Can public health influence the required political shift from ‘best start in life’ aspirational policy rhetoric to delivering a fairer start for all?

By Dr Amy Barnes and Michelle Black

A recent BBC News article ‘Children ‘failed in first 1,000 days’ says MPs’ highlights that ‘nearly a third of children are not school ready’ in England. It is about the ‘First 1000 days of life’ report – recently published by The Health and Social Care Committee – which calls for a cross-party government strategy for an early years ‘revolution’, including a revamped Healthy Child Programme in England to give children and families more support, earlier.

Interestingly, the Committee’s report draws attention to variation in policy to support early child development across the four countries of the UK; for example, mentioning the Family Nurse Partnership and Flying Start in Wales, which provides childcare for eligible 2-3 year olds, enhanced health visiting and targeted support for families with 0-4 year olds who live in disadvantaged areas; and highlighting that there are less health visitor contacts here in England than the other three countries of the UK.

The Committee call for the health visiting programme in England to be extended and for the government to develop a programme that children and families who need more targeted support can access; recognising, however, that these types of policy initiatives are only a ‘sticking plaster’ for the persistent inequality, poverty and deteriorating social conditions that undermine healthy child development across the UK.

These issues resonate with the findings from an ADPH and Health Foundation supported study that we recently completed, which looked at how policy and public health systems have contributed to children’s early developmental outcomes across the UK since political devolution (the open access paper has just been published on the Journal of Public Health website).

The study found that early child development is on the policy agenda in each UK country, but that public health systems are subject to many influences that shape outcomes. Since political devolution, all national policies have championed a ‘prevention approach’ to early child development, emphasising (at least in policy rhetoric) cross-sectoral work, integrated forms of family support and entitlements to early education and care.

Yet political factors have given rise to examples of policy difference:

  • Variation in the way that child development is framed within national policy (e.g. ‘preparing for life’ in Scotland versus ‘preparing for school’ in England) and in the way that pre-school provision is presented (e.g. as a ‘universal entitlement’ or an ‘earned benefit’);
  • Variation in the number of health visitor contacts offered (11 in Scotland compared to 5 in England) – also highlighted by the Health and Social Care Committee); and
  • Distinctive legislation by the Scottish and Welsh governments focusing on wider determinants – though action on this has been limited by the extent of devolved powers.

These similarities and differences, from the child’s perspective, are visualized in Figure 1 below and in an associated infographic.

Figure 1: Early Years Infographic

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Crucially, our study found that, across all countries of the UK, political factors and resourcing issues were key influencing factors; with, for example, systemic pressures relating to short-term funding, funding cuts to children’s centres, issues of financial sustainability in relation to early education or childcare, and pressures on health visitors as key members of the early years public health workforce.

Politics and resourcing are likely to be key factors shaping any discussions arising from the Health and Social Care Committee’s ‘1000 days’ report. The report itself appears to have been well received by the public health community (so far) but the issue of investment has already been raised by the ADPH in their response:

After years of deep cuts to public health, the Government must properly fund current provision before any extension of the Healthy Child Programme is considered.

We argue that an adequate government response will inevitably require political choices to be made. Not only about how much resource a ‘revamped’ Healthy Child Programme might need and where that resource will be distributed within the public health system (ie. to local authorities, in training health visitors, and so on). But also, more fundamental political choices about how to deal with persistent inequality and child poverty within the UK, about what ‘prevention’ is and about social justice and equity. This means political leaders making choices about welfare reform, how to intervene in the labour market, whether to further devolve political powers, and reform tax and transfer policies in ways that will lift families with children out of poverty.

There are challenges and opportunities here for the public health community. Perhaps a fundamental question is how we contribute to the political framing of ‘prevention’ so that it is about action to address wider determinants of early child development. As the Health Foundation and Frameworks Institute point out, this needs to involve reframing public conversations and communicating more effectively about inequalities and health; and is something that needs to happen at all levels of the public health system.

Influencing political action on early child development will also mean we need to find better and timely ways to communicate evidence at national levels, and to do so in ways that resonate with central policy makers’ knowledge, understanding and constraints (see Paul Cairney’s blog). It means finding ways to garner public support and to act as a louder and more cohesive public health voice to influence the political system at national, and also local levels, to ensure that children are enabled to thrive and no longer ‘failed in the first 1000 days’. We have work to do…

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Visualising the public health system in a way that engages, and levers change

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Public Health is ‘the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society’. We know a fair amount about ‘the science’ of what social, economic and environmental conditions enable good health and wellbeing, but we know a lot less about ‘the art’ of affecting change to create those conditions, largely because public health is complex.

The constituent parts of what makes up a public health system are quite well known and famously visualised through the Dahlgren and Whitehead rainbow model (fig 1).

Fig 1 Dahlgren and Whitehead model

PH systems_2

(Source: Dahlgren and Whitehead, 1991)

Trying to work out how to influence this complex public health system is hard. Some of the difficulty is being able to conceptualise ‘a system’ and unpick what we can do to influence change.

This is why we’ve been working on an APDH and Health Foundation supported study looking at public health policy and systems across the four constituent countries of the UK. As part of this project, we developed a public health systems framework, drawing on the views of stakeholders and refined through two systematic reviews. With the help of a graphic designer, we have created a picture of the public health system which was both true to our research findings and useful to those trying to bring about change.

Whilst this will not give us the answer, it helps us ask the right questions. For example, the way that politics shapes the type of policy that is developed, as well as organisational relationships and day-to-day partnerships work; the way politics intersects with systems leadership; or how systems leadership itself might affect how public health problems are framed. The list could go on!

The visual is included here (fig 2). We’ve called it a Framework as it as a way to frame our understanding of the elements that affect public health outcomes at different levels. We see it as one way to help promote reflection on how to reshape the system, and as sitting ‘under the Dahlgren and Whitehead rainbow’.

Fig 2 Public Health Systems Framework 

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Imagine you are trying to improve air quality within one of the most deprived communities where you live or work. This would be the outcome that you are trying to achieve. The Framework helps you think about the different system elements that might be shaping this from the perspective of where you are in the system (e.g. local authority, community organisation, PHE). It helps you identify what enables or constrains change.

Putting the framework into practice, you could ask yourself or your team, what existing policy is there on air quality (locally, nationally) and how does this enable or constrain? What’s the organisational structure and system you need to work within and across? Who are your key partners, and do they have ways of working which may for example help you frame the problem? What are the influencing factors (e.g. data, local politics, system leadership) in your favour? It is the interactions between these elements which shape public health and working across them will help to identify synergies within the system to improve it.

By reflecting on these elements, we think that the visual framework can help us build up a more detailed understanding of the public health system and develop a strategy for who and how to engage to lever system-level change.

We’d love to get your thoughts on this Framework. Please post your comments on this site.

Michelle Black, Public Health Speciality Registrar and  Amy Barnes, Lecturer, School of Health and Related Research at The University of Sheffield

Andrew Furber, Centre Director, Public Health England (Yorkshire and Humber)

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The problem of waste in Nepal – understanding the risks facing informal waste workers by Michelle Black and Jiban Kumar Karki

We are awash with plastic and it is damaging our environment. Anyone who watched the BBC’s Blue Planet will have seen the toxic effect it is having on our oceans and sea life. But what about the direct impact of waste on people?

Up to 56 million people worldwide, largely the urban poor, earn a living from working with waste. They sell collect and recycle waste outside of any formal employment. People who make a living in this way are known as informal waste workers (IWW). They are making a positive contribution to waste management but unfortunately this is largely unrecognised by society.

The informal waste sector has grown because in developing countries the authorities can’t keep pace with the growth in waste that comes from increased urbanisation and consumerism. The finance, human resource, technical capability and perhaps political will to invest in robust waste management systems is lacking.

waste_Nepal

Furthermore, the level of awareness among the consumers in developing countries is still relatively low compared to the developed countries.

What’s ScHARR’s involvement?

A team from ScHARR is working with the non-government organisation, Phase Nepal (thanks to funding from Médecins du Monde), to identify the characteristics and health risks of waste workers in the Kathmandu Valley, Nepal. Nepal is one of the poorest countries in South Asia and waste is a problem in its capital city and surrounds with approximately 620 tonnes produced daily in the Kathmandu valley. To identify the health needs of the IWW population there (thought to be between 7,000 and 15,000) we undertook a large demographic health survey.

What did we find?

  • The waste workers are at risk of injury, infectious disease and chronic conditions such as respiratory conditions and mental ill health.
  • They face inequalities compared with the Nepali population
    • lower literacy
    • higher prevalence of smoking and alcohol consumption
    • higher prevalence of mental ill health
    • their children have lower rates of uptake of childhood vaccinations
    • female waste workers have worse antenatal care
    • long working hours with low earnings and little social protections
  • Only a third protect themselves with Personal Protective Equipment (PPE) such as gloves and masks.
  • Males, people of Indian origin and older people are less likely to use PPE.
  • Knowledge that the work is risky is likely to increase use of PPE.

What are we going to do with these findings?

We visited Kathmandu in February and worked with Phase Nepal to present our findings to the main stakeholders in the region. A programme of interventions such as PPE distribution, empowerment of the IWWs and reinforcement of their protective behaviors and provision of health clinics, informed by our research findings, is now underway. We are keen to influence policy makers in the region that whilst moving to a formal waste management system is the goal this has to be balanced with the needs of the urban poor whose livelihoods could be displaced. We are helping to advocate for integrating informal waste workers into the formal waste management sector.  

Nepal group_waste

What can you do?

In relation to waste and particularly plastic: ‘reduce, reuse, recycle’. Next time you pass a plastic bottle on the street pick it up and put it in the bin. Use less plastic.

You can read the full report here:

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Sit Less at Work – reviewing the evidence and developing a useful framework by Dr Kelly Mackenzie

KellyI recently published a paper, the first from my National Institute for Health Research Doctoral Research Fellowship, looking at the topic of sitting in the workplace.  What follows is a brief summary of the research that was done and the key findings.

Why is prolonged sitting in the workplace an important issue?

We now know that prolonged sitting is bad for our health – it’s linked to a range of health conditions such as heart disease, type 2 diabetes, some cancers, depression, and musculoskeletal problems.  Workplaces are of particular interest when thinking about ways to reduce sitting time as the increase in desk-based jobs has meant an increase in the amount of time many of us spend sitting at work.  Over recent years, there have been a range of interventions tested in different workplaces, but reviews of these interventions have found that the impact these have had on sitting time has been inconsistent.  In order to understand why these interventions have/have not worked, we aimed to explore the factors that may help these interventions to be rolled out.  This information in turn may help to produce interventions that have a greater impact on sitting time and hence be more successful.

Sit Less image

What did we do?

To address the aim of this research, we conducted a qualitative systematic review of the evidence.  This involved comprehensively searching for research studies that had undertaken sit less at work interventions.  From these studies we took out author descriptions of what the interventions included, and how they were developed, implemented and evaluated.  From that information, we were able to identify some commonalities between the studies.

What did we find?

The main finding from this review was the identification of steps which are important for the development, implementation and evaluation of sit less at work interventions.  Some of the key steps included: ensuring the intervention is based on some form of theory; using staff to develop and implement their own sit less at work interventions; and ensuring there is an assessment of what does/does not change and how these changes may have come about.  In addition, it was found that many studies did not report details about where the intervention was rolled out, e.g. what type of organisation was involved, how big this organisation was, and what the structure/culture of the organisation was like.  This information is important as it helps fellow researchers to understand whether this intervention could work in a similar type of organisation.  These findings were then incorporated into a framework (see below), which provides researchers with clear steps needed to develop, implement and evaluate sit less at work interventions.

What’s next?

The rest of my Doctoral Research Fellowship will involve testing this framework during the development, implementation and evaluation of sit less at work interventions in four different organisations.  Based on these findings, the framework may be refined so that it is then ready to be included in a toolkit for organisations to develop, implement and evaluate their own sit less at work interventions.

For more information, the full article can be accessed here:  Mackenzie K, Such E, Norman P, Goyder E (2018). The development, implementation and evaluation of interventions to reduce workplace sitting: a qualitative systematic review and evidence-based operational framework. BMC Public Health 18:833.

Operational framework for sit less at work interventions:

intervention framework

Please note, this research was funded by the National Institute for Health Research  (www.nihr.ac.uk).

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Thrills and spills in Israel – Adventures of a PhD student – Philippa Fibert

The European Network of ADHD Conference took place this year in Tel Aviv, Israel, March 19th – 21st. It seemed like a good opportunity to present the results of my PhD pilot feasibility study assessing the effectiveness of treatment by homeopaths and nutritional therapists for children with ADHD, so I applied, and was accepted to do a poster presentation.

I was thrilled, but somewhat intimidated to then be asked to do an oral presentation in the non-pharmacological intervention symposium at the conference. The speaker list was littered with academics referenced in my thesis and I think I was the only non-doctor on the list. On my request, my ‘Dr’ prefix was removed from the programme, but it had crept back by the time the conference started.

As one of the co-authors, Professor David Daley from Nottingham University (who was chair of the trial steering committee) put it: you are speaking amongst giants.  My nervousness increased further when the symposium was moved from a small, cosy setting to the enormous hall where the plenary lectures took place, due to the popularity of the topic.

The title of my presentation was Rethinking ADHD Intervention Trials: Feasibility Testing of Two Treatments (Nutritional Therapy and Homeopathic Treatment).  During the presentation I discussed the importance of pragmatic trials to assess whether interventions might improve the long term negative outcomes associated with ADHD.  I also presented the pilot findings regarding the effectiveness of the two treatments tested using the Trials Within Cohorts (TWiCs) methodology developed by my supervisor, Clare Relton.

The majority of attendees were clinicians: psychiatrists, psychotherapists and psychologists. They told me that they appreciated the pragmatic nature of the design and assessment of the two interventions, since they attended the conference to receive practical information which might be helpful to their patients. I found myself unusual amongst the presenters in taking a more ‘public health’ approach to trials. The vast majority of ADHD research is conducted within Psychology departments, where pragmatic trials are rare, and more explanatory approaches the norm.

It is a significant tenet of my thesis that there is an unmet need for pragmatic trials of main and non-mainstream interventions for ADHD, to answer important questions as to whether treatments might improve long-term, negative outcomes. It was gratifying that clinicians agreed with me, and their enthusiasm is fueling my post-doc aspirations. But first I need to submit that thesis, and get through that viva………….

 

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Dr Liz Such awarded NIHR Knowledge Mobilisation Research Fellowship to explore how policy can be made healthier

liz-such

ScHARR Research Fellow, Dr Liz Such, has been awarded an NIHR Knowledge Mobilisation Research Fellowship for 4 years to help mobilise knowledge and conduct research about Health in All Policies. Her £200K award will support her development as a knowledge mobilisation specialist in the field of policy for health equity. The focus for the work will be on how local government policy, strategy and practice supports or constrains health promotion and equity.

This work takes place at an important time for local government. Financially, times are tough and there is growing recognition that the NHS and local public health departments cannot tackle health and health inequalities alone. Liz will be shadowing local government officials and council members as they seek to address local challenges – economic and social – whilst pursuing better health and wellbeing among local populations. She is particularly interested in how health is integrated into decisions and actions around ‘inclusive economic growth’ in local areas.

She will be conducting several packages of research and knowledge mobilisation activity with the support of mentors in the University of Sheffield, including Professor Elizabeth Goyder in ScHARR and Professor Sarah Salway in Social Sciences, the University of Edinburgh, UCL, the Health Foundation and Sheffield City Council.

For more information contact Liz at e.such@sheffield.ac.uk

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Understanding Stability and Change in British Drinking

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The Economic and Social Research Council (ESRC) have awarded £650,000 to Prof Petra Meier, Dr John Holmes, Dr Monica Hernandez and Prof Alan Brennan from ScHARR and Prof Alan Warde from the University of Manchester to investigate how and why British drinking culture is changing.

During 2001 to 2016, Britain experienced a historic peak and subsequent steep decline in alcohol use. There were a lot of things going on during this time – licensing reforms, a ban on smoking in pubs, debates about alcohol duty and minimum prices, media focus on ‘Binge Britain’ and ‘Ladette’ culture, and a new generation of young adults who rarely or never drink alcohol. Of course, there were also major macroeconomic and social shifts – first and foremost recession and austerity. Together, these influences are suspected to have contributed not only to a reduction in consumption but to fundamental changes in our drinking culture. However, so far these have been sparsely documented and poorly understood. For example, we know young adults are drinking some 40% less than a decade ago, but we know little about what has changed in terms of where, when, why, how or with whom they are drinking, and how drinking fits into their everyday lives. This limits our ability to provide expert commentary on how changes in alcohol use relate to wider cultural and structural shifts, to anticipate and respond to future trends in both alcohol use and related harm, and to inform public policy and debate.

By combining rich contextual market research data, new applications of theories of practice and sophisticated statistical analyses, the project aims to address these challenges and provide new quantitative insights into how Britain drinks. In particular, it focuses on investigating activities that involve drinking as social practices, reflecting the varied range of different behaviours and types of occasions that together make up the phenomenon “alcohol consumption”. The new insights will support the development of public health policy approaches that are targeted at disrupting problematic practices whilst supporting transitions to less risky drinking and non-drinking practices.

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Four key questions will guide our work:

  1. How did drinking occasions and their characteristics change from 2001 to 2016?
  2. What explains variation in occasions across population groups, between places and over time?
  3. What macro-level trends in alcohol consumption can occasion-level data help to explain?
  4. How did major societal and policy changes between 2001 and 2016 affect drinking occasions?

Petra says:

“My team and I are delighted to have been awarded this grant which we hope will shed light on how and why alcohol consumption has changed so dramatically over the last two decades. Recent reductions in consumption levels have been welcome news but only a thorough understanding of why they have occurred will allow us to lock in the benefits and transfer learning across to other settings or health behaviours.”


If you want to read more, three of the investigators have set out their thinking in a recent publication:

Meier PS, Warde A, Holmes J (2017) ‘All drinking is not equal: how a social practice theory lens could enhance public health research on alcohol and other health behaviours‘, Addiction, 113 (2), pp.206-13

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10th ECTMIH conference

Sarita Panday

Sarita presenting her poster entitled “Impact of community-level factors on the volunteers’ services in rural Nepal: a qualitative study”

Sarita Panday (SIID) and Julie Balen (ScHARR/SIID) recently attended the 10th European Congress on Tropical Medicine and International Health (ECTMIH), held in Antwerp, Belgium. Beyond presentations of their research from Nepal and The Gambia, Sarita and Julie reflect on what they gained from attending the conference, and what some of their main take home messages were.

ECTMIH is a biennial event that brings together scientists and experts from Europe and from all over the world, including a large proportion of delegates from low and middle income countries (LMICs), as well as many of the Emerging Voices. It is patronised by the Federation of European Societies of Tropical Medicine and International Health (FESTMIH). Both Sarita and Julie were impressed by the huge representation of countries and regions at the conference. There was a great diversity of scholars and research presented from Afghanistan to Zimbabwe, giving the conference a truly international flavour.

Similarly, there was a wide range and breadth of disciplines represented, including some in sessions that ran using rather innovative formats. Julie attended the Emerging Voices session entitled “Making Promises, Breaking Commitments: What is the Role of Health Policy and Systems Research in Transforming Political Commitments into Better Health Systems?”. The format of this session was an interactive debate with pre- and post-debate voting by the audience. Both sides put forward an impassioned and convincing set of arguments for and against the motion: “health policy and systems research (HPSR) has focused too much on evidence, blind to the fact that policy is about interests, values, power and politics, which has made HPSR largely irrelevant to the creation and implementation of political commitments”. The audience was fairly divided, and some even tried to vote for and against, seeing both sides of the argument.

Of particular interest to Sarita and Julie were the numerous sessions focussing on community engagement and participation, given the focus of the ESRC project 1 Sarita and Julie are both involved in, as well as Julie’s Global Health Trials funded study 2. Sarita will shortly be heading Nepal for fieldwork using video-voice methodology for data collection. Although no sessions focussed specifically on video-voice, there was a session entitled “The Power of the Image: Use of Multimedia in Health Research, Advocacy and Dissemination” which explored the use of photovoice to explore aspects of social inclusion/exclusion of children with special needs in Uganda. This session also explored use of video for advocacy and research, as well as agenda setting in the Indian health policy sphere.

Finally, one stimulating aspect of the conference is that all delegates were encouraged to attend at least 1 session in a different field or discipline to what they themselves work on. Indeed this kind of cross-disciplinary thinking was encouraged throughout the conference by ensuring that all the Opening, Plenary and Closing Sessions included speakers focussing on the basic science / clinical aspects of global health, as well as the applied science / implementation aspects of global health. Breaktime discussions with other delegates from a range of disciplines were aided by this kind of formal attempt at cross-fertilisation of ideas. We hope that future conferences continue to find ways of breaking down the silos that we all commonly find ourselves in. Overall, ECTMIH was a successful conference and Sarita and Julie represented Sheffield University, engaged with alumni, and met old and new colleagues and collaborators, whilst also presenting and gaining feedback on their research.
1 Resilience policymaking in Nepal: giving voice to communities (2017-2018)
2 Reactive household-based self-administered treatment against residual malaria transmission: a cluster randomised trial (2015-2018)

Written by Julie Balen & Sarita Panday

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New Year, New Students

We are delighted to welcome our new cohort of taught postgraduate students to ScHARR.

Students from across the globe have arrived today to study programmes in public health, management and leadership, health economics and decision modelling and clinical research.

We also welcome students to our online programmes. Although they may not be based in Sheffield, students studying international health leadership and management, advanced emergency care, public health or health technology assessment at a distance are equally part of the ScHARR community.

Intro Week 2017 student cohort

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ScHARR contributes to new report on liver disease and alcohol consumption

A new report published by the Foundation for Liver Research and endorsed by the Lancet Commission on Liver Disease includes new estimates from the Sheffield Alcohol Research Group (SARG) of the burden that alcohol places on the NHS and society. The report was featured on the front page of the Guardian newspaper on Monday 24th July, 2017.

SARG team

The figures used in the report come from the Sheffield Alcohol Policy Model, a complex behavioural and epidemiological simulation model which combines data on patterns of alcohol consumption and purchasing, current rates of harm for 43 different alcohol-related health conditions, evidence on the relationship between prices and purchasing, and epidemiological evidence on the links between drinking at different levels and risks of harm.

The numbers show that alcohol is estimated to cause 35 deaths and 2.300 hospital admissions a day in England, and over the next 5 years this will cost the NHS almost £17billion at a time when healthcare resources and budgets are already being stretched. This research also highlights the potential for policies such as a Minimum Unit Price for alcohol to reduce this burden.

This report comes out just as the UK Supreme Court is hearing the final stage in a lengthy court battle between the Scottish Government and the Scotch Whisky Association about the legality of Scotland’s efforts to introduce a Minimum Unit Price for alcohol.

Evidence from SARG and the Sheffield Model has formed an integral part of the court case, highlighting that the policy would effectively target the heaviest drinkers and have a positive effect on socioeconomic inequalities in health. The court’s judgement is expected to be delivered in the Autumn, with a host of other countries, including Wales and Ireland, looking on. Both countries have announced their intention to introduce a Minimum Unit price, supported by SARG modelling, however this seems certain to be conditional on the Supreme Court ruling that the policy is not in breach of EU law.

The report can be downloaded from the “Downloads” section on the right hand side of this page.

University of Sheffield press release.

Guardian article featuring SARG’s work.

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