Addressing health inequalities in times of austerity: implementation of a place-based approach in multitiered local government

AIMS

This article focuses on how local authorities in England are tackling wider determinants of health and inequalities in their population's outcomes while budgets for public services are diminishing.

METHODS

It reports the experience from one case study engaged in rolling out a devolved, place- and asset-based strategy over multiple tiers of local government. Relating these findings to relevant social theory, we draw out aspects of context and mechanisms of change. We offer plausible hypotheses for the experiences observed, which supports transferability and implementation of place-based strategies in other local authority areas struggling with similar challenges.

RESULTS

Findings highlight the importance of high-level and political buy-in, as well as the role of the COVID-19 pandemic as a potential catalyst to rollout. Creating the foundations for a new, place-based working was important for achieving coherence among partners around what local government was trying to achieve. These included investment in infrastructure, both relational and tangible inputs such as organisational and human resources, to establish the conditions for systemic change towards early intervention and prevention.

CONCLUSION

This study identified clear foundations for place-based action, plus enablers and barriers to significant transformation of practice towards asset-based approaches between local authorities, partners and the public.

Understanding place-based public health to reduce inequalities in the context of austerity

Background

Ageing populations and increased prevalence of long-term conditions, combined with reduced public funding following the financial crisis mean health needs often outstrip provision. Furthermore, austerity policies across Europe have been associated with a steep rise in health inequalities.

Methods

A comparative case study design, drawing on realist evaluation, examines the place-based strategies used by five UK Local Authorities (LAs) to maximise resources and reduce health inequalities. LAs were selected based on their implementation of innovative interventions and/or their experience of better or worse than expected trends in reducing health inequalities. Initial programme theories (IPTs) were developed through stakeholder consultation and literature searches, which will be tested and refined using case study data. Data collection methods are tailored to each case study context, but include: documentary analysis; system mapping exercises; and interviews with stakeholders and community members.

Preliminary Results

Initial programme theories were developed detailing the place-based strategies that are most effective in maximising resources and improving health outcomes, depending on contextual conditions. These theories cover strategies such as income generation schemes to supplement taxation; the introduction of ’disruptive’ voices into decision processes; outsourcing and widening skill-sets; reviewing and streamlining resources; and the development of tightly defined targets.

Conclusions

There is currently a lack of guidance on the optimal allocation of limited resources and effective delivery of services and interventions in contexts of reduced spending. Employing a realist approach has enabled us to move beyond the particularities of local contexts and strategies to produce pragmatic and transferable solutions which can inform the funding decisions of local government.

Key messages

LAs have to innovate to balance growing needs with shrinking resources. Pragmatic lessons are drawn to inform decision making applicable beyond local contextual specificities.

Setting the agenda for further research on health and welfare

Background

Given the recognised relationship between poverty, welfare provision and health, welfare rights advice has emerged as a potentially key intervention in improving health and reducing inequalities. The generation of evidence in this area has proven difficult however, creating a need to take stock of existing research and develop an agenda for future work.

Methods

A series of four workshops was convened involving researchers from four UK universities who had previously undertaken work examining the relationship between welfare advice and health, from a range of methodological perspectives. Run concurrently to a scoping of the literature, these workshops aimed to synthesise lessons from prior research; formulate outstanding research questions; and outline potential methodological approaches for addressing these. A survey was undertaken with professionals (from welfare or legal advice sectors, the health sector, commissioning, local government, and housing services, n = 50) to test out, refine and add to these research questions.

Results

Key research questions developed from these workshops were: Are there inequalities in the impact and reach of advice services across social groups? How/ does advice delivery mode matter?What are the individual and system level impacts of the de-implementation of advice services?What are the impacts of changes to welfare provision on children, inter-generationally and throughout the life course?How do experiences of social welfare vary by social group, geographically and across generations? How do different identities combine to influence how social welfare is understood?

Conclusions

While the collaborative process brought challenges in balancing research and practitioner expertise, this model of working has been successful in setting an agenda for further research with maximum utility to practice. Direct outputs from the projects have been the collaborative submission of a journal article and a research bid.

Key messages

The collaboration, which was supported by the NIHR School of Public Health Research, led to the establishment of a concise research agenda. Through extensive stakeholder consultation, this will have maximal utility for practice.

The impact of precarious employment on the health and wellbeing of immigrants: a systematic review

Background

Migration and precarious employment are social determinants associated with adverse health outcomes. In the United Kingdom, migration policy and labour market characteristics mean that migrants are often engaged in precarious work. We synthesise evidence on the experiences of migrants and explore the effects of precarious employment on their health and wellbeing.

Methods

Electronic databases were searched for peer-reviewed qualitative studies describing the experiences of United Kingdom migrants in precarious employment. Title and abstracts were screened, followed by full text screening using pre-specified inclusion and exclusion criteria. Data on employment experiences and effects of working conditions on physical and mental health and perceived wellbeing were extracted. The Centre for Reviews and Dissemination (2009) framework was used to conduct a narrative synthesis.

Results

Out of 1577 unique citations, 5 met our inclusion criteria. All included studies reported negative outcomes on physical and mental health. 2 reported positive or negative outcomes for perceived wellbeing depending on pre-migration experience. Musculoskeletal pain, exhaustion, anxiety and depression were commonly reported effects of precarious employment. Communication difficulties and over qualification were identified as migrant specific factors influencing health outcomes.

Conclusions

Stress response theories and risk factors associated with occupational injury explain how employment specific factors influence health. Extrinsic factors such as immigration policies, pre-migration experience, responsibilities in home country and acculturation mediate precarious employment effect on health.

Key messages

Migrants feel isolated in precarious employment and are vulnerable to negative mental and physical health impacts. Broader migration related policies impact on experiences of employment and health.

A taxonomy of mechanisms underpinning the impact of welfare rights advice on health

Background

Welfare rights advice has potential to help address the social determinants of health and reduce inequalities. Existing logic models identify the sequence of proximal to distal outcomes following welfare advice, but attribution remains challenging. This paper reports on the contextual influences and key mechanisms leading to health outcomes.

Methods

We undertook comprehensive searches of the literature addressing the links between welfare advice and health. Titles and abstracts were screened first, then full text, using inclusion and exclusion criteria. Employing a realist logic of analysis, data extraction and synthesis focused on disentangling evidence of how and why advice improves (or not) health related outcomes, depending on the context. These insights were then paired with existing theory (either explicitly referenced or inferred by authors), in order to produce a robust explanatory model of when and how advice leads to improved health.

Results

59 articles were included in the analysis. Preliminary findings point to the significance of target group in influencing the types of outcomes achieved. Fineman’s (2013) typology of embodied, situational and structural vulnerability helped explain the differential impact of advice. Where people experience embodied vulnerabilities, such as life-limiting illness or disabling physical or mental health conditions, advice may increase quality of life, but is less likely to improve existing health status. Likewise, advice interventions alone are unlikely to alter health outcomes stemming from entrenched structural disadvantages such as poverty or discrimination, and appear to be most effective in addressing situational vulnerabilities generated more temporarily by difficult circumstances.

Conclusions

The review provides a more nuanced understanding of how and why welfare advice may impact on health. These insights will help to more appropriately target, tailor and monitor the health impact of welfare advice.

Key messages

Welfare advice has differential impact, depending on specific client vulnerabilities. This highlights the importance of appropriate targeting, and selecting suitable measures of success.

The importance of relationships in adolescent risk behaviour prevention

Methods

This review used a customised realist approach, to explore how, why, for whom, and in what circumstances programmes are most successful in preventing multiple health risk behaviours in adolescents. The review synthesised evidence from published literature, along with qualitative data from stakeholders collected through focus groups with young people (n = 28) and school nurses (n = 22), and interviews with adolescent health and wellbeing practitioners (n = 8).

Findings: Across all the realist programme theories developed, the role of relationships was the most commonly occurring theme. This theme goes beyond the expected impact of the relationship between programme deliverers and recipients, and familial and peer attachments, also taking in to consideration the relationships between programme and school leaders and staff, support networks and collaborative relationships between staff, and wider social connectedness within the community. These in turn were impacted upon by wider contextual factors, such as family, community, culture, socioeconomic status, intersectionality, and health inequalities.

Conclusions

These findings provide important insight in to understanding how, why, for whom, and in what circumstances multiple risk behaviour prevention programmes succeed or fail. Further to this they highlight key areas for consideration in the development of future adolescent public health interventions.

Key messages

Relationships built on trust and genuine care can improve adolescent risk behaviour prevention outcomes. Broader sociocultural context provide key explanations for variations in programme outcomes.

Exposing the impact of Citizens Advice Bureau services on health: a realist evaluation protocol

INTRODUCTION

Welfare advice services can be used to address health inequalities, for example, through Citizens Advice Bureau (CAB). Recent reviews highlight evidence for the impact of advice services in improving people's financial position and improving mental health and well-being, daily living and social relationships. There is also some evidence for the impact of advice services in increasing accessibility of health services, and reducing general practitioner appointments and prescriptions. However, direct evidence for the impact of advice services on lifestyle behaviour and physical health is currently much less well established. There is a need for greater empirical testing of theories around the specific mechanisms through which advice services and associated financial or non-financial benefits may generate health improvements.

METHODS AND ANALYSIS

A realist evaluation will be conducted, operationalised in 5 phases: building the explanatory framework; refining the explanatory framework; testing the explanatory framework through empirical data (mixed methods); development of a bespoke data recording template to capture longer term impact; and verification of findings with a range of CAB services. This research will therefore aim to build, refine and test an explanatory framework about how CAB services can be optimally implemented to achieve health improvement.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee at Northumbria University, UK. Project-related ethical issues are described and quality control aspects of the study are considered. A stakeholder mapping exercise will inform the dissemination of results in order to ensure all relevant institutions and organisations are targeted.

A realist synthesis of the evidence on outreach programmes for health improvement of Traveller Communities

Background

Improving the health of Traveller Communities is an international public health concern but there is little evidence on effective interventions. This study aimed to explain how, for whom and in what circumstances outreach works in Traveller Communities.

Methods

A realist synthesis was undertaken. Systematic literature searches were conducted between August and November 2011. Grey literature was sought and key stakeholders were involved throughout the review process. Iterative steps of data extraction, analysis and synthesis, followed by additional searches were undertaken.

Results

An explanatory framework details how, why and in what circumstances participation, behaviour change or social capital development happened. The trust status of outreach workers is an important context of outreach interventions, in conjunction with their ability to negotiate the intervention focus. The higher the outreach worker's trust status, the lower the imperative that they negotiate the intervention focus. A ‘menu’ of reasoning mechanisms is presented, leading to key engagement outcomes.

Conclusions

Adopting a realist analysis, this study offers a framework with explanatory purchase as to the potential of outreach to improve health in marginalized groups.

An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health

BACKGROUND

There is a need to identify and analyse the range of models developed to date for delivering health-related lifestyle advice (HRLA), or training, for effectiveness and cost-effectiveness in improving the health and well-being of individuals and communities in the UK, with particular reference to the reduction of inequalities.

OBJECTIVES

To identify the component intervention techniques of lifestyle advisors (LAs) in the UK and similar contexts, and the outcomes of HRLA interventions.

DATA SOURCES

Stakeholder views, secondary analysis of the National Survey of Health Trainer Activity, telephone survey of health trainer leads/coordinators. A search of a range of electronic databases was undertaken [including the Applied Social Sciences Index and Abstracts (ASSIA), EMBASE, NHS Economic Evaluation Database (NHS EED), MEDLINE, Psyc INFO, etc.], as well searching relevant journals and reference lists, conducted from inception to September 2008.

REVIEW METHODS

Identified studies were scanned by two reviewers and those meeting the following criteria were included: studies carrying out an evaluation of HRLA; those taking place in developed countries similar to the UK context; those looking at adult groups; interventions with the explicit aim of health improvement; interventions that involved paid or voluntary work with an individual or group of peers acting in an advisory role; advice delivered by post, online or electronically; training, support or counselling delivered to patients, communities or members of the public. After quality assessment, studies were selected for inclusion in the review. Data were abstracted from each study according to an agreed procedure and narrative, and realist and economic approaches were used to synthesise the data. Cost-effectiveness analysis of interventions was undertaken.

RESULTS

In total, 269 studies were identified but 243 were excluded. The 26 included studies addressing chronic care, mental health, breastfeeding, smoking, diet and physical activity, screening and human immunodeficiency virus (HIV) infection prevention. Overall, there was insufficient evidence to either support or refute the use of LAs to promote health and improve quality of life (QoL), and thus uncertainty about the interventions' cost-effectiveness. However, the economic analysis showed that LA interventions were cost-effective in chronic care and smoking cessation, inconclusive for breastfeeding and mental health and not cost-effective for screening uptake and diet/physical activity. LA interventions for HIV prevention were cost-effective, but not in a UK context.

LIMITATIONS

The wide variety of LA models, delivery settings and target populations prevented the reviewers from establishing firm causal relationships between intervention mode and study outcomes.

CONCLUSIONS

Evidence was variable, giving only limited support to LAs having a positive impact on health knowledge, behaviours and outcomes. Levels of acceptability appeared to be high. LAs acted as translational agents, sometimes removing barriers to prescribed behaviour or helping to create facilitative social environments. Reporting of processes of accessing or capitalising on indigenous knowledge was limited. Ambiguity was apparent with respect to the role and impact of lay and peer characteristics of the interventions. A future programme of research on HRLA could benefit from further emphasis on identification of needs, the broadening of population focus and intervention aims, the measurement of outcomes and the reviewing of evidence.

FUNDING

This study was funded by the Health Technology Assessment programme of the National Institute for Health Research.