Mhairi Mackenzie

Promoting Social Change: The Experience of Health Action Zones in England

When New Labour came to power in the UK in1997 it brought with it a strong commitment to reducing inequality and social exclusion. One strand of its strategy involved a focus on areabased initiatives to reduce the effects of persistent disadvantage. Health Action Zones (HAZs) were the first example of this type of intervention, and their focus on community-based initiatives to tackle the wider social determinants of health inequalities excited great interest both nationally and internationally. This article draws on findings from the national evaluation of the initiative. It provides an overview of the HAZ experience, and explores why many of the great expectations associated with HAZs at their launch failed to materialise. It suggests that, despite their relatively limited impact, it is best to consider that they made a good start in difficult circumstances rather than that they failed. As a result there are some important lessons to be learned about the role of complex community-based interventions in tackling seemingly intractable social problems for policy-makers, practitioners and evaluators.

The Practice and the Theory Lessons from the Application of a Theories of Change Approach

Theory-based evaluation approaches are becoming increasingly popular in the evaluation of comprehensive community initiatives. Such an approach, Theory of Change (ToC), has been used in the external evaluations of two of four Scottish Health Demonstration projects. This article provides an empirically based analysis of the issues raised in the process of articulating a project’s ToC. It then considers the value of the approach in relation to sharpening planning, providing formative feedback, improving performance management, guiding internal and external evaluation, judging impact and reducing problems of attribution. A conclusion is reached that, whilst such approaches are by no means a panacea, they offer one useful framework within which to negotiate a range of evaluation practice decisions.

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

Feasibility and indicative results from a 12-month low-energy liquid diet treatment and maintenance programme for severe obesity

BACKGROUND There is no established primary care solution for the rapidly increasing numbers of severely obese people with body mass index (BMI) > 40 kg/m(2). AIM This programme aimed to generate weight losses of ≥15 kg at 12 months, within routine primary care. DESIGN AND SETTING Feasibility study in primary care. METHOD Patients with a BMI ≥40 kg/m(2) commenced a micronutrient-replete 810-833 kcal/day low-energy liquid diet (LELD), delivered in primary care, for a planned 12 weeks or 20 kg weight loss (whichever was the sooner), with structured food reintroduction and then weight-loss maintenance, with optional orlistat to 12 months. RESULT Of 91 patients (74 females) entering the programme (baseline: weight 131 kg, BMI 48 kg/m(2), age 46 years), 58/91(64%) completed the LELD stage, with a mean duration of 14.4 weeks (standard deviation [SD] = 6.0 weeks), and a mean weight loss of 16.9 kg (SD = 6.0 kg). Four patients commenced weight-loss maintenance omitting the food-reintroduction stage. Of the remaining 54, 37(68%) started and completed food reintroduction over a mean duration of 9.3 weeks (SD = 5.7 weeks), with a further mean weight loss of 2.1 kg (SD = 3.7 kg), before starting a long-term low-fat-diet weight-loss maintenance plan. A total of 44/91 (48%) received orlistat at some stage. At 12 months, weight was recorded for 68/91 (75%) patients, with a mean loss of 12.4 kg (SD = 11.4 kg). Of these, 30 (33% of all 91 patients starting the programme) had a documented maintained weight loss of ≥15 kg at 12 months, six (7%) had a 10-15 kg loss, and 11 (12%) had a 5-10 kg loss. The indicative cost of providing this entire programme for wider implementation would be £861 per patient entered, or £2611 per documented 15 kg loss achieved. CONCLUSION A care package within routine primary care for severe obesity, including LELD, food reintroduction, and weight-loss maintenance, was well accepted and achieved a 12-month-maintained weight loss of ≥15 kg for one-third of all patients entering the programme.

An evaluation of police reporting of road casualties

Background: Under-reporting of road traffic casualties in police records has been well documented. Objectives: To investigate the extent and nature of possible under-reporting of road traffic casualties in the West of Scotland. Design: A linked database comprising both police data (STATS19) and hospital in-patient records (SMR01) was created. The study period was 1997–2005 inclusive. Contrasting the number of SMR01-identified road casualties that were also recorded (“linked”) in STATS19 records with those that were not (“unlinked”) gives an indication of the extent and types of under-reporting of hospitalized road casualties by the police. Results: 45% of hospital admissions due to road casualties were not reported to (or recorded by) the police. The STATS19 “slight casualties” that were linked to the SMR01 data was the only category that showed an increase in numbers (+4%) over the study period, whereas the numbers of STATS19 KSI (killed or seriously injured—combining fatal and serious casualties) decreased substantially (−38%). Pedal cyclists and motorcyclists were most likely to be missed by police recording. No third-party involvement, older casualties, females, length of stay in hospital (day cases), and earlier year of crash were also significantly associated with under-reporting. Conclusions: A general decline in the completeness of STATS19 is unlikely to have occurred, but there may have been an increasing tendency over time for police officers to report injuries as slight rather than serious. To improve the quality of this information, routine linkage of road casualty data derived from police and hospitalization databases should be considered.

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.

Changes in body weight and food choice in those attempting smoking cessation: a cluster randomised controlled trial

BackgroundFear of weight gain is a barrier to smoking cessation and significant cause of relapse for many people. The provision of nutritional advice as part of a smoking cessation programme may assist some in smoking cessation and perhaps limit weight gain. The aim of this study was to determine the effect of a structured programme of dietary advice on weight change and food choice, in adults attempting smoking cessation.MethodsCluster randomised controlled design. Classes randomised to intervention commenced a 24-week intervention, focussed on improving food choice and minimising weight gain. Classes randomised to control received “usual care”.ResultsTwenty-seven classes in Greater Glasgow were randomised between January and August 2008. Analysis, including those who continued to smoke, showed that actual weight gain and percentage weight gain was similar in both groups. Examination of data for those successful at giving up smoking showed greater mean weight gain in intervention subjects (3.9 (SD 3.1) vs. 2.7 (SD 3.7) kg). Between group differences were not significant (p = 0.23, 95% CI −0.9 to 3.5). In comparison to baseline improved consumption of fruit and vegetables and breakfast cereal were reported in the intervention group. A higher percentage of control participants continued smoking (74% vs. 66%).ConclusionsThe intervention was not successful at minimising weight gain in comparison to control but was successful in facilitating some sustained improvements in the dietary habits of intervention participants. Improved quit rates in the intervention group suggest that continued contact with advisors may have reduced anxieties regarding weight gain and encouraged cessation despite weight gain. Research should continue in this area as evidence suggests that the negative effects of obesity could outweigh the health benefits achieved through reductions in smoking prevalence.Trial registrationCurrent Controlled Trials ISRCTN73824458

Working-class discourses of politics, policy and health: ‘I don’t smoke; I don’t drink. The only thing wrong with me is my health’

It is known that population health is socially and politically determined. A gap, however, between the evidence and policy (where behavioural approaches dominate) is evident. This study used semi-structured interviews in two deindustrialised areas in Scotland to explore understandings of the causes of (ill)health in local communities. Using Raphael’s Discourses of Social Health Determinants, we found that participants typically had highly integrated explanations of health, including vivid articulation of links between politics, policies, deindustrialisation, damage to community fabric, and impacts on health. This understanding contrasts with that identified by research elsewhere. We posit explanations for our findings, and discuss their implications.

Using and generating evidence: policy makers' reflections on commissioning and learning from the Scottish Health Demonstration Projects

This article discusses the gap between rhetoric and reality in evidence-based policy making using data derived from external evaluations of two of Scotlands national Health Demonstration Projects. More specifically, it reports on the extent to which policy makers used evidence to commission the projects, and on the type of evidence that they expected to flow from them to feed into future government strategy. Using primary data, this article confirms that policy decisions are made on the basis of factors that go beyond research evidence and suggests that both policy makers and evaluators would gain from more explicit acknowledgement of what lies beneath the veneer of evidence-based policy making.

The hidden cost of clinical audit: a questionnaire study of NHS staff

OBJECTIVES To determine the full cost of clinical audit in one health board area and extrapolate the result of Scotland. METHODS A questionnaire was sent ot a representative sample of NHS staff to determine time spent on clinical audit. This was combined with cost data from clinical audit budgets and unit cost data for staff time. RESULTS Seventy-two percent of staff participated in clinical audit at some point in time. Medical staff were significantly more likely to participate in audit than non medical staff (P <0.0001). Those who participated in clinical audit devoted only a small proportion of time to it. However, due to the high participation rates in clinical audit, this aggregated to a significant amount. In Forth Valley the total cost was estimated to be pound 1.72m (pound 1.37m-pound 2.10m) and in Scotland pound 36.3m (pound 29.6m-pound 44.0m). Staff time accounted for over 80% of the total cost of clinical audit. CONCLUSIONS Clinical audit is widespread within the Scotish NHS and the total cost of staff time devoted to audit is substantial. Research is needed into the value of clinical audit and the potential cost implications of clinical governance need to be explicitly recognised.