Applied Research

Our applied research applies stated preference methods to identify the views and preferences of the public, patients and healthcare professionals. 

Current Projects

Does calorie labelling need the green light? Using eye-tracking within a discrete choice experiment

The purpose of this project is to analyse how consumers react to traffic light colour coding (TLCC) information regarding fat, saturated fat, sugar, salt and calories, as well as price, when purchasing a sandwich.

The main research question will specifically look at the impact of colour coding calories (the current policy recommendation is for calories not to be colour coded) on consumer’s choices. In order to better understand our results, we will also be analysing aspects consumers focus on when looking at TLLC label nutrition information as well as the role price plays on their choices. Potential behavioural differences associated with socio-economic characteristics will be taken into account.

This project is being conducted in collaboration with the Rowett Institution of Nutrition and Health.

HERU researchers involved in this research project: Patricia Norwood, Mandy Ryan and Anne Ludbrook

External Collaborator: N. Krucien (Evidera)

Exploring remote working practices for patient public involvement and engagement in health and social care research – responding to COVID-19 and rising health inequalities

Patient public involvement and engagement (PPIE) in research can lay the groundwork for improving health care and services for all. This is especially the case for disadvantaged groups. The study has been prompted by the shift to remote, non-face-to-face, forms of working in PPIE brought on by Covid-19 prevention measures. Shielding and social distancing have changed the ways of involving the public in research (such as face-to-face meetings and events). This is a mixed-methods study with: surveys, qualitative interviews, and a discrete choice experiment. We will produce an analysis of how remote working in PPIE is affected by socio-economic and health inequalities, make recommendations for improving practice and develop training packages. We will recruit public contributors involved in research projects across the UK: the NIHR, charities, universities and other research organisations and people involved professionally with PPIE. The findings will help us address the inequities of remote PPIE and inform policies that ensure everyone is able to have their say in research.

HERU researchers involved in this research project: Verity Watson and Luis Loría-Rebolledo

External collaborators: L. Frith, M. Gabbay (University of Liverpool); S. Hassan  (University of Liverpool); A. Porroche-Escudero (Lancaster University)

Improving the patient-pharmacist interaction: a new approach to help patients make informed decisions

As the patient-facing roles of pharmacists increase in practice, pharmacists need to develop effective consultation skills. This includes a patient-centred approach and shared decision making (SDM). For effective SDM, patients should be well-informed about options, evaluate the benefits versus risks and integrate these with their values. The discrete choice experiment (DCE) is a tool which structures a decision problem into an attribute-based framework and asks individuals to value options in a series of choices, highlighting the concept of trade-offs inherent in healthcare decisions. They have been used extensively to value patient experiences in healthcare, including pharmacy services. The mechanism underlying a DCE gives it a potential role as a decision aid tool (DAT).

This study will be conducted in three phases:

Phase 1 - literature review and qualitative interviews with patients, pharmacists and doctors to confirm what is important in the delivery of chronic pain treatment, and inform the DAT development.

Phase 2 - development and pre-testing of the DAT. The DAT will include multimedia information about chronic pain and a personalised-DCE component programmed to provide real-time feedback. 

Phase 3 – a pilot randomised trial will assess the acceptability of the DAT, recruitment and retention rates, and patient satisfaction with the pharmacist-patient interaction, and test outcome measures.

HERU researchers involved in this research project: Mandy Ryan, Terry Porteous and Luis Loría

External collaborators: C. Bond (Centre for Academic Primary Care, University of Aberdeen); R. Adam, P. Murchie (Institute of Applied Health Sciences, University of Aberdeen); and N. Krucien (Evidera)

Lives and livelihoods: understanding public preferences and trade-offs for government responses during a pandemic

Public health responses to the COVID-19 pandemic have impacted on people's physical and mental health, and have also had, sometimes profound, economic consequences. Public health responses must then balance protecting the population and healthcare system with the impact on the economy and personal freedoms. A better understanding of public preferences and how they differ across communities may help policy makers decide which interventions to deploy. We will use a DCE survey to elicit the relative importance of different attributes of public health responses to pandemics, and the trade-offs individuals are willing to make between these attributes.

The attributes include the type and the duration of the lockdown, the impact on the health service, the number of infections and excess deaths, the impact on household spending and job losses. We will also test if respondents’ preferences differ based on moral attitudes, demography, socioeconomic circumstances, health status, country of residence, or experience of COVID-19. We aim to collect preference data using an online survey of 4000 individuals from across the four UK countries (1000 per country).

HERU researchers involved in this research project: Mesfin GenieLuis Loría-RebolledoMandy Ryan, Ruben Sakowsky and Verity Watson

External collaborators: Shantini Paranjothy and Daniel Powell (University of Aberdeen)

Metastatic prostate cancer men’s Attitude towards Treatment of the local Tumour and metastasis Evaluative Research (MATTER)

Systemic therapy has increased overall survival in men with hormone-sensitive metastatic prostate cancer.  Novel local cytoreductive treatments and metastasis directed therapy are being evaluated, these can confer additional harm, but might improve survival. We aim to elicit men’s preferences for and willingness to accept trade-offs between potential improved survival and cytoreductive treatment risks using a discrete choice experiment.

HERU researchers involved in this research project: Verity Watson and Mesfin Genie

External collaborators: M. Connor and H. Ahmed (Imperial College London)

Predicting hesitancy and uptake for COVID-19 vaccination in France and Scotland

The Covid-19 pandemic and health policy response suggests that mitigation strategies including tiered restrictions will be in place until herd immunity is reached, i.e. above two-thirds of the population is immune against SARS-CoV-2. However, mitigation strategies aim to reduce viral transmission and therefore slow the build-up of natural immunity from infections in the population. Therefore, herd immunity may only be achieved by mass vaccination against SARS-CoV-2 infection. 

We use a discrete choice experiment (DCE) survey to assess population preferences for a range of attributes that differentiate possible vaccines. We estimate the relative importance of different aspects vaccines, and the trade-offs people are willing to make between these. We will specify a model of vaccine uptake that accounts for and models the determinants of vaccine hesitancy.

HERU researchers involved in this research project: Verity Watson

External collaborators: Schwarzinger, M. (University of Bordeaux); Luchini, S. (Aix-Marseille University); Watson, V. (HERU); Alla, F. (University of Bordeaux); Arwidson, P. (Santé Publique France)

Reducing land degradation and carbon loss from Ethiopia's soil to strengthen livelihoods and resilience (RALENTIR)

Land and soil degradation is a major problem in Ethiopia as in many countries in Sub-Saharan Africa. Restoring degraded common lands through the establishment of "exclosure" areas where traditional community access is restricted is common in Ethiopia. Both degradation and measures to restore land are inherently unequally distributed in time and space. Hence, aspects of justice and equity need to be taken into account for soil restoration measures to be sustainable in the long run.

The project will develop and apply frameworks for the analysis of equity within the case study areas to design specific interventions. Through a range of participatory, communication, and survey methods the project will explore - the impact of the interventions on the participants in terms of their attitudes, changes in behaviour, livelihoods etc - the influence of process characteristics, power relationships and communication practices on people's responses to these interventions - what worked/what didn't, how it compared to expectations - the impact of the changing knowledge and experience of the interventions on wider attitudes and community preferences for local natural resource governance.

HERU researchers involved in this research project: Verity Watson

External collaborators: Phimister, E. (Business School, University of Aberdeen); Smith, J.U., Hallett, P. (Institute of Biological and Environmental Science, University of Aberdeen); Mekuria, W., Haile, A., Tekle, A. (Nile Basin & East Africa Office, International Water Management Institute); Ameda, T.T., Lemma Argaw, T. (Hawassa University); Byg, A. (James Hutton Institute); Edo., G. (Southern Agricultural Research Institute); Fischer, A. (Swedish University of Agricultural Science); Allan, J. (Health Psychology, University of Aberdeen) and Scott, T. (University of Melbourne).

Putting men's preferences at the centre of the doctor-patient relationship: the Prostate cancer treatment preferences (PARTNER) test

Prostate cancer (PCa) affects 1 in 10 men and is the most common cancer amongst men in UK. Usually men with localised PCa can choose between several treatment options, such as active surveillance, radiation therapy, or surgery. Different treatments are associated with different risks and types of side effects including urinary incontinence, bowel function, and erectile dysfunction. There is no overall best treatment for localised PCa in terms of cancer control. Therefore, treatment choice should depend on men’s views about the different harms and benefits of each treatment. This means men face a difficult decision that will affect their quality of life.

This project will develop a new tool that can easily be used by both men and health care professionals, which will improve communication by identifying men’s preferences for PCa treatment. The tool will achieve two goals: (i) to help men identify what matters most to them by asking them to think about the PCa treatment in a simple, structured way; (ii) to communicate information about men’s preferences to consultants.

HERU researchers involved in this research project: Verity Watson

External collaborators: Krucien, N. (Evidera); MacLennan, S., MacLennan, S.J., N’Dow, J. (Institute of Health Sciences, University of Aberdeen); and Ahmed, H. (Imperial College London)

Should Scotland provide whole genomic sequencing for diagnosis of rare disorders? A health economic analysis

Taken together, rare disorders are common and affect 6-8% of the Scottish population. Most are severe and life-threatening with a profound impact upon the quality of life and wellbeing of the individual and their family. The typical journey to diagnosis, or ‘diagnostic odyssey’, can take many years, with numerous hospital visits, costly and invasive tests, several misdiagnoses, and shattered hopes and expectations; many families never receive a diagnosis. As 80% of rare disorders have a genetic origin, increasing access to genetic diagnosis is a key component of UK and Scottish Rare Disease policy. Standard genetic testing is limited to examination of DNA from single gene variants to smaller gene panels (typically <100 genes) and is triggered by specialist clinical suspicion. More recently, comprehensive sequence analysis of a person’s entire DNA (Whole Genome Sequencing/WGS) or all the protein coding parts of their DNA (Whole Exome Sequencing/WES) increases diagnostic yield (% of cases receiving a positive diagnosis) and is expected to enable quicker diagnosis.

Potential benefits to patients and families of comprehensive sequence analysis include improved diagnostic yield, reduced length and scope of the diagnostic odyssey, reduced need for clinical attendance and investigative tests, and information for family planning and clinical management. However, little is known about how patients and families value such aspects of comprehensive DNA sequencing. The financial implications are also unclear.

This study will address the evidence gap around the benefits to service users (patients and families) and assess the resource implications of different genomic testing pathways.

HERU researchers involved in this research project: Mandy RyanLynda McKenzieRodolfo Hernández and Michael Abbott

External collaborators: Z. Miedzybrodzka, L. Mennie, C. Clark (Medical Genetics, University of Aberdeen) and S. Heidenreich (Evidera)

Supporting shared decision making in early and advanced breast cancer: what matters to patients in an era of personalised care

Patients face information overload when considering the balance of risks and benefits from the wide variety of treatment options for early and advanced breast cancer. Clinical teams need help to understand what matters most to patients if they are to help them navigate these difficult choices.

The Breast Cancer Institute is funding an 18-month project to investigate preferences for breast cancer treatment. Using the discrete choice experiment (DCE) methodology, this project aims to better understand which side effects are important to individuals when balanced against potential clinical benefits.

The project will work with local patients and the clinical team to develop an online survey that seeks to measure the preferences of patients, clinicians and the general public for benefits versus specific risks. The analysis will help understand how such preferences vary between individuals and will unpick the disparity between the perceptions of the clinical team and the reality of patient wishes.

The results will be available as a basis for the development of improved shared decision-making processes, patient information or decision aids. The attributes and levels for the DCE will be informed by recent Public and Clinical Engagement (PACE) statements during the assessment of new medicines by the Scottish Medicines Consortium.

HERU researchers involved in this research project: Mandy Ryan and Luis Loría-Rebolledo

External collaborators: P. Hall (Edinburgh Cancer Research Centre, University of Edinburgh); E. Gray (University of Edinburgh) and S-M. O’Hare (Edinburgh Breast Unit)

Valuing baby boxes: what’s important to parents

The introduction of baby boxes is a Scottish policy that is unique within the UK. The policy aims to improve health outcomes for babies and provide practical support for new parents in Scotland. A Scottish Government commissioned pilot evaluation notes that rigorous longer-term studies of impact are required. Developing appropriate outcome measures for these longer-term studies is necessary.

While the importance of ‘hard’ health outcomes such as infant mortality and morbidity is clear, wider societal benefits and cultural changes to parenting may also be important. A review of safe sleep interventions found some evidence that providing cheap cribs, along with information about safe sleeping, is associated with reduced sudden infant deaths and increased parental knowledge. However, there has been very little research into the wider social and cultural impact of baby boxes. Such information is crucial for future evaluations.

Our work will explore what factors should be considered in future evaluations of baby box programmes. We will conduct analysis of both media coverage of the introduction of baby boxes within Scotland and online parental discussion forums. In addition, we will carry out a series of focus groups with women attending mother and baby groups within the NHS Grampian area. We will purposively sample a diverse group to ensure we include the views of women from different socio-economic backgrounds, educational level, geographical contexts and age groups.

As well as providing invaluable information for future evaluations of baby box programmes, and public health interventions more generally, the research will also consider the role of media coverage and online discussion forums (in addition to the more commonly used focus groups) to inform the development of valuation in economic evaluation models.

HERU researchers involved in this research project: Mandy Ryan

External collaborators: Z. Skea, L. Locock (Health Services Research Unit, University of Aberdeen); H. Morgan (Institute of Applied Health Sciences, University of Aberdeen); M. Black (Aberdeen Women's Centre, University of Aberdeen).

Other Current Stated Preference Projects

These are current projects from other Research Themes in HERU that are using stated preference methods.

Economic modelling: reducing health harms of foods high in fat, sugar or salt

Having a poor diet and being overweight can have a negative impact on health and wellbeing. To address this public health concern, the Scottish Government published its Diet and Healthy Weight Delivery Plan in July 2018. This included a number of actions focusing on children, the food environment, weight management services and leadership to promote healthy weight and diet. The primary aim of plan is to reduce the public health harm associated with the excessive consumption of calories, fat, sugar and salt, including the risks of developing type 2 diabetes, various types of cancer and other conditions such as cardiovascular disease. One commitment was to consult on plans to restrict the promotion and marketing of targeted foods high in fat, sugar or salt.

This research will use existing data from Kantar World Panel and collect new primary data on consumer preferences, using Discrete Choice Experiments, inform future Scottish Government policy on the impact of restricting the promotion and marketing of discretionary foods high in fat, sugar and salt.

HERU researchers involved in this research project: Paul McNamee and Patrícia Norwood

External Collaborators: C. Revoredo (Scotland Rural College)

Enhancing recruitment and retention of rural doctors in Scotland: a mixed-methods study

Communities living within remote and rural areas of Scotland face difficulties in accessing quality healthcare. One of the largest challenges in providing healthcare to such communities is the ability to recruit and retain healthcare staff. While there is some evidence that people born or brought up in remote and rural areas are more likely to want to work there, there is little evidence about how to attract in and keep people from more diverse backgrounds.

This Chief Scientist Office funded project, will use qualitative interviews to better understand the experiences and motivation of doctors with respect to remote and rural medical positions within Scotland. The findings from this qualitative phase, led by our sister Unit HSRU, will then inform the development within HERU of a discrete choice experiment to value the factors which influence career decision making in relation to remote and rural working.

HERU researchers involved in this research project: Diane Skåtun and Verity Watson

External collaborators: L. Locock, Z. Skea (Health Services Research Unit (HSRU); J. Cleland (Nanyang Technological University, Singapore); P. Wilson (Rural Health, Institute of Applied Health Sciences, University of Aberdeen); P. Murchie, R. Hollick (Institute of Applied Health Sciences, University of Aberdeen).

GRIP - Glaucoma Risk Prediction in ocular hypertension

A cohort study using electronic medical records to validate a risk predictor and determine the cost-effectiveness of different monitoring schemes according to risk of conversion to glaucoma.

Glaucoma is a common eye condition that can lead to loss of vision if not identified and treated early. One factor which can increase the chance of developing glaucoma is ocular hypertension (high eye pressure), which is usually detected during an eye health test at the optometrist. A tool which could identify those at the greatest risk of progressing from ocular hypertension to glaucoma would support clinical decision-making and patient communication.

The GRIP study, funded by the National Institute for Health Research (NIHR), aims to improve and validate an existing glaucoma risk calculator and also determine if it is worthwhile to treat people with milder eye pressure. NHS records of over 23,000 people who have ocular hypertension and have been monitored at eleven hospital eye services across the UK will be reviewed. The risk prediction tool will be evaluated for different follow-up periods.

Patients’ values and experiences regarding the management of ocular hypertension will also be explored with focus groups and interviews, and their preferences will be formally assessed in a discrete choice experiment (DCE).

There is more information on the study at the NIHR Journals Library.

HERU Researchers: Rodolfo Hernández and Verity Watson

Collaborators: A. Azuara-Blanco (Queen’s University Belfast); Y. Takwoingi (University of Birmingham); A. King (Nottingham University Hospitals NHS Trust); G. Gazzard, (Moorfields Eye Hospital NHS Foundation Trust); D. Crabb; City, University of London; J. Morgan (Cardiff University); C. Cardwell (Queen's University of Belfast).


PACFIND - Patient-centred Care for Fibromyalgia: New pathway Design

Fibromyalgia is a common condition with symptoms of pain, fatigue and sleep disturbance. There is not much evidence on the best way to organise health services for fibromyalgia. Patients are dissatisfied with current services and believe no-one takes responsibility.

This project will gather information from patients about their current situation and their levels of access to healthcare services. We will work with health professionals to understand how services are organised. We will then identify what better care for patients with fibromyalgia looks like. We will also estimate the benefits and costs of existing and alternative care models. We plan to undertake a discrete choice experiment (DCE) that will allow us to understand the strength of patients’ preferences for alternative models of care for fibromyalgia. By the end of the study we will have developed a new model of care for people with fibromyalgia. We will develop a plan for how the service can be put in place to ensure higher levels of patient satisfaction across the country. 

HERU researchers involved in this research project: Paul McNamee and Patrícia Norwood

External Collaborators: G. MacFarlane, G. Jones, N. Basu, K. Martin, S. MacLennan, L. 

REFLeCt trial - Fluoride toothpaste to prevent dental caries

REFLECt trial: A Randomised controlled trial to Evaluate the clinical and cost effectiveness of prescribing high concentration FLuoride toothpaste in preventing and treating dEntal Caries in high-risk older adulTs

The RELFECT study is a two arm, parallel group pragmatic open label randomised controlled trial with 36 month follow.  The trial will randomise participants from Manchester, Scotland and Northern Ireland.  The primary clinical outcome for the study is restoration or extraction due to caries.  The health economic outcomes for the study are NHS and patient perspective costs, willingness to pay and net benefit.  Two economic analyses will be completed, the first, a within trial analysis over a three year time horizon.  Discrete choice experiments will be used to value the trial outcomes within a cost-benefit analysis framework to reflect broader measures of value to patients.  The findings will be compared with a standard cost-utility analysis.  A micro-simulation modelling study will be conducted to extrapolate the findings of the trial over a participant’s lifetime.   This study will provide important information on the value of prescribing a treatment which is increasing in use, without any evidence to support its effectiveness or cost-effectiveness.

HERU researchers involved in this research project: Dwayne Boyers

External collaborators:  Tickle, M., Walsh, T., Worthington, H., Glenny, A-M., Pretty, I., Birch, S. (University of Manchester); Clarkson, J. (University of Dundee).

What keeps doctors practising? An investigation into the factors that influence doctors' retirement decisions

This project will investigate what factors doctors consider when deciding when to retire, the relative importance of these factors and how doctors might trade-off between them.

Continuing HERU’s collaboration with the Centre for Healthcare Education Research and Development (CHERI), this research will identify the push-pull factors related to the intention to retire, and will employ a discrete choice experiment (DCE) to examine which of these factors are most valued by doctors nearing the end of their careers. The research will use qualitative face-to-face interviews along with a Scotland-wide survey; distribution of which will be facilitated by the British Medical Association and NHS Education for Scotland.  

HERU researchers involved in this research project: Diane Skåtun, Ourega-Zoé Ejebu, Terry Porteous and Mandy Ryan

External collaborators: Cleland, J, (CHERI)

Recently Completed Projects

A discrete choice experiment to value the personalisation of support for self-management of chronic pain

The context was the support people receive for self-management, firstly for chronic pain, then in a replication study, for chronic lung disease. The DCE included four attributes: information (‘relevant to you’ vs. ‘the same for everyone’); communication style (‘friendly and personal’ vs. ‘neutral professional’); situation relevance (‘makes suggestions which fit your situation’ vs. ‘takes little account of your situation’); and what matters in life (‘works with you on what you want to get from life’ vs. ‘seems to think everyone wants to get the same from life’). A cost attribute was included so that willingness to pay (WTP) could be estimated.

We recruited participants from an online panel: 517 with self-reported chronic pain and 200 with breathlessness. Participants revealed positive valuations for increased personalisation of all four attributes. Greater personalisation on the attributes relating to situation relevance (WTP £15.51) and what matters in life (WTP £14.10) were valued most highly; tailored information was valued less (WTP £10.86) and more friendly communication valued least (WTP £3.46). The replication study in breathlessness showed similar results. We also found heterogeneity in valuation, particularly around the relative value of tailored information.

Outcome and Translation 

Our results should lead healthcare providers to rethink how we make support for self-management properly person-centred. Person-centred healthcare must emphasise the substance of personalisation and not just the style.

HERU researchers involved in this research project: Mandy Ryan and Nicolas Krucien.

External collaborators: C Burton, T Porteous, A Elliott (Centre of Academic Primary Care, University of Aberdeen) and V Entwistle (HSRU, University of Aberdeen)

This project is funded by The Health Foundation Inspiring Improvement programme.

Applying discrete choice experiments in pharmacy: applied and methodological issues. MRC/ESRC Postdoctoral Fellowship

MRC/ESRC Postdoctoral Fellowship. Applying discrete choice experiments in pharmacy: applied and methodological issues

This postdoctoral fellowship funded the development of peer-reviewed papers from the PhD, as well as the development of research skills in three areas: development of DCEs; their application to pharmacy, and their impact on economic evaluations in healthcare. A key focus was the evaluation of pharmacy, taking account of the patient experience and the incorporation of patient experience with an economic evaluation framework.

Outcome and Translation

Findings have implications for DCE practitioners generally – when incorporating a DCE into an economic evaluation a number of questions are raised: what factors should be valued, whose values (trial-groups vs. all–trial-population) and when should they be elicited (still-receiving-the-intervention or afterwards). Consideration should also be given to status quo bias.

Student: Michaela Tinelli

Supervisors: Mandy Ryan (HERU); Christine Bond (Academic Primary Care, University of Aberdeen).

Evaluating patient preferences for treating localised prostate cancer

An evaluation of patient preferences for the treatment of localised prostate cancer

Men with localised prostate cancer have to choose between active surveillance and radical therapy, which can entail a variety of treatment options from radiotherapy to surgery or minimally invasive interventions. This study applies a discrete choice experiment to elicit men’s preferences for, and trade-offs between, the attributes of pre-treatment evaluation, treatment and post-treatment follow-up for several available treatments. The study also investigates how subjects’ characteristics affect their treatment preference.

Outcome and Translation

The available treatments have minimal differences in terms of mortality. This study added to the evidence about how men with localised prostate cancer trade-off the differences between the treatment process and side effects.

HERU researchers involved in this research project: Verity Watson, Divine Ikenwilo and Nicolas Krucien

External collaborators: Hashim Ahmed and Mark Emberton (UCL)

Gatekeeping in intensive care: what factors influence professionals’ decision-making surrounding admission to the intensive care unit

Informed by a literature review and data from observation and interviews with ICU clinicians and outreach nurses, we designed a choice experiment. Senior intensive care doctors (consultants) and nurses were presented with pairs of patient profiles and asked to prioritize one of the patients in each task for admission to ICU.

For the consultants, patient’s age had the largest impact at admission followed by the views of their family, and severity of their main comorbidity. Physiologic measures indicating severity of illness had less impact than the gestalt assessment by the ICU registrar. We identified four distinct decision-making patterns, defined by the relative importance given to different factors. 

Outcome and Translation

ICU consultants vary in the importance they give to different factors in deciding who to prioritize for ICU admission. Transparency regarding which factors have been considered in the decision-making process could reduce variability and potential inequity for patients.

HERU researchers involved in this research project: Mandy Ryan and Nicolas Krucien

External collaborators: C. Bassford, F. Griffiths, G. Perkins, S. Quinton, K. Rees and A.M. Slowther (University of Warwick)

Improving the public health sector in South Africa: eliciting public preferences using a discrete choice experiment

The proposed introduction of a national health insurance (NHI) scheme in South Africa is the most important issue currently on the health policy agenda in that country, with implications for the whole health system. The scheme aims to achieve universal health coverage. To date there has been little opportunity for public engagement in the development of health policy around this scheme. This study aimed to better understand the community’s preferences in relation to key aspects of healthcare services when selecting healthcare providers, in order to identify priority areas for reform in the supply of public healthcare. It used a discrete choice experiment to elicit public preferences of the community in the Western and Eastern Cape.

Outcome and Translation

Communities are prepared to tolerate public sector health service characteristics such as a long waiting time, poor staff attitudes and lack of direct access to doctors if they receive the medicine they need, a thorough examination and a clear explanation of the diagnosis and prescribed treatment from health professionals. These findings prioritise issues that the South African government must address in order to meet their commitment to improve public sector health-care service provision.

HERU researchers involved in this research project: Mandy Ryan

External collaborators: A Honda, D McIntyre (Health Economics Unit, University of Cape Town, South Africa) and R Van Nierkerk (Rhodes University)

Integrating monetary and non-monetary approaches to assessing shared, plural and cultural values of ecosystems

By improving our understanding of the differences between individual, shared, plural and cultural values, and how to assess them, this research will provide policy-makers with the evidence and tools necessary to give social impacts more robust consideration in future policy decisions.

The project includes three deliberative monetary- and non-monetary valuation case studies assessing the value of ecosystem services (the benefits of ecosystems to human well-being). These consider how social processes might shape shared values, and will test the merit of different monetary and non-monetary techniques for capturing these values. Although the project is largely framed around ecosystems and biodiversity, it will also review shared values around health and the project outcomes are expected to be valuable to all fields requiring social-economic valuation of non-marketed goods.

Outcome and Translation

Shared values are different from individual values and elicitation of shared values can have substantial advantages over conventional individual valuation. The ethical, moral and justice dimensions of many environmental issues necessitate approaches that allow for the elicitation of shared and plural values. However, there is widespread conflation and diversity of ways in which shared, plural, cultural and social values are used, but they are rarely conceptualised and often they are used interchangeably.

A mixed method approach is required to elicit the multiple dimensions of shared values. Deliberative and social learning processes can help people understand the values of others and can lead to increased sharing of values or greater acceptance of the decisions that emerge from such processes.

This research is a collaboration with the Aberdeen Centre for Environmental Sustainability (ACES) within the National Ecosystem Assessment Shared Values Working Group.

HERU researchers involved in this research project: Verity Watson and Mandy Ryan

External collaborators are: J Kenter (Aberdeen Centre for Environmental Sustainability, University of Aberdeen) and M Pinard (School of Biological Sciences, University of Aberdeen)

Investigation of the value placed on the National Clinical Assessment Service by referrers in the National Health Service

In 2008 around 800 performance concern cases were referred to the attention of the NHS National Clinical Assessment Service (NCAS) from all parts of the UK. These cases required NCAS support, which ranges from phone advice to major and multidimensional assessment with the possibility of suspending or excluding the healthcare professional. A ‘mixed methods’ approach was used to investigate NHS organisations’ preferences for the services provided by NCAS.

The study combined interviews, discussion groups and a discrete choice experiment (DCE). The discussion groups explored which aspects of the services provided by NCAS are important and why, and the discussion groups were used to identify drivers of preference heterogeneity for NCAS services.

The focus groups and discussion groups informed the DCE, which was administered during 2010. The final report was published in June 2010 by NCAS. This project informed NCAS about the value to NHS organisations of clinical performance support services.

Outcome and Translation

The results of this study can be used to assess the value for money of NCAS, and can inform future changes to the range of services which they provide.

HERU researchers involved in this research project: Verity Watson and Mandy Ryan

External collaborators: J Sussex (Office of Health Economics)

Patients preferences for treatment of lower urinary tract symptoms: a discrete choice experiment

In this study, we used a mixed methods approach to establish men’s preferences for different lower urinary-tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) treatment characteristics, the impact of LUTS and LUTS treatment on their quality of life, and the trade-offs men are prepared to make between treatment characteristics and quality of life. Our mixed methods approach combined online focus groups and a DCE. The mixed methods approach provided a rich data set that can be used to explore preferences for treatment of LUTS/BPH.

Outcome and Translation

We find LUTS have a large impact on many aspects of men’s quality of life. Many men were reluctant to take medication in general. However, men value treatment that improves day-time frequency of urination, night-time frequency, and urgency of urination. A medicine targeting a mix of symptoms, with a particular focus on improving urgency combining either reducing night-time frequency or substantially reducing day-time frequency, is likely to have the highest benefit for patients.

HERU researchers involved in this research project: Divine IkenwiloMandy Ryan, Verity Watson and Sebastian Heidenreich

Public attitudes towards drug misuse and drug treatment strategies

Research evidence is strong for opiate replacement treatment (ORT), and current policy is moving from harm reduction to rehabilitation. However, public opinion (attitudes) can be at odds with evidence. This study explored the relationships between attitudes, knowledge of drugs and a range of socio-demographic variables that potentially influence attitude. Values were elicited using willingness to pay (WTP).

The response rate was 38.1% (1,067/2,803). Less than 10% had personal experience of drug misuse but 16.7% had experience of drug misuse via a friend/acquaintance. Regression modelling revealed more positive attitudes towards drug users in those with personal experience of drug misuse, (p < 0.001), better knowledge of drugs (p = 0.001) and higher income (those earning >£50,000 per annum compared to <£15K; p = 0.01). Over half of respondents were not willing to pay anything for drug treatment, indicating they did not value these treatments. Respondents were willing to pay most for community rehabilitation and least for methadone maintenance treatment. Qualitative analysis of open responses indicated strong negative attitudes, doubts over the efficacy of methadone and consideration of addiction as self-inflicted. There was ambivalence with respondents weighing up negative feelings towards treatment against societal benefit.

Outcome and Translation

There is a gap between public attitudes and evidence regarding drug treatment. Findings suggest a way forward might be to develop and evaluate treatment that integrates ORT with a community rehabilitative approach. Evaluation of public engagement/education to improve knowledge of drug treatment effectiveness is recommended.

HERU researchers involved in this research project: Mandy Ryan

Valuing comprehensive genome sequencing to improve diagnosis of rare disorders: a health economic perspective

In the single-centre micro-costing exercise, mean costs of clinical evaluation, local laboratory processing, variant interpretation, result reporting and data storage were around £6,924 per family trio for WGS, compared to £2,452 for trio-based WES. Median costs for standard laboratory testing (including tests performed within and outside Scotland) were £1,478 per singleton patient with intellectual disability and £1,997 per patient with other phenotypes. We are in the process of validating our costings in the three other Scottish genetics centres.

The EQ5D-3L is the current UK standard for assessing the value of health care intervention. However, concern has been raised about its applicability to DNA sequencing due to its focus on health outcomes, thus ignoring wider benefits which have been recognised as important.

To understand the EQ5D-3L’s ability to assess the patients’ and families’ valuation of WGS, we interviewed six parents of affected children and three adults with a rare condition. Although the negative effect on wellbeing of the diagnostic odyssey is well documented, participants reported perfect health on all dimensions of EQ5D-3L (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). Thus, any change in wellbeing attributable to WGS would not be detected using EQ-5D. While the chance of obtaining a diagnosis was valued, other important factors include: length of time to get results; secondary findings; health-related information for other family members; and contribution to future research from having the test.

Using the economic instrument of willingness to pay, which provides a monetary measure of value, respondents were willing to pay between £200 and £2000 for WGS. Our results support the need to go beyond diagnostic yield and EQ-5D when valuing WGS, and to more appropriately assess the user perspective.

This project on will be the focus of our future research.

Outcome and Translation

A key outcome of this project was to develop a grant application to the Scottish Government to take this work forward, conducting a cost-effectiveness and cost-benefit analysis of WGS in Scotland. 

HERU researchers involved in this research project: Mandy RyanLynda McKenzie, Blanca Moran and Sebastian Heidenreich (Honorary HERU and Evidera)

External Collaborators: Professor Zofia Miedzybrodzka and Dr Lynne Mennie (Medical Genetics, University of Aberdeen)

What health care experiences matter to patients and how can we assign value to them for policy making purposes?

Healthcare policy leaders internationally recognise that people’s experiences of healthcare delivery are important, and invest significant resources to monitor and improve these. However, the value of particular aspects of these experiences – relative to each other and to other healthcare outcomes – is unclear.

This project considered how economic techniques have been and might be used to generate quantitative estimates of the value of experiences of healthcare delivery.

The project first developed a conceptual map of patients’ experiences. The map reflected insights from the capabilities approach. We conducted a systematic review of applications of economic techniques to healthcare delivery. We found that these techniques have been quite widely used to estimate the value of standardised features of healthcare systems and processes (e.g. of care delivery by a nurse rather than a doctor, or of a consultation of 10 minutes rather than 15 minutes), but not to estimate the value of the (potentially diverse) implications of these for patients’ experienced capabilities. To inform future research relating to the valuation of experiences of healthcare delivery, we organised a workshop for key stakeholders.

Participants undertook and discussed ‘exercises’ that explored the use of different economic techniques with capabilities-based descriptions of experiences of healthcare delivery. The workshop identified a number of methodological issues that need careful attention, and highlighted some important concerns about the ways in which quantitative estimates of value might be used in relation to aspects of healthcare delivery. However, it confirmed enthusiasm for efforts to attend to experiences of capability associated with healthcare delivery.

Outcome and Translation

It is hoped this research will provide an impetus for bodies such as NICE, and those involved in evaluation studies such as RCTs, to broaden their measure of value in line with what matters to patients in the provision of healthcare.

HERU researchers involved in this research project: Mandy Ryan, Philip Kinghorn

External collaborators: V Entwistle, J Francis and C Fraser (HSRU, University of Aberdeen)