Better Health For All

Independent Review of the State Pension Age 2022, Baroness Neville-Rolfe DBE, CMG, published March 2023 for presentation to Parliament in May 2023.

The Independent Review¹ proved to be a rubber stamping exercise, with a bit of fiddling at the margins.  It recommends that: (1) the State Pension Age should continue to be tied to life expectancy²; (2) the increase in the State Pension Age to age 67 years, as planned, should go ahead during the years 2026-2028; and the further increase to 68 years should be moved to 2041-2043, three years earlier than currently legislated; 2046-48 is suggested for the move to 69 years. 

All of which leaves Public Health with a number of challenges:

Prevention:  To the effect of an extended working life on those already in poor health will be added the futility of Workfare’s hostile medical scrutiny, conditionality (proof of looking for work) and sanctioning (cuts to benefits that are already below the State Pension and far below older people’s extremely conservative Minimum Income for Healthy Living). 

Inequalities:  The health effects of the policy will be amplified for those who have had the hardest lives, including many employed in Key and Essential occupations whose everyday heroism kept the rest of us alive during the recent Covid-19 pandemic lockdowns. 

Medical care:  Informal, unpaid caring and volunteering will suffer at a time when the need for them is increasing and family finances will be reduced where the withdrawal of grandparent care of grandchildren no longer allows parents to take paid employment; with predictable consequences for an already stretched Primary Care service.   

Population science:  Disability-Free Life Expectancy (DFLE) is more appropriate than life expectancy, as the measure to guide changes in the State Pension Age, because the ability to continue in paid employment at older ages requires more than simply being alive; the physical and mental capacity to work is also necessary.    Nevertheless, the use of DFLE is rejected by the Review, perhaps because it is falling (p.55, Table 5), not increasing, so cannot be used to justify further increases in the State Pension Age and, in contrast, would suggest reducing it.   

Having done their duty by HM Treasury, the Review cautiously addresses some of these Public Health challenges, impressed one suspects by the near unanimity of views collected by their diligent research. 

• Further work is required into the difficulties faced by informal, unpaid carers (p.8, Wider Considerations, paragraph 1), although these are already well established – perhaps the Review was asking for a consensus on the best solutions.      
• Explore the possibility of early access to State Pension for those who have worked in physically challenging jobs for many years (p.8, Wider Considerations, paragraph 4; also p.81, Recommendations, paragraphs 206 & 207), with a brief discussion of possible actuarial qualifying criteria.     

In summary, State Pension Age policy will continue to be a cause of concern for Public Health, made more complex by the changing nature of work, which draws attention to the potential benefits of closer collaboration between the Faculties of Public Health and Occupational Medicine. 

David Blane, Professor Emeritus of Imperial College London.

FOOTNOTES

1. The full report can be downloaded from the Department for Work and Pensions website; the reference details in the present blog refer to this full report. 
2. Rather confusingly, there are two very different things called life expectancy: period life expectancy which is calculated from death rates and cohort life expectancy which is the best guess of a panel of experts.  The Review does not say what assumptions were used by the Government Actuary’s expert panel to produce their cohort life expectancy prophesies, but it is reasonable to wonder whether climate change and its unexpectedly rapid acceleration was considered; and whether the almost inevitable next global pandemic was included.                             

Dr. Alexander Woodman and Dr. Besher Al Attar at Saudi Center for Organ Transplantation and King Salman Center for Kidney Diseases

Organ donation is an act of mercy, benevolence, altruism, and love for humanity. Since the application of bioethical principles is an integral part of the decision-making process associated with organ donation, knowledge, personal attitudes, social structure, cultural practices about organ donation are essential factors influencing people’s decisions. Consequently, one of the primary responsibilities of healthcare providers is to understand and inform patients, donors, and recipients about what principles support the proposed decision to donate or receive organs. It is equally important to respect the ethical rules followed in each region, country, and ethnic group. 

Saudi medical students and organ donation 

Organ donation is an integral part of medical ethics in Saudi Arabia, which follows the Islamic bioethics, a system of moral assessment designed to identify, analyze and address ethical issues that arise in medical practice and research, based on Islamic moral and legislative sources.

The development of organ donation laws and legislation has been accompanied by numerous social, legal, and ethical debates. The general public of Saudi Arabia is usually skeptical about such a development in science and tends to show significant ambivalence in their attitude. These notions prompted Dr. Alexander Woodman and his colleagues to explore the knowledge, attitudes, and behaviours in relation to organ donation and transplantation among medical students as future healthcare providers. The study conducted in the Eastern Province of the Kingdom resulted in a number of emerging patterns that are essential to be shared with the global community of health science and educators.

The most thought-provoking findings related to knowledge, with less than a third of medical students having adequate knowledge, with the source of knowledge being mostly social media or television. Essentially, the fifth and sixth-year students had higher average knowledge scores. This pattern was truly emerging since the comparison showed that earlier studies resulted in better knowledge among Saudi medical students. Does this mean that the new generation is less interested in organ donation and transplantation? To answer “yes” to this question would be an imprecise undertaking and too persuasive a statement since the patterns of attitude were quite opposite.

The majority of students had a positive attitude towards organ donation and transplantation, with the reasons for organ/tissue donation being mainly helping others (88.8%) and empathy (59.8%). At the same time, attitudes vary depending on specific socio-demographic factors such as gender, age, and educational level. Thus, women had more positive attitudes compared to men, with younger participants (18-20 years old) being more positive compared to 27-29 years old. The latter had a particular emerging pattern, showing that while more experienced students (year of study) had better knowledge, their attitudes were less positive. 

The correlation between knowledge-attitude, knowledge-practice, and attitude-practice in this study contradicted the relationship between knowledge-attitude and practice. Does this study allow to conclude that insufficient knowledge can lead to a positive attitude and better knowledge to a negative one? To answer this question, a health education campaign should be carried out among healthcare providers, students, and the general public to address the gap between the knowledge-attitude-practice of organ donation and transplantation.

The findings of research have been published in Transplantation Proceedings, ELSEVIER publishing and can be found at https://authors.elsevier.com/a/1fZJ~9MbWadC~.

Dr. Alexander Woodman and Dr. Besher Al Attar

Russia invaded Ukraine on Feb 24^th 2022, this act has had a direct and devastating impact on the country’s healthcare system as a whole, compounding the impact of Covid-19. In any circumstance conflict tends to exacerbate existing public health concerns and place strain on all systems currently in place. Destruction of infrastructure, disruption of supply chains, displacement of people and changes in funding priorities all act to create difficulties. 

Threats to Health and Access to Healthcare

The leading cause of premature death in Ukraine in 2020 was non-communicable disease, with cardiovascular disease accounting for 66% of this burden.[1] Ukraine has the second highest number of newly diagnosed HIV cases in Europe and the fifth highest number of confirmed cases of extensively drug-resistant tuberculosis in the world. These conditions all require regular medications to prevent complications and routine monitoring for disease progression, access to primary healthcare is therefore vital. Ukraine has one of the highest maternal mortality rates in Europe and infant mortality is also relatively high compared to its neighbours.[2] The risk of communicable disease increases with conflict due to damaged infrastructure, limited access to safe water, over-crowding and unsanitary conditions.

The WHO verified 715 attacks on healthcare settings from 24^th Feb to 30^th Nov 2022 resulting in 129 reported injuries and 100 deaths of healthcare personnel and patients.[3] This damage alongside the shelling and occupation of territory has led to limited access to medical care for the population. The WHO and other NGO’s are working within Ukraine to support the delivery of healthcare and to rebuild the public health system.

A health needs assessment completed in September 2022 by the WHO reported that despite a deterioration in the level of access to health care, this is not universal and the system as a whole remained resilient.[4] Although more than half of people attempting to access primary care faced at least one barrier, only 4% were unable to get the care required. The biggest barrier reported was cost, followed by time constraints involved in getting to and from health facilities and limited transportation options. Cost is particularly a problem for women as they do not earn as much as men and also access more routine healthcare. Lack of availability of medication affected 25% of respondents and 19% reported that required treatments were unavailable to them. In areas under Russian control and close to active hostilities the difficulties accessing healthcare are far greater, 15% report no access at all to a family doctor. This population is also harder to reach so it is likely that the difficulties are higher than reported by those surveyed. Displaced individuals are also more likely to struggle to access family doctors and medication with one in five saying they have no access at all and 46% saying they have no access in person. Since this data was collected in September 2022 the situation has deteriorated in several areas and the winter temperatures have created an additional burden on the healthcare system.

Displacement

By October 2022 around 14.3 million exits from Ukraine had been registered, the speed and scale of this mass exodus makes it the largest and quickest displacement of people in Europe since World War 2.[5] The majority of these refugees are women and children and a significant number will carry a mental health burden from the trauma of the invasion and family separation.

The International Organization for Migration (IOM) reports that as of January 2023 5.4 million people are internally displaced within Ukraine, this is a reduction from around 7 million in August 2022.[6] 58% of these individuals have been displaced for 6 months or more yet the situation remains dynamic with 12% displaced in the last few weeks, nearly a third have been displaced more than once. This mass displacement of the population includes medical workers and staff responsible for the running of medical facilities, creating challenges for the maintenance of the healthcare system. Displacement of the population creates temporary overcrowding, particularly in collective centres, increasing the spread of communicable disease and making it more difficult to maintain care for those with chronic medical conditions. Displaced individuals are also less likely to have the clothes and kit required to keep warm through the winter months.

Mental Health

Ukraine is facing a mental health crisis, it is reported that nearly a quarter of the country’s population is at risk of developing a mental-health condition,[7] with 5.7 million school-aged children impacted directly.[8] A WHO public situation analysis has labelled mental health as one of the country’s most urgent public health risks. Evidence shows that the seven year war in the Eastern Donbas region significantly increased alcohol and substance misuse amongst veterans, displaced people and civilians.[9] There will be an increased healthcare need moving forwards for those suffering with substance misuse and other mental health disorders as a result of the conflict, exacerbated by the Covid-19 pandemic. A WHO supported roadmap on mental health and psychosocial support sets out priority actions for different sectors.[10] The aim is to build a mental health system in line with the best global practices to ensure provision of mental health services to individuals in Ukraine.

Winter

Winter in Ukraine is harsh, with temperatures dropping as low as –20°C. This extreme cold increases morbidity and mortality from both acute and chronic disease. Damaged buildings with inadequate insulation and attacks on the energy infrastructure have posed huge challenges this winter. Electricity cuts affect the whole country and are reported to last 8-12 hours per day.[11] There have been power cuts lasting up to three days, leaving homes and healthcare facilities without essential power. In desperation people are turning to alternative heating methods, which themselves pose health risks. The Ukrainian Government have set up ‘invincibility centres’ as warm spaces for people across the country, these also have mental health support workers. Despite this many continue to suffer in life threateningly cold conditions.

Vaccination

Prior to the invasion Ukraine had a vaccination programme but many people remain at risk from vaccine preventable diseases due to years of vaccine hesitancy and low coverage.[12] In 2018 Ukraine had Europe’s largest outbreak of measles since the vaccine became widely available and in 2021 there was an outbreak of vaccine-derived polio. Roll out of Covid vaccination was slow with only 39.7% of the population receiving one dose by February 2022.[13] Disruption to logistical chains and supply lines has made vaccination more difficult since the invasion, particularly in active conflict areas and for displaced people. For adult Covid vaccination (23%) and childhood vaccines (14%) of displaced people were unable to access a vaccine compared with 13% and 6% respectively of those who remained in their homes.[14] Mobile vaccination teams have been set up to try and address the issue but the numbers seeking vaccination remain low resulting in low levels of herd immunity. Many of those who have fled Ukraine have entered countries who also have low vaccination coverage, increasing the risk of outbreaks in overcrowded settings. The European Centre of Disease Prevention and Control recognised this soon after the invasion and recommend that all Ukrainian refugees without evidence of previous vaccination should be offered vaccinations with the priority being COVID-19, measles, and polio, ideally within 14 days of arrival in a host country.[15]

Technological and Industrial Emergencies

Ukraine has four operational nuclear power plants and many industrial chemical sites. These are potentially at risk from damage due to the conflict and could lead to public health emergencies of international concern should radio-nuclear or toxic chemicals be unintentionally released.[16] The WHO is working to increase preparedness and response capacities relating to these threats that could cause devastation should an incident occur.

Public Health System and Recovery

The Ukrainian public health system has been through a period of transformation and development since 2015. In 2019 Ukraine ranked 94^th of 195 countries in its ability to fight epidemics due to suboptimal capabilities to prevent, detect, and respond to significant infectious disease outbreaks.[17] In September 2022, despite the outbreak of war, Ukraine adopted the law “On The Public Health System” providing a framework for building a public health system in Ukraine.[18] A National Recovery Plan is being designed to restore the health system’s infrastructure and technical, professional, and staffing areas.The WHO, the European Union Delegation to Ukraine, the U.S. Agency for International Development (USAID) Mission in Ukraine, and the World Bank have prepared a joint discussion paper to complement Ukraine’s National Recovery Plan and describe a common vision of key priorities for rebuilding capacity over the next two years.[19] The international community are key in supporting the rebuilding of a system able to manage the demands of both pandemic and war recovery. Initially emergency actions are required to stabilise the system whilst longer term recovery and rebuilding are planned.

The Faculty of Public Health Global Health Committee is currently involved in WHO efforts to strengthen the global public health and emergency workforce. The WHO Roadmap system aims to define essential public health functions, strengthen competency based education and map and measure occupations delivering public health functions to ensure that a unified global response to future public health threats is possible.[20] This work is crucial to ensuring that the public health world is prepared to manage any future pandemic threats and vital to support countries, such as Ukraine, that require the most help in establishing efficient and capable public health systems.

[1] https://ncdalliance.org/news-events/news/ukraine-humanitarian-crisis-ensuring-protection-and-health-services-for-millions-of-people-living-with-chronic-diseases (accessed 12/02/2023)

[2] https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_47b-en.pdf (accessed 13/02/2023)

[3] https://www.who.int/publications/i/item/WHO-EURO-2022-6172-45937-67791 (accessed 23/01/23)

[4] https://www.who.int/europe/publications/i/item/WHO-EURO-2023-6904-46670-67870 (accessed 02/02/2023)

[5] https://euaa.europa.eu/news-events/joint-euaa-iom-and-oecd-report-provides-new-insights-displacement-and-within-ukraine  (accessed 17/01/2023)

[6] https://dtm.iom.int/reports/ukraine-internal-displacement-report-general-population-survey-round-12-16-23-january-2023 (accessed 12/02/2023)

[7] https://www.who.int/europe/news/item/28-11-2022-who-supports-ukrainian-health-care-system-as-winter-approaches (accessed 02/02/2023)

[8] https://reliefweb.int/report/ukraine/war-leaving-invisible-scars-ukrainians-under-secretary-general-tells-security-council-noting-one-fourth-population-will-develop-mental-health-condition (accessed 13/02/23)

[9] Patel SS, Sukhovii O, Zvinchuk O, Neylan JH, Erickson TB. Converging Impact of the Ongoing Conflict and COVID-19 Pandemic on Mental Health and Substance Use Disorders in Ukraine. J Emerg Manag. 2021;19(9):63-68. doi: 10.5055/jem.0603. PMID: 35281482; PMCID: PMC8916750.

[10] https://www.who.int/europe/news/item/28-11-2022-who-supports-ukrainian-health-care-system-as-winter-approaches (accessed 02/02/2023)

[11] https://www.savethechildren.org.uk/news/media-centre/press-releases/ukrainian-families-girm-struggle-for-winter-survival0 (accessed 13/02/23)

[12] Addressing vaccine inequities among Ukrainian refugees

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00366-8/fulltext

[13] https://ourworldindata.org/coronavirus/country/ukraine#what-share-of-the-population-has-received-at-least-one-dose-of-the-covid-19-vaccine (accessed 13/02/2023)

[14] https://www.who.int/europe/publications/i/item/WHO-EURO-2023-6904-46670-67870 (accessed 02/02/2023)

[15] https://www.ecdc.europa.eu/sites/default/files/documents/Operational-considerations-Russia-aggression-towards-Ukraine-final.pdf (accessed 13/02/2023)

[16] https://www.who.int/emergencies/situations/ukraine-emergency/technological-hazards-and-health-risks-in-ukraine (accessed 15/02/2023)

[17] https://eurohealthobservatory.who.int/news-room/articles/item/ukraine-country-snapshot-public-health-agencies-and-services-in-the-response-to-covid-19 (accessed 13/02/2023)

[18] https://www.tdmu.edu.ua/en/2022/09/11/verkhovna-rada-of-ukraine-adopted-the-law-on-the-public-health-system/ (accessed 13/02/2023)

[19] https://www.who.int/europe/publications/m/item/priorities-for-health-system-recovery-in-ukraine-joint-discussion-paper (accessed 13/02/2023)

[20] https://www.who.int/news-room/events/detail/2022/05/18/default-calendar/phewf_roadmap_launch (accessed 13/02/2023)

Faculty of Public Health Global Violence Prevention Special Interest Group

February 2023

On 24^th January 2023, the Secretary of State for Health announced plans to develop and publish a Major Conditions Strategy in consultation with NHS England and colleagues across government.   This has meant the withdrawal of plans for a standalone 10 Year Mental Health Strategy.  There has been no government mental health strategy since 2011 and England is in danger of not only falling out of line with other UK countries but with the World Health Organisation recommendations.

The forthcoming strategy will bring together mental ill health with cancer, cardiovascular disease, chronic respiratory diseases, dementia, and musculoskeletal conditions. This presents a welcome opportunity to promote an integrated, person-centred and holistic approach to care and prevention. However, there are some key concerns that the Faculty and other stakeholders recognise. Importantly, we are still a long way from achieving parity of esteem for mental health, and particularly prevention – and losing an explicit focus on mental health may limit action on mental health overall.

With this in mind, we propose the following recommendations that will help to maximise the benefits of this new approach and ensure that an explicit focus on prevention and wellbeing promotion are maintained.

1. Resources must be rebalanced towards prevention and early intervention

The field of public mental health is much wider than treatment and clinical services on an individual level. Many people experience short and long-term damage to their mental and physical health as a result of stress, trauma and adversity. It is vital to understand the wider determinants of mental health and wellbeing, and to take preventative action to address the causes of poor mental health across the life course – this means universal action to promote good mental wellbeing in the whole population as well as early and targeted support for those affected by social disadvantage, material deprivation and trauma.

Without fully integrating primary prevention and wellbeing promotion into the prevention and management of long-term health problems, including mental health problems, there is a very real risk that the progress made over the last decade to understand and improve the psychosocial determinants of health[1] will be undermined. Furthermore, shifting focus and funding back to diagnosable conditions at the exclusion of population-level prevention and early help activity would only increase the prevalence of longer-term or more severe problems later on. There is strong evidence that investing in prevention represents good value for money, as well as supporting people to live well for longer.[2]

2. Prevention and early intervention must include action across the life course

People with mental health problems present much earlier than the majority of physical health conditions, with 75% of mental health problems presenting by mid 20s.  Prevention and treatment necessarily takes place earlier in the life course, and there is a risk that the focus on diseases of older age within the government’s Major conditions strategy will shift focus away from the early years and life course approach necessary to improve population mental health.

While action in the early years and childhood are key to early intervention and prevention, it is also important to ensure that people are able to access timely and appropriate support with issues causing stress or distress at any stage of their lives – such as bereavement, financial hardship, abuse or discrimination – whether they are in contact with mental health services or not.

3. Targeted action on preventing and treating major conditions in people with severe and enduring mental health problems

On average, people with severe and enduring mental health problems die 15-20 years younger on average than the general population and two thirds of these deaths are from preventable physical illnesses, including cancer and heart disease (Centre for Mental Health.). The determinants of physical and mental health problems often overlap; mental health problems disproportionately affect people living in poverty, those who are unemployed and who already face discrimination. Poor mental health also has a detrimental effect on health behaviours; for example, 40.5% of adults with SMI in England are smokers compared with 13.9% of the general population.

Recognising these inequalities and the inextricable link between physical and mental health is central to the Equally Well agenda, which is to treat care for mental health needs in the same way as other needs. Integrated Care Systems have a statutory duty to address inequalities and need to be supported by a strategy that gives due value to the relative and historic funding needs for mental health services compared to those for physical health conditions. A more holistic and integrated approach to care and prevention could have major benefits for individuals with severe and enduring mental health problems who have co-occurring health conditions that both contribute to their poor mental health and are exacerbated by it.

4. Promoting person- and community-centred prevention and care

if we are to reduce inequalities in the distribution of the major conditions we need to work with communities experiencing the poorest health, including those with severe mental illness and other inclusion health groups, to tackle underlying issues systemically. Approaches to prevention and care need to be coproduced, starting with good insight on what people’s needs are and how they can best be met.  The NHS statutory guidance on working with people and communities should apply to public health, prevention and the development and implementation of the Major Conditions Strategy.

To conclude, the psychosocial pathways to health have been well established and there are opportunities to be gained from this strategy.  Many factors that underpin good mental health and wellbeing are often the same as for physical health, and many prevention and promotion related policies and interventions could have joint benefit across all conditions. If the UK government is to realise the potential benefits of an integrated strategy, and the commitment to person-centred care, then the Long Terms Conditions strategy needs to be leveraged to assure parity of esteem, embed a psychosocial pathways approach and not lose focus on prevention of mental illness and promotion of mental health.

[1] Stansfield J, Bell R. Applying a psychosocial pathways model to improving mental health and reducing health inequalities: practical approaches. International Journal of Social Psychiatry. 2019 Mar;65(2):107-13.

[2] Policy paper: Prevention is better than cure: our vision to help you live well for longer. DHSC, 5 Nov 2018: https://www.gov.uk/government/publications/prevention-is-better-than-cure-our-vision-to-help-you-live-well-for-longer

Faculty of Public Health Public Mental Health Special Interest Group

February 2023

In our research into the oral health inequalities experienced by children in care and young care leavers we knew that we wanted to work collaboratively with children and young people (CYP) to produce the research. We wanted to give them the opportunity to be involved throughout the production process from concept to completion, helping to produce outcomes and services that are relevant and important to them. To support this, we conducted a rapid literature review (to be published Spring 2023) to learn from previous research on how to meaningful involve vulnerable CYP in research.

Co-approaches and participatory research

The terms co-creation, co-design and co-production are often used interchangeably and are ill-defined (1,2).

One study defined co-design as “meaningful end-user engagement in research design”, adding that it includes “instances of engagement that occur across all stages of the research process and range in intensity from relatively passive to highly active and involved.”

“Co-production” refers to much more than “meaningful end-user engagement”. It is committed to working in partnership to generate ideas, evidence and research outputs, recognising the importance and validity of different forms of knowledge. The UK National Institute for Health Research 5 key principles of co-production (3) are:

• Sharing power;
• Including all perspectives and skills;
• Respecting and valuing the knowledge of all those working together on the research;
• Reciprocity;
• Building and maintaining relationships; Joint understanding and consensus and clarity over roles and responsibilities.

“Participatory research” goes beyond this. It challenges the power dynamics between researchers and those with lived experience, seeking to democratise research and to question traditional ideas of knowledge and expertise.

Grindell (2) coined the term ‘co’approaches to encompass co-creation, co-design and co-production.

Taking a pragmatic approach

Given the lack of clarity around definitions, we took a pragmatic approach in the rapid review. We defined research ‘co’approaches with vulnerable CYP as “involvement of vulnerable CYP in an explicitly described role contributing to the planning and/or conduct of research”. We used the Children’s Commissioner for England (2017) definition of vulnerability to identify populations of interest (4). These include, those that have safeguarding concerns or are in state care, have health problems and/or disabilities, low income, have challenging family circumstances, are not engaged or excluded from education, are involved in offending or anti-social behaviour, have experience of abuse/exploitation or come from minority populations.

So, what did we learn that would be useful in using a co-approach in our research?

We learnt a lot about the challenges.

Some would apply to involving any child or young person in research, such as maintaining interest and motivation and fitting the research in with their other commitments such as school, work and social activities. Other challenges related specifically to the life circumstances of vulnerable CYP with examples such as childhood trauma, homelessness, poverty, addiction, parenting responsibilities and mental and physical health issues. In research which took an explicitly participatory approach, working with and accommodating the needs of vulnerable CYP called for support beyond that related to carrying out research to encompass aspects of their daily lives.

The need for flexibility and responsiveness to the varying needs and abilities of CYP to facilitate their meaningful involvement in the research has implications for time and budget. The fluidity of what can be a “messy” situation may not sit well with the needs of funders (4). It can also present challenges when trying to navigate the systems for obtaining ethical approval which call for detailed and explicit description of all processes (especially for work with vulnerable CYP). Other challenges concern academic researchers and their ability to engage with the CYP and to relinquish power.

Researchers in the studies we identified tended to write less about how to overcome the challenges. However, some key principles emerged.

There was a strong focus on “building trust” with CYP as co-researchers, especially where CYP may have a history of disappointing encounters with adults and authority. Making the research process interactive and task driven and, where possible, giving CYP the power to decide how to deliver the tasks helped maintain engagement and facilitated a collaborative approach. Identifying motivators, recognising the different skills and strengths of individual co-researchers and supporting them to learn new skills gave them the tools to collaborate on their terms. Team-building activities and regular meetings to support team bonding were an important feature of some studies. It is also important to formally acknowledge co-researchers’ contribution.

The findings from our review echo the 5 principles identified by NIHR (3) and highlight some of the practical hurdles faced in taking a ‘co’approach. We look forward to exploring how, informed by this review, we might work collaboratively together with children in care and care leavers to tackle oral health inequalities.

Authors:

Dr Jo Erwin¹, Post doctoral Research Fellow, Public Health Dentistry, Peninsula Dental School

Ms Lorna Burns¹, Lecturer in Evidence Based Healthcare – Information Specialist, Peninsula Dental School

Dr Nick Axford¹, Associate Professor in Health Services (Research), NIHR ARC South West Peninsula (PenARC)

Ms Sarah Kaddour², Inclusion Oral Health Fellow

Ms Jane Horrell¹, Research Fellow, Peninsula Dental Social Enterprise CiC, Peninsula Dental School

Prof Jill Shawe¹, Professor in Maternal and Family Health, School of Nursing and Midwifery

Dr Hannah Wheat¹, Senior Research Fellow in Dementia Research, Peninsula Medical School

Prof. Robert Witton¹, Professor of Community Dentistry, Chief Executive Peninsula Dental Social Enterprise CIC, Peninsula Dental School

Prof Paul Brocklehurst³, Professor of Health Services Research and the Director of NWORTH Clinical Trials Unit at Bangor University.

Dr Martha Paisi¹, Research Lead, Peninsula Dental Social Enterprise CiC, Peninsula Dental School; Senior Research Fellow, School of Nursing and Midwifery

¹ University of Plymouth; ² Pathway Charity ; ³ University of Bangor.

References:

1. Brandsen T, Honingh M. Distinguishing different types of coproduction: a conceptual analysis based on the classical definitions. Public Admin Rev. 2016; 76(3):427–435.

2. Grindell C, Coates E, Croot L, O’Cathain A. The use of co-production, co-design and co-creation to mobilise knowledge in the management of health conditions: a systematic review. BMC Health Serv Res. 2022; 22(1):877.

3. Hickey G, Brearley S, Coldham T, Denegri S, Green G, Staniszewska S, Tembo D, Torok K, and Turner K. (2018) Guidance on co-producing a research project. Southampton: INVOLVE.

4. Slattery P, Saeri AK, Bragge P. Research co-design in health: a rapid overview of reviews. Health Res Policy Syst. 2020;18(1):17.

Acknowledgments: This rapid review is part of a larger project “Dental care for children and adolescents in care- Caring for children and their smiles” funded by The Borrow Foundation (https://www.borrowfoundation.org/ ). Special thanks to members of our PPI and stakeholder groups who have reviewed this blog.

Dr Jo Erwin

February 2023

Would I like to observe the judging panel of the fourth biannual International Public Health Film competition? There’s only one answer to that question and it’s a big YES! Finally – my chance to be at the table with a veryimpressive line-up of judges, discussing all things international, public health, and film – my favourite ingredients for a great afternoon.

Established in 2016, the International Public Health Film competition (IPHFC) and associated Public Health Film Festival (PHFF) celebrates diversity in public health film. The event, run by a UK registered charity, is one several public health-related film events (see below) that have taken place over the last decade to provide a platform for film makers working in this field to showcase their work, and for health specialists to engage with artists and visual story-tellers about public health topics.

Illustrating the increasing popularity of film as a medium to convey public health messages, the first International Public Health festival received 84 films from 20 countries in 2016. This time around, despite or even because of the recent pandemic, the competition received over 1,400 films from 100 countries! Unsurprisingly, around one in six submissions included a COVID-19 theme, but topics otherwise showcased just how wide the wider determinants of health are.  

The IPHFC has kept its inclusion criteria deliberately broad, allowing submissions from all over world, covering all manner of subjects, and any duration: from a few minutes to well, how long is a reel of film?

In preparation for the judging committee, I spent a weekend on my sofa with suitable public-health-approved snacks, watching the ten shortlisted films. Testament to just how well the films were scripted, acted, filmed, and produced, it was an emotional two days as I joined the characters on their journeys through mental health, physical health, and natural disasters. Moments of light and joy and humour provided an appropriate counterbalance to the call to action running as an undercurrent through many of the films. The cinematography was, at times, absolutely breath taking and I was briefly transported from my mid-terrace in autumnal Wales into others’ lives across the world.

Then, the day arrived! I was honoured (and slightly nervous) to be around the virtual table with an incredibly impressive judging panel, comprising:

• Dr Uy Hoang, President, Public Health Film Society and Chair of the UK Faculty of Public Health Specialist Interest Group in Film  
• Professor Kevin Fenton, President of the UK Faculty of Public Health 
• Linda Bergonzi-King, Chair of the American Public Health Association (APHA) Global Public Health Film Festival, Producer/ Director/ Consultant at TriBella Productions 
• Nimish Kapoor, Festival Director, National / International Science Film Festivals of India 
• Dr Olena Seminog, Vice-President, Public Health Film Society and Researcher at Nuffield Department of Population Health, University of Oxford 

But how could we possibly choose the “best” film? What even is the “best” film? The first festival sparked the development of formal public health film judging criteria, based on criteria used by others such as the American Movie Awards. Ten criteria were developed and tested in 2016; it is these criteria that we used in our discussions. They are:

1. Originality and creativity
2. Public health importance
3. Plot and structure
4. Pacing
5. Character and storyline
6. Cinematography and direction
7. Entertainment value / watchability
8. Dialogue
9. Overall quality of production
10. Use and evaluation of impact

The scoring criteria guided us through critiquing and analysing the relative merits of each film, as well as facilitating increased transparency in the judges’ decision making. However, there is more to decisions than simply numbers, as the shortlisted films were so diverse, tackling different subjects in very different ways, and ranging from 5 minutes’ duration to full feature length. Cue, stage right: the judging panel discussion!

An animated conversation started almost immediately, the judges’ passion for film immediately evident. Judges brought different ideas and perspectives to the virtual table, by virtue of their diversity of background, film, and public health experience, as well as varied life experiences. One film, for example, could have been a Hollywood movie for its cinematic tricks – but fell short with its consistency in health messaging. This demonstrates the importance of a broad array of marking criteria, but mostly the importance of a multi-disciplinary discussion to ensure the winning films contained the right balance between filmic quality and public health messages that were conveyed. Agreement was important: the winning films would be endorsed by the group, and it was essential we were all happy with the group decision. We returned again and again to the importance of a consistent public health message. Enjoying the benefits of a geographically diverse panel, we considered how different films may be received by different communities across the world, and how that influenced the messages contained within the film.

Eventually, consensus was reached! All the winning films were high-scoring, and in our conversations it was clear that we had all earmarked these films as having a je ne sais quoi, films that had stimulated an emotional response in us all.

The judges’ prize went to A Fire Inside, which thoroughly deserves the accolade. A full-length feature film taking on Australia’s devastating “Black Summer” bushfires in 2019/2020, the film sensitively tells the stories of the heroes on the frontline of firefighting and the “heroes in plain clothes” supporting them. Beautifully and respectfully filmed and with incredibly powerful cinematography, we were shown “hell on earth”. Once the fires were dowsed, feelings of abandonment and trauma surfaced amongst those affected. Scenes of utter devastation filled the screen. But, amongst the charred landscape, we saw volunteers overwhelmed by donations, we heard of the kindness of strangers and those who saw an opportunity to help, and so helped. A poignant film which shows the power of healing.

Given the high quality of the entries, the judges deemed three other films deserved an honourable mention given their filmic quality or the impact of their public health message: Hysterical Sisters; Solstice; and A Black Cloud.

Hysterical Sisters is a beautifully choreographed and narrated fusion of art, storytelling, information, and film which tackles stigma head on.  The impact of two common conditions (endometriosis and adenomyosis) on every aspect of the women’s everyday lives – school, relationships, others’ indifference to their pain – and the surrounding silence by society, by the medical profession, by research, is viscerally told.

Solstice broke my heart. Dedicated to Mary and those who didn’t make the night, Mary Baker’s parents tell their story of losing their teenage daughter to suicide. Interspersed with stories told by others who have lost loved ones, the message is clear: different people, different backgrounds – we can all be affected. Mary’s parents, now well known for their advocacy around mental health and suicide prevention, organise an annual event, Solstice, which mobilises the community, supports people affected by mental health concerns to work together towards a common cause, and to campaign: “in community lies strength”. In 2021, Solstice filled out the square it was hosted in, and was watched by 20,000 people across the globe. Mary’s story was invited to join the Museum of Lost and Found Potential in London, as the Australian exhibit. The film provides hope that change is happening, and political space is being made for suicide prevention.

The short film A Black Cloud cleverly uses real patient voices with animations to tell women’s stories of reproductive trauma and bereavement. It is a powerful, moving, sensitive, compassionate, and brave insight into very personal experiences which are often not shared. The film comforts those affected that they are not alone, and encourages them to seek help to start their own journey of recovery.

~

Thank you very much to Dr Uy Hoang, for inviting me to join the judging panel. I very much enjoyed all the shortlisted films, and our discussions during the competition. I look forward to watching this genre expand over the next few years, and who knows, maybe we’ll be organising the Public Health Oscars one day soon!

~

For more information on the Public Health Film SIG: https://www.fph.org.uk/policy-advocacy/special-interest-groups/special-interest-groups-list/public-health-film-special-interest-group/

For more information on the International Public Health Film competition: 

• https://publichealthfilms.org/international-public-health-film-competition-2022/%20
• Hoang, U et al (2017) First International Public Health Film Competition 2016—reflections on the development and use of competition judging criteria, Journal of Public Health, available from: https://academic.oup.com/jpubhealth/article/40/1/169/3089818%20

Other Public Health Film festivals include:

• The American Public Health Association Film Festival: http://www.apha.org/filmfest
• The Global Health Film Festival: http://www.globalhealthfilm.org/
• Medfest: http://www.medfest-archive.com/aboutmedfest.htm
• Scottish Mental Health Arts and Film Festival: https://www.mhfestival.com/

For more projects offered through the FPH: https://www.fph.org.uk/training-careers/specialty-training/training-placements/fph-projects-scheme/

Dr Emily Clark

February 2023

Finding this project was striking speciality training gold. Combining my love for international public health, and sexual and reproductive health, the project specification could have been copy-pasted from my wish list of ideal jobs.

The UK Faculty of Public Health (FPH) had been working with their Specialist Interest Groups (SIG) to create new training opportunities for Specialty Trainees for the last few years through the FPH Projects Scheme.

Demonstrating incredibly fortuitous timing, Development Media International (DMI), a London-based NGO who create evidence-based mass media behaviour change campaigns to improve health, advertised a Specialty Training project in collaboration with the FPH Film SIG just when I needed it!

The project involved working on a campaign in the southwest of Côte d’Ivoire called “Pour une family saine et prospère”, which translates to “for a healthy and prosperous family”.

After a virtual interview, I felt very lucky to have been selected for the Project Scheme.

“Famille”, as the project was known colloquially, was adapted from a similar DMI campaign in Burkina Faso, which was evaluated using a cluster randomised controlled trial. The results demonstrated a 20% increase in modern contraceptive uptake rate and seemed to be mediated by improvements in attitudes towards modern contraceptives.

For Famille, the Burkina campaign was tailored to the Cote d’Ivoirian context using a thorough literature review and in-person formative research plan to explore barriers, motivators, challenges and enablers to contraception use, and collect any further local intelligence that might be important for our campaign. Having found a fantastic in-country qualitative research consultant, the focus groups and interviews with community members and key informants could begin! What followed was a series of fascinating Zoom calls with the research consultant as she described her findings to us. We learned about changing traditions, as women no longer leave the marital home for a prolonged period of time to give birth and nurse the baby before returning home. The cost of living was putting pressure on families in Côte d’Ivoire too – men wanted their partners at home to help look after other children, and to help with work. This changing tradition, which previously would have ensured a natural and healthy birth spacing between babies, now meant women were more likely to experience high frequency pregnancies, putting both their health and that of their children at risk. We also learned that the unpredictable side effects of hormonal contraception were unacceptable to some couples, where bleeding prohibited women from cooking or sleeping in the marital bed. Differences in side effects experienced by women was fertile ground for rumours and misinformation to spread. Men and women were worried about the risk of lasting infertility following the use of modern contraception.

The report, rich with quotes, together with the literature review provided a strong basis upon which to write the message briefs from which the campaign content was adapted. We focused on three messages for our campaign:

1. Modern methods of contraception are easy, safe, effective, and reversible 
2. Men, family planning is your business too. Talk to your partner about family planning, and accompany your wife to the health centre
3. You can use modern methods of contraception to space child births, and create a healthy, happy and prosperous family

Soon, we had 8 radio spots which conveyed our key messages in a fun, engaging way using humour and storytelling. These were tested with focus groups in Côte d’Ivoire and then recorded in five local languages using local actors. Once approved by the Ministry of Health, broadcasting could begin on the 27 partner radio stations. Each spot aired 10 times per day for up to two weeks based on DMI’s “Saturation+” approach. 

Next it was time to think about the process evaluation. Many hours of discussion ensued whilst we tried to balance ideal research study designs with pragmatism including budgets, access to villages, and weather conditions in the field (it was the rainy season at the time). We developed a protocol – based on the Capability-Opportunity-Motivation (COM-B) model of behaviour to assess women’s access to radio; social networks; attitudes and norms towards modern contraception use and birth spacing; current and intended contraception use; and their recognition of our campaign. Analysis of findings demonstrated that most women held beliefs supportive of their own reproductive autonomy (that they should be able to make decisions for themselves), however, many concurrently (and contradictorily) believed that other women did not share this belief; that other women would not support their views; and that their husbands believed they should make the decisions on contraception. These findings stimulated plenty of ideas for future campaigns – and the positive feedback received by our partners suggests further campaigns would be very welcome indeed. 

This experience provided me with a smorgasbord of learning. Not only have I discovered a huge amount about sexual and reproductive health and practices in Côte d’Ivoire, I have gained experience of the practicalities of designing a research-based radio campaign for behaviour change. Supported by my supervisor, I provided the research input for an international multi-disciplinary team. The importance of stakeholder engagement was really clear throughout the project – Famille was only possible because of the existing trusted relationships between the organisation, the radio stations, and other partners. Approval was needed at all stages of the project from the Côte d’Ivoire Ministry of Health. Collaboration with the Ivorian Midwives Association yielded benefits for us all – I was incredibly grateful for the opportunity to discuss our emerging findings with very knowledgeable professionals. As I reflect on project, it is clear it has been a fantastic immersive experience with many transferable skills that I will bring back to my day job!  

~

I would like to say a huge thank you to Development Media International for hosting me, to my supervisor Dr Abbie Clare for all her guidance and support, and to Dr Uy Hoang and Dr Stella Botchway from the FPH Public Health Film Special Interest Group for helping to organise the Project Scheme with DMI.

~

For more information about DMI, please visit: https://www.developmentmedia.net

For more information about the project (including one of the spots), please visit: https://www.developmentmedia.net/project/pour-une-famille-saine-et-prospere/

Information on the landmark RCT in Burkina Faso can be found here: https://www.developmentmedia.net/project/familyplanningrct/

For more projects offered through the FPH: https://www.fph.org.uk/training-careers/specialty-training/training-placements/fph-projects-scheme/#:~:text=FPH%20projects%20The%20Faculty%20of%20Public%20Health%20%28FPH%29,a%20Special%20Interest%20Group%20%28SIG%29%20within%20the%20FPH.

Dr Emily Clark

February 2023

As co-chairs of the Faculty of Public Health’s Sexual and Reproductive Health Special Interest Group (SRH SIG) it was a pleasure to attend the All Party Parliamentary Group for Sexual and Reproductive Health’s (APPG SRH) event on ‘Equipping the NHS to deliver for Women’s Reproductive Health’. Healthcare professionals, parliamentarians and community representatives came together for a fascinating discussion about the challenges currently facing the sexual and reproductive health (SRH) workforce, their impact on women’s reproductive health and what can be done to protect the workforce to ensure that women’s needs are met.

Colleagues described the wide-ranging SRH workforce which comprises doctors from genitourinary medicine (GUM), community sexual and reproductive health (CSRH), general practice and infectious diseases; nurses; midwives and other healthcare professionals. It is responsible for providing contraception, termination of pregnancy and testing and treatment for sexually transmitted infections (STIs) and HIV alongside many other services. Clearly, the SRH workforce not only has an important clinical function but also a public health one; and it was concerning to hear about the difficulties filling training and consultant posts, insufficient funding for some training posts and the fragmentation of the workforce due to the disjointed commissioning arrangements.

It is evident that the challenges facing the SRH workforce have significant public health implications. The APPG SRH’s enquiry into access to contraception identified data showing that nearly half of pregnancies and one-third of births in England are unplanned or ambivalent[1]. Abortion rates in England and Wales are rising and, in 2021, reached their highest rate since the introduction of the Abortion Act[2], suggesting an unmet need for contraception. Black women have disproportionately high rates of abortions and rates are higher among the most deprived populations compared with the least deprived² indicating the health inequalities faced by these groups. In 2021, the number of consultations by sexual health services rose by nearly 16% from 3,460,100 in 2020 to 4,002,827[3], demonstrating the increased pressure that services are under.

The data paints a stark picture and without intervention things will only get worse. So, what can we do in public health to help protect the SRH workforce?

• With the commissioning of sexual health services being the responsibility of local authorities, it is essential that we consider the impact of our commissioning decisions on the SRH workforce and work with our clinical colleagues when designing service models.
• Using a public health perspective, we can support efforts to promote entry into the SRH workforce, such as the British Association for Sexual Health and HIV LOVE GUM campaign.

As the Faculty of Public Health’s SRH SIG we are keen to support the work that needs to take place to address this hugely important agenda and look forward to more opportunities to engage with the APPG SRH and other partners.  

Dr Natalie Daley and Dr Rachael McCarthy

Co-Chairs of the Sexual and Reproductive Health Special Interest Group

[1] https://www.fsrh.org/documents/full-report-december-womens-lives-womens-rights/

[2] https://www.gov.uk/government/statistics/abortion-statistics-for-england-and-wales-2021/abortion-statistics-england-and-wales-2021#:~:text=Key%20points%20in%202021,-There%20were%20214%2C256&text=The%20age%20standardised%20abortion%20rate,the%20Abortion%20Act%20was%20introduced.

[3] https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables/sexually-transmitted-infections-and-screening-for-chlamydia-in-england-2021-report#overall-trends-in-consultations-sti-testing-and-diagnoses-at-shss-among-england-residents

Public health as a specialty is committed to improving health and reducing inequalities. It can only do this if it is a fair profession: it reflects the population we serve and all in it feel included and treated equally.  While demographic characteristics have been recorded and measured in the past, we are putting a renewed focus on identifying inequalities and working to remove them. This will involve not only looking at data on diversity and progression, but also asking people whether they feel included.

Our initial focus is on ethnic differences but we will be looking at all protected characteristics and wider measures of inequality. Ultimately, we aim to have a Fair Training Culture and fair career structure.

The first detailed report we have made available is on the process of recruitment into public health – we are grateful to Health Education England for commissioning the work and Imperial College London for doing such an excellent study. The stimulus for this was a report in the British Medical Journal in February 2020 highlighting inequalities in recruitment process across medical profession. The work was delayed by COVID but is now complete and looks in detail at the different parts of the recruitment pathway.

These results are a wake-up call. Those working in recruitment are committed to fairness, so it is surprising to see unfair processes built in. Specifically, the assessment centre tests for numeracy, critical reasoning and situational judgement (done on a computer at a test centre) have significant biases. We have previously focused on training interviewers to reduce biases, but now we have identified this specific issue we can start to do something about it. It is not immediately apparent why this is happening but we are revising the SJT with a much more diverse group of assessors, improving the availability of support materials and hope to start exploring alternatives to the current tests.

Further work over the coming months will look at progress through training including exams and annual reviews, and then we will look at appointments and career progress. We are grateful for the work many members in the Faculty are doing in this area, from the Equality, Diversity and Inclusion Committee and Special Interest Group but also are looking for further capacity from members to undertake this work.

Professor Kevin Fenton, FPH President

Dr David Chappel, FPH Academic Registrar

October 2022

FPH just hosted a conference – “Climate and health: what can we do?” – on 22 September 2022, which Kevin Fenton, the FPH President opened, outlining some of the key issues on climate and health interfaces and acknowledging the importance of climate and health as a public health priority on which we must all take action now.

The conference itself was mainly the brainchild of Cat Pinho-Gomes, one of the specialist registrars who have supported the development and implementation of the Climate and Health Strategy, but it is also thanks to the FPH staff team for all their work to deliver the conference, and of course to the speakers on the day.

This event was part of the Climate and Health Strategy. It commits FPH to developing events “to continuously develop a membership with strong expertise in effective public health action in tackling the climate emergency”. It is one of sixteen initiatives the C&H Strategy has committed to in its first year and most of them are complete or well on their way.

The conference invited presentations from climate and health leaders and advocates from across the globe and the UK, and we heard everything from decolonising climate action and learning from indigenous cultures and the environment in New Zealand (Aotearoa), to devastating oil industry impacts in Niger Delta communities, to nature based solutions in Asian cities, to mental health impacts of climate change, to the ‘Incredible edible’ approach, to responses to climate in Argentina and to what one attendee described as “a master class in climate communication” from an emergency department physician from Canada. They were wonderful, powerful, moving presentations, from which we all learned a lot – the talks were inspirational.

We also heard fabulous case studies from abstracts submitted to the conference, many of them on local work by specialist registrars –clearly our public health leaders of the future. We hope that these speakers at the conference will submit their work as case studies, so that other members of the FPH can benefit from work already done and be able to connect and learn from it.

Even though this was a conference held remotely, the energy generated amongst the 500+ registrants was palpable and the ‘chat’ was full of exciting thoughts, sharing ideas, gems of information and links. I was blown away.

The conference also heralded the re-launch of FPH’s resources on climate and health, put together by the Sustainable Development Special Interest Group (SIG) and covering a range of key science and related reports and topics to help members bring climate issues into their day to day portfolios. Whether that includes working on air quality, food, inequalities, active travel, physical activity, housing, infectious diseases, the environment, green spaces, young people or most other public health topics, there are health impacts and aspects pertaining to climate and health. The “co-benefits” are the health gains achieved from taking climate action. These case studies will also form part of the FPH resources.

The C&H Strategy priorities will be reviewed over the next couple of months so please contribute to that rethink.

What a day. The conference was recorded so, if you were not able to attend you can still take the opportunity to share in the knowledge and awareness raising.

Sue Atkinson

September 2022