Doing something about inequalities in health

Posted by Jean Adams

I was at a meeting in Edinburgh at the end of last year on inequalities in health. It was one of those events full of eminent (and emeritus) professors where I felt slightly out of my intellectual depth. I didn't trust myself to say much. But I tried to listen well.

We need to pro-actively engage with the media - like CJ Cregg did everyday

One of the things about health inequalities is that we all sort of know what the solution is. When I told my dad I was going to do a PhD on why poorer people tend to die younger than richer people, he said "well isn't it just because they don't have as much money?". This confused me. What I was interested in was the physiology - how does poverty "get under the skin?". I don't think the money thing had even crossed my mind.

Now, ten years later, I increasingly agree with my dad. Who cares about the physiology? Sure we could know more about the detailed biological processes going on, but what difference would it make to what we might do about inequalities? The solution remains that to change health inequalities to any substantial extent, we have to change the social structure. Reduce income inequalities, redistribute wealth.

You don't need to be a professor to work that out.

The problem seems to be that we (who? the academic community?) think any sort of drastic wealth redistribution is unattainable, or maybe just too difficult to attain. So we think of other little things we might be able to do to alleviate the problem, rather than tackle the cause. You know, target cancer screening programmes better, that sort of thing.

What would it take to get wealth redistribution? Political will. What would it take to get political will? Public pressure. What would it take to get public pressure? Media agitation. Just like everything else.

One of the things that I was slightly surprised we ended up talking about in Edinburgh was engaging with the media. Sure, I like a bit of science communication. But it's not something that has come up in any of my previous conversations about health inequalities. In fact in previous discussions about science communication, the conversation has rather stopped dead whenever I’ve mentioned inequalities.

The phenomenon of inequalities in health is not inherently media friendly. There are no breakthroughs to report on. No big shiny gadgets to take pictures of. Poorer people get sicker more and die younger. As one participant at the Edinburgh meeting pointed out, if there's a report documenting the extent of inequalities it might get a bit of coverage, but it will be presented as if this is some big, new finding. The coverage won’t go much beyond the data to explore what the cause or solution might be. Then there will likely be a few years of editorial 'fatigue' when it feels like that story has been done recently. Once everyone's forgotten, a new report might spark more interest, but again the coverage will be superficial. And the cycle will repeat.

Other participants described instances of reporters looking for a human angle on inequalities stories traipsing off to the most deprived parts of Glasgow and asking the people they met there why their health was so rubbish.

Mainstream media coverage doesn’t have to be like this. But it will be unless those of us within the public health academic and practice communities interested in inequalities in health get a bit more media-savvy. We need to pro-actively generate informed media debate ourselves. One fairly easy approach is to pitch articles to online outlets such as Comment is Free and newspaper blogs that are desperate for informed and timely content on policy issues.

We also need to be ready to publicly comment on anything to do with inequalities even before we are asked. One researcher, very experienced in media work, described how they prepare written commentary on new reports and statements on inequalities issues the day before they are released. It is fairly easy to guess in advance what the content of any new report will be and so respond appropriately – with final tweaks made on the day once they’ve had a chance to read the details. By staying a step ahead of events, it is possible to guide journalists and debate away from simple reporting to more in-depth consideration of what could be done to alleviate the problem.

Which is obviously all rather more easily said than done. We are, after all, full-time researchers, not part-time journalists. But maybe we could hold each others’ hands a bit and take it step by step and see how it goes? It seems we might have much more to gain, than to lose, from trying.

So who wants in with me on a Comment is Free post on what we need to do about health inequalities in the UK today? Ready to be pitched to coincide with the next big report.

A Christmas Blogpost

Posted by Heather Yoeli

And so, it’s That Season again. The time of year to do everything with alcohol and food which Public Health Guidelines say you shouldn’t, the time of year to tie-dye six multi-packs of Primark socks as Christmas and/or Hannukah presents for your ever-burgeoning brood of nephews and nieces, the time of year to argue with one’s partner about whose should come to fix your perennially inept combi-boiler. Happy times. Well, maybe; maybe not. This year, things do feel different.

The time of year to think about Those Less Fortunate Than Ourselves

This year does feel very different. It’s the first time – within my lifetime, at least – that such austerity and hardship and poverty in Britain have been so widespread. Certainly, this country has always had its marginalised and disadvantaged and poor... but the food banks, and the stories of people walking ten miles on foot to reach one because they cannot afford the bus fare, and the talk of “nutritional recession”: that’s new. It’s new, and it’s frightening. It reminds us that we live in one of the most unequal countries in the developed world and that, whereas that inequality is getting worse, we are most of us just one job loss, one relationship breakdown or one investment disaster away from destitution.

And so, it’s That Season again. The time of the year to think about Those Less Fortunate Than Ourselves, the time of year to try and decide whether to donate to That Charity or to get angry about the need for That Charity even to exist, the time of year to give an extra few quid to the Big Issue seller and to awkwardly wish him a merrier Christmas than he’ll probably be having. And so, I’m now going to propose that we in Public Health research do need to invest some more thought about what we’re doing to address this new sort of poverty and hunger we’re seeing across Britain. Do we organise collections and donations for our local homeless charity, or do we set up evaluations of cookery classes for vulnerable families, do we invite Osborne round to tea for a chat about the bankers and their bonuses, or do we set up a protest camp and get radical?

I don’t know what the answer is, I really don’t. But let’s talk about it, anyway...

Making the connection

Guest post by Kathryn Oliver

About 2 years ago, I had one of those ‘Eureka’ moments that totally changed my life. Genuinely. It was right up there with finding out about Oyster cards, or washing machines, or something.

At the time, I was a PhD student in my first year, working on a fairly standard project about developing health indicators. As a project, it was fine – about the use of evidence by policy makers, one of my main interests, and I was getting lots of experience in survey design. But for years, I’d been kicking round ideas in my head about the importance of personal relations. Didn’t they really explain nearly all human behaviour? Weren’t peer effects important for the spread of obesity or smoking? Wasn’t social capital important for mental health?

I’d been living on my own in London for a year or two and had found myself pondering the role of human relationships more and more. Of course, I had friends and relations, but I also liked being known by the man in the newsagents and the end of the road, and saying 'hi' to the neighbours. Did they count, I wondered? Would these relationships be enough to protect me from isolation, or going ballistic on the tube?

Imagine my delight when, attending a Social Network Analysis seminar day, run by the Mitchell Centre at the University of Manchester, I discovered an entire body of research – methods, philosophy, approaches – which looked at connections between individuals using formal statistical methods. Finding out that other people had had similar ideas to me, and had developed dedicated research methods to investigating these ideas was probably one of the best research moments I’ve ever had.

Unlike traditional statistics, network analysis does not treat individuals (whether bridges, policy makers, or swingers) as independent. Instead, any ties between actors are identified, described quantitatively and/or qualitatively and mapped. The statistics used are based on graph theory, but you don’t have to understand it to admire the elegance and usefulness of network analysis. Depending on the relationship collected, people’s attitudes, behaviours, health outcomes and more can be predicted.

For me, this is really the missing element from a lot of public health research. It can be used to identify good targets for research, or opinion leaders in secondary schools, so more targeted messages can be produced and sent out. It allows us to understand, describe, and analyse the social context within which individuals live. And, of course, make beautiful pictures. 

Example of Social Network Analysis diagram.

People have used network analysis to study all kinds of things – it’s very popular in the business world to identify ‘future leaders’ or ‘people who make things happen within my business’. Researchers have compared US senators voting patterns to cows who lick one another.

My PhD changed quite a lot after this seminar. I ended up using a combination of social network analysis and ethnography to study where public health policy makers found evidence, who the main sources of evidence were and how evidence was incorporated in the policy process. For years, academics in my field have been talking about the importance of interpersonal knowledge translation and how policy makers prefer to get their info from real people. Now I’ve been able to add my own tiny part of the story, come up with new research ideas on the basis of my findings, and learn a niche method (always useful).

My boyfriend still calls them snog webs though.

On evidence

Posted by Simon Howard

In my first week at medical school, one of the professors warned that most of what we were to be taught was factually wrong. It was an arresting statement, but it may have been true: Studies have shown that textbooks and experts frequently lag behind evidence, sometimes recommending “treatments” that are actually known to be harmful.

Do Primary Care Trusts do the same? PCTs, like the one I work in, currently commission the majority of NHS services provided to patients in their catchment areas (though not for much longer). Sometimes, academics get frustrated with PCTs for seemingly doing things that either have little evidence, or appear to contradict it altogether. Given that evidence is the bedrock of public health, and given the potential for decisions to affect whole populations, this might seem worrying.

In defence of PCTs, a lot of evidence based work does happen. Most major pieces of work include a review of academic literature at an early stage, and follow the findings. The annual Joint Strategic Needs Assessment and regular detailed Health Needs Assessments also take into account published literature and local and national data in a fairly systematic way.

But there are lots of barriers to following the evidence. Books and books could be written on this topic, from the applicability of evidence in the real-world to deciding if research is really relevant to a particular population. But I’m no expert, and I’m not going to try and describe anything technical, complicated, or even remotely clever. These are just a few examples of practical barriers to following the letter of the academic evidence in public health.

One huge barrier is – as with most things in life – money. In a world of ever-tightening budgets, an academic’s seemingly reasonable intervention can be unaffordable. As an extreme example, research by the FAA and CAA suggests that three or four lives would be saved in an average aircraft fire if all passengers were provided with smoke hoods. However, the vanishing rarity of in-flight fires, the enormous cost of supplying and maintaining smoke hoods, and the cost of the fuel required to propel them around the world, all make this proposal financially unjustifiable.

Not all examples are quite so clear-cut. Sometimes, instead of choosing not to do something, PCTs try to cherry-pick the best bits of interventions in a way that is almost certainly infuriating to the academics who pioneered them, and possibly less effective in practice. But, sometimes, doing something is better than doing nothing.

Often, there can be a big lag between publication of evidence and its implementation. One reason is the complex contractual nature of commissioning: it’s often difficult to make small changes to services that have already been commissioned. The constant pressure to reduce costs incentivises longer contracts which spread the financial risk, but which also increase the evidence-practice lag. I’m sure it’s deeply frustrating to be an academic shouting “there’s a better way to do this” while services continue unchanged.

There’s also a political element to public health. Decisions to cut services that are no longer supported by evidence are particularly tricky. In England and Northern Ireland, the evidence that cervical screening in women under the age of 25 causes more harm than good has led to a withdrawal of the service in this age group. The clear evidence, combined with clear recommendations from the World Health Organisation and National Screening Committee hasn’t stopped this becoming a topic for political debate and petition, and hasn’t (yet) changed policy in Wales or Scotland. It seems likely that this political element will play a bigger part in decision making as public health moves to the overtly politicised world of local authorities.

To me personally, the most frustrating barrier to following the evidence is an inability to access it. It continues to baffle me that the NHS doesn’t have anything like the level of straightforward desktop access to literature that university colleagues have. In the 21st century, it seems crazy that I sometimes have to ask the BMA to take a paper journal off a physical shelf, scan it in, and email it to me as the only practical cost-effective way to access a paper that’s of general interest, rather than something specific to any individual project.

I think a latent awareness of what’s going on in academia is important in public health. It might not matter so much when someone’s doing a big literature review prior to introducing a new service, but it can help with horizon-scanning, and with those little every day decisions that aren’t worthy of a trawl though the literature, and with planning for the future. This is something we can all play a part in: public health professionals probably need to broaden their awareness of the academic things going on around them, and academics probably need to shout louder about the latest developments in their fields. As an associate member, I’m probably biased, but I think FUSE is great at helping both groups.

From aged PhD to aged Intern

Posted by Lynne Forrest

I’ve previously blogged on why I’m doing a PhD in my forties and how I regard it as a career ‘second chance’, having not really quite got it together, career-wise, for the first 20 years of working life. As part of that spirit of positive thinking, when I started my PhD I decided I would embrace all the opportunities that came along. One of these was the chance to do a three month Internship, via my PhD funder the ESRC.

Now Internships don’t generally get a very good press, being pretty much regarded as a way for businesses to avoid paying someone a salary whilst offering ‘job experience’ that mostly consists of filing and making the tea.

However, I’d recently read that doing an internship was a good PhD career move. Also, as these were paid internships that were being offered by a range of high profile Government and charity organisations which required specific skills (of which tea-making wasn’t one), it seemed like a good idea. As a mature student, I didn’t need an internship to gain general work experience. I was looking for an opportunity to develop my skills base and gain experience in an area that wasn’t covered by my PhD.



The internship that I was interested in involved working in the Strategic Research Team at the Scottish Government conducting health research and translating the research into policy and practice. They were looking for someone with systematic reviewing experience, advanced quantitative skills and who had worked with large datasets, all of which applied to me. It seemed a perfect fit. And it was – they’ve offered it to me!

Although I’m very excited at this opportunity, the same age and status-related worries apply to doing an internship as to doing a PhD. However, for the most part, PhD students are treated similarly to staff in my department* and so I’m sure I will cope just as well as an aged Intern as I do being an aged PhD student. Unlike young interns I also have children, who are not best pleased that I will be away for 3 months. I’m hoping to negotiate flexible working hours and will be home every weekend, so I’m ignoring the emotional blackmail and guilt and am going anyway. It’s just too good an opportunity to turn down.

I think it’s going to be very interesting to be able to observe the reality of how the translation of evidence to policy actually works in a political environment and, indeed, to see how much policy is, in fact, evidence-based.

As well as the amazing career opportunity, the other positive for me is that I will be spending three months in Edinburgh, my home town. Having spent the past 15 years in Newcastle, I’ve latterly become terribly nostalgic for Scotland (getting all misty eyed over VisitScotland adverts and watching tartan and bagpipe-style programmes at New Year. I know. I need help). The reality of a few months in dreich Edinburgh over the winter may be just what I need to get over this.

Anyway, I’ll let you know how I get on….

*except that PhD students are required to ‘hot desk’. When I complained and got a proper desk it was on the understanding that I gave it up if someone ‘more important’ required it…

How to get the evidence message across

Guest post by Katie Cole

The mantra of “but there’s no evidence for it!” is one I’ve said or thought many times, both in my work, discussions with family and friends, or when shouting at the BBC Today programme.

But as an early-career academic, I’m increasingly aware there is a complex web of considerations when trying to translate evidence into policy, and that there are times when chanting our mantra may do more harm than good.

I recently attended a Royal College of Physicians/Alma Mata seminar on alcohol advocacy. At one point, a panel member suggested that social norms interventions to address excessive alcohol consumption on university campuses “sounded very promising” and policy-makers were considering it. I’ve looked into US research into these interventions: a national evaluation concluded that they are ineffective in reducing alcohol consumption. Whilst I could have made this point, I felt it was more complex than that. Don’t we need to test the policy in the UK drinking context to make a more robust contribution to the debate? Shouldn’t we seek to support policy-makers to integrate evaluations into pilots, or to finance full-scale trials?

Another challenge I’ve had was during a placement at a Primary Care Trust. I was involved in the Individual Funding Request process, where the PCT considers funding treatments and procedures not normally available on the NHS. I worked up a number of cases, looked at the evidence base and presented the case to a panel of clinicians and non-clinicians. In most cases, the evidence base was of poor quality: finding a case series for the exact condition and treatment in question represented a minor professional achievement. Usually, the case series found that, lo and behold, most cases improved, which often sparked disproportionate optimism that we had a justification for funding the treatment. In contrast, when I found a randomised controlled trial with only modest results, the panel were more inclined to propose not funding the treatment. Here I was challenged to explain the difference between the strength of the evidence base, and the strength of the effect size; whilst at the same time, acknowledging the difficulty of decision-making against a poor evidence base.

A final challenge has been in developing The Lancet UK Policy Matters website, which includes short summaries of the evidence underpinning a range of UK health-related policy changes. In developing the format of the summaries, we had to be very clear to authors that statements purporting the intended benefit of the policy should not be included in the ‘evidence’ sections of the summary – this was reserved for peer-reviewed research or evaluations. Our experience in guiding authors highlighted to us how meticulous we as professionals need to be in the choice of language we use when drawing on our scientific expertise.

Above all other lessons, these experiences have taught me that advocating for evidence in policy making is challenging, complicated and requires skill. It demands an understanding of the evidence itself – its strengths and limitations – but also of the policy making process. Whilst these issues can be difficult to reconcile, the above experiences have only strengthened my drive to communicate effectively with all actors in the policy making process.

Katie Cole co-founded The Lancet UK Policy Matters website with Rob Aldridge and Louise Hurst.