538140 research-article2014
RSH0010.1177/1757913914538140PolicyPolicy
Policy
Policy: supporting parents to ensure a good start The first policy objective of the Marmot Review1 Fair Society, Healthy Lives is to ‘give every child the best start in life’. Young children are heavily reliant upon their parents to ensure that they are set up for life with the emotional, cognitive and physical skills they need to thrive. Ensuring high-quality parenting is key to fulfilling this policy objective, and the mental wellbeing of parents is a vital determinant of the parenting a child receives. Dodge et al.2 conceptualise mental wellbeing as ‘the balance between an individual’s resource pool and the challenges faced’. Some of the resources that may be important to ensuring wellbeing are self-efficacy, dispositional optimism, selfesteem, goal pursuit, hope and resiliency.3,4 The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) was developed specifically to capture a broad range of mental wellbeing components from a UK cultural perspective and includes positive affect (defined in terms of optimism, cheerfulness and relaxation), psychological functioning (including energy, clear thinking, self-acceptance, personal development, autonomy and competence) as well as satisfying interpersonal relationships.5 To achieve mental wellbeing, an individual must not only have these resources, but be able to deploy them successfully when needed.6 The UK Government’s recent mental health strategy7 sets good mental wellbeing for all as a key policy objective and highlights its role in protecting against mental illness. Mental wellbeing, however, is not just of importance to individuals in isolation, it is important for society collectively, not least because of the potential impact it has on the way we parent the next generation.
The importance of good parenting Children develop secure attachments when their needs are met by caregivers, and this is vital to good child development.8 Parenting styles theory posits four general parenting styles: authoritarian, authoritative, permissive and neglectful/disengaged, based on the levels of warmth, conflict and control (discipline) present.9,10 High warmth, low hostility and consistent discipline are associated with authoritative parenting, which is also closely linked to ‘positive parenting’. The latter focuses on parents using positive methods, including praise to encourage good behaviour, being sensitive to a child’s emotional needs and setting clear boundaries.11 Evidence suggests that authoritative/positive parenting is important for overall child health12 as well as preventing child conduct disorders.13 Abusive or neglectful parenting adversely affects child brain development,14 and epigenetic research has highlighted how early social environment can affect gene expression across the life course.15 Overall, an extensive literature of research suggests that ‘parental warmth consistently predicts favourable developmental outcomes for children, whereas parental hostility consistently predicts unfavourable developmental outcomes’.16 If receiving positive parenting is a key determinant of child outcomes, it is important to understand what influences the types of parenting that a child receives. Belsky’s17 process model posits three main determinants of parenting, of which the first is closely linked to mental wellbeing: 1. Parental ontogenic origins and personal psychological resources 2. The child’s characteristics of individuality 3. Contextual sources of stress and support
Linking mental wellbeing with parenting There is a large body of literature highlighting the links between maternal depression and parenting behaviour. A metaanalysis by Lovejoy et al.18 found that a moderate effect size was present linking depression and negative parenting behaviours, and a negative correlation between depression and positive parenting behaviours (positive play, praise, affectionate contact), strongly mediated by socio-economic status – advantaged mothers with depression were significantly more likely than disadvantaged mothers with depression to maintain high levels of positive parenting behaviours. Interestingly, depression was found to impact parenting due to disturbances in affect (or emotion), and as affect is a key component of mental wellbeing, it highlights one link between depression and overall wellbeing. Lovejoy et al.18 followed their meta-analysis on depression and parenting behaviour with a meta-analysis looking at the impact of positive maternal affect and parenting behaviour.19 Despite a wide range of methods included in the meta-analysis and positive affect defined in a range of ways, an overall effect size of 0.2 was found for positive affect and positive parenting behaviours, providing good evidence for a positive correlation between positive affect (and potentially the broader concept of mental wellbeing) and positive parenting behaviours. Belsky and Barends20 highlight that to parent well: One needs to be able to decenter from self, consider the world from the child’s perspective, regulate one’s emotions, especially negative affect, and thus be tolerant and patient with children rather than impulsive and excessively controlling or neglectful and detached.
182 Perspectives in Public Health l July 2014 Vol 134 No 4
Policy
This suggests a level of psychological maturity, which some researchers have sought to investigate as an element of mental wellbeing. Drawing on work by Loevigner,21 psychological maturity has been conceptualised as a spectrum based on ego development. The ego is seen as ‘a holistic construct representing the fundamental structural unity of personality organization’,22 and it is theorised to develop across the lifespan from lesser to greater psychological maturity. Levine et al.23 found that non-adolescent mothers scored significantly higher on the ego development scale than adolescent mothers, and that higher ego development was significantly positively correlated with maternal positive affect and time spent in mutual gaze between mother and child, an indicator of warm parenting. Bringing together work on ego with psychological resources, Van Bakel and Riksen-Walraven24 assessed how egoresiliency, defined as ‘a general capacity for flexible and resourceful adaptation to external and internal stressors’, is linked to parenting behaviour. Parenting behaviour was scored for provision of emotional support, non-intrusiveness, limit setting, quality of instructions and hostility. These scores were converted to a composite measure assessing quality of parental interactive behaviour. Greater ego-resiliency was associated with more positive interactive behaviour. Other psychological resources have also been investigated in relation to parenting behaviour. For example, one group of researchers used self-report measures to represent self-esteem, hostility, emotional unresponsiveness and emotional instability, indicating that positive parenting is associated with higher levels of psychological functioning.25 Russell used self-report measures of parent personality, including questions relating to self-esteem and self-concept, to assess its relationship with positive parenting.26 A positive correlation was found between positive parental personality and positive parenting in mothers. It is notable that there has not been a study undertaken that specifically looks at mental wellbeing, using a well validated scale, and parenting behaviours. In order to address this gap, I have recently undertaken a master’s dissertation looking specifically at the issue of mental wellbeing (assessed using WEMWBS) and (self-reported) parenting behaviour. The study of mothers with children aged 0–4 years found that maternal mental wellbeing was significantly positively correlated with warm parenting behaviour and negatively correlated with hostile parenting behaviour (full dissertation available on request). This supports the literature cited above, adding further strength to the argument that increasing mental wellbeing is not just for this generation, but the next.
Next Steps The five ways to wellbeing, connect, be active, take notice, keep giving and learn, suggest practical ways of increasing wellbeing, highlighting that better wellbeing is within the reach of all. Increasing parental wellbeing in order to support positive parenting should be considered as a key means of improving the health and wellbeing of the next generation. Caitlyn Donaldson Policy and Research Manager, RSPH
References 1. Marmot M. Fair Society, Healthy Lives. The Marmot Review: Strategic Review of Health Inequalities in England Post-2010. 2010. Available online at: http://www. instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review (Last accessed 9th January 2013). 2. Dodge R, Daly AP, Huyton J, Sanders LD. The challenge of defining wellbeing. International Journal of Wellbeing 2012; 2(3): 222–35. 3. Hobfoll SE. Social and psychological resources and adaptation. Review of General Psychology 2002; 6(4): 307–24. 4. Luthans F, Vogelgesang GR, Lester PB. Developing the psychological capital of resiliency. Human Resource Development Review 2006; 5(1): 25–44. 5. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): Development and UK validation. Health and Quality of Life Outcomes 2007; 5: 63. 6. Kirkwood T, Bond J, May C, McKeith I, Teh M. Mental Capital through Life: Future Challenges. Foresight Mental Capital and Wellbeing Project. London: The Government Office for Science, 2008. 7. Department of Health. Closing the Gap: Priorities for Essential Change in Mental Health. London: Department of Health, 2014. Available online at: https://www. gov.uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf (Last accessed 13th March 2014). 8. Bowlby J. Attachment and Loss: Volume 1: Attachment. London: The Hogarth Press and the Institute of Psycho-Analysis, 1969. 9. Baumrind D. Parental disciplinary patterns and social competence in children. Youth & Society 1978; 9(3): 239–76. 10. Maccoby EE, Martin JA. Socialization in the context of the family: Parent–child interaction. In P P Mussen and EM Hetherington (eds) Handbook of Child Psychology, Volume IV: Socialization, Personality, and Social Development, 4th edn. New York: Wiley, 1983; pp.1–103. 11. NSPCC. Encouraging Better Behaviour: A Practical Guide to Positive Parenting. NSPCC, 2013. Available online at: http://www.nspcc.org.uk/help-and-advice/forparents-and-carers/guides-for-parents/better-behaviour/better-behaviour-pdf_wdf90719.pdf (Last accessed 14th March 2014). 12. Belsky J, Bell B, Bradley RH, Stallard N, Stewart-Brown SL. Socioeconomic risk, parenting during the preschool years and child health age 6 years. European Journal Public Health 2007; 17(5): 508–13. 13. Gardner F, Burton J, Klimes I. Randomised controlled trial of a parenting intervention in the voluntary sector for reducing child conduct problems: Outcomes and mechanisms of change. Journal of Child Psychology and Psychiatry 2006; 47(11): 1123–32. 14. Schore A. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 2001; 22(1–2): 7–66. 15. Heim C, Shugart M, Craighead WE, Nemeroff CB. Neurobiological and psychiatric consequences of child abuse and neglect. Developmental Psychobiology 2010; 52(7): 671–90. 16. Dix T. The affective organization of parenting: Adaptive and maladaptive processes. Psychological Bulletin 1991; 110(1): 3–25. 17. Belsky J. The determinants of parenting: A process model. Child Development 1984; 55(1): 83–96. 18. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behaviour: A meta-analytic review. Clinical Psychology Review 2000; 20(5): 561–92.
July 2014 Vol 134 No 4 l Perspectives in Public Health 183
IN PRACTICE
19. Rueger SY, Katz RL, Risser HJ, Lovejoy MC. Relations between parental affect and parenting behaviours: A meta-analytic review. Parenting: Science and Practice 2011; 11(1): 1–33. 20. Belsky J, Barends N. Personality and parenting. In MH Bornstein (ed.) Handbook of Parenting, Volume 3: Being and Becoming a Parent. London: Routledge, 2002, pp. 415–38. 21. Loevigner J. Scientific Ways in the Study of Ego Development. Worcester, MA: Clark University Press, 1979. 22. Manners J, Durkin K. A critical review of the validity of ego development theory and its measurement. Journal of Personality Assessment 2001; 77(3): 541–67. 23. Levine L, Garcia Coll CT, Oh W. Determinants of mother-infant interactions in adolescent mothers. Pediatrics 1985; 75(1): 23–9. 24. Van Bakel HJA, Riksen-Walraven JM. Parenting and development of one-year-olds: Links with parental, contextual and child characteristics. Child Development 2002; 73(1): 256–73. 25. Belsky J, Hertzog C, Rovine M. Causal analysis of multiple determinants of parenting: Empirical and methodological advances. In ME Lamb, AL Brown and B Rogoff (eds) Advances in Developmental Psychology, vol. 4. Hillsdale, NJ: Lawrence Erlbaum Associates, 1986; pp. 193–217. 26. Russell A. Individual and family factors contributing to mothers’ and fathers’ positive parenting. International Journal of Behavior Development 1997; 21(1): 111–32.
In Practice Good hospital food is better for patients and the economy Food has a unique role in hospitals: not only does it provide key nutrients to aid and support recovery, it has a social role in offering patients respite from the medicalised environment and brings some normality and comfort into what can otherwise be an unsettling and unfamiliar experience. Susannah McWilliam from the Food for Life Partnership takes a look at the meals served in hospitals to patients, staff and visitors and explains how this food can have the potential to improve public health. counts: it benefits local economies, reduces food miles, raises trust by ensuring traceability and can reduce costs while improving food quality.
The Long Distance Sandwich
Some people have questioned the importance of traceable, local food in hospitals, but change is afoot. Following the horsemeat scandal, support has grown for the provision of local and traceable food in public sector catering, including hospitals. With the food and drink sector in rural areas supporting 3.7 million jobs and contributing £90 billion to the UK economy, the social and economic benefits of local food are clear. Initiatives on the ground, such as the Food for Life Catering Mark, are proving that local food in hospitals is making a positive contribution on numerous
In 2001, a patient inspired the beginning of a food journey in Cornwall by asking why a sandwich had travelled 250 miles to his bedside when it could have been made locally. The seeds of the Cornwall Food Programme were sown, and supported by the Soil Association and EU Objective One funding, a shift was made to use local suppliers where possible, and fresh, local and seasonal produce was provided across a number of Cornish hospitals. Results were startling: the percentage spent within the local economy doubled; 110,000 fewer miles were travelled in food deliveries; carbon dioxide emissions from transport fell by 70%; and the switch to more local produce cost no more overall.1 Among a number of shining examples, one product in
184 Perspectives in Public Health l July 2014 Vol 134 No 4
particular illustrated the benefits. Prior to the programme, long life yogurt was on the menu, and much was typically left uneaten. By working through a local wholesaler, a local supplier began to produce smaller pots of high quality, fresh, nutritionally dense yogurt for the programme’s hospitals at slightly reduced costs. Patients loved the new product, and waste levels reduced dramatically: the benefits were clear.
A Stronger Policy Agenda for Local Food Despite such benefits, EU and national legislation and guidance, which has tended to prioritise low cost over social value, has discouraged many from looking closer to home, but change is on the way. In January 2014, EU rules on public procurement were updated to allow for contracts to be awarded on environmental and social grounds, to encourage small and medium-sized enterprise (SME) engagement and to allow public authorities to procure goods and services
In Practice in line with local priorities.2 National governments have two years to assimilate these changes, but clear signs have been given that buying local has an important role to play in the United Kingdom. For those who procure services, including catering services, the Public Services (Social Value) Act is clear that all public authorities, including the National Health Service (NHS), must consider ‘how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area’.3 Never before has there been such a clear remit in support of food and services that add social value locally. NHS England has also highlighted initiatives that support local procurement through Commissioning for Quality and Innovation (CQUIN) guidance. Introduced in December 2013, a new exemplar CQUIN rewards excellence in hospital food through the take up of recognised standards, including those of the Food for Life Catering Mark. In addition to upholding the nutritional elements of the Government Buying Standards, the Catering Mark Award requires seasonal menus at Bronze level and rewards the uptake of local produce at Silver and Gold levels.
Nottingham worked closely with local suppliers. Local ingredients now make up 77% of the raw ingredient spend, with meat, fresh produce, bakery products and milk all sourced locally. Independent evaluation of Catering Mark menus shows increased local economic benefits as Silver and Gold menus provide a social return on investment of £3 for every £1 spent, offering greater business security, additional contracts and income, additional jobs, improved job security and enhanced wellbeing.4
Good Food Needn’t Cost More Local food is often perceived as more expensive, but as Cornwall found, a creative approach to procurement helps to balance the books. At Nottingham University Hospitals NHS Trust, a flexible menu is key as Chris Neal, Central Food Production Manager explains: Having a flexible menu and working in partnership with local suppliers enables us to buy and produce food with fresh ingredients when they are available, and take them off our menu out of season. As we are such a large organisation committed to using the local produce, this also provides stability to the local economy, and supports British supply chains.
Supporting the Local Community Over five million Food for Life Catering Mark certified meals are served to patients, staff and visitors in hospitals every year, and the interest is rapidly growing. Nottingham University Hospitals NHS Trust was the first to achieve a Gold Catering Mark award earlier this year. Working towards Gold meant the team at
This flexibility, along with other efficiency measures, has kept costs down and supplies patients, staff and visitors with high-quality meals at an in gredient cost of £4.53 per patient per day for breakfast, lunch, supper, snacks and
seven beverages. While the economic and social benefits of using local food are clear for local producers and the wider community, does local food make a difference to patients? Research suggests that it does. A study by Hartwell and Edwards5 found that while patients wanted healthy, nutritious and familiar meals, they were also concerned about what ingredients were used and where they came from. Patient benefits are borne out in hospitals with the Catering Mark in place: four out of five have above average ratings for catering in Patient Led Assessments of the Care Environment (PLACE). Hospitals are key places in the local community and in the lives of local people, and food has a vital role to play. Why then should the food they serve be placeless? While the days when local food could meet all the needs of large organisations are long gone, and the benefits of fairly traded goods are clear, local and seasonal food has an important place at the table. In challenging the norm of placeless food, hospitals can reconnect themselves, patients and staff with their own locality through food: they can support and develop jobs and the local economy through their spending power; they can benefit themselves financially and can take pride in the contribution their food makes to the health of patients and local businesses. Susannah McWilliam Hospitals and Workplace Health Project Manager, Food for Life Partnership
References 1.
2.
Soil Association. A Fresh Approach to Hospital Food. 2007. Available online at: http://www. soilassociation.org/LinkClick.aspx?fileticket=M zWMRYaQNu0%3D&tabid=388 (Last accessed 8th May 2014). Euractiv. EU Brings Innovation into Public Procurement Rules. Euractiv.com., 2014. Available online at: http://www.euractiv.com/ future-eu/parliament-approves-new-rules-punews-532783 (Last accessed 8th May 2014).
3.
4.
Legislation.gov.uk. Public Services (Social Value) Act 2012. UK Government, 2012. Available online at: http://www.legislation.gov. uk/ukpga/2012/3/enacted (Last accessed 8th May 2014). Kersley H. The Benefits of Procuring School Meals through the Food for Life Partnership: An Economic Analysis for FFLP. 2011. Available online at: http://www.neweconomics. org/publications/entry/the-benefits-of-
5.
procuring-school-meals-through-the-food-forlife-partnership (Last accessed 8th May 2014). Hartwell H, Edwards J. Descriptive menus and food branding in hospital foodservice: A pilot study. International Journal of Contemporary Hospitality Management 2009; 21: 906–16.
July 2014 Vol 134 No 4 l Perspectives in Public Health 185
RSH0010.1177/1757913914538140PolicyPolicy
Policy
Policy: supporting parents to ensure a good start The first policy objective of the Marmot Review1 Fair Society, Healthy Lives is to ‘give every child the best start in life’. Young children are heavily reliant upon their parents to ensure that they are set up for life with the emotional, cognitive and physical skills they need to thrive. Ensuring high-quality parenting is key to fulfilling this policy objective, and the mental wellbeing of parents is a vital determinant of the parenting a child receives. Dodge et al.2 conceptualise mental wellbeing as ‘the balance between an individual’s resource pool and the challenges faced’. Some of the resources that may be important to ensuring wellbeing are self-efficacy, dispositional optimism, selfesteem, goal pursuit, hope and resiliency.3,4 The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) was developed specifically to capture a broad range of mental wellbeing components from a UK cultural perspective and includes positive affect (defined in terms of optimism, cheerfulness and relaxation), psychological functioning (including energy, clear thinking, self-acceptance, personal development, autonomy and competence) as well as satisfying interpersonal relationships.5 To achieve mental wellbeing, an individual must not only have these resources, but be able to deploy them successfully when needed.6 The UK Government’s recent mental health strategy7 sets good mental wellbeing for all as a key policy objective and highlights its role in protecting against mental illness. Mental wellbeing, however, is not just of importance to individuals in isolation, it is important for society collectively, not least because of the potential impact it has on the way we parent the next generation.
The importance of good parenting Children develop secure attachments when their needs are met by caregivers, and this is vital to good child development.8 Parenting styles theory posits four general parenting styles: authoritarian, authoritative, permissive and neglectful/disengaged, based on the levels of warmth, conflict and control (discipline) present.9,10 High warmth, low hostility and consistent discipline are associated with authoritative parenting, which is also closely linked to ‘positive parenting’. The latter focuses on parents using positive methods, including praise to encourage good behaviour, being sensitive to a child’s emotional needs and setting clear boundaries.11 Evidence suggests that authoritative/positive parenting is important for overall child health12 as well as preventing child conduct disorders.13 Abusive or neglectful parenting adversely affects child brain development,14 and epigenetic research has highlighted how early social environment can affect gene expression across the life course.15 Overall, an extensive literature of research suggests that ‘parental warmth consistently predicts favourable developmental outcomes for children, whereas parental hostility consistently predicts unfavourable developmental outcomes’.16 If receiving positive parenting is a key determinant of child outcomes, it is important to understand what influences the types of parenting that a child receives. Belsky’s17 process model posits three main determinants of parenting, of which the first is closely linked to mental wellbeing: 1. Parental ontogenic origins and personal psychological resources 2. The child’s characteristics of individuality 3. Contextual sources of stress and support
Linking mental wellbeing with parenting There is a large body of literature highlighting the links between maternal depression and parenting behaviour. A metaanalysis by Lovejoy et al.18 found that a moderate effect size was present linking depression and negative parenting behaviours, and a negative correlation between depression and positive parenting behaviours (positive play, praise, affectionate contact), strongly mediated by socio-economic status – advantaged mothers with depression were significantly more likely than disadvantaged mothers with depression to maintain high levels of positive parenting behaviours. Interestingly, depression was found to impact parenting due to disturbances in affect (or emotion), and as affect is a key component of mental wellbeing, it highlights one link between depression and overall wellbeing. Lovejoy et al.18 followed their meta-analysis on depression and parenting behaviour with a meta-analysis looking at the impact of positive maternal affect and parenting behaviour.19 Despite a wide range of methods included in the meta-analysis and positive affect defined in a range of ways, an overall effect size of 0.2 was found for positive affect and positive parenting behaviours, providing good evidence for a positive correlation between positive affect (and potentially the broader concept of mental wellbeing) and positive parenting behaviours. Belsky and Barends20 highlight that to parent well: One needs to be able to decenter from self, consider the world from the child’s perspective, regulate one’s emotions, especially negative affect, and thus be tolerant and patient with children rather than impulsive and excessively controlling or neglectful and detached.
182 Perspectives in Public Health l July 2014 Vol 134 No 4
Policy
This suggests a level of psychological maturity, which some researchers have sought to investigate as an element of mental wellbeing. Drawing on work by Loevigner,21 psychological maturity has been conceptualised as a spectrum based on ego development. The ego is seen as ‘a holistic construct representing the fundamental structural unity of personality organization’,22 and it is theorised to develop across the lifespan from lesser to greater psychological maturity. Levine et al.23 found that non-adolescent mothers scored significantly higher on the ego development scale than adolescent mothers, and that higher ego development was significantly positively correlated with maternal positive affect and time spent in mutual gaze between mother and child, an indicator of warm parenting. Bringing together work on ego with psychological resources, Van Bakel and Riksen-Walraven24 assessed how egoresiliency, defined as ‘a general capacity for flexible and resourceful adaptation to external and internal stressors’, is linked to parenting behaviour. Parenting behaviour was scored for provision of emotional support, non-intrusiveness, limit setting, quality of instructions and hostility. These scores were converted to a composite measure assessing quality of parental interactive behaviour. Greater ego-resiliency was associated with more positive interactive behaviour. Other psychological resources have also been investigated in relation to parenting behaviour. For example, one group of researchers used self-report measures to represent self-esteem, hostility, emotional unresponsiveness and emotional instability, indicating that positive parenting is associated with higher levels of psychological functioning.25 Russell used self-report measures of parent personality, including questions relating to self-esteem and self-concept, to assess its relationship with positive parenting.26 A positive correlation was found between positive parental personality and positive parenting in mothers. It is notable that there has not been a study undertaken that specifically looks at mental wellbeing, using a well validated scale, and parenting behaviours. In order to address this gap, I have recently undertaken a master’s dissertation looking specifically at the issue of mental wellbeing (assessed using WEMWBS) and (self-reported) parenting behaviour. The study of mothers with children aged 0–4 years found that maternal mental wellbeing was significantly positively correlated with warm parenting behaviour and negatively correlated with hostile parenting behaviour (full dissertation available on request). This supports the literature cited above, adding further strength to the argument that increasing mental wellbeing is not just for this generation, but the next.
Next Steps The five ways to wellbeing, connect, be active, take notice, keep giving and learn, suggest practical ways of increasing wellbeing, highlighting that better wellbeing is within the reach of all. Increasing parental wellbeing in order to support positive parenting should be considered as a key means of improving the health and wellbeing of the next generation. Caitlyn Donaldson Policy and Research Manager, RSPH
References 1. Marmot M. Fair Society, Healthy Lives. The Marmot Review: Strategic Review of Health Inequalities in England Post-2010. 2010. Available online at: http://www. instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review (Last accessed 9th January 2013). 2. Dodge R, Daly AP, Huyton J, Sanders LD. The challenge of defining wellbeing. International Journal of Wellbeing 2012; 2(3): 222–35. 3. Hobfoll SE. Social and psychological resources and adaptation. Review of General Psychology 2002; 6(4): 307–24. 4. Luthans F, Vogelgesang GR, Lester PB. Developing the psychological capital of resiliency. Human Resource Development Review 2006; 5(1): 25–44. 5. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): Development and UK validation. Health and Quality of Life Outcomes 2007; 5: 63. 6. Kirkwood T, Bond J, May C, McKeith I, Teh M. Mental Capital through Life: Future Challenges. Foresight Mental Capital and Wellbeing Project. London: The Government Office for Science, 2008. 7. Department of Health. Closing the Gap: Priorities for Essential Change in Mental Health. London: Department of Health, 2014. Available online at: https://www. gov.uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf (Last accessed 13th March 2014). 8. Bowlby J. Attachment and Loss: Volume 1: Attachment. London: The Hogarth Press and the Institute of Psycho-Analysis, 1969. 9. Baumrind D. Parental disciplinary patterns and social competence in children. Youth & Society 1978; 9(3): 239–76. 10. Maccoby EE, Martin JA. Socialization in the context of the family: Parent–child interaction. In P P Mussen and EM Hetherington (eds) Handbook of Child Psychology, Volume IV: Socialization, Personality, and Social Development, 4th edn. New York: Wiley, 1983; pp.1–103. 11. NSPCC. Encouraging Better Behaviour: A Practical Guide to Positive Parenting. NSPCC, 2013. Available online at: http://www.nspcc.org.uk/help-and-advice/forparents-and-carers/guides-for-parents/better-behaviour/better-behaviour-pdf_wdf90719.pdf (Last accessed 14th March 2014). 12. Belsky J, Bell B, Bradley RH, Stallard N, Stewart-Brown SL. Socioeconomic risk, parenting during the preschool years and child health age 6 years. European Journal Public Health 2007; 17(5): 508–13. 13. Gardner F, Burton J, Klimes I. Randomised controlled trial of a parenting intervention in the voluntary sector for reducing child conduct problems: Outcomes and mechanisms of change. Journal of Child Psychology and Psychiatry 2006; 47(11): 1123–32. 14. Schore A. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 2001; 22(1–2): 7–66. 15. Heim C, Shugart M, Craighead WE, Nemeroff CB. Neurobiological and psychiatric consequences of child abuse and neglect. Developmental Psychobiology 2010; 52(7): 671–90. 16. Dix T. The affective organization of parenting: Adaptive and maladaptive processes. Psychological Bulletin 1991; 110(1): 3–25. 17. Belsky J. The determinants of parenting: A process model. Child Development 1984; 55(1): 83–96. 18. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behaviour: A meta-analytic review. Clinical Psychology Review 2000; 20(5): 561–92.
July 2014 Vol 134 No 4 l Perspectives in Public Health 183
IN PRACTICE
19. Rueger SY, Katz RL, Risser HJ, Lovejoy MC. Relations between parental affect and parenting behaviours: A meta-analytic review. Parenting: Science and Practice 2011; 11(1): 1–33. 20. Belsky J, Barends N. Personality and parenting. In MH Bornstein (ed.) Handbook of Parenting, Volume 3: Being and Becoming a Parent. London: Routledge, 2002, pp. 415–38. 21. Loevigner J. Scientific Ways in the Study of Ego Development. Worcester, MA: Clark University Press, 1979. 22. Manners J, Durkin K. A critical review of the validity of ego development theory and its measurement. Journal of Personality Assessment 2001; 77(3): 541–67. 23. Levine L, Garcia Coll CT, Oh W. Determinants of mother-infant interactions in adolescent mothers. Pediatrics 1985; 75(1): 23–9. 24. Van Bakel HJA, Riksen-Walraven JM. Parenting and development of one-year-olds: Links with parental, contextual and child characteristics. Child Development 2002; 73(1): 256–73. 25. Belsky J, Hertzog C, Rovine M. Causal analysis of multiple determinants of parenting: Empirical and methodological advances. In ME Lamb, AL Brown and B Rogoff (eds) Advances in Developmental Psychology, vol. 4. Hillsdale, NJ: Lawrence Erlbaum Associates, 1986; pp. 193–217. 26. Russell A. Individual and family factors contributing to mothers’ and fathers’ positive parenting. International Journal of Behavior Development 1997; 21(1): 111–32.
In Practice Good hospital food is better for patients and the economy Food has a unique role in hospitals: not only does it provide key nutrients to aid and support recovery, it has a social role in offering patients respite from the medicalised environment and brings some normality and comfort into what can otherwise be an unsettling and unfamiliar experience. Susannah McWilliam from the Food for Life Partnership takes a look at the meals served in hospitals to patients, staff and visitors and explains how this food can have the potential to improve public health. counts: it benefits local economies, reduces food miles, raises trust by ensuring traceability and can reduce costs while improving food quality.
The Long Distance Sandwich
Some people have questioned the importance of traceable, local food in hospitals, but change is afoot. Following the horsemeat scandal, support has grown for the provision of local and traceable food in public sector catering, including hospitals. With the food and drink sector in rural areas supporting 3.7 million jobs and contributing £90 billion to the UK economy, the social and economic benefits of local food are clear. Initiatives on the ground, such as the Food for Life Catering Mark, are proving that local food in hospitals is making a positive contribution on numerous
In 2001, a patient inspired the beginning of a food journey in Cornwall by asking why a sandwich had travelled 250 miles to his bedside when it could have been made locally. The seeds of the Cornwall Food Programme were sown, and supported by the Soil Association and EU Objective One funding, a shift was made to use local suppliers where possible, and fresh, local and seasonal produce was provided across a number of Cornish hospitals. Results were startling: the percentage spent within the local economy doubled; 110,000 fewer miles were travelled in food deliveries; carbon dioxide emissions from transport fell by 70%; and the switch to more local produce cost no more overall.1 Among a number of shining examples, one product in
184 Perspectives in Public Health l July 2014 Vol 134 No 4
particular illustrated the benefits. Prior to the programme, long life yogurt was on the menu, and much was typically left uneaten. By working through a local wholesaler, a local supplier began to produce smaller pots of high quality, fresh, nutritionally dense yogurt for the programme’s hospitals at slightly reduced costs. Patients loved the new product, and waste levels reduced dramatically: the benefits were clear.
A Stronger Policy Agenda for Local Food Despite such benefits, EU and national legislation and guidance, which has tended to prioritise low cost over social value, has discouraged many from looking closer to home, but change is on the way. In January 2014, EU rules on public procurement were updated to allow for contracts to be awarded on environmental and social grounds, to encourage small and medium-sized enterprise (SME) engagement and to allow public authorities to procure goods and services
In Practice in line with local priorities.2 National governments have two years to assimilate these changes, but clear signs have been given that buying local has an important role to play in the United Kingdom. For those who procure services, including catering services, the Public Services (Social Value) Act is clear that all public authorities, including the National Health Service (NHS), must consider ‘how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area’.3 Never before has there been such a clear remit in support of food and services that add social value locally. NHS England has also highlighted initiatives that support local procurement through Commissioning for Quality and Innovation (CQUIN) guidance. Introduced in December 2013, a new exemplar CQUIN rewards excellence in hospital food through the take up of recognised standards, including those of the Food for Life Catering Mark. In addition to upholding the nutritional elements of the Government Buying Standards, the Catering Mark Award requires seasonal menus at Bronze level and rewards the uptake of local produce at Silver and Gold levels.
Nottingham worked closely with local suppliers. Local ingredients now make up 77% of the raw ingredient spend, with meat, fresh produce, bakery products and milk all sourced locally. Independent evaluation of Catering Mark menus shows increased local economic benefits as Silver and Gold menus provide a social return on investment of £3 for every £1 spent, offering greater business security, additional contracts and income, additional jobs, improved job security and enhanced wellbeing.4
Good Food Needn’t Cost More Local food is often perceived as more expensive, but as Cornwall found, a creative approach to procurement helps to balance the books. At Nottingham University Hospitals NHS Trust, a flexible menu is key as Chris Neal, Central Food Production Manager explains: Having a flexible menu and working in partnership with local suppliers enables us to buy and produce food with fresh ingredients when they are available, and take them off our menu out of season. As we are such a large organisation committed to using the local produce, this also provides stability to the local economy, and supports British supply chains.
Supporting the Local Community Over five million Food for Life Catering Mark certified meals are served to patients, staff and visitors in hospitals every year, and the interest is rapidly growing. Nottingham University Hospitals NHS Trust was the first to achieve a Gold Catering Mark award earlier this year. Working towards Gold meant the team at
This flexibility, along with other efficiency measures, has kept costs down and supplies patients, staff and visitors with high-quality meals at an in gredient cost of £4.53 per patient per day for breakfast, lunch, supper, snacks and
seven beverages. While the economic and social benefits of using local food are clear for local producers and the wider community, does local food make a difference to patients? Research suggests that it does. A study by Hartwell and Edwards5 found that while patients wanted healthy, nutritious and familiar meals, they were also concerned about what ingredients were used and where they came from. Patient benefits are borne out in hospitals with the Catering Mark in place: four out of five have above average ratings for catering in Patient Led Assessments of the Care Environment (PLACE). Hospitals are key places in the local community and in the lives of local people, and food has a vital role to play. Why then should the food they serve be placeless? While the days when local food could meet all the needs of large organisations are long gone, and the benefits of fairly traded goods are clear, local and seasonal food has an important place at the table. In challenging the norm of placeless food, hospitals can reconnect themselves, patients and staff with their own locality through food: they can support and develop jobs and the local economy through their spending power; they can benefit themselves financially and can take pride in the contribution their food makes to the health of patients and local businesses. Susannah McWilliam Hospitals and Workplace Health Project Manager, Food for Life Partnership
References 1.
2.
Soil Association. A Fresh Approach to Hospital Food. 2007. Available online at: http://www. soilassociation.org/LinkClick.aspx?fileticket=M zWMRYaQNu0%3D&tabid=388 (Last accessed 8th May 2014). Euractiv. EU Brings Innovation into Public Procurement Rules. Euractiv.com., 2014. Available online at: http://www.euractiv.com/ future-eu/parliament-approves-new-rules-punews-532783 (Last accessed 8th May 2014).
3.
4.
Legislation.gov.uk. Public Services (Social Value) Act 2012. UK Government, 2012. Available online at: http://www.legislation.gov. uk/ukpga/2012/3/enacted (Last accessed 8th May 2014). Kersley H. The Benefits of Procuring School Meals through the Food for Life Partnership: An Economic Analysis for FFLP. 2011. Available online at: http://www.neweconomics. org/publications/entry/the-benefits-of-
5.
procuring-school-meals-through-the-food-forlife-partnership (Last accessed 8th May 2014). Hartwell H, Edwards J. Descriptive menus and food branding in hospital foodservice: A pilot study. International Journal of Contemporary Hospitality Management 2009; 21: 906–16.
July 2014 Vol 134 No 4 l Perspectives in Public Health 185
