Tom Ling

Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis

BackgroundGovernments can intervene to change health-related behaviours using various measures but are sensitive to public attitudes towards such interventions. This review describes public attitudes towards a range of policy interventions aimed at changing tobacco and alcohol use, diet, and physical activity, and the extent to which these attitudes vary with characteristics of (a) the targeted behaviour (b) the intervention and (c) the respondents.MethodsWe searched electronic databases and conducted a narrative synthesis of empirical studies that reported public attitudes in Europe, North America, Australia and New Zealand towards interventions relating to tobacco, alcohol, diet and physical activity. Two hundred studies met the inclusion criteria.ResultsOver half the studies (105/200, 53%) were conducted in North America, with the most common interventions relating to tobacco control (110/200, 55%), followed by alcohol (42/200, 21%), diet-related interventions (18/200, 9%), interventions targeting both diet and physical activity (18/200, 9%), and physical activity alone (3/200, 2%). Most studies used survey-based methods (160/200, 80%), and only ten used experimental designs.Acceptability varied as a function of: (a) the targeted behaviour, with more support observed for smoking-related interventions; (b) the type of intervention, with less intrusive interventions, those already implemented, and those targeting children and young people attracting most support; and (c) the characteristics of respondents, with support being highest in those not engaging in the targeted behaviour, and with women and older respondents being more likely to endorse more restrictive measures.ConclusionsPublic acceptability of government interventions to change behaviour is greatest for the least intrusive interventions, which are often the least effective, and for interventions targeting the behaviour of others, rather than the respondent him or herself. Experimental studies are needed to assess how the presentation of the problem and the benefits of intervention might increase acceptability for those interventions which are more effective but currently less acceptable.

Evaluating complex and unfolding interventions in real time

This article discusses an approach to managing the evaluation of complex interventions. Complex interventions pose significant challenges to the role and conduct of evaluations. In particular, they combine with reflexive learning and change to produce significant uncertainties making it hard to describe in advance what the intervention will do or what the outcomes might be. These uncertainties vary in nature and addressing these uncertainties leads to different evaluation approaches. That such evaluations often take place in ‘real time’ and have a strong formative dimension adds to the challenge. This article proposes a way of approaching this problem by incorporating the concepts of uncertainty and complexity into a Theory of Change-based approach.

Genetic tests for common diseases: new insights, old concerns

The clinical utility of newly identified genetic variants associated with common diseases needs evaluation

A novel performance monitoring framework for health research systems: experiences of the National Institute for Health Research in England

BackgroundThe National Institute for Health Research (NIHR) was established in 2006 with the aim of creating an applied health research system embedded within the English National Health Service (NHS). NIHR sought to implement an approach for monitoring its performance that effectively linked early indicators of performance with longer-term research impacts. We attempted to develop and apply a conceptual framework for defining appropriate key performance indicators for NIHR.MethodFollowing a review of relevant literature, a conceptual framework for defining performance indicators for NIHR was developed, based on a hybridisation of the logic model and balanced scorecard approaches. This framework was validated through interviews with key NIHR stakeholders and a pilot in one division of NIHR, before being refined and applied more widely. Indicators were then selected and aggregated to create a basket of indicators aligned to NIHRs strategic goals, which could be reported to NIHRs leadership team on a quarterly basis via an oversight dashboard.ResultsSenior health research system managers and practitioners endorsed the conceptual framework developed and reported satisfaction with the breadth and balance of indicators selected for reporting.ConclusionsThe use of the hybrid conceptual framework provides a pragmatic approach to defining performance indicators that are aligned to the strategic aims of a health research system. The particular strength of this framework is its capacity to provide an empirical link, over time, between upstream activities of a health research system and its long-term strategic objectives.

Moving beyond individual choice in policies to reduce health inequalities: the integration of dynamic with individual explanations

Abstract Background A strong focus on individual choice and behaviour informs interventions designed to reduce health inequalities in the UK. We review evidence for wider mechanisms from a range of disciplines, demonstrate that they are not yet impacting on programmes, and argue for their systematic inclusion in policy and research. Methods We identified potential mechanisms relevant to health inequalities and their amelioration from different disciplines and analysed six policy documents published between 1976 and 2010 using Bacchi’s ‘What’s the problem represented to be?’ framework for policy analysis. Results We found substantial evidence of supra-individualistic and relational mechanisms relevant to health inequalities from sociology, history, biology, neuroscience, philosophy and psychology. Policy documents sometimes expressed these mechanisms in policy rhetoric but rarely in policy recommendations, which continue to focus on individual behaviour. Discussion Current evidence points to the potential of systematically applying broader thinking about causal mechanisms, beyond individual choice and responsibility, to the design, implementation and evaluation of policies to reduce health inequalities. We provide a set of questions designed to enable critique of policy discussions and programmes to ensure that these wider mechanisms are considered.

Community Hospitals in Selected High Income Countries: A Scoping Review of Approaches and Models

Background: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. Methods: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. Results: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. Conclusions: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.

Modifiable barriers to meeting care and support needs of patients with advanced chronic obstructive pulmonary disease (COPD) and their informal carers

Introduction COPD is a progressive condition with high symptom burden. Advanced COPD management should relieve symptoms, optimise daily functioning and reduce carer burden. Our knowledge of clinician barriers and facilitators to meeting the needs of these patients and their informal carers is limited. Aim To identify modifiable barriers to meeting care and support needs of patients with advanced COPD and their carers. Methods Purposively-sampled clinicians nominated by a population-based cohort of patients with advanced COPD participating in the Living with Breathlessness Study, took part in Longitudinal qualitative interviews on barriers and facilitators to meeting needs, and analysed using a Framework approach. Identified barriers were reviewed and recommendations to overcome them presented to stakeholders via workshop and online survey methods. Results Identification and assessment of patient need, and barriers and facilitators to doing so, were largely driven by organisational and medical agendas, rather than person-centred care models. There was little evidence of clinician engagement with patients’ informal carers. There was a mismatch between clinicians’ perceptions of changes in patient need during the 18-month study duration and those of patients and carers. Clinicians felt unprepared for end-of-life care discussions and found patient readiness for these conversations difficult to assess. Clinician-identified patient, organisational and professional facilitators included trust, time and accessibility. Conclusion Actioning recommendations such as stopping focusing on the challenge of prognostication as a barrier to meeting need, changing targets to incentivise person-centred care and identifying and supporting carers could improve care and support of patients and carers living with advanced COPD. This report is independent research supported by the National Institute for Health Research (Career Development Fellowship, CDF-2012-05-218). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Evaluation in an emerging field: Developing a measurement framework for the field of counter-violent-extremism

Despite previous research, the field of counter-violent-extremism has not benefited significantly from evaluation. By comparison, and despite a number of challenges, the evidence-based healthcare movement has an established track record of using evaluation to develop practice. We seek lessons from the evidence-based healthcare movement about what it might take to develop evaluation capacity in the emerging field of counter-violent-extremism. Based on this, we offer a framework for measurement in counter-violent-extremism: the ‘Violent Extremism Evaluation Measurement Framework’. We map out states and manifestations associated with violent extremism and radicalisation, then suggest how to measure levels and changes in relevant attributes.

Transforming Urgent and Emergency Care and the Vanguard Initiative: Learning from Evaluation of the Southern Cluster

Urgent and Emergency Care (UEC) vanguards aim to improve the quality, efficiency and effectiveness of UEC services so that patients receive the most appropriate care at the right time and in the right place, and so that unnecessary admissions to accident and emergency (A&E) and hospitals are reduced. The Southern Cluster comprises three such UEC vanguards. RAND Europes evaluation examined the impacts of the vanguards, the processes underpinning delivery (and associated enablers and challenges), and implications for future policy and practice. The evaluation used a multi-method approach, including theories of change, document review, workshops, interviews, surveys and data dashboards. The Southern Cluster UEC vanguards have made progress across core activities. Clinical hubs are operational across the sites. Direct booking capacity into primary care is progressing more with out-of-hours than with in-hours services. Gradual but variable progress has been made towards joint planning and governance of UEC services. Efforts to ensure seamless data sharing between providers, and interoperable IT infrastructure are progressing somewhat slower than originally hoped. Vanguard funding, committed leadership and practical mechanisms to support joint working helped drive progress. Public engagement, workforce-capacity and data interoperability will need to be addressed for longer-term impact at scale. The study makes recommendations concerning: (i) UEC health and care workforce capacity-building, (ii) local-national coordination around UEC transformation, (iii) collaboration across localities and professions, (iv) support for an end-to-end UEC pathway with mutually reinforcing activities, (v) cost and outcome data, (vi) an interoperable data infrastructure, and (vii) capacity for evaluation and learning.

17 Improving care and support in advanced copd: six recommendations of the population-based living with breathlessness study

Introduction Chronic obstructive pulmonary disease (COPD) is a chronic progressive condition with high symptom-burden. National guidance calls for quality end-of-life care for patients with any condition, yet we rely on frameworks developed for cancer with its largely predictable trajectory. Aim To inform a new framework to improve care and support in advanced COPD. Methods The Living with Breathlessness Study was a multiple-component, population-based, mixed-method longitudinal, multiple-perspective programme to identify new evidence on health and social care needs and preferences of patients with advanced COPD and their carers. It followed more than 500 patients and carers for up to 18 months through interview and survey methods. Qualitative data on barriers and facilitators to meeting needs were collected from clinicians. Programme-wide evidence was synthesised to identify recommendations. Stakeholder views were then collected through a workshop and online survey. Results Six inter-related recommendations emerged, linked by the concept of proactive person-centred care, supported by action points to enable delivery. In brief: (1) stop focusing on the challenge of prognostication as a barrier to meeting need, (2) change targets to incentivise person-centred care, (3) enable identification of patient support needs, (4) identify and support carers, (5) identify and respond to psychological morbidity, (6) change societal understandings. The recommendations garnered significant support from stakeholders, with caution regarding ease of implementation. Conclusion These recommendations could inform a new framework for care and support in advanced COPD likely to have resonance for those living with other advanced non-malignant long term conditions, and clinicians striving to support them.