Public Health in the News Diabetes Obesity »Childhood Obesity »School Dinners (Jamie Oliver) Smoking in Public Places Binge Drinking Health Inequalities Incapacity Benefit
Health Strategies National Assembly for Wales (2002) Well being in Wales. Cardiff: National Assembly for Wales. The challenge of improving peoples well being and of reducing health and other inequalities means that success is well beyond the achievement of single organisations working alone. Success hinges on effective partnership working and this is continuing to develop in Wales.. (p.10).
…Strategies…. National Assembly for Wales (2003) The Review of health and Social Care in Wales. Cardiff: National Assembly for Wales. There should be a strategic adjustment of service to focus them on prevention and early intervention. Potentially this offers significant long-term cost and quality of life gains. (p.2 conclusions). We recommend a much greater emphasis on preventing ill health and early intervention in order to raise public awareness of its importance to the ability of health and social care services in Wales. (4.6).
…Strategies… National Assembly for Wales (September 2003) Wales: A Better Country. Cardiff: National Assembly for Wales. Reported levels of poor health are significantly higher in Wales than in the rest of the UK, and are heavily associated with patterns of deprivation. The recent Wanless report has underlined that improving levels of health means not just better services to treat ill-health, but a much greater emphasis on primary care and the promotion of healthy life-styles, to prevent ill-health arising. This is a key challenge that we are determined to address in a holistic way.
..and more Strategies… Welsh Assembly Government (2005) Designed for Life: Creating world class Health and Social Care for Wales in the 21st century. Cardiff: Welsh Assembly Government. We will focus on health and wellbeing, not illness Establishing an evidence base…..and acting on it, is a vital component of our approach
Action plans and implementation? National Service Frameworks »Increasingly high level »Early NSF (CHD) included specific service targets »Mainly in treatment services »Few in primary prevention Childrens NSF »Weak evidence base
Health improvement practice on the ground largely determined by »Local health and wellbeing strategies »Local practitioners in health boards and local authorities Little engagement with evidence base or research community Practitioner networks to share good practice but poor connection to evidence
Public Health Improvement – priority for action and research We recommend a much greater emphasis on preventing ill health and early intervention in order to raise public awareness of its importance to the ability of health and social care services in Wales. We recommend policy action to raise public awareness, and more research to produce an evidence base into the gains which different sorts of action may yield. We recommend a programme to develop further the research base to enable an evidence-based approach to indicate what gains can be expected for different types of public health/prevention expenditure in Wales, to inform future policy making and resource allocation decisions. National Assembly for Wales (2003) The Review of Health and Social Care in Wales. Cardiff: National Assembly for Wales. Dai Wanless
The need to generate high quality evidence Even with greater prioritisation and a clearer focus on delivery, the major constraint to further progress on the implementation of public health interventions is the weakness of the evidence base regarding their effectiveness and cost-effectiveness across the majority of risk factors. (p. 107). The dearth of evidence is not unrelated to the lack of funding of public health intervention research – with funding from research organisations and the private sector heavily directed towards clinical, pharmaceutical, biological and genetic research – and the lack of a clear and coherent set of Government priorities for the public health research which does exist. (p.107). Wanless D (2004) Securing Good Health for the Whole Population, Final Report. HM Treasury.
Summary so far Health improvement and health inequality priorities for action Weak evidence base Practice largely determined locally with little reference to evidence Need to increase quality, volume and relevance of research evidence Need to increase impact/use of evidence
PHIRN Public Health Improvement Research Network
Barriers to high quality evidence generation Clinical NHS research: »Trial recruitment »Ethics, regulation and governance »Infrastructure – staff and CRFs Public health intervention research »Scale, expense, complexity of interventions »Unexploited potential for natural experiments »Multidisciplinary, multi-sectoral »Not just NHS
Weaknesses »Limited dialogue between or within research, policy and practice communities, no structures »Little investment in high quality primary research »Opportunities to rigorously evaluate innovations in services not taken »Pockets of excellence not integrated or well- known
AIM: To increase the quantity and quality of public health improvement research in Wales that is relevant to policy and practice Break down divide between academic intervention research and local evaluation activity
A network of academics, policy makers and practitioners The network will facilitate a continuous process of: identification and exploration of research priorities identification of teams with academic, policy and practitioner representation to take forward priority research projects exchange of new evidence, policy developments, practitioner innovation exchange of innovative methodological approaches identification of innovations in policy and practice at an early stage in planning, maximizing the opportunities for natural experiments development of high quality research project protocols execution of funded research protocols.
Research Development Groups Small groups to identify and drive forward projects Multidisciplinary and multisectoral Protocol development, including commissioning briefs Funding applications Organically formed, active »14 funded studies (£3.2M), 1 (£5M) UK centre of excellence
Other PHIRN Activities Health Challenge Wales Evidence for Policy Seminar Series All Wales Public Health Scientific Conference PHIRN Website »Membership »Database of members, RDGs Electronic discussion group(s) RDG project management and support Linkage with CRCC and Wales R&D infrastructure
Policy Trials Free School Breakfast Initiative »Cluster randomised trial of 111 schools National exercise referral scheme »Randomised trial of c.2000 patients referred to exercise specialists based in community leisure centres Cooking bus »Exploratory trial
Completed projects with major policy impact MRC ASSIST Trial – adolescent smoking prevention (Starkey et al 2005) SHARPS health inequality programme – 7 linked community participatory action research projects (Cropper et al 2007) Food co-operatives (Elliott et al 2007) Adolescent smoking cessation (Macdonald et al 2007)
Development and Evaluation of Complex Interventions for Public Health Improvement UKCRC Public Health Research Centre of Excellence
UKCRC call Overall need to boost infrastructure and build capacity Main issues emerging Training and career structure Multi-disciplinary and collaborative working Maximising use of existing data Methodological issues Specific areas highlighted Diet and nutrition Physical activity Alcohol, tobacco and drugs
Objectives of Centres Promote research excellence Increase investment in infrastructure Build sustainable research capacity - new academic posts and training programmes Encourage multi-disciplinary partnerships between leading academics, practitioners and policy makers Promote leadership to tackle issues such as methodology and use of existing data sets
Levels of changeApproach and target IntrapersonalIndividual characteristics that influence behaviour such as attitudes and beliefs InterpersonalInterpersonal and group influences such as social networks and social support OrganisationalRules, regulations, policies and ethos that may promote or endanger health CommunityShared identities, experiences and resources for health Environment/PolicyPolicies, advocacy, environments and structures that impact on health SOCIO-ECOLOGICAL FRAMEWORK (McLeroy et al 1989)
Public Health Improvement interventions and policies to improve the health and well-being of the public, whether through disease prevention or action to change the wider determinants of health. PHIR reflects a focus on developing and testing interventions, rather than a focus on epidemiology or needs assessment; the scope of interventions to be tested will not be restricted to health technology or to the NHS, but will include a very broad conception of initiatives to improve the health and well-being of the public, from simple to complex, small- to large-scale, and including policies and interventions instigated outside the health and social care arena; that interventions and policies will be developed and tested both in terms of their effectiveness in reducing health inequalities as well as improving population health and well- being.
Complexity of health improvement interventions Effective interventions are likely to: –Be well targeted –Be informed by research and understanding of target audience and key mechanisms –Be theoretically based –Involve complex interactions Of sufficient intensity Reinforced at multiple levels –Vary in effectiveness depending on context
Multidisciplinary Public Health Improvement Research: Challenges Cross-disciplinary Cross-departmental Cross academia / policy / practice –No home, no champions RAE – low esteem Complexity, duration, high-risk
Phases of RCTs of complex interventions: MRC April 2000
Mission Statement DECIPHer will undertake methodologically innovative multidisciplinary research with a focus on the development and evaluation of complex interventions and policies to achieve sustainable improvements in the health and well-being of the public. There will be an initial focus on children and young people. DECIPHer will lead and facilitate research of international excellence, placing emphasis on tackling health inequalities, creating new research capacity and maximising impact on and engagement with policy and practice in the UK and beyond.
What do the funds cover? NOT project funding Infrastructural funding –M£5 over 5 years (@70% FEC), potential for 5 more –Expectation that Centres self-sustaining New posts, PhD studentships Training and career development programmes Infrastructure to underpin research activities Outreach with policy, practice, public
Strategic Research Programmes Multiple risk behaviours in young people and their underlying causes Developing innovative and sustainable child and youth centred interventions Health promoting schools and other youth settings Sustainable health improvement in communities, households and families Environmental determinants of health and the evaluation of environmental and policy interventions
Key areas of methodological development Phased development and experimental evaluation of complex interventions Policy trials with nested process evaluation Social network analysis, Multi level modelling Evidence synthesis and knowledge translation Mixed methods analysis of environmental influences on behaviour Participatory action research Data linkage, secondary data analysis
Applicants Cardiff –Laurence Moore, Chris Butler, Gareth Williams, David Fone, Glyn Elwyn, Soren Holm, Simon Murphy [SOCSI/MEDIC/CLAWS/DENTL] Bristol –Rona Campbell, Jenny Donovan, David Gunnell, Matt Hickman [Social Medicine] Swansea –Ronan Lyons [HIRU]
The overall aim of the Centre is to conduct research that will lead to measurable improvements in the health of individuals and the public. The key objectives of the DECIPHer Centre are: 1.To play a lead role in increasing the quantity, quality, value, relevance and impact of multi-disciplinary research to improve public health in the UK and internationally 2. To create sustainable multidisciplinary research capacity with substantial added value from the strategic partnership 3. To develop a training and career development programme and an excellent environment for multidisciplinary public health improvement research career development 4. To develop new collaborations with organisations concerned with the health of the public in Wales and SW England through nurturing and expanding existing partnerships and creating new opportunities for exchange, engagement and personal development
5. To develop an effective and innovative public involvement strategy that is sensitive to equality and diversity issues and the particular needs of children and young people 6. To develop rich interdisciplinary understandings of the determinants of health and health behaviour, particularly among young people, that will lead to the identification of potentially modifiable causal pathways and the development of interventions 7. To develop innovative interventions to tackle the key health problems of the public, and evaluate them pragmatically and rigorously in diverse populations and settings 8. To provide a focal point for collaboration between academia, policy and practice in public health that will maximise the relevance, innovation, translation and impact of public health improvement research nationally and internationally.
Project examples Trial of national exercise referral scheme (WAG) Trial of free breakfast initiative (WAG) Trial of fruit tuck shops in primary schools (FSA) Trial of emergency contraception lessons (NHS R&D) ASSIST Trial of peer-led intervention to reduce adolescent smoking (MRC) TAP study of peer-led intervention to reduce adolescent problem drinking (AERC / WORD) SHIP Trial of smoking cessation in pregnancy (MRC)
Fruit tuck shop trial (funded by Food Standards Agency) Schools given minimal support in setting up tuck shops, with wide variability in detailed operation 43 schools in study, 23 randomised to set up tuck shop, 20 controls Detailed process evaluation Environment of school and locality Operation of fruit tuck shops Detailed case studies of 8 selected schools FSA Booklet on how to set up fruit tuck shops Strong evidence of effectiveness of fruit tuck shops and importance of snacks-to-school policies
ASSIST Trial (funded by Medical Research Council) 59 secondary schools randomised »30 received peer-led intervention, 29 control »Intervention delivered as it would be the case if rolled out in the real world Process evaluation in all 30 intervention schools, in-depth process evaluation in sub-sample Effective in reducing risk of smoking uptake by 19% Being rolled out across Wales and some PCTs
Free Breakfast Initiative Trial (funded by Welsh Assembly Government) 111 schools, half intervention, half control In Communities First areas in 7 LEAs Variable models of staffing and delivery Trial powered to identify overall mean effect on dietary and behavioural outcomes Process evaluation to monitor variation in delivery and identify strengths and weaknesses Report in with WAG
National Exercise Referral Trial (funded by Welsh Assembly Government) c.4000 participants National standardised scheme, but local variability in delivery Trial powered to identify overall mean effect on physical activity Process evaluation to monitor variation in delivery and identify strengths and weaknesses 12-month follow-up
Contact details Professor Laurence Moore Cardiff Institute of Society, Health and Ethics Email: MooreL1@cf.ac.uk Tel: 02920 875387 Website: www.cf.ac.uk/socsi/cishewww.cf.ac.uk/socsi/cishe »Details of projects, publications etc.