Elizabeth McGill

Trading quality for relevance: non-health decision-makers' use of evidence on the social determinants of health.

Objectives Local government services and policies affect health determinants across many sectors such as planning, transportation, housing and leisure. Researchers and policymakers have argued that decisions affecting wider determinants of health, well-being and inequalities should be informed by evidence. This study explores how information and evidence are defined, assessed and utilised by local professionals situated beyond the health sector, but whose decisions potentially affect health: in this case, practitioners working in design, planning and maintenance of the built environment. Design A qualitative study using three focus groups. A thematic analysis was undertaken. Setting The focus groups were held in UK localities and involved local practitioners working in two UK regions, as well as in Brazil, USA and Canada. Participants UK and international practitioners working in the design and management of the built environment at a local government level. Results Participants described a range of data and information that constitutes evidence, of which academic research is only one part. Built environment decision-makers value empirical evidence, but also emphasise the legitimacy and relevance of less empirical ways of thinking through narratives that associate their work to art and philosophy. Participants prioritised evidence on the acceptability, deliverability and sustainability of interventions over evidence of longer term outcomes (including many health outcomes). Participants generally privileged local information, including personal experiences and local data, but were less willing to accept evidence from contexts perceived to be different from their own. Conclusions Local-level built environment practitioners utilise evidence to make decisions, but their view of ‘best evidence’ appears to prioritise local relevance over academic rigour. Academics can facilitate evidence-informed local decisions affecting social determinants of health by working with relevant practitioners to improve the quality of local data and evaluations, and by advancing approaches to improve the external validity of academic research.

Does Shared Decision Making in Cancer Treatment Improve Quality of Life? A Systematic Literature Review

Background. The growing consensus espousing the use of shared decision making (SDM) in cancer treatment has coincided with the rise of health care evaluation paradigms that emphasize quality of life (QOL) as a central outcome measure. This review systematically examines the association between treatment SDM and QOL outcomes in cancer. Methods. A range of bibliographic databases and gray literature sources was searched. The search retrieved 16,726 records, which were screened by title, abstract, and full text to identify relevant studies. The review included 17 studies with a range of study designs and populations. Data were extracted on study methods, participants, setting, study or intervention description, outcomes, main findings, secondary findings, and limitations. Quality appraisal was used, in conjunction with a narrative approach, to synthesize the evidence. Results. The review found weak, but suggestive, evidence for a positive association between perceived patient involvement in decision making, a central dimension of SDM, and QOL outcomes in cancer. The review did not find evidence for an inverse association between SDM and QOL. The poor methodological quality and heterogeneity of the extant literature constrained the derived conclusions. In addition, the literature commonly treated various subscales of QOL instruments as separate outcomes, increasing the probability of spurious findings. Conclusions. There is weak evidence that aspects of shared decision-making approaches are positively associated with QOL outcomes and very little evidence of a negative association. The extant literature largely assessed patient involvement, only capturing one aspect of the shared decision-making construct, and is of poor quality, necessitating robust studies examining the association.

Shared decision-making and outcomes in type 2 diabetes: A systematic review and meta-analysis

OBJECTIVE Type 2 diabetes is a chronic disease which necessitates the development of a therapeutic alliance between patient and provider. This review systematically examines the association between treatment shared decision-making (SDM) and outcomes in diabetes. METHODS A range of bibliographic databases and gray literature sources was searched. Included studies were subjected to dual data extraction and quality assessment. Outcomes were synthesized using meta-analyses where reporting was sufficiently homogenous or alternatively synthesized in narrative fashion. RESULTS The search retrieved 4592 records, which were screened by title, abstract, and full text to identify 16 studies with a range of study designs and populations. We found evidence of an association between SDM and improved decision quality, patient knowledge and patient risk perception. We found little evidence of an association between SDM and glycemic control, patient satisfaction, quality of life, medication adherence or trust in physician. CONCLUSIONS This work elucidates the potential clinical utility of SDM interventions in the management of Type 2 Diabetes and helps inform future research on the topic. PRACTICE IMPLICATIONS A more complete understanding of the associations between SDM and outcomes will guide and motivate efforts aimed at improving uptake of the SDM paradigm.

Consequences of removing cheap, super-strength beer and cider: a qualitative study of a UK local alcohol availability intervention

Objectives Increasingly, English local authorities have encouraged the implementation of an intervention called ‘Reducing the Strength’ (RtS) whereby off-licences voluntarily stop selling inexpensive ‘super-strength’ (≥6.5% alcohol by volume (ABV)) beers and ciders. We conceptualised RtS as an event within a complex system in order to identify pathways by which the intervention may lead to intended and unintended consequences. Design A qualitative study including a focus group and semistructured interviews. Setting An inner-London local authority characterised by a high degree of residential mobility, high levels of social inequality and a large homeless population. Intervention piloted in three areas known for street drinking with a high alcohol outlet density. Participants Alcohol service professionals, homeless hostel employees, street-based services managers and hostel dwelling homeless alcohol consumers (n=30). Results Participants describe a range of potential substitution behaviours to circumvent alcohol availability restrictions including consuming different drinks, finding alternative shops, using drugs or committing crimes to purchase more expensive drinks. Service providers suggested the intervention delivered in this local authority missed opportunities to encourage engagement between the council, alcohol services, homeless hostels and off-licence stores. Some participants believed small-scale interventions such as RtS may facilitate new forms of engagement between public and private sector interests and contribute to long-term cultural changes around drinking, although they may also entrench the view that ‘problem drinking’ only occurs in certain population groups. Conclusions RtS may have limited individual-level health impacts if the target populations remain willing and able to consume alternative means of intoxication as a substitute for super-strength products. However, RtS may also lead to wider system changes not directly related to the consumption of super-strengths and their assumed harms.

How do Cumulative Impact Policies work? Use of institutional ethnography to assess local government alcohol policies in England

Abstract Background The Licensing Act (2003) gives English local authorities the power to implement Cumulative Impact Policies (CIPs), which are intended to strengthen licensing powers and limit the growth of on-premise and off-premise alcohol outlet density. Local authorities can now implement CIPs by designating boundaries within their borough as cumulative impact zones (CIZs) if adverse social effects of alcohol market saturation can be demonstrated. We are evaluating this intervention in a London borough, which as of January, 2013, had seven CIZs. Methods The qualitative arm of our study is informed by institutional ethnography. This sociological research tradition has had limited application in public health sciences despite obvious applicability to understanding processes of multilevel institutional regulation. We conducted semi-structured individual and group interviews with stakeholders (eg, licensing officers, councillors, police, trade), documentary analysis, and ethnographic data collection. Research participants were purposively selected to include diverse stakeholders from within our case study area as well as neighbouring boroughs with CIPs. We developed a detailed map to account for the ways in which different texts (eg, laws, policies, licensing forms) coordinate sequences of action related to alcohol licensing (eg, the work of granting or rejecting a licence application). Findings CIPs are an example of multilevel governance where national and local alcohol licensing priorities, interests, and legal powers interface. CIPs informed how some licensed premises conducted their business, including terms and conditions voluntarily adopted to minimise alcohol-related harms (eg, willingness to stop selling high-strength, inexpensive beer and cider). With newfound regulatory powers at the local level, came complex forms of work that local authorities had to negotiate, including assembling evidence and contesting licensing claims of applicants who sought to be granted new or modified licences. Interpretation Understanding the social and public health effects of CIPs requires innovative research strategies. Institutional ethnography offers important opportunities for methodological innovation in public health science. The map we developed reveals that CIPs must be viewed in relation to other alcohol initiatives. This qualitative research also generated nuanced questions about the social and public health effects of this alcohol intervention to which our ongoing quantitative analysis will contribute. Funding This work was supported by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR).

Use of retail data in the assessment of natural experiments: the case of Reducing the Strength, an intervention to reduce alcohol availability

Abstract Background Retailers routinely collect data about peoples purchasing behaviours and access to consumer products associated with health and wellbeing. Here we discuss how retail data can be used in public health research and consider potential strengths and limitations to such research. To illustrate the discussion we refer to an evaluation of an intervention called Reducing the Strength, whereby off-licence shops and supermarkets voluntarily stopped selling inexpensive superstrength (≥6·5% alcohol by volume) beers and ciders. Methods Monthly data from a large retail chain (East of England Co-operative Society) were obtained for three UK counties (141 stores). In one county the intervention started 12 months earlier than the others, allowing for a pre–post study design with a delayed implementation comparator. Difference-in-differences analysis of unit alcohol sales controlled for socioenvironmental confounders and shop-level characteristics including shop size, parking facilities, cash machines, opening hours, and other factors. Findings The retail data detailed shop-level characteristics and sales data such as prices, quantities, product brands, alcohol content, sales, and factors affecting sales. The wide geographical coverage, shop-level data, including data for potential confounding factors, and frequent timepoints made the retail data well-suited for a quasi-experimental evaluation capitalising on temporal and spatial variations in intervention exposure. Limitations of this study include a lack of longitudinal data for individual customers, and shops that are not covered by the data. Qualitative interviews with shop workers and customers, and triangulation using alternative data sources can help to address limitations. Alternative sources of retail data such as private sector consultants who specialise in collecting shop-level and sales data for a range of companies might also address some limitations; however, there are potential barriers of expense, accessibility, and coverage associated with the use of such consultants. Interpretation Increasingly, researchers recognise the potential of retail data for evaluating interventions affecting social determinants of health and inequalities, such as local access to alcohol. However, shop-level data have frequently proved difficult for researchers to obtain. By obtaining such data we have been able to assess, using a quasi-experimental design, the effects of removing strong, cheap beers and ciders from shops. We have also been able to explore in more detail how to optimise the strengths and address some limitations of the data in ways that could potentially assist others planning to use this important data source in their research. Funding The study is funded as part of the School of Public Health Research by NHS National Institute of Health Research. AJ, SA, and JW contributed as employees of Public Health Suffolk, Suffolk County Council.

Challenging, co-operating and splitting: a qualitative analysis of how the trade press responded to cumulative impact policies in England and Wales

Abstract Introduction: Cumulative impact policies (CIPs) increase English and Welsh local authority powers to regulate licences to sell alcohol. Commercial actors’ responses to CIPs potentially affect implementation and impacts. An analysis of the trade press provides perspectives on how commercial actors respond to this intervention. Methods: Qualitative, thematic analysis of trade press articles (published 2003–2016, n = 6 trade journals) focusing on depictions and responses to CIPs, including strategies for commercial actors engaging with the intervention. Results: Included articles (n = 257) provided both positive, but more typically, negative depictions of CIPs. CIPs were criticised for being unfair and an economic threat. Legal challenges to CIPs were at times advocated. Partnership and dialogue with local authority stakeholders were presented as a means by which licence applicants could promote their commercial interests in areas where CIPs were implemented, or as an alternative to regulatory interventions such as CIPs. Some alcohol retailers hoped CIPs could protect their businesses from market competition. Conclusions: Commercial actors do not respond uniformly to alcohol regulation. This study of CIPs found that at times different commercial interests could be served by directly challenging the intervention or strategically co-operating with implementers. Implementation and evaluation of such interventions should consider commercial actors’ responses.