John McAteer

Seven key investments for health equity across the lifecourse: Scotland versus the rest of the UK

While widespread lip service is given in the UK to the social determinants of health (SDoH), there are few published comparisons of how the UKs devolved jurisdictions ‘stack up’, in terms of implementing SDoH-based policies and programmes, to improve health equity over the life-course. Based on recent SDoH publications, seven key societal-level investments are suggested, across the life-course, for increasing health equity by socioeconomic position (SEP). We present hard-to-find comparable analyses of routinely collected data to gauge the relative extent to which these investments have been pursued and achieved expected goals in Scotland, as compared with England and Wales, in recent decades. Despite Scotlands longstanding explicit goal of reducing health inequalities, it has recently been doing slightly better than England and Wales on only one broad indicator of health-equity-related investments: childhood poverty. However, on the following indicators of other ‘best investments for health equity’, Scotland has not achieved demonstrably more equitable outcomes by SEP than the rest of the UK: infant mortality and teenage pregnancy rates; early childhood education implementation; standardised educational attainment after primary/secondary school; health care system access and performance; protection of the population from potentially hazardous patterns of food, drink and gambling use; unemployment. Although Scotland did not choose independence on September 18th, 2014, it could still (under the planned increased devolution of powers from Westminster) choose to increase investments in the underperforming categories of interventions for health equity listed above. However, such discussion is largely absent from the current post-referendum debate. Without further significant investments in such policies and programmes, Scotland is unlikely to achieve the ‘healthier, fairer society’ referred to in the current Scottish Governments official aspirations for the nation.

Improving preconception health and care: a situation analysis

BackgroundThe purpose of this situation analysis was to explore the views of health and non-health professionals working with women of childbearing age on current and future delivery of preconception care in one National Health Service (NHS) Board area in Scotland.MethodsThe situation analysis was undertaken using a mixed methods approach. Six focus groups were conducted organised by profession – general practitioners (GPs), practice nurses, health visitors, family nurses, guidance teachers and youth workers. Existing evidence of effective preconception care interventions informed focus group guides. A survey was undertaken with community pharmacists which provided qualitative data for analysis. Focus group transcripts were analysed by two researchers using a thematic analysis approach.ResultsThere was lack of awareness of preconception health and its importance amongst the target group. Levels of unplanned pregnancy hampered efforts to deliver interventions. Professional knowledge, capacity and consistency of practice were viewed as challenges, as was individual compliance with preconception care advice. Improvement requires multifaceted action, including ensuring the school curriculum adequately prepares adolescents for future parenthood, increasing awareness through communication and marketing, supporting professional knowledge and practice and capitalising on existing opportunities for preconception care, and ensuring services are equitable and targeted to need.ConclusionsDelivery of preconception care needs to be improved both before and between pregnancies to improve outcomes for women and infants. Action is required at individual, organisational and community levels to ensure this important issue is at the forefront of preventative care and preventative spending.

A systematic review of adolescent physiological development and its relationship with health-related behaviour: a protocol

BackgroundAt any one time, there are one billion people worldwide who are in the second decade of their life, and 1.8 billion in the 10–24 age range.Whilst a great deal of focus has been placed on healthy early years development, the adolescent years are also a unique period of opportunity: exposure to health-influencing behaviours such as alcohol consumption or cigarette smoking, may serve to establish patterns that have significant health consequences in later life. Although there is often an emphasis on risk-taking and detrimental health behaviours during adolescence, these years also provide significant opportunities for behaviour to be shaped in positive ways that may improve longer term health outcomes. However, it is firstly important to understand the complex physiological changes that are taking place within the human body during this period and their relationship with health-related behaviour. Such knowledge can help to inform health policy and intervention development.AimThe aim of this study is to gain a comprehensive understanding of the relationship between physiological development and health-related behaviours in adolescence.MethodsThe principles of an integrative review will be used. Such reviews are of use where research has emerged in different fields, to combine existing knowledge and produce a more extensive understanding. Studies from a range of different methodological approaches, published or unpublished, will be included. A range of databases and literature depositories will be searched using a pre-defined search strategy. The review will include studies that focus on adolescents (nominally, those aged 10–24xa0years). We will seek papers that focus on both physiological development and health behaviour, or papers focusing solely on physiological development if there are clear implications for health behaviour. Studies with a focus on participants with specific health conditions will be excluded.Two reviewers will independently screen potential studies for eligibility and quality; members of the project team will act as third reviewers in the case of uncertainty or discrepancy.Further analyses (e.g. meta-analysis, meta-synthesis, meta-summary) will be decided upon, and sub-set analyses carried out. Finally, an integrative summation will be produced, giving a critical analysis of the results and providing conclusions and recommendations.

Experiences of knowledge brokering for evidence-informed public health, policy, and practice: 3 years of the Scottish Collaboration for Public Health Research and Policy

Abstract Background Despite interest in knowledge translation and exchange (KTE) in public health, few reports provide an account of knowledge brokerage organisations such as the Scottish Collaboration for Public Health Research and Policy (SCPHRP). SCPHRPs role is to identify public health interventions that equitably address major health priorities, foster collaboration between public health stakeholders, and build capacity for collaborative intervention research. Methods Four working groups, including members from research, practice, and policy, were formed to address prioritised topics across the life course. Directed by these groups, structured rapid reviews of the published work were undertaken. Various KTE and collaborative activities were used to strategically disseminate the review findings and to engage with stakeholders in implementation of the recommendations. These activities included events such as workshops, seminars and public meetings, and training courses. Findings SCPHRP commissioned and seed-funded several projects to support intervention development. The pilot studies and review findings contributed to the development of new research across the four topics. The timeliness and extent of convergence with current government priorities and initiatives probably had the greatest effect on policy makers receptivity. SCPHRP is working with Scottish Government and NHS Health Scotland on several policy relevant projects, including development of an evidence-informed parenting strategy; assessment of alcohol brief interventions; piloting of a measurement instrument to assess early child development at the population level; and obesity management and prevention. Interpretation The extent to which SCPHRP has successfully influenced government public health decision making will be known only in the longer term. However, our experiences suggest that successful KTE relies on the identification, development, and facilitation of networks that bridge the divide between scientific research, policy, and practice. These networks should ideally be developed early and involve stakeholders from policy, research, and practice from the outset. Windows of opportunity for engagement with policy makers on public health priorities should be identified and fully exploited. Funding UK Medical Research Council and Chief Scientist Office of the SCottish Government.

The physiology of adolescent sexual behaviour: A systematic review

Abstract Objectives: To examine physiological influences of adolescent sexual behaviour, including associated psychosocial factors. Methods: Systematic review. Results: Thirteen studies met the inclusion criteria relating to adolescents, physiology and sexual behaviour. We excluded studies relating to abnormal development. Findings highlighted hormonal and gender differences. Females appear to be more influenced by psychosocial aspects, including the effects of peers, than males. Males may be more inclined to engage in unprotected sex with a greater number of partners. Early maturing adolescents are more likely to be sexually active at an early age. Conclusions: Hormonal, psychosocial context, and sexual preference need to be acknowledged in intervention development. Stage of readiness to receive information may differ according to gender and physiological maturity.

Delivery of alcohol brief interventions in community-based youth work settings: exploring feasibility and acceptability in a qualitative study

BackgroundAlcohol Brief Interventions (ABIs) are increasingly being delivered in community-based youth work settings. However, little attention has been paid to how they are being implemented in such settings, or to their feasibility and acceptability for practitioners or young people. The aim of this qualitative study was to explore the context, feasibility and acceptability of ABI delivery in youth work projects across Scotland.MethodsIndividual, paired and group interviews were conducted with practitioners and young people in nine community projects that were either involved in the delivery of ABIs or were considering doing so in the near future. A thematic analysis approach was used to analyse data.ResultsABIs were delivered in a diverse range of youth work settings including the side of football pitches, on the streets as part of outreach activities, and in sexual health drop-in centres for young people. ABI delivery differed in a number of important ways from delivery in other health settings such as primary care, particularly in being largely opportunistic and flexible in nature. ABIs were adapted by staff in line with the ethos of their project and their own roles, and to avoid jeopardising their relationships with young people. Young people reacted positively to the idea of having conversations about alcohol with youth project workers, but confirmed practitioners’ views about the importance of these conversations taking place in the context of an existing trusting relationship.ConclusionABIs were feasible in a range of youth work settings with some adaptation. Acceptability to staff was strongly influenced by perceived benefits, and the extent to which ABIs fitted with their project’s ethos. Young people were largely comfortable with such conversations. Future implementation efforts should be based on detailed consideration of current practice and contexts. Flexible models of delivery, where professional judgement can be exercised over defined but adaptable content, may be better appreciated by staff and encourage further development of ABI activity.

Use of public health science to inform Scotland's National Parenting Strategy: an outcomes framework approach

Abstract Background A shift to an outcomes approach in Scotland has been triggered by the creation of the National Performance Framework (NPF). The aim of the NPF is to focus public reporting on progress towards achieving national outcomes. The Scottish Government tasked NHS Health Scotland with supporting this shift. One type of support has been to provide resources (outcomes frameworks) that help planners link local activities with the NPF. NHS Health Scotland has recently led the development of an outcomes framework for Scotlands National Parenting Strategy in collaboration with a wide range of partners. The aim of the framework is to identify the key outcomes for Scotlands National Parenting Strategy; specify those local activities that might be undertaken to achieve these shared outcomes; understand the contribution of partnership activities to delivering outcomes; and bring together and summarise the existing relevant evidence for effective interventions to support parents and families. We present an overview of the framework and the evidence contribution to its development. Methods Three logic models underpin the outcomes framework. Two nested models—interventions to support parents, families, and society; and structures and systems—flow into a strategic model. Together, these models set out the actions, reach, and outcomes for the strategy and its contribution to other national outcomes. In turn, these models were informed by a series of evidence reviews carried out by NHS Health Scotland and the Scottish Collaboration for Public Health Research and Policy. Findings The evidence reviews established the best available evidence for effective interventions to support parents and families. They covered interventions for parents of infants and children in the early years; interventions for parents of older children and adolescents; and characteristics of effective and ineffective adolescent health interventions with a parental component. These reviews were used to develop the rationale for national and local activities in supporting the identified key outcomes. Interpretation Outcomes frameworks like that for Scotlands National Parenting Strategy can help implementation of public health science into both national policy and local practice. Funding None.

Credibility of subgroup analyses by socioeconomic status in public health intervention evaluations: An underappreciated problem?

There is increasing interest amongst researchers and policy makers in identifying the effect of public health interventions on health inequalities by socioeconomic status (SES). This issue is typically addressed in evaluation studies through subgroup analyses, where researchers test whether the effect of an intervention differs according to the socioeconomic status of participants. The credibility of such analyses is therefore crucial when making judgements about how an intervention is likely to affect health inequalities, although this issue appears to be rarely considered within public health. The aim of this study was therefore to assess the credibility of subgroup analyses in published evaluations of public health interventions. An established set of 10 credibility criteria for subgroup analyses was applied to a purposively sampled set of 21 evaluation studies, the majority of which focussed on healthy eating interventions, which reported differential intervention effects by SES. While the majority of these studies were found to be otherwise of relatively high quality methodologically, only 8 of the 21 studies met at least 6 of the 10 credibility criteria for subgroup analysis. These findings suggest that the credibility of subgroup analyses conducted within evaluations of public health interventions’ impact on health inequalities may be an underappreciated problem.

CARE: The development of an intervention for kinship carers with teenage children

The study addresses the needs of Scottish kinship carers of teenage children who have been identified as being in need of extra support. It designs and tests an appropriate support programme, defined as CARE. The CARE intervention study reported here applied the Six Steps for Quality Intervention Development framework, a pragmatic, evidence-based framework. The Six Steps for Quality Intervention Development framework comprises six steps: the first three steps seek to reveal the concerns of the kinship carer group and to generate a theory of change; the remaining three steps generate a theory of action for the intervention, and subsequently for its implementation. There were three main benefits reported: first, the self-care techniques had a reportedly positive stress-reduction effect on kinship carers, and in their dealings with their teenager; second, kinship carers reported an increased self-awareness of their communication or connectedness with their teenager; and third, there was a reported positive impact upon behaviour control as a result of the stress-reduction and improved connectedness. The development of the CARE intervention programme suggests that the Six Steps in Quality Intervention Development provides a useful methodological underpinning for intervention procedures which can be applied in a range of public health and social work settings.

Adolescents and health-related behaviour: using a framework to develop interventions to support positive behaviours

BackgroundExperimentation is a natural part of adolescent maturation. In conjunction with increased exposure to behaviours such as alcohol or substance use, and the potentially intensified influence of peer groups, unhealthy behaviour patterns may develop as part of this experimentation. However, the adolescent years also provide considerable opportunity for behaviour to be shaped in positive ways that may improve immediate and longer term health outcomes. A systematic review carried out by the authors concluded that physiological changes during adolescence need to be considered when designing or implementing interventions, due to their influence on health behaviours. The aim of the study is to demonstrate how the six steps in quality intervention development (6SQuID) framework can be used, in conjunction with research or review findings, to inform the development of pilot or feasibility studies. Using the synthesised findings from our adolescent systematic review, we sought to illustrate how adolescent interventions might be designed to target specific health behaviours and augment positive adolescent health outcomes.MethodsWe applied the 6SQuID framework to the findings from a review of adolescent physiological influences on health behaviour. This involved following the process defined within 6SQuID and applying the sequential steps to build a proposed pilot study, based on the pre-defined findings of our systematic review. We used the Social Learning Theory to assist in identifying how and why change can be influenced, with and for adolescents.ResultsWe devised a pilot study example, targeting teaching assistants, to illustrate how the detailed steps within the 6SQuID framework can assist the development and subsequent implementation of adolescent interventions that are likely to be effective.ConclusionsThis paper gives details of how the 6SQuID framework can be used for intervention development, using specific research findings, across a variety of adolescent health behaviours. This example provides details of how to operationalise 6SQuID in practical terms that are transferrable to other populations and situations. In this respect, we anticipate that this illustrative case may be of use in the design, development, and implementation of a wide variety of interventions.