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Moving upstream: SEWAHSP and Public Health


Moving upstream: SEWAHSP and Public Health Moving upstream: SEWAHSP and Public Health Laurence Moore DECIPHer Schools of Social Sciences and Medicine – PowerPoint PPT presentation

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Title: Moving upstream: SEWAHSP and Public Health

Moving upstream SEWAHSP and Public Health
Moving upstream SEWAHSP and Public Health
  • Laurence Moore
  • DECIPHer
  • Schools of Social Sciences and Medicine
  • Cardiff University

  • Why move upstream?
  • Action outside NHS to support NHS needs
  • How to more forward
  • Local excellence
  • Future potential

Why focus upstream? A To Improve Public Health
  • Since 1900, the average life expectancy for
    Americans has increased by about 30 years. Public
    health initiatives account for about 25 of those
    additional years.
  • Turnock, BJ. Public Health What it is and How
    it Works, 3rd Edition. Sudbury, MA Jones and
    Bartlett Publishers, 2004.

Top 10 Public Health Achievements
  • Increased average lifespan
  • 1900 49 years
  • 1999 75 years
  • Sanitation and water
  • Vaccination
  • Control of Infectious Disease
  • Safer Workplaces

Top 10 Public Health Achievements
  • Healthier mothers and babies
  • Family planning
  • Safer food
  • Heart disease and stroke prevention
  • Smoking

Public health improvements 20 years added to
lifespan Medical improvements 5 years added to
Why focus upstream? B To Help Sustain NHS
  • Wanless critical importance of public health in
    defining the affordability of the NHS
  • Threats to NHS sustainability
  • Health inequalities
  • Obesity
  • Alcohol
  • Diabetes
  • Chronic disease
  • Mental Health
  • Cancer
  • All avoidable!

Nice in theory
  • Health promotion doesnt work
  • No evidence base"

Nice in theory
  • Health promotion doesnt work
  • No evidence base"

Owen et al (2011) J Public Health
  • With pressure on budgets and fundamental
    changes underway in the NHS and public health
    structure, there is a need for evidence to
    support the case for investing in public health
    interventions. This is the first study to provide
    a comprehensive list of the cost-effectiveness of
    public health interventions. Using a standard set
    of methods, the analysis has shown that the vast
    majority of public health interventions
    considered thus far by NICE are highly

Cost-effective solutions often lie outside the NHS
  • As with infectious disease..
  • environmental health.
  • effective preventative actions lie outside the NHS

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How to move forward?
  • Transdisciplinary action research partnerships
  • Researchers from multiple disciplines working
    with policy and practice partners on NHS
  • Behavioural, social, environmental,
    organisational sciences as well as medical and
    health sciences
  • Applied team science focussing on research
    questions identified by service partners
  • Multiphase projects, complex interventions
  • What works, for whom, under what circumstances,
    why and at what cost?

  • Funded by the National Institute for Social Care
    and Health Research (NISCHR) in October 2006, the
    South East Wales Trials Unit draws together
    existing expertise in trials and other well
    designed multi-centre studies to form an
    experienced team to support excellence in Wales.
  • Around 55 staff
  • Psychologists, statisticians, dieticians,
    midwives, sociologists, IT specialists,
    qualitative researchers etc
  • 2011/12 running 62 studies totalling 44,355,865

  • Sample subheading sample heading

Knowledge Exchange Cycle
Front line Innovation Local focus
Ivory towers REF / RAE Agenda Publications
Excellent environment to support applied public
health / primary care research and translation
to improve services
  • Service-relevant applied research questions to
    drive agenda and resource allocation
  • Attract excellent research teams to form around
    these questions
  • Requires supportive processes and criteria
  • DECIPHer/PHIRN RDG model
  • SEWTU model
  • Bristol Health Partners HIT model

  • Stemming the tide of antibiotic
  • resistance (STAR). A blended learning
  • programme addressing appropriate
  • antibiotic prescribing in general practice.

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What the clinicians said?
  • GPs were concerned about the issue of
    antimicrobial resistance and agreed it was
  • Many said they infrequently encountered its
    consequences in their practice and some
    questioned the evidence linking their prescribing
    decisions to resistance and poorer outcomes for
    their patients.
  • They felt conflicted by their apparent inability
    to influence the problem in the face of many
    other competing demands.
  • They would welcome more information about
    resistance patterns locally, and felt that
    undergraduate and graduate education about
    antimicrobial prescribing and resistance should
    be enhanced.
  • A few mentioned that a heightened awareness of
    antimicrobial resistance locally may cause them
    to prescribe more second line agents as empirical

What next?
  • A group of clinicians, psychologists,
  • statisticians, web designers, educationalists,
  • health economists etc got together.
  • We developed a theory based blended
  • learning programme to promote appropriate
  • antibiotic prescribing.

  • The study is a randomized controlled trial with
    general practices as the unit of randomization
    and analysis.
  • Process evaluation.
  • Cost effectiveness evaluation

Study Recruitment and Training
  • 70 practices recruited across Wales
  • 68 practices randomised (2 withdrew)
  • 33 practices each in the Experimental and Control
  • Experimental Group
  • 33 seminars completed
  • 127 GPs/NPs completed online training
  • 31 process evaluation interviews conducted
  • Control group
  • 117 GPs/NPs participating

Results Cost Effectiveness
  • The mean cost of the STAR Educational Program was
    2,923 per practice (SD 1,187).
  • There was a 5.5 reduction in the cost of
    dispensed antibiotics in the intervention group
    compared to the control (p 0.07) equivalent to
    a reduction of about 830 a year for an average
    intervention practice.

4 year follow-up data
  • After controlling for baseline dispensing rate,
    there was a 6.2 (95 CI1.7, 10.6) reduction
    in total oral antibiotic dispensing for the 4th
    year following the intervention in the
    intervention group compared to the control group
    (p 0.009).

What can we take from these results?
  • The STAR programme led to a statistically and
    clinically important reduction in antibiotic
    prescribing at one and four years following
    intervention delivery
  • Achieved with no evidence of increased
    complications or reconsultations
  • A relatively brief intervention of around 5 hours
    can make an important difference even 48 months
    down the line
  • Readily implemented in practice at low cost and
    cost effective, probably cost saving

Study Publications
  • Effectiveness of multifaceted educational
    programme to reduce antibiotic dispensing in
    primary care practice based randomised
    controlled trial. Butler CC, Simpson SA, Dunstan
    F, Rollnick S, Cohen D, Gillespie D, Evans MR,
    Health SL, Alam MF, Bekkers MJ, Evans J, Moore L,
    Howe R, Hayes J, Hare M, Hood K, BMJ , Volume 344
    (2012) pp.d8173-d8173
  • Enhancing the quality of antibiotic prescribing
    in primary care qualitative evaluation of a
    blended learning intervention. Bekkers MJ,
    Simpson SA, Dunstan F, Hood K, Hare M, Evans J,
    Butler CC, STAR Study Team None, BMC Fam Pract ,
    Volume 11 (2010) pp.34-34
  • Stemming the Tide of Antibiotic Resistance
    (STAR) a protocol for a trial of a complex
    intervention addressing the 'why' and 'how' of
    appropriate antibiotic prescribing in general
    practice. Simpson SA, Butler CC, Hood K, Cohen
    D, Dunstan F, Evans MR, Rollnick S, Moore L, Hare
    M, Bekkers MJ, Evans J, STAR Study Team None, BMC
    Fam Pract , Volume 10 (2009) pp.20-20

A peer-led social network based smoking
prevention intervention for adolescents findings
from a randomised trial in UK schools (The
ASSIST study)
ASSIST intervention
  • Developed in response to discussions with Health
    Authority and in partnership with them WG
  • Year 8 (aged 12-13)
  • Not a typical school-based peer-led
  • Influential students nominated by their year
  • Trained to be peer supporters to diffuse norms
    of non- smoking behaviour through their social
  • Adapted from Kellys (1997) sexual health gay
    hero / Popular Opinion Leader in US mid-west

Peer nomination
  • Did not want only high-achieving females
  • Did want influential students
  • Did want a mix (sex, friendship group, behaviour)
  • Identified through three questions
  • Who do you respect in Year 8 at your school?
  • Who are good leaders in sports or other group
    activities in Year 8 at your school?
  • Who do you look up to in Year 8 at your school?
  • Viral marketing through social networks

Peer supporter training
  • Parental consent obtained
  • Peer supporters given two days of training off
    school premises
  • Training delivered by outside trainers
  • Peer supporters trained to intervene in everyday
    situations (e.g. at break-time, after school) to
    encourage other Year 8 students not to smoke

What evidence do we have that it is
effective? Campbell R et al. Lancet
Study design
  • Randomised controlled trial 59 schools (10,730
  • Two centres Bristol and Cardiff
  • Outcome evaluation
  • self-reported smoking status (questionnaires)
  • salivary cotinine status (saliva samples)
  • baseline, post intervention, Year 1 and Year 2
  • Process evaluation
  • Economic evaluation
  • Social network analysis

Results, Conclusions, Impact
  • ASSIST intervention is effective in reducing
    adolescent smoking
  • Findings generalisable to range of schools
  • If implemented on a UK-wide basis could prevent
    40,000 14-15 year olds taking up smoking
  • Recommended by NICE
  • Cost effective under highly conservative
  • Company set up by Universities to license
  • Now implemented across Wales and England

Future potential
  • Alignment of LHB, Public Health Wales and Welsh
    Government priorities
  • Excellent data linkage to support service
    evaluation, trials, needs assessment and
    epidemiology SE Wales Laboratory
  • SEWTU and DECIPHer
  • Excellence in high quality applied translational
    research in primary care and public health