Public Health Improvement Research in Wales

1. Public Health Improvement Research in Wales Prof. Laurence Moore

2. Outline • Importance of public health / prevention • Public health improvement research network- PHIRN • UKCRC Centre of Excellence - DECIPHer • Projects

4. Public Health in the News • Diabetes • Obesity • Childhood Obesity • School Dinners (Jamie Oliver) • Smoking in Public Places • Binge Drinking • Health Inequalities • Incapacity Benefit

5. Health Strategies National Assembly for Wales (2002) Well being in Wales. Cardiff: National Assembly for Wales. “The challenge of improving people’s well being and of reducing health and other inequalities means that success is well beyond the achievement of single organisations working alone. Success hinges on effective partnership working and this is continuing to develop in Wales..” (p.10).

6. …Strategies…. National Assembly for Wales (2003) The Review of health and Social Care in Wales. Cardiff: National Assembly for Wales. “There should be a strategic adjustment of service to focus them on prevention and early intervention. Potentially this offers significant long-term cost and quality of life gains.” (p.2 conclusions). “We recommend a much greater emphasis on preventing ill health and early intervention in order to raise public awareness of its importance to the ability of health and social care services in Wales.” (4.6).

7. …Strategies… National Assembly for Wales (September 2003) Wales: A Better Country. Cardiff: National Assembly for Wales. “Reported levels of poor health are significantly higher in Wales than in the rest of the UK, and are heavily associated with patterns of deprivation. The recent Wanless report has underlined that improving levels of health means not just better services to treat ill-health, but a much greater emphasis on primary care and the promotion of healthy life-styles, to prevent ill-health arising. This is a key challenge that we are determined to address in a holistic way.”

8. ..and more Strategies… Welsh Assembly Government (2005) Designed for Life: Creating world class Health and Social Care for Wales in the 21st century. Cardiff: Welsh Assembly Government. “We will focus on health and wellbeing, not illness” “Establishing an evidence base…..and acting on it, is a vital component of our approach”

9. Action plans and implementation? • National Service Frameworks • Increasingly high level • Early NSF (CHD) included specific service targets • Mainly in treatment services • Few in primary prevention • Children’s NSF • Weak evidence base

10. Health improvement practice on the ground largely determined by • Local health and wellbeing strategies • Local practitioners in health boards and local authorities • Little engagement with evidence base or research community • Practitioner networks to share good practice but poor connection to evidence

11. Public Health Improvement – priority for action and research “We recommend a much greater emphasis on preventing ill health and early intervention in order to raise public awareness of its importance to the ability of health and social care services in Wales.” “We recommend policy action to raise public awareness, and more research to produce an evidence base into the gains which different sorts of action may yield.” “We recommend a programme to develop further the research base to enable an evidence-based approach to indicate what gains can be expected for different types of public health/prevention expenditure in Wales, to inform future policy making and resource allocation decisions.” National Assembly for Wales (2003) The Review of Health and Social Care in Wales. Cardiff: National Assembly for Wales. ‘Dai Wanless’

12. The need to generate high quality evidence “Even with greater prioritisation and a clearer focus on delivery, the major constraint to further progress on the implementation of public health interventions is the weakness of the evidence base regarding their effectiveness and cost-effectiveness across the majority of risk factors.” (p. 107). “The dearth of evidence is not unrelated to the lack of funding of public health intervention research – with funding from research organisations and the private sector heavily directed towards clinical, pharmaceutical, biological and genetic research – and the lack of a clear and coherent set of Government priorities for the public health research which does exist.” (p.107). Wanless D (2004) Securing Good Health for the Whole Population, Final Report. HM Treasury.

13. Summary so far • Health improvement and health inequality priorities for action • Weak evidence base • Practice largely determined locally with little reference to evidence • Need to increase quality, volume and relevance of research evidence • Need to increase impact/use of evidence

14. PHIRN Public Health Improvement Research Network

15. Barriers to high quality evidence generation • Clinical NHS research: • Trial recruitment • Ethics, regulation and governance • Infrastructure – staff and CRFs • Public health intervention research • Scale, expense, complexity of interventions • Unexploited potential for natural experiments • Multidisciplinary, multi-sectoral • Not just NHS

16. Weaknesses • Limited dialogue between or within research, policy and practice communities, no structures • Little investment in high quality primary research • Opportunities to rigorously evaluate innovations in services not taken • Pockets of excellence not integrated or well-known

17. AIM: To increase the quantity and quality of public health improvement research in Wales that is relevant to policy and practice • Break down divide between ‘academic’ intervention research and ‘local’ evaluation activity

18. A network of academics, policy makers and practitioners The network will facilitate a continuous process of: • identification and exploration of research priorities • identification of teams with academic, policy and practitioner representation to take forward priority research projects • exchange of new evidence, policy developments, practitioner innovation • exchange of innovative methodological approaches • identification of innovations in policy and practice at an early stage in planning, maximizing the opportunities for ‘natural experiments’ • development of high quality research project protocols • execution of funded research protocols.

19. Research Development Groups • Small groups to identify and drive forward projects • Multidisciplinary and multisectoral • Protocol development, including commissioning briefs • Funding applications • Organically formed, active • 14 funded studies (£3.2M), 1 (£5M) UK centre of excellence

20. Other PHIRN Activities • Health Challenge Wales Evidence for Policy Seminar Series • All Wales Public Health Scientific Conference • PHIRN Website • Membership • Database of members, RDGs • Electronic discussion group(s) • RDG project management and support • Linkage with CRCC and Wales R&D infrastructure

21. Policy Trials • Free School Breakfast Initiative • Cluster randomised trial of 111 schools • National exercise referral scheme • Randomised trial of c.2000 patients referred to exercise specialists based in community leisure centres • Cooking bus • Exploratory trial

22. Completed projects with major policy impact • MRC ASSIST Trial – adolescent smoking prevention (Starkey et al 2005) • SHARPS health inequality programme – 7 linked community participatory action research projects (Cropper et al 2007) • Food co-operatives (Elliott et al 2007) • Adolescent smoking cessation (Macdonald et al 2007)

23. UKCRC Public Health Research Centre of Excellence Development and Evaluation of Complex Interventions for Public Health Improvement

24. UKCRC call • Overall need to boost infrastructure and build capacity • Main issues emerging • Training and career structure • Multi-disciplinary and collaborative working • Maximising use of existing data • Methodological issues • Specific areas highlighted • Diet and nutrition • Physical activity • Alcohol, tobacco and drugs

25. Objectives of Centres • Promote research excellence • Increase investment in infrastructure • Build sustainable research capacity - new academic posts and training programmes • Encourage multi-disciplinary partnerships between leading academics, practitioners and policy makers • Promote leadership to tackle issues such as methodology and use of existing data sets

26. The main determinants of health

27. SOCIO-ECOLOGICAL FRAMEWORK (McLeroy et al 1989)

28. Public Health Improvement • interventions and policies to improve the health and well-being of the public, whether through disease prevention or action to change the wider determinants of health. PHIR reflects a focus on developing and testing interventions, rather than a focus on epidemiology or needs assessment; • the scope of interventions to be tested will not be restricted to health technology or to the NHS, but will include a very broad conception of initiatives to improve the health and well-being of the public, from simple to complex, small- to large-scale, and including policies and interventions instigated outside the health and social care arena; • that interventions and policies will be developed and tested both in terms of their effectiveness in reducing health inequalities as well as improving population health and well-being.

29. Complexity of health improvement interventions • Effective interventions are likely to: • Be well targeted • Be informed by research and understanding of target audience and key mechanisms • Be theoretically based • Involve complex interactions • Of sufficient intensity • Reinforced at multiple levels • Vary in effectiveness depending on context

30. Multidisciplinary Public Health Improvement Research: Challenges • Cross-disciplinary • Cross-departmental • Cross academia / policy / practice • No home, no champions • RAE – low esteem • Complexity, duration, high-risk

31. Phases of RCTs of complex interventions: MRC April 2000

32. ASSIST Trial:Study phases & timetable 1993/4: Phase 0: Seminar, discussion, networking 1995: Phase 1: Development, piloting, feasibility testing 1998/99: Phase 2: Publication, planning and fund-seeking 2001: Phase 3:Full-scale randomised trial (£1.5M) 2001 Further piloting School recruitment 2002 Baseline measures, intervention 2003 1-year follow-up 2004 2-year follow-up 2006-: Phase 4: Implementation

34. Mission Statement • DECIPHer will undertake methodologically innovative multidisciplinary research with a focus on the development and evaluation of complex interventions and policies to achieve sustainable improvements in the health and well-being of the public. There will be an initial focus on children and young people. • DECIPHer will lead and facilitate research of international excellence, placing emphasis on tackling health inequalities, creating new research capacity and maximising impact on and engagement with policy and practice in the UK and beyond.

35. What do the funds cover? • NOT project funding • Infrastructural funding • M£5 over 5 years (@70% FEC), potential for 5 more • Expectation that Centres self-sustaining • New posts, PhD studentships • Training and career development programmes • Infrastructure to underpin research activities • Outreach with policy, practice, public

36. Strategic Research Programmes • Multiple risk behaviours in young people and their underlying causes • Developing innovative and sustainable child and youth centred interventions • Health promoting schools and other youth settings • Sustainable health improvement in communities, households and families • Environmental determinants of health and the evaluation of environmental and policy interventions

37. Key areas of methodological development • Phased development and experimental evaluation of complex interventions • Policy trials with nested process evaluation • Social network analysis, Multi level modelling • Evidence synthesis and knowledge translation • Mixed methods analysis of environmental influences on behaviour • Participatory action research • Data linkage, secondary data analysis

38. Applicants • Cardiff • Laurence Moore, Chris Butler, Gareth Williams, David Fone, Glyn Elwyn, Soren Holm, Simon Murphy [SOCSI/MEDIC/CLAWS/DENTL] • Bristol • Rona Campbell, Jenny Donovan, David Gunnell, Matt Hickman [Social Medicine] • Swansea • Ronan Lyons [HIRU]

39. The overall aim of the Centre is to conduct research that will lead to measurable improvements in the health of individuals and the public. The key objectives of the DECIPHer Centre are: 1.To play a lead role in increasing the quantity, quality, value, relevance and impact of multi-disciplinary research to improve public health in the UK and internationally 2. To create sustainable multidisciplinary research capacity with substantial added value from the strategic partnership 3. To develop a training and career development programme and an excellent environment for multidisciplinary public health improvement research career development 4. To develop new collaborations with organisations concerned with the health of the public in Wales and SW England through nurturing and expanding existing partnerships and creating new opportunities for exchange, engagement and personal development

40. 5. To develop an effective and innovative public involvement strategy that is sensitive to equality and diversity issues and the particular needs of children and young people 6. To develop rich interdisciplinary understandings of the determinants of health and health behaviour, particularly among young people, that will lead to the identification of potentially modifiable causal pathways and the development of interventions 7. To develop innovative interventions to tackle the key health problems of the public, and evaluate them pragmatically and rigorously in diverse populations and settings 8. To provide a focal point for collaboration between academia, policy and practice in public health that will maximise the relevance, innovation, translation and impact of public health improvement research nationally and internationally.

41. Project examples • Trial of national exercise referral scheme (WAG) • Trial of free breakfast initiative (WAG) • Trial of fruit tuck shops in primary schools (FSA) • Trial of emergency contraception lessons (NHS R&D) • ASSIST Trial of peer-led intervention to reduce adolescent smoking (MRC) • TAP study of peer-led intervention to reduce adolescent problem drinking (AERC / WORD) • SHIP Trial of smoking cessation in pregnancy (MRC)

42. Fruit tuck shop trial (funded by Food Standards Agency) • Schools given minimal support in setting up tuck shops, with wide variability in detailed operation • 43 schools in study, 23 randomised to set up tuck shop, 20 controls • Detailed process evaluation • Environment of school and locality • Operation of fruit tuck shops • Detailed case studies of 8 selected schools • FSA Booklet on how to set up fruit tuck shops • Strong evidence of effectiveness of fruit tuck shops and importance of snacks-to-school policies

43. ASSIST Trial (funded by Medical Research Council) • 59 secondary schools randomised • 30 received peer-led intervention, 29 control • Intervention delivered as it would be the case if rolled out in the ‘real world’ • Process evaluation in all 30 intervention schools, in-depth process evaluation in sub-sample • Effective in reducing risk of smoking uptake by 19% • Being rolled out across Wales and some PCTs

44. Free Breakfast Initiative Trial (funded by Welsh Assembly Government) • 111 schools, half intervention, half control • In Communities First areas in 7 LEAs • Variable models of staffing and delivery • Trial powered to identify overall mean effect on dietary and behavioural outcomes • Process evaluation to monitor variation in delivery and identify strengths and weaknesses • Report in with WAG

45. National Exercise Referral Trial (funded by Welsh Assembly Government) • c.4000 participants • National standardised scheme, but local variability in delivery • Trial powered to identify overall mean effect on physical activity • Process evaluation to monitor variation in delivery and identify strengths and weaknesses • 12-month follow-up

46. Contact details Professor Laurence Moore Cardiff Institute of Society, Health and Ethics Email: MooreL1@cf.ac.uk Tel: 02920 875387 Website: www.cf.ac.uk/socsi/cishe • Details of projects, publications etc.