Antony Morgan

Evidence based public health: A review of the experience of the National Institute of Health and Clinical Excellence (NICE) of developing public health guidance in England

This paper describes the application of the principles of evidence based medicine to public health. It recounts the experience of the National Institute for Health and Clinical Excellence in England (NICE) which acquired a remit to develop public health guidance in 2005. Some of the history of the origins of the evidence based approach is described in the writings of Cochrane and others, and the way that this came to be a critical part of the NICE approach to developing clinical cost effectiveness is outlined. The challenge of applying these methods to an evidence base which is social and psychological as well as biomedical is considered. Key problems are identified: the breadth of the evidence base, different analytic levels of explanation, and the length of the causal chain between interventions and outcomes in public health.

Assessing equity in systematic reviews: realising the recommendations of the Commission on Social Determinants of Health

A group from the Cochrane Collaboration, Campbell Collaboration, and the World Health Organization Measurement and Evidence Knowledge Network has developed guidance on assessing health equity effects in systematic reviews of healthcare interventions. This guidance is also relevant to primary research

Measuring mental health and well-being of school-children in 15 European countries using the KIDSCREEN-10 index

Objectives:To test the psychometric properties and measurement results of the KIDSCREEN-10 Mental Health Index in school children from 15 European countries.Methods:Within the cross-sectional Health Behaviour in School-aged Children 2005/2006 Survey, 78,000 pupils aged 11, 13, 15 answered the KIDSCREEN and additional measures. Cronbach’s alpha, Rasch partial credit model itemfit and ANOVAs were conducted.Results:Cronbach’s alpha was 0.81, Rasch infit mean square residuals were 0.7–1.3. Mean scores varied 0.8 standard deviation across countries. Older pupils (effect size [ES] = 0.6), girls (ES = 0.2), pupils with low socio-economic status (ES = 0.5) or frequent health complaints (r = 0.5) reported decreased mental health.Conclusions:The KIDSCREEN-10 displayed good psychometric properties. Measured differences between countries, age, gender, SES, and health complaints comply with theoretical considerations.

A conceptual framework for public health: NICE's emerging approach

This paper outlines the National Institute for Health and Clinical Excellences (NICE) emerging conceptual framework for public health. This is based on the experience of the first 3 years of producing public health guidance at NICE (2005-2008). The framework has been used to shape the revisions to NICEs public health process and methods manuals for use post 2009, and will inform the public health guidance which NICE will produce from April 2009. The framework is based on the precept that both individual and population patterns of disease have causal mechanisms. These are analytically separate. Explanations of individual diseases involve the interaction between biological, social and related phenomena. Explanations of population patterns involve the same interactions, but also additional interactions between a range of other phenomena working in tandem. These are described. The causal pathways therefore involve the social, economic and political determinants of health, as well as psychological and biological factors. Four vectors of causation are identified: population, environmental, organizational and social. The interaction between the vectors and human behaviour are outlined. The bridge between the wider determinants and individual health outcomes is integration of the life course and the lifeworld.

Adolescent multiple risk behaviour: an asset approach to the role of family, school and community

BACKGROUND Engagement in risk behaviours may pose a significant threat to health if involvement spans multiple behaviours. The asset model suggests that contextual aspects of young peoples lives, such as factors related to family, school and community, serve as a protective function against health risk behaviours. METHODS A risk-taking index was created from the English health behaviour in school-aged children study on 15 years olds, substance use and sexual activity. Using a multinomial regression, potential asset variables relating to school, family, peers, community and family affluence were tested for their association with levels of risk behaviours. RESULTS Sense of neighbourhood belonging, strong school belonging and parental involvement in decision-making about leisure time were related to lower engagement in health risk behaviours. A weaker sense of family belonging was associated with increased risk behaviours if connectedness with teachers was also low. Factors related to school and community played a greater role in adolescent participation in health-related risk behaviours than family-related factors, including family affluence. CONCLUSIONS Feelings of safety and belonging in the out-of-home settings of adolescents were positively associated with reduced risk behaviours, and indicate the importance of the wider community alongside parents and school as protective assets for health.

Adolescent Place Attachment, Social Capital, and Perceived Safety: A Comparison of 13 Countries

In adolescence, children become increasingly independent and autonomous, and spend more time in neighborhood settings away from home. During mid-to-late adolescence, youth often become more critical about the place they live. Their attachment to home and even community may decrease as they explore and develop new attachments to other specific places. The aim of this study is to understand how 15-year-old students from 13 countries perceive their local neighborhood area (place attachment, social capital and safety), and how these different community cognitions are interrelated. We hypothesize that their place attachment predicts safety, and that the relationship is mediated in part by social capital. Result show that, despite cross-cultural differences in neighborhood perceptions, the proposed theoretical model fits robustly across all 13 countries.

The cost-effectiveness of public health interventions

BACKGROUND The need to make best use of limited resources in the English National Health Service is now greater than ever. This paper contributes to this endeavour by synthesizing data from cost-effectiveness evidence produced to support the development of public health guidance at the National Institute of Health and Clinical Excellence (NICE). No comprehensive list of cost-effectiveness estimates for public health interventions has previously been published in England. METHODS Cost-effectiveness estimates using English cost data were collected and analysed from 21 (of 26) economic analyses underpinning public health guidance published by NICE between 2006 and 2010. RESULTS Two hundred base-case cost-effectiveness estimates were analysed, 15% were cost saving (i.e. the intervention was more effective and cheaper than comparator). Eighty-five per cent were cost-effective at a threshold of £20,000 per quality-adjusted life year and 89% at the higher threshold of £30,000. A further 5.5% were above £30,000 and 5.5% of the interventions were dominated (i.e. the intervention was more costly and less effective than comparator). CONCLUSIONS The majority of public health interventions assessed are highly cost-effective. The next challenge is to provide commissioners with a framework that allows information from economic analyses to be combined with other criteria that supports making better investment decisions at a local level.

The contribution of club participation to adolescent health: evidence from six countries

Background: Social networks have been recognised as an important factor for enhancing the health of people and communities. Bridging social capital, characterised by numerous and varied weak ties, exemplifies a particular type of network that can help people reach their goals and improve their health. This study seeks to contribute to the evidence base on the use of positive social networks for young people’s health by exploring the importance of club participation in predicting the health and health-related behaviours of 15-year-old girls and boys across Europe and North America. Methods: Data are derived from a 2005–6 World Health Organization collaborative study, to establish the relationships between different types of club and a range of health outcomes (self-perceived health, wellbeing and symptoms) and health-related behaviours (smoking, drinking). Multi-level logistic regression was used to assess the independent effects of club participation by controlling for gender and socioeconomic position. Data were compared across six countries. Results: All the considered outcomes, both in terms of perceived health and wellbeing and health behaviours were associated with participation in formal associations. The associations are in the expected direction (participation corresponding to better health) except for some particular association types. Conclusions: Participation in formal associations seems supportive for good health and health behaviours in adolescence, and should be promoted in this age group.

Sustaining a positive body image in adolescence: an assets-based analysis

The increasing impetus to provide an effective response to childhood obesity has generated a corresponding concern that weight management interventions may lead to emotional problems among young people, notably in relation to the development of a negative body image. However, currently the processes and factors that contribute to the acquisition of body image among young people is poorly understood. Drawing on salutogenic theory, this paper employs an assets-based approach that focuses on health promoting and protective factors to identify how young people may create or sustain positive body images. Secondary data analysis was undertaken from the WHO Health Behaviour in School Aged Children Study. During the spring term of 2002, information was collected from 6425 English adolescents aged 11-15 using a self-administered questionnaire. The data were analysed using stepwise multinomial logistic regression to determine which factors were associated with positive body image; a total of 2898 students were included in the final analysis. Adolescents who self-identified as having a positive body image were more likely to report ease of talking with a father figure, feeling intelligent, perceiving that their family were well off and a belief that their teachers were interested in them as people. Body Mass Index, age, gender and living within a household containing a father were also significant predictors of body image. The discussion provides an exploration of how the construction of young peoples emotional health is in part linked with the attainment of a secure and positive body image. The implications for health promotion and educational programmes are then examined. By considering the assets, which support or sustain a positive body image during adolescence, obesity prevention programmes could be better tailored to meet the needs of young people. In the future, a salutogenic curriculum might provide an alternative to unsustainable levels of deficit led, targeted programmes.

The association between social capital and mental health and behavioural problems in children and adolescents: an integrative systematic review

BackgroundMental health is an important component of overall health and wellbeing and crucial for a happy and meaningful life. The prevalence of mental health problems amongst children and adolescent is high; with estimates suggesting 10-20% suffer from mental health problems at any given time. These mental health problems include internalising (e.g. depression and social anxiety) and externalising behavioural problems (e.g. aggression and anti-social behaviour). Although social capital has been shown to be associated with mental health/behavioural problems in young people, attempts to consolidate the evidence in the form of a review have been limited. This integrative systematic review identified and synthesised international research findings on the role and impact of family and community social capital on mental health/behavioural problems in children and adolescents to provide a consolidated evidence base to inform future research and policy development.MethodsNine electronic databases were searched for relevant studies and this was followed by hand searching. Identified literature was screened using review-specific inclusion/exclusion criteria, the data were extracted from the included studies and study quality was assessed. Heterogeneity in study design and outcomes precluded meta-analysis/meta-synthesis, the results are therefore presented in narrative form.ResultsAfter screening, 55 studies were retained. The majority were cross-sectional surveys and were conducted in North America (n = 33); seven were conducted in the UK. Samples ranged in size from 29 to 98,340. The synthesised results demonstrate that family and community social capital are associated with mental health/behavioural problems in children and adolescents. Positive parent–child relations, extended family support, social support networks, religiosity, neighbourhood and school quality appear to be particularly important.ConclusionsTo date, this is the most comprehensive review of the evidence on the relationships that exist between social capital and mental health/behavioural problems in children and adolescents. It suggests that social capital generated and mobilised at the family and community level can influence mental health/problem behaviour outcomes in young people. In addition, it highlights key gaps in knowledge where future research could further illuminate the mechanisms through which social capital works to influence health and wellbeing and thus inform policy development.