Jayne Parry

Why are there so few working-class applicants to medical schools? Learning from the success stories

Objectivesu2002 Students from lower socio‐economic circumstances remain under‐represented in UK medical schools despite recent shifts in other demographic variables and specific policy emphasis on widening participation (WP). This study aimed to further understanding of the reasons for this.

Community participation in health impact assessments: intuitively appealing but practically difficult.

Health impact assessment (HIA)attemptsan extremely difficult task. It tries notonly to project the impacts of policies,programmes and developments on publichealth but to influence the politicaldecision-making process on the basis ofits findings. Given its high ambitions,it is not surprising that governments haveencountered difficulties in institutionaliz-ing HIA within the process of makingpolicy. Anticipating health impacts andinfluencing decision-making are difficultenough in their own right, withoutcombining the two in one process. Theambitions of HIA and the time andresource restrictions inherent in the policyprocess dynamic thus place seriousdemands on one another, and the politicaland institutional barriers confrontingHIA may necessitate sober compromiseswithinitsgeneralprocessandmethodology.One key methodological issue thatmay challenge the relationship betweenHIA and policy is the involvement of thecommunity in the HIA process. TheGothenburg consensus paper makes clearthe need for participation to underpinthe assessment process in order to main-tainvaluesofdemocracy,transparencyandequity (1). Indeed, community participa-tion is a central ideal found in almostall the contemporary major national andinternational declarations on health, butlittleempiricalworkhasexploredtheutilityof participation in attaining HIA’s objec-tives. For example, does broad-basedcommunity participation result in a moreaccurate prediction of impacts, improveddecision-making, increased transparency,local accountability, and increased com-munity empowerment and ownershipof policy?Whilst little work has been under-taken in the context of HIA, there is asubstantialbodyofliteraturethatdescribesthe impact of participation in other areasof health policy formulation and imple-mentation(2–4).Communityinvolvementmay have a positive impact on the successof project development and implementa-tion. Participation may also directly affectindividuals by changing attitudes andactions towards the causes of ill-health,promoting a sense of responsibility andincreasing personal confidence and self-esteem.Involvement inthepolicyprocessmay decrease alienation among sociallyexcluded groups and reorient powerrelationships with the ‘‘professional’’decision-makers.But other researchers have reportedconsiderable difficulties in conductingcommunity participation exercises (5–7).Participation is time-consuming andcommunities often questioned the valueof investing time and effort in a project.Local people are often too busy goingabout their daily business to becomeinvolvedinparticipatoryactivities,andthelegitimacy of those who chose to partici-pate with regard to representing the viewsof the wider community is unclear.Communities are not some homogenousbody — they are often fraught withdivisions, tensions and conflicts, andcertainvulnerablegroupsmaybeunwillingor even unable to participate.What can we learn for HIA fromthe participatory experiences of otherprevious policy programmes? Participa-tion is intuitively appealing but it is clearthat participatory approaches do notalways run smoothly. Working with com-munities is far from easy and participatorypartnerships take time to build if theyaretobetrulyparticipatory.Andhereinliesthe problem: HIA usually has to be donereasonably quickly, so as to operatewithinthepolicy-makingtimescale.Togetcommunity participation quickly necessi-tates the use of existing structures andpeople; it means compromising the extentof consultation with hard-to-reachgroups; and it means that assessmentsalmost certainly have to be predomi-nately ‘‘top-down’’ professionally-ledexercises. This type of HIA runs the riskof legitimizing a decision in which asubstantial proportion of the communityhave not been involved despite theassessment being conducted under thebanner of ‘‘participation’’.Sohowcanwecombineparticipationand HIA? Colleagues are developingtechniquesforrapidparticipatoryappraisaland these may go some way towardsovercoming some of the problemsdiscussed (8). But perhaps a more radicalsolution would be to suggest that in thecontext of HIA, limiting involvement toasmallgroupofexpertsmightbethemostappropriate and efficient means to gen-erate sufficient information to influencethe policy-making process (9). Supportfor such an approach comes not froma rejection of the validity of communityinvolvement but because if HIA is to getbeyond the field of purely academicinterest and gain credibility with policy-makers, it must fit policy-makers’ require-ments. And if it is to do this, communityparticipation may be difficult, if notimpossible, to achieve, given the time andresource constraints of the policy-makingdynamic. HIA should explicitly acknowl-edgethetensionbetweenthetimerequiredto deliver on the policy agenda and thetime required to build true participatorypartnerships with communities.Whilst ideal, participation may simplynot be possible for the majority ofHIAs. Those working on HIA should notapologize for this: if an assessment hasnot got the time or resources to bringabout meaningful community participa-tion, is it wise to attempt it at all?

What impact will an increased number of teaching general practices have on patients, doctors and medical students?

Backgroundu2002 Recommendations for medical training have seen a growing drive for undergraduate teaching to take place within the community – primarily in the general practice surgery. In light of the ongoing expansion of medical student numbers, many more general practices will be required to participate in undergraduate teaching.

Participation in health impact assessment: objectives, methods and core values

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIAs aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the communitys experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to expert and research-generated evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy.

Will the NHS continue to function in an influenza pandemic? a survey of healthcare workers in the West Midlands, UK

BackgroundIf UK healthcare services are to respond effectively to pandemic influenza, levels of absenteeism amongst healthcare workers (HCWs) must be minimised. Current estimates of the likelihood that HCWs will continue to attend work during a pandemic are subject to scientific and predictive uncertainty, yet an informed evidence base is needed if contingency plans addressing the issues of HCW absenteeism are to be prepared.MethodsThis paper reports the findings of a self-completed survey of randomly selected HCWs across three purposively sampled healthcare trusts in the West Midlands. The survey aimed to identify the factors positively or negatively associated with willingness to work during an influenza pandemic, and to evaluate the acceptability of potential interventions or changes to working practice to promote the continued presence at work of those otherwise unwilling or unable to attend. Likelihood and persuadability scores were calculated for each respondent according to indications of whether or not they were likely to work under different circumstances. Binary logistic regression was used to compute bivariate and multivariate odds ratios to evaluate the association of demographic variables and other respondent characteristics with the self-described likelihood of reporting to work.ResultsThe survey response rate was 34.4% (n = 1032). Results suggest absenteeism may be as high as 85% at any point during a pandemic, with potential absence particularly concentrated amongst nursing and ancillary workers (OR 0.3; 95% CI 0.1 to 0.7 and 0.5; 95% CI 0.2 to 0.9 respectively).ConclusionLevels of absenteeism amongst HCWs may be considerably higher than official estimates, with potential absence concentrated amongst certain groups of employees. Although interventions designed to minimise absenteeism should target HCWs with a low stated likelihood of working, members of these groups may also be the least receptive to such interventions. Changes to working conditions which reduce barriers to the ability to work may not address barriers linked to willingness to work, and may fail to overcome HCWs reluctance to work in the face of what may still be deemed unacceptable risk to self and/or family.

Hostile teaching hospitals and friendly district general hospitals: final year students' views on clinical attachment locations

Contextu2002 The NHS Plan has indicated the need to increase the number of doctors in the NHS. To accommodate the substantial increase in student numbers in Birmingham, clinical teaching will need to expand from its traditional base within established teaching hospitals (THs) to district general hospitals (DGHs). Previous studies elsewhere have suggested the experience of students who undertake clinical attachments in DGHs is different from that of students attached to THs. We sought to investigate whether such differences exist in the West Midlands region and to explore the opportunities and problems such differences may present to educators and students alike.

‘Health and well-being’: questioning the use of health concepts in public health policy and practice

In recent years, health and well-being have been ‘mainstreamed’ as a policy issue and have become the concern of a widening range of agencies. Simultaneously, increasing weight has been placed on the measurement of population health status, the implementation of evidence-based practice in public health and the more effective evaluation of policy interventions targeted at health gain and health inequalities. Thus, at a time when greater conceptual clarity is crucial, there are more stakeholders in ‘health’, each with a potentially different perspective and understanding of what ‘health’ is. In this study, we explore the need for greater conceptual clarity in relation to health, using the term ‘well-being’ as an exemplar. We draw on findings from a research project undertaken with community and professional groups in the Black Country and Shropshire that explored shared ways to measure aspects, and determinants, of health. We suggest a lack of attention to health concepts and their clarification, as indicated by the use of ‘well-being’ as an ill-defined tag to health, is having a negative impact on public healths ability to deliver health gain, and that commitment to clarifying concepts would lead to a range of benefits. At present, however, the term ‘well-being’ muddies the waters, acting more as an open-ended catch-all category than a clearly considered component of ‘health’.

Institutionalizing policy-level health impact assessment in Europe: is coupling health impact assessment with strategic environmental assessment the next step forward?

European Union (EU) Member States are interested in using health impact assessment (HIA) as a means of safeguarding their obligations to protect human health under the 1997 Treaty of Amsterdam. However, several have encountered difficulties institutionalizing HIA with the policy-making process. As a consequence, the World Health Organization (WHO) Regional Office for Europe has suggested coupling HIA with strategic environmental assessment (SEA). Traditionally, the incorporation of HIA into other forms of impact assessment has been resisted, for fear of losing its focus on health issues to environmental concerns, and compromising its social model of health with the introduction of biophysical indicators. But can these fears be substantiated? In this paper, we investigate the grounds for such concerns by reviewing the relevant policy documents and departmental guidelines of four non-European countries that have considered the use of integrated assessment. We found that the case for associating HIA with SEA in Europe is strong, and offers potential solutions to problems of screening, theoretical framework, causal pathways and ready entry to the policy process. Coupling HIA with SEA may thus be the next step forward in a longer journey towards institutionalizing HIA as an independent policy-linked device.

Exploring Resident (Non-)participation in the UK New Deal for Communities Regeneration Programme:

Current policy responses to low levels of resident participation in urban regeneration schemes may be based on flawed assumptions for the reasons underpinning non-participation amongst certain sections of disadvantaged communities. Ethnographic fieldwork in a New Deal for Communities area demonstrates that some residents actively avoid participation as part of `survival strategies that have been developed to cope with long-term multiple disadvantage. Capacity building exercises are unlikely to impact upon participation rates among these individuals and groups. Instead, a more radical approach to social policy provision is called for, that explicitly acknowledges and understands the socio-cultural context within which residents make decisions regarding participation.

Contextual influences on the development of obesity in children: A case study of UK South Asian communities

Objective An advocated approach to childhood obesity prevention research is the use of local community knowledge to inform intervention development. This paper demonstrates the value of accessing such local knowledge, and discusses how this information fits with existing conceptual models of childhood obesity. Methods A series of 9 focus groups were run in 2007 with 68 local community stakeholders (including parents, school staff, community leaders and health and local government representatives) from 8 South Asian communities in Birmingham, UK to explore perceptions of factors contributing to the development of childhood obesity. Results Perceptions of causal influences were grouped into several contexts, from the individual to the macro-level, that influence diet and physical activity. Specific cultural contextual data emerged that may explain decisions around physical activity and food intake of children within these communities. Assumptions made about South Asian communities were frequently contested. Conclusions In order to truly understand the contextual influences on childhood obesity in target communities, it is necessary to access knowledge from local community members. Existing conceptual models of childhood obesity do not bring the role of cultural factors to the fore, but this context needs to be explicitly considered in the development of childhood obesity interventions.