Practicalities of public health practice and evaluation : the case of mental wellbeing in Coventry

The introduction of mental wellbeing as an outcome measure created a momentum of change for understanding complex health interventions and outcomes among stakeholders; it assisted those delivering the CHIP programme to understand the underlying health improvement rationale for their programme better.

Abstract

There are gaps in the UK knowledge base for understanding the implementation
\nand evaluation of public health interventions which aim to improve the mental health
\nand wellbeing of participants. In this thesis I examine the measurement of mental
\nwellbeing and the implementation of health improvement interventions in a
\ncommunity setting and investigate the practicalities of their evaluation using a
\nmeasure of mental wellbeing -- WEMWBS.
\nMethods: Using a mixed methods approach I collected and analysed i) three cross
\nsectional surveys of Coventry residents, ii) quasi-experimental before and after
\noutcome evaluations of three CHIP projects, and iii) undertook semi-structured
\ninterviews with CHIP stakeholders. Data were integrated using a matrix technique.
\nResults: A total of 8188 individuals (~40% response rate) completed valid survey
\nquestionnaires in 2010-2012, while 590 individuals (~88% response rate) completed
\nvalid before-after mental wellbeing outcome evaluations in 2011 and 2012 from
\nthree CHIP projects. Fifteen one-on-one interviews were completed. I found that
\nhealth and lifestyle variables ‘sleep quality’ ‘physical activity’ and ‘fruit and vegetable
\nconsumption’ showed the strongest and most consistent patterns of association with
\nlevels of mental wellbeing measured using WEMWBS. CHIP projects demonstrated
\nassociations between the intervention and increases in mental wellbeing, some of
\nwhich were both statistically significant and clinically meaningful. Some were
\nsustained at three months.
\nInterview findings showed that the difference between the plans and the observed
\nimplementation practices resulted in some of the projects struggling to cope with the
\nevolving and changing needs of the programme, for example moving from outputs
\nto outcomes, introducing mental wellbeing and changing concepts of health, and the
\nwork required to achieve partnership with the local authority). The effect on
\nprogramme level outcomes and outcome measurement of these struggles was a
\nreduction in the number and quality of valid evaluation returns from some of the
\nprojects in the programme and reduced staff capacity to deliver project objectives.
\nThe introduction of mental wellbeing as an outcome measure created a momentum
\nof change for understanding complex health interventions and outcomes among
\nstakeholders; it assisted those delivering the CHIP programme to
\nunderstand the underlying health improvement rationale for their programme better.
\nThrough integrating quantitative datasets I provided a benchmark from which to
\nmake comparisons between population estimates of WEMWBS and observed
\nevaluation findings. Integrating quantitative evaluation process challenges and
\nqualitative insights from stakeholder interviews allowed for complex issues to be
\n‘untangled’. Interrelated mechanisms affected facilitators and barriers of programme
\nplanning, implementation, evaluation and sustainability. Integrating my quantitative
\nand qualitative findings highlighted some clear health benefits from the projects but
\nalso highlighted a lack of congruence between the documented linear,
\nunidirectional and unrealistic operational planning which I found in CHIP at a
\nprogramme level, compared to practical implementation on the ground, which was
\nnonlinear, complex and dynamic.
\nConclusion: Iterative, transitional stages of programme development could benefit
\nimplementation processes and potentially health outcomes, including mental
\nwellbeing, in future public health practice. Further research in this area should
\nexplore the extent to which complex, collective, and adaptive operational planning
\ncan result in more successful public health improvement programmes.