What happens to NICE public health guidelines after publication in terms of how they are viewed and used by local government officers? – A realist inquiry

Background: In 2013, many public health responsibilities were returned to local government control. The structures, inherent customs and practices, differed to those in the NHS where the specialism had previously been hosted. At the same time, the remit of a repurposed National Institute for Health and Care Excellence was extended to impact upon local authorities. Post 2013, NICE public health guidance lands in a shifting world of local democracy and accountability. Methods: This realist inquiry identified, tested and refined theories to explain how NICE guidance was received in local government, following its release, and why this reception occurred. The initial theories were surfaced using: mind maps as access points to several literature forays and a Delphi consensus panel to check for explanatory relevance. Three hypotheses were targeted; two on the nature of decision-making and one on the uniqueness of individual authorities. These hypotheses were tested by methodically reviewing the literature using theory-guided searches, data extraction and synthesis, and by primary data collection during fieldwork located within public health practice in 3 local councils. Findings: The inquiry identified patterns of visibility of NICE guidelines within decision-making processes which were explained by identifying how knowledge is exchanged between officers and politicians. Mechanisms operating within these exchanges such as mutual respect, trust, and evidence weaving begin to point to the emergence of the ‘craft’ of public health practice in local government. Conclusions: Findings confirmed the usefulness of three key transferable knowledge explanations: mutual exchange of resources by local bureaucratic elites; the trick to balancing knowledges (nature of decision-making) and the pre-eminence of place. When presented to local government officers these explanations resonate and illustrate the strength of realist inquiry in adding to our understanding of contemporary public health craft practices and how these might be developed

What is a research derived actionable tool, and what factors should be considered in their development? A Delphi study

Background: Research findings should be disseminated appropriately to generate maximum impact. The development of research derived 'actionable' tools (RDAT) as research outputs may contribute to impact in health services and health systems research. However there is little agreement on what is meant by actionable tool or what can make them useful. We set out to develop a consensus definition of what is meant by a RDAT and to identify characteristics of a RDAT that would support its use across the research-practice boundary. Methods: A modified Delphi method was used with a panel of 33 experts comprising of researchers, research funders, policy makers and practitioners. Three rounds were administered including an initial workshop, followed by two online surveys comprising of Likert scales supplemented with open-ended questions. Consensus was defined at 75% agreement. Results: Consensus was reached for the definition and characteristics of RDATs, and on considerations that might maximize their use. The panel also agreed how RDATs could become integral to primary research methods, conduct and reporting. A typology of RDATs did not reach consensus. Conclusions: A group of experts agreed a definition and characteristics of RDATs that are complementary to peer reviewed publications. The importance of end users shaping such tools was seen as of paramount importance. The findings have implications for research funders to resource such outputs in funding calls. The research community might consider developing and applying skills to coproduce RDATs with end users as part of the research process. Further research is needed on tracking the impact of RDATs, and defining a typology with a range of end-users

A qualitative exploration of evidence-based decision making in public health practice and policy : the perceived usefulness of a diabetes economic model for decision makers

Purpose The purpose of this paper is to explore the perceived usefulness of a diabetes economic model as a potential tool for aiding evidence-based decision making in public health. Methods Fifteen interviews and two focus groups with four participants each were conducted with health and management professionals working in one public health department in a local council. Data were analysed using inductive thematic analysis to generate four themes. Findings Findings reflect attitudes and beliefs of a diverse staff group situated in public health services. They demonstrate that the model had perceived usefulness, and participants reported positive views regarding the principles of economic modelling for decision making. The model was perceived as useful but potentially problematic in practice due to organisational constraints linked to limited resources, restricted budgets and local priorities. Differences in institutional logics of staff working in public health and local government were identified as a potential barrier to the use of the model in practice. Discussion The findings highlight anticipated challenges that individuals tasked with making decisions for public health practice and policy could face if they selected to implement an economic modelling approach to fulfill their evidence needs. Previous studies have revealed that healthcare decision makers would find evidence around the economic impacts of public health interventions useful, but this information was not always available in the format required. This paper provides insights into how staff working in public health perceive economic modelling, and explores how they consider evidence from a model when making public health practice and policy decisions

“Seeing” the Difference: The Importance of Visibility and Action as a Mark of “Authenticity” in Co-production Comment on “Collaboration and Co-production of Knowledge in Healthcare: Opportunities and Challenges”

The Rycroft-Malone paper states that co-production relies on ‘authentic’ collaboration as a context for action. Our commentary supports and extends this assertion. We suggest that ‘authentic’ co-production involves processes where participants can ‘see’ the difference that they have made within the project and beyond. We provide examples including: the use of design in health projects which seek to address power issues and make contributions visible through iteration and prototyping; and the development of ‘actionable outputs’ from research that are the physical embodiment of coproduction. Finally, we highlight the elements of the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) architecture that enables the inclusion of such collaborative techniques that demonstrate visible co-production. We reinforce the notion that maintaining collaboration requires time, flexible resources, blurring of knowledge produceruser boundaries, and leaders who promote epistemological tolerance and methodological exploratio

Thermal Sensation in Older People with and without Dementia Living in Residential Care: New Assessment Approaches to Thermal Comfort Using Infrared Thermography

The temperature of the indoor environment is important for health and wellbeing, especially at the extremes of age. The study aim was to understand the relationship between self-reported thermal sensation and extremity skin temperature in care home residents with and without dementia. The Abbreviated Mental Test (AMT) was used to discriminate residents to two categories, those with, and those without, dementia. After residents settled and further explanation of the study given (approximately 15 min), measurements included: tympanic membrane temperature, thermal sensation rating and infrared thermal mapping of non-dominant hand and forearm. Sixty-nine afebrile adults (60–101 years of age) were studied in groups of two to five, in mean ambient temperatures of 21.4–26.6 °C (median 23.6 °C). Significant differences were observed between groups; thermal sensation rating (p = 0.02), tympanic temperature (p = 0.01), fingertip skin temperature (p = 0.01) and temperature gradients; fingertip-wrist p = 0.001 and fingertip-distal forearm, p = 0.001. Residents with dementia were in significantly lower air temperatures (p = 0.001). Although equal numbers of residents per group rated the environment as ‘neutral’ (comfortable), resident ratings for ‘cool/cold’ were more frequent amongst those with dementia compared with no dementia. In parallel, extremity (hand) thermograms revealed visual temperature demarcation, variously across fingertip, wrist, and forearm commensurate with peripheral vasoconstriction. Infrared thermography provided a quantitative and qualitative method to measure and observe hand skin temperature across multiple regions of interest alongside thermal sensation self-report. As an imaging modality, infrared thermography has potential as an additional assessment technology with clinical utility to identify vulnerable residents who may be unable to communicate verbally, or reliably, their satisfaction with indoor environmental conditions

Talking about weight in pregnancy : an exploration of practitioners' and women's perceptions

Prevalence of maternal obesity is increasing, with health risks for mother and infant. Effective health promotion depends on sufficient knowledge and appropriate communication skills. We aimed to explore women's, midwives' and health visitors' perceptions of current practice in helping women manage their weight and supporting healthy behaviour change during pregnancy, and their perceived training needs. A modified grounded theory methodology was adopted, based upon critical realist assumptions. Following consultation events with fifty six practitioners to inform data collection tools, twenty (different) practitioners and nine women participated in focus groups. Comparative analysis generated four themes: A core theme, “Discouraging discourses”, described health professionals’ negative beliefs and reactive approach to communicating about weight. “Staff resources” identified limitations in and requirements for practitioner knowledge, skills and tools for effective communication. “Contextual influences” were social factors, which hindered practitioners’ efforts to achieve healthy behaviour change. “Communicating as a Team” identified the importance of and challenges to a team approach. Findings have implications for weight management in pregnancy, practitioner resources, teamwork, and national health promotion campaigns

Interpersonal touch interventions for patients in intensive care: A design-oriented realist review

Aim: To develop a theoretical framework to inform the design of interpersonal touch interventions intended to reduce stress in adult intensive care unit patients. Design: Realist review with an intervention design‐oriented approach. Methods: We searched CINAHL, MEDLINE, EMBASE, CENTRAL, Web of Science and grey literature sources without date restrictions. Subject experts suggested additional articles. Evidence synthesis drew on diverse sources of literature and was conducted iteratively with theory testing. We consulted stakeholders to focus the review. We performed systematic searches to corroborate our developing theoretical framework. Results: We present a theoretical framework based around six intervention construction principles. Theory testing provided some evidence in favour of treatment repetition, dynamic over static touch and lightening sedation. A lack of empirical evidence was identified for construction principles relating to intensity and positive/negative evaluation of emotional experience, moderate pressure touch for sedated patients and intervention delivery by relatives versus healthcare practitioners

Developing the embedded researcher role: learning from the first year of the National Institute for Health and Care Research (NIHR), Health Determinants Research Collaboration (HDRC), Doncaster, UK.

Strategies to embed research knowledge into decision making contexts include the Embedded Research (ER) model, which involves the collocation of academic researchers in non-academic organisations such as hospitals and local authorities. A local authority in Doncaster, United Kingdom (UK) has adopted an embedded researcher model within the National Institute for Health and Care Research (NIHR), Health Determinants Research Collaboration (HDRC). This five-year collaboration enables universities and local authorities to work together to reduce health inequalities and target the social determinants of health. Building on previous embedded research models, this approach is unique due to its significant scale and long-term investment. In this opinion paper Embedded Researchers (ERs) reflect on their experiences of the first year of the collaboration