Volunteering for the Commonwealth Games: what can realist synthesis contribute to health policy making?

The aim of this thesis was to investigate, using the real-time test case of the 2014 Commonwealth Games, whether the realist synthesis methodology could contribute to the making of health policy in a meaningful way. This was done by looking at two distinct research questions: first, whether realist synthesis could contribute new insights to the health policymaking process, and second, whether the 2014 Commonwealth Games volunteer programme was likely to have any significant, measurable, impact on health inequalities experienced by large sections of the host population. The 2014 Commonwealth Games legacy laid out ambitious plans for the event, in which it was anticipated that it would provide explicit opportunities to impact positively on health inequalities. By using realist synthesis to unpick the theories underpinning the volunteer programme, the review identifies the population subgroups for whom the programme was likely to be successful, how this could be achieved and in what contexts. In answer to the first research question, the review found that while realist methods were able to provide a more nuanced exposition of the impacts of the Games volunteer programme on health inequalities than previous traditional reviews had been able to provide, there were several drawbacks to using the method. It was found to be resource-intensive and complex, encouraging the exploration of a much wider set of literatures at the expense of an in-depth grasp of the complexities of those literatures. In answer to the second research question, the review found that the Games were, if anything, likely to exacerbate health inequalities because the programme was designed in such a way that individuals recruited to it were most likely to be those in least need of the additional mental and physical health benefits that Games volunteering was designed to provide. The following thesis details the approach taken to investigate both the realist approach to evidence synthesis and the likelihood that the 2014 Games volunteer programme would yield the expected results.

Methods matter: computational modelling in public health policy and planning

This work is aimed at understanding and unifying information on epidemiological modelling methods and how those methods relate to public policy addressing human health, specifically in the context of infectious disease prevention, pandemic planning, and health behaviour change. This thesis employs multiple qualitative and quantitative methods, and presents as a manuscript of several individual, data-driven projects that are combined in a narrative arc. The first chapter introduces the scope and complexity of this interdisciplinary undertaking, describing several topical intersections of importance. The second chapter begins the presentation of original data, and describes in detail two exercises in computational epidemiological modelling pertinent to pandemic influenza planning and policy, and progresses in the next chapter to present additional original data on how the confidence of the public in modelling methodology may have an effect on their planned health behaviour change as recommended in public health policy. The thesis narrative continues in the final data-driven chapter to describe how health policymakers use modelling methods and scientific evidence to inform and construct health policies for the prevention of infectious diseases, and concludes with a narrative chapter that evaluates the breadth of this data and recommends strategies for the optimal use of modelling methodologies when informing public health policy in applied public health scenarios.

Evaluating health policy and legal responses : how to reduce barriers and improve access to orphan drugs for rare diseases in Canada

Abstract : Rare diseases are debilitating conditions often leading to severe clinical manifestations for affected patients. Orphan drugs have been developed to treat these rare diseases affecting a small number of individuals. Incentives in the legal framework aimed to recoup the research and development cost of orphan drugs for pharmaceutical companies have been implemented in the United States and the European Union. At the present time, Canada is still lacking a legal and policy framework for orphan drugs. Several problems at the federal and provincial levels remain: lack of research funds for rare diseases, discrepancies on orphan drug policies between provinces, difficulties to access and reimburse these high price drugs. Recommendations and measures are proposed, such as a pan-Canadian (national) scientific committee to establish evidence-based guidelines for patients to access orphan drugs uniformly in all provinces with a disease specific registry, a formal agreement for a centralized Canadian public funding reimbursement procedure, and increasing the role of “guardian” for prices by the Patented Medicines Review Board in Canada. These recommendations and measures will be beneficial for the implementation of a policy framework for orphan drugs in Canada.

A conduit between epidemiological research and regional health policy

OBJECTIVE: To transform data from a research setting into a format that could be used to support strategies encouraging healthy lifestyle choices and service planning within local government. METHODS: Details of the health status and lifestyle behaviours of the Geelong, Victoria, population were generated independently by the Geelong Osteoporosis Study (GOS), a prospective population-based cohort study. Recent GOS follow-up phases provided evidence about patterns of unhealthy diet, physical inactivity, smoking and harmful alcohol use. These factors are well-recognised modifiable risk factors for chronic disease; the dataset was complemented with prevalence estimates for musculoskeletal disease, obesity, diabetes, cardiovascular disease, asthma and cancer. RESULTS: Data were provided to Healthy Together Geelong in aggregate form according to age, sex and suburb. A population statistics company used the data to project health outcomes by suburb for use by local council. This data exchange served as a conduit between epidemiological research and policy development. CONCLUSION AND IMPLICATIONS: Regional policy makers were informed by local evidence, rather than national or state health survey, thereby optimising potential intervention strategies.

Modelled cost-effectiveness evaluation of bipolar disorder treatments to guide health policy

This analysis evaluates the cost-effectiveness of acute andmaintenance treatments for bipolar disorder (I and II) to assist inefficient allocation of resources to reduce the burden of this condition.

Standardised tobacco packaging:a health policy case study of corporate conflict expansion and adaptation

Objectives: To investigate opposition to standardised tobacco packaging in the UK. To increase understanding of how transnational corporations are adapting to changes in their access to policymakers precipitated by Article 5.3 of the Framework Convention on Tobacco Control (FCTC). Design: Case study web-based documentary analysis, using NVivo V.10. Examination of relationships between opponents of standardised packaging and transnational tobacco companies (TTCs) and of the volume, nature, transparency and timing of their activities. Setting: UK standardised packaging policy debate 2011-2013. Participants: Organisations selected on basis of opposition to, or facilitation thereof, standardised tobacco packaging in the UK; 422 associated documents. Results: Excluding tobacco manufacturing and packaging companies (n=12), 109 organisations were involved in opposing standardised packaging, 82 (75%) of which had a financial relationship with 1 or more TTC. These 82 organisations (43 actively opposing the measure, 39 facilitating opposition) were responsible for 60% of the 404 activities identified, including the majority of public communications and research production. TTCs were directly responsible for 28% of total activities, predominantly direct lobbying, but also financially underwrote third party research, communication, mass recruitment and lobbying. Active organisations rarely reported any financial relationship with TTCs when undertaking opposition activities. Conclusions: The multifaceted opposition to standardised packaging was primarily undertaken by third parties with financial relationships with major tobacco manufacturers. Low levels of transparency regarding these links created a misleading impression of diverse and widespread opposition. Countries should strengthen implementation of Article 5.3 of the FCTC by systematically requiring conflict of interest declarations from all organisations participating in political or media debates on tobacco control.

Alcohol consumption among university students: a typology of consumption to aid the tailoring of effective public health policy

Objective: Elevated levels of alcohol consumption among university students are well documented. Policymakers have attempted to combat this issue at a university, national and international level. Tailoring public health policy to effectively tackle alcohol use is crucial. Using Q-methodology, the current study aims to develop a typology of alcohol consumption in the Irish university student population. Setting: A large Irish university. Participants Hundreds of possible statements on types of consumption were generated from a systematic review and a set of one-on-one interviews. These were reduced to 36 statements, 6 statements which define each of the 6 previously defined consumption types. Participants were advised to scan through the 36 statements and fill the statements into a ‘forced choice, standardised distribution’. Following this, a 45–90 min interview was conducted with students to illuminate subjectivity surrounding alcohol consumption. Analysis was conducted using PQ Method and NVivo software. Principal component analysis, followed by varimax rotation, was conducted to uncover the final factor information. Results: In total, 43 students completed the Q-study: 19 men and 24 women. A typology describing 4 distinct groupings of alcohol consumer was uncovered: the guarded drinker, the calculated hedonist, the peer-influenced drinker and the inevitable binger. Factor loadings of each of the consumer groupings were noted for type description. Conclusions: This is the first study to propose ideal types of alcohol consumption among a university student population. Further research is required to investigate the degree to which each of these ideal types is subscribed. However, this typology, in addition to informing public policy and strategies, will be a valuable analytic tool in future research.

Having a yarn about smoking : using action research to develop a 'no smoking' policy within an Aboriginal health organisation

Objectives: This article reports on a culturally appropriate process of development of a smoke-free workplace policy within the peak Aboriginal Controlled Community Health Organisation in Victoria, Australia. Smoking is acknowledged as being responsible for at least 20% of all deaths in Aboriginal communities in Australia, and many Aboriginal health workers smoke. Methods: The smoke-free workplace policy was developed using the iterative, discursive and experience-based methodology of Participatory Action Research, combined with the culturally embedded concept of ‘having a yarn’. Results: Staff members initially identified smoking as a topic to be avoided within workplace discussions. This was due, in part, to grief (everyone had suffered a smoking related bereavement). Further, there was anxiety that discussing smoking would result in culturally difficult conflict. The use of yarning opened up a safe space for discussion and debate,enabling development of a policy that was accepted across the organisation. Conclusions: Within Aboriginal organisations, it is not sufficient to focus on the outcomes of policy development. Rather, due attention must be paid to the process employed in development of policy, particularly when that policy is directly related to an emotionally and communally weighted topic such as smoking.

Policy entrepreneurship in the development of public sector strategy: the case of London health reform

The development of health policy is recognized as complex; however, there has been little development of the role of agency in this process. Kingdon developed the concept of policy entrepreneur (PE) within his ‘windows’ model. He argued inter-related ‘policy streams' must coincide for important issues to become addressed. The conjoining of these streams may be aided by a policy entrepreneur. We contribute by clarifying the role of the policy entrepreneur and highlighting the translational processes of key actors in creating and aligning policy windows. We analyse the work in London of Professor Sir Ara Darzi as a policy entrepreneur. An important aspect of Darzi's approach was to align a number of important institutional networks to conjoin related problems. Our findings highlight how a policy entrepreneur not only opens policy windows but also yokes together a network to make policy agendas happen. Our contribution reveals the role of clinical leadership in health reform.

Democratizing health : consumer groups in the policy process

This timely book examines the role of consumer organisations in the health policy process. In an age of shifting boundaries between state and civil society, consumer groups are potentially drivers of democratisation in the health domain. Their activities bring new dynamics to relations between service providers, the medical profession, government agencies, and other policy actors. This book is unique in comprehensively exploring the opportunities and dilemmas of this type of activism, including sometimes ambiguous partnerships between consumer groups and stakeholders such as the pharmaceutical industry. These themes are explored within an internationally comparative frameThis book examines the important role of consumer activism within health policy in different national contexts. In an age of shifting boundaries between state and civil society, consumer groups are potentially drivers of democratization in the health domain. The expert contributors explore how their activities bring new dynamics to relations between service providers, the medical profession, government agencies, and other policy actors. This book is unique in comprehensively analysing the opportunities and dilemmas of this type of activism, including ambiguous partnerships between consumer groups and stakeholders such as the pharmaceutical industry. These themes are explored within an internationally comparative framework, with case studies from various countries. work, with case studies from many countries.

Policy and practice impacts of applied research: a case study analysis of the New South Wales Health Promotion Demonstration Research Grants Scheme 2000-2006

Background
Intervention research provides important information regarding feasible and effective interventions for health policy makers, but few empirical studies have explored the mechanisms by which these studies influence policy and practice. This study provides an exploratory case series analysis of the policy, practice and other related impacts of the 15 research projects funded through the New South Wales Health Promotion Demonstration Research Grants Scheme during the period 2000 to 2006, and explored the factors mediating impacts.

Methods
Data collection included semi-structured interviews with the chief investigators (n = 17) and end-users (n = 29) of each of the 15 projects to explore if, how and under what circumstances the findings had been used, as well as bibliometric analysis and verification using documentary evidence. Data analysis involved thematic coding of interview data and triangulation with other data sources to produce case summaries of impacts for each project. Case summaries were then individually assessed against four impact criteria and discussed at a verification panel meeting where final group assessments of the impact of research projects were made and key influences of research impact identified.

Results
Funded projects had variable impacts on policy and practice. Project findings were used for agenda setting (raising awareness of issues), identifying areas and target groups for interventions, informing new policies, and supporting and justifying existing policies and programs across sectors. Reported factors influencing the use of findings were: i) nature of the intervention; ii) leadership and champions; iii) research quality; iv) effective partnerships; v) dissemination strategies used; and, vi) contextual factors.

Conclusions
The case series analysis provides new insights into how and under what circumstances intervention research is used to influence real world policy and practice. The findings highlight that intervention research projects can achieve the greatest policy and practice impacts if they address proximal needs of the policy context by engaging end-users from the inception of projects and utilizing existing policy networks and structures, and using a range of strategies to disseminate findings that go beond traditional peer review publications.