Sally Macintyre

Developing and evaluating complex interventions: the new Medical Research Council guidance

Evaluating complex interventions is complicated. The Medical Research Councils evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidance

Area, Class and Health: Should we be Focusing on Places or People?

In Britain there has been a long tradition of research into associations between area of residence and health. Rarely has this involved investigating socio-economic or cultural features of areas that might influence health; usually studies use area level data, for example about specific pathogens or about levels of deprivation, as surrogates for individual level data, rather than being interested in the areas themselves. This paper reviews the literature on the relationship between area and health. It advocates directly studying features of the local social and physical environment which might promote or inhibit health, illustrating this approach with some findings from a study in the West of Scotland, and suggests that improvements in public health might be achieved by focusing on places as well as on people.

Gender differences in health : are things really as simple as they seem ?

It is conventional wisdom in medical sociology and social epidemiology that in industrialized societies men die earlier than women, but that women have poorer health than men. A number of explanations for these differences have been postulated and tested (for example, different biological risks, acquired risks, reporting biases and experiences of health care). Using two recent British data sets we find that the pattern of sex differences in morbidity is more complicated than the conventional wisdom often suggests. The direction and magnitude of sex differences in health vary according to the particular symptom or condition in question and according to the phase of the life cycle. Female excess is only consistently found across the life span for psychological distress and is far less apparent, or reversed, for a number of physical symptoms and conditions. Detailed inspection of papers on gender differences published in the last decade reveals that our findings are not unique, but that a relatively undifferentiated model of consistent sex differences has nevertheless continued to predominate in the literature. We believe that the topic of gender differences in health warrants periodic re-examination.

Using natural experiments to evaluate population health interventions: new Medical Research Council guidance

Natural experimental studies are often recommended as a way of understanding the health impact of policies and other large scale interventions. Although they have certain advantages over planned experiments, and may be the only option when it is impossible to manipulate exposure to the intervention, natural experimental studies are more susceptible to bias. This paper introduces new guidance from the Medical Research Council to help researchers and users, funders and publishers of research evidence make the best use of natural experimental approaches to evaluating population health interventions. The guidance emphasises that natural experiments can provide convincing evidence of impact even when effects are small or take time to appear. However, a good understanding is needed of the process determining exposure to the intervention, and careful choice and combination of methods, testing of assumptions and transparent reporting is vital. More could be learnt from natural experiments in future as experience of promising but lesser used methods accumulates.

“Food deserts”—evidence and assumption in health policy making

Assertions can be reported so often that they are considered true (“factoids”). They may sometimes even be used to determine health policy when empirical information is lacking. Steven Cummins and Sally Macintyre use the claimed existence of “food deserts”—poor urban areas where residents cannot buy affordable, healthy food—to illustrate why policy makers need to look more critically at the facts In December 2001 a cross party motion on food poverty signed by 198 UK MPs gained its first reading in parliament. The Food Poverty (Eradication) Bill is now waiting to be read for a second time.1 Though this bill is a laudable attempt to introduce a policy designed to improve the nutrition of those with the lowest incomes and in the poorest places, it is an example of how some ideas become accepted as fact though they may not be true. They become “factoids”: assumptions or speculations reported and repeated so often that they are popularly considered true; they are simulated or imagined facts.2 This paper illustrates how, if the social climate is right, facts about the social world can be assumed and hence used as the basis for health policy in the absence of much empirical information. ### Summary points Factoids are assumptions or speculations reported and repeated until they are considered true They are sometimes used to determine health policy when empirical information is lacking The assumption that in the United Kingdom there are poor urban areas where residents cannot buy affordable, healthy food (“food deserts”) is a factoid Policy strategies to combat the existence of food deserts exemplify how factoids can influence health and social policy The burden of proof, or demand for evidence, may vary according to a policys perceived fit within current collective world views Policy makers need to move away from unquestioning acceptance and should …

Evidence for public health policy on inequalities: 1: The reality according to policymakers

Objective: To explore with UK and international policy advisors how research evidence influences public health policy making, and how its relevance and utility could be improved, with specific reference to the evidence on the production and reduction of health inequalities. Design, setting, and participants: Qualitative residential workshop involving senior policy advisors with a substantive role in policy development across a range of sectors (mainly public health, but also including education, social welfare, and health services). In four in depth sessions, facilitated by the authors, focused questions were presented to participants. Their responses were then analysed thematically to identify key themes, relating to the availability and utility of existing evidence on health inequalities. Main results: The lack of an equity dimension in much aetiological and evaluative research was highlighted by participants. Much public health research was also felt to have weak underlying theoretical underpinnings. As well as evaluations of the effectiveness and cost-effectiveness of policy and other interventions, they identified a need for predictive research, and for methodological research to further develop methods for assessing the impact on health of clusters of interventions. Conclusions: This study reinforces the view that there is a lack of information on the effectiveness and cost-effectiveness of policies, and it uncovered additional gaps in the health inequalities evidence base. A companion paper discusses researchers’ views of how the production of more relevant public health evidence can be stimulated.

Graffiti, greenery, and obesity in adults: secondary analysis of European cross sectional survey

Obesity levels are high and increasing worldwide. Being overweight is linked with increased death rates and contributes to a wide range of conditions, including ischaemic heart disease, hypertension, stroke, diabetes, certain cancers, and diseases of the gall bladder.1 The principal cause of obesity is an imbalance between energy intake and energy expenditure. And there is growing recognition that, independently of individual characteristics, place of residence may be associated with health outcomes, including body size2 and health related behaviours, such as level of physical exercise.3 Few studies have explored which features of the local neighbourhood might be related to these outcomes or behaviours, although perceived attractiveness has been found to be related to levels of physical activity.4 Levels of incivilities, such as litter and graffiti, are associated with poorer health outcomes such as general wellbeing but not, to our knowledge, with levels of physical activity. Few studies use …

Deprivation amplification revisited; or, is it always true that poorer places have poorer access to resources for healthy diets and physical activity?

BackgroundIt has commonly been suggested (including by this author) that individual or household deprivation (for example, low income) is amplified by area level deprivation (for example, lack of affordable nutritious food or facilities for physical activity in the neighbourhood).DiscussionThe idea of deprivation amplification has some intuitive attractiveness and helps divert attention away from purely individual determinants of diet and physical activity, and towards health promoting or health damaging features of the physical and social environment. Such environmental features may be modifiable, and environmental changes may help promote healthier behaviors. However, recent empirical examination of the distribution of facilities and resources shows that location does not always disadvantage poorer neighbourhoods. This suggests that we need: a) to ensure that theories and policies are based on up-to-date empirical evidence on the socio-economic distribution of neighbourhood resources, and b) to engage in further research on the relative importance of, and interactions between, individual and environmental factors in shaping behavior.SummaryIn this debate paper I suggest that it may not always be true that poorer neighbourhoods are more likely to lack health promoting resources, and to be exposed to more health damaging resources. The spatial distribution of environmental resources by area socioeconomic status may vary between types of resource, countries, and time periods. It may also be that the presence or absence of resources is less important than their quality, their social meaning, or local perceptions of their accessibility and relevance.

Environmental and lifestyle factors associated with overweight and obesity in Perth, Australia

Purpose. To examine associations between environmental and lifestyle factors and overweight or obesity. Design. A cross-sectional survey and an environmental scan of recreational facilities. Setting. Metropolitan Perth, Western Australia. Subjects. Healthy sedentary workers and homemakers aged 18 to 59 years (n = 1803) living in areas within the top and bottom quintiles of social disadvantage. Measures. Four lifestyle factors, one social environmental factor, and five physical environment factors (three objectively measured). Results. After adjustment for demographic factors and other variables in the model, overweight was associated with living on a highway (odds ratio [OR], 4.24; 95% confidence interval [CI], 1.62–11.09) or streets with no sidewalks or sidewalks on one side only (OR, 1.35; 95% CI, 1.03–1.78) and perceiving no paths within walking distance (OR, 1.42; 95% CI, 1.08–1.86). Poor access to four or more recreational facilities (OR, 1.68; 95% CI, 1.11–2.55) and sidewalks (OR, 1.62; 95% CI, .98–2.68) and perceiving no shop within walking distance (OR, 1.84; 95% CI, 1.01–3.36) were associated with obesity. Conversely, access to a motor vehicle all the time was negatively associated with obesity (OR, .56; 95% CI, .32–.99). Watching 3 or more hours of television daily (ORs, 1.92 and 1.85, respectively) and rating oneself as less active than others (ORs, 1.66 and 4.05, respectively) were associated with both overweight and obesity. After adjustment for individual demographic factors and all other variables in the model, socioeconomic status of area of residence and leisure-time physical activity were not associated with overweight or obesity. Conclusion. Factors that influence overweight and obesity appear to differ, but aspects of the physical environment may be important. Objectively measured neighborhood environment factors warrant further investigation.

Perceptions of Place and Health in Socially Contrasting Neighbourhoods

This paper describes an analysis of perceptions of the local residential environment and self-reported health in four socially contrasting neighbourhoods in Glasgow in the late 1990s. After adjusting for individual characteristics such as age, sex and social class, neighbourhood of residence predicted perceptions of problems and neighbourhood cohesion in the area: and self-assessed health, mental health and recent symptoms were associated with perceived local problems and neighbourhood cohesion. Housing tenure and employment status also predicted perceptions of the neighbourhood. These results support the importance of tackling anti-social problems in worst-off areas and of neighbourhood management across a range of areas.