Developing empirically supported theories of change for housing investment and health

The assumption that improving housing conditions can lead to improved health may seem a self-evident hypothesis. Yet evidence from intervention studies suggests small or unclear health improvements, indicating that further thought is required to refine this hypothesis. Articulation of a theory can help avoid a black box approach to research and practice and has been advocated as especially valuable for those evaluating complex social interventions like housing. This paper presents a preliminary theory of housing improvement and health based on a systematic review conducted by the authors. Following extraction of health outcomes, data on all socio-economic impacts were extracted by two independent reviewers from both qualitative and quantitative studies. Health and socio-economic outcome data from the better quality studies (n = 23/34) were mapped onto a one page logic models by two independent reviewers and a final model reflecting reviewer agreement was prepared. Where there was supporting evidence of links between outcomes these were indicated in the model. Two models of specific improvements (warmth and energy efficiency; and housing led renewal), and a final overall model were prepared. The models provide a visual map of the best available evidence on the health and socio-economic impacts of housing improvement. The use of a logic model design helps to elucidate the possible pathways between housing improvement and health and as such might be described as an empirically based theory. Changes in housing factors were linked to changes in socio-economic determinants of health. This points to the potential for longer term health impacts which could not be detected within the lifespan of the evaluations. The developed theories are limited by the available data and need to be tested and refined. However, in addition to providing one page summaries for evidence users, the theory may usefully inform future research on housing and health

External validity in healthy public policy: application of the RE-AIM tool to the field of housing improvement

<b>Background</b><p></p> Researchers and publishers have called for improved reporting of external validity items and for testing of existing tools designed to assess reporting of items relevant to external validity. Few tools are available and most of this work has been done within the field of health promotion.<p></p> <b>Methods</b><p></p> We tested a tool assessing reporting of external validity items which was developed by Green & Glasgow on 39 studies assessing the health impacts of housing improvement. The tool was adapted to the topic area and criteria were developed to define the level of reporting, e.g. “some extent”. Each study was assessed by two reviewers.<p></p> <b>Results</b><p></p> The tool was applicable to the studies but some items required considerable editing to facilitate agreement between the two reviewers. Levels of reporting of the 17 external validity items were low (mean 6). The most commonly reported items related to outcomes. Details of the intervention were poorly reported. Study characteristics were not associated with variation in reporting.<p></p> <b>Conclusions</b><p></p> The Green & Glasgow tool was useful to assess reporting of external validity items but required tailoring to the topic area. In some public health evaluations the hypothesised impact is dependent on the intervention effecting change, e.g. improving socio-economic conditions. In such studies data confirming the function of the intervention may be as important as details of the components and implementation of the intervention

Developing best available evidence to inform healthy public policy

Healthy public policy refers to the use of policies beyond the health services which have the potential to improve health, typically by improving determinants of health, for example socio-economic conditions such as employment, income, housing etc.. While improvements to living conditions have long been viewed as an important mechanism to promote public health, the concept of healthy public policy was formally described more recently in the World Health Organisation’s (WHO) Ottawa Charter in 1986. The rationale for healthy public policy rests heavily on a wealth of cross-sectional data reporting links between socio-economic factors and health. Many of these relationships are well established, providing strong empirical support for hypotheses that intervening to improve socio-economic conditions will lead to improved health. However, hypotheses around health benefits need to be validated: There are many examples of well-intended interventions which did not produce the expected benefits, and in some cases had adverse effects. Compared to many clinical interventions, social interventions are characteristically difficult to control, and likely to be more susceptible to the effect of confounding and mediating factors. These issues increase the level of uncertainty inherent in hypotheses about the impacts of social interventions, in particular health impacts which are influenced by many factors, and further underlines the need for empirical validation. Evidence from empirical research evaluating the health impacts of social interventions needs to be used to inform and refine future policy if the potential for public policy to contribute to health improvement is to be realised. Both reviews of previous research evidence as well as the pursuit of new evidence can be used to develop the evidence base. Previous evidence needs to be reviewed rigorously and comprehensively to minimise the potential for selective interpretations which may be subject to bias; this is best done using transparent systematic review methods. New evaluations are required to provide up-to-date evidence as well as to improve the quality of evidence and plug gaps in the evidence which systematic reviews are well placed to identify. Having synthesised previous evidence and generated newly relevant evidence, it is crucial that the available evidence is made available to those in policy and practice who are most likely to use the evidence. It is necessary that the evidence is disseminated beyond academic audiences and translate the evidence or knowledge to provide syntheses of evidence which are accessible to and tailored to the needs of potential evidence-users. The use of systematic reviews, evaluations of health impacts, and knowledge transfer work has existed for many years within both the health and social policy field. However, the application of these approaches to the field of healthy public policy and the health impacts of social interventions is relatively novel. Application of conventional methods to this new area has required adapting and developing existing methods appropriately. The proposed submission The portfolio of publications selected for this submission represents a selection of the applicant’s publications since 2001. Hilary Thomson is the lead author on each of these publications which were prepared from work carried out with the Evaluation programme (original title Evaluation of the health impacts of non-health sector interventions) of research based at the Medical Research Council’s Social & Public Health Sciences Unit, Glasgow. This programme was funded by the Chief Scientist’s Office of the Scottish Government in 1999 to provide evidence on the health impacts of social interventions, and thus to inform the development of healthy public policy. This thesis presents 10 peer reviewed international publications in this field; nine of these are from high impact public health journals, and one is an example of knowledge transfer that was commissioned by the WHO. The work is presented in three key themes each of key relevance to the development of best available evidence for healthy public policy. Theme I: Systematic review Three publications are presented in this theme, each of these reports the key findings of a systematic review. Paper I reports the findings of a systematic review of the health impacts of housing improvement; Paper III reports the findings of a similar review which has been substantially updated, both methodologically and in content. Paper II presents the findings of a systematic review of the health and socio-economic impacts of urban regeneration investment in the UK since 1980. Theme II: Evaluation & generation of new evidence Four publications are presented in this theme. Paper IV and Paper V report the empirical findings of studies investigating the health impacts of local community leisure facilities, and a local programme of housing-led neighbourhood regeneration respectively. Paper VI and Paper VII present a commentary and reflection based on the author’s experience in the field on how to develop best available evidence to inform healthy public policy. These papers focus on assessing the health impacts of income supplementation interventions, such as welfare benefits, and housing and regeneration investment, however, the emerging lessons and issues have a relevance to the wider field of healthy public policy. Theme III: Knowledge transfer Three publications are presented in this theme. Each of these illustrates how my work has gone beyond reviewing and generating evidence for an academic audience, by providing accessible evidence syntheses which are accessible to and tailored to the needs of policy makers and practitioners who wish to use evidence in their work. Paper VIII and Paper IX were commissioned by the Scottish Health Impact Assessment Network and report how I developed evidence syntheses on housing improvement and transport policy. Paper X presents an evidence synthesis on housing and health commissioned by the WHO for use by European policymakers

Assessing reporting of narrative synthesis of quantitative data in public health systematic reviews

No abstract available

The effect direction plot revisited: application of the 2019 Cochrane Handbook guidance on alternative synthesis methods

Effect direction (evidence to indicate improvement, deterioration, or no change in an outcome) can be used as a standardized metric which enables the synthesis of diverse effect measures in systematic reviews. The effect direction (ED) plot was developed to support the synthesis and visualization of effect direction data. Methods for the ED plot require updating in light of new Cochrane guidance on alternative synthesis methods. To update the ED plot, statistical significance was removed from the algorithm for within‐study synthesis and use of a sign test was considered to examine whether patterns of ED across studies could be due to chance alone. The revised methods were applied to an existing Cochrane review of the health impacts of housing improvements. The revised ED plot provides a method of data visualization in synthesis without meta‐analysis that incorporates information about study characteristics and study quality, using ED as a common metric, without relying on statistical significance to combine outcomes of single studies. The results of sign tests, when appropriate, suggest caution in over‐interpreting apparent patterns in effect direction, especially when the number of included studies is small. The revised ED plot meets the need for alternative methods of synthesis and data visualization when meta‐analysis is not possible, enabling a transparent link between the data and conclusions of a systematic review. ED plots may be particularly useful in reviews that incorporate nonrandomized studies, complex systems approaches, and diverse sources of evidence, due to the variety of study designs and outcomes in such reviews

Consistency of behaviours over time and context in zebrafish

Animal personality is defined as individual variation in behaviour which is consistent over time and across contexts; the five major components of personality are activity, boldness, exploration, sociability, and aggression. Many taxa show sex differences in behaviours, including in personality. Most studies do not assess repeatability of behaviour, and if they do, they generally assess repeatability over only relatively short time periods (e.g., a week or a month). Understanding whether personality traits are repeatable over longer periods is important for the assessment of individual differences in behaviour; if a behaviour is not repeatable over time, then it is uninformative about consistent behavioural syndromes within individuals. A core notion of personality research is that behaviours are consistent in different contexts, but there is also evidence of behaviour changing within individuals with a change in certain contexts. Thus, understanding which contexts cause a change in behaviour and which do not may be important for future research that assumes consistency of behaviour. In this thesis, I use zebrafish (Danio rerio) as a model to assess behavioural consistency over time and context. In Chapter 2, I investigate the repeatability of activity, exploration, boldness, anxiety, and sociability to obtain longer-term (6 month) estimates of repeatability. I hypothesised: that these behaviours would be repeatable; that there would be sex differences both in repeatability estimates and in actual values; and, finally, that behavioural syndromes would be expressed. Specifically, this required that the expression of one personality trait would be correlated with another. To answer these questions, individuals were filmed in a test sequence, comprising a novel arena assay (to test activity, anxiety and exploration) and a novel object assay within the same tank (to test boldness). Single-sex groups were then filmed in a different arena to test sociability. Behaviours were quantified using the behavioural analysis programs EthoVision XT and idTracker. Overall, activity and exploration in individuals, and sociability at the tank level, were fairly repeatable over six months. Boldness was also repeatable, but to a lesser degree. A commonly-used measure of anxiety was more repeatable in the novel arena assay than the novel object test. There were clear sex differences in aspects of activity and sociability, in that males were more active and shoaled less tightly than females. However, while males were more repeatable in exploratory behaviour, there were minimal sex differences in the mean expression of exploration and boldness. There was evidence for an activity-boldness-exploration behavioural syndrome, but conclusions drawn from this part of the analysis are tentative because of the non- independence of the activity and exploration data. After demonstrating that anxiety over the first ten minutes in a novel tank is a repeatable behaviour in zebrafish, in Chapter 3 I assessed how a behavioural challenge, like social isolation, affects anxious behaviour. In social animals, isolation from conspecifics can negatively affect both behaviour and physiology. It has been previously demonstrated that isolating zebrafish from conspecifics can induce them to become more anxious and aggressive, but I aimed to investigate whether individuals that were more or less anxious than the norm would react differently, and whether their anxiety levels would remain similar to their initial behaviour. I predicted that, after a three-week period of isolation, initially non-anxious zebrafish would become more anxious, and anxious fish would remain so. Using only the extreme anxious and non-anxious fish, I kept each individual either isolated or in a group of five for a three-week period, and then phenotyped these same fish again to get a post-treatment estimate of anxiety. I found that all four treatment groups (anxious or non- anxious, and isolated or grouped) showed a mean change in anxiety, but while the anxious isolated and group-housed fish remained on the anxious side of the spectrum and the non- anxious group-housed fish remained on the non-anxious side, the non-anxious isolated fish showed double the change of any other group, and were (on average) classed as mostly anxious after the treatment. My sample sizes were small, and so my model did not detect an overall significant change, but the effect sizes indicated a true effect of treatment despite the low power of my study. This supports part of my hypothesis that non-anxious fish would become more anxious after a period of isolation. The major findings from this study were that activity- and exploration-related (and, to a lesser degree, boldness-related) behaviours were repeatable over a six-month period, and that social isolation is enough of a behavioural challenge to alter previous anxiety levels, especially in initially non-anxious fish. I also found evidence of both sex differences and behavioural syndromes over time. The research done in this thesis contributes to the established literature by generating long-term behavioural repeatability estimates for a model species, as well as an experimental assessment of how social isolation can alter anxiety levels. Future research should evaluate the applicability of behavioural tests to the behaviours they intend to study

Assessing the unintended health impacts of road transport policies and interventions: translating research evidence for use in policy and practice

Background: Transport and its links to health and health inequalities suggest that it is important to assess both the direct and unintended indirect health and related impacts of transport initiatives and policies. Health Impact Assessment (HIA) provides a framework to assess the possible health impacts of interventions such as transport. Policymakers and practitioners need access to well conducted research syntheses if research evidence is to be used to inform these assessments. The predictive validity of HIA depends heavily on the use and careful interpretation of supporting empirical evidence. Reviewing and digesting the vast volume and diversity of evidence in a field such as transport is likely to be beyond the scope of most HIAs. Collaborations between HIA practitioners and specialist reviewers to develop syntheses of best available evidence applied specifically to HIA could promote the use of evidence in practice. Methods: Best available research evidence was synthesised using the principles of systematic review. The synthesis was developed to reflect the needs of HIA practitioners and policymakers. Results: Aside from injury reduction measures, there is very little empirical data on the impact of road transport interventions. The possibility of impacts on a diverse range of outcomes and differential impacts across groups, make it difficult to assess overall benefit and harm. In addition, multiple mediating factors in the pathways between transport and hypothesised health impacts further complicate prospective assessment of impacts. Informed by the synthesis, a framework of questions was developed to help HIA practitioners identify the key questions which need to be considered in transport HIA. Conclusion: Principles of systematic review are valuable in producing syntheses of best available evidence for use in HIA practice. Assessment of the health impacts of transport interventions is characterised by much uncertainty, competing values, and differential or conflicting impacts for different population groups at a local or wider level. These are issues pertinent to the value of HIA generally. While uncertainty needs explicit acknowledgement in HIA, there is still scope for best available evidence to inform the development of healthy public policy

Lone parents, health, wellbeing and welfare to work:a systematic review of qualitative studies

Abstract Background Lone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children. Methods We conducted a systematic review of qualitative studies reporting lone parents’ accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies. Results Screening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts. Conclusion WtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW