Who knows best? A Q methodology study to explore perspectives of professional stakeholders and community participants on health in low-income communities

Young people's perspectives on addressing UK health inequalities: utopian visions and preferences for action

INTRODUCTION

It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing.

METHODS

Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist-facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy.

FINDINGS

Proposals ranged from radical, whole-systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual-level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate.

CONCLUSION

Young people contributed wide-ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for 'upstream' systemic change to achieve reductions in social inequalities and the health differences that flow from these.

PUBLIC CONTRIBUTION

An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers.

A severely fragmented concept: Uncovering citizens' subjective accounts of severity of illness

Universal healthcare is constrained by national governments' finite health resources. This gives rise to complex priority-setting dilemmas. In several universal healthcare systems, the notion of severity (Norwegian: 'alvorlighet') is a key consideration in priority setting, such that treatments for 'severe' illness may be prioritised even when evidence suggests it would not be as cost-effective as treatment options for other conditions. However, severity is a poorly-defined concept, and there is no consensus on what severity means in the context of healthcare provision - whether viewed from public, academic, or professional perspectives. Though several public preference-elicitation studies demonstrate that severity is considered relevant in healthcare resource distribution, there is a paucity of research on public perceptions on the actual meaning of severity. We conducted a Q-methodology study between February 2021 and March 2022 to investigate views on severity amongst general public participants in Norway. Group interviews (n = 59) were conducted to gather statements for the Q-sort ranking exercises (n = 34). Data were analysed using by-person factor analysis to identify patterns in the statement rankings. We present a rich picture of perspectives on the term 'severity', and identify four different, partly conflicting, views on severity in the Norwegian population, with few areas of consensus. We argue that policymakers ought to be made aware of these differing perspectives on severity, and that there is need for further research on the prevalence of these views and on how they are distributed within populations.

Policy actors' perceptions of public participation to tackle health inequalities in Scotland: a paradox?

BACKGROUND

Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities.

METHODS

In 2019-2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking.

RESULTS

Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges.

CONCLUSIONS

Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities.

Eliciting public values on health inequalities: missing evidence for policy windows?

BACKGROUND

There is a widening health divide in the UK despite health inequalities being a long-standing subject of policy and research. New types of evidence are needed.

KEY POINTS FOR DISCUSSION

Knowledge of public values for non-health policies and their associated (non-)health outcomes is currently missing from decision-making processes. Eliciting public values using stated preference techniques can provide insights on what the general public would be willing to give-up for different distributions of (non-)health outcomes and the policies that can achieve them. To understand the role this evidence could have in decision-making processes, Kingdon's multiple streams analysis (MSA) is used as a policy lens to explore how evidence of public values could affect policy processes for ways to tackle health inequalities.

CONCLUSIONS AND IMPLICATIONS

This paper outlines how evidence of public values could be elicited through the use of stated preference techniques and suggests this could facilitate the creation of policy windows for tackling health inequalities. Additionally, Kingdon's MSA helps make explicit six cross-cutting issues when generating this new form of evidence. This suggests the need to explore reasons for public values and how decision-makers would use such evidence. With an awareness of these issues, evidence on public values has the potential to support upstream policies to tackle health inequalities.

Evaluating meaningful impact of Patient and Public Involvement: A Q methodology study among researchers and young people with a chronic condition

Introduction

Although Patient and Public Involvement (PPI) of young people with a chronic condition (YPCC) is receiving increasing attention, evidence of impact is lacking. This is partly due to inadequate understanding of what meaningful impact entails. This study aimed to gain an in‐depth understanding of researchers’ and YPCC's perspectives on meaningful impact.

Methods

We conducted a Q methodology study in a group of 26 researchers and a group of 20 YPCC with experience in PPI. Participants ranked statements about impact (e.g., ‘YPCC acquire new knowledge and skills’) based on their agreement with them. During interviews, they reflected on their rankings (Q sorts). Factor analysis was conducted to identify similar patterns in the individual Q sorts. The interviews were used to determine and interpret the final factor solution. The resulting factors represented distinct perspectives on meaningful impact.

Results

Four distinct perspectives on meaningful impact of PPI were identified. Two were predominantly based on the Q sorts of researchers, for example improving research quality and facilitating dialogue and understanding, and two on the Q sorts of YPCC, for example achieving equality and inclusivity and doing justice to YPCC's rights. The factors were defined by 37 Q sorts (80%); 9 Q sorts did not load significantly on any of the factors.

Conclusion

The results indicate that researchers and YPCC can have different views about the meaningful impact of PPI. The perspectives identified here can serve as an aid when discussing these different views and formulating operational indicators of impact.

Patient or Public Contribution

An adolescent with a chronic condition was involved in the early phases of this study. She helped in formulating the statements and recruiting YPCC.

Public understandings of potential policy responses to health inequalities: Evidence from a UK national survey and citizens' juries in three UK cities

A substantial body of research describes the distribution, causes and potential reduction of health inequalities, yet little scholarship examines public understandings of these inequalities. Existing work is dominated by small-scale, qualitative studies of the experiences of specific communities. As a result, we know very little about what broader publics think about health inequalities; and even less about public views of potential policy responses. This is an important gap since previous research shows many researchers and policymakers believe proposals for 'upstream' policies are unlikely to attract sufficient public support to be viable. This mixed methods study combined a nationally representative survey with three two-day citizens' juries exploring public views of health inequalities and potential policy responses in three UK cities (Glasgow, Manchester and Liverpool) in July 2016. Comparing public opinion elicited via a survey to public reasoning generated through deliberative processes offers insight into the formation of public views. The results challenge perceptions that there is a lack of public support for upstream, macro-level policy proposals and instead demonstrate support for proposals aiming to tackle health inequalities via improvements to living and working conditions, with more limited support for proposals targeting individual behavioural change. At the same time, some macro-economic proposals, notably those involving tax increases, proved controversial among study participants and results varied markedly by data source. Our analysis suggests that this results from three intersecting factors: a resistance to ideas viewed as disempowering (which include, fundamentally, the idea that health inequalities exist); the prevalence of individualising and fatalistic discourses, which inform resistance to diverse policy proposals (but especially those that are more 'upstream', macro-level proposals); and a lack of trust in (local and national) government. This suggests that efforts to enhance public support for evidence-informed policy responses to health inequalities may struggle unless these broader challenges are also addressed.

Exploring the perspectives of medical students of application on e-learning in medical education during the COVID-19 pandemic

BACKGROUND

The use of e-learning has become mandatory during the COVID-19 pandemic. However, there are many barriers to applying e-learning in medical education.

OBJECTIVE

This study aimed to explore medical students' perspectives on the application of e-learning in medical education during the COVID-19 pandemic.

METHODS

This Q-methodology explorative study was conducted in Kurdistan Region of Iraq. A sample of 37 medical students was purposively selected to represent different characteristics. The students distributed 37 statements representing different aspects of e-learning in medical education into a nine-point scoring grid from "least agree" to "most agree."

RESULTS

Data analysis revealed three distinct viewpoints. The first viewpoint, complete dependence on e-learning, emphasized a preference for e-learning to continue medical education and complete the study year with a minimal return to study halls or practical/clinical sessions. The second viewpoint, opponents of applying e-learning in medical education, included a generally negative view about e-learning and its role in medical education during the COVID-19 pandemic. The third viewpoint, e-learning as a supplement to medical education, emphasized a generally positive view about e-learning and considered it a supplement to the theoretical parts of medical education during the pandemic.

CONCLUSION

The three diverse viewpoints are primarily distinguished by the availability of e-learning experience and skills, availability of technology, risk perception of COVID-19, and the need for in-hospital clinical teaching. Provision of necessary facilities and training is required to strengthen the role of e-learning in medical education. A safe environment is needed for on-campus or hospital clinical teaching.

Public perspectives on health improvement within a remote-rural island community

Background

Rural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health.

Objective

To identify and describe shared perspectives within a remote‐rural community on how to improve rural health.

Method

Using Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews.

Results

Sixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services.

Discussion and conclusions

Factors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice.

Public Contribution

Members of the public were involved in the development and piloting of the statement set.

Microcredit as a public health initiative? Exploring mechanisms and pathways to health and wellbeing

The widening health gap between the best and worst-off in the UK requires innovative solutions that act upon the social, economic and environmental causes of ill-health. Initiatives such as microcredit have been conceptualised as having the potential to act on the social determinants of health. However, pathways that lead to this impact have yet to be empirically explored. People living on low incomes, who are financially-excluded, require access to credit to cope with everyday financial needs. While research shows the connections between debt and health, this link is often focused on over-indebtedness and negative health outcomes. In this paper, we investigate the impact of responsibly-delivered credit on the health and wellbeing of borrowers. In 2016-17, in-depth, semi-structured interviews were undertaken with fourteen borrowers from two microcredit providers offering personal and business microloans, operating in Glasgow, United Kingdom. Findings are presented, using social determinants of health as an analytic lens, and illustrated in a conceptual model explaining the loan mechanisms and pathways connecting microcredit to health and wellbeing. Microcredit, and the mechanisms through which it is delivered, were perceived by participants as positively impacting on their health and wellbeing. Access to flexible, responsibly-delivered, microloans enabled participants to plan and feel secure when faced with (un)expected financial events, reducing the associated stress, sustaining social relationships and empowering borrowers to take greater control over their lives. For some, receiving microcredit was stressful, as it is still a debt that needs to be repaid. Such stress can also be exacerbated by particular aspects of the lending model; for example, group lending. Our results contribute to growing evidence on the impact of financial inclusion approaches on health and wellbeing, highlighting the potential role of microcredit as a public health initiative and the need to support 'alternative' economic spaces in the UK to serve the financially-excluded.