a fish bone), or delayed from a day or two (vomiting after microbial food poisoning) to years or even decades (CHD from the continual consumption of an inappropriate diet). One important source of variance is the extent to which people themselves can control their level of exposure. It is probably fair to say that at this moment in history, the food and drink in the developed world is as safe as it has ever been, due to improved food production practices and public hygiene standards. However, in some cases, inappropriate behaviour continues to put consumers at significant risk from a variety of the hazards indicated. To improve consumer health and reduce food and drink risks, it is therefore important to understand consumers, particularly why they act as they do. While some food-related behaviours are simply habitual, and others are driven by a lack of knowledge, such as inappropriate storage and cooking of foods, the way people perceive and judge the risks of specific hazards may lead them to behave seemingly perversely in some situations. Many people voluntarily engage in hazards with considerable levels of risk, while they may go to great lengths to avoid hazards that pose only little risk. Still, many people choose to smoke, knowing that smoking causes cancer, and others indulge in high-risk sports knowing the danger of breaking bones. The UK has seen a substantial decline in parents inoculating their children with the combined MMR (measles, mumps, rubella) vaccine for fear of inducing autism in spite of evidence to the contrary, and thereby increasing the risk of a serious national measles epidemic (Murch, 2003). Evidence suggests that in some cases consumer responses to food and drink hazards are similarly ‘illogical’—although perhaps not to the extent they at first seem. …any ingested substance, even water, is potentially harmful if consumed in large enough quantities Of the list of potential hazards discussed in the previous section, only a relative few have been studied from a consumer perspective. This choice perhaps reflects contemporary concerns, rather than any attempt to measure and compare different risks and hazards systematically. Nevertheless, these studies show that consumers’ behaviour and attitudes towards these hazards indicate a different ranking of risks in their minds. If we take contaminants as an example, consumers can be highly sensitive to information about relatively minor incidences of physical contamination in foods—such as epoxidized soya bean oil, used to seal jars of baby food, that was found to seep into the product (BBC, 1999)—and consequently avoid the relevant products. However, it is likely that a high proportion of these same people do not wash their hands after going to the lavatory—in spite of having some knowledge of the risks involved in this activity—thereby increasing the chance of microbiological food contamination. Although determining an exact figure is difficult, it is estimated that 17% of women and 31% of men do not regularly wash their hands after using the toilet (Food Standards Agency, 2000). Similar cases of apparent overreaction have been found regarding food allergies. Some sources have suggested that as many as 20%–30% of adults in the UK believe they have a food allergy or intolerance, but official figures are 1%–2%. Likewise, some parents readily attribute hyperactivity in their children to various additives in confectionery, despite only tenuous evidence for such a link (Food Commission, 2002). Conversely, cases of ‘under-reaction’—that is, under-consumption of the recommended daily intake of fruit and vegetables—are apparent in inappropriate nutrition, which occurs in spite of people knowing, at least at a qualitative level, what a ‘healthy’ diet is. In other cases, such as with choking and food intolerance, there is only limited information about consumer perceptions. One interesting example of apparent misperception concerns an issue that does not even appear in our list of food hazards, namely, genetically modified (GM) foods. European consumers remain deeply concerned about GM foods, as shown time and again by various surveys (Shaw, 2002). This is despite an absence of scientific evidence that anyone has or will be adversely affected (GM Science Review, 2004). Other research has taken a comparative approach, looking at relative perceptions of a variety of food hazards, which also reveals instances of apparent perceptual discrepancies. For example, Fife-Schaw & Rowe (1996) found that people were more concerned about botulism than about saturated fats and cholesterol, in spite of the risks of the latter being greater. Kirk et al (2002) found a similar pattern, with saturated fats being the least dreaded hazard and Salmonella among the most dreaded. These studies show that consumers’ perceptions of risk do not necessarily correspond with scientific assessments. Consequently, the risk communication field has traditionally assumed that consumers are ignorant, in some cases hysterical, and for the most part misinterpret statistical likelihood. From this perspective, the so-called ‘deficit model’, the appropriate presentation of ‘the truth’ is all that is needed to dispel ‘faulty’ beliefs and induce ‘correct’ behaviour (Hansen et al, 2003). However, reality is more complex than this: although in some cases apparent misperceptions appear to be related to cognitive limitations, in other cases consumers’ beliefs seem to be based on alternative, sensibly informed frameworks. Certainly, past encounters with food scares have left consumers with an understandable level of caution… People frequently use a number of quick decision-making rules when dealing with uncertain situations. In many cases these so-called heuristics, or ‘rules of thumb’, allow people to function successfully in everyday life by making the most efficient use of limited cognitive abilities and time, and their inability to cope with vast amounts of information. Cognitive research suggests five situations in which people may be prone to using such rules: when they are overloaded with information; when they do not have enough time; when the issues are not overly important to them; when they have little knowledge or information on the topic; and when a specific shortcut comes to mind easily (Pratkanis & Aronson, 1992). Tversky & Kahneman (1974) identified several of these heuristics including availability, representativeness, and anchoring and adjustment. If we take the availability heuristic as an example, this leads people to judge the likelihood of an event based on how easily they can recall similar past cases. Often this is a good rule to use. However, recall can be influenced by many factors, one of which is how vivid is an event. Images of personal suffering from vCJD are highly dramatic, perhaps more so than images of people suffering from heart disease as a possible consequence of poor diet. Consequently, using the availability heuristic alone may lead people to overestimate some risks and underestimate others. Optimistic bias is another phenomenon associated with apparent misperception of risks (Weinstein, 1980). Research has found that people tend to believe that they are less likely to experience negative events and more likely to experience positive events when compared with other people. For example, people may believe themselves less at risk from the effects of a diet rich with high-fat foods than similar others, therefore reducing the need to change their behaviour. The underlying causes of this are still in dispute, and range from the cognitive to the motivational or some combination of the two (Miles & Scaife, 2003). consumers can be highly sensitive to information about relatively minor incidences of physical contamination in foods Although human cognitive limitations may at times lead to faulty judgments about risk, at other times—or perhaps even simultaneously—differences between consumer estimations and expert-derived statistics may be a consequence of alternative framings of, or emphasis on, the issue. In essence, consumers do not understand ‘risk’ in the same way as do scientists. This discovery of Paul Slovic and colleagues has been replicated in different ways by other researchers and demonstrates that, when judging risk, consumers take into account other qualitative aspects beyond the likelihood of ensuing harm. For example, Slovic et al (1980) reported that two dimensions were important when laypeople judge risks: the first aspect being the extent to which a hazard is ‘dreaded’ (severe, likely, uncontrollable, involuntary, catastrophic) and the second being how ‘known’ the hazard is (known to science, new, has delayed effects). Sparks & Shepherd (1994), using a similar methodology to consider food hazards, found three perceptual dimensions that they termed ‘severity’, ‘unknown’ and ‘number of people exposed’, which subsequent research has largely replicated (Fife-Schaw & Rowe, 1996). In real terms, this means that consumers are frequently interpreting risk in a non-statistical manner, which is arguably quite sensible in incorporating uncertainty. Taking GM foods as an example, while it may be true that scientific evidence suggests that the actual risk is minimal, consumers may be considering the novelty of the technology and hence assume that there may well be risks that have not yet been identified. When there are familiar and relatively risk-free alternatives to GM foods available, who is to say that consumer avoidance of GM foods is illogical? Certainly, past encounters with food scares have left consumers with an understandable level of caution; for example, when UK authorities maintained in the early days of the BSE crisis that eating beef was safe, which then turned out to be otherwise. This example highlights the important role of risk communicators as sources of information, and indicates how consumer perceptions can mediate reactions to their messages. Public reactions to risk communications are frequently determined by factors other than just information, such as the credibility and trustworthiness of the information source. Indeed, trust in industry and government can be such an important factor in risk perception in some cases that it may supersede the inherent characteristics of the specific hazard (Senauer, 1992). Clearly, trust has a crucial influence on risk perception, although the exact relationship between trust, perceived risk and hazard acceptability is less clear (Eiser et al, 2002). Its relevance to the food domain was shown in a large US study, which found that trust in the regulation of pesticides was positively correlated with the perceived benefits of such products (Dittus et al, 1993). Bord & O'Connor (1992) reported similar results with food irradiation. Unfortunately, the main communicators of food hazard information are not particularly well trusted: in general, medical sources are the most trusted and government and industry the least. However, consumers frequently expect food hazard information to come from government sources (Frewer et al, 2001), and also expect the government to make risk decisions on their behalf when needed (Earle & Cvetkovich, 1995). But if these sources are not trusted, this creates both a communication and policy dilemma. Lack of consumer trust thus has important implications for the communication of food hazard information and subsequent health policy. European consumers remain deeply concerned about GM foods… despite an absence of scientific evidence that anyone has or will be adversely affected In summary, while consumers are faced with numerous different food hazards, their perceptions of the risks associated with them do not always correspond to scientific risk estimates, although the levels of risk associated with many of these hazards are scientifically uncertain. Past risk communication strategies assumed that these differences were essentially a consequence of consumer ignorance of ‘the facts’ and that presentation of ‘the truth’ would cure misjudgements. However, although cognitive limitations occasionally do hamper consumer judgements of risks, at other times, consumers’ judgements are often understandable and consider many other qualitative factors than are accounted for in a standard risk assessment. It is therefore important for scientists, communicators and policy makers to consider the basis of these qualitative consumer beliefs, both to preempt future food-related health and policy crises and to communicate more effectively before, during and after such events. Acknowledgements The authors would like to acknowledge funding from the Core Strategic Grant of the UK Biotechnology and Biological Sciences Research Council. Biographies Susan B T Wilkinson, Gene Rowe and Nigel Lambert are at the Institute of Food Research in Norwich, Norfolk, UK. Gene Rowe Nigel Lambert References Allergy Clinic (2004) Food allergy and additive intolerance. http://www.allergy-clinic.co.uk/food_allergy_for_doctors.htmGoogle Scholar Bord RJ, O'Connor RE (1992) Determinants of risk perceptions of a hazardous waste site. 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Objective To elicit patients' preferences for the treatment of angina.Design Angina patients were interviewed in order to elicit their personal reasons underlying preferences for various treatment options. Interviews followed a general repertory grid technique, in which seven treatment options were presented to patients in triads. Treatments considered ranged from medication to invasive revascularization therapies, with a 'no treatment' option.Setting Two general practices in Norwich, Norfolk.Subjects Twenty-one patients with diagnosed angina, which was both mild and stable.Main outcome measures Treatment preferences verbalized by patients during interview, and the underlying reasons for these.Results Attitudes voiced towards the range of treatments for angina were diverse; 27 different reasons underlying patients' preferences were identified. Patients' preferences were largely justified by reasons associated with the conditional effectiveness or otherwise of treatments. When presented with treatment triads, medication (drug) treatments were over 2.5 times more likely to be chosen as a most preferred option than invasive or surgical treatments. Although surgical treatments were generally considered to be 'effective', it was perceived that they were more appropriate for situations when the condition became life-threatening. There were occasions, however, when preferences were driven by other reasons, such as a desire to avoid surgery because it was perceived negatively as 'invasive' and 'frightening'. Drug treatments were viewed as 'quick', 'easy' and reversible. Personal experiences of the effectiveness or otherwise of treatments were frequently cited as reasons for stated preferences. However, patients often commented that they would prefer the doctor to make the decision about their treatment.Conclusions Patients choices among treatments was largely driven by perceptions of their effectiveness or otherwise. Although surgery was perceived as 'effective' it was also seen as conditionally so, dependent upon severity of the condition - which is not necessarily the case, as the risks of adverse events and surgical complications increase for emergency cases. As such, access to better information about the effectiveness and timeliness of interventions is needed. Although respondents held anxieties about treatment, particularly invasive or surgical treatments, fewer choices were driven by emotional and lifestyle factors unrelated to 'effectiveness', such as fear or ease of treatment.

Life is full of risk—everyday we encounter all sorts of hazards, some of which are unavoidable. Eating and drinking are paramount to maintaining life, but unfortunately, are also coupled with a multitude of potential and sometimes fatal health risks. These risks are not to be taken lightly, which is highlighted by the current increase in obesity and related diseases in the developed world, a trend that has the World Health Organization worrying about a growing epidemic of obesity (WHO/FAO, 2003). Similarly, public health officials are increasingly concerned about a dramatic increase in diabetes and coronary heart diseases that are caused by an inappropriate and ultimately hazardous diet. But food holds many more health risks, and recognizing these would greatly benefit human health.

In the past, it has been assumed that consumers would accept novel foods if there is a concrete and tangible consumer benefit associated with them, which implies that functional foods would quickly be accepted. However, there is evidence that individuals are likely to differ in the extent to which they are likely to buy products with particular functional properties. Various cross‐cultural and demographic differences in acceptance found in the literature are reviewed, as well as barriers to dietary change. In conclusion, it is argued that understanding consumers’ risk perceptions and concerns associated with processing technologies, emerging scientific innovations and their own health status may enable the development of information strategies that are relevant to wider groups of individuals in the population, and deliver real health benefits to people at risk of, or suffering from, major degenerative illnesses.

Encouraging the UK public to quit smoking has been a public health feature for over a century to a greater or lesser degree. Persuading people to consume five or more portions of fruits and vegetables is a far newer health policy, with a history of only some ten years. The article compares the established anti‐smoking campaign with that of the fledgling “five‐a‐day” campaign to discover what, if anything, the latter can learn from the former, and what the future prospects may be for improving food choice. The two campaigns are compared in terms of the quality of health message and the environmental pressures adopted to facilitate the desired health behaviour. Motivation issues and the need to engage the public more were also seen as key campaign factors.