Socioeconomic differences in food preference and their influence on healthy food purchasing choices

Background: Studies have shown that socioeconomic groups differ in their dietary behaviours, and it has been suggested that these differences partly account for health inequalities between social groups. To-date, however, we have a limited understanding of why socioeconomic groups differ in their dietary behaviours. This paper addresses this issue by examining the relationship between socioeconomic status, food preference (likes and dislikes) and the purchase of 'healthy' food (i.e. food consistent with dietary guideline recommendations). Methods: This study was based on a dual-sample, dual-method research design. One sample was systematically selected from the Australian Commonwealth electoral roll and the data collected using a mail-survey methodology (81% response rate, n =403). The second consisted of a convenience sample of economically disadvantaged people recruited via welfare agencies (response rate unknown, n =70). A mail survey methodology was deemed inappropriate for this sample, so the data were collected by personally delivering the questionnaire to each respondent. Results: Socioeconomic groups differed significantly in their food purchasing choices and preferences. The food choices of respondents in the welfare sample were the least consistent with dietary guideline recommendations, and they reported liking fewer healthy foods (all results were independent of age and sex). Notably, socioeconomic differences in preference explained approximately 10% of the socioeconomic variability in healthy food purchasing behaviour. Conclusion: Whilst it is not clear why socioeconomic groups differ in their food preferences, possible reasons include: reporting bias, differential exposure to healthy food as a consequence of the variable impact of health promotion campaigns, structural and economic barriers to the procurement of these foods, and subculturally specific beliefs, values, meanings, etc.     

Evidence-based purchasing of health promotion: methodology for reviewing evidence

In recent years, greater emphasis has been placed on evidence-basedpractice by health care purchasers, managers and practitionersaround the world. This is seen as a means of delivering greaterbenefits to patients and populations within existing resources.Evidence-based practice requires accessible information in aform that is relevant to the problems decision-makers face.The process of evidence-based practice needs to be informedby the best available research evidence of the effectivenessof health-promoting interventions combined with good judgementas to the applicability of that evidence and the feasibilityof implementation in the local context. The nature of evidencewhich can be brought to bear on the decision-making processmay vary in both quality and reliability. In the field of healthpromotion, the nature of problems requiring solutions is complex.Commonly there are multiple variables affecting multiple healthoutcomes. In addition, there is limited available evidence forthe effectiveness of interventions and it is of variable quality.These factors pose problems for ensuring evidence-based healthpromotion. This article describes New Zealand research commissionedby one of four regional purchasers of health services. The purchaserrequired the development of a framework to prioritize interventionsin 22 health promotion areas identified as priorities by theMinister of Health. Our framework was used to consider a broadrange of different kinds of evidence, including scientific research,organizational capacity, socio-cultural factors and local community-basedknowledge related to the determinants of health. Making explicitthe nature of our framework and the evidence we considered,enabled our recommendations about the most appropriate interventionsto be as valid and reliable as possible. Our judgement is thatas for evidence-based medicine, evidence-based health promotionmust employ both quantitative and qualitative evidence, andthat the final judgement about purchasing of health promotioninitiatives is essentially subjective and political.     

Quality in health promotion

Less health finance and the competitive contract culture areleading many health services to adopt quality methods to proveand improve their quality. Health promotion programmes facesimilar changes, but have not made great use of modern qualitymanagement methods. In part this has been because the definitionsand approaches to quality have not appeared to be relevant tohealth promotion. Practitioners need to consider which methodsand approaches are most suited to their programmes. This papershows that many quality ideas and methods are congruent withgood practice in health promotion, and may help to implementsuch practices more widely as well as to develop theory andpractice. There is a danger that inappropriate ways of defining, specifyingand assuring quality will be imposed on programmes. Practitionersneed to consider which methods and approaches are most suitedto their programmes. This paper seeks to stimulate debate aboutthe need to prove and improve quality in health promotion, andabout how best to do so. It considers definitions of quality,measurement, competing quality paradigms, quality in contractingand concepts of process and system in the context of healthpromotion programmes.     

The search for theory in health behaviour and health promotion

Health promotion is often viewed as based in experience; theoryis seemingly at a more abstract level. The reasons for thisare many. This paper explores some theoretical perspectiveswhich are relevant to health promotion. In particular, it considersa collective approach to the making of theory and what the componentsof a health behaviour and health promotion theory might include.     

Socioeconomic differences in the cost,availability and quality of healthy food in Sydney

Objective: To compare the cost of a basket of staple foods, together with the availability and quality of fresh fruit and vegetables, by supermarket store type in high and low socioeconomic suburbs of Sydney. Methods: A food basket survey was undertaken in 100 supermarkets in the 20 highest and 20 lowest socioeconomic suburbs of Sydney. We assessed the cost of 46 foods, the range of 30 fresh fruit and vegetables and the quality of ten fresh fruit and vegetables. Two major supermarket retailers, a discount supermarket chain and independent grocery stores were surveyed. Results: The food basket was significantly cheaper in low compared to high socioeconomic suburbs ($177 vs $189, p<0.01). Discount supermarkets were at least 30% cheaper than other supermarket stores. There were fewer varieties and poorer quality fruit and vegetables in stores in low socioeconomic suburbs. Conclusions: Food basket prices and the availability and quality of fruit and vegetables varied significantly by store type and socioeconomic status of suburb. Implications for public health: A nationwide food and nutrition surveillance system is required to inform public health policy and practice initiatives. In addition to the food retail environment, these initiatives must address the underlying contributors to inequity and food insecurity for disadvantaged groups.     

Socioeconomic position and sleep quantity in UK adults

STUDY OBJECTIVE: To investigate the association between markers of socioeconomic position (years of full time education, access to a car or van, and occupational social class) and mid-range sleep quantity (6.5 to 8.5 hours). DATA SOURCE: Office of National Statistics Omnibus Survey, May 1999. PARTICIPANTS: 3000 households were randomly selected from the UK postcode address file and one person aged over 16 years from each household was randomly selected and invited to take part in the survey. All respondents aged 25 and over (n = 1473) were included in the analyses where appropriate data were available. MAIN RESULTS: Total sleep quantity was greater in more deprived women as measured by years in full time education. There was no linear association between total sleep quantity and any of the markers of socioeconomic position in men. Mid-range sleep quantity was more common in more educated women. Similar, non-significant, trends were seen in men. CONCLUSION: There is little evidence that more socioeconomically deprived people obtain less sleep than more advantaged ones--indeed, the reverse may be true--but some evidence that more advantaged women are more likely to report mid-range sleep. Any hypothesis implicating sleep in socioeconomic inequalities in health should take into account mid-range, rather than total, sleep quantity. Further work should focus both on mid-range, or "healthy" sleep, quantity as well as sleep quality.     

Social determinants of health: a veil that hides socioeconomic position and its relation with health

The emergence of theoretical models of social determinants of health has added conceptual ambiguity to the understanding of social inequalities in health, as it is often not possible to clearly distinguish between socioeconomic position and these determinants. Whether the existence of social inequalities in health is based on differences in health or on differences in social determinants of health that are systematically associated with socioeconomic position, policymakers should be clearly informed of the importance of socioeconomic position for health. Thus, the following three basic requirements are proposed: to reach a consensus about the dimensions that reflect socioeconomic position; to agree about what are to be considered the social determinants of health and whether or not these determinants are a construct that can be distinguished from socioeconomic position; and finally, to establish which dimensions and measures of socioeconomic position are most appropriate for the evaluation of interventions that aim to reduce these inequalities.     

A 'component circuit approach' to needs assessment and strategy selection in health promotion

An approach to formative research in health promotion is describedwhereby significant ‘components’ in the field areidentified and involved as part of a circuit, to test and generateideas. The underlying model is similar to corporate planningprocedures whereby relevant ‘stakeholders’ are identified,and their need and interactions taken into account in generatingthe organization strategic plans for achieving its corporategoals. The process involves aspects of quantitative and qualitativeresearch, the mix of which can vary according to the requirementsof the situation. The use of the process for developing nutritionstrategies for the ‘Health for All Committee’ inone State of Australia is described.     

Education and training in health promotion: theory and methods

Health promotion is evolving into a discrete concept with adefinition commonly understood by all who use the term. Thisis to be distinguished from the kind of umbrella approach usedby all manner of groups and disciplines to define their intentionsor activities in this general area. Further, such a processof clarification is critical to progress and is dependent onhaving a theoretical basis through which research can be undertaken.In turn, the education of those engaged in health promotioncan be expected to shape their skill range and perspective.We find, therefore, a kind of interdependent and reciprocalsituation is developing. At the present time, for chronological reasons as much as anythingelse, practitioners of health promotion come from a varietyof academic and training backgrounds. The process of enablingindividuals to take control of their own health involves a widespectrum of determining factors and hence expertise is veryvaried. Two key elements, for this writer at least, are these:the approach is positive and holistic rather than reductionist,and context is recognised as a major factor in health choices. This paper seeks to discuss the priorities for education againstthis background. It uses as resource the proceedings of a workshopon education and training held as part of a World Health Organizationsupported workshop held in Copenhagen in 1992. We find thatmost graduate level training is in dedicated Master level programmesthat have considerable overlap with those in public health.Discussion will centre on whether we have sufficiently evolvedour thinking to discriminate skill areas unique to health promotionthat should be taught. The intuitive basis on which courseshave developed to date will be examined. Finally, the paperasks whether or not the standardisation that may follow is inany way antithetical to the embracing principle of health promotionitself.     

Socioeconomic measures in early old age as indicators of previous lifetime exposure to environmental health hazards

The relationship between disadvantage in early old age and disadvantage earlier in life was investigated by collecting lifetime residential and occupational histories from 294 subjects aged between 63 and 78 years. Lifetime exposure scores, expressed as the age-adjusted number of years exposed to a range of health hazards, were calculated. Associations between these scores and six measures of socioeconomic position after retirement were examined. Compared with the more advantaged, the more disadvantaged on each post-retirement socioeconomic measure had higher lifetime exposure scores. Mutual adjustment showed that the Registrar General's (RG) social class, based on the person's own last main occupation, had the strongest association with previous hazard exposure. In the absence of the information required to assign an RG class status, receipt of state welfare benefits in early old age had the strongest association with previous hazard exposure for women, whilst for men, current tenure status was most strongly associated.     

Socioeconomic Indicators Are Independently Associated with Nutrient Intake in French Adults: A DEDIPAC Study

Studies have suggested differential associations of specific indicators of socioeconomic position (SEP) with nutrient intake and a cumulative effect of these indicators on diet. We investigated the independent association of SEP indicators (education, income, occupation) with nutrient intake and their effect modification. This cross-sectional analysis included 91,900 French adults from the NutriNet-Santé cohort. Nutrient intake was estimated using three 24-h records. We investigated associations between the three SEP factors and nutrient intake using sex-stratified analysis of covariance, adjusted for age and energy intake, and associations between income and nutrient intake stratified by education and occupation. Low educated participants had higher protein and cholesterol intakes and lower fibre, vitamin C and beta-carotene intakes. Low income individuals had higher complex carbohydrate intakes, and lower magnesium, potassium, folate and vitamin C intakes. Intakes of vitamin D and alcohol were lower in low occupation individuals. Higher income was associated with higher intakes of fibre, protein, magnesium, potassium, beta-carotene, and folate among low educated persons only, highlighting effect modification. Lower SEP, particularly low education, was associated with lower intakes of nutrients required for a healthy diet. Each SEP indicator was associated with specific differences in nutrient intake suggesting that they underpin different social processes.     

Socioeconomic Inequalities in Self-Rated Health Among Middle-Aged and Older Adults

Despite increased attention to health disparities in the United States, few studies have examined the impact of socioeconomic inequalities on self-rated health over time. Using data from the Health and Retirement Study, this article investigates socioeconomic inequalities in self-rated health among middle-aged and older adults. The findings indicated that higher level of income, assets, and education, and having private health insurance predicted better self-rated health. In particular, increases in income or assets predicted slower decline in self-rated health. Interestingly, economic status had greater impact on females' decline in self-rated health. Blacks were less likely to suffer rapid decline in self-rated health than were whites. The findings led to the conclusion that health disparities should be understood as the interplay of socioeconomic status, gender, and race/ethnicity.     

Quality-based purchasing in health care

Quality-based purchasing is a growing trend that seeks to improve healthcare quality through the purchaser-provider relationship. This article provides a unifying conceptual framework, presents examples of the purchaser-provider relationship in countries at different income levels, and identifies important supporting mechanisms for quality-based purchasing. As countries become wealthier, a higher proportion of healthcare spending is channeled through pooled arrangements, allowing for greater involvement of purchasers in promoting the quality of service provision. Global and line item budgets are the most common type of provider payment system in low and middle-income countries. In these countries, improving public hospital performance through contracting and incentives is a key issue. In middle and high-income countries, there are several documented examples of governments contracting to private or non-governmental health care providers, resulting in higher perceived quality of care and lower delivery costs. Encouraging quality through employer purchasing arrangements has been promoted in several countries, particularly the United States. Community-based financing schemes are an increasingly common form of health financing in parts of sub-Saharan Africa and Asia, but these schemes still cover less than 10% of national populations in countries in which they are active. To date, there is little evidence of their impact on healthcare quality. The availability of information--concerning healthcare service provision and outcomes--determines the options for establishing and monitoring contract provisions and promoting quality. Regardless of the context, quality-based purchasing depends critically on informa-tion--reporting, monitoring, and providing useful information to healthcare consumers. In many low and middle-income countries, the lack of availability of information is the principal constraint on measuring performance, a critical component of quality-based purchasing.     

Collaboration between the dietetic profession and the food industry in health education—a discussion paper

The predicted trend towards increased use of nutrition and health information in food marketing in the 1990's is likely to promote consumer interest in nutrition. In order to capitalize on this trend, the author contends that the dietetic profession should increase the priority given to nutrition education campaigns aimed at improving the diets of consumers. In practice however, the resources available to dietitians to implement substantial nutrition education campaigns are likely to be minimal, unless innovative approaches are considered. The author puts forward two suggestions for consideration by dietitians. First, nutrition education campaigns should use nutrition and health information provided on food labels and in advertisements as major resources.
Secondly, an effective way of resourcing nutrition education campaigns could be by collaboration between the dietetic profession and the food industry. This paper elaborates these proposals and examines implications for the British Dietetic Association (BDA).     

Quality indicators for health promotion programmes

Methods for systematically following up and auditing health promotion have been in demand for a considerable period of time. Quality assurance as an auditing method has opened up new opportunities in this area. On the basis of Donabedian's 'triad' of structure, process and outcome, the theoretical preconditions for and implementation of a number of successful health promotion programmes/ projects have been analysed with regard to their common characteristics. These characteristics have been generalized and then transformed into indicators of a successful health promotion programme/project. To ensure the practical applicability of the quality indicators, they were operationalized in what we call a 'question pro-forma'. Any negative response to a question on the pro-forma indicates quality defects in a programme, and any positive response the opposite. The 'template' can be employed for both the planning and auditing for quality assurance on health promotion programmes and projects. The question pro-forma has been tested successfully on a number of programmes and projects. The results from one study are shown in the article.     

Cost and availability of healthy food choices in a London health district

To assess whether the foods and diet being promoted by the local Food Health Policy are affordable by and available to all sections of the community, cost and availability of a wide range of foods was recorded in the main supermarkets in Hampstead, an Inner London Health District. It was found that the recommended foods and diet were more expensive and less available than alternatives, particularly in deprived areas. This is a constraint to changing over to a healthier diet, particularly for people on very low levels of income i.e. those on pensions and benefits. Healthy eating programmes should take these constraints into consideration and efforts to increase the availability of cheap, healthy food should be a priority at national and local level. Higher pensions and benefit levels would also create more equitable access to healthy diets.