Fuse blog

The importance of partnership working to improve priority-setting in public health decision-making (Fri, 10 Feb 2017 06:00:00 +0000)

Guest post by Sarah Hill, Fuse PhD student, Newcastle University

Last month I attended a workshop in London that explored how local authorities could be supported in setting priorities to improve people’s health and wellbeing. The workshop provided a platform to report the findings of a follow-on study to the Fuse led "Shifting the Gravity of Spending?" project and to explore methods for supporting local authorities in priority-setting.  Watch the video below to find out more about the study.

As a health economics PhD student looking into methods of evaluating public health interventions, the workshop was of interest to me since the prioritisation tools focused on at the workshop are a part of the evaluative toolkit I am examining. Additionally, as a health economist by trade - who was thrown-in at the deep-end of public health just over a year ago when I started my PhD research - any opportunity to meet those working in the public health field is one that I seize in order to broaden my knowledge and appreciation of the public health context.  Particularly public health officers and those working outside of the academic realm.

A full report of the workshop can be found here for those who are interested in the outcomes of the event; I will focus here on a few of the key points from the event.

Small group discussions centred around partnership working
At the close of the workshop, following small group discussions, each group of delegates was asked to feedback one key point that came out of their discussion regarding how to aid the use of prioritisation tools for public health spending decisions. Interestingly, a number of the points fed back from each group were related to partnership working to make decisions; such as:
  •  “gathering together” with NHS partners to ensure funding for effective interventions is secured when benefits may fall outside of public health’s remit and more under the NHS umbrella; 
  • considering a “place based” approach to seek good outcomes within a place rather than within separate organisations and;
  • working with local politicians to move decisions forward by understanding their objectives.
The take-home message I got from these points was that for priority-setting to be most successful in public health, a wider viewpoint needs to be considered given the number of stakeholders outside of public health teams that are involved in funding decisions and interventions being successfully implemented. This point echoes a sentiment voiced by Professor Peter Kelly at the recent Fuse meeting on inequalities (see Professor Paul Johnstone’s blog on the meeting here) who emphasised the huge reduction in both alcohol-related hospital admissions and smoking rates in the North-East since a regional approach has been taken to tackling tobacco and alcohol through pooling local resources to invest in initiatives like Fresh and Balance.

The impetus placed on collaborative working coming out of the workshop has given me something to think about for my PhD research since it appears that being able to evaluate interventions in such a way that incorporates and reflects that way of working is valuable. In fact, this is not necessarily a new thought; incorporating intersectoral costs and consequences has been established as a challenge to be addressed when evaluating public health interventions by health economists previously. A review I recently conducted on existing economic evaluations of public health interventions indicates that there is still a lot of room for improvement when it comes to overcoming this challenge and actually incorporating intersectoral costs and consequences. Often evaluations are conducted from either a health care or provider perspective, thus only considering the costs to those sectors exclusively. Also, of the evaluations I reviewed and those previously identified in the literature, the incorporation of consequences (i.e. benefits or disbenefits) to sectors other than the intervention provider is practically non-existent.

Perhaps if more evaluations were able to reflect who benefits from an intervention and to what extent this may enable more collaborative working between different partners and sectors in either funding and/or aiding with the implementation of interventions. Of course the availability of appropriate data is a real barrier since an evaluation is only as good as its data, thus a drive needs to be made within public health departments to stipulate the collection of appropriate outcomes data from the very beginning of an intervention being commissioned to build up the database for effective evaluations.

Shifting the Gravity of Spending? Workshop to explore methods in public health priority-setting was held on the 17 January 2017, and funded by the NIHR School of Public Health Research and supported by the Local Government Association and Public Health England.  The “Shifting the Gravity of Spending?” project is led by Fuse Deputy Director Professor David Hunter at Durham University.

Mannequin challenge: preparing cancer nurses through simulating emergency situations (Fri, 03 Feb 2017 06:00:00 +0000)

Guest post by Gillian Walton, Director of Learning and Teaching, Northumbria University 

Tomorrow (4 February) is World Cancer Day, a day where millions of people across the world unite to raise awareness of cancer. One in two people will be diagnosed with cancer at some point in their lives (cancer research UK), an alarming statistic. Currently, 8.2 million people die from cancer worldwide every year, out of which, 4 million people aged 30 to 69 years die prematurely.

Of the millions of people diagnosed, a high percentage will receive systemic chemotherapy (anti-cancer drugs that are injected into a vein or given by mouth) as a primary, secondary or palliative form of treatment.

Students role play chemotherapy induced emergency situations
As a previous oncology nurse I’m acutely aware that managing chemotherapy and the potential life threatening side effects can be demanding and highly stressful. Management of acute side effects is usually a nursing responsibility which adds extra pressure not only on resources but the knowledge required of the many drugs available to treat over 200 different cancers. Chemotherapy drugs are highly toxic and can have life threatening side effects, so managing severe reactions is essential. This can therefore be a scary environment for both the nurse and the patient!

Mannequins mimic the symptoms of a deteriorating patient 
At Northumbria University I run a chemotherapy module and have designed a simulation based interactive educational (SBE) activity to encourage students to engage in scenarios to simulate chemotherapy induced emergency situations. Simulated practice has been described as the "activities that mimic the reality of a clinical environment and are designed to demonstrate procedure, decision making and critical thinking through techniques such as role playing and the use of devices such as interactive manikins” (Jefferies 2005)1. Ongoing qualitative research by my colleague Alan Platt who collaborates with me on this project has shown that the use of simulation informs and improves student performance. His knowledge and findings have facilitated translating the theory into practice. We use high fidelity mannequins, which can mimic the symptoms of a deteriorating patient so the student can role play chemotherapy induced emergency situations in a safe simulated clinical environment. Students are briefed prior to the encounter about the clinical scenario and their role as a nurse caring for a patient in a chemotherapy day unit. They are asked to be themselves and to act as they would if they were at work in the clinical area. A clinical expert assists the learning experience by providing prompts for the nurses to manage the emergency situation. Covert cameras record the scenario in real time and allow the students to review and reflect “on action” and evaluate their performance following the scenario. I then debrief the group which is widely recognised as a critical element of simulation-based education. Debriefing following the scenario allows the students to engage in reflective learning(Fanning and Gaba 2007)2,3 as well as consider decision making, risk management, patient safety and communication amongst the team. Although the students initially find it a bit daunting being filmed and working with dummies that can actually speak, breath and blink their eyes, they also have said that it’s a fun and great way to learn.

All students complete a questionnaire after the SBE relating to the learning experience. To date, 100% of the students reported that the use of simulation enhanced their learning and that the learning was stimulating and exciting. The majority of the students said that they would recommend the learning experience to a colleague. Comments suggest that they learnt how to react if they experienced the situation again in practice which increased their overall confidence; the main objective of the exercise.

The use of simulation means students feel much better prepared to manage chemotherapy emergencies. Overall they valued the learning experience and the opportunity to reflect on their practice in a safe environment. This in turn translates to greater safety for students and patients.

Evaluation and research findings provide support that simulation is an effective learning technique which prepares students to manage the situation should it arise in clinical practice.

  1. Jeffries, P. (2005) A framework for designing, implementing and evaluation simulation used as teaching strategies in nursing. Nurse Education Perspective; 26: 2, pp96-103
  2. Fanning RM, Gaba DM. (2007) The role of debriefing in simulation-based learning. Simul healthc;2:115Y125.
  3. Gaba DM. (2004) The future vision of simulation in health care. Qual Saf Health Care;13(suppl 1):i2Yi10.

The first step to an equal North (Fri, 27 Jan 2017 06:00:00 +0000)

Guest post Professor Paul Johnstone, Regional Director, Public Health England, North of England

The inaugural meeting of the North of England’s research and practitioner network to address health and social inequalities, hosted by Fuse in Newcastle, was an inspiring beginning. Over 350 people have signed up to ‘Equal North’, including most universities and local practitioners. Judging by the energy and ideas in the room this is going to be an interesting and important development and journey.

EQUAL North: how can we reduce health inequalities in the North?

We heard from Professor Dame Margaret Whitehead (pictured left) who chaired the original ‘Due North’ inquiry on health inequality in the north in 2014. Due North had flagged health in all policies as a potential lever and her recent work with the House of Commons All Parliamentary Party Group on Health in All Policies was particularly impressive.

Professor Peter Kelly (right), Director for the North
East Public Health England (PHE) Centre reflected on earlier work by primary care trusts and the health authority from which to draw important lessons.

And I (pictured left) described some of what has happened since Due North was published. In preparing my slides I wanted to go back and look myself at earlier work from Yorkshire and Humber days when we measured health inequalities in life expectancy, a government target 10 years ago.

What I found was striking: affluent areas, such as York, North Yorkshire and East Riding which had life expectancies above the England average five years ago (78.6 years for men / 82.6 years for women) improved still further to the national trend (which has increased by an average of 0.4 years over five years). Lowest for life expectancy - such as Hull for men and Doncaster, Wakefield and Barnsley for women - made no improvement at all. The increasing gap is the challenge; whether we look at health, education, or the economy. In a highly-centralised country like England such inequalities are hardwired into the fabric of the country from infrastructure investment to schools.

The seismic shifts following the Brexit vote could change all of this. Theresa May said on the steps of Downing Street that she wants to address the injustice of inequality and the ‘nine year gap’, referring to recent PHE published data on life expectancy. The new Industrial Strategy, launched on 22 January at a regional Cabinet held in an innovation park in Warrington; the RSA* Inclusive Growth Commission; and the early outputs from the National Infrastructure Commission and the Children’s Commissioner for England’s Growing Up North, again address what is needed.

It is in this context of widening inequality, with new national resolve to address it, that we launched Equal North. As a network of researchers and practitioners across the north this gives us a tremendous opportunity to influence policy:
  • What can we learn from earlier government inequalities polices, from the days of spearheads, for example?
  • How best do we translate complex data on inequalities into simple local actions and how best to influence local devolution deals for elected mayors and local politicians?
This needs to put communities and individuals at the heart of the action, not graphs and charts. I said earlier that this could be an interesting and important journey. Together we made the first step in Newcastle.

For more information about this Fuse Quarterly Research Meeting please visit the event page on the Fuse website.  The presentations from the event will be available soon.

*Royal Society for the encouragement of Arts, Manufactures and Commerce

An education in how research influences parliament, policy & practice (Fri, 20 Jan 2017 06:00:00 +0000)

Guest post by Charlotte Kitchen, PhD student, Mental Health Research Centre, Durham University

It seems fitting that my first post for the Fuse Open Science Blog is about my time in the Parliamentary Office of Science and Technology (POST).

I have just returned from a three-month secondment from my PhD; this meant relocating from Durham University’s Queens Campus to POST's Westminster Offices in London. As you can imagine this was a bit of a culture shock for a country girl but it was also an amazing opportunity that I would definitely recommend to others. POST is Parliament’s in-house source of independent, balanced and accessible analysis of public policy issues from across the biological, physical and social sciences, as well as engineering and technology topic areas. POST is responsible for producing briefings (usually four page summaries of a topic) for MPs and Peers in order to place the findings of academic research on these topics into a policy context for Parliamentary use. The main mechanism for achieving this is the recruitment of POST fellows (that's me!) who are PhD students who undertake short placements with the objective of producing a briefing on a topic area of interest to Parliament.

The Parliamentary Archives
Big Ben (Elizabeth Tower) at Christmas

I was tasked with preparing a ‘POSTbrief’ on ‘selective education’ which was a responsive policy briefing based on a mini literature review. This was in reaction to the current debate on the issue and the government consultation on grammar schools, which closed in December 2016. I was required to research and write the brief, interview a range of leading academics and stakeholders, attend debates in the Houses of Commons and Lords as well as liaising with the House of Commons Education Select Committee. My PhD is in adolescent mental health so the prospect of working in a new topic area was daunting but it turned out to be a challenging and rewarding experience that has definitely improved my confidence, ability to articulate complex information and writing skills.

Whilst working at POST, I was asked to support the House of Commons Education Select Committee during the Autumn 2016 term - a lot more interesting than it sounds! I got to meet various MPs, attend a committee meeting where I was asked to brief the committee on the topic and had the opportunity to feed directly into the everyday work of Parliament. The enquiry the Committee was undertaking on the topic will report shortly. My work at POST culminated in the publication of an open-access parliamentary briefing 'Academic Evidence on Selective Secondary Education' which was circulated to MPs on the Education Select Committee and others with an interest in the area. I also had the opportunity to undertake some speech writing for an MP (under supervision, of course) just to keep things interesting!

Mr Speaker selfie
The take home message of my blog is don’t be afraid to apply for a POST fellowship - like I was! Before I applied, people said they were too competitive and it wasn’t a good idea to take time off during your PhD but three months away from your thesis is a small price to pay for the experiences I have had in the Houses of Parliament. Where else do you work where there is not one or two, but three gift shops!? One of the more surreal highlights had to be a selfie with the Rt Hon John Bercow MP, the Speaker of the House of Commons whilst attending a Christmas Carol Service. In all seriousness, this fellowship has added a parliamentary publication to my CV, provided me with much needed policy experience, opened my eyes to how research influences parliament, policy and subsequently practice. I learnt many of the practical ways you can get your research noticed: from keeping an up to date academic biography and profile, publishing open-access so non-academic institutions can access your work, producing blogs to make your work more accessible to non-specialists and utilising social media to publicise your research.

The whole experience at POST is one I will not forget in a hurry and it was made possible through funding from the British Psychological Society; the closing date for this year’s fellowship scheme is 31 August 2017. There are other funders who have different deadlines throughout the year such as research councils, societies and charities. For more established academics there are also opportunities to work more closely with parliament that are worth considering.

And finally, the obligatory tourist shot...

Me and my mum

A prescription for tackling riskier drinking? (Fri, 13 Jan 2017 06:00:00 +0000)

Guest post by John Mooney, Fuse associate and Senior Lecturer in Public Health, University of Sunderland.

In keeping with the ‘Dry-January’ season, John Mooney reflects on a current initiative to assess the feasibility of alcohol brief interventions in high street pharmacies…

“A man walks into a high street chemist – and asks for a paracetamol and an Alka-Seltzer…” could be the start of a very unpromising joke or sketch outline… Thankfully, it’s neither, as it more accurately depicts a very common scenario, which might represent the basis of a potentially effective setting (namely pharmacy / high street chemist shops) for health promotion messages around the health risks from alcohol misuse and / or overconsumption.

AUDIT score card collection box, with prize incentive to participate
Alcohol unit indicator diagram

Unsurprisingly perhaps, it is by now fairly well established that “alcohol brief interventions” (ABIs) - in which short well-validated questionnaires about habitual drinking patterns and consequences are linked to tailored advice and feedback - can be an effective intervention in primary care based consultations / GP practices as evidenced in the SIPS trial. Evidence for the effectiveness of such interventions however is less convincing in other settings, even those where, as in a GP consultation, health is the primary focus of the interaction. Pharmacy outlets for example might be considered an obvious parallel candidate ‘setting’ where, as in the scenario above, there may clearly have been an alcohol related context surrounding the primary reason for the person’s visit.

Indeed, in addition to over-the-counter ‘remedies’ which might be sought out after alcohol over-indulgence, there are a number of ‘indicator-prescriptions’ which could be suggestive of a more chronic / long-term damaging level of alcohol consumption (such as stomach acid suppressants or high blood pressure medications). High street chemists therefore, by virtue of their community embedded location, specialist knowledge and windows of opportunity for engagement, could theoretically present a very promising setting for ABIs. The lack of evidence of effectiveness in studies where this has been rigorously evaluated, has prompted questions as to why this might be the case. Investigators have speculated on the explanation being attributable to anything from the variable attitudes of pharmacy staff to the additional time and resource constraints associated with modern pharmacy practice. A recent Master of Pharmacy dissertation at the University of Sunderland(1) – which explored possible reasons in interviews with pharmacy staff, provided some local corroboration for these potential explanations. Interviews with participating pilot sites had also however noted the value of the awareness raising aspect of the process:

“Some patients had been drinking a bottle of wine a night and didn’t realise that it could contain 9-10 units and they were really shocked when they realised”

Other potential strengths of pharmacies as a setting for ABIs might be the now well established practice of providing support to pharmacies looking to embrace a wider health promotion role. As part of NHS England’s current ‘Promotion of Healthy Lifestyles’ programme, pharmacies are now required to participate in up to six health promotion campaigns per year(2). This generally involves the display and distribution of leaflets provided by NHS England or other collaborating institutions or stakeholders. As a result, there are usually highly visible and engaging ‘health promoting and awareness raising materials’ adorning the display areas of high street pharmacies and messages around alcohol health risks and reducing them are often a focus of such displays.

Given that the brief questionnaires and tailored advice of alcohol brief interventions is a more pro-active approach than the passive display of information, a current UK pilot feasibility study for pharmacies in several UK regions funded by Drinkaware UK, involves participants self-completing a score card that is the basis of most ABI interventions. Abbreviated as AUDIT, the Alcohol Use Disorder Identification Test, developed by the World Health Organisation(3), involves a series of questions about drinking habits and the extent to which drinking might have impacted on daily activities. Not quite ‘shock tactics’, the revelation of a score that flags up concern – can give respondents some cause for reflection – especially after the season of excess! Of course the score cards themselves have information on where respondents can seek further help and participating outlets receive training in responding to questions that might arise. Essentially the pilot aims to examine how best to integrate ABIs, as unobtrusively as possible into the day-to-day working of the pharmacy.

Not a programme lacking in ambition, the same score cards are also being distributed by trained advisors in selected participating supermarkets and other community settings across the UK, the evaluation of which is set to be complex and challenging. Ultimately the organisers hope to be able to make best practice recommendations about the most effective way to implement ABIs in pharmacies and other settings, where traditionally ‘hard to reach groups’ including working age men (a key high risk group for developing alcohol related health problems) can be more easily targeted.

AUDIT score cards with information leaflets
Indeed the current Drinkaware national campaign (‘Have a little less’) of which the above initiative is a part, will be run to coincide with 'Dry-January'. With a particular focus on working age men aged between 45-60, the message is that ‘Having a little less’ alcohol can have significant health benefits. This is in line with an emerging expert consensus around some of the potential drawbacks of an over-emphasis on one month of the year(4) and that it would be more beneficial for example to achieve three drinking free days for every week of the year. With long term trends in UK consumption still on the rise and a 44 per cent increase since 2009 in those aged 50 and over accessing alcohol treatment, all initiatives exploring innovative ways of getting the message across are to be welcomed. Don’t be too surprised therefore if you are asked about alcohol consumption the next time you collect a prescription!

Note: The Sunderland University Team who are evaluating the Drinkaware community ABI pilot comprises: Prof Jonathan Ling, Mr John Mooney (PI), Dr Zeibeda Sattar and Dr Nicola Hall. Please address any correspondence to john.mooney@sunderland.ac.uk

  1. Asghar S. Assessing the Feasibility and Practicality of delivering Alcohol Brief Interventions in Pharmacy Settings. MPharm Dissertation, University of Sunderland 2015/16.
  2. PSNC page on promoting healthy lifestyles: http://psnc.org.uk/services-commissioning/essential-services/public-health/ 
  3. PHE Guide to WHO AUDIT: https://www.alcohollearningcentre.org.uk/Topics/Latest/AUDIT-Alcohol-Use-Disorders-Identification-Test/ 
  4. http://theconversation.com/dry-january-is-it-worth-giving-up-alcohol-for-a-month-51956
Photography by Eileen Robinson Art ©

Engaging ‘harder-to-reach’ service users - Food as a Lifestyle Motivator (Thu, 05 Jan 2017 06:00:00 +0000)

Guest post by Dr Clare Pettinger, Registered Dietitian, Registered Nutritionist (Public Health) and Lecturer in Public Health Dietetics, Plymouth University

My research (the Food as a Lifestyle Motivator (FLM) project) has explored the use of creative methods to engage with homeless individuals in discussions about their wellbeing. The project demonstrates that food, as well as being central to many health concerns, may also be a powerful ‘lifestyle motivator’ for those on the edges of society. During the project, powerful visual and narrative food themed data have been generated that provided a ‘voice’ for homeless individuals, challenging traditional research paradigms and identifying innovative approaches for engaging and empowering community groups that are traditionally ‘harder-to-reach’.

FLM was based on local evaluation work showing that, by engaging in food projects, unemployed and homeless individuals showed improvements in eating, self-esteem, and social skills (Pettinger and Whitelaw, 2012)1. I saw, first hand, socially excluded individuals being so moved and empowered by food activities that something really shifted in them. This was a ‘light bulb’ moment for me in my (early) research career!

The stark realities of extreme poverty (homelessness) are well documented, including food-related chronic/acute health problems and drug/alcohol addictions. Such transient communities have multiple and complex needs that present challenges for researchers, therefore, a democratic and creative approach can be beneficial.

The FLM pilot used ‘Photo-Elicitation’, which involved participants being issued with disposable cameras, given brief instructions on their use, then taking photos of their food activities over a ten-day period. Photos were then developed and focus groups run for them to discuss their images. In this context, the photograph is seen as a neutral third party (Schulze, 2007)2 and particularly useful when discussing issues with ‘vulnerable’ people (Liamputtong, 2009)3. Our findings illustrate how self-captured food photos (see selected examples) can both facilitate the process of food research itself, but also generate important ‘in-roads’ for lifestyle and wellbeing enhancements. Our small sample of nine homeless service users provided powerful narratives, showing that for them, food holds meaning, elicits emotion and exerts power; and that the food environment can be a critical social place: food preparation can provide companionship and occupation. Thus revealing the highly individualised perspectives of those who are doing the best they can in light of multiple deprivations.

"…I can’t eat in the dining room, because I am scared of crowds and large groups of people…" (Nemo)
"Food has become a major part of my life. I really enjoy cooking actually it beat the demons in my head……look how far I have come…" (Ross)
These creative methods have had their challenges. As an evidence based practitioner, I am trained to assess the hierarchy of evidence to ensure rigour and transferability of research design. Yet such highly structured and often sterile/impersonal research designs are far from appealing to the participant group I am interested in. With public engagement currently a key priority for research impact, the need to make methods more accessible to participants is crucial. Understanding the diversity of ‘harder-to-reach’ community groups, giving them a ‘seat at the table’ and listening to their voices is crucial to their engagement.

With hunger a topic of national debate, there is an urgent need to consider how to engage better with socially excluded individuals and communities. Creative approaches, such as Photo Elicitation, offer great potential and as such should be endorsed by public health directorates across the country.

This project has gained a lot of local (and regional) interest because it ‘ticks the box’ for innovative commissioning practices. Not only can this approach be used as a means to enhance health and wellbeing in a diverse range of service users, it can also be used for public consultation on service (re)design. Other than publishing the work (currently underway), current FLM data collection with service providers across the city is mapping food related assets and using ‘appreciative inquiry’ interviews to establish key priorities. Thus aiming for these approaches to be embedded into the local inequalities strategy, to inform food/nutrition policies - recommending the use of participatory socially inclusive food activities as part of service provision.

"Getting involved in food can be a starting point to address other things that are ‘broken’ and lead to progress in other ways" (quote from homeless shelter keyworker). Creative food methods can offer meaningful occupation, thus generating a virtuous circle where food promotes engagement and engagement promotes interest in self-care. Food, therefore, becomes an expression of empowerment, with the potential to enhance health, wellbeing and social justice.

  1. Pettinger C and Whitelaw E (2012) Food Cultures: Growing, cooking, eating: “An exploration of improving food practices in young men and older adults in Plymouth” Report written for DH funded project. Unpublished - available at http://www.foodplymouth.org/wordpress/wp-content/uploads/2013/01/Food-Cultures-FINAL.pdf 
  2. Schulze, S (2007) The usefulness of reflexive photography for qualitative research: a case study in higher education. South African Journal of Higher Education 21 (5) 536-553
  3. Liamputtong P (2009) Researching the vulnerable. A guide to sensitive research methods. London Sage. p112

Merry Christmas and Happy New Year from Fuse (Thu, 22 Dec 2016 06:00:00 +0000)


Understanding the health benefits of the ‘sugar tax’: how will the soft drinks industry respond? (Fri, 16 Dec 2016 06:00:00 +0000)

Guest post by Oliver Mytton, Centre for Diet and Activity Research (CEDAR) & MRC Epidemiology Unit, University of Cambridge
Today our paper, a health impact assessment of the government’s proposed ‘sugar tax’ was published in the Lancet Public Health. The government’s proposal, announced in April of this year, took health campaigners by surprise. Not only was it unexpected, but the government’s proposal was unusual.

Other countries, notably Mexico, have introduced a sales or excise tax on sugary drinks. However, the UK government proposed a levy on soft drinks manufacturers or importers based on the volume of sugary drinks sold. There will be two levels of tax, a higher level on drinks with more than 8g per 100ml, and a lower level on drinks with 5g to 8g per 100ml.

With others, I have previously modelled the potential health benefits of a ‘simple’ excise tax on sugary drinks, but the industry levy is more complicated.

Industry levy – how it might work  

The levy might lead to a reduction in sugary drinks consumption through a number of pathways, and from listening to industry experts and reviewing statements made by soft drinks manufacturers, it was apparent that nobody knew quite how the industry would respond.

The nature and magnitude of these responses might lead to very different health outcomes, which is what we describe in our paper. For our health impact assessment, we identified three broad responses that the industry might make:
  1. reformulation (reducing sugar content); 
  2. price rises that pass the cost on to consumers; and
  3. changes in marketing practices to ‘shift’ consumer preferences, e.g. away from high sugar drinks to diet drinks.
For each response, we then identified a ‘best case’ and ‘worst case’ scenario.

Modelled health benefits

From these six scenarios, we were able to estimate changes in consumption of sugary drinks. We then estimated changes in health, using data describing the relationship between sugary drinks consumption and three outcomes (dental caries, type 2 diabetes and obesity).

The most beneficial modelled scenario for health was reformulation (reduction of sugar content by 15% for ‘mid-sugar’ drinks and 30% for ‘high-sugar’ drinks), with an estimate of 140,000 fewer adults and children with obesity; 19,000 fewer incident cases of diabetes each year, and 270,000 fewer decayed, missing, or filled teeth annually in the UK. Important reductions in disease were also associated with the maximum expected price increase (equivalent to half the levy cost being passed onto consumers) and changes in marketing share.

The least beneficial modelled scenario for health was a change in market share that resulted in consumers switching not only from high-sugar drinks, but also from diet drinks, to low sugar drinks. This might result in an (small) increase in consumption of sugary drinks and consequent (small) increase in disease (using the measures we looked at). If the price is passed on to all soft drinks (rather than just sugary drinks) the health benefits were also substantially reduced.

Across the scenarios the most striking finding was the concentration of the health benefits in terms of obesity and dental caries amongst children and younger adults. They are the major consumers of sugary drinks. Diabetes follows a different pattern with many more cases likely to be prevented amongst adults than children, because there are relatively few incident cases of type 2 diabetes among children and young adults.

In doing this, we have not made an overall estimate of the health benefits of the new levy, rather we have identified the benefits attributable to different industry responses to the levy and put upper and lower bounds on those responses.

Policy implications

Consumers appear to be turning away from sugary drinks

Our assessment shows that the health benefits of the levy will be greatly affected by how the industry responds. We have identified scenarios where the health benefit is minimal (or conceivably negative). However, we think this is unlikely: there are strong signs from industry that there will be significant reformulation, consumers appear to be turning away from sugary drinks and most of the scenarios we modelled were beneficial for health.

While we are not as optimistic about reformulation as others, our work does further suggest that reformulation of sugary drinks has potential to mitigate some of the health risks associated with regular consumption of sugary drinks. Reformulation of soft drinks probably has more scope than I previously thought. The government levy may, particularly by using two tiers, be a relatively effective tool to incentivise reformulation.

It also suggests that the industry levy may not be a ‘simple’ intervention. Whilst we have described discrete responses, it is possible that the levy may stimulate several changes. Not just the changes described in our study but others, e.g. changes in consumer attitudes, reductions in portion sizes and introduction of new low sugar products. If it does do this, the government’s approach may be very effective, perhaps more effective than a ‘simple’ excise tax.

On the flipside, it may also be more uncertain or risky as its success depends on how industry responds. This creates a potential role for government and health organisations to apply pressure on industry to respond in ways that improve health. This uncertainty also underscores the need for a careful evaluation that can capture the important industry responses.

Finally, whilst there are reasons to be optimistic and the government should be applauded for this initiative, it does underscore the need for ‘brave and bold’ action across a variety of areas concerned with food and physical activity (which the recent Childhood Obesity Plan failed to deliver) to markedly reduce obesity. As I have written before, this measure alone will not ‘solve’ obesity, but it can be an important step towards improving population health.

The one where we ask you to vote... (Thu, 08 Dec 2016 06:00:00 +0000)

Posted by Mark Welford, Fuse Communications Officer, Teesside University

This post is a little like those episodes of Friends in which one of the cast says: “Do you remember the time when [cue wobbly vertical lines]…” and the rest of the 22-23mins is made up of clips from previous shows.

Courtesy of photobucket.com/user/xuyu79/media/blog/s7/s07e18 / Warner Bros.
Let me take you back to a post on Thursday 7 January in which we made a shameless plea to ask for your votes in the UK Blog Awards 2016.  In that post we told you how the blog’s 334 posts had received just over 167,000 views.  Eleven months on and 40 additional blog posts later, the page views have risen to nearly 325,000 - a fantastic achievement I hope you’ll agree!  I discovered this when an ambitious academic asked me if I could provide them with some killer stats about the blog to support their bid for a promotion. The power this blog wields!

This year we have had posts covering everything from Dry January, the ‘nanny state’, animation, Jamie Oliver's school dinner and sugar tax campaigns, to ‘fat shaming’, indigenous Australians, Baywatch, energy drinks, Grandmothers, e-cigarettes, and 'legal highs'.

Five years on from the blog's inception and we have reached the point where people are actively approaching us and generously giving up their time to write posts, rather than having to send in our crack team (the fear inducing) ‘blog working group’ to chase, harry and cajole*.  Could this - and the increased viewing figures - have something to do with the little matter of winning a UK Blog Award last year?  I'd like to think so.

And now, we come to the crux of this post.  It is you, our dear readers and contributors that make the blog a success and it is thanks to you that we won a national award.  So we've decided to go for it again in the UK Blog Awards 2017!

Here comes the shameless plug

The blog has again been entered into two categories: 'Health and Social Care', and 'Education'.  You can vote for us in either category but of course we would really appreciate it if you voted for us in both.

Vote now by following this link

The above link takes you to our profile page on the UK Blog Awards website in which we have chosen two of our favourite posts from 2016:
Voting closes at 10am on Monday 19 December.  One vote per email address.

Hopefully it won't be a maple syrup bottle we'll be holding aloft in celebration come April 2017!

Thank you for your support.

*We do still need your posts!  Please contact me (m.welford@tees.ac.uk) if you would like to write a post for the Fuse blog. Here’s how to take part.

The biology of inequality and the role of the generalist (Thu, 01 Dec 2016 06:00:00 +0000)

Guest post by Tony Robertson, Lecturer in Public Health, University of Stirling

My research focuses on trying to better understand how our cultural, social and economic circumstances ‘get under the skin’ to impact on our physiological systems and influence our health and the development of disease. The emergence of this field investigating the social-to-biological transition has grown over the last twenty years with the increased availability of biological measures biomarkers in many of the large, population-based health and social surveys such as Understanding Society and the English and Scottish Health Surveys. This growth in collecting simultaneous biological and social data, longitudinally (repeatedly over a period of time from the same individuals) and across the life course, is key if we are to continue to advance our knowledge of the biological and health impacts of our environments and society. So far, much of the evidence is based on cross-sectional data (data collected at only one point in time, rather than repeatedly) or where we have biomarkers measured once, but with repeat social data for the same individuals over a number of years. However, studies such as Understanding Society are beginning to provide us with biological measures from the same individuals measured over several years. This type of longitudinal data will help us to better understand how our bodies change over time and the relative importance of different stages of our lives (for example, childhood versus young adulthood).

The increase in data linkage to routinely collected data records (e.g. education surveys linked to health records) is also allowing us to research the long-term health consequences of social and economic circumstances, even after studies and surveys have stopped running. It may also be possible in the future to carry out such linkage between health and social data with biomarker data, collected when visiting your doctor for example. There are obviously many ethical, financial and practical challenges and questions linked to these types of data linkage ideas, but they offer possibilities to broaden our knowledge of the social determinants of health. It is also becoming slightly more common to see intervention studies including biomarker measures that will allow us to see the physiological effects that will be occurring long before we ‘feel’ or see changes in health, perhaps changing how we can demonstrate ‘effectiveness’.

Public health and social epidemiology are often multidisciplinary pursuits, or at least many of us arrive working in these fields from multiple academic and professional backgrounds. However, there remains a need for greater cross-discipline collaborations to help us better study the links between our social, cultural, environmental and political circumstances and our wellbeing, health and physiology. I am keen to see more biologists, epidemiologists, social scientists, statisticians etc. work together on these projects. I trained as a biologist up to and including PhD-level before moving into public health and social epidemiology. One of the key roles I now fulfil (and enjoy) is acting like a match-maker, and sometimes a translator, for lab scientists and social and public health scientists to come together to work on research projects. This type of role is becoming ever more common, especially in public health where we need a mix of specialists and more of these generalists, with expertise across a range of disciplines. This is by no means an easy role to play as it can mean being the conduit to link specialist researchers and/or practitioners together without then being able to play a leading role in the development and implementation of these research studies. It’s the ‘jack of all trades, master of none’ issue. However, without these generalists with interests and expertise that span multiple disciplines we continue to risk limiting innovation and interaction to help impact on areas like health inequalities. Perhaps the saying ‘a jack of all trades is a master of none, but oftentimes better than a master of one’ is a better representation of what I’m aiming for. I hope.

If you’re interested in finding out more, please visit Tony’s website www.BiologyOfInequality.com and you can also find him on Twitter @tonyrobertson82 

Photo attribution: 
  1. “jack-of-all-trades” by shai aharony via Flickr.com, copyright © 2016: https://www.flickr.com/photos/139807035@N05/25607414481 
  2. “match_maker_love_machine” by Capes Treasures via Flickr.com, copyright © 2012: https://www.flickr.com/photos/26652069@N07/8390808924

Novel Psychoactive Substances: “Cheap drug, better buzz for your money” (Thu, 24 Nov 2016 06:00:00 +0000)

Posted by Fuse Associate Dr Michelle Addison, Institute of Health and Society, Newcastle University

At the beginning of November practice partners, police, health professionals, academics and service users came together at ‘The Core’ in Newcastle to discuss the impact and consequences of Novel Psychoactive Substances (NPS) – commonly known as ‘legal highs’. Before anything had even begun we had the BBC on the phone, asking if they could come and film us and interview people about NPS for their forthcoming Panorama show, airing in 2017. NPS is certainly newsworthy. It has captured the public imagination in a myriad of ways, sparking fears of an epidemic, concerns over the impact it is having on resources, and headlines from The Independent declaring Newcastle to be ‘Britain’s most addicted city’. How much truth is there in these claims and how much of this is just hyperbole? What impact are NPS having on North East England, and what are the consequences? We tackled these questions during the event, generating lively debate. These discussions were grounded in the most up-to-date research, as well as city-wide strategies to tackle NPS, and personal accounts of NPS use.

Image courtesy of the bbc website
But what are NPS I hear you ask? They’ve been around a while – they are a group of synthetic or plant based substances that mimic the effects of other more well know illicit drugs like cannabis, ecstasy and heroin – to name a few. They have become increasingly popular across most of the United Kingdom, but particularly in the North East. The law recently changed in the UK (26 May 2016) making it an offence to produce, supply, offer to supply, possess with intent to supply, import or export (including over the internet) any psychoactive substances. However, possession of NPS is not an offence except in a custodial institution. The debates during our event showed that the speed of change in this drug market and an increase in the reported associated harms of NPS have meant that they are a growing concern to local, regional and national bodies.

Professor Eugene Milne, the Director for Public Health in Newcastle Local Authority, opened the discussions by highlighting that NPS use is continuing to put pressure on available resources across emergency responders in the local area, that service providers are working hard to develop pathways to treatment, and that there are unknown long-term health consequences for this group of people. He spoke about the local and city-wide strategies that are currently being developed through a collaborative process within the ‘Task and Finish’ group focused on tackling issues around NPS use, distribution and management.

Dr Michelle Addison (that’s me!) and Dr Kelly Stockdale were up next to discuss our research, funded by N8 Policing Partnership, about the impact and consequences that NPS are having on police practitioners and substance users in the North East. We showed that NPS users are perceived to be extremely volatile in custody and the staff were concerned with managing risk – both to themselves and this vulnerable group of people. The custody nurse was viewed to be a great asset but users were still frequently transferred to A&E – creating a further resourcing challenge. NPS users felt that the substances were be highly addictive and linked to poor health outcomes. They were keen on getting help and treatment but were unsure about where to access this.

We were joined by Kieran Platts, Project Officer at Youth Homeless North East (YHNE). He gave a lively account of the really valuable work he has undertaken exploring young people’s views on NPS. This work was prompted by concerns raised through the housing and youth homeless sector who report finding it increasingly difficult to manage the impact of NPS on their resources and service users. Kieran added to the debate, saying that NPS are undermining the operational delivery of services for homeless young people and adversely effecting young people’s ability to address their individual housing and associated needs.

Professor Simon Thomas, from Newcastle University, talked about the toxicology of NPS – an elegant and accessible insight into their chemistry and toxic effects. He presented interim data from the Identification of Novel psychoActive Substances (IONA) study which is collating information about the range and prevalence of NPS that are present in patients who have ingested acutely toxic substances in the UK. He talked everyone through the emerging trends of NPS use in different areas of the UK, as well as changes over time, and differences in clinical effect.

Lorna Smith, (Public Health Registrar) and Rachael Hope (Community Safety Specialist - Drugs) Newcastle City Council, delivered important key messages about the evidence led approach underway to address NPS across Newcastle. Leading on the Task and Finish group, they have developed a detailed city-wide plan focused on understanding the circumstances of the NPS user, improving practice, and ways of protecting vulnerable groups of people. They highlighted the importance of tackling supply in the city and across the force area, but described this as an iterative process of action and learning in a relatively unknown context.

Chris Strachan, who is currently a volunteer at Positive Response to Overcoming Problems of Substance misuse (PROPS) North East, talked us through his personal account of NPS from a user perspective – offering bold and challenging insights into how users are perceived. Not all users are vulnerable and some would prefer to self-identify as psychonauts (Davey et al., 2012) – people who purposely experiment with drugs and establish detailed technical knowledge. His feelings were that practitioners should not be fearful about engaging with NPS users, adding that they are often incredibly knowledgeable about the chemical structures of these substances.

We couldn’t permit the BBC to film us for ethical reasons, but many of our speakers have been in communication with them since and will appear on Panorama in 2017. After a lot of rich debate however, Chief Inspector Lisa Hogan, Northumbria Police, brought it all together by emphasising that there are ongoing strategies and research underway to expand the evidence base around NPS – but this needs to be further developed. These discussions helped to provide in depth insight into where we are at with NPS, and what we currently know – but of course, there is more to be done. Future directions at the moment are focused on developing meaningful therapeutic interventions to help support users and understand the long-term health outcomes from NPS use.

The event Novel Psychoactive Substance (NPS) use and its consequences was delivered in partnership with Public Health England (John Liddell) and Fuse.

Join the discussion on Twitter using: #NPSimpact

What do I really get from a conference? (Thu, 17 Nov 2016 06:00:00 +0000)

Posted by Christina Cooper, Fuse Postgraduate Researcher, Faculty of Health & Life sciences, Northumbria University

As a PhD student there comes a point in your research when you are ready to start disseminating your work and opening it up to feedback from your peers. This is not only important for your personal development as a researcher, but also in demonstrating your contribution to knowledge, a vital step, the importance of which is reinforced throughout the PhD process. Conferences provide an accessible and valuable way for students to present their work, as either a poster or short oral presentation. Attending a conference can feel daunting at first, but regardless of whether you are presenting or not, the benefits of attending and participating cannot be highlighted enough. Conferences can be regional, national or international, but they all share in common the opportunity to learn from, and network with peers and experts with some shared common interest.

Far from being 'just a poster' - an opportunity to discuss my work
I am a public health PhD student at the beginning of my third, and final, year investigating what works, for whom, and in what circumstances in the prevention of risky behaviour by young people, using realist methodologies. For me, my second year felt like the ideal time to begin disseminating my work, through publishing in peer reviewed journals and attending conferences. I have participated in a number of conferences over the last year, from small university based and local regional conferences, to larger national and international conferences. Submissions so far have been in poster format, detailing various aspects of my research covering the research protocol, methodology, and early findings. Far from being ‘just a poster’ these presentations have provided me with an opportunity to discuss my work with other students, and professionals in the field, helping me to develop my ideas, make connections with those investigating similar subjects, and perhaps most importantly, to build up a support network with those in a similar position to myself. The expert advice and guidance gained from a conference is of course invaluable, but often there is nothing more reassuring, when you are struggling with a difficult concept, than hearing the words ‘me too’. Knowing you are not alone can be just the motivation you need to keep reading, keep talking, and keep going until you find a way through.

Most recently I attended the 2nd International Conference on Realist Evaluation and Synthesis held by the Centre for Advancement of Realist Evaluation and Synthesis (CARES), in London. The focus of which was Advancing Principles and Strengthening Practice. Aside from the benefits of presenting
as discussed above, attendance at this three day conference allowed me to attend talks and presentations by a wide range of researchers, including some of the biggest names in realist research. Covering subjects addressing complexity in public health research, attaining funding for realist projects, and knowledge building and translation. The breadth and depth of the material presented provided insight into the realist methodology that would be hard to gain elsewhere. In addition to these thought provoking sessions, time was given to discussion of the myriad of ways in which the realist methodology is employed in research, and how these may be developed to advance knowledge, not just within our specific fields, but also within the methodology itself. These ‘open mic’ sessions, in which disagreement was not only welcome, but encouraged, provided an opportunity to think through new ideas, allowing us to present, debate, challenge and defend our use of the realist methodology regardless of level of expertise. For me, being present for and involved in these discussions was a unique opportunity which allowed me to engage with my chosen methodology at a deeper level.

"...disagreement was not only welcome, but encouraged..."
As a student, relatively new to realism, two key themes emerged repeatedly over the course of the conference. Firstly, how do I know what I am doing is really realist? Secondly, the difficulty of grappling with the complexity of realist research as a lone working student. Both issues I have experienced myself in the last two years, and were indeed part of the reason I wanted to attend the conference; it was greatly reassuring to discover I was not the only one. Not only were there other students there feeling exactly the same way, many of the other delegates, including some of the ‘big names’ such as Professor Ray Pawson, Dr Gill Westhorp, and Professor David Byrne were able to identify with us, and provide support and encouragement. There is still a great deal of work to be done in taking the realist methodology forwards and I am excited about being a part of that, both in the work towards my PhD, and as a researcher in the future.

Photo attribution: “Academic fact fight - debate” by Frits Ahlefeldt FA-L.com via Flickr.com, copyright © 2015: https://www.flickr.com/photos/hikingartist/17163831686

It’s complicated: health inequalities and e-cigarettes (Thu, 10 Nov 2016 06:00:00 +0000)

Guest post by Frances Thirlway, Fuse Associate member, Anthropology Department, Durham University

While the e-cigarette wars continue to rage, we still have very little information on the extent to which the most disadvantaged smokers are using e-cigarettes to quit. The smoking toolkit provides invaluable information regarding overall UK usage; however, most international research into the practices of e-cigarette users has been done via on-line user groups or forums. For anyone concerned with health inequalities and the social gradient in smoking, this is of limited use since the digital divide means that e-cigarette users active on internet forums are unlikely to come from the poorer communities where smoking is now concentrated.

Figure 1: The life cycle of a vaper - but note the gendered image

In contrast, slow research ‘takes the local as a starting point’ and does this through ‘extended interaction in particular sites’ (Adams 2014 p. 181). Anthropological work involving in-depth place-based research and examining local culture as a dynamic influence can be particularly helpful in researching e-cigarette use. This is not only because user practices vary according to age, gender, class and other factors, but also because e-cigarettes themselves are not a single product. Moreover, the typical ‘user life cycle’ involves a progression from basic to more sophisticated models of e-cigarettes over time. Complete smoking cessation can happen at any point in this process and is likely to be gradual and difficult to capture in simplistic smoker/former smoker divisions, which is why research which follows smokers and quitters over months or years is needed – one participant in my recent study took three years to move from dual use of tobacco and e-cigarettes to e-cigarette use only, and he was not untypical. As Figure 1 and the associated article illustrate, most successful users start with ‘first-generation’ models, but those who persevere generally find that second-generation models and beyond are more satisfying.

The key word here is ‘successful’ - because switching from tobacco to e-cigarettes is not an easy process. I found that users: ‘struggle with the time, effort and expense involved in finding the ‘right’ e-cigarette and the frequency of product failure i.e. cheaper tank models splitting, leaking, or bubbling if over-tightened or dropped, and problems with batteries running out or failing to charge.’ This meant that: ‘unless users were highly motivated to quit, smoking was significantly easier, and often cheaper taking into account the cost of e-cigarette replacement and the ready availability of illicit tobacco.’ (Thirlway 2016 pp. 109-110)

Whilst some public bodies and individual users have started to provide information and guidance about using e-cigarettes to quit smoking, many barriers to use remain, particularly for the poorest. There is little doubt that you are more likely to switch successfully if you can afford to try different models, and replace the ones you break. It also helps if you have time to spare, a fondness for electronic gadgets and the ability to feel at home in the – largely male - vaping subculture.

These and other issues are explored further in: Thirlway, F. (2016) Everyday tactics in local moral worlds: e-cigarette practices in a working-class area of the UK. Social Science & Medicine 170 pp. 106-113

Too stressed for words? Involving those experiencing stress in research (part 2) (Wed, 02 Nov 2016 06:00:00 +0000)

Posted by Fuse members Sonia Dalkin, Lecturer in Public Health and Wellbeing, and Natalie Forster, Senior Research Assistant, Northumbria University

Following on from our post last year on National Stress Awareness Day, and in light of the current media attention paid to welfare benefits, we wanted to take the opportunity to reflect on the difficulties of involving those experiencing stress in research. This is in relation to our recent recruitment efforts for a realist evaluation of the impact of Citizens Advice (CA) on health.

"Stress" by Bernard Goldbach
CA provide independent, impartial, confidential, and free advice to everyone on their rights and responsibilities. This includes advice on debt, benefits, employment, housing and discrimination. Throughout the study, a recurrent theme of stress has been evident. The links between stress and health are abundant. This stress lens therefore formed the health focus of the study, overcoming the difficulties of recording the variety of outcomes leading to health improvements and capturing changes to health which would only be evident beyond the study timescale. Determining if and how CA services reduce stress should enable us to project the potential health impact of CA.

We carried out a mixed methods evaluation, detailed here. This required CA clients to complete a questionnaire when they first accessed CA and six weeks later. CA staff collected the questionnaire data for the research. Twenty-seven clients were also invited to participate in interviews. CA staff were initially apprehensive about data collection, due to clients often being in crisis and therefore having extremely high levels of stress.

Initially, recruitment was very slow. This was due to a variety of factors, some of which could be related to stress:
  • Some clients were too stressed to engage in completing the questionnaire at Time 1 (initial contact with CA).
  • CA staff found it extremely difficult at times to get in contact with clients at Time 2 (six weeks later). This was often due to their own heavy workload but also due to client reluctance to answer calls from unknown numbers (CA has a withheld number) and client wishes to move on with their lives once issues had been resolved.
  • Clients were reluctant to participate in interviews because they were too stressed and had often been let down by other organisations when disclosing personal information. 
  • Some clients also suffered from severe mental health issues which meant they found the prospect of an interview very stressful. 
To overcome these barriers, several strategies were employed. These were developed collaboratively with CA, and through engagement with the project steering group.

  • We worked with CA staff to develop a bespoke questionnaire, meaning that CA staff felt confident that it was not over burdensome for clients. This included shortened versions of questionnaires where possible. Questionnaires were also carried out by a client’s named CA contact who they trusted and would be more comfortable disclosing information to.
  • We ensured that CA staff had a detailed understanding of the research aims in order to explain the research clearly to participants and gain their trust in the research. They could therefore highlight the importance of completing the Time 2 questionnaire to participants. When participants understood that the research aim was to show the ‘good work’ CA do, as opposed to focusing on their issues, they were more likely to engage. 
  • Offering interviews at a client’s home or via skype, in addition to the original offer of interviews at CA Gateshead allowed for participants to be in a location where they felt most relaxed.
  • Offering clients the option of having their named and trusted CA staff member attend the interview for the first 10 minutes allowed this trusting relationship to be transported to the interviewer.
  • Offering clients the option of having a relative or friend attend the interview also helped to put the client at ease. In one case, the client gave permission for their partner to do the interview on their behalf as they had been highly involved in the process of interacting with CA.
These improved strategies led to the collection of 261 Time 1 questionnaires with a 92 per cent follow up rate, and 23 clients participating in interviews.

Although CA staff were initially apprehensive about data collection, working in partnership and being flexible with recruitment strategies overcame this. It is important to provide all clients with the option of participating in research; presumptions of non-participation remove client autonomy which is unethical. In this research project and all research with people experiencing difficult circumstances it is essential to involve - where possible - any potential participants, the organisations working with clients, and experts, to find the most fruitful recruitment strategies.

The CA research team also consists of Monique Lhussier (Reader in Public Health and Wellbeing); Philip Hodgson (Senior Research Assistant) and Sue Carr (Professor of Public Health Research), who have all read and contributed to this blog post.

The study ‘Exposing the impact of advice services on health and inequalities’ is funded by the NIHR School for Public Health Research (SPHR), via the Public Health Practice Evaluation Scheme (PHPES). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.


Photo attribution: “Stress” by Bernard Goldbach via Flickr.com, copyright © 2011: https://www.flickr.com/photos/topgold/6273248505

Mapping collaboration and constructing a compass (Thu, 27 Oct 2016 05:00:00 +0000)

Guest post by Lindy Turnbull, Senior Lecturer, Faculty of Health and Life Sciences, Northumbria University

Collaboration is promoted as a key aspect of commissioning and delivery in public health (NHS England, 2016) and health care (NHS England and NHS Improvement, 2016). Joint working and integration of services are seen as the way forward for the future NHS with new integrated models of care at the forefront of service redesign, and collaboration core to managing increased demands with diminishing resources. Although collaboration is a familiar concept and has been the subject of research and discussion it is still an area of practice which is poorly understood. It is striking that existing definitions of collaboration identify professional sharing with the focus on patient care, yet there is little representation of patients in most studies and the role of patients in collaboration seems to be missing from the existing theory.

I began my research after leading the development of Outpatient Parenteral Antimicrobial Therapy (OPAT) a new model of care which required collaborative working across secondary and primary care to deliver treatment in patient homes. The development of this service was challenging and required strong collaborative relationships to overcome the organisational barriers to integration. Having experienced the challenges of collaborating to develop an integrated service I wondered if these difficulties continue into the delivery of the service in practice, and how collaboration takes place within the challenging environment of the constantly reorganised NHS.

The aim of my research was to develop substantive theory about what collaboration means in the delivery of integrated care, the way it is manifested in day-to-day practice and how it is shaped by the situation in which it takes place. I viewed patients and professionals as participants in collaboration and interviewed three patients and 21 professionals. I have used a social constructionist approach to grounded theory (Charmaz, 2008) and a range of situational mapping techniques (Clarke, 2005)1 to map collaboration within the situation of integrated care delivery. Analysis was a fascinating and absorbing experience as I used mind mapping software to analyse and compare the perspectives of those involved in collaboration and then to combine perspectives to map and analyse the complexity of the situation.

Participants expressed a number of interactive mechanisms (trusting, communicating, co-ordinating and rehearsing) which were influenced by a range of situational co-ordinates (goals, limits, certainty, uncertainty and power) and these were used together to navigate the complexity of the healthcare situation and direct the process and outcomes of collaboration. The capability of individuals to act, or interact was informed by their interpretation of the situation and this directed the capacity for collaboration within the care situation. Positional mapping techniques identified four directions of collaboration: developing, maintaining, limited and disrupted, and I found that limiting factors were significant in changing the direction of collaboration. The communication of some social limitations such as terminal illness, professional roles or work requirements altered an individual’s capability to collaborate and the capacity for collaboration within the situation.

My analysis has constructed a collaboration compass which is used to navigate the situation and direct the collaboration experienced by patients and professionals. I am in the process of writing up and still fighting my enthusiasm to write about everything I found and learned during my study; there simply aren’t enough words!

  1. Clarke, A. (2005). Situational analysis: Grounded theory after the postmodern turn. Thousand Oaks, CA: Sage.
Health Research Authority summary: The Meaning and Manifestation of Collaboration in Domiciliary Outpatient Parenteral Antibiotic Therapy: A Grounded Theory Situational Analysis.

Who wins: the tortoise or the hare in the race for health benefits? (Thu, 20 Oct 2016 05:00:00 +0000)

Posted by Liane Azevedo, Fuse staff member and Senior Lecturer in Physical Activity and Public Health, Teesside University

At the 63rd American College of Sports Medicine Annual Meeting in Boston, USA this year, an interesting debate took place which was titled ‘Who Wins: the Tortoise or the Hare?'. The debate discussed the latest research findings on a hot topic in physical activity research: what is better for your health; high intensity exercise or reducing sedentary behaviour in favour of light to moderate exercise? I was expecting a heated debate; however, the session was quite balanced with both sides presenting the pros and cons of their approach, followed by a talk on the middle ground by Tim Church suggesting that the best is exercise in moderation (the benefits of regular moderate-intensity exercise).

Let’s start with the arguments for reducing sedentary behaviour. The sedentary behaviour ‘defence’ was presented by Genevieve Healy from the University of Queensland. She talked about a study which showed that a reduction in sitting, in favour of more standing or stepping, could both promote cardio-metabolic benefits (concerning heart disease and metabolic disorders such as diabetes) to improvements in glucose and lipid metabolism (the synthesis and breakdown of glucose and fatty acids). Similar results were shown in other presentations at the conference with a number of studies also showing that interrupted sitting with walking (rather than just standing) can improve insulin response, resting blood pressure and lipid concentration. Moreover, Genevieve provided a number of examples of interventions for the workplace and for older populations, such as Small Steps, Stand Up For Health and Stand Up Australia, which have all shown to be effective

I presented evidence of this argument myself at the conference in a poster about a systematic review which we conducted on sedentary behaviour interventions for children. We found that sedentary interventions are mostly ineffective to reduce BMI (body mass index) in a mixed-weight population but can be effective for treatment of an overweight or obese population.

In the case of sedentary behaviour major questions still remain, for instance, are the risks of sedentary behaviour for cardiovascular diseases independent of physical activity? In other words, if you have a job like mine that requires you to sit for long hours and you try to compensate for this behaviour at the end of the day by doing 30-40 mins of moderate to vigorous physical activity, does this mean that you still have the same cardiovascular disease risks as, for instance, someone who does not exercise? The answer appears to be no; the risk seems lower (phew … ). However, the data in the literature is still contradictory. But it was interesting to see well known scientists in the field like Charles Matthews recognising that these behaviours might not be as independent of each other as it was originally thought when it relates to health risks.

The case for the opposite argument - that high intensity exercise is more important for your health - was made by Professor Ulrik Wisløff from the Norwegian University of Science and Technology. He presented a number of studies which showed the additional benefits of vigorous activity compared to moderate or total physical activity on a number of health indicators, such as all-cause mortality, improvement of maximum aerobic capacity and in endothelial (the inner lining of blood vessels) function, and as an effective treatment of arterial fibrillation (abnormal heart rhythm) in unhealthy patients.

The audience questioned Professor Wisløff about the risk of injury when doing high intensity exercise, how to translate these findings into physical activity guidelines, and the long term sustainability of this type of exercise. Wisløff said that in their studies there were no report of injuries, but admitted that long term sustainability still needs to be investigated. A starting point for demonstrating the feasibility of high intensity exercise in a real-life setting can be found in the study completed by Dr Kathryn Weston at Teesside University. In the study she investigated the effect of a school-based high-intensity interval training on cardio-metabolic health. She found that the high intensity exercise did not only improve some cardio-metabolic parameters but was also delivered as intended.

Therefore, I would say that the answer to the question ‘who wins the tortoise or the hare?’ is that both are winners. For some people high intensity exercise can be the most exciting way to exercise, while for others just the substitution of sedentary to light and moderate is the suitable (also it doesn’t need to be one or the other). The most important point is to choose something that will encourage you to do physical activity, because the health benefit is there for both.

Acknowledgment: Liane Azevedo would like to thank Fuse and Teesside University for the support to attend this Conference.

Photo attribution: “Image from page 216 of "St. Nicholas [serial]" (1873)” by Internet Archive Book Images via Flickr.com: https://www.flickr.com/photos/internetarchivebookimages/14781657201

Bridging the gap between (mental) health services and needs: negotiating power and political values (Thu, 13 Oct 2016 05:00:00 +0000)

Guest post by Dr Angus Forsyth, Senior Lecturer in Mental Health Nursing, Northumbria University

As Monday was World Mental Health day, there will be familiar messages in the media about the barriers faced by people with mental health problems when seeking appropriate care and treatment. These include (but are not limited to) the difficulties that children and young people face in accessing local services, not to mention specialist services, such as support for young people who may experience eating disorders. For adults the suicide rate has increased, and there are more and more pressures on crisis services and in-patient beds. As overall funding within the NHS is further reduced, mental health services face additional financial cuts as their funding is diverted to other clinical groups whose needs have been identified as more of a priority. 

Steve McDonald (Simon Gregson) battled depression in Coronation Street

As if lack of access to mental health services is not problematic enough, people with mental health problems are also more predisposed to physical health disorders due to the combined effects of certain medications, lifestyle factors, such as smoking and lack of exercise, contributing to obesity and other metabolic disorders. This contributes to early mortality for people with long standing mental health diagnosis such as schizophrenia, having a reduced lifespan of 20 years. Despite these inequalities the Department of Health’s guidance (2011) recommended parity of esteem for people with mental health problems to have the same level of access to services as those with physical illnesses. And even this recommendation has yet to be achieved. 

On the positive side, there has been a relative increase in coverage of mental health related issues within the media and society, either through celebrities disclosing personal issues, storylines in popular TV dramas; magazines, and social media. However, there still persists a stigma associated with the experience of mental ill-health, for example that people with Schizophrenia are unpredictable and predisposed to violence (Houses of Parliament 2015).

Whilst fear and lack of understanding are factors that maintain stigmatising beliefs and attitudes, power inequalities are also evident when exploring the above barriers to meaningful services. These power imbalances can lead to the development of oppressive social systems and organisational practices where the exercise of authority or power can lead to the marginalisation of specific groups. An example of this is the implementation of government policy, for example the reduction of resources and the subsequent allocation of funding by commissioning agencies (as servants of government), can result in further disadvantaging of citizens as in the case of young people attempting to access mental health care. In the majority of these cases, care can only meaningfully be accessed when there is a serious risk to self and others and is provided under the legislative procedures of the mental health act and in locations far from the individual’s home. This example illustrates how healthcare is provided in an oppressive system.

This brief summary of the challenges in accessing comprehensive care and resources that are available to people with mental health issues highlight that as the expression of mental health becomes more dominant, service provision and resource allocation has not kept pace with increasing need and demand for services. This is particularly in light of mental and physical ill-health co-existing and becoming common bedfellows in chronic disease management. Let’s hope that World Mental Health Day not only highlights issues related to the experience of mental health but acts as a catalyst to mobilise meaningful social actions such as:-
  1. Reviewing the public and political structures to include the meaningful involvement of service users at all levels of the decision making process (Rethink 2016). This would further highlight inequalities and disadvantage experienced by individuals and meaningfully influence the development of comprehensive mental health service provision.
  2. Reorganise health and social care structures around the holistic needs of service users rather than in the functional silos that currently operate.
  3. Use World Mental Health Day to evaluate the impact of service delivery for vulnerable groups to identify meaningful changes and clarify further challenges.

A nation stood still for 25 years: Can we find solutions for action in policy and practice? (Thu, 06 Oct 2016 05:00:00 +0000)

Guest post by Ben Rigby (pictured), a postgraduate student in Durham University’s School of Applied Social Sciences and Associate Member of the Wolfson Institute of Health and Wellbeing Research

Fourteen – the number of pieces of legislation published since 1991 which specifically state ‘physical activity’ (PA) in the context in which Public Health England presents as a problem needing a long-term solution. That is, an unsustainable burden on the UK economy, resulting from diminished health and well-being, which may be alleviated by increasing population-level PA.
I want to help do something about this problem. For the next few years, I will be undertaking a North East Doctoral Training Centre ESRC-funded PhD to research how PA-related practice, evidence, and policy interact to benefit or disadvantage different population subgroups. This project will be supervised by both Dr Emily Oliver and Dr Caroline Dodd-Reynolds, co-directors of Durham University’s Wolfson Institute Physical Activity Special Interest Group. 

Although advances in public health policy and evidence have emerged, not least through the work of the Fuse’s Physical Activity Group on improving evaluation and translation, for example, there remains a clear disconnect between use of evidence, proper evaluation and the influence (and interference) of policy and politics in decision making and the provision of activity opportunities. Having worked for Hampshire’s County Sport Partnership for the past year, these are issues I have experienced first-hand.
As a practitioner, it was often difficult to translate available evidence into viable practice. Reasons for this were numerous, though included funding issues, difficulty in physically accessing research, as well as in understanding complex ideas of theory and evaluation, within the particularly vague policy context by which one was guided. Emerging literature also highlights issues in policy, such as failing to consider local implementation barriers, persistent participation inequalities or the intricacies of behaviour change.
The aim of my research will be to identify systems and opportunities that facilitate a more integrated relationship between PA evidence, policy and practice. In order to garner a holistic appreciation of these factors, it is vital to understand how policy makers receive, adapt and adopt evidence; how organisational factors constrain or facilitate its adoption and importantly, recognise values and interests of those influencing responses to the evidence or policy problem. A particularly neglected policy research topic has been individual or organisational capacity to act upon evidence.
Previous research has perhaps been somewhat one dimensional in these areas. Alternatively by employing a mixed-methods approach and my applied social sciences background, I will be able to generate a much-needed complex understanding of the extent that local, regional and national stakeholders use evidence in PA policy design and implementation, and review factors associated with successful policy implementation. Whilst building upon existing literature, it is intended that this will offer a unique interpretive perspective on people, practices and policy processes (both locally and nationally), enabling and supporting policy development and implementation.
Does sitting and talking, and a lack of progressive
 policy action, promote our sedentary society?
Specifically by investigating the following two core propositions initially, I propose that it may be possible to find equitable solutions for progress in increasing physical activity and provide an important contribution to the field of public health research:
  1. Weak evidence results in inherently conflicting and ambiguous PA policy, thus constraining implementation efforts
  2. Political entrepreneurs may offer more effective solutions for policy development and implementation 
Being a fledgling researcher
One of my relatives (a PhD recipient herself), once told me that doing a PhD will be the hardest thing I ever do. I am under no illusions about the task before me, the complexity of which may be compounded by investigating one of society’s most entrenched problems. However I welcome the challenge and cannot wait to get stuck in, even if a little part of me wonders if I have what it takes to make a difference in the world, as I am sure many new Social Policy researchers before me have. I hope that my research will land well and have impact in the academic sense, but also in tangible real life outcomes for local communities in time.
I am not alone in this quest, and hope over the coming years to work closely with Fuse and its focus on Translational Research; specifically, the Fuse Physical Activity group offers an important platform for me to engage with physical activity policy makers, practitioners and academics who I hope will engage with me in developing this programme of work. I believe research evidence should be free and accessible wherever possible, an issue I have already raised. I wish to experiment with how better to present evidence to make it attractive to both policy makers and practitioners. At the same time, I am conscious of having to develop my academic reputation and profile and balancing this with experimentation is something I am wary of at this stage. 
I wish to build networks within local institutions with like-minded students and academics to share ideas and findings. My aim is to disseminate throughout my project and beyond. I hope to be able to present to Fuse research fora, access advice and support from the group’s members, as well as contribute to this blog. I welcome any feedback on this post. In particular I would be delighted to hear from individuals, practitioners or groups who:
  • have shared research interests
  • are responsible for PA-policy production locally
  • research health inequalities
  • had difficulties implementing policy guidance and evidence
  • believe research in this area may benefit their line of work
Ben can be emailed at benjamin.p.rigby@durham.ac.uk. He is also on Twitter, LinkedIn and has a blog.

Notes and References:

  1. Figure taken 27 June 2016 – using the search term ‘physical activity’ at http://www.legislation.gov.uk. Between 1991 and this date 72,088 pieces of legislation were published. Results were manually screened and filtered for ‘physical activity’ as recognised by the World Health Organisation as benefitting health, well-being and personal and social development.
  2. Bowen and Zwi.2005. Pathways to evidence-informed policy and practice: a framework for action.
  3. http://www.mirror.co.uk/news/uk-news/john-prescott-battle-jeremy-corbyn-8720209.

Giving Grandmothers a Voice (Sun, 02 Oct 2016 05:00:00 +0000)

Guest post by Roz Rigby, a Health Improvement Practitioner at Newcastle City Council and Doctoral student in Public Health at Northumbria University

Today is Grandparents’ Day, a day which celebrates the contributions of grandparents to families and
society overall. Grandparents can have important roles in the health related decisions of families and my research is looking at the influence of grandmothers on introducing solid food. Much of the literature describes grandmothers in a negative light, suggesting they may advise their daughters to start solids before the recommended six months. I found that there was very little research that addressed this from the perspectives of grandmothers’ themselves, and therefore I set out on my research journey with the intention of finding out ‘how do grandmothers make sense of the role they play in introducing solid foods to their grandchildren?’

 I am using constructivist grounded theory methods based on the works of Charmaz (2014)1, and am still finding new meaning in my data, as I try to write up my findings. I am finding this an exciting time in the research, after the arduous task of trying to understand the terminology in qualitative methodology! I must admit that I expected to find grandmothers defending the older methods of introducing solids, which was generally started at around four months, but I actually found that they were open to change and generally accepted the new guidelines. I have also uncovered a complicated web of dynamic family interactions in which grandmothers can struggle to come to terms with competing values of the wider family that they find themselves in. Some grandmothers expressed how marginalised they feel, as they do not have access to the latest information, except through their daughters or daughters in law, and yet, they are often providing extensive childcare.

One of the issues that this research has highlighted for me, is the contested levels of responsibility that grandmothers face. On the one hand they are ‘proxy’ parents, making autonomous decisions about the food that they offer their grandchildren, whilst on the other hand, this can compete with the parents’ decisions and parenting styles (which may in turn be influenced by the other grandparents). Being able to switch this responsibility on and off can cause tension and conflict, particularly if there is a feeding issue. The problems of having a fussy eater can cause parents and grandparents immense distress, with issues of power and control coming to the fore. Grandmothers often worry about conflict within the family and are wary about raising their concerns, for fear of fracturing relationships and possibly losing contact with their children and grandchildren.

Of course it’s not all doom and gloom, as they all report feeling immense love for their grandchildren and a similar nurturing feeling that they had for their own children. They get tremendous satisfaction from these relationships, and I hope that my research will help practitioners to have a better understanding of the issues grandmothers face. I am looking forward to using the findings to develop an intervention that will help families navigate potential intergenerational conflicts and find ways of developing collaboration within families, as they all have the best interests of the children at the heart of what they do.

  1. Charmaz, K. (2014) Constructing Grounded Theory (2nd Edition). Sage

Is the UK an intolerant society for children? (Thu, 22 Sep 2016 05:00:00 +0000)

Posted by Peter van der Graaf, AskFuse Manager, Teesside University

UNICEF statistics about child wellbeing among the 29 wealthiest countries in the world made for uncomfortable reading in 2007 with the UK bottom of the league table. Children and young people in Britain were among the unhappiest, unhealthiest, poorest and least educated in the developed world in the early years of the new millennium. Since then many initiatives and policies have been implemented to increase child wellbeing in the UK and when the league table was repeated by UNICEF in 2013 the UK moved up 15 places to a mid-table position of 16th.

However, we are still behind many European countries and with the ongoing austerity measures and continued disinvestment in health and social care services for children we could find ourselves back at the bottom league in the not too distant future. This begs the questions whether ‘simply’ improving health and other services for children is enough?

According to Sir Al Aynsley-Green, Professor Emeritus of Child Health at University College London and former President of the British Medical Association, the problem runs much deeper. He argued at the Fuse Knowledge Exchange Seminar yesterday in Newcastle, titled 'Think Adult - Think Child', that the real problem in the UK is that we are becoming an intolerant society for children. He pointed to the dire straits of politics for children in the UK: not only is the voice of children lacking from national policy making (an argument that he is well positioned to make as the first Children’s Commissioner for England), the policy making itself has often been poor.

The BMA published a damning report in 2013 in which it concluded that “the national focus on children has been short term, inconsistent and untrustworthy”. Specific policies to support children, such as Every Child Matters, have been systematically eroded by consecutive governments; the recent much watered-down Childhood Obesity Strategy is another example of this and Theresa May’s new enthusiasm for grammar schools strikes further fear into the hearts of child rights advocates.

Politicians are not the only ones to blame according to Sir Al: the media regularly publish headlines about children and young people being a nuisance and causing crimes, while shops put up signs in their windows stating that dogs are welcome but that kids can only enter two at a time and, only then, without a backpack and when closely supervised. Most shockingly, public places such as railway stations are increasingly being fitted with high pitched devices that adults can’t hear but which are very unpleasant for young people and deliberately intend to drive them away.

One area where the neglect of children’s needs is particularly visible is bereavement: every 22 minutes a child in the UK loses a parent. While no routine data are collected in the UK on this group, estimates suggest that the majority of young people face the death of a close relative or friend by the time they are 16 years old. In spite of the many services available to families to help them stop smoking, exercise more and eat healthier, there is very little available for children who experience bereavement.

Sir Al presenting at the Fuse Knowledge Exchange Seminar
Specialist service providers attending the Knowledge Exchange (KE) seminar expressed their concern about not being able to cope with the current demand, as school teachers and parents lack basic skills in being able to talk to children about emotional problems, such as bereavement. In spite of this, we know from research that bereavement can have a lasting impact on the life of children long into adulthood. Bereavement in childhood has been linked to educational underachievement, joblessness, fractured adult relationships, adverse psychological and psychiatric consequences, together with poor physical health.

Sir Al’s presentation was therefore more a call to arms. What can we do in and outside Fuse to improve child health and wellbeing in the North East? Firstly, we can act as an advocate organisation to draw more attention to the needs of children and their position in society. Are their voices heard within Fuse? Do we engage with them in our projects?

Secondly, we can bring partners together across public health and related sectors in the North East to focus attention on this topic and bring together evidence and best practice to inform new collaborations. The KE seminar provided a platform for this that could be followed up. We also have a dedicated Early Life and Adolescence Programme (ELAP) within Fuse but does our research link to education and events later in the life course? For example, in Finland shops can rent a grandparent to help them engage with children when they visit their shop.

Thirdly, we need to turn this dialogue into a research agenda for child wellbeing in the North East. How can we mobilise evidence to change the prevailing attitude among politicians and the wider society so that they instead see children as valuable assets and a key policy priority for any government? This also involves challenging popular concepts, such as school readiness, which focus on individual responsibility. As Sir Al suggested at the end of the seminar, we should turn this concept around: are schools ready for children and what do they need to be able to be ready? Are they able to support children’s emotional development and can they help them to cope with bereavement experiences?

Making the UK a better place to live for children requires more than service redesign, it needs political will and consistent pressure from a coalition of organisations to achieve this, supported by actionable research to change hearts and minds.

Dealing with emotions and breakaway training: reflections on collecting survey data in a prison (Thu, 15 Sep 2016 05:00:00 +0000)

Guest post by Jennifer Ferguson, Research Associate (Alcohol Team), Teesside University

“Wear tracksuit bottoms, bring your trainers and be prepared for Judo style moves” – not something you hear every day when trying to set up data collection. Working in a prison has been an eye opener, in ways I expected, and in ways I could never have anticipated. I sit on F wing, the wing that prisoners are brought on to when they arrive. It is in the middle of this wing that I carry out surveys about brief alcohol interventions with each new prisoner for a research project at Teesside University.

When I think back to the phone call I received about “breakaway training” and how I felt on that day, (being told how to physically hurt people should I be attacked, and kicking grown men) it was all very useful and I believe necessary when working on a prison wing. However, what I should have been preparing for was how mentally challenging it is. Prison staff become hardened (through lack of choice) to what happens in there, they have to become emotionally disentangled from each prisoner, and some literally make fun of the inmates. Of course we need to know how to hide our keys, get out of basic holds, locate the alarms and know basic breakaway techniques. But the awful feeling I felt in the pit of my stomach for a vulnerable new prisoner who enquired as to where everyone was going with their towels (they were lining up for the showers), and who was told by another inmate: “swimming mate, you wanna go? Just go up there and ask ‘Mr Jones’”, will stay with me for a long time.

Prisoners don’t expect you to be nice to them, and no one uses first names. It is surnames for prisoners and Sir and Miss for staff. They don’t touch you, even to shake your hand. The language is horrific. This is just the way it is. So in my first few weeks - hearing ‘Thompson’ tell me about how he misses his wife and kids, ‘Scott’s’ emotional breakdown because he is terrified of being inside, and ‘Smith’s’ heartbreak about his childhood and battle with drink and drugs - I soon realised I didn’t need to know how to defend myself against anyone. What I needed to learn, and fast, was how to switch off emotionally in front of these grown men. I am an emotional person and could easily fill up with tears in an instant at some stories. In my time as a researcher, when writing papers, collecting data in various formats and spending hours inputting it into a statistics software package, I have never had to deal with grown men crying. That being said, I am told every day by the peer prisoners not to believe everything I am told. I will learn how to deal with my emotions and what prisoners tell me… and by then be finished data collection. I wonder if my perspective will change the more time I spend in there? 

I guess my point is that I am learning that you cannot understand everything in public health research from articles and text books. A class room cannot prepare for you for the mental challenge of working in prison setting. However, this difficult piece of data collection will be vital to our study and my development as a researcher.

Photo attribution: “Jailed.” by disastrous via Flickr.com, copyright © 2008: https://www.flickr.com/photos/bienaventurada/2912658697

Stress is a universal experience, but is it unequally distributed across society? (Thu, 08 Sep 2016 05:00:00 +0000)

Posted by Dr Joanne-Marie Cairns and Dr Emily Henderson, Durham University and Fuse.

How are you feeling today? Stressed at all?! If so, you are in good company.

Stress is so pervasive in our society that it contributed to a shocking 9.9 million working days lost in 2014/15(1), which equates to an average of 23 days per person. From an evolutionary perspective, stress is useful to animals such as humans to help us react to physical and social threats, commonly known as the ‘fight or flight’ response. According to Danielsson(2) and colleagues, stress can simply be defined as an imbalance between demands placed on us and our ability to cope with them. But if stress continues over a long period of time then a permanent imbalance may arise between the body’s degenerative (reduced growth) and regenerative (regrowth) functions. Stress can also lead to everyday problems including poor performance at work, low mood, lack of motivation, fatigue, sleep disturbance and chest and muscular pain as well as major life-limiting health problems such as high blood pressure, depression and chronic pain.

In light of these concerns, we organised a Health Summit on inequalities-related stress, with colleagues from the Local Area Research & Intelligence Association (LARIA), the Wolfson Research Institute for Health and Wellbeing, and Fuse - the Centre for Translational Research in Public Health. This event was hugely popular and brought together a wonderful mix of delegates and speakers from policy, practice and academia, from the North East and across the UK. The programme, which includes a list of speakers and a description of the talks, can be found here.

While stress can be a universal experience, it doesn’t manifest equally amongst certain population groups. For instance, Thoits(3) conducted a review which highlighted how unequally high exposure to stress by women and people in lower socioeconomic and minority groups lead to inequalities in health outcomes. Moreover, we see health inequalities accumulate over the life course as a result of this unequal distribution of disadvantage, for example Thoits refers to a study conducted by Turner and colleagues(4) that examined the effect of cumulative stressors in adults. These stressors that accumulated over time, explained a significant 50 per cent of the Socioeconomic status (SES) gap in depressive symptoms.

What are health inequalities then? These are differences in health status or determinants of health between different population groups. There are also intersecting inequalities, for example, if you are a lone parent but also on a low income, living in a disadvantaged area. Moreover, coping mechanisms sometimes adopted to mitigate stress can be health-damaging and lead to other forms of health problems, such as smoking or alcohol misuse. John Watson (Deputy Chief Executive, Action on Smoking & Health (ASH) Scotland) quite rightly argues that smoking IS NOT A LIFESTYLE ISSUE; rather in his words it is a form of medication to society’s maladies. Just think of the current global economic downturn as a societal issue that can be at the root cause of individual depression. As well, unequal access to jobs (at least good jobs that aren’t precarious in nature or that might lack autonomy) or good schools, which already limit an individual’s future prospects and may as a result contribute to psychosocial stress and poorer health highlighting the structural factors that are beyond the individual. Furthermore, stress at the population-level can manifest into geographical health inequalities. Data published by the Health and Social Care Information Centre (HSCIC) shows that the North East Strategic Health Authority (SHA) had the highest admission rate due to anxiety of any of England's 10 SHAs (just under 24 per 100,000 of the population), while South Central SHA had the lowest (at nearly 11 per 100,000), mirroring other health outcomes and shows the stark North-South health divide in England.

‘Lifestyle’ is used ubiquitously in current public discourse, and can be understood as a set of factors that describe a person’s daily living. Obesity-related lifestyle often refers to people’s behaviours and apparent food choices(5). These so-called behaviours are ways in which individuals respond to challenging circumstances. They are not choices in the purest sense of the word. Rather, an individual may be experiencing financial difficulties and, feeling the demands in their life which outweigh their ability to cope, may respond to the situation by smoking, drinking or comfort eating. But what is actually causing the financial difficulty in the first place? Are individuals to blame for reacting to the bleak reality of poverty and the social gradient they find themselves in? The seminal work by Sir Michael Marmot tells us that we instead need to consider the “causes of the causes” of inequality, not just the symptoms. Politics is also important, as we have seen in the government’s release of the new obesity strategy which continues to support healthy choices, and maintains the voluntary efforts by industry by suggesting a 5 per cent sugar reduction in children’s food and drink. The chairwoman of the Health Select Committee, Dr Wollaston, told BBC Radio 5 live that “it does show the hand of big industry lobbyists and that’s really disappointing”(6). A key political talking point relates to the fact that what was a 50-page document was shortened to a mere 10 pages which does not do something as complex as obesity justice – it was “weak and watered down”.

To sum up, the discussions from our Health Summit supported the principle of moving away from individualised and stigmatising conceptions of unhealthy behaviours; after all it is not just poor people that behave poorly!

  1. Figures obtained from: http://www.hse.gov.uk/statistics/causdis/stress/ [last accessed 17/08/16]
  2. Danielsson M, Heimerson I, Lundberg U, Perski A, Stefansson C-G, Ákerstedt T. 2012. Psychosocial stress and health problems. Scandinavian Journal of Public Health, 40(9):121-134.
  3. Thoits PA. 2010. Stress and Health: Major finding and policy implications. Journal of Health and Social Behavior, 51(s):41-53.
  4. Turner R, Jay and William R. Avison. 2003. Status Variations in Stress Exposure: Implications for the Interpretation of Research on Race, Socioeconomic Status, and Gender. Journal of Health and Social Behavior,44:488–505.
  5. Nettleton S. Lay health beliefs, lifestyles and risk. The sociology of health and illness. 2nd ed. Cambridge: Polity Press; 2006. p. 33-70.
  6. http://www.bbc.co.uk/news/health-37108767 [last accessed 19/08/16]

Where you live can kill you (Tue, 30 Aug 2016 05:00:00 +0000)

Posted by Clare Bambra, Associate Director of Fuse and Professor of Public Health Geography, Durham University

In 1842, the English social reformer Edwin Chadwick documented a 30-year discrepancy between the life expectancy of men in the poorest social classes and the gentry. He also found a North-South health divide with people from all social classes faring better in the rural South than in the industrial North.

Today, these inequalities persist. People in the most affluent areas of the United Kingdom, such as Kensington and Chelsea, can expect to live 14 years longer than those in the poorest areas, such as Glasgow or Blackpool. Men and women in the North of England will, on average die two years earlier than those in the South. Scottish people also suffer a health penalty with the highest mortality rates in Western Europe.

House for sale in New Orleans
Such geographical inequalities in health exist, to varying degrees, in all high-income countries. People living in more deprived areas fare particularly badly in the casino capitalism of the United States; where gaps in life expectancy between rich and poor areas of some cities, such as New Orleans, are as large as 25 years. Indeed, the US as a whole has a significant health disadvantage in comparison to other high-income countries with, for example, American men living on average three years less than their counterparts in France and five years less than Swiss men.

Understanding and reducing these health inequalities remains a major public-policy challenge worldwide and has garnered significant recent political attention. For example, in her opening speech on the steps of 10 Downing Street, the new British Prime Minister Theresa May highlighted the nine-year gap in life expectancy between the richest and the poorest boys in England. It is not only a moral issue though; health inequalities carry significant economic costs to individuals and society (e.g. NHS costs, lost productivity). But the causes of such inequalities are complex and the solutions contested.

Explaining health and place

Where you live affects how long you live and the health of different places is determined both by the population composition (who lives here) and the environmental context (where you live).

Who lives here? The demographic, health behaviours and socio-economic profile of the people within a place influences its health outcomes. Generally speaking, health deteriorates with age, women live longer than men, and health status also varies by ethnicity. Levels of smoking, alcohol, physical activity, diet, and drugs – all influence the health of populations significantly. The socio-economic status – or social class in “old money” – of people living in a country also matters as those with higher occupational status (e.g. professionals such as teachers or lawyers) have better health outcomes than non-professional workers (e.g. manual workers). So differences in the characteristics of people living in a country, city or neighbourhood will impact on the health of that place.

However, where you live matters. The economic environment of a country, such as poverty rates, unemployment rates, or wage levels can all influence public health. The social environment, including the services provided within a country to support people in their daily lives such as child care or health care and welfare, can also impact on population level health. The physical environment is also an important determinant with research suggesting that proximity to waste facilities and brownfield or contaminated land, as well as levels of air pollution can negatively affect health. So countries, cities or neighbourhoods with worse economic, social or physical environments will have worse health outcomes.

Reducing health inequalities

Even though both composition and context matter, and can be supported by scientific evidence, politics can matter more than science in determining which strategies policymakers pursue to reduce health divides – or if they even care about inequalities at all. After all, some potential solutions are politically easier to implement within existing systems than others.

For example, interventions aimed at changing individual health behaviours are far less challenging to prevailing power structures than those that demand extensive investment in improving the social economic environment. Indeed, by blaming people for their own health problems, such interventions let governments and businesses off the hook for the wider economic, social and environmental determinants of health inequalities.

Such “downstream” approaches only tackle one side of the coin and there is little evidence that lifestyle interventions are effective in reducing health inequalities: more comprehensive measures are needed. Most of the health gains over the nineteenth and twentieth centuries were brought about by far-reaching economic, political, and social reforms which improved the wider environment and also significantly improved the financial position of the poorest people.

It has been clearly demonstrated that more equal societies almost always do better in health terms and the poorest and most vulnerable groups, say in Sweden or Norway, are far healthier and live longer than the equivalent groups in the UK or the US. These countries have done so through the development of a stable, inclusive economy, a supportive welfare system and a high standard of living.

So, where you live matters for how long you live – and changing how we live could reduce health inequalties.

Professor Bambra’s book Health Divides: where you live can kill you is available now from Policy Press.

Clare Bambra
Professor of Public Health Geography, Department of Geography, Durham University, Associate Director of Fuse: the Centre for Translational Research in Public Health and lead of the Health Inequalities research programme
Twitter @ProfBambra

Photo attribution: “House for sale, New Orleans” by K.G. Schneider via Flickr.com, copyright © 2006: https://www.flickr.com/photos/kgs/177196564/in/

Au revoir et bonnes vacances (Thu, 04 Aug 2016 05:00:00 +0000)

Posted by Emma Dorée, Fuse Communications Assistant, Teesside University

The blog has spent the last few weeks trying to stay motivated at work whilst watching everyone else share their holiday snaps on social media - enough of the hot-dog legs, already!  It feels as though everyone is enjoying a nice relaxing break except for the blog. However that is all about to change as it is holiday time!

It’s been another busy (academic) year for the blog but the crowning glory has to be winning the award for best blog in the Education category at this year's UK Blog Awards. A fantastic achievement for everyone involved, especially as this was the first time the Fuse blog had been nominated.

So where is the blog going on holiday this year I hear you ask? Well, instead of going abroad it is having an ever so trendy ‘staycation’ and going to the Lake District. This will be a good chance for the blog to get away from its desk, do some physical activity and take in the lovely views. Not to mention, improve its chances of catching some water-type Pokémon - gotta catch 'em all!
Saying goodbye to friends at Teesside University

As well as the blog taking a well-deserved break, this will be my last blog post as a Communications Assistant for Fuse. After having a holiday myself in the sunny south of France, I will be working at West Park Hospital in Darlington as a Communications Assistant.

I have really enjoyed my time working for Fuse and have gained much experience and many skills from being given the opportunity of working in this post. Working as part of a great team to help the blog to victory in the UK Blog Awards has definitely been one of my greatest achievements and something that I will treasure.

So that’s it! It’s farewell from me and happy holidays from the blog.

The blog will return in September with many more exciting posts about public health. Enjoy your summer everyone!


We still need your 500-700 word blog posts so that we can start September in style.

Please email them to Mark Welford (m.welford@tees.ac.uk).

Here’s how to take part and why you should blog.

Making an impact with your research: may I have this dance? (Thu, 28 Jul 2016 05:00:00 +0000)

Posted by Peter van der Graaf, AskFuse Manager, Teesside University

Early career researchers from the five UK Public Health Research Centres of Excellence met recently (14-15 July) in Norwich to discuss their research and bust out a few moves on the dancefloor at the conference dinner. While some career-focused academics (the conference theme was about career transitions) might frown upon this behaviour, the policy and practice partners participating in the conference made it very clear that, for them, dancing is a key move in public health, particularly if you want to make an impact with your research. 

Before you don your dancing shoes, let me explain what keynote speaker Jim McManus, Director of Public Health at Hertfordshire County, was talking about. He argued that knowledge exchange is not really a science or even an art but very much a dance: a dance between researchers and policy makers about the use of research evidence. To complete this dance successfully and get evidence used in commissioning, both partners need to follow certain steps. However, learning the steps (science) or performing them perfectly (art) is not sufficient: it requires instinct and feel for where you are in the dance and why you are doing it.

You need to understand who you are engaging with and why they are the best partner to talk to. How would you like them to use your evidence and why would it be of interest/ value to them? In other words, as a researcher it is not enough to present your partner with the latest evidence. You need to know when and how to use your evidence and this cannot be gleaned from an internet profile page or academic paper, but is based on an ongoing relationship with policy makers. As the context and process in which evidence is useful changes constantly it is an important skill for researchers to be able “to go with the music”.
For instance, if a public health commissioner is challenged in a council meeting by an elected member about the lack of progress in bringing down local childhood obesity, it is of limited use to the commissioner to cite a research paper on the complexity of obesity and the need for a long-term, multi-pronged approach, particularly in times of austerity. A better move could be to signpost the commissioner to an existing two-page evidence brief about the most effective way to reduce inequalities in childhood obesity. A more elaborate dance routine could involve suggesting an action research project to identify how to make better use of existing services in a more integrated way, based on in-depth conversations with elected members and other service providers and users.

To get a better feel for the music, Jim McManus emphasised the need for emotional engagement between researchers and policy makers. A heart-to-heart helps you feel the steps and allows you to adapt your steps based on where you are going. This might sound difficult and un-academic but, given what I witnessed at the evening do, the participants at the UKCRC16 conference in Norwich proved that they were more than happy to move around the dancefloor with our public health partners, given the right music.