Meet Trish Greenhalgh, Distinguished Fellow
Trish Greenhalgh is also Professor of Primary Care Health Sciences at Nuffield Department of Primary Care Health Sciences at the University of Oxford.
What inspired you to work in health research, and what keeps you motivated?
I think I’ve always had a ‘research brain’. Even at my university interview back at age 17, I was asking the interviewers more questions about their research than they asked me! Research is the systematic search for new knowledge. Whether qualitative or quantitative, research is characterised by careful selection of the appropriate methods to answer the question posed, rigorous application of those methods to the highest standard achievable, reflexive awareness of the possibility of error, and measures taken to minimise and take account of error. I guess what keeps me motivated is the excitement of discovery. And by that, I don’t mean dramatic Eureka moments but the more incremental enlightenment we get as we deepen our understanding of complex phenomena.
If you hadn’t gone into health, what would you have done instead?
If I hadn’t been accepted for medicine, I would have kept applying until I got in. I wanted to be a doctor from age three. I never had a Plan B.
What do you see as the most pressing goals for public health?
The 17 Sustainable Development Goals announced last year by the United Nations are pretty good. One, “good health and well-being”, is explicitly about health; the other 16 e.g. “end poverty”, “reduce inequalities”, “reduce climate change” are all health-related in some way. I think those of us who are interested in the strategic direction of public health are shifting from single-issue approaches to a more ‘health in all policies’ mindset. I once heard Sir Andy Haines give a brilliant lecture on planetary health; he talked about how he’s working increasingly with zoologists, soil scientists and other experts outside health to try to address global challenges.
When do you think health initiatives work best and can you give an example?
Health initiatives tend to flop when they’re too narrowly conceived, e.g. not sufficiently interdisciplinary, and when they fail to take account of context and practicalities. Indeed, I worry about the medical mind-set whose basic script is the ‘drug for a disease’ model. Physician researchers over-use randomised controlled trials – which focus the analysis on demonstrating internal validity (‘can it work’) at the expense of external validity (‘is it going to work here?’). Yes you’re right that research, advocacy and policy need to come together, but I would also say that these streams of activity need to co-evolve from the outset so that – for example – the researcher is writing the grant application with a clear and respectful idea of where the policymakers and advocates are coming from, and that research as it unfolds takes continual account of its intended end-users, ideally through ongoing, cross-sector dialogue.
Here’s an example. My team have been doing a series of studies, mostly secondary research and modelling, on how best to prevent type-2 diabetes through both individual and population measures. We worked from the outset with local policymakers, and also from an early stage, national policymakers to shape the questions we were asking. They told us that they found existing systematic reviews unhelpful because the questions posed were of academic interest but did not tell them for example which options were likely to be affordable, given local contingencies. Our recent publications, and more in the pipeline, have been tightly focused on providing the kind of answers that policymakers will find useful. See for example:
- Efficacy and effectiveness of screen and treat policies in prevention of type-2 diabetes: systematic review and meta-analysis of screening tests and interventions.
- Preventing type-2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programs and metformin, with and without screening, for pre-diabetes.
- Economic evaluation of type-2 diabetes prevention programs: Markov model of low- and high-intensity lifestyle programs and metformin in participants with different categories of intermediate hyperglycaemia.
What recent research excites you and why?
I love Richard Osborne’s work on health literacy. He’s extended the term ‘health literacy’ from the narrow meaning of 'can the person understand medical terms', to a much broader meaning that embraces capacity to access care - including such things as ability to navigate the system, social support, digital access/literacy and what I’d call self-advocacy - and various additional dimensions of being unmotivated, downhearted and downtrodden. These of course relate to the traditional social determinants of health such as poverty and social exclusion. In the OPHELIA project, Osborne’s team have developed high-quality survey instruments to assess these wider aspects of health literacy in a particular community and use those to target different aspects of service development and community support. See for example:
- Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia)
- Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support
- Measuring health literacy in community agencies: a Bayesian study of the factor structure and measurement invariance of the health literacy questionnaire (HLQ)
- Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ)
What would you like to see come out of your work with the think tank?
I’m keen to develop some ideas on system-level change and what we might do to complement and/or replace the dominant randomised trial approach. Don’t get me wrong – I owe my life to randomised trial research and I believe these designs have a crucial place in healthcare. But I think The George Institute for Global Health is now at the stage where it’s asking what other methodologies might be helpful in addressing global grand challenges, and how can we apply these appropriately. One of my specific interests is large-scale IT projects and why they so often fail or, if they don’t fail completely, why they so often don’t achieve the benefits anticipated. Whilst I’d be happier studying successful IT projects, I think we’ll have plenty of material to chew on as we consider why some of the tech initiatives funded by The George Institute in recent years have been partial rather than unqualified successes.