"We don't snack": Attitudes and perceptions about eating in-between meals amongst caregivers of young children.

OBJECTIVE: Little is known about caregiver attitudes and perceptions towards snacking by toddlers and preschool children outside of the U.S. This qualitative study examined caregiver attitudes and perceptions towards the provision of both foods and beverages in-between meals, along with what constitutes a snack, or snacking occasion, amongst Swiss caregivers. STUDY DESIGN, SETTING AND PARTICIPANTS: This qualitative study used in-depth interviews (n = 17) conducted with caregivers (16 = female, 3 = male, ages = 20-46y, low to high income). The "Food Choice Process Model" was used as a theoretical framework. Interviews explored experiences, attitudes and perceptions about the provision of foods and beverages to children (1-5y) in-between meals. Interview transcripts underwent a thematic analysis and key themes were developed from the data. RESULTS: Five key themes were identified; 1) Timing is everything 2) Location + food type = snacking 3) Snacks are junk 4) Snacks are small 5) Not in front of the children. The clock-time at which young children were fed, the location, the food type and the portion size delineated how caregivers conceptualised snacking. Feeding children at 10am and 4pm was not viewed as snacking, nor was providing milk before bedtime. CONCLUSIONS AND IMPLICATIONS: Eating in-between meals and snacking may be perceived by caregivers as different concepts and vary according to geography, contexts, time of day, food type and location. The findings highlight some agreement with similar studies conducted in the U.S. but also provide new insights into how the consumption of foods and beverages in-between meals may vary between geographic settings. The opportunities for better defining "snacking" within nutrition study design, and how this may inform dietary intake data interpretation, are discussed.

Therapeutic mobilities: walking and 'steps' to wellbeing and health.

There is now an extensive literature on therapeutic landscapes, those settings and places that can contribute to wellbeing and good health. Less attention has been paid to the therapeutic qualities of the act of moving from one place to another. The recent emergence of a significant mobilities 'turn' in social science is welcome, but this has as yet had relatively little to say about the consequences of mobility for health and wellbeing. This paper maps the relations between one form of mobility - walking - and wellbeing and health. Such relations may be theorised as 'therapeutic mobilities', a concept that sits comfortably alongside that of therapeutic landscapes. I explore three elements of such relations: activity; connection; and context. Although only one form of mobility is considered, the notion of therapeutic mobilities can be extended to other forms of travel.

Variation in geographic access to specialist inpatient hospices in England and Wales.

We seek to map and describe variation in geographic access to the set of 189 specialist adult inpatient hospices in England and Wales. Using almost 35,000 small Census areas (Local Super Output Areas: LSOAs) as our units of analysis, the locations of hospices, and estimated drive times from LSOAs to hospices we construct an accessibility 'score' for each LSOA, for England and Wales as a whole. Data on cancer mortality are used as a proxy for the 'demand' for hospice care and we then identify that subset of small areas in which accessibility (service supply) is relatively poor yet the potential 'demand' for hospice services is above average. That subset is then filtered according to the deprivation score for each LSOA, in order to identify those LSOAs which are also above average in terms of deprivation. While urban areas are relatively well served, large parts of England and Wales have poor access to hospices, and there is a risk that the needs of those living in relatively deprived areas may be unmet.

Digging deep: using diary techniques to explore the place of health and well-being amongst older people.

To date, solicited diaries have been relatively neglected as a social science research method. This is particularly true within the field of health research. Yet, these narrative approaches can provide invaluable insights into the health behaviours of individuals and how these are played out across time and space. To illustrate this, we draw on recent research in the north west of England that investigated the potential benefits of communal gardening as opposed to other social activities in maintaining the health and emotional well-being of older people. As part of a wider study using largely qualitative techniques, our analysis revealed that, contrary to the findings of earlier studies, diaries can be used effectively over relatively long periods of time and are equally effective in exploring health issues amongst both older men and women. With the benefit of good researcher support, we argue that diary techniques can offer some unique insights into the ongoing health routines and coping strategies of older people and can prove invaluable in uncovering those, often hidden, aspects of their daily lives and routines that impact on their health histories. Through the gathering of chronologically organised data about daily activities, diaries can act as both a record and reflection of the health experiences, activities and life-worlds inhabited by older people.

Complexity theory and geographies of health: a critical assessment.

The interest of social scientists in complexity theory has developed rapidly in recent years. Here, I consider briefly the primary characteristics of complexity theory, with particular emphasis given to relations and networks, non-linearity, emergence, and hybrids. I assess the 'added value' compared with other, existing perspectives that emphasise relationality and connectedness. I also consider the philosophical underpinnings of complexity theory and its reliance on metaphor. As a vehicle for moving away from reductionist accounts, complexity theory potentially has much to say to those interested in research on health inequalities, spatial diffusion, emerging and resurgent infections, and risk. These and other applications in health geography that have invoked complexity theory are examined in the paper. Finally, I consider some of the missing elements in complexity theory and argue that while it is refreshing to see a fruitful line of theoretical debate in health geography, we need good empirical work to illuminate it.

Mapping the determinants of health inequalities in social space: can Bourdieu help us?

Considerable research effort has been devoted to describing and explaining, at a variety of spatial scales, geographical inequalities in health outcomes within the developed world. Following Bourdieu, we argue that structures of the social world may be revealed in different kinds of 'social' space. We outline the relational thinking that underlies these ideas. We then 'map', using correspondence analysis (on which Bourdieu himself drew), the structure of social space according to the differential availability of some forms of capital, across four study areas in north-west England. We use logistic regression analysis to explain variation in psychological morbidity (GHQ-score) and then portray the significant predictors of morbidity using multiple correspondence analysis. The area of residence of the survey respondents is used to associate them with particular locations in these social spaces.

"Cultivating health": therapeutic landscapes and older people in northern England.

While gardening is seen, essentially, as a leisure activity it has also been suggested that the cultivation of a garden plot offers a simple way of harnessing the healing power of nature (The therapeutic garden, Bantam Press, London, 2000). One implication of this is that gardens and gardening activity may offer a key site of comfort and a vital opportunity for an individual's emotional, physical and spiritual renewal. Understanding the extent to which this supposition may be grounded in evidence underpins this paper. In particular, we examine how communal gardening activity on allotments might contribute to the maintenance of health and well being amongst older people. Drawing on recently completed research in northern England, we examine firstly the importance of the wider landscape and the domestic garden in the lives of older people. We then turn our attention to gardening activity on allotments. Based on the findings of our study, we illustrate the sense of achievement, satisfaction and aesthetic pleasure that older people can gain from their gardening activity. However, while older people continue to enjoy the pursuit of gardening, the physical shortcomings attached to the aging process means they may increasingly require support to do so. Communal gardening on allotment sites, we maintain, creates inclusionary spaces in which older people benefit from gardening activity in a mutually supportive environment that combats social isolation and contributes to the development of their social networks. By enhancing the quality of life and emotional well being of older people, we maintain that communal gardening sites offer one practical way in which it may be possible to develop a 'therapeutic landscape'.

Beyond 'beer, fags, egg and chips'? Exploring lay understandings of social inequalities in health.

This paper seeks to contribute to the limited body of work that has directly explored lay understandings of the causes of health inequalities. Using both quantitative and qualitative methodology, the views of people living in contrasting socio-economic neighbourhoods are compared. The findings support previous research in suggesting that lay theories about causality in relation to health inequalities, like lay concepts of health and illness in general, are multi-factorial. The findings, however, also illustrate how the ways in which questions about health and illness are asked shape people's responses. In the survey reported on here people had no problem offering explanations for health inequalities and, in response to a question asking specifically about area differences in health experience, people living in disadvantaged areas 'constructed' explanations which included, but went beyond, individualistic factors to encompass structural explanations that gave prominence to aspects of 'place'. In contrast, within the context of in-depth interviews, people living in disadvantaged areas were reluctant to accept the existence of health inequalities highlighting the moral dilemmas such questions pose for people living in poor material circumstances. While resisting the notion of health inequalities, however, in in-depth interviews the same people provided vivid accounts of the way in which inequalities in material circumstances have an adverse impact upon health. The paper highlights ways in which different methodologies provide different and not necessarily complementary understandings of lay perspectives on the causes of inequalities in health.

A proper place to live: health inequalities, agency and the normative dimensions of space.

This paper explores the links between lay knowledge, place and health related social action (or agency) at the individual and collective level. It is based on an analysis of in-depth interviews and neighbourhood survey data across four localities in two cities in the North West of England.The qualitative analysis has identified 'guidelines' that we argue provide socially shared understandings of the normative contours of 'proper places' which shape the way people respond to the everyday lived reality of places. The quantitative findings suggest that a substantial minority of people, particularly in disadvantaged areas, are exposed to significant dissonance between the normative dimensions and lived experience of place. The analysis points to potential interactions between individual and collective action which may affect the health of individuals and populations and 'ontological fit'-people's ability to (re) construct a positive identity despite living in what they and others perceive to be an 'improper' place. This is linked to their biographical connections with particular places and the extent to which they can localise problems and people in places at a distance from themselves. The paper contributes to understanding about the processes that generate inequalities in the health experience of people living in sharply contrasting socio-economic circumstances as well as finer-grained health inequalities between the 'poor' and the 'poorest'.

Place of death: analysis of cancer deaths in part of North West England.

BACKGROUND: Relatively little work of a detailed geographical nature has been undertaken on the distribution of place of death. In particular, given evidence that most cancer patients would prefer to die at home there is a need to examine the extent to which this preference is met differentially from place to place. METHODS: Using data on cancer deaths for a single Health Authority in North West England we conducted both small area and individual analyses of place of death, using binomial and binary logistic regression models, respectively. RESULTS: Results from the small area analysis show that in more deprived areas cancer patients are more likely to die in hospital or hospice, and less likely to die at home, but that the effect disappears for home and hospice deaths once other factors are controlled for. At the individual level, the probability of death at home decreases among those living in deprived areas, whereas the probability of death in hospital increases as area deprivation increases. Age, gender, type of cancer, and proximity to hospital or hospice all have some effect on the probability of dying in a particular setting. CONCLUSION: There is significant place-to-place variation in place of death among cancer patients in part of North West England. However, studies of place of death among cancer patients need to consider the full range of settings and, if examining the impact of deprivation or social class, need to adjust for other factors, including proximity to different settings.

Variations in use of tertiary cardiac services in part of North-West England.

We assess the extent to which the need for tertiary cardiac care is being met uniformly within two Health Authorities in North-West England. We analyse small-area data from 1993-1996 on standardised rates of investigation (angiography) and surgery (bypass grafts and angioplasty). Utilisation by electoral ward is shown to be related to material deprivation. Small areas in which the Asian population is high have significantly fewer angiograms and angioplasties than might be expected according to need, while there is some evidence that women do not receive the levels of bypass surgery that might be expected.