#CLAHRCYH in the #ReducingHealthInequalities #CLAHRC E-newsletter @CLAHRCP @ProfKEPickett

NIHR CLAHRC Community e-newsletter- Reducing Health Inequalities Issue 52 

Welcome to the community e-newsletter for the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) bringing you the latest news and interesting developments from across the thirteen collaborations and the health service research community. The NIHR CLAHRCs are funded by the NIHR and form part of the NIHR infrastructure. This newsletter looks at the work NIHR CLAHRCs are doing around Reducing Health Inequalities.

CLAHRC Yorkshire and Humber: The Divide

The Divide is a feature documentary film from director Katharine Round and Dartmouth Films, inspired by Professor Kate Pickett’s (NIHR CLAHRC YH Inequalities lead) research, with Professor Richard Wilkinson, on how income inequality creates health and social problems. The film brings the statistical analyses to life, telling the stories of 7 individuals trying to cope with the damage caused by inequality in in the UK and USA – where the top 0.1% own as much wealth as the bottom 90%.  The film shows how profoundly we are all affected by the gap between rich and poor. The Evening Standard described the film as ‘jaw dropping stuff’ and New Scientist ‘a fascinating social portrait’. As well as public screenings, the film has been shown to think tanks and charities to increase awareness of the research at a policy level. It’s also being used as a teaching tool in universities. The Divide is an example of the multiple ways we can tell the stories of research findings. Film, especially in this digital age, reaches different, and much larger, audiences than research papers and books.

Further information: The Divide: The Spirit Level Documentary

Kate Pickett’s research profile.

CLAHRC Yorkshire and Humber: Summary of Worsktream

A project to identify local authorities’ health and wellbeing priorities was conducted by the Public Healthand Inequalities theme of the NIHR CLAHRC YH. The research findings from a deep dive analysis and interviews across Yorkshire and Humber local authorities have highlighted priorities to support wider local authority staff and their partners around understanding health inequalities. A link to a presentation about the wider project can be accessed here.

Three workshops were delivered across Yorkshire and Humber by Dr Stephanie Prady, (the inequalities role in CLAHRC Yorkshire and Humber is now covered by Dr Sarwat Shah) with the aim of introducing health inequalities and considering the impact of local action on the wider determinants of health. A presentation on Inequalities and Intervention Research can be found here.

Workshops were delivered to 89 delegates to allow consideration of health inequalities and to gain a deeper understanding that collaboration across all sectors is required to target, impact and reduce health inequalities.


CLAHRC East Midlands:Centre launchedto reduce ethnic health inequality in East Midlands.

The Centre for Black and Minority Ethnic (BME) Health East Midlands has been launched by CLAHRC East Midlands. The Centre is working to reduce health inequality in the region by working with patients, the public, community and voluntary sectors, researchers, health and social care organisations, to:

  • inspire community-led research
  • develop and promote culturally sensitive resources
  • raise awareness about community engagement
  • encourage active research participation
  • collaborate with researchers to widen participation.

There are major health issues within all BME communities in the East Midlands, but crucially, there are significant disparities in health equality. There is a prevalence of certain illnesses within specific communities but there are also major concerns in relation to basic access to healthcare.
The Centre intends to focus its attention on addressing such inequalities. It will do so, first and foremost, by involving community members in a meaningful fashion, so that people’s voices and their opinions are not only heard but form the basis of solutions.
Visit the Twitter page to find out more.

CLAHRC East Midlands:Campaign raises diabetes awareness in Leicestershire ethnic minority communities.

CLAHRC East Midlands has launched a new drive to raise awareness of Type 2 diabetes in ethnic minority communities in Leicestershire.

A six-month programme of activities, including dancing sessions and healthy eating workshops, has started in a bid to help prevent people from developing the serious condition.
The campaign is being organised by the Centre for Black and Minority Ethnic Health East Midlands.

Dr. Natalie Darko is a Community Lead Researcher at the Centre and is leading the programme called Raising Awareness and prevention of Type 2 DIAbeTEs (RADIATE).
She said: “People from minority ethnic groups are at a disproportionate risk of Type 2 diabetes and experiencing associated complications. We are working to address this through the RADIATE project by increasing knowledge about the consequences of Type 2 diabetes through a six-month community engagement programme.”

The project builds on previous research exploring the experiences, knowledge and understanding of Type 2 diabetes and its prevention in minority ethnic communities. The 2014 study concluded that lack of motivation, poor understanding of diet content and parenting acted as barriers to leading healthier lifestyles. Click here to read more.

CLAHRC East Midlands:Screening programme reveals diabetes concerns in ethnic minority groups.

Almost three quarters of South Asian people screened for diabetes at a pilot programme held at community faith centres in Leicester were found to have a ‘high risk’ of developing the condition.
Results of a study from CLAHRC East Midlands have revealed that 72.4 per cent of the 202 people screened during four separate sessions across the city recorded a high diabetes risk score.

As part of the screening programme, all those identified as being at potential risk were offered a ‘walking away from diabetes’ workshop aimed at increasing exercise levels and raising awareness of the condition.

Professor Kamlesh Khunti Director of CLAHRC East Midlands, said: “It is important to identify those with undiagnosed diabetes and those at high risk of developing diabetes. We want to show them that it’s not too late to introduce small changes to their lives, which could make a big difference to their health.”

The study looked at the feasibility of carrying out regular screening and education sessions in community faith centres, targeting multi-ethnic populations. The results could now help inform the NHS National Diabetes Prevention Programme. Click here to read more.

CLAHRC East of England (EoE): Responding to the complex and multiple health inequalitiesexperienced by people with intellectual (learning) disabilities.

As a group, people with intellectual disabilities (IDs) are a) more likely than the general population to experience physical and/or mental ill-health but b) less likely to receive high quality assessment and treatment. Specialist community services, normally locality-based community teams, are attempting to address this issue but little is known about their work. As part of an on-going programme of mixed-methods research funded by the CLAHRC East of England, we have investigated one county-wide specialist community service. Findings have been tested through feedback and discussion at local and national levels.

Our findings indicate that: a) a clear vision is needed of the role and purpose of community services and their relationship with existing generic services (Clare et al., 2016); b) healthcare and social care are often inseparable meaning that services need to work closely with carers and social care providers; c) the complex interface between NHS health services, local authority commissioning and provision, and independent social care provision requires clarity about knowledge exchange and management (Farrington et al., 2015); and d) given the range and complexity of the needs of people with IDs, community services need to include practitioners with a range of expertise, able to work together flexibly to meet those needs.

Reducing health inequalities affecting people with ID is the responsibility of everyone. Our findings suggest that specialist services need to maintain strong partnerships with people with IDs, carers and independent social care providers, and primary and secondary health care services. This is difficult to achieve through service models that are entirely focussed on out-patient clinics. Rather, specialist ID services need to have a visible and readily accessible community presence.
For details of the publications and further information, please contact Isabel Clareichc2@medschl.cam.ac.uk

CLAHRC East of England (EoE): Are adults with Autism Spectrum Conditions at greater risk of feeling suicidal?

People with Autism Spectrum Conditions (ASC) often do not receive the support they require.  A recent study (Cassidy et al., 2014) reported that those with ASC might be at increased risk of suicidal behaviour.  Of 374 adults with Asperger Syndrome, 66% had experienced suicidal ideation (thoughts), 35% had made plans or attempts, and 31% had suffered with depression.  The risk of suicidal ideation was almost tenfold that found in the general population.  To determine whether people with ASC are also at increased risk of completing suicide, researchers funded by CLAHRC EoE are examining Coroner’s reports in three UK cities.  Preliminary analyses appear to confirm that people with ASC are over-represented in cases of completed suicide.  This research will inform relevant authorities (e.g. suicide prevention programmes, GPs, Department of Health) who have responsibilities for provision of services and may lead to new initiatives.  For instance, GPs could screen people with ASC for suicidal thoughts during appointments relating to mental health.  Such recommendations will need to wait until the project is completed, although even the 2014 study can serve as a wake-up call that without adequate services for adults with Asperger Syndrome, suicide may be a significant risk.
For more information, visit the website of CLAHRC East of England.
Link to Cassidy et al. (2014):
http://docs.autismresearchcentre.com/papers/2014_Cassidy_et_al_Suicidality_LancetPsychiatry.pdf

CLAHRC East of England (EoE): Reducing health inequalities in later life for people with Down’s Syndrome: supporting the complex pathways to new treatments.

People with Down’s syndrome (DS) are the most at risk group in the population for developing Alzheimer’s Disease (AD) with over 50% having dementia by their 50s. Earlier clinical research by us has informed Best Practice Guidance. The focus of research now is on understanding causation and on developing and testing treatments aimed at preventing dementia. We have used advanced MRI and PET neuroimaging to characterise age-related changes in brain amyloid binding and brain structure and function and have also investigated age-related changes in mitochondrial functioning. We are identifying early biomarkers of dementia in DS in the eye and by using EEG. This research programme asks a lot of participants and is critically dependant on the goodwill of people with DS and those who support them. Their inclusion and on-going engagement requires new approaches, as does disseminating the findings. Funding from CLAHRC East of England to its Enduring Disabilities &/or Disadvantage Theme, has provided support to enhance the work of the DS Research Group. This research programme, in partnership with the Down’s Syndrome Association, was previously funded by the MRC and DSA and is now supported by grants from AR-UK and the US NIH.  CLAHRC EoE initiated activities have included open days to celebrate World Down’s Syndrome Day, workshops about research for people with DS and their supporters, regular newsletters, and a survey about attitudes to research. Most recently, the film ‘Together’ premiered at the Cambridge Arts Picturehouse as part of Dementia Week, illustrated how researchers, and participants with DS and their supporters, must work together to reduce this major health inequality.

Full details of the research programme, newsletters and publications can be found here.

CLAHRC Greater Manchester: Setting the agenda for end-of-life research in Greater Manchester.

The NIHR CLAHRC Greater Manchester has been working with local carers and healthcare professionals to shape future research in end-of-life care. Since the end of 2015, the team has worked closely with patients, carers and healthcare professionals to find out what they think the important issues are when thinking about care at the end-of-life.

Ten key priority areas had already been identified through national work by the Palliative and end of life care Priority Setting Partnership (PeolcPSP). Through early discovery discussions, the CLAHRC team identified six topics within which they had the knowledge and skills to deliver end-of-life research in Greater Manchester, with one topic being “equal access for all”.

For more information, please read the easy-to-read summary or full project report.

CLAHRC Greater Manchester: Reducing inequalities in access to primary care.

In June 2014, the twelve Greater Manchester clinical commissioning groups agreed to the Healthier Together standard that by the end of 2015 “everyone in Greater Manchester who needs medical help will have same-day access to primary care services, supported by diagnostic tests, seven days a week.” This is a key early implementation priority of the Greater Manchester health and social care devolution programme.

Building on its previous evaluation of the primary care demonstrator communities, the NIHR CLAHRC Greater Manchester is conducting an independent academic evaluation of the roll-out of 7 day access to primary care across Greater Manchester. This will ensure that the work is accompanied by a robust evaluation to explore and promote an understanding the associated processes, activities, outcomes and impacts. Read more here.

CLAHRC North Thames: Addressing health inequalities.

One of CLAHRC North Thames’ stated objectives is to tackle health and health care inequalities, which can manifest themselves in poorer life chances, poorer health outcomes and unequal access to services for sections of the population we serve.

Examples of work in this area include our research investigating multimorbidity and how having two or more chronic diseases concurrently plays a role in contributing to the well-established “inequalitiesgap” in survival. With the support of partners in the insurance industry CLAHRC North Thames researchers are estimating the impact of living with more than one health condition on life expectancy, and how multimorbidity plays out across different socio-economic groups.

Our Nurture Early for Optimal Nutrition (NEON) project works with the Bangladeshi population of East London to promote healthy nutrition in their children, who have a much higher risk of poor nutrition and obesity than the average child in the UK.  Working with trained community facilitators, the project team has investigated how a model from South Asia which has significantly improved maternal and neonatal survival rates – introducing female health workers into local women’s groups – can “travel” to a UK setting.

Our memory project is working with Black African and Caribbean communities to tackle the disparity in access to support among their elders who develop dementia. This population develop the condition more often and earlier than their white counterparts but access services later and usually in crisis. Following focus groups and interviews with Black African and Caribbean elders and their carers, the team have developed and are testing a tailored evidence-based intervention to encourage earlier help seeking for dementia. They will then evaluate the intervention’s effect on attitudes and intentions to seek help for memory problems, which can be an early sign of dementia.

CLAHRC North West Coast: CLAHRC NWC ensures its research reduces health inequalities by developing toolkit.

NIHR CLAHRC North West Coast developed the Health Inequalities Assessment Toolkit (HIAT) to help ensure that all of its activities have potential to contribute to reducing health inequalities. The CLAHRC NWC Steering Board requires all research proposals seeking support to include a Health InequalitiesAssessment Report, which can be found in the Resources drop-down menu, on the website.http://www.hiat.org.uk/

The HIAT includes an explanation of why we are focusing on the reduction of health inequalities and its drivers, and guidance on its use. There are also links to resources that may help those using HIAT to assess whether the work they wish to undertake is as sensitive as it can be to the drivers of healthinequalities and that it maximises the impact it can have on reducing these.

NIHR CLAHRC NWC staff and partners collaboratively developed the HIAT in a series of workshops in 2014-15. It is revised regularly to ensure it is sensitive to the experience of users.
At every stage of the toolkit the user is guided to question whether appropriate and adequate public involvement is in place.

Regular social media usage to promote the website as a free resource to the wider research community is made.

CLAHRC North West Coast: From Community resilience to Neighbourhood resilience – a systems approach to addressing the social determinants of health inequalities.

The Public Health (PH) theme of CLAHRC North West Coast is delivering a programme of action research that aims to develop greater resilience in 10 relatively disadvantaged areas and evaluate its impact on the social determinants of health and on health inequalities.  The Neighbourhood Resilience programme is underpinned by a systems approach which sees resilience as emerging from the interactions between people who live in an area and the organisations that operate there – private, public or voluntary.  Working with local authority partners the CLAHRC NWC PH theme has developed a resilience framework comprising four components – social cohesion, economic security, the quality of the living environment and community involvement in governance.  In each ‘Neighbourhood for Learning’, which range from Cumbria to Cheshire West and Chester, a local multi-sectoral group is working with residents to identify and implement evidence based initiatives to improve one or more of these aspects of resilience.  In one Neighbourhood, for example, the focus is on improving the quality of privately rented accommodation; in another the focus is on improving social cohesion.  A range of resources is being provided to support the work in the Neighbourhoods including a series of rapid evidence reviews (focused for example, on approaches to reduce debt/increase economic security and on selective licensing of private landlords).

A Community Research and Engagement Network (COREN) is being established to support residents in the 10 Neighbourhoods to get involved in the programme.  An early COREN engagement initiative has involved running a Digital Photography competition in seven of the Neighbourhoods, encouraging residents to capture images of events, sites, people, places or things they like (and dislike) in their community.  Winning photographs will be published in a Community Calendar specific to each Neighbourhood which can be used to record key local events including events linked to the Neighbourhood Resilience programme.

CLAHRC North West London: Addressing Health Inequalities.

The CLAHRC Northwest London project currently in progress at Northwick Park Hospital is an educational programme for those who care for patients with symptoms of alcoholism and recovery therefrom. Too often patients being treated for other physical maladies are released with limited understanding and support. During the soft launch of the improvement project alcohol dependent patients were referred to an alcohol nurse specialist, who was better equipped to support transition into a detox programme.

Protocols follow existing NICE guidelines and utilise existing treatment and support programmes, but provide liaising and cross referenced services between them that can make all the difference to patient success and wellbeing. For a variety of reasons, women are less likely to seek treatment for alcohol dependency, and while not all of these are addressed in this programme, accessibility, and thus the potential for improvement in their level of care, is increased. Read more here.

CLAHRC Oxford: Improving the management of depression for patients at the end of life.

Many people who have a physical illness also have a mental illness; this combination is called medical-psychiatric multimorbidity. Multimorbidity is important because it leads to poorer quality of life and worse outcomes for patients as well as greatly increasing the cost of medical care.
In patients with poor prognosis cancers, like lung cancer, depression and anxiety are both common, often go untreated, and can blight the time these people have left to live.

However, the quality of life of these patients can be significantly improved with a new, integrated approach to care, called ‘Depression Care for People with Cancer’ (DCPC), as revealed by NIHR CLAHRC Oxford part-funded research published in The Lancet.

In the study 142 lung cancer patients who received an integrated care programme – addressing both their physical and mental health needs – had a significantly greater improvement in depression symptoms compared with those receiving existing treatments, thereby enhancing their quality of life.

The treatment is delivered by a team of specialist cancer nurses and supervising psychiatrists, who work in collaboration with the patient’s oncology team and GP. Most sessions are delivered face-to-face. More information here.

CLAHRC Oxford: CLAHRC Oxford: Enhanced Care Home Outcomes (ECHO).

Improving care for people with dementia is a key priority in Oxfordshire’s Joint Health and Wellbeing Strategy 2012-16.

ECHO integrates the established care home support service with a new mental health in-reach service. This aims to improve the quality of care and health outcomes for people with dementia, and empower family and paid carers to be better supported in delivering their caring role.
The ECHO model of care combines new ways of working which have been shown to be effective in research trials and will evaluate their effectiveness in the ‘real world’ routine NHS setting.
The evaluation will cover a number of areas, including:

  • health and well-being of people with dementia
  • family/carer satisfaction
  • staffs’ perception of the benefits and difficulties of the new model
  • service quality
  • rates of recognition of dementia and people presenting for early diagnosis
  • referrals to community services within Oxford Health NHS FT
  • crisis admissions to acute mental health wards and acute hospital wards
  • length of hospital stay and
  • the economic impact of this model of care.

The data is currently being analysed and the service is continuing to run. Further developments will be responsive to the findings of the study which are due in autumn 2016.

The outcomes will be analysed and reported to commissioners, service users and through CLAHRC Oxford and the Academic Health Science Network Oxford. Read more here.

CLAHRC Oxford: Lower Costs and Improved Outcomes for Young People with Psychosis.

Psychosis is a common and disabling disorder estimated to cost the UK economy £11.8 billion per year. Randomised controlled trials of ‘Early Intervention in Psychosis’ (EIP) services for those aged 16-35 have shown that specialist community treatment teams can reduce inpatient bed use, improve clinical outcomes, and reduce costs. Yet, despite this evidence, many EIP services have either been lost, or strayed from the basis of the original model.

In a collaborative project with Jansen Healthcare, led by Professor Belinda Lennox, the NIHR CLAHRC Oxford examined whether using EIP services in NHS practice, outside of an RCT setting, would also result in improved outcomes and cost-savings.

The work showed clear evidence for savings of £5,200 per patient in EIP per year. These patients also had significantly fewer mental health bed days, reduced attendances at A&E, and improved occupational outcomes.

Working with the Oxford AHSN Early Intervention in Mental Health Network, CLAHRC Oxford fed this evidence back to clinicians, service managers, commissioners and Trusts, leading to plans for improving EIP services (including reinstatement in one Trust that had dismantled them) and paving the way for the AHSN to install this innovative mental health service for young people with psychosis more widely. More information here

CLAHRC South West Peninsula: What happens when ADHD children grow into ADHD young adults?

Attention deficit hyperactivity disorder (ADHD) is a condition which affects children and adolescents – and with growing evidence that it can continue into adulthood, it is now recognised as a long term condition. Services for children with ADHD are well established but what happens when they become young adults with ADHD and are too old to be under the care of children’s services? CATCh-us is a project supported by NIHR PenCLAHRC, which is examining this gap in provision. Find out more here.

CLAHRC South West Peninsula: Support for prisoners with mental health problems when released from prison

A higher proportion of prisoners have mental health problems than in any other group in society. The moments just before and on release are crucial for prisoners with mental health issues, because they are at their most vulnerable in terms of lack of support, difficulty with family relationships, employment, long-term illness, self-harm and re-offending. Engager is a project supported by NIHR PenCLAHRC. This two-phase project is investigating the support that prisoners with mental health problems receive on release. Phase one encompasses therapy, medication, housing, training and employment and the availability of continued care. It will also build the evaluation mechanism for phase two, which is a randomised control trial to evaluate the various interventions. Find out more here.

CLAHRC South West Peninsula: Transforming disadvantaged neighbourhoods.

Connecting Communities (C2) is a project supported by NIHR PenCLAHRC that aims to transform disadvantaged neighbourhoods, reduce health and social inequalities and create conditions conducive to healthy behaviours. The project is underpinned by 10 years of case study research and has been embraced by Clinical Commissioning Groups across the country. Commissioned by Plymouth City Council, C2 forms part of the Plymouth Fairness Commission. Results so far are impressive – involvement in the regeneration of housing stock in one area led to an increase of 100 per cent educational attainment of KS2 SATS for boys, a 40 per cent decrease in child protection issues, a 71 per cent increase in employment and a 52 per cent reduction in overall crime. Find out more here.

CLAHRC South West Peninsula:  Web-based coaching and the exercise referral scheme.

Would people with chronic physical and mental health problems benefit from web-based support as they take part in the GP exercise referral scheme (ERS)? A team supported by NIHR PenCLAHRC are investigating if this method, called e-coachER, could increase uptake and maintain health benefits. Working with patients across the South West, the West Midlands and Glasgow, the study is investigating whether the addition of e-coachER leads to more patients taking up ERS and whether they will persevere for the full programme. An analysis of cost-effectiveness will also be conducted. Find out more here.

CLAHRC West: Evaluating telephone outreach for NHS Health Checks to improve uptake in more deprived communities.

Cardiovascular disease (CVD) is a major cause of early death, ill-health and disability in the UK. The burden of this type of disease falls more heavily on people living in deprived circumstances and people from black and minority ethnic (BME) communities.

Bristol Public Health has developed a telephone outreach initiative to encourage uptake of NHS HealthChecks among communities where risk of cardiovascular disease is higher, and where patients are less likely to respond to an invitation to attend. The Ethnography team at NIHR CLAHRC West is undertaking a qualitative study to explore the effectiveness of telephone outreach for NHS HealthChecks. They will do this through understanding the experiences, attitudes and views of patients, the community workers delivering the service and the GP practices hosting them.

Find out more on the CLARHC West website

CLAHRC West: Understanding the needs of Somali families affected by autism in Bristol.

There is no word for ‘autism’ in the Somali language, but research suggests that children whose parents have migrated from Somalia to western countries, including the UK, may be at greater risk of developing autism than children from other groups. The needs of these families aren’t well understood, and local health services may not be supporting them in the best way.

NIHR-funded researchers at the University of Bristol teamed up with local community group Autism Independence, to work closely with people from the Somali community on a research project looking at the experiences of these families. It aimed to find out about the experiences of Somali families, living in Bristol, who have a child with autism, to understand how autism is understood in their community, and how health and social care services can be best delivered to support them.

Read more on the CLAHRC West website.

CLAHRC West Midlands: Does lay support for pregnant women improve health of mothers (and children) with identified social risk factors?

A Pregnancy Outreach worker (POW) service for first time mothers with identified social risk factors (such as teen parent, drug/alcohol misuse and/or smoking) has been evaluated by a randomised trial. Researchers from CLAHRC West Midlands Theme 1 (Maternity and Child Health) hypothesised that this service might improve engagement with maternity services (and thereby mother and baby birth outcomes).

Outcomes included engagement with antenatal care, measured by number of antenatal visits attended and maternal postnatal depression (measured using the Edinburgh Postnatal Depression Scale, EPDS). First time mothers over the age of 16, who were less than 28 weeks pregnant and who were found to have social risk factors were recruited from three maternity trusts in Birmingham (16 community midwifery teams) and were randomly allocated to standard care or the addition of referral to the POW service. In the postnatal period (the six weeks following childbirth), POWs also provided advice about breastfeeding and how to care for babies.

The study found no difference in the number of antenatal attendances in each arm. For women with two or more social risk factors, mean EPDS was significantly improved with the addition of the POW service, but there was no difference for the group as a whole. The authors concluded that additional lay support for first-time mothers with identified social risk factors is likely to reduce postnatal depression in women with two or more social risk factors, but does not appear to have an effect on engagement with maternity services. For more information, visit www.clahrc-wm@nihr.ac.uk.

Reference: Kenyon SJolly K, Hemming K, et al. Lay support for pregnant women with social risk: a randomised controlled trial. BMJ Open. 2016.6(3):e009203. [http://goo.gl/HIULYf]

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