NIHR CLAHRC e-newsletter - Reducing Health Inequalities

Generic Health Relevance
Published Date: 29 Mar 2018

Welcome to the community e-newsletter for the NIHR CLAHRCs, bringing you news from across the thirteen collaborations and the health services research community. This newsletter looks at the work that the NIHR CLAHRCs are doing around Reducing Health Inequalities.

CLAHRC Greater Manchester:

CLAHRC Greater Manchester: Improving the physical health of people with severe and enduring mental illness (SMI) in Greater Manchester

Compared to the general population, people with SMI have much poorer physical health, a higher risk of cardiovascular disease and diabetes, and a significantly reduced life expectancy. To improve the physical health of people with SMI we developed a new model of working. The new model involves a number of different facets, the most notable being the introduction of a Community Physical Health Coordinator (CPHC) within Community Mental Health Teams (CMHTs). The CPHC’s role is to coordinate the physical health management of people under the care of the CMHT. They do this with GPs via multi-disciplinary team (MDT) meetings. This model has been picked up by the British Medical Association and it was included as a case study in their national report on physical health and SMI in 2014.

The initial evaluation report detailing the model components and the work with one CMHT is available here. This was followed by a second stage evaluation, which presents the evaluation findings for the roll out of the model across all CMHTs (six in total) within a local mental health trust.

For more information, please contact Programme Manager, Michael Spence.
Understanding the impact of pre-existing dementia on access to stroke rehabilitation

People with pre-existing dementia have poorer functional outcomes after stroke than those without. It is unclear, however, whether these outcomes are linked to difficulties accessing rehabilitation or care received in the hospital phase. This PhD study, being undertaken as part of CLAHRC GM, aims to (a) explore current practice and experience of professionals from six teams working with people with pre-existing dementia/cognitive impairment in stroke settings, (b) examine whether pre-existing dementia/cognitive impairment affects stroke-specific rehabilitation care processes, and (c) explore patient experience of rehabilitation with dementia/cognitive impairment.  
For more information please contact Verity Longley.


CLAHRC North Thames:

CLAHRC North Thames tackles inequality through community engagement, collaboration and mobilisation

Research conducted within the CLAHRC North Thames’child and adolescent health theme - led by Professors Angela Harden, and Monica Lakhanpaul- has developed innovative and creative solutions to address health inequalities among children, young people and familiesliving in some of the most deprived areas of East London. There are substantial inequalities in health and wellbeing outcomes in the Capital andthere are additional challenges for children and young people living with or at risk of developing chronic conditions. Our applied research projects on diabetes, asthma and nutrition have all used methods that facilitate partnership working with families, children, young people and the wider community to co-develop solutions to improve health outcomes.

Our diabetes researchers have trained and supported a group of young people living with diabetes as Young Commissioners to work together with Bart’s Health NHS Trust and Newham CCG to co-design services and care pathways that are more appropriate to their needs. The project has been highlighted as an exemplar of collaborating with young people and features in a How to Guide for commissioners and providers who want to support person-centred commissioning.

To reduce hospital admissions amongst children and young people with asthma, the research team have developed an online asthma control assessment tool, a board game, and a community youth theatre production to raise awareness and mobilise support amongstpeers and teachers in schools. Children and young people have been involved in the design of all of these approaches to ensure relevance an increase their potential effectiveness for improving outcomes.

Finally, the Nurture Early for Optimal Nutrition (NEON) team have mobilised a community to support healthy nutrition in children of Bangladeshi origin. The team have adopted and tested the Participatory Learning and Action (PLA) cycle - an intervention proven to prevent mother and child deaths in rural settings in resource poor countries – within Tower Hamlets. Community facilitators are working with families and health professionals to identify and prioritise issues around nutrition and feeding practices, and then develop solutions through facilitated group discussions.

Studies across this theme have successfully tackled health inequalities in partnership with local communities at the early stages of the life course to prevent further complications in adulthood.

For more information contact: Diabetes: Dr Darren Sharpe;  Asthma: Dr Gioia Mosler;  Nutrition: Professor Monica Lakhanpaul


CLAHRC East of England:

The CLAHRC EOE Prison Programme 

For further information please contact:
Building on the success of the two previous studies, and at the request of key stakeholders involved, the third of the prison programme’s interlinked projects focuses on specific care pathways for prisoners living with dementia. Currently in progress, this study is examining and charting current and alternative care and support pathways – from reception to release – for prisoners with dementia.
The studies found that care and support provision for older prisoners was patchy across the country, and that there were no published evaluations of interventions for this group of prisoners. Prisoners living with dementia are a particularly vulnerable group, but it was found that it was possible to apply the community-developed Dementia Friendly Community approach in this environment with some positive results.
The first study included a global literature review and a review of policy and practice in England & Wales concerning care and support for older prisoners with complex care needs. In partnership with the Alzheimer’s Society, the second study implemented and evaluated the government endorsed Dementia Friendly Community approach in two diverse prisons in the East of England. This involved delivering dementia friends awareness sessions to staff and prisoners, as well as senior prisons staff working with Alzheimer’s Society representatives.
The CLAHRC EoE prison programme comprises three interlinked projects exploring the care and support of older prisoners, with specific focus on prisoners living with dementia. Older prisoners are the fastest growing age group being imprisoned, with health and social care needs that are greater and costlier than their younger counterparts – but, research has been scarce.


CLAHRC North West Coast:

CLAHRC NWC: Health Inequalities Assessment Toolkit (HIAT)

The HIAT ( is a free online resource that has been developed by CLAHRC NWC for researchers to clarify what aspects of health inequalities and socio-economic drivers are relevant to the topic to be addressed in their proposed work. It is a valuable resource including worked examples of applying the HIAT and questions to help researchers clarify the pathways linking activity to a reduction in socio-economic inequalities in health.

CLAHRC NWC: Published research in relation to reducing health inequalities

Barr Ben, et al . Investigating the impact of the English health inequalities strategy: time trend analysisBMJ 2017; 358 :j3310

Higgerson J, et al. Impact of free access to leisure facilities and community outreach on inequalities in physical activity: a quasi-experimental study J Epidemiol Community Health 2018;0:1–7.


CLAHRC NWC:  Pathways to Inequalities in Child Mental Health (in progress)

Reducing inequalities in mental health outcomes is a public health priority in the UK, and there is increasing recognition that the early years of a child’s life are critical periods during which inequalities can develop. With this in mind, this project aims to explore the effect of socioeconomic status on early years’ trajectories in child mental health and development outcomes, in the Wirral Child Health and Development Study and Millennium Cohort Study.

CLAHRC NWC: Better Care Now – a Partner Priority Programme (PPP) initiative between CLAHRC NWC and Blackpool Teaching Hospitals NHS Foundation Trust (in progress)

The main aims of the evaluation are to explore the reasons for readmission into hospital and look at alternative ways to improve safeguarding, decrease social isolation, improve health and wellbeing, reduce health inequalities and enable independence of the older person.
The evaluation will be informed by a systematic review of literature and the use of natural experimental techniques as well as utilisation of qualitative and quantitative data. In addition the findings will be measured against evidence based practice. Our focus group will consist of patients who have accessed a period of rehabilitation following admission to an acute bed based service. Data will be gathered using newly devised informatics tool to inform reasons for readmission and also identify successful discharge versus the need for readmission. In addition qualitative data will be gained from patients, carers and public advisors to inform the evaluation. The outcomes of the evaluation will be used to inform change in regards to discharge planning and clinical decision making to reduce the risk of readmission for patients who are discharged from Clifton Hospital.


CLAHRC North West London: 

Predictors of outcomes for patients with common mental health disorders receiving psychological therapies in community settings: a systematic review.

Amati F, Banks C, Greenfield G, Green J.


Psychological therapies are increasingly delivered in community care settings. In existing literature, patient, disorder and service variables are known to have a significant impact on the recovery outcomes for patients undergoing psychological treatment in secondary care. The aim of this review is to establish which predictors have a significant impact on recovery from common mental health disorders in community settings.

A systematic review of the literature was conducted according to PRISMA guidelines to identify variables with a predictive power on psychological therapy outcomes. We searched databases using key words and MeSH terms and a strict scoring system and bias check were used. A total of 486 unique references were identified from the search. Overall, 19 papers met the inclusion criteria. These reported on a total of 34 778 patients from five countries in various community care settings. Predictive factors identified and found to be significant were initial severity and comorbid depression (11/19 studies), which negatively impacted outcome in all studies identified key predictors for recovery in a community settings from five countries.

The evidence currently available for this setting is limited, so this review serves as a starting point to highlight key factors that warrant further investigation. To read the full publication click here.



Connecting Communities

The Connecting Communities (C2) project seeks to transform our most disadvantaged neighbourhoods by reducing health and social inequalities and creating the conditions for healthful behaviours to emerge. Its delivery is achieved through a series of processes which lead to the formation of a resident–led neighbourhood partnership, from which new ways of community working and behaving are realised.

Various transformative workshops have been established within communities as a direct result of C2 engagement, one of which was awarded the Queen’s Award for Voluntary Service. Plymouth Council have also commissioned C2 as part of the Plymouth Fairness Commission to support new ways of working with neighbourhoods in areas of high disadvantage.  For more information visit the project page.

Developing effective, non-stigmatising responses to mental distress in low-income communities: The DE-STRESS Project

Within low-income communities the use of antidepressant medication is relatively high. Current strategies tend to frame mental distress as an individual psychological problem, rather than addressing the factors that are often the root causes of suffering. The DE-STRESS project is examining how beliefs surrounding individual responsibility and welfare entitlements influence the medicalisation of mental distress caused by material deprivation and social disadvantage. Read more here.

Chronic viral hepatitis in ethnic minorities - strategies to prevent the predicted increase in mortality: The HepFree Project

The prevalence of viral hepatitis is at least ten times greater in immigrants than in the indigenous community, and there is abundant data that the mortality and morbidity in ethnic minorities is growing rapidly. The Advisory Group on Hepatitis and The National Screening Committee have considered screening immigrants for chronic viral hepatitis, but there is no data on whether this is feasible and/or clinically cost effective. PenCLAHRC’s operational research team, PenCHORD, are part of the HepFree project, which aims to determine whether screening immigrants in primary care is achievable, acceptable to the communities at risk, and practical. For more information visit the project page.


CLAHRC Wessex: 

Inequalities and developing a measure of collective efficacy 

Researchers working around the theme of engagement with self-directed support  have been working on  a project to  develop a collective measure of network support which can be used in practice and for further applied research.

Maximising and connecting to the benefits that can be gathered from support which  originates in the collective efforts of the people who they come into contact with is one way of addressing inequalities in self-care support initiatives.

With regards to self-care support for long term management collective efficacy can be  defined as - the shared views capacity and effort aimed at performing maintaining or changing practices and behaviour.

Our programme of research and implementation around collective efficacy includes:

  • A review of the notion applied to self-management support
  • The design development and testing of a measure of  collective efficacy
  • Dissemination and use in research and in practice through pursing adoption a

The first two of these projects  are near completion and awaiting publication and the third represents our next project.

In terms of addressing inequalities collective efficacy represents the wider  network and community capacity to identify and measure sources of support. Just as social capital plays a positive role in mitigating income inequality being able to measure the collective efficacy that people with a long term condition have access  to  has potential for  identifying  and ameliorating inequalities in  people’s capacity to access, mobilise and  use of resources  which help with everyday health and well-being behaviour and practices.
Further information can be found here:




Creating a stigma-free environment for drug dependent female street sex workers

CLAHRC West is looking at the feasibility of a novel complex intervention to reduce illicit drug use in female drug dependent street sex workers (SSWs). It involves running drug treatment groups for SSW only, provided by female staff in an SSW only setting. Female staff from NHS trauma services will screen, diagnose and treat participants for post-traumatic stress disorder with eye movement desensitisation and reprocessing therapy.

This new approach aims to create a stigma-free environment for street sex workers to be able to discuss their work during drug treatment groups, as well as addressing trauma as part of the treatment. Service users and multidisciplinary service providers have been crucial in developing and designing the intervention and study. This mixed methods study will investigate the feasibility and acceptability of this intervention to inform a future randomised controlled trial.


Telephone outreach to enhance uptake of NHS Health Checks in more deprived communities

NHS Health Checks are a national cardiovascular risk assessment and management programme in England. There is concern that the programme may increase inequalities because people in lower socioeconomic and some black and minority ethnic communities don’t take them up.
In Bristol telephone outreach is used to reach these communities. Community workers telephone patients from groups that may be at higher risk of cardiovascular disease and less likely to take up a written invitation, aiming to engage them with the NHS Health Checks programme.  Where possible, the cultural background and main language of the outreach caller is matched with the patient.  The call includes an invitation to book an appointment for an NHS Health Check, lifestyle questions from the check and, where appropriate, signposting to local lifestyle services. CLAHRC West is interviewing patients and community outreach workers to investigating their views and experiences.

Research for equitable health and care

‘Equity, appropriateness and sustainability’ is one of CLAHRC West’s four research themes, and it informs both the research which we do and how we go about doing it. As part of this theme, in the past year we’ve had internal conversations about the issues relating to inequality or inequity that we’re coming across in the course of the projects we’ve been involved in. This was an exploratory, informal process, intended to inform plans for potential future work.

Early cross-cutting themes which emerged from these conversations included:

  • Missing data / voices / evidence: the data we don’t have, or we don’t take account of; voices that are missing, and gaps in the evidence we’re using
  • Unequal power relationships: this is clearly linked with the first theme, as those with more power are more likely to be able to influence what evidence is produced and used – in research, but also in decisions about which services are provided in our region, and how they are provided, as well as decisions about care at an individual level
  • Differential access – which again has clear connections to the other two



CLAHRC West Midlands:

Understanding how best to support overweight and obese adolescents to achieve a healthy weight

A third of children in England are overweight/obese (Body Mass Index >25 kg/m2). The physical and psychosocial effects of obesity in adulthood are now seen in children and adolescents. Obesity is also associated with socioeconomic inequalities, such as social and economic deprivation. Current NICE guidance recommends that obese adolescents attend a family-based multi-component lifestyle weight management programme. Cochrane reviews have shown that lifestyle programmes can be effective in reducing the level of overweight in child and adolescent obesity. However, these programmes suffer from low recruitment and high rates of drop-outs.  Therefore, one of CLAHRC WM projects aim to understanding the views of adolescents attending lifestyle weight management for the planning and development of future interventions.

Findings from a qualitative systematic review highlighted the importance of long-term professional, family and peer support in this age group. Additionally, the need for interventions to be tailored to the adolescent age group was important. Adolescents enjoyed taking part in physical activity but often had worries prior to attending an intervention. Findings from this review have been used to develop online focus groups that will be used to gather the views of overweight and obese adolescents who have attending a weight management programme in Wolverhampton, an area in the West Midlands with high levels of deprivation. Interviews will also be conducted with relevant community stakeholders to explore the policy and practical implications of findings from the qualitative systematic review and online focus groups with adolescents.

It is envisaged that findings from this research may inform local and national policy makers and services in the development of future interventions for overweight and obese adolescents that recognise their needs. Developing interventions with adolescent views in mind may assist in improvement of recruitment and attrition rates, which may contribute towards tackling the increasing issue of obesity.

Contact: Helen Jones (


CLAHRC Yorkshire & Humber: 


Current efforts to increase access to opportunities for physical activity in deprived communities with high levels of obesity and chronic disease need ways to attract more participants whilst preserving the perceived benefits of smaller events that may promote community ownership and engagement. In Sheffield, over 1200 people currently participate every week in “Parkruns”. These are weekly community based 5k running/walking events run by volunteers. We explored factors that affect participation across the five Sheffield parkrun events.
Main completed project was presented at regional Y&H conference (Y&H Association of Directors of Public Health Sector Led Improvement Annual Conference - Friday 9th February 2018, Leeds)

Developing, implementing and evaluating a ‘Healthy Conversations’ (Making Every Contact Count) training programme across Sheffield City Council (SCC)

The ‘Healthy Conversations’ (HC) programme, was hosted by the Public Health and Inequalities Theme of the CLAHRC YH and funded by Sheffield Hospitals Charitable Trust. Based on the principles of Making Every Contact Count (MECC), the aim was to develop, implement and evaluate an innovative and locally tailored training programme for Sheffield City Council staff. The programme adopted a ‘MECC Plus’ social model drawing on national best practice ( 
Staff teams were drawn from a variety of services and selected for training based on a number of factors including the amount of face to face contact they had with customers. The 3 hour programme was developed and delivered by Learning and Development Consultants within SCC. HC training was delivered to 430 staff between 2015 and 2017. Staff reported that the training had increased their confidence to instigate a HC with customers and identified potential barriers such as perceived time constraints and a lack of infrastructure supporting onward referral. 
The programme has evaluated well and the development process has identified that it can be flexibly delivered in 1, 2 and 3 hour formats. A number of staff have also been trained on a more advanced course branded ‘Coaching for Wellbeing’.