April 27th, 2010
One thing that has marked this election is the growing focus on science issues. This has partly been down to the interest of some politicians in the subject, and mostly due to the activism of a number of scientists (natural and social), science journalists and bloggers.
The focus of these discussions has been around tackling key issues around science (funding, support, listening to expertise etc). And while it is really important these topics are being debated, I’d invite a step back to think a little bit more about the way politicians understand and use ‘evidence’ from science and healthcare in practice. Otherwise we may miss opportunities to work with politicians and inform political thinking – and in turn help the public on key issues around health, education, innovation and technology.
In order to explore some of these core issues I’d like to reflect on my experiences of working with the Department of Health (DH) on their sexual health campaigns, where I had the chance to see where there are major barriers to using, applying and understanding good approaches to sound science. Which results in misleading information and a lot of money wasted.
I began volunteering on the DH campaigns in 2001 and between then and 2008 I increased the work I was doing, eventually becoming both a consultant and spokesperson on the public sexual health campaigns RUThinking, Playing Safely, Want Respect? Use A Condom (see also their great ad campaign), and Condom Essential Wear. Most of which have now been updated for Sex and Young People and Sex, worth talking about (where I currently volunteer for NHS Choices answering questions on psychosexual health topics).
This work involved identifying core evidence to underpin key messaging and liaising with civil servants, ministers and PR companies to ensure accurate, accessible and engaging messages were shared at a variety of different audiences in diverse formats (print, online and broadcast media as well as live events like music festivals).
I came to this work through my background as an academic who teaches healthcare practitioners and policymakers internationally how to access, critically appraise and understand evidence. And through my research which has focused on the sex and relationships health topics of education, service improvement of reproductive health, and addressing psychosexual problems, with a particular interest in media and public health campaigning. All of which I apply via advice giving through educational events, practitioner training and the media.
I was honoured to be part of the campaigning work and believe there were a number of key areas where major achievements were made around getting sex talked about within the media, and particularly with young people. There were some great examples of innovative practice and in the activities I was involved in we ensured work was ethical, based on sound evidence, while still being engaging.
However, during the seven years of working on the campaigns I noticed a number of core problems. I don’t know if these are repeated within other government departments, but it would be worth investigating whether the issues outlined below are happening elsewhere. My hunch is they’re not unique to health.
It was for that reason I asked the Guardian’s Science Test of politicians (by Martin Robbins) to clarify how political parties intended to oversee and manage public health campaigns and associated PR companies.
Here are the key areas I noticed problems around the application and interpretation of research and evidence:
Bidding for contracts
The majority of public engagement activity run by the government (and via political parties) is organised through PR companies. That in itself is not problematic, PR companies are experts in ensuring messages reach the right people in a timely fashion. What is problematic is for health, education and other campaigns there seems to be frequent bidding process orchestrated by different government departments. Meaning several months on any contract will be spent preparing to bid to renew it (in competition with other PR companies). And until any bids have been renewed no new activity can take place. Which restricts the amount of work you can do to reach the public.
There is also the difficulty posed when a PR company is replaced. Where the company who has held the contract has built up their own contacts, messages, experience in delivering information and goodwill among the media. Because they are a commercial organisation this information remains with them if they lose the contract. Meaning the incoming agency has to begin from scratch building up these contacts, there is no organisational memory, and a lot of time lost in repeating activities. It also means experience built up on campaigns can be lost.
Uncertainty of messaging
During the time I worked on the DH campaigns there were periods where ministers were unsure about the direction in which they intended to go. That was not because they were engaged in a systematic review of the evidence which might help them decide, but because they were anxious about media and public responses to their messages. Particularly relating to sensitive issues like contraception, teenage pregnancy and STIs. It took three years to move the more fragmented ‘sex lottery’ campaign of 2003 into the national media run ‘Condom Essential Wear’ launched in 2006. [This was the first widespread government-backed public media campaign on STIs since the HIV/AIDS one of the 1980s]. Fear over how the press/public will respond led to haphazard delivery of messaging, also hampered by a limited budget.
It has also led more recently to overlooking evidence of good practice – which is about easier access to services, accessibility of testing and treatment, combined with prevention messaging. Instead the government has opted far more towards promoting testing, and has moved away from their 2006 approach which suggested prevention based messaging/normalising condom use. This appears to be based around cost decisions and attempts to deal with rising STI rates. While it is right that we alter messages depending on new information from research and evaluation, it is problematic if politicians and civil servants do not understand this process, or ignore it in favour of activity that is based around anticipated public opposition or healthcare spending cuts. And equally worrying given it muddles the public and healthcare staff around what they should be doing.
Reinventing the wheel
In the past decade our public sexual health campaigns have begun with the Sex Lottery, which became Playing Safely, which morphed into Condom Essential Wear and is currently Sex, worth talking about. And that’s just the campaign aimed at young adults. Teen campaigns for sexual health, general health and pregnancy have also morphed in similar ways. This has included new websites, logos, branding and core messaging for each iteration of the campaign. And within each development an additional range of agencies working on digital, creative, and marketing tasks. While material written for the web has been reused for some of these campaigns, in many cases new content has had to be created although again not always based on core evidence. It results in confusion to the public who are presented with different names, brands, and websites to find. Individual NHS trusts paying for their own sexual health websites that replicate content found on government ones wastes additional money. All of which results in a lot of activity, a lot of money spent, but no real sense of outcomes – the impact such campaigns have had. Sadly the focus of evaluation is often reduced simply to mentions within the media or visits to the campaign websites. Again indicating a lack of awareness of how to fully assess activity undertaken.
Flashy, gimmicky, but has it worked?
One aspect of the public sexual health campaigns has been a focus on getting young people involved. That has included viral videos, myspace pages, interviews with celebrities and texting services. More recently England’s Sexual Health Quiz was launched. Critics have questioned why this uses a kids vs parents approach (given evidence indicates competitive based education in this area is rarely successful). Other concerns have been expressed about the accuracy of the questions (particularly relating to cancer) and whether knowing how much water a condom holds really tells you anything about your ‘knowledge’ of sex and relationships, or your sexual health needs.
All of these activities are clearly costly, and most of them are focused online, which excludes large numbers of the population. We also have no idea how much they have cost, or what impact they have had. When asked, the Department of Health’s response to me was the latest quiz encourages ‘friendly conversation’ between parents and teens and provides right and wrong information. They had no information about whether this approach had been successfully piloted or was working to increase communication between parents and young people.
We have no idea whether, post election, the current quiz will still exist, or whether the data will be used to inform public health campaigning in the future.
Activity that doesn’t make the headlines
While we may be concerned over the quality of public engagement activity, there is the additional problem of campaigns that are paid for, but fail to reach the public or make much impact. For example one survey called ‘pulling pants’ was carried out for the DH by Tickbox which was to identify whether people chose ‘lucky pant’s to go out in. The survey indicated people spent time thinking about what underwear to wear – and clearly did have special undies they wore in the hope of pulling. But they did not put the same focus on taking condoms with them. This was a playful message, but actually quite important if you think about intentions to have sex. However, despite the survey being designed, run, data collected and the PR and polling company paid, it never made it to the media as ministers and civil servants were worried about the underlying messages. While I have a copy of the data, I do not have the costs for this particular project, but it would be equivalent to a standard public survey of 1000 participants spread across the UK.
Another activity that did make the headlines, but not in any great way, was the Alesha Dixon photospread run in 2008. It produced a series of gorgeous photos, but hardly any media outlets picked up on it (if memory serves only a couple of online editions of tabloid papers ran it). Which again represents a lot of money spent for very little return. [This is not a criticism of Ms Dixon who showed a genuine commitment to a campaign on a topic very few celebrities will be associated with]
It is not unusual within mainstream research or any public engagement activity for ideas to change, for messages to occasionally fail, or for problems to arise. But in relation to the cost of these campaigns – particularly when front line services are being cut – this is a worry. Not least when you add it to the fees for the more online activities, surveys run and time lost while rebidding for contracts.
Part of the problem of messaging being ineffective is the timing of them – Valentine’s Day, for example, is such a busy period to get any media pickup. But it’s also not a particularly good time to run public sexual health messaging – a better time would be around Christmas/New Year when people are more likely to have unprotected sex.
Policy/public health education and the role of the PR Company
By far the biggest problem around evidence-based approaches to public messaging is related to PR companies. In 2008 the Telegraph reported the government were spending approximately £1million per week on polls and focus groups and it may be the figure is far higher if you factor in consultations, and other public facing activity such as websites run by different government departments.
This issue has not really been fully explored and I think a canny journalists might be able to identify a far larger spend than already suggested.
These surveys and focus groups are not run to identify people’s key problems or needs, nor to improve services or our wellbeing. Instead they are run to collect information that will be used to inform media activity. Because nowadays most journalists won’t cover stories unless they can pin them to a survey or similar.
This wastes time and money on a number of levels. It firstly overlooks existing evidence on health, education or business that may well be useful to help us understand or deal with an issue. Peer reviewed research is rarely consulted or used to underpin such activity. Instead we see a number of leading questions used to get answers that in turn will generate headlines and discussions points for radio. Which can work if you have a spokesperson allied to a campaign that can translate that information into accurate and contemporary advice. But this is sadly not often the case given the use of PR companies of spokespeople who may not be the best qualified within an area to interpret and share information.
Research to inform public health is led by PR companies, not academics/practitioners
Over the years there has been a shift within public health campaigns where instead of being informed by key academics/practitioners about current evidence of best practice there is now the approach that the PR Company comes up with the idea for an activity as well as being responsible for promoting it.
A key example, and one that led me to resign from supporting the Department of Health’s sexual and reproductive campaign, came from the new PR agency they appointed. They had heard about some research covered in the Daily Mail where researchers counted the number of mentions of alcohol in the media. They suggested the same approach be used, but focusing on condoms.
Their recommendation was for someone (an academic) to observe the media over an unspecified period, and from that they could indicate how little condoms were mentioned in the media, and flag this up as a problem. They also incorrectly claimed no similar research had ever been conducted on this before (because they had not found any in searches they had undertaken).
Civil servants at the Department of Health seemed impressed with this idea. My opposition to it ran as follows. Such an activity if carried out correctly is very time consuming and costly. It would require very clear parameters around what media would be studied over what period. Given that we already know condoms are not mentioned much within mainstream media there is probably little point in doing such an in depth activity. But given we also know that integrating safer sex messages into mainstream media works see here and here and here and here, perhaps using that knowledge might allow us to bypass the research and focus instead on working directly with journalists – particularly in television where often plot lines in soap operas can be requested to focus on core issues (e.g. sexuality, bullying, teenage pregnancy). My advice was ignored.
On 20 February the Department of Health announced they had commissioned research that looked at media coverage of condoms in a report called ‘Mis Selling Sex’. The report still has not been publicly launched, and there is no clear information on who did the analysis, how it was conducted, and how much the activity cost. Moreover, there is no clear information on how the findings would be implemented outside of talking to television companies, which, as we already have seen, could have been done without having to do a full-scale study.
It is sadly a common problem within health research where people repeat studies, but in the case of a government department being advised they did not need to do this research – and could have used their money elsewhere – it is worrying such advice was ignored. If we do not see particular changes within mainstream media, this work will have been wasted. And even if we do see such messages in media they need to be sustained and supported.
What did I learn from my time in the field?
It would be wrong of me to imply those working on various government health campaigns are not doing their best or lack good intentions. My experience of working with ministers, civil servants and the PR companies behind the campaigns suggested a lot of well meaning people. There were also a few practitioners like me who volunteered our time and skills to inform campaigns and improve sexual health.
However, high staff turnover, fear of the response of the Daily Mail, a reliance on ‘desk based’ research and the focus towards ‘policy based evidence making’ rather than ‘evidence based policy making’ meant many good ideas were blocked, and weaker activities green lit.
Given sexual and reproductive health services are so underfunded, and yet given our equally worrying rising STI rates, it is vital any activity we undertake is cost effective, appropriate, built on evidence and evaluated. And that it directs people to the services they need. Spending money on campaigns that do not achieve this means people won’t go for help and while services continue to struggle with lack of funding.
I wonder how much better we may have done if money simply had been spent on improving services, and telling people where they could find them?
As mentioned I cannot speak for the rest of the activities run in different government departments but it is my belief that money and time has been wasted elsewhere. It is also my belief that politicians and civil servants will continue to struggle after the election because they are not supported by the public or by scientists/practitioners to use evidence to inform policies and services.
While we debate science and how important it is, we need to be aware of the real life problems encountered on the ground that means very often poor practice is allowed to continue because nobody is adequately checking what is being done, and few practitioners volunteer to ensure good services can be offered.
Please, while you’re campaigning for science, think about offering your services and scrutiny to ensure we can stop wasting time and money in the name of government backed health research and education.Tweet