Reflection On The Ppph And Mph Course

My life before the MPH

I have been at the University of Liverpool for the past sixteen years, starting as a BSc Microbiology student, then with my PhD on Sexually Transmitted Diseases (STD), and finally working as a research associate on several clinical trials in Malawi, Africa and in Liverpool.

I am currently in Primary Care and have just undertaken a feasibility intervention study by NHS Health trainers. Working on this study promoted me to reflect on my own work experience and identify any gaps in my knowledge, which resulted in me applying as a part-time student on the MPH course. Because I only had a contract to the summer of 2010, I was only able to register for some of the course, as a PGCert student. As a result, I have not done the complete MPH, but only the five modules outlined below.

First Semester

Health & Society

Quantitative Research Methods I

Second Semester

An intro to Qualitative Research

Health Economics

Policy & Politics in Public Health

I choose these particular modules in relation to the gaps in my knowledge, except in the case of QRM I, which I saw as a refresher course. I would describe myself as a quantitative researcher, who had very little qualitative experience. Although on trials in Malawi and Liverpool, members of the team undertook some qualitative research that I managed on a day-to-day basis. Therefore, I had some understanding of the practicalities in undertaking this type of research but not in the theoretical background, methodology and analysis. Therefore, it was very important for me to do the qualitative parts of the course, as within my current role in Primary Care I will be more hands on with qualitative research.

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As part of the NHS Health trainer feasibility study, the team looked at the health economics and its implications, in collaboration with colleagues at the University of East Anglia; therefore, it was valuable for me to do this module. In addition, as part of this study I looked at the history and development of the NHS Health trainer policy by the government so I did the PPPH module to help me to put this research into context.

So what would I say was my Public Health experience? Well to start with, I think I have worked on research topics of public health importance throughout my time at the University of Liverpool but I may not have formally seen it as the case. I can see this when I reflect on my previous experiences, starting with my PhD, where I studied STD’s in Nigeria, as part of my time there we undertook some promotion of condoms within the local rural community. Also in Malawi, one project was on reproductive health issues and again as part of a team, we promoted the safe motherhood programme. Moreover, in the last clinical trial in Malawi, the team was testing an efficacy of a Rotavirus vaccine against diarrhoeal disease, which because of that research has become part of the recommended World Health Organisation vaccine schedule for babies. For that reason, although there has clearly been a public health agenda within my work but I did not see it, it was very important for me to undertake this course. In order to supplement my previous knowledge within the theoretical basis of Public Health and learn some new practical ways to help when I am conducting future research.

Public Health Policy Module

On of my reason for undertaking, this module was to understand how people create public health policy, the impact of politics has in that, and finally how the implementation of the policy comes into being for ordinary people. As a result, I came into the module with the aims of understanding the workings of the process of policy formation. Overall, I have found the topics in the module very interesting and motivating.

As stated earlier, as part of my job I looked at the history and development of the NHS Health trainer policy with their role in helping people to have a healthy life-style. But when I looked at the document trial for this policy I was shocked to see that the role of “NHS Health Trainer” just seemed to appear in the 2004 white paper “Choosing Health: Making healthy choices easier” (1), without any supporting research evidence, or even case studies showing how this worked in a UK setting in that white paper. Nevertheless, it was still enshrined into government policy, which has resulted in people, all over the country, employed to be NHS Health trainers. Therefore, I hoped that the PPPH module would give me some insight into how this happened.

Consequently, in that context I found the readings and lectures for week two, on “Public Health Policy – Theoretical background to Policy Formulation and Development in the UK context” very enlightening. In the lecture on “What is policy”, it was interesting that hear that a definition of health policy described as anything the government does, making decisions and implementing actions that allocates a value and how they translate their political vision to deliver ‘outcomes’ – desired changes in the real world. Also outlined were the various different models, which brought home to me the complexity in the development of policy, and the importance that policy should be evidence based.

When I related this lecture back to my own experience with NHS Health trainer policy, I could see that how it derived its origin, from the political idea of “choice” in influencing public behaviour to improve health and wellbeing. This idea was supported by one of the pre-lecture readings, where Mulgan (2010) stated that we know people care about their health and the link of illness with their everyday choices, but they find it hard to adopt healthier behaviours, therefore how does the government help people to make to help people make the right choices for them (2). Therefore, it seems that the NHS Health trainer policy appears to be political intervention, designed to mop up gaps and strengthen other areas driven by the idea of having a healthy choice.

In addition, I saw how the government has not adopted the ‘nudge’ approach to this policy, which soft and non-intrusive and preserves an individual freedom of choice in that you do not remove the unhealthy choice altogether. But, used the ‘stewardship’ model, which sees government as having an active, positive role, in that it promotes health by providing information and advice, with NHS Health trainer programme to help people overcome unhealthy behaviours (3).

I can see the NHS Health Trainers policy ticking all the right boxes, such as community involvement, not top down, and client focused but the evidence base for this policy is weak, with the NHS Health Trainers Initiative website devoted to guidance notes and health trainer only. Up till now, recent publications on the main outcomes of the national and local reports for NHS Health Trainers Initiative of Health trainers have focussed on recruitment and training of Health trainers and analysis of service delivery but not client outcomes (4;5). Crucially, no studies have examined the effectiveness of Health Trainers at promoting heart-healthy lifestyles, with our work being only a feasibility study, which we have not yet published. This seemed to me to be back to front way of doing it. However, in reflection the lectures, in week 3, on Influencing Public Health Policy were interesting as, I am looking at to how my own work on Health trainers could have an impact on the current policy. These lectures brought home again, how complex the world of Policy and Politics is within Public Health. I can draw on the experiences of the speakers, in week 3, in their roles as advocates for policy change from inside and outside the system. It is clear that policy change is not linear but follows a circular pattern; within this circle therefore, as a researcher, I can contribute by increasing the knowledge base for this policy.

I found researching for the debate, I was part of the team looking at the argument for the motion on the Marmot Report, gave me a greater insight into the difficulties of addressing the health problems in our society. One of the key points our team made, was that the way our current public health policy looks at tackling the symptoms rather than the root causes of health inequalities. Moreover, from my reading around in preparation for this work, the question arose as to how we do not address the real issues, which at the root of it is the political ideology of Neo-liberalism. Navarro (2007) pointed out that real problem is not absolute resources but the degree one has control over one’s own life in every society (6). In this article, Navarro gave an example of this quoted below.

“An unskilled, unemployed, young black person living in the ghetto area of Baltimore has more resources (he or she is likely to have a car, a mobile phone, a TV, and more square feet per household and more kitchen equipment) than a middle-class professional in Ghana, Africa. If the whole world were just a single society, the Baltimore youth would be middle class and the Ghana professional would be poor. And yet, the first has a much shorter life expectancy (45 years) than the second (62 years). How can that be, when the first has more resources than the second? (6)”

This created a powerful image, which brought home that message to me about how the inequalities affect our society. There has been a focus on the phenomenon of “lifestyle drift,” whereby governments start with a commitment to dealing with the wider social determinants of health but end up instigating narrow lifestyle interventions on individual behaviours, even where action at a governmental level may offer the greater chance of success, this can be seen in the NHS Health trainer policy.

Even though I had to argue for the impossibility in implementing the recommendations of Marmot, I strongly believe that when making changes we need to be part of a collective membership where we take decisions not just in the interest of an individual but also for the everyone as a whole. On the other hand, on a note of pessimism I was shocked as to how successive governments failure to act on the health inequalities reports prior to Marmot, such as the Black Report (1980), Acheson Report (1998) and Wanless Report (2004). Consequently, we need to understand the political determinants of health and act upon them, even if it seems risky and painful to implement the changes needed.

Has my perspective changed?

As I have only done some modules of the MPH, I will reflect on the impact of these. However as it now seems I will be, continuing next year with the remaining modules, I expect these views to change in the coming year as do the other modules. The question asks what affect this course has had my own understanding of and my future approach to public health. Well, as explained earlier, before undertaking this course I could see how my work has had elements of dealing with public health issues at the coalface, as it were in Africa and latterly in the UK, but I seemed unaware of them at the time. I think that is clearly one of the important changes to how I view public health from now on. Over the course of all the modules, I have seen very much the interconnectivity of all the disciplines in both developing the knowledge base for and creating public health policy itself.

As I have trained as a quantitative scientist, very much grounded in the positivist view of society, I found the two qualitative modules very enlightening. One of the results from my study on the NHS Health trainer was how little people engaged with the programme even though we recruited people into the study because of they had risk factors for cardiovascular disease, such as obesity. A group of people who at the outset we thought would be an ideal group for the intervention. However, when looking at the pattern of behaviour in the quantitative data at each stage of the study, a higher than normal proportion of this group did not take up our offer and engage with our Health trainers. Fortunately, in parallel to this research the team conducted qualitative interviews with some of the participants. Therefore, we were able to get some information on why we saw this affect, with the view coming out that some people were hoping that the LHTs would find a nutritional ‘magic bullet’ but when faced with the reality that the programme only involved motivational support they disengaged. Therefore, as a specific example of a change in my practice in the future, I see the need to incorporate a mixed paradigm approach, quantitative and qualitative, to get the whole research picture. Therefore, in undertaking the two qualitative modules I know feel I have a good understanding of the theory and practice to start adopting this as an effective approach to my research.