Background

The World Health Organisation (WHO) defines health equity as the “absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (e.g. sex, gender, ethnicity, disability, or sexual orientation). Health is a fundamental human right. Health equity is achieved when everyone can attain their full potential for health and well-being.” [1].

Health inequities may be driven by:

  • different experiences of the wider determinants of health, such as the environment, income, or housing.

  • differences in health behaviours or other risk factors, such as smoking, diet and physical activity levels.

  • psychosocial factors, such as social networks and self-esteem.

  • unequal healthcare access, experience, or outcomes [2].

The COVID-19 pandemic has exposed and exacerbated inequities in society [3,4,5,6,7,8,9,10,11,12,13,14]. Often the communities that are least able to cope have suffered the most, both from the disease, as well as through the indirect effects of policies aimed at containing viral spread [15].

Health protection issues, such as low vaccine uptake, infectious diseases (e.g., Tuberculosis (TB) and Hepatitis C) and antimicrobial resistance (AMR), disproportionately affect inclusion health groups (e.g. some migrant groups, people in contact with the criminal justice system, people who misuse drugs or alcohol, those who are homeless) or other at-risk groups who already experience health inequities (e.g. based on ethnicity or sexual orientation) [16,17,18]. In regards to health protection hazards, vulnerable populations are at greater risk, due to environmental or behavioural risk factors and also have specific prevention needs which may not be met; additionally, these groups may have poorer healthcare access, experience and outcomes, and lack of social support to enable timely diagnosis and treatment, resulting in further transmission and/or more adverse consequences of disease, and widened inequities [16, 19].

Achieving health equity requires identifying and addressing inequities, wherever they exist. Narrowing inequities is complex and often described as a ‘wicked problem’ requiring system-wide solutions and innovative thinking [20].

The 2010 Marmot Report [20] laid out six policy objectives to reduce health inequalities and a framework for delivering and monitoring reductions in health inequalities along the social gradient. However, Marmot’s 2020 ‘10 years on’ report [21] showed that improvements in life expectancy had slowed dramatically and poor health had increased everywhere. This is concerning, as the substantial negative health outcomes and economic consequences within populations are generally avoidable, with targeted evidence-based interventions.

Current strategies and approaches in England include:

  • The NHS Long Term Plan (NHS LTP) which sets out an objective on prevention and health inequalities, with a focus on reducing local health inequalities and unwarranted variation [22, 23].

  • NHS England and NHS Improvement’s Core20PLUS5 approach to support the reduction of health inequalities at both national and system level. The approach defines a target population cohort for action that includes the most deprived 20% of the national population (the ‘Core20’) and inclusion health groups and protected characteristic groups (PLUS). The ‘5’ refers to focus clinical areas requiring accelerated improvement [24].

  • The government’s ‘Levelling Up’ White Paper which has a mission to: narrow the gap in Healthy Life Expectancy (HLE) between local areas where it is highest and lowest, by 2030; and raise HLE by 5 years, by 2035 [25].

The 2021 public health reform dissolved Public Health England (PHE) (an organisation whose aim was to protect and improve the nation’s health and wellbeing, and reduce health inequalities [26]), and created the Office for Health Improvement and Disparities (OHID) and the UK Health Security Agency (UKHSA). OHID’s focus is on improving the nation’s health so that everyone can expect to live more of life in good health, and on levelling up health disparities to break the link between background and prospects for a healthy life [27]; and UKHSA is responsible for protecting every member of every community from the impact of infectious diseases, chemical, biological, radiological and nuclear incidents and other health threats [28].

The UK Health Security Agency’s (UKHSA) Health Protection Teams (HPTs) provide specialist public health advice and operational support to the NHS, local authorities, and other agencies. HPTs also prevent and reduce the effect of diseases, chemical and radiation hazards, and major emergencies, through: local disease surveillance; maintaining alert systems; investigating and managing health protection incidents and outbreaks; and implementing and monitoring national action plans for infectious diseases at local level [29].

The UKHSA’s remit letter states that, to support delivery of the Department for Health and Social Care (DHSC)’s approach to health disparities, the organisation has a role in co-ordinating with partners to ensure all members of the community are, as far as possible, equally protected from health threats. As part of its core activities, UKHSA will develop and implement an internal UKHSA health equity strategy, supported by the newly established health equity division [30]. This reveals a unique opportunity for UKHSA’s groups, divisions, and teams to inform the development of UKHSA’s health equity strategy and priorities, including Health Protection Teams (HPTs).

Aims

This study aims to collate the views of Health Protection Teams, and explores:

  • Current health equity activities and structures within HPTs.

  • Desired future health equity activities.

The findings will be used to inform national and regional health protection strategies to tackle inequities.

Methods

Recruitment and sampling

Initially, a named Health Equity Lead from all nine regional Health Protection Teams in England, were invited to either a 1–1 (interview) or group (focus group) discussion with the lead researcher (RA), depending on participants’ preference. Subsequently, any colleagues recommended by the Health Equity Leads were also invited to participate.

Interview schedule

The semi-structured interview schedule (Supplementary 1.), developed using the Theoretical Domains Framework (TDF) ( a behavioural science tool used to identify and describe factors that influence a behaviour) [31], covered:

  • Roles, responsibilities, and the structure of the team in relation to tackling health inequities.

  • Use of strategies / guidance / tools / continuing professional development, aimed at tackling health inequities.

  • Priority population / disease groups.

  • Barriers and facilitators to tackling health inequities.

In practice, the terms health disparity, inequality and inequity are often, albeit incorrectly, used interchangeably. At PHE the agreed terminology in this space was ‘health inequalities’, however, to better describe the ambition of the UKHSA, the term ‘health equity’ was adopted. As such, interviewees’ responses often shifted between these terms as these new organisations were formed and settled.

Interview sessions

Discussions were conducted by RA over Microsoft Teams at a time convenient to the participant(s). Participants were reassured that there was an understanding that the organisation was going through a period of change, and that there was no expectation regarding current health equity activities within their HPT. Participants were also reassured that the transcripts would be anonymised, so they could be as open with their opinion and share as much as they felt comfortable with. The interviewer (RA) was an experienced researcher, with a background in Public Health, but no experience of working in Health Protection Teams. On average, discussions lasted approximately 50 min.

Analysis

With the participants’ consent, the discussions were recorded and transcribed, verbatim. Transcripts were checked for accuracy by RA and anonymised. RA thematically analysed the transcripts [32] and mapped the main themes to the Theoretical Domains Framework using NVIVO 11 [31]. Half-way through data collection, the existing anonymised transcripts were randomly circulated to a small group (including RA, SA, DJR, as well as three other public health colleagues) to review and discuss: the main themes; suggested implications of the findings; any recommended changes to the interview schedule for the remaining discussions.

All UKHSA participants were invited to a follow-up workshop to review the main findings and discuss future priorities for national strategy and regional HPTs’ business plans.

Results

Between November 2021 – March 2022, twenty-seven participants from all nine UKHSA regions took part in the study (Table 1.). Participants were mainly health protection consultants (14), and health protection practitioners (4). One focus group was with a health equity working group, including OHID regional health and wellbeing colleagues.

Table 1 Breakdown of Participants’ Characteristics (N = 27)
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The main themes that emerged from the discussions are outlined below. These were reviewed in a follow-up workshop where 85% of attendees voted that they mostly agreed (41%; 13/32) or fully agreed with the findings (44%; 14/32).

Structures, roles and responsibilities

Participants felt that the remit of the UKHSA was to achieve health equity by considering and accounting for health inequities in their health protection response work, but it was not felt that it was necessarily the role of HPTs to directly address the wider determinants of health inequities. Participants expressed that they felt their role was about finding the balance of reducing disease transmission compared to the risks of mitigation strategies required to do so. Participants felt that, although they were clear of the end goal, health equity was not always routinely considered in HPTs’ work.

“Realistically, I think the majority of the time, actually what we’re really talking about is equity. So, if we’re looking at people who are intravenous drug users, or people who are homeless, we’re almost certainly going to have to go that additional mile. We’re going to be doing things with them that we wouldn’t do with other people, so it’s not equal, but it’s equitable to make sure that they’re getting the same experience as other people, and that we’re striving to have the best, the same health outcomes for them all.” (CCDC-I-17122021B).

“I remember one of my colleagues saying to me that our job is just to reduce and stop infectious disease spreading. And I don’t believe my job is to stop infectious disease spreading at all costs, it is to balance the risks and reduce the risk of infectious disease against those other risks. So, in schools, the risk of reducing infectious disease by sending all the kids home is not worth it for the impact it has on inequalities.” (CCDC-I-18,012,022).

“…address the impacts rather than the underlying causes. Our service isn’t able to address the underlying causes of health inequalities… I mean, we can highlight the need for tackling the inequality from a Health Protection perspective, but we’re not the providers of accommodation or income or healthcare, so we can’t directly impact that; we could highlight that it’s an issue that needs to be addressed.” (CCDC-1-17122021 A).

There was an appetite and enthusiasm among participants to address health inequity, and many participants reported this as their motivation for working in public health. Generally, participants felt that there was interest from other team members too, but some were concerned about staff time and capacity to focus on health equity.

Although there were many differences, there was general agreement that HPTs have a role in:

  • liaising with other organisations / agencies to tackle inequities.

  • advocating for health equity in outbreak / incident management meetings.

  • developing regional HPT health equity action plans.

  • managing day-to-day incidents, with extra effort put into reaching under-served populations.

  • pro-actively working with identified inclusion groups to understand their lived experiences and co-develop interventions to address inequities.

HPT staff discussed the challenge of splitting their time between managing health protection incidents (e.g., COVID as the main priority at the time) and pro-active work (e.g., programmes aimed at reducing risk from external hazards for vulnerable populations, including migrant health, Tuberculosis (TB), Sexually Transmitted Infections (STIs), migrants and asylum seekers, early years and school-aged children, people in contact with the criminal justice system). Staff members also had roles as geographical patch leads (leading for UKHSA on activity in a local authority area), managing local health protection incidents and strategic work with local stakeholders, such as local authority public health.

“The core team, which is made up a mixture of consultants and practitioners…where we’re all providing an acute response, and we do that by a single acute desk. Practitioners are likely to spend the majority of their time ….on the acute desk, and then they will have a range of programmes that they feed into, and one of those programs is the inequalities programme… Sounds marvellous until you bring in the fact that our practitioners are constantly told to deprioritise programmes and prioritise the desk.” (CCDC-1-18012022).

In relation to health equity activities, there was a full spectrum, in terms of progress, set-up and activities officially labelled as health equity projects. For example, where some HPTs already had a health equity team within their regional HPT, there was a desire from other HPTs to set this up, with a named champion within each patch. At the time, one HPT had a health inequities group which also included their OHID regional health and wellbeing team, which was considered advanced progress.

“Within **[region] there are three Health Protection teams. There are periods of time and elements of work which we do across **[region]. So, for example all our SOPs around how we manage a particular infection or how we manage a particular situation are developed within a Pan **[region] group with representation from each of the three HPTs. However, each of the three HPT works a little bit differently and takes on different projects, and cover different populations, so there will be slightly different issues within each of those areas. And so, from the point of view of health inequalities, we hadn’t, across **[region], until late last year, really had a formalised health inequalities group and then the convening of that first national meeting, kind of pushed us to do that. So, all three of the HPTs had done various bits of work or had more, or less, formalised programmes of work with regards to health inequalities.” (CCDC-FG-24,012,022).

“My honest opinion is that people are doing it and not realizing they’re doing work towards it… As an example, avian flu, we have had quite a lot of it in **[location], and there is a specific sort of population of people who end up doing a lot of the sort of nasty work with avian flu, picking up dead birds, and that sort of thing, and that population tends to have sort of worse health outcomes, they’re in poorer health, they’re less likely to take Tamiflu, they are managed by a different organization, no proper occupational health, disengaging… There’s a fair bit on health inequalities here that needs addressing, even if it’s not labelled as such, if that makes sense. And so, I think that that goes for health practitioners, business support as well, who are on the phones. Now, what I think, potentially we could do, is expand that and recognize what we’re doing, and in recognizing it and labelling it, you enable people to do it more.” (CCDC-I-19,012,022).

There were also differences in team staffing as some HPTs reported access to data and surveillance expertise that could provide intelligence, to inform action and decision making, which was considered beneficial.

Participants acknowledged that health inequities were a clear thread in public health curricula, but recognised that, post-COVID, HPTs and the wider UKHSA were more professionally diverse than before the UKHSA formed, resulting in mixed awareness and knowledge of health inequities.

(See Supplementary 2. for additional quotes and examples related to ‘Structure, Roles and Responsibilities’).

Priority population / disease groups

There was a general agreement to move to a more holistic approach to support populations most in need, rather than siloed disease / hazard-specific working. Table 2. shows the groups that participants reported requiring the most focus to address health inequities, and the diseases / health protection issues they most associated with health inequities. (See Table 3. and Supplementary 3. for case studies of health protection health equity activities).

Table 2 HPTs’ views on population and disease / health protection issues to prioritise health equity action
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Table 3 Quotes and examples related to ‘Priority Population / Disease Groups’, including examples of health equity activities
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Monitoring and measuring impact

Generally, participants found responding to questions about monitoring progress towards health equity challenging. Their reasoning for this was that health equity objectives had not previously been explicitly set within health protection, and therefore, it had probably never been measured before in their work. They recognised that demonstrating progress on defined outcomes (e.g., vaccination uptake) would take time and that data was crucial to monitor it. Participants suggested that looking at the existing metrics on published data sources e.g. OHID’s Fingertips [33], would be a useful starting point, and then considering what data is relevant for particular populations, and what HPTs could impact. The example of vaccination uptake was a common suggestion.

“The best thing to do, for the start, would be to review what metrics we already have nationally, and so using the fingertips, etc. and saying, which of these indicators do we have an impact on? So, you know, we don’t have an impact, for example, on number of children in poverty. That’s not something really that the Health Protection team can add any weight on. But we do have an impact on immunization rates… And let’s review them more regularly for our boroughs. So, you know, that tool is really good, actually, isn’t it, for being able to compare geographies? And we could just, as a matter of routine, once every six months, or once a year, look at where our boroughs sit, compared to other things, and come up with a sort of action plan about where we focus our attentions according to those metrics. I think that would be the start. Don’t reinvent the wheel. Those metrics have been thought out very carefully, but there are probably new metrics also and some of them are probably quite easy to think about, and sort of more audit type metrics. I mean, even reviewing the number of situations that we’ve managed over a time period which affect a specific group.” (CCDC-FG-24,012,022).

Other suggestions for ways to measure and monitor progress in the HPT health equity arena was through auditing HPTs’ case and incident management against agreed standards to understand whether cases were managed according to guidance and whether standard operating procedures (SOPs) could be improved to better consider health inequities. Participants suggested that the relevant fields to facilitate this and other quality improvement activities and research should be built into the new HPT electronic case and incident management system currently being developed (CIMS).

“In terms of measuring impact, proving that impact, I think there does need to be quantitative measure… And actually, it’s made a real difference… as a result of doing what we’re doing, we’ve got this many people in to stop smoking services.… this is the percentage change in intravenous drug use and homeless people with TB adhering to treatment. I think the difficulty is that the baseline for that doesn’t exist at the moment, so it’s around kind of getting some of that baseline. And maybe it is around kind of recording that, but it has to be done in a simple way… maybe looking at things like CIMS [UKHSA’s Case and Incident Management System] for example. I’m thinking about like really quick checkboxes for example, that people could do within the programme that says, you know, have you done XY&Z and then we could kind of have a look at the outcomes of that. Working perhaps with local authorities around gathering, so if we are referring into services, for example kind of trying to get some of that information back. So how many times have Health Protection referred into our services and what has that resulted in? I guess, kind of linking up some of those data streams.” (CCDC-I-17122021B).

Participants suggested that they would consider that their actions had made a difference to health inequity if there were changes in national guidance, such as national guidance on diagnosing measles, rash in pregnancy, chicken pox, hepatitis B etc., to include how rashes or jaundice will appear on various skin types or amending the population groups recommended Hep B vaccinations (See Supplementary 2. for additional quotes and examples related to ‘Monitoring and Measuring Impact’.)

Challenges and Future Direction

Resources, staffing levels, time constraints and organisational barriers, were mentioned as factors that impact the ability of staff to tackle health inequity. Participants reflected on these issues and suggested solutions to overcome them.

See Tables 4 and 5 for challenges and recommendations for health equity activities within Health Protection Teams’ remit.

Table 4 Challenges and recommendations / future direction for health equity activities within Health Protection Teams’ remit
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Table 5 Quotes and examples related to ‘Challenges and Future Direction’
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Discussion

Summary

UKHSA Health protection teams see that they have a role in addressing health equity going forward, both within their reactive management of health protection incidents and outbreaks, as well as with their pro-active project and stakeholder working. At the time of data collection, challenges to this included: time and capacity to put the processes in place to embed health equity; lack of evidence about effective interventions for health protection; challenging systems, data collection and access to data; mixed awareness / knowledge of health equity in the professionally diverse, post-COVID HPT workforce; uncertainty in the UKHSA and HPTs’ health equity remit, and future ways of working between key organisations.

Comparison to other literature and recommendations

It is known that public health agencies have a fundamental role in understanding the health needs of deprived communities and inclusion health groups, identifying interventions to improve their health and providing leadership at local and national levels [19]. However, to our knowledge, this is the first study explicitly exploring the involvement of Health Protection Teams in England to deliver the health equity agenda.

HPTs identified a role in pro-actively working with inclusion health groups to understand their lived experiences and co-develop interventions to address inequities. This community-centred approach is consistent with the published place-based approach to tackling health inequalities [34]. However, HPTs felt that the evidence behind effective interventions were lacking, which was corroborated by the 2018 systematic review and meta-analysis of morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders [35]. The review recommended that consistent data collection will allow public health agencies to develop, implement, and evaluate structural interventions that improve the health of inclusion health groups [19]. Saini et al. support the value of involving patients and public in research and evaluation [36].

The King’s Fund state that “now is the time to embed work to address health inequalities” [37]; these views were also shared by HPTs who expressed that, given the importance of tackling health inequities to protecting health, now is the time for collective action to address health equity. Given the recent changes to the public health system in England, there is a real opportunity to inform development of the health protection teams’ role. The continued importance of addressing health inequity is also evidenced by explicitly considering health inequalities in the UK COVID-19 Inquiry, which aims to examine the UK’s response to and impact of the COVID-19 pandemic, and learn lessons for the future [38].

There is agreement in the literature that population health concepts should sit at the core of health curricula [39], with a focus on inclusion health groups [40,41,42]. However, due to the multi-disciplinary background of the public health workforce, development of a health protection-specific health equity training is recommended. Any education or training developed could be based on existing resources and evidence-based approaches and tools, such as All Our Health [43], Health Equity Assessment Tool (HEAT) [44], or Making Every Contact Count (MECC) [45].

Strengths and limitations

The main strengths of this study are the robust methodology, underpinned by behavioural science; and the timeliness of the discussions, to capture the views of HPTs shortly after transition from PHE to UKHSA, which can be used to inform development of the UKHSA health equity strategy. Further studies could go further to address and unpack some of the themes and the relative impact HPTs might make addressing health inequalities through different mechanisms e.g. on wider determinants.Furthermore, although there were more participants from London and the West Midlands, these teams covered some of the largest populations, and had many smaller areas within their regions; therefore, it was appropriate to collect the views from colleagues across the region, as recommended by the regional health equity lead. Moreover, participants from health protection teams from all nine UKHSA regional teams in England participated in the study, implying that we can be confident that the findings provide a true picture of current approaches to health equity across HPTs. However, the findings are limited to reflecting the English health protection system, and therefore may not be generalisable to other countries. It could also be argued that there were bias in findings as the primary participants were the nominated health equity lead(s) for their health protection team, suggesting that they were already engaged, and could therefore bias the results. However, all health equity lead(s) were given the opportunity to suggest as many other colleagues as they thought could input into the discussion, and every suggestion was invited to participate in the study.

Recommendations

Acknowledging that resources, staffing levels, time constraints and organisational barriers, following re-organisation of Public Health agencies, all impact the ability of staff to tackle health inequity is important; to overcome them requires leadership, a focus on the most impactful interventions, and efficient cross-organisational working.

Although many challenges, there was an appetite and enthusiasm to address health inequity within health protection, and UKHSA’s HPTs have a role in this. Recommendations include:

  • development of a Health Equity Strategy which sets out the remit and expectations of HPTs and the wider UKHSA.

  • take a more holistic health protection approach to support populations most in need, rather than siloed disease / hazard-specific working.

  • embed health equity into business-as-usual e.g., including / considering in SOPs, guidance, audit, clinical reviews, outbreak report, risk assessments, job roles, commissioning contracts. Approaches to embedding in health equity in national guidance, could include ensuring that all guidance and supporting resources are inclusive in their language and descriptions and promote equitable public health action across all population e.g., national guidance on diagnosing measles, rash in pregnancy, chicken pox, hepatitis B etc., to include how rashes or jaundice will appear on various skin types.

  • develop the workforce through skills audit and health equity training to improve knowledge and provide specific skills relating to evidence-based approaches to health equity.

These findings will support a more integrated approach to addressing health equity through health protection work.