The 2006-2011 research programme was developed in consultation with the DH Policy Research Programme and informed by current policy needs. It had a focus on major health determinants, the the programme included projects on smoking, obesity and its associated risk factors, and, as an important wider determinant, the workplace. The three areas addressed barriers and facilitators to behavioural change in different population groups (such as children and young people) and evaluated the scope for different interventions across different settings (such as communities and schools) and using a range of strategies. It also included cross-cutting projects and projects to support the translation of evidence into policy and practice, and to apply learning from projects on our chosen themes of smoking, obesity and the workplace to other important determinants of health.
Through the National Children's Bureau, a main collaborator in the Consortium, a young person's public health reference group was established to provide input and advice from young people.
Smoking is a key proximal determinant of health and an important contributor to England’s ‘big killers’ of coronary heart disease and cancer. Cigarette smoking is a primary cause of preventable morbidity and premature death in England: between 1998 and 2002, it is estimated to have lead to an average of 86,500 deaths per year. Cigarette smoking also generates high health care costs for the NHS, and for the wider economy.
Additionally, social inequalities in smoking make a major contribution to social inequalities in health. Although smoking prevalence is considerably lower than it was in the 1970s, the rate of decline slowed in the mid-1990s and this pattern of gradual decline has continued. Estimates suggest that prevalence rates are dropping by 0.4% a year. Socioeconomic inequalities in cigarette smoking remain pronounced for both men and women. Patterns by equivalised household income capture these socioeconomic differentials in smoking. Prevalence rates in the lowest income quintile for men (36%) and women (30%) are more than twice those found in the highest income quintile (16% and 13% respectively). There are also inequalities in exposure to second-hand smoke, with mean hours of exposure estimated to be highest among those in the lowest-income households.
Reducing the public health burden of cigarette smoking is central to improving health in England. Tobacco control policy is therefore a key lever of government policy. As well as investment in NHS smoking cessation services, policy has recently been strengthened by the introduction of additional restrictions on the promotion and sale of cigarettes and, following legislation, virtually all enclosed public places became smokefree from July 2007.
It is against this background that the Consortium’s smoking projects were set.
The prevalence of overweight and obesity continues to rise in England, a trend evident on a global scale. In England, 30% of children aged 2 to 15 and 60% of adults are estimated to be overweight or obese. Obesity is estimated to be responsible for 9,000 premature deaths a year in England and to reduce life expectancy by an average of 9 years. It is estimated that that the cost of obesity to the NHS is approximately £4.2 billion, with a wider economic cost of £16 billion.
The rise in overweight and obesity has been associated with changes in its social profile. Socioeconomic inequalities in obesity were inconsistently seen in children growing up in the 1960s, 70s and 80s. As rates have increased, evidence suggests that inequalities in childhood obesity have strengthened, with rates tending to increase most among children from poorer backgrounds. A similar pattern is evident among women, with rates of obesity higher among those living in poorer circumstances. In England, the age-standardised prevalence of obesity climbs from 19% among women living in households in the highest income quintile to 32% among women in the lowest income quintile. Social gradients are less pronounced for men but there is evidence that they are emerging. The recent Foresight project on obesity concluded that ‘the factors underpinning the social gradient are currently poorly understood’.
The Consortium’s projects on obesity and its risk factors were set against this background.
Individual risk factors like smoking and obesity are widely recognised to be major determinants of health. But there is increasing appreciation that wider determinants also matter.
With earnings providing the major source of income for households above the UK poverty line, entry into paid work has been central to tackling child poverty and social exclusion. The contribution that sustained employment can make to improving people’s lives and life chances in adulthood has also been recognised, where particular emphasis is put on enabling people with long-term health problems to secure appropriate employment.
Employment rates for both men and women have been on a strongly upward trend over the last decade. They are now are at their highest-ever level, with 75% of the working age population in paid work. While women are more likely than men to work part-time, the majority are in full-time work. However, employment rates among men and women with a disability or chronic illness are appreciably lower, pointing to the potential for improving work opportunities and promoting employment rights for disabled people.
While paid work can contribute positively to health by providing a route out of poverty, working conditions can also have negative effects on health. There is evidence that adverse working conditions, including shift work and work characterised by low levels of control, take a toll on physical and psychological health. Those in lower-skilled and lower-paid jobs are at greater risk of exposure to adverse working conditions, with studies suggesting that social gradients in the quality of work contribute to social gradients in health. This suggests that the workplace is an important intervention point for addressing social and health inequalities, for example through measures which enable shift workers to influence their working patterns.
Recognising the importance of the work environment, the Consortium included two projects with a focus on the labour market and the workplace.
The cross-cutting projects were selected to address barriers to improving the evidence base for policies to improve health and tackle health inequalities. The barriers were highlighted in a series of reviews of public health research capacity and most notably in the Wanless report. The Wanless report recognised that public health research and policy cover a large canvas, including both ‘interventions to reduce risk factors for disease and interventions to address the wider determinants of health’. Informed by this broad perspective on public health, it provided a helpful summary of the challenges facing the research and policy communities. The Consortium drew on its assessment in identifying priorities for the cross-cutting projects.
Firstly, the report pointed to ‘the almost complete absence of an evidence base on the cost-effectiveness of public health interventions’ and recommended that this gap be urgently addressed. A major issue for cost-effectiveness analyses in public health is that the standard methods have been developed for clinical rather than public health interventions. Assessing the challenges of applying these standard methods was the focus of one of the cross-cutting projects.
Secondly, the Wanless report noted that ‘little is known about the likely impact of interventions that tackle the wider determinants of health and health inequalities’. A project mapped the evidence on interventions addressing wider determinants as a first stage to identifying gaps and priorities for future studies.
Thirdly, the report argued that most public health interventions are not amenable to evaluation through a randomised control trial (RCT). In consequence, it argued that other approaches are required to assess the impact of such interventions. As it observed, ‘there is an urgent need to develop an appropriate practical framework for evaluating public health interventions’. It noted that such frameworks should be capable of capturing the effects of interventions to address wider determinants, including their potential differential effects. These observations have informed the third of our cross-cutting projects. It develops a framework through which to map and to assess how policies in the early years might be expected to influence health inequalities.