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

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity has now achieved international political importance with endorsement from the World Health Assembly in 2009.  The failure of systematic reviews to consider effects on health equity is cited by decision-makers as a limitation to their ability to inform policy and program decisions. 

OBJECTIVES

To systematically review methods to assess effects on health equity in systematic reviews of effectiveness.

SEARCH STRATEGY

We searched the following databases up to July 2 2010: MEDLINE, PsychINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Index to Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on October 7 2010.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities.

DATA COLLECTION AND ANALYSIS

Data were extracted using a pre-tested form by two independent reviewers. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews. 

MAIN RESULTS

Thirty-four methodological studies were included.  The methods used by these included studies were: 1) Targeted approaches (n=22); 2) gap approaches (n=12) and gradient approach (n=1).  Gender or sex was assessed in eight out of 34 studies, socioeconomic status in ten studies, race/ethnicity in seven studies, age in seven studies, low and middle income countries in 14 studies, and two studies assessed multiple factors across health inequity may exist.Only three studies provided a definition of health equity. Four methodological approaches to assessing effects on health equity were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (all 34 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (12/34 studies); 3) analytic approaches (10/34 studies); and 4) applicability assessment (11/34 studies). Both analytic and applicability approaches were not reported transparently nor in sufficient detail to judge their credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to assess and report effects on health equity in systematic reviews.

Evidence summaries tailored to health policy-makers in low- and middle-income countries

OBJECTIVE

To describe how the SUPPORT collaboration developed a short summary format for presenting the results of systematic reviews to policy-makers in low- and middle-income countries (LMICs).

METHODS

We carried out 21 user tests in six countries to explore users' experiences with the summary format. We modified the summaries based on the results and checked our conclusions through 13 follow-up interviews. To solve the problems uncovered by the user testing, we also obtained advisory group feedback and conducted working group workshops.

FINDINGS

Policy-makers liked a graded entry format (i.e. short summary with key messages up front). They particularly valued the section on the relevance of the summaries for LMICs, which compensated for the lack of locally-relevant detail in the original review. Some struggled to understand the text and numbers. Three issues made redesigning the summaries particularly challenging: (i) participants had a poor understanding of what a systematic review was; (ii) they expected information not found in the systematic reviews and (iii) they wanted shorter, clearer summaries. Solutions included adding information to help understand the nature of a systematic review, adding more references and making the content clearer and the document quicker to scan.

CONCLUSION

Presenting evidence from systematic reviews to policy-makers in LMICs in the form of short summaries can render the information easier to assimilate and more useful, but summaries must be clear and easy to read or scan quickly. They should also explain the nature of the information provided by systematic reviews and its relevance for policy decisions.

Barriers to, and facilitators of, the prevention of unintentional injury in children in the home: a systematic review and synthesis of qualitative research

Background

This review considers barriers to, and facilitators of, success for interventions to reduce unintentional injury to children in the home through supply and/or installation of home safety equipment, and looks at risk assessments.

Methods

A systematic review of qualitative research. Bibliographic databases were searched for studies on interventions to reduce unintentional child injury in the home, or on related attitudes and behaviours. Studies were quality appraised, findings extracted, and a conceptual framework was developed to assess factors affecting the success of interventions.

Results

Nine peer-reviewed journal articles were included. Barriers and facilitators were highlighted at organisational, environmental and personal levels. Effective provision of safety equipment involves ongoing support with installation and maintenance. Take up and success of interventions depends on adjusting interventions according to practical limitations and parents' cultural expectations. A particular barrier was parents' inability to modify rented or shared accommodation.

Conclusions

The review highlights ways in which health inequalities affect the take up and success of home safety interventions, and how health workers can use this knowledge to facilitate future interventions.

Normalisation process theory: a framework for developing, evaluating and implementing complex interventions

BACKGROUND

The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).

DISCUSSION

In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.

SUMMARY

The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial.

Development and formative evaluation of the e-Health Implementation Toolkit (e-HIT)

BACKGROUND

The use of Information and Communication Technology (ICT) or e-Health is seen as essential for a modern, cost-effective health service. However, there are well documented problems with implementation of e-Health initiatives, despite the existence of a great deal of research into how best to implement e-Health (an example of the gap between research and practice). This paper reports on the development and formative evaluation of an e-Health Implementation Toolkit (e-HIT) which aims to summarise and synthesise new and existing research on implementation of e-Health initiatives, and present it to senior managers in a user-friendly format.

RESULTS

The content of the e-HIT was derived by combining data from a systematic review of reviews of barriers and facilitators to implementation of e-Health initiatives with qualitative data derived from interviews of "implementers", that is people who had been charged with implementing an e-Health initiative. These data were summarised, synthesised and combined with the constructs from the Normalisation Process Model. The software for the toolkit was developed by a commercial company (RocketScience). Formative evaluation was undertaken by obtaining user feedback. There are three components to the toolkit--a section on background and instructions for use aimed at novice users; the toolkit itself; and the report generated by completing the toolkit. It is available to download from http://www.ucl.ac.uk/pcph/research/ehealth/documents/e-HIT.xls.

CONCLUSIONS

The e-HIT shows potential as a tool for enhancing future e-Health implementations. Further work is needed to make it fully web-enabled, and to determine its predictive potential for future implementations.

Knowledge in process? Exploring barriers between epidemiological research and local health policy development

BACKGROUND

In the Netherlands municipalities are legally required to draw up a Local Health Policy Memorandum every four years. This policy memorandum should be based on (local) epidemiological research as performed by the Regional Health Services. However, it is largely unknown if and in what way epidemiological research is used during local policy development. As part of a larger study on knowledge utilization at the local level in The Netherlands, an analytical framework on the use of epidemiological research in local health policy development in the Netherlands is presented here.

METHOD

Based on a literature search and a short inventory on experiences from Regional Health Services, we made a description of existing research utilization models and concepts about research utilization. Subsequently we mapped different barriers in research transmission.

RESULTS

The interaction model is regarded as the main explanatory model. It acknowledges the interactive and incremental nature of policy development, which takes place in a context and includes diversity within the groups of researchers and policymakers. This fits well in the dynamic and complex setting of local Dutch health policy.For the conceptual framework we propose a network approach, in which we "extend" the interaction model. We not only focus on the one-to-one relation between an individual researcher and policymaker but include interactions between several actors participating in the research and policy process.In this model interaction between actors in the research and the policy network is expected to improve research utilization. Interaction can obstruct or promote four clusters of barriers between research and policy: expectations, transfer issues, acceptance, and interpretation. These elements of interactions and barriers provide an actual explanation of research utilization. Research utilization itself can be measured on the individual level of actors and on a policy process level.

CONCLUSION

The developed framework has added value on existing models on research utilization because it emphasizes on the 'logic' of the context of the research and policy networks. The framework will contribute to a better understanding of the impact of epidemiological research in local health policy development, however further operationalisation of the concepts mentioned in the framework remains necessary.

Evaluation design for a complex intervention program targeting loneliness in non-institutionalized elderly Dutch people

BACKGROUND

The aim of this paper is to provide the rationale for an evaluation design for a complex intervention program targeting loneliness among non-institutionalized elderly people in a Dutch community. Complex public health interventions characteristically use the combined approach of intervening on the individual and on the environmental level. It is assumed that the components of a complex intervention interact with and reinforce each other. Furthermore, implementation is highly context-specific and its impact is influenced by external factors. Although the entire community is exposed to the intervention components, each individual is exposed to different components with a different intensity.

METHODS/DESIGN

A logic model of change is used to develop the evaluation design. The model describes what outcomes may logically be expected at different points in time at the individual level. In order to address the complexity of a real-life setting, the evaluation design of the loneliness intervention comprises two types of evaluation studies. The first uses a quasi-experimental pre-test post-test design to evaluate the effectiveness of the overall intervention. A control community comparable to the intervention community was selected, with baseline measurements in 2008 and follow-up measurements scheduled for 2010. This study focuses on changes in the prevalence of loneliness and in the determinants of loneliness within individuals in the general elderly population. Complementarily, the second study is designed to evaluate the individual intervention components and focuses on delivery, reach, acceptance, and short-term outcomes. Different means of project records and surveys among participants are used to collect these data.

DISCUSSION

Combining these two evaluation strategies has the potential to assess the effectiveness of the overall complex intervention and the contribution of the individual intervention components thereto.

Self-assessed health of young-to-middle-aged adults in an English-speaking Caribbean nation

BACKGROUND

Gender differences in self-assessed health in young-to-middle-aged adults are understudied in the English-speaking Caribbean nations.

AIMS

The aims of the current research are to (1) provide demographic characteristics of young adults, (2) examine the self-assessed health of young adults, (3) identify social determinants that explain good health status for young adults, (4) determine the magnitude of each social determinant, and (5) reveal gender differences in self-assessed health.

MATERIALS AND METHODS

This study extracted a subsample of 3,024 respondents from a larger nationally cross-sectional survey of 6,782 Jamaicans. Statistical analyses were performed using the SPSS v 16.0. Descriptive statistics were used to provide demographic information on the sample. Chi-square was used to examine the association between nonmetric variables, and an independent sample t-test was used to test the relationships between metric and dichotomous categorical variables. Logistic regression examined the relationship between the dependent variable and some predisposed independent variables.

RESULTS

One percent of the sample claimed injury and 8% illness. Self-reported diagnosed illnesses were influenza (12.7%), diarrhea (2.9%), respiratory disease (14.1%), diabetes mellitus (7.8%), hypertension (7.8%), arthritis (2.9%), and unspecified conditions (41.2%). The mean length of illness was 26 days (SD = 98.9). Nine social determinants and biological conditions explained 19.2% of the variability of self-assessed health. Biological conditions accounted for 78.1% of the explanatory model.

CONCLUSION

Injury accounts for a miniscule percentage of illness and so using it to formulate intervention policies would lack the necessary depth to effectively address the health of this cohort.

National policy-makers speak out: are researchers giving them what they need?

The objective of this empirical study was to understand the perspectives and attitudes of policy-makers towards the use and impact of research in the health sector in low- and middle-income countries. The study used data from 83 semi-structured, in-depth interviews conducted with purposively selected policy-makers at the national level in Argentina, Egypt, Iran, Malawi, Oman and Singapore. The interviews were structured around an interview guide developed based on existing literature and in consultation with all six country investigators. Transcripts were processed using a thematic-analysis approach. Policy-makers interviewed for this study were unequivocal in their support for health research and the high value they attribute to it. However, they stated that there were structural and informal barriers to research contributing to policy processes, to the contribution research makes to knowledge generally, and to the use of research in health decision-making specifically. Major findings regarding barriers to evidence-based policy-making included poor communication and dissemination, lack of technical capacity in policy processes, as well as the influence of the political context. Policy-makers had a variable understanding of economic analysis, equity and burden of disease measures, and were vague in terms of their use in national decisions. Policy-maker recommendations regarding strategies for facilitating the uptake of research into policy included improving the technical capacity of policy-makers, better packaging of research results, use of social networks, and establishment of fora and clearinghouse functions to help assist in evidence-based policy-making.

Difference in social determinants of health between men in the poor and the wealthy social strata in a Caribbean nation

BACKGROUND

Studies that have examined social determinants of health have made their investigations on the population, but none have reviewed them from the perspective of particular social hierarchies.

AIM

The study examined the factors determining the self-reported health of men of different socioeconomic status, by using models derived through econometric analyses. MATERIALS #ENTITYSTARTX00026;

METHODS

The study used a sample of 6,474 respondents: 2,704 from the two poor quintiles and 3,770 from the two wealthy quintiles. The survey used a random stratified probability sampling technique and involved the use of self-administered questionnaires. Multiple logistic regression technique was used to identify variables which are associated with health conditions of men in the two social hierarchies.

RESULTS

The findings revealed that the self-reported health of men in the two wealthiest quintiles were substantially influenced by private health insurance coverage (Odds Ratio (OR) = 32.9, 95%CI: 20.64, 52.45) and age of respondents (OR = 1.03, 95%CI: 1.02, 1.04) This was similar for men in the two poorest income quintiles; private health insurance coverage (OR = 16.97, 95%CI: 10.18, 28.27) and age (OR=1.05, 95%CI: 1.03, 1.06). Negative affective psychological conditions, consumption and medical expenditure affected the self-reported health of those in the two wealthiest quintiles, while positive affective, secondary levels of education and living alone influenced those in the two poorest quintiles.

CONCLUSION

This research serves as a foundation for further work relating to the determinants of self-reported health conditions, inequity across socio-economic strata for men, and how patient care should be addressed.

Protocol for a mixed methods study investigating the impact of investment in housing, regeneration and neighbourhood renewal on the health and wellbeing of residents: the GoWell programme

BACKGROUND

There is little robust evidence to test the policy assumption that housing-led area regeneration strategies will contribute to health improvement and reduce social inequalities in health. The GoWell Programme has been designed to measure effects on health and wellbeing of multi-faceted regeneration interventions on residents of disadvantaged neighbourhoods in the city of Glasgow, Scotland.

METHODS/DESIGN

This mixed methods study focused (initially) on 14 disadvantaged neighbourhoods experiencing regeneration. These were grouped by intervention into 5 categories for comparison. GoWell includes a pre-intervention householder survey (n = 6008) and three follow-up repeat-cross sectional surveys held at two or three year intervals (the main focus of this protocol) conducted alongside a nested longitudinal study of residents from 6 of those areas. Self-reported responses from face-to-face questionnaires are analysed along with various routinely produced ecological data and documentary sources to build a picture of the changes taking place, their cost and impacts on residents and communities. Qualitative methods include interviews and focus groups of residents, housing managers and other stakeholders exploring issues such as the neighbourhood context, potential pathways from regeneration to health, community engagement and empowerment.

DISCUSSION

Urban regeneration programmes are 'natural experiments.' They are complex interventions that may impact upon social determinants of population health and wellbeing. Measuring the effects of such interventions is notoriously challenging. GoWell compares the health and wellbeing effects of different approaches to regeneration, generates theory on pathways from regeneration to health and explores the attitudes and responses of residents and other stakeholders to neighbourhood change.

Research, policy and funding - academic treadmills and the squeeze on intellectual spaces

In recent years, there has been a great deal of collective rumination about social scientists' role in society. In the post-1997 UK context, public policy commitments to 'evidence-based policy' and 'knowledge transfer' have further stimulated such reflections. More recently, Michael Burawoy's 2004 address to the American Sociological Association, which called for greater engagement with 'public sociology' has reverberated throughout the discipline, motivating a series of debates about the purpose of sociological research. To date, most such contributions have been based on personal experience and anecdotal evidence. In contrast, this paper responds directly to Burawoy's suggestion that we should 'apply sociology to ourselves,' in order that we 'become more conscious of the global forces' driving our research (Burawoy 2005: 285). Drawing on an empirical research project designed to explore of the relationship between health inequalities research and policy in Scotland and England, in the period from 1997 until 2007, this paper discusses data from interviews with academic researchers. The findings suggest that the growing pressure to produce 'policy relevant' research is diminishing the capacity of academia to provide a space in which innovative and transformative ideas can be developed, and is instead promoting the construction of institutionalized and vehicular (chameleon-like) ideas. Such a claim supports Edward Said's (1994) insistence that creative, intellectual spaces within the social sciences are increasingly being squeezed. More specifically, the paper argues we ought to pay far greater attention to how the process of seeking research funding shapes academic research and mediates the interplay between research and policy.

Stimulating the development of national Streptococcus suis guidelines in Viet Nam through a strategic research partnership

PROBLEM

Streptococcus suis is a common cause of adult bacterial meningitis in Viet Nam, and possibly other parts of Asia, yet this disabling infection has been largely neglected. Prevention, diagnosis and treatment are relatively straightforward and affordable but, in early 2007, no national diagnostic, case management or prevention guidelines existed in Viet Nam.

APPROACH

Enhanced detection of S. suis infections was established in 2007 as part of a collaborative research programme between the National Hospital for Tropical Diseases, a key national hospital with very close links to the Ministry of Health, and a research group affiliated with Oxford University based in Viet Nam. The results were reported directly to policy-makers at the Ministry of Health.

LOCAL SETTING

Viet Nam is a low-income country with a health-care system that has seen considerable improvements and increased autonomy. However, parts of the system remain fairly centralized the Ministry of Health.

RELEVANT CHANGES

Following the improved detection and reporting of S. suis cases, the Ministry of Health issued guidance to all hospitals in Viet Nam on the clinical and laboratory diagnosis, treatment and prevention of S. suis. A public health laboratory diagnostic service was established at the National Institute of Hygiene and Epidemiology and training courses were conducted for clinicians and microbiologists. Ministry of Health guidance on surveillance and control of communicable diseases was updated to include a section on S. suis.

LESSONS LEARNT

Research collaborations can efficiently inform and influence national responses if they are well positioned to reach policy-makers.

Research and advice giving: a functional view of evidence-informed policy advice in a Canadian Ministry of Health

CONTEXT

As evidence-based medicine grows in influence and scope, its applicability to health policy prompts two questions: Can the principles and, more specifically, the tools used to bring research into the clinical world apply to civil servants offering advice to politicians? If not, what approach should the evidence-oriented health policy organization take to improve the use of research?

METHODS

This article reviews evidence-based medicine and models of research use in policy. Then it reports the results of interviews with civil servants in the Ontario Ministry of Health, which recently adopted a stewardship rather than an operational role, incorporating many evidence-oriented strategies. The interviews focused on functional roles for research-based evidence in policy advice.

FINDINGS

The clinical context and tools for evidence-based medicine can rarely be generalized to policy. Most current models of research use offer lessons to researchers wishing to apply their work to policy but little help for civil servants wishing to become more evidence oriented. The interviews revealed functional roles for research in setting agendas (noting upcoming issues and screening interest groups' claims), developing new policies (reducing uncertainty, helping speak truth to power, and preventing repetition and duplication), and monitoring or modifying existing policies (continuously improving programs and creating a culture of inquiry). Each area requires different tools to help filter the push of evidence from researchers and set agendas, to facilitate the urgent pull on relevant research by civil servants developing new policy, and to support ongoing linkage and exchange between civil servants and researchers for monitoring and modifying existing policy.

CONCLUSIONS

A functional framework for evidence-informed policy advice is useful for distinguishing the activity from evidence-based medicine and "auditing" the balance of efforts across the different functional roles of research in policy.

Care and compromise: developing a conceptual framework for work-related stress

In this paper we argue that in the current global healthcare climate, practitioners’ ability to provide compassionate and high quality care is undermined on a daily basis, not least by the organisational priorities of cost containment, of science and technology and, paradoxically, innovations experienced as demands such as specialisation. It is not surprising that the financial and workforce constraints of the global healthcare system, now more than ever, affect the practitioners’ capacity to deliver the optimum level of care, care that is positively influenced by patient satisfaction, a current indicator of quality. Whilst the notions of quality and standards have increasingly become the concern of healthcare organizations, quality cannot be considered in isolation from the healthcare management and occupational health of the workforce. In this paper we argue that healthcare practitioners are especially vulnerable to stress because the very nature of caring as a profession demands high levels of emotional engagement and compromise. It is clear that at a time when healthcare systems are under-resourced and over-stretched, practitioners may experience additional stress, ironically at a time when services need to increase retention, recruitment and job satisfaction. We propose a conceptual framework of stress and compromise in relation to caring and a methodology for developing an intervention that would consider how compromise itself may be utilised and adapted to both alleviate stress and inform individual and professional development.

Paradoxes in self-evaluated health data in a developing country

BACKGROUND

Statistics showed that males reported fewer illnesses and greater mortality rates than females, but are outlived by approximately 6 years by their female counterparts, yet their self-rated health status is the same as that of females.

AIMS

THIS STUDY EXAMINES THE FOLLOWING QUESTIONS: (1) Are there paradoxes in health disparity between the sexes in Jamaica? and (2) is there an explanation for the disparity outside of education, marital status, and area of residence?

METHODS AND MATERIALS

The current study utilised a data set collected jointly by the Planning Institute of Jamaica and the Statistical Institute of Jamaica. The data set is a survey on the living conditions of Jamaicans. It was conducted between May and August of 2007. The JSLC is a modification of the World Bank's Living Standards Measurement Study. The sample size was 6,783 respondents, with a non-response rate being 26.2%.

RESULTS

Good health status was correlated with self-reported illness (OR =0.23, 95% CI = 0.09-0.59), medical care-seeking behaviour (OR = 0.51, 95% CI = 0.36-0.72), age (OR = 0.96, 95% CI = 0.96-0.97), and income (OR = 1.00, 95% CI = 1.00-1.00). Self-reported illness is statistically correlated with sex (OR = 0.25, 95% CI = 0.10-0.62), head of household (OR = 0.33, 95% CI = 0.12-0.96), age (OR = 1.04, 95% CI = 1.01-1.07) and current good self-rated health status (OR = 0.32, 95% CI = 0.12-0.84).

CONCLUSION

This paper highlights that caution must be used by researchers in interpreting self-reported health data of males.

A translational framework for public health research

BACKGROUND

The paradigm of translational medicine that underpins frameworks such as the Cooksey report on the funding of health research does not adequately reflect the complex reality of the public health environment. We therefore outline a translational framework for public health research.

DISCUSSION

Our framework redefines the objective of translation from that of institutionalising effective interventions to that of improving population health by influencing both individual and collective determinants of health. It incorporates epidemiological perspectives with those of the social sciences, recognising that many types of research may contribute to the shaping of policy, practice and future research. It also identifies a pivotal role for evidence synthesis and the importance of non-linear and intersectoral interfaces with the public realm.

SUMMARY

We propose a research agenda to advance the field and argue that resources for 'applied' or 'translational' public health research should be deployed across the framework, not reserved for 'dissemination' or 'implementation'.

What is population health intervention research?

Population-level health interventions are policies or programs that shift the distribution of health risk by addressing the underlying social, economic and environmental conditions. These interventions might be programs or policies designed and developed in the health sector, but they are more likely to be in sectors elsewhere, such as education, housing or employment. Population health intervention research attempts to capture the value and differential effect of these interventions, the processes by which they bring about change and the contexts within which they work best. In health research, unhelpful distinctions maintained in the past between research and evaluation have retarded the development of knowledge and led to patchy evidence about policies and programs. Myths about what can and cannot be achieved within community-level intervention research have similarly held the field back. The pathway forward integrates systematic inquiry approaches from a variety of disciplines.

Evaluating the global 'Evidence Footprint': how can evidence better serve the needs of global public health?

The Cochrane Collaboration must strive to become a more global organization and help facilitate the use of evidence to improve public health, especially in the developing world. It can do so by improving the scope and relevance of its systematic reviews, by building capacity in countries to synthesize and use evidence for health policy development, and by addressing the challenge of developing methodologies for dealing with different types of evidence commonly used by health decision-makers in resource- and evidence-challenged settings.

What is population health intervention research?

Population-level health interventions are policies or programs that shift the distribution of health risk by addressing the underlying social, economic and environmental conditions. These interventions might be programs or policies designed and developed in the health sector, but they are more likely to be in sectors elsewhere, such as education, housing or employment. Population health intervention research attempts to capture the value and differential effect of these interventions, the processes by which they bring about change and the contexts within which they work best. In health research, unhelpful distinctions maintained in the past between research and evaluation have retarded the development of knowledge and led to patchy evidence about policies and programs. Myths about what can and cannot be achieved within community-level intervention research have similarly held the field back. The pathway forward integrates systematic inquiry approaches from a variety of disciplines.

Reviewing evidence on complex social interventions: appraising implementation in systematic reviews of the health effects of organisational-level workplace interventions

BACKGROUND

The reporting of intervention implementation in studies included in systematic reviews of organisational-level workplace interventions was appraised. Implementation is taken to include such factors as intervention setting, resources, planning, collaborations, delivery and macro-level socioeconomic contexts. Understanding how implementation affects intervention outcomes may help prevent erroneous conclusions and misleading assumptions about generalisability, but implementation must be adequately reported if it is to be taken into account.

METHODS

Data on implementation were obtained from four systematic reviews of complex interventions in workplace settings. Implementation was appraised using a specially developed checklist and by means of an unstructured reading of the text.

RESULTS

103 studies were identified and appraised, evaluating four types of organisational-level workplace intervention (employee participation, changing job tasks, shift changes and compressed working weeks). Many studies referred to implementation, but reporting was generally poor and anecdotal in form. This poor quality of reporting did not vary greatly by type or date of publication. A minority of studies described how implementation may have influenced outcomes. These descriptions were more usefully explored through an unstructured reading of the text, rather than by means of the checklist.

CONCLUSIONS

Evaluations of complex interventions should include more detailed reporting of implementation and consider how to measure quality of implementation. The checklist helped us explore the poor reporting of implementation in a more systematic fashion. In terms of interpreting study findings and their transferability, however, the more qualitative appraisals appeared to offer greater potential for exploring how implementation may influence the findings of specific evaluations. Implementation appraisal techniques for systematic reviews of complex interventions require further development and testing.

Policy-makers' attitudes to decision support models for coronary heart disease: a qualitative study

OBJECTIVES

To explore attitudes to the use of models for coronary heart disease to support decision-making for policy and service planning.

METHODS

Qualitative study using semi-structured interviews with 33 policy- and decision-makers purposively sampled from the UK National Health Service (NHS) (national, regional and local levels), academia and voluntary organizations. Interviews were transcribed, coded and emergent themes identified using framework analysis aided by NVivo software.

RESULTS

Policy-makers and planners were generally enthusiastic about models to assist in decision-making through: predicting trends; assessing the effect of interventions on health inequalities; quantifying the impact of population level and targeted interventions, and facilitating economic evaluation. The perceived advantages of using models included: more rational commissioning; the facility for scenario testing; advocacy for population level interventions and off-the-shelf synthesis to aid real time decision-making. However, although participants were aware of models to support decision-making, these were not being used routinely. Some participants felt that models oversimplify complex situations and that there is a lack of shared understanding as to how models work. Factors that increase confidence in decision support models included: rigorous validation and peer review, the availability of user-support and increased transparency.

CONCLUSION

Policy-makers and planners were generally enthusiastic about the use of models to support decision-making, illustrating the potential uses for models and the factors that improve confidence in them. However, existing models are often not being used in practice. So new models that are fit for practice need to be developed.

Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making

Background

In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making.

Methods

Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified.

Results

Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established.

Conclusion

Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.

Beyond evidence--to ethics: a decision-making framework for health promotion, public health and health improvement

Echoing the rise of 'evidence-based medicine', the concept of evidence-based policy and practice in the inter-related fields of health promotion, public health and health improvement has attracted increasing attention over the past two decades. More recently, again with roots traceable to biomedical thinking, there has been growing interest in ethics in relation to these fields. This paper links these two topical themes in a practical way. It explores the extent to which policies and activities 'on the ground' can and should be based on evidence, and considers the relative places of evidence and ethics in decision-making. It goes on to present the 'decision-making triangle', a framework that gives primacy to a set of ethical principles--with available evidence and plausible theory being used to inform the application of these. After introducing the concept of 'ethical logic modelling', the paper concludes by suggesting an 'ethical imperative' for health promotion, public health and health improvement: to make decisions based on the explicit application of ethical principles, using available evidence and theory appropriately.

"We're not short of people telling us what the problems are. We're short of people telling us what to do": an appraisal of public policy and mental health

Background

There is sustained interest in public health circles in assessing the effects of policies on health and health inequalities. We report on the theory, methods and findings of a project which involved an appraisal of current Scottish policy with respect to its potential impacts on mental health and wellbeing.

Methods

We developed a method of assessing the degree of alignment between Government policies and the 'evidence base', involving: reviewing theoretical frameworks; analysis of policy documents, and nineteen in-depth interviews with policymakers which explored influences on, and barriers to cross-cutting policymaking and the use of research evidence in decisionmaking.

Results

Most policy documents did not refer to mental health; however most referred indirectly to the determinants of mental health and well-being. Unsurprisingly research evidence was rarely cited; this was more common in health policy documents. The interviews highlighted the barriers to intersectoral policy making, and pointed to the relative value of qualitative and quantitative research, as well as to the imbalance of evidence between "what is known" and "what is to be done".

Conclusion

Healthy public policy depends on effective intersectoral working between government departments, along with better use of research evidence to identify policy impacts. This study identified barriers to both these. We also demonstrated an approach to rapidly appraising the mental health effects of mainly non-health sector policies, drawing on theoretical understandings of mental health and its determinants, research evidence and policy documents. In the case of the social determinants of health, we conclude that an evidence-based approach to policymaking and to policy appraisal requires drawing strongly upon existing theoretical frameworks, as well as upon research evidence, but that there are significant practical barriers and disincentives.

Saúde bucal no contexto do Programa Saúde da Família: práticas de prevenção orientadas ao indivíduo e ao coletivo

As práticas profissionais refletem a estruturação dos serviços de saúde, relacionando-se aos princípios norteadores do modelo de atenção vigente. Nesse sentido, objetivou-se conhecer as práticas preventivas e educativas em saúde bucal realizadas pelos dentistas do Programa Saúde da Família de Natal, Rio Grande do Norte, Brasil. Realizou-se entrevista estruturada com 80 dentistas e análise documental no SIA-SUS (Sistema de Informações Ambulatoriais do SUS) e no Sistema de Informação de Atenção Básica. As atividades individuais de orientação de higiene bucal e de aplicação tópica de flúor, entre todos os entrevistados, corresponderam a 87,5% e 95%, respectivamente. Em âmbito coletivo, todos que atuavam nas escolas (91,2%) realizavam aplicação tópica de flúor, enquanto 86,2% desenvolviam ações educativas. Nos registros do SIA-SUS, as atividades preventivas representaram 41% do total de procedimentos. Dentre essas, aplicação tópica de flúor gel por sessão correspondeu a 24,4% e escovação supervisionada, a 31%. Quanto às atividades educativas, 57,4% realizaram-se no estabelecimento de saúde e 42,6%, na comunidade. Diante dos resultados, constatou-se que as práticas preventivas direcionam-se à cárie dentária, com maior atenção aos escolares, sendo necessária ampliação para diferentes problemas bucais, grupos e espaços sociais.

"Developing good taste in evidence": facilitators of and hindrances to evidence-informed health policymaking in state government

CONTEXT

Policymaking is a highly complex process that is often difficult to predict or influence. Most of the scholarship examining the role of research evidence in policymaking has focused narrowly on characteristics of the evidence and the interactions between scientists and government officials. The real-life context in which policymakers are situated and make decisions also is crucial to the development of evidence-informed policy.

METHODS

This qualitative study expands on other studies of research utilization at the state level through interviews with twenty-eight state legislators and administrators about their real-life experiences incorporating evidence into policymaking. The interviews were coded inductively into the following categories: (1) the important or controversial issue or problem being addressed, (2) the information that was used, (3) facilitators, and (4) hindrances.

FINDINGS

Hindrances to evidence-informed policymaking included institutional features; characteristics of the evidence supply, such as research quantity, quality, accessibility, and usability; and competing sources of influence, such as interest groups. The policymakers identified a number of facilitators to the use of evidence, including linking research to concrete impacts, costs, and benefits; reframing policy issues to fit the research; training to use evidence-based skills; and developing research venues and collaborative relationships in order to generate relevant evidence.

CONCLUSIONS

Certain hindrances to the incorporation of research into policy, like limited budgets, are systemic and not readily altered. However, some of the barriers and facilitators of evidence-informed health policymaking are amenable to change. Policymakers could benefit from evidence-based skills training to help them identify and evaluate high-quality information. Researchers and policymakers thus could collaborate to develop networks for generating and sharing relevant evidence for policy.

Psychosocial risk factors in home and community settings and their associations with population health and health inequalities: a systematic meta-review

BACKGROUND

The effects of psychosocial risk factors on population health and health inequalities has featured prominently in epidemiological research literature as well as public health policy strategies. We have conducted a meta-review (a review of reviews) exploring how psychosocial factors may relate to population health in home and community settings.

METHODS

Systematic review (QUORUM) of literature reviews (published in any language or country) on the health associations of psychosocial risk factors in community settings. The literature search included electronic and manual searches. Two reviewers appraised included reviews using criteria for assessing systematic reviews. Data from the more robust reviews were extracted, tabulated and synthesised.

RESULTS

Thirty-one reviews met our inclusion criteria. These explored a variety of psychosocial factors including social support and networks, social capital, social cohesion, collective efficacy, participation in local organisations - and less favourable psychosocial risk factors such as demands, exposure to community violence or anti-social behaviour, exposure to discrimination, and stress related to acculturation to western society. Most of the reviews focused on associations between social networks/support and physical or mental health. We identified some evidence of favourable psychosocial environments associated with better health. Reviews also found evidence of unfavourable psychosocial risk factors linked to poorer health, particularly among socially disadvantaged groups. However, the more robust reviews each identified studies with inconclusive findings, as well as studies finding evidence of associations. We also identified some evidence of apparently favourable psychosocial risk factors associated with poorer health.

CONCLUSION

From the review literature we have synthesised, where associations have been identified, they generally support the view that favourable psychosocial environments go hand in hand with better health. Poor psychosocial environments may be health damaging and contribute to health inequalities. The evidence that underpins our understanding of these associations is of variable quality and consistency. Future research should seek to improve this evidence base, with more longitudinal analysis (and intervention evaluations) of the effects of apparently under-researched psychosocial factors such as control and participation within communities. Future policy interventions relevant to this field should be developed in partnership with researchers to enable a better understanding of psychosocial mechanisms and the effects of psychosocial interventions.

Research evidence can successfully inform policy and practice: insights from the development of the NSW Health Breastfeeding Policy

Strengthening the bridge between research and policy has been identified as a priority if evidence-based policy is to become the norm. However, current understanding of the research-policy interface is limited. A recent policy in NSW was the first evidence-based directive with specific actions to promote and support breastfeeding within a state health system in Australia. This paper explores the development of this policy, highlighting the factors that facilitated the incorporation of research evidence into the policy. The funding of a research centre to support NSW Health policy and workforce development was significant to the process. The existing organisational linkage ensured that the research evidence was identified, synthesised and effectively communicated, with the needs of the research users in mind and within a clear framework to guide action. The research evidence was not only strong, but also relevant with regard to prevailing political interests. The process was strengthened by the commitment of key researchers and policy makers to breastfeeding. Other types of evidence were considered, including the expert opinions of senior service providers regarding the capacity to act on the research evidence.

"Profits before people"? A systematic review of the health and safety impacts of privatising public utilities and industries in developed countries

Debates on government privatisation policies have often focused on the alleged effects of privatisation on health and safety. A systematic review (through Quality of Reporting of Meta-analysis) of the effects of privatising industries and utilities on the health (including injuries) of employees and the public was conducted. The data sources were electronic databases (medical, social science and economic), bibliographies and expert contacts. Experimental and quasi-experimental studies were sought, dating from 1945, from any Organisation for Economic Cooperation and Development member country (in any language) that evaluated the health outcomes of such interventions. Eleven highly heterogeneous studies that evaluated the health impacts of privatisation of building, water, paper, cement, bus, rail, mining, electric and gas companies were identified. The most robust study found increases in the measures of stress-related ill health among employees after a privatisation intervention involving company downsizing. No robust evidence was found to link privatisation with increased injury rates for employees or customers. In conclusion, public debates on the health and safety implications of privatisation have a poor empirical base, which policy makers and researchers need to address. Some evidence suggests that adverse health outcomes could result from redundancies associated with privatisation.

[Gender-sensitive epidemiological data analysis: methodological aspects and empirical outcomes. Illustrated by a health reporting example]

In Germany gender-sensitive approaches are part of guidelines for good epidemiological practice as well as health reporting. They are increasingly claimed to realize the gender mainstreaming strategy in research funding by the federation and federal states. This paper focuses on methodological aspects of data analysis, as an empirical data example of which serves the health report of Bremen, a population-based cross-sectional study. Health reporting requires analysis and reporting methods that are able to discover sex/gender issues of questions, on the one hand, and consider how results can adequately be communicated, on the other hand. The core question is: Which consequences do a different inclusion of the category sex in different statistical analyses for identification of potential target groups have on the results? As evaluation methods logistic regressions as well as a two-stage procedure were exploratively conducted. This procedure combines graphical models with CHAID decision trees and allows for visualising complex results. Both methods are analysed by stratification as well as adjusted by sex/gender and compared with each other. As a result, only stratified analyses are able to detect differences between the sexes and within the sex/gender groups as long as one cannot resort to previous knowledge. Adjusted analyses can detect sex/gender differences only if interaction terms have been included in the model. Results are discussed from a statistical-epidemiological perspective as well as in the context of health reporting. As a conclusion, the question, if a statistical method is gender-sensitive, can only be answered by having concrete research questions and known conditions. Often, an appropriate statistic procedure can be chosen after conducting a separate analysis for women and men. Future gender studies deserve innovative study designs as well as conceptual distinctiveness with regard to the biological and the sociocultural elements of the category sex/gender.

Developing evidence-based recommendations in public health--incorporating the views of practitioners, service users and user representatives

BACKGROUND

Guidance based on a systematic assessment of the evidence base has become a fundamental tool in the cycle of evidence-based practice and policy internationally. The process of moving from the formal evidence base derived from research studies to the formation and agreement of recommendations is however acknowledged to be problematic, especially in public health; and the involvement of practitioners, service commissioners and service users in that process is both important and methodologically challenging.

AIM

To test a structured process of developing evidence-based recommendations in public health while involving a broad constituency of practitioners, service commissioners and service user representatives.

METHODS

As part of the development of national public health recommendations to promote and support breastfeeding in England, the methodological challenges of involving stakeholders were examined and addressed. There were three main stages: (i) an assessment of the formal evidence base (210 studies graded); (ii) electronic and fieldwork-based consultation with practitioners, service commissioners and service user representatives (563 participants), and an in-depth analytical consultation in three 'diagonal slice' workshops (89 participants); (iii) synthesis of the previous two stages.

RESULTS AND CONCLUSIONS

The process resulted in widely agreed recommendations together with suggestions for implementation. It was very positively evaluated by participants and those likely to use the recommendations. Service users had a strong voice throughout and participated actively. This mix of methods allowed a transparent, accountable process for formulating recommendations based on scientific, theoretical, practical and expert evidence, with the added potential to enhance implementation.

Health systems research in Lao PDR: capacity development for getting research into policy and practice

BACKGROUND

Lao PDR is a low-income country with an urgent need for evidence-informed policymaking in the healthcare sector. During the last decade a number of Health Systems Research (HSR) projects have been conducted in order to meet this need. However, although knowledge about research is increasing among policymakers, the use of research in policymaking is still limited.

METHODS

This article investigates the relationship between research and policymaking from the perspective of those participating in HSR projects. The study is based on 28 interviews, two group discussions and the responses from 56 questionnaires.

RESULTS

The interviewees and questionnaire respondents were aware of the barriers to getting research into policy and practice. But while some were optimistic, claiming that there had been a change of attitudes among policymakers in the last two years, others were more pessimistic and did not expect any real changes until years from now. The major barriers to feeding research results into policy and practice included an inability to influence the policy process and to get policymakers and practitioners interested in research results. Another barrier was the lack of continuous capacity development and high-quality research, both of which are related to funding and international support. Many of the interviewees and questionnaire respondents also pointed out that communication between those conducting research and policymakers must be improved.

CONCLUSION

The results show that in the case of Lao PDR, research capacity development is at a crucial stage for implementing research into policy and practice. If research is going to make a consistent impact on policymaking in the Lao health care sector, the attitude towards research will need to be changed in order to get research prioritised, both among those conducting research, and among policymakers and practitioners. Our findings indicate that there is awareness about the barriers in this process.

Social determinants of health: a veil that hides socioeconomic position and its relation with health

The emergence of theoretical models of social determinants of health has added conceptual ambiguity to the understanding of social inequalities in health, as it is often not possible to clearly distinguish between socioeconomic position and these determinants. Whether the existence of social inequalities in health is based on differences in health or on differences in social determinants of health that are systematically associated with socioeconomic position, policymakers should be clearly informed of the importance of socioeconomic position for health. Thus, the following three basic requirements are proposed: to reach a consensus about the dimensions that reflect socioeconomic position; to agree about what are to be considered the social determinants of health and whether or not these determinants are a construct that can be distinguished from socioeconomic position; and finally, to establish which dimensions and measures of socioeconomic position are most appropriate for the evaluation of interventions that aim to reduce these inequalities.

Do differences in health make a difference? A review for health policymakers

While many societies have made remarkable progress in population health improvements, health inequalities remain as a central concern to health policy. There is substantial evidence to show that differences in health achievements and access to health care are increasing both within and among societies. Socio-economic and environmental health determinants are strongly associated to population health status regardless of what risk factor or technological advance is in vogue. Understanding the fundamental causes underlying the existence of health inequalities is useful for guiding health policy as it provides a direction to guide resource allocation and the targeting of policy interventions. The purpose of this paper is to review current perspectives and methods in the assessment of health inequalities with particular relevance to public health policymakers and practitioners.

Health inequalities in Scotland and England: the contrasting journeys of ideas from research into policy

Both the UK's Labour Government and Scotland's devolved Labour-Liberal Democrat coalition Executive have committed themselves to reducing health inequalities. Furthermore, both institutions have emphasised the importance of using evidence to inform policy responses. In light of such political commitments, a significant amount of work has been undertaken in the field of health inequalities in order to: (i) review the available research evidence; (ii) assess the extent to which policies have been based on this research evidence; and (iii) evaluate the success (or failure) of policies to tackle health inequalities. Yet so far only limited attention has been given to exploring how key actors involved in research-policy dialogues understand the processes involved. In an attempt to address this gap, this article draws on data from semi-structured interviews with 58 key actors in the field of health inequalities research and policymaking in the UK to argue that it is ideas, rather than research evidence, which have travelled from research into policy. The descriptions of the varying journeys of these ideas fit three types--successful, partial and fractured--each of which is outlined with reference to one example. The paper then employs existing theories about research-policy relations and the movement of ideas in an attempt to illuminate and better understand the contrasting journeys. In the concluding discussion, it is argued that the third approach, which focuses on the entrepreneurial processes involved in the marketing of ideas, is most helpful in understanding the research findings, but that this needs to be discussed in relation to the political context within which negotiations take place.

Understanding differences in income-related health inequality between geographic regions in Taiwan using the SF-36

This paper measures and decomposes socio-economic inequality in general and mental health of Taiwan residents using concentration indices. The data from the 2001 Taiwanese National Health Interview Survey is based on multi-stage systematic sampling: 18,142 subjects aged 12 and above provided answers to questions on general and mental health domains of SF-36 Taiwan version. Significant inequalities favouring higher income groups emerge in both general and mental health, but these are particularly high for residents in remote areas. The decomposition analysis shows that in both areas income itself accounts for a significant and sizeable contribution (40-73%) of general and mental health inequality. The second largest contribution comes from inequality in education (15-22%) for general health and from employment status (17-18%) for mental health. Apart from these factors, age, and lifestyles are also important contributors for both general and mental health. We also find important regional disparities in income-related inequalities.

The role and theoretical evolution of knowledge translation and exchange in public health

BACKGROUND

There is an increased emphasis in public health research on effective models and strategies to support knowledge translation (KT), the exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. In other words, KT can be seen as an acceleration of the knowledge cycle-an acceleration of the natural transformation of knowledge into use (Canadian Institutes of Health Services Research. Knowledge Translation Strategy, 2004). The most recent conceptualizations consider the complexities of public health decision-making. The role of practitioners and communities is increasingly considered.

METHODS

We identify, describe and discuss the theoretical underpinnings of KT and recommend a way forward to build the evidence for more effective practice.

RESULTS

Theoretical perspectives increasingly influence research on KT in public health. A range of innovative work is being conducted to explore methods for KT using practical tools, often with the support of government.

CONCLUSIONS

KT describes a crucial and to date under-developed element of the research process. There is an important gap in theoretically informed empirical studies of effectiveness of proposed approaches in public health, health promotion and preventive medicine, and thus much of the debate remains abstract. There is clearly an urgent policy need to establish the effectiveness of KT models in a range of contexts. This must include both the consideration of development and the utilization of knowledge.

Natural experiments: an underused tool for public health?

Policymakers and public health researchers alike have demanded better evidence of the effects of interventions on health inequalities. These calls have been repeated most recently in the UK in the final Wanless report, which spoke of the "almost complete lack of an evidence base on the cost-effectiveness of public health interventions", and pointed more generally to the limited evidence base for public health policy and practice. Wanless and others have suggested that the gaps may be partially filled by exploiting the opportunities offered by "natural experiments", such as changes in employment opportunities, housing provision, or cigarette pricing. Natural experiments have an important contributions to make within the health inequalities agenda. First, they can play an important role in investigating the determinants of health inequalities. Second, they can assist in the identification of effective interventions, an area where it is widely acknowledged that the evidence-base is currently sparsely populated. This paper discusses some of the benefits and limitations of using this type of evidence, drawing on two ongoing quasi-experimental studies as examples.

The limitations of 'evidence-based' public health

This paper examines how the concept of the 'evidence-based' approach has transferred from clinical medicine to public health and has been applied to health promotion and policy making. In policy making evidence has always been interpreted broadly to cover all types of reasoned enquiry and after some debate the same is now true for health promotion. Taking communities rather than individuals as the unit of intervention and the importance of context means that frequently randomized controlled trials are not appropriate for study of public health interventions. Further, the notion of a 'best solution' ignores the complexity of the decision making process. Evidence 'enlightens' policy makers shaping how policy problems are framed rather than providing the answer to any particular problem. There are lessons from the way that evidence-based policy is being applied in public health that could usefully be taken back into medicine.

Out-of-home day care for families living in a disadvantaged area of London: economic evaluation alongside a RCT

BACKGROUND

Children born into poverty have lifelong disadvantages compared with those more fortunate; social interventions seek to break this cycle of poverty and deprivation. Early Years Centres are one such intervention. These were established in deprived areas in the UK to provide high quality out-of-home day care. This paper reports the results of an economic evaluation conducted alongside a randomized controlled trial of one of these centres in the Borough of Hackney, London.

METHODS

Participants were randomized to receive either high quality day care as provided by the centre or to other child care that they secured for themselves where they chose to do so. Information on resource use (early years education and care, as well as health and social care) was collected over an 18-month period; this was valued using appropriate unit costs. The cost of education, social and health care together with the value of productivity gains and out-of-pocket costs were then compared with the effectiveness of the intervention, increased labour force participant in mothers.

RESULTS

From the societal perspective, the value of employment outweighs the costs of health and social services used, and in both groups there are cost savings. These are greater in the intervention group, therefore Early Years day care is an efficient use of resources. However, there is a net cost to the public sector of providing the intervention. The cost of achieving an additional mother in the labour force at 18 months is pound38 550 (85% CI of -pound1273, pound416 172).

CONCLUSION

From the societal perspective, over an 18-month period, all child care is cost saving, but high quality day care provided by the Early Years Centre is a cost-effective alternative to day care provided by other local services in Hackney. The public sector, however, incurs added expense from this intervention.

Use of health impact assessment in incorporating health considerations in decision making

STUDY AIM

The aim of this project is to identify from a range of sources the factors associated with the success of a health impact assessment (HIA) in integrating health considerations into the final decision and implementation of a planned policy, programme, or project.

DESIGN

Three methods were adopted: (a) a review of HIA case studies; (b) a review of commentaries, reviews and discussion papers relating to HIA and decision making; and (c) an email survey of a purposive sample of HIA academics, HIA practitioners, and policymakers. Information was captured on the following characteristics: information on the year undertaken; geopolitical level; setting; sector; HIA type; methods and techniques used; identification of assessors.

MAIN RESULTS

Two groups of factors were identified relating to the decision making environment and to the technical conduct of the HIA. With regard to the environment, striking a balance between decision maker ownership and HIA credibility; organisational, statutory and policy commitment to HIA, and the provision of realistic, non-controversial recommendations were cited as enablers to the integration of HIA findings into the decision making process. Barriers included a lack of knowledge of the policymaking environment by those conducting HIA. Regarding factors relating to the conduct of the HIA: use of a consistent methodological approach; inclusion of empirical evidence on health impacts; timing of the HIA congruent with the decision making process; involvement of expert HIA assessors; and shaping of recommendations to reflect organisational priorities were cited as enablers while lack of a standardised methodology; lack of resources and use of jargon were cited as barriers.

CONCLUSIONS

The findings emphasise the importance of considering the politico-administrative environment in which HIA operates. The extent to which HIA fits the requirements of organisations and decision makers may be as important as the technical methods adopted to undertake it.