Emma Halliday

Do health improvement programmes fit with MRC guidance on evaluating complex interventions

Although planning of new health policy could be improved to enable more robust evaluation, Mhairi Mackenzie and colleagues argue that randomised controlled trials are not always suitable or practical

Evaluating the health inequalities impact of area-based initiatives across the socioeconomic spectrum: a controlled intervention study of the New Deal for Communities, 2002–2008

Background Previous evaluations of area-based initiatives have not compared intervention areas with the full range of areas from top to bottom of the social spectrum to evaluate their health inequalities impact. Setting Deprived areas subject to the New Deal for Communities (NDC) intervention, local deprivation-matched comparator areas, and areas drawn from across the socioeconomic spectrum (representing high, medium and low deprivation) in England between 2002 and 2008. Data Secondary analysis of biannual repeat cross-sectional surveys collected for the NDC National Evaluation Team and the Health Survey for England (HSE). Methods Following data harmonisation, baseline and time trends in six health and social determinants of health outcomes were compared. Individual-level data were modelled using regression to adjust for age, sex, ethnic and socioeconomic differences among respondents. Results Compared with respondents in HSE low deprivation areas, those in NDC intervention areas experienced a significantly steeper improvement in education, a trend towards a steeper improvement in self-rated health, and a significantly less steep reduction in smoking between 2002 and 2008. In HSE high deprivation areas, significantly less steep improvements in five out of six outcomes were seen compared with HSE low deprivation areas. Conclusions Although unable to consider prior trends and previous initiatives, our findings provide cautious optimism that well-resourced and constructed area-based initiatives can reduce, or at least prevent the widening of, social inequalities for selected outcomes between the most and least deprived groups of areas.

Professional and service-user perceptions of self-help in primary care mental health services

Self-help is becoming an increasingly accessible option for addressing mental health problems. Despite this, self-help is subject to a variety of interpretations, little is known about how professionals and service-users conceptualise self-help, or how service-users engage in self-help activities. This study aimed to explore the views of self-help by service-users and health professionals in one area of Scotland, including the perceptions of what constitutes self-help and how it might be used to address mental health problems in primary care. The research involved semistructured interviews with 31 primary care mental health professionals, and in-depth interviews with 34 service-users. We found that professionals and service-users describe self-help in different ways, which has great implications for referral to and implementation of self-help in primary care settings. It also emerged that self-help was not necessarily perceived to be able to address the causes of mental distress, which could leave some professionals defaulting to offering no interventions despite the fairly positive attitude service-users show to self-help strategies. Finally, professionals need to be convinced that interventions are useful, effective and accessible as there are significant barriers in professionals using self-help; if they are not convinced, such approaches will support their therapeutic approach. The research supports the need to develop methods of delivery that offer self-help as part of a broad package of care that also considers social causes of distress.

Measuring the tail of the dog that doesn't bark in the night: the case of the national evaluation of Choose Life (the national strategy and action plan to prevent suicide in Scotland)

BackgroundLearning about the impact of public health policy presents significant challenges for evaluators. These include the nebulous and organic nature of interventions ensuing from policy directives, the tension between long-term goals and short-term interventions, the appropriateness of establishing control groups, and the problems of providing an economic perspective. An example of contemporary policy that has recently been subject to evaluation is the first phase of the innovative Scottish strategy for suicide prevention (Choose Life).Discussion and summaryThis paper discusses how challenges, such as those above, were made manifest within this programme. After a brief summary of the overarching approach taken to evaluating the first phase of Choose Life, this paper then offers a set of recommendations for policymakers and evaluators on how learning from a second phase might be augmented. These recommendations are likely to have general resonance across a range of policy evaluations as they move from early planning and implementation to more mature phases.

Local policies to tackle a national problem: Comparative qualitative case studies of an English local authority alcohol availability intervention

Cumulative impact policies (CIPs) are widely used in UK local government to help regulate alcohol markets in localities characterised by high density of outlets and high rates of alcohol related harms. CIPs have been advocated as a means of protecting health by controlling or limiting alcohol availability. We use a comparative qualitative case study approach (n=5 English local government authorities, 48 participants) to assess how CIPs vary across different localities, what they are intended to achieve, and the implications for local-level alcohol availability. We found that the case study CIPs varied greatly in terms of aims, health focus and scale of implementation. However, they shared some common functions around influencing the types and managerial practices of alcohol outlets in specific neighbourhoods without reducing outlet density. The assumption that this will lead to alcohol harm-reduction needs to be quantitatively tested.

Health trajectories in regeneration areas in England: the impact of the New Deal for Communities intervention

Background A large body of evidence documents the adverse relationship between concentrated deprivation and health. Among the evaluations of regeneration initiatives to tackle these spatial inequalities, few have traced the trajectories of individuals over time and fewer still have employed counterfactual comparison. We investigate the impact of one such initiative in England, the New Deal for Communities (NDC), which ran from 1999 to 2011, on socioeconomic inequalities in health trajectories. Methods Latent Growth Curve modelling of within-person changes in self-rated health, mental health and life satisfaction between 2002 and 2008 of an analytical cohort of residents of 39 disadvantaged areas of England in which the NDC was implemented, compared with residents of comparator, non-intervention areas, focusing on: (1) whether differences over time in outcomes can be detected between NDC and comparator areas and (2) whether interventions may have altered socioeconomic differences in outcomes. Results No evidence was found for an overall improvement in the three outcomes, or for significant differences in changes in health between respondents in NDC versus comparator areas. However, we found a weakly significant gap in life satisfaction and mental health between high and low socioeconomic status individuals in comparator areas which widened over time to a greater extent than in NDC areas. Change over time in the three outcomes was non-linear: individual improvements among NDC residents were largest before 2006. Conclusions There is limited evidence that the NDC moderated the impact of socioeconomic factors on mental health and life satisfaction trajectories. Furthermore, any NDC impact was strongest in the first 6 years of the programmes.

[Accepted Manuscript] Local policies to tackle a national problem: Comparative qualitative case studies of an English local authority alcohol availability intervention.

Cumulative impact policies (CIPs) are widely used in UK local government to help regulate alcohol markets in localities characterised by high density of outlets and high rates of alcohol related harms. CIPs have been advocated as a means of protecting health by controlling or limiting alcohol availability. We use a comparative qualitative case study approach (n=5 English local government authorities, 48 participants) to assess how CIPs vary across different localities, what they are intended to achieve, and the implications for local-level alcohol availability. We found that the case study CIPs varied greatly in terms of aims, health focus and scale of implementation. However, they shared some common functions around influencing the types and managerial practices of alcohol outlets in specific neighbourhoods without reducing outlet density. The assumption that this will lead to alcohol harm-reduction needs to be quantitatively tested.

Putting context centre stage: evidence from a systems evaluation of an area based empowerment initiative in England

Abstract It is now widely accepted that context matters in evaluations of the health inequalities impact of community-based social initiatives. Systems thinking offers a lens for uncovering the dynamic relationship between such initiatives and their social contexts. However, there are very few examples that show how a systems approach can be applied in practice and what kinds of evidence are produced when this happens. In this paper, we use data from ethnographic fieldwork embedded within a multi-site mixed method evaluation to demonstrate how a systems approach can be applied in practice to evaluate the early stages of an area-based empowerment initiative – Big Local (funded by the Big Lottery Fund and delivered by Local Trust). Taking place in 150 different local areas in England and underpinned by an ethos of resident-led collective action, Big Local offers an illustration of the applicability of a systems approach to better understand the change processes that emerge as social initiatives embed and co-evolve within a series of local contexts. Findings reveal which parts of the social system are likely to be changed, by what mechanisms, and with what implications. They also raise some salient considerations for knowledge generation and methods development in public health evaluation, particularly for the evaluation of social initiatives where change does not necessarily happen in linear or predictable ways. We suggest future evaluations of such initiatives require the use of more flexible designs, encompassing qualitative approaches capable of capturing the complexity of relational systems processes, alongside more traditional quantitative methods.

Leisure centre entrance charges and physical activity participation in England

Reducing or eliminating the cost to the public of using leisure facilities is one tool that local authorities have available to reduce inequalities in physical activity (PA). There is limited evidence about the effect of leisure entrance charges and their impact on participation. This study aimed to ascertain how facility pricing influenced the decisions people made about how to pay and what to pay for and how, in turn, these decisions impacted on participation for different groups. A total of 83 members of the public living in 4 local authorities in the North West of England were involved in focus groups or individual interviews. The results show that cost was a key factor which influenced PA participation in low income neighbourhoods. In practise, however, the majority of service users navigated the range of prices or payment options to find one that was suitable rather than simply reporting whether leisure was affordable or not. Whilst pre-paid options (e.g. direct debit memberships) encouraged participation, entrance charges incurred each time an individual participated had a negative impact on frequency but were a convenient way of paying for occasional use or for people who were unable to afford a pre-paid option. Free access also helped people who could not afford pre-paid membership to exercise regularly as well as incentivizing non-users to try activities. The research concluded that policies that include components of free access and offer more flexible payment options are most likely to contribute to reducing inequalities in PA.

Getting Scotland on the move? Reflections on a 5-year review of Scotland's national physical activity strategy

The public health risks of physical inactivity have led many national governments to develop policies that aim to increase population levels of physical activity. There is however, little evidence available about the effectiveness of such strategies and physical activity leaders may also face challenges in securing sufficient levels of political will and lasting investment for physical activity. This article reports on a review of a national physical activity strategy in Scotland after 5 years of implementation and offers lessons that may assist policymakers, practitioners and communities seeking to mobilise political commitment and leadership for physical activity in their own countries.