Fuse blog

Star Trekkin' across the (research and quality improvement) universe (Fri, 05 May 2017 05:00:00 +0000)

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

Does improving the quality of care from health organisations need research? This was the question asked at the Annual Network Event of the Clinical Research Network for the North East and Cumbria. The network has been successful over the last four years in bringing together a wide range of clinical staff across the region and promoting and supporting high quality health research, which was celebrated at the event, but the organisers didn’t shy away from asking some tough questions.

Q (John de Lancie) pictured behind Captain Jean-Luc Picard (Patrick Stewart)
While the network has put a strong focus on numbers, particularly related to regional recruitment targets for patients in trials, its clinical Director, Professor Stephen Robson, acknowledged that this was only part of the story and that it also ignored what happened later in the research process. For instance, how do we ensure that the research findings get adopted by practice organisations? Brilliant studies are useless if they don’t result in changing clinical practice. But how to change this practice?

The event therefore put a renewed focus on quality improvement. How can we help health professionals to improve their practice? One of the network’s partners, the Academic Health Science Network for the North East and Cumbria (AHSN NENC), joined forces last year with NHS England and the Health Foundation to play a leading role in the national roll out of the Q community.

Unfortunately for us ‘Trekkies’, this is not a new Star Trek episode about the famous Q tormenting various Starfleet Captains; instead, the Q community is a force for good that connects health professionals across the UK to improve health and care quality. The virtual community supports members in their existing improvement work and tries to enhance their skills, helps members to share ideas and enable them to make changes in their organisations that benefit patients.

For this episode, Q came out of the 2013 Berwick report, which followed the publication of the Francis Report into the breakdown of care at the infamous Mid Staffordshire Hospital. The report urged health organisations to make better use of members of staff with improvement expertise and made a case for a system devoted to continual learning and improvement. In response, NHS England (with support from the Health Foundation) developed the Q community in 2015, which now has 236 members in the North East (5000+ nationally) and is expected to grow considerably over the next few years.

I unashamedly applied to become a member of this network last year and they were crazy enough to accept me, so I was looking forward to the Q workshop at the annual event, led by Suzy Cook. The workshop looked at the link between research and quality improvement but, to my surprise, focused on the differences and argued that they should be viewed as separate activities with distinct aims, following different processes and timescales. Research was described as a linear and long-term process that is mostly concerned with the effectiveness of existing and new services, while quality improvement was pictured as a more cyclic and shorter term process with linked PDSA cycles (Plan-Do-Study-Act) that focus on the sustainability of services.

This distinction does not do justice to both activities and feels like a rather odd separation: why can’t research inform what practice needs to improve and how? And what about evaluating quality improvement; isn’t research a key component of the PDSA cycle? Luckily, participants in the workshop raised the same objections and an alternative view was provided in the next workshop by Seamus O’Neill, Chief Executive of AHSN NENC.

He argued instead that there was a clear link between research and quality improvement by looking at the adoption of research in the NHS. Quality improvement needs evidence to select the right intervention in the right context. Just sinking money into an innovation because we think it is going to make a difference will not impress funding and commissioning bodies. At the same time, he warned that many quality improving and cost-saving interventions are not used by health care organisations. They are either not aware of them (clinicians do not read journal articles) or they do not know how to adopt them (how can we make it work here?). According to Seamus, this is where quality improvement can come in: using dedicated health professionals, such as the Q community, and their skills to study, plan, do and act on the research evidence.

Researchers and quality improvement professionals need each other, not to put more clear blue water between them, but to make both activities more useful and effective. Even Q in Star Trek perhaps saw the wisdom of this when he remarked: “I look at the universe in an entirely different way now. I mean, I can't go around causing temporal anomalies or subspace inversions without considering the impact it'll have”. (Star Trek: Voyager: The Q and the Grey #3.11, 1996).

North East and North Cumbria - Annual Network Event: Research Matters was held on 26 April at the Stadium of Light in Sunderland.



Photo attribution: “John de Lancie, Denise Crosby (at back), Patrick Stewart, Star Trek TNG, "Encounter at Farpoint," 1987” by Classic Film © 2015: https://www.flickr.com/photos/29069717@N02/20607700773

From the office to Eastern Africa: how digital technologies can be used to assess diet (Fri, 28 Apr 2017 05:00:00 +0000)

Guest post by Emma Foster, Lecturer in Public Health Nutrition, Human Nutrition Research Centre, Newcastle University

Life in academia can be tough at times. It can be difficult to switch off, the list of tasks can seem never ending and just when you think things are going to quieten down along comes that call for proposals that you simply can’t miss.

I’ve worked at Newcastle University for almost 20 years now and throughout that time my research has focused on improving how we measure dietary intake. In the early years this involved going into school and talking to children and parents, which was always good fun. More recently we’ve been working with adults developing online systems for measuring intake along with colleagues at Open Lab. The work is really interesting and I’m enormously proud of the system we have produced but life is predominantly office based now.

Earlier this year though, my enthusiasm for work was suddenly re-ignited with a slight change in focus for my research. For 12 days in February I left behind my 6 year old son (bad mummy!) and my husband and headed off to do some research looking at how digital technologies could be used to assess dietary intake in Africa. Along with my colleague - research associate Maisie Rowland - I headed to Tanzania to learn about the food environment there, looking at the range of foods available, and the way things are cooked, served and eaten. We also looked at the uptake of technology such as use of smartphones and internet access. We started our visit in Moshi near Kilimanjaro (every time I say Kilimanjaro I still break into a smile). The weather there was lovely and warm and the people were too. We’d been put in touch with a school teacher, Amina who showed us around two primary schools and one secondary school in the area. Seeing the cooking facilities at the schools was really eye opening. The schools all cooked over wood fires.


I was amazed at the secondary school kitchen; this was what I had expected to find in the homes in poorer rural communities but not in a large (700+ pupils) secondary school. Yet the staff managed to cook enough food to feed all of the students and had taken the time to provide information for us on the common local foods.

Every day for school lunch the children got maize and beans, one of the schools added oil to the mixture to make sure the children got some fat in their diet. Children brought a bowl, plate or other container (some had margarine tubs) and most ate with their hands. The children ate their food outside. Amina invited us over for dinner one evening. “I thought I’d cook you banana stew and elephant leg” she said, monitoring our faces for a reaction. Politely we said “that sounds lovely” but we clearly looked a bit worried before Amina roared with laughter and told us that elephant leg was a vegetable….it just got its name because it apparently looks a bit like one!

Before we left Moshi we got to tour the local food markets, where people buy the majority of their food. There was very little in the way of pre-packaged foods consumed.

Our next stop was Dar es Salaam where we worked with the Tanzanian Food and Nutrition Centre (TFNC). We conducted two workshops, one with nutritionists, dietitians, food technologists and public health workers at the TFNC, which Maisie and I ran in English, and one with a rural community group which the TFNC researchers ran in Swahili. Through the workshops we gathered lots of information about the foods consumed and how these differed between regions, the time of year, celebrations and droughts, and how people would share recipes and consume foods. We learned that African power cuts can last a whole day - the workshop at the TFNC was done in 35 degree heat with the power (and therefore air conditioning) off! We discovered that the foods we were served for breakfast at the hotel were usually only reserved for celebrations for the local population.

We took our research very seriously and ate at a wide variety of restaurants, cafes and street food stalls. The food over there was really tasty. For breakfast every day we had an amazing beef stew that we got the recipe for. I’ve tried to re-create it but mine isn’t quite up to scratch, I think it’s probably to do with the way that they rear the cows rather than my cooking skills....

We plan to work with the staff at TFNC to put in a proposal to the Global Challenges Research Fund with the aim to develop a technology based method of assessing dietary intake that will enable them to run what would be the first National dietary survey for Tanzania.

….Now back to the office for some proposal writing to get us back out there. Next time I might even take the family with me!

Sleepless in the slammer (Fri, 21 Apr 2017 05:00:00 +0000)

Charlotte Randall, Higher Assistant Psychologist and MSc student, Northumbria University

The current prison population is 85,641 and around 50% of this population suffers from symptoms of insomnia. While this is similar to the general population there are a limited amount of resources to help treat this disorder in prisons.

Having worked in prisons for seven years, I am all too familiar with the problems that a lack of sleep can have on an offender's ability to engage with the prison regime, and the impact this has on their mental health. Due to the high prevalence of mental health problems, substance misuse and personality disorders in the prison population, the issue of sleep is often side-stepped and the importance of obtaining and having a healthy sleep practice can be forgotten about.

I am part of the Mental Health In-reach team in a prison in the North East, and have witnessed first-hand the effect poor sleep can have on an offender’s mental health. As this is an under-researched area, I decided it would be interesting and beneficial to conduct research on insomnia in the custodial setting. The aim of the study was to see whether a 60-70 minute session of Cognitive-Behavioural-Therapy for Insomnia (CBT-I) with an accompanying self-help pamphlet was an effective treatment in reducing the symptoms of insomnia in male prisoners.

As I work in the prison Mental Health Team full time, I thought this would be a simple project to undertake, however there were several hurdles along the way. Firstly I was required to gain ethical approval from several different organisations; NHS; National Offender Management (NOMS); and the University. Offenders are classed as a vulnerable population for research purposes, and therefore there is heightened scrutiny from ethic boards as a result of this. This process was lengthy; I had to complete three separate documents explaining the project’s benefits for each organisation. Once submitted, I was required to attend a full Research Ethics Committee (REC) where the research protocol and IRAS (Integrated Research Application System) form were discussed and additional questions were asked. It was then a waiting game to see whether the study had been granted ethical approval. As with any research project there was a deadline of September 2016, in which my dissertation needed to be submitted. Ethical approval was granted in June 2016, after recommendations had been made by the NHS and NOMS ethic boards and an amendment report was submitted.

On the other hand, recruitment for the study was relatively easy, which surprised me! Although it also identified the need for insomnia interventions in the custodial setting and confirmed that this research was important. The offenders were keen to engage, due to the lack of pharmacological (drug related) and psychological interventions for insomnia they were eager to find something that helped them sleep.

Results from this research were positive and highlighted that there was a significant reduction in insomnia related symptoms after completing the 60-70 minute session of CBT-I, with the accompanying self-help pamphlet with category C adult male prisoners. This research is the first of its kind to assess whether an adapted versions of CBT-I is effective in the prison population, where there are limited interventions and resources to help aid sleep disturbances. Although the results were positive, they have to be taken with caution as the prison where this research was undertaken has a unique regime and all prisoners are in single-cells which allowed them to complete certain aspects of CBT-I e.g. sleep restriction.

My experience of completing this research was positive; I enjoyed the prospect of analysing an undiscovered area and hopefully informing academia and practice within a public health setting. I did however find it hard in the early stages of this project, specifically going through the ethics process and length of time this took. A written report has been disseminated to NOMS highlighting the findings of this research. It also identifies how this research could be taken forward and inform future research opportunities. The single session of CBT-I is being delivered in the prison where the research was completed, more data is being gathered and will hopefully be published in 2017.


Photo attribution:
  1. “sans horizon” by poirpom via Flickr.com, copyright © 2015: https://www.flickr.com/photos/poirpom/16479845789/
  2. “prison” by erin via Flickr.com, copyright © 2007: https://www.flickr.com/photos/insunlight/1037277952
  3. “Insomnia” by Ben Harrison via Flickr.com, copyright © 2011: https://www.flickr.com/photos/48755144@N02/5564362009

Life inside foodbank Britain (Fri, 14 Apr 2017 05:00:00 +0000)

Post by Kayleigh Garthwaite, Research Associate at Newcastle University and Fuse Associate Member

For the last three years, I’ve been a volunteer and a researcher at a Trussell Trust foodbank in central Stockton, North East England, finding out how a foodbank works, who uses them, and why. My new book ‘Hunger Pains: life inside foodbank Britain’ tells the stories of the people I met inside the foodbank over an 18 month period. The experiences throughout the book offer a serious challenge to persistent myths that foodbank users are simply seeking emergency food as a result of flawed lifestyle choices.

Every week, I prepared the three days’ worth of food that goes into each food parcel. I dealt with the administration of the red vouchers required to receive food, making sure that anyone who needed further support was signposted to where it could be obtained. I weighed kilograms of food in and out. I volunteered at the collections at Tesco supermarkets, asking people to add an extra tin to their weekly shop. Most importantly, I sat and listened to the stories of the hundreds of people who came through the foodbank doors for emergency food.

The idea that more people are using foodbanks because there are more foodbanks is a popular one. But, in reality, people are using foodbanks as a last resort, when the benefit delays, sanctions, debt and low pay have finally caught up with them. My research, as well as that of other academics, charities and frontline professionals showed that a major reason for people using foodbanks was the impact of welfare reform. It was common for people to have experienced significant problems with benefit delays and sanctions, which led to lengthy periods without income for themselves and their families. Other reasons that brought people through the foodbank doors were ill health, bereavement, relationship breakdown, substantial caring responsibilities, precarious jobs, and redundancy.

Although research has repeatedly emphasised the link between foodbank use and welfare reform over the past five years, the Government denies that a connection between the two exists. Instead, it chooses to dismiss foodbank use as a lifestyle choice of those who are unable to budget properly or who would rather spend their money on cigarettes, flat screen televisions, alcohol, and iPhones. Perhaps unsurprisingly, I found that this political rhetoric had a strong influence on beliefs about foodbank use and deservingness, and could lead to stigma, shame, and embarrassment for the people who needed to use them. As a result, people would postpone asking for foodbank support until they were truly desperate.

The big challenge is ensuring that ‘emergency’ food support continues to be seen by the public as a consequence of food poverty and inequality, rather than a permanent solution. We need to listen to the stories and the voices of people foodbanks so that we can understand who uses them, why, and what it feels like. Perhaps these messages are reaching a wider audience now with Ken Loach’s latest award winning film I, Daniel Blake, which has been called ‘a rallying cry for social justice’ with its depiction of the inefficient and often cruel bureaucracy of the benefits system. It is hard to not feel empathy when watching lead character Katie in the haunting foodbank scene, or in witnessing Daniel’s day-to-day struggles in applying for job after job, despite being unfit for work.

But it is hugely important to make sure that the messages in the film, as well as the messages of the book, are heard not just by people who are sympathetic to what the research is saying, but also by people who don’t quite believe that the benefits system is really that bad, or who are adamant that poverty is a lifestyle choice.

Kayleigh’s book ‘Hunger Pains: life inside foodbank Britain’ was placed second in the British Sociological Association / BBC Radio 4 Thinking Allowed Award for Ethnography 2017.

Passionate Advocacy versus Dry Evidence (Sat, 08 Apr 2017 05:00:00 +0000)

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

Should public health researchers be passionate advocates of their work when engaging with policy makers or should they present their findings in the most neutral way possible, sticking to the facts only (and preferably economic figures) to encourage take up of their research? This question was the focus of a heated debate at the recent national School for Public Health Research Annual Scientific Meeting, bringing together researchers from eight different centres of excellence across the UK and a selection of senior health practitioners at the Royal Society in London.

Chris Whitty: academics should present their findings neutrally
to politicians without making any advocacy statements
The tone for the debate was set by Professor Chris Whitty, Chief Scientific Adviser for the Department of Health, who challenged the audience to be more ambitious in their public health goals. At the same time, he warned academics to play to their strengths: if they wanted to ensure impact of their work, academics should present their findings neutrally to politicians without making any advocacy statements, as this would deter politicians. Advocacy should be reserved for politicians, who in turn are supported by economic advisors. Therefore, academics would do well to present their data in terms of opportunity costs and trade-offs; without solid economic back-up, any evidence claim would be quickly dismissed by politicians, according to Whitty.

This provoked strong reactions from audience members and particularly on Twitter, where a lively discussion ensued throughout the rest of the day. People questioned whether it is possible or even desirable to leave advocacy at the door when dealing with politicians. Some argued that, from a social science perspective, there is no such thing as neutral evidence and that it is our duty as public health scientists to take a stand and advocate against increasing health inequalities. Others disputed the need from politicians for dry evidence, stating that purely evidence based approaches can leave politicians cold without a persuasive narrative. Instead, emotionally informed and narrative research was important to persuade local government. Researchers needed to align themselves with local government concerns and cultures and acknowledge the importance of context to have any impact.

Duncan Selbie: academics should be more ruthless, coordinated and angry
in the interactions with policy makers to get them to act on the evidence
Duncan Selbie, Chief Executive at Public Health England, poured oil on the fire in the afternoon by appealing for the exact opposite to Chris Whitty’s call for more neutrality: academics should be more ruthless, coordinated and angry in the interactions with policy makers to get them to act on the evidence that academics have generated. He encouraged public health researchers to make more use of behavioural science to help policy makers take notice and implement their findings. This provoked several reactions, with some participants highlighting the role that advocacy played in the public health fight against the tobacco industry, while others made passionate pleas on soapboxes for the re-politicising of public health science, arguing that it was unhelpful to divide science and politics into two separate worlds.

The storm seemed to settle towards the end of the day, when Twitter users and audience members started suggesting solutions for the debate, which was dubbed “Passionate Advocacy vs. Dry Evidence”. One suggestion was that public health researchers should develop a ‘horses for courses’ approach: at certain times some people needed to be passionate advocates, while others at different times needed be neutral scientists to get the listening ear of politicians. The different approaches were related to different levels at which politicians operate: local politicians were more persuaded by narratives emerging from research and advocacy, while national politicians valued neutrally presented evidence and data.

Others suggested the use of intermediates to make the advocacy case for public health, such as voluntary community organisations that represent the will of the people, and by focusing research on the key questions that front line workers are struggling with. Or even better, persuade policy makers to become advocates of research evidence!

Overall, participants agreed that science needed to be pushed more up the policy agenda, as research is currently losing out to politics and economics. Therefore, in some circumstance researchers need to consider accept that submitting good enough evidence quickly is better than waiting too long for perfect peer reviewed publications. Furthermore, we need to be aware that different kinds of evidence are used in decision making processes.

My favourite solution was proposed by Professor John Frank, Director of the Scottish Collaboration for Public Health Research & Policy: if you want good policy influencers, you need to change the academic model to produce them. The biggest barriers to knowledge mobilisation are structural and often in academia. As long as we don’t train public health students in engaging with policy and practice partners, fail to teach and reward them in how to use different types of evidence and do not involve them in collaborative research, we will keep returning to this debate for many Annual Scientific Meetings to come.

Do public health practitioners make good fire fighters? (Fri, 31 Mar 2017 05:00:00 +0000)

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

Given ongoing budget cuts and diminishing local capacity, one might be forgiven for thinking that soon public health practitioners will only be responding to emergencies, such as disease outbreaks and substance abuse epidemics. Fighting these public health fires would leave little time and resources for prevention and working with other public organisations. An event co-organised by Fuse, Durham County Council and Darlington Fire & Rescue Service recently proved quite the opposite: fire fighters and other public organisations are very capable of ‘doing’ public health.

Can public health researchers learn a trick or two from fire fighters?
The increasing focus of the Fire and Rescue Services on prevention over the last 10 years has seen the development of innovative approaches that support public health: from helping people with dementia, to tackling child obesity and getting people active (for some excellent examples, see the Local Government Association (LGA) report Beyond fighting fires).

In Durham, the Fire and Rescue Service implemented so-called Health and Wellbeing Visits. As part of home visits to check fire safety, fire fighters ask residents questions about their health and wellbeing (e.g. about falls, smoking and alcohol use, heating and loneliness and isolation) and provide them with advice or signpost residents to relevant services to address any health concerns.

Over the past year (Feb 2016 – Jan 2017), no less than 15,732 Health and Wellbeing Visits have taken place with over 1,800 referrals to various services in Durham and Darlington, accessing vulnerable residents that are often not on public health’s radar. Because of their trusted reputation, the Fire and Rescue Service can get behind the front doors of these people and help them access health services. Perhaps not surprisingly most referrals relate to loneliness and isolation, with an ageing population keen to live at home independently but with a social care system lacking resources to support these people in and outside their homes.

Even the police is getting in on the act of public health prevention with partnerships being established between health and the police across the UK to support, among others, suicide prevention and reduce alcohol-related harm, as was recently illustrated in a Public Health England paper.

In turn, public health practitioners are taking on new activities that were previously deemed outside of their scope. For instance, the Durham County Council’s public health team is actively supporting energy efficiency improvement schemes (such as Warm and Healthy Homes), in recognition of the link between excess winter death and cold houses. Poor quality housing, low incomes and high energy costs result in residents having to choose between food or fuel. To prevent residents from having to make that choice, council officers are providing tenants at high risk (e.g. people with cardiovascular and respiratory conditions) with new central heating, boiler repairs, home insulation and energy saving advice.

This blurring of boundaries between public professionals is not new, but public health moving back into local authorities has created opportunities for linking prevention activities across a wider range or organisations. The event provided many other examples of this, e.g. GPs prescribing boilers to patients with long-term conditions and Citizens Advice providing welfare rights advice to elderly residents.

This new boundary blurring builds on existing policy initiatives, such as Making Every Contact Count and Health in All Policies, which all involve the wider public health system. Participants at the event made it clear though that this is not a simple cost-saving exercise, allowing councils to pass the public health buck to other parts of the system. Instead, these new partnerships are characterised by a genuine exchange of knowledge and practices between public organisations at the front-line. It highlights a new way of working that recognised joint priorities and the values of other professions to achieve these priorities through the sharing of resources and by taking on new roles. As Professor David Hunter outlined in his presentation at the start of the event, these new partnerships require a different form of leadership, which is less hierarchical and formal, not so much concerned with Key Performance Indicators and commissioner-provider splits, but more focused on the value of relationship building, trust and 'soft' skills.

The event provided a platform for looking at these new partnerships and the evidence for their effectiveness. If anything, it highlighted a challenge for public health academics to research these new partnerships: how to make sense of the contribution of each partner in a system where boundaries are rapidly blurring? Maybe public health researchers can learn a trick or two from fire fighters.

Find out more about the event: Creating Healthy Places in the North East: the Role of Fire and Rescue Services and Fuel Poverty Partnerships

Photo attribution: "Rochdale Fire Station Opening Day" by Manchester Fire via Flickr.com, copyright © 2014: https://www.flickr.com/photos/manchesterfire/13288225965/

Beyond bricks and mortar: re-thinking home and health (Fri, 24 Mar 2017 06:00:00 +0000)

Dr Philip Hodgson, Senior Research Assistant, Northumbria University

In a time of continued public spending cuts, policy drivers to age in place (to grow old in the home or in a non-institutional setting in the community) and an increasing ageing population, the challenge to ensure that people can live longer and healthier in their own homes is growing. Yet, solutions for this, when a host of other factors – the development of housing to meet commercial rather than health pressures, future generations with little equity in housing that can be used to fund future care, the prevalence of a belief in a “forever home” – are difficult to identify.

That was one of the core messages discussed at the first ‘Home and Health’ research group hosted by Northumbria University and Fuse (via the pump-priming research fund) last month. This brings together researchers, practitioners and policy makers interested in the impact of housing on health. The seminars aim to foster a core working group, culminating in the development of concrete plans for collaborating on further research in this area. Building on insights from previous Fuse Quarterly Research Meetings (‘Creating Healthy Places in the North East’ in October 2015 and ‘Reuniting Planning and Health’ in April 2016), the seminars aim to take stock of existing evidence on how housing conditions can promote or impede healthy ageing, and identify gaps for further research. Our first seminar explored priorities for research from a policy perspective and we were thrilled to welcome Gill Leng (National Home and Health Advisor to Public Health England) to present.

Gill Leng, Public Health England, presenting at the Fuse research meeting
Gill highlighted the need to think about ‘homes’ (a term which people identify with and encompasses emotional connections to a place of living) rather than just ‘housing’ (a term used when referring to the workforce and describing bricks and mortar). While evidence and action often focuses on the risks posed by unhealthy homes, little is done to address unsuitable or precarious housing. Although most older people own their homes, these are not necessarily healthy. The challenge we face is to identify an approach to housing which allows its support to develop and mirror our own changing health needs through the life course. This is not just a case of using adaptations and facilities, but reframing how we conceptualise the home as a physical location, a part of a wider social environment and a personal / psychological space.

The conceptual spaces of home illustration used in the seminars 
Group discussions focused on this issue (among others). At the personal level, a tension was found between the maintenance of private life and the role of external sources of support. Current policy relies on care delivered by family members, but this can in turn cause problems for individuals without these links. Also, how do we develop mechanisms that initiate people’s thoughts on the best accommodation for them before they reach a point when they’re in crisis / a change is urgently needed and driven by necessity rather than choice (e.g. when people with dementia still have capacity to make an informed choice)? At the level of buildings and services, these problems take on a more concrete form, where the permanence, inconvenience and cost of a housing adaptation to support health is seen more as an obstacle to avoid rather than an enabler in the future. Meanwhile, within social and environmental factors, the current focus of housing policy on volume, rather than quality of public space, and a decrease in social cohesion were both noted as linked factors that could influence health as the population ages. The depth of discussion at each of these levels highlighted the importance of issues of home and health. But to address it we need to move beyond the ideas of bricks and mortar, and consider how we think about and use our homes to facilitate our health and wellbeing as individuals and a wider society.


Our first seminar explored priorities for research from a policy perspective
All of these issues will be picked up in future sessions, which will focus on good practice, existing research in the field and funding opportunities. We’ll be continuing to blog about each of these events and their outcomes, so please check back for more information soon.

If you are interested in joining the group and attending future seminars, please contact Phil Hodgson philip2.hodgson@northumbria.ac.uk

From left: Peter van der Graaf, Monique Lhussier, Natalie Forster, Phil Hodgson
and Dominic Aitken; organising team for the home and health research interest group

Food as a job, life and research: the many meanings of what we eat (Fri, 17 Mar 2017 05:59:00 +0000)

Posted by Amelia Lake, dietitian and public health nutritionist & Fuse Lecturer in Knowledge Exchange in Public Health, Durham University


Food is my job. As an academic dietitian and public health nutritionist I spend my time questioning why people eat what they eat, and thinking about what we can do to change behaviours. As a mum, I also spend a lot of time at home wondering why a 4-year-old and a 17-month-old eat what they eat!

Its nutrition and hydration week, which aims to highlight, promote and celebrate improvements in the provision of nutrition and hydration locally, nationally and globally. So this is an excellent opportunity to explore the many roles of food in public health.
Top shelf material

Food is life. We need nutrition and hydration for life and to maintain health.

Food is a thread that moves through every aspect of our life from the everyday to the special occasion.

I read somewhere that the origin of culture was when raw ingredients were cooked. The importance of this event was not so much in how food was prepared but in the organisation of individuals around meals and meal times.

Food has shifted populations and started wars; think of the thirst for sugar, tea and coffee (also known as the ‘hot drinks revolution of the eighteenth century’) and the impact that had on various countries and their populations.

Food is our culture and identity; it is an intrinsic description of who we are and where we come from. For example, I am a complex mixture of Persian dishes, Indonesian dishes and some Northern Irish wheaten bread and Tayto crisps.

Food is our comfort. That dish your mother made, it’s a warm familiar blanket; it evokes memories, both good and bad. It is a way in which we show others that we care for them and are thinking of them.

The party bag horde - a focal point for arguments
Food is a focal point for arguments: “No you can’t have any more sweets from the party bag…” A conversation every parent has at one point or another.

Our social media feeds provide us with ‘food porn’, hands that whizz up magical results in seconds. Additionally, social media and the press provide us with self-styled food and nutrition 'experts' presenting us with spiralised courgette and clean eating advice.

Food continues to dominate our life and the public health agenda on a global scale.

The World Health Organization’s global targets for 2025 to improve maternal, infant and young child nutrition tackle a range of issues from obesity to stunting and wasting.

In this country we are familiar with the concept of our obesogenic environment; an environment in which calories are easily accessible and available and with little opportunity to expend that energy. In an attempt to tackle the obesity problem in this country our government will follow Mexico and introduce a sugar levy.

Despite the issues of over-nutrition and the seemingly endless opportunity to buy food, food poverty is a term we have become more familiar with. Despite it sounding like it belongs to another era, it’s a very real issue for a significant proportion of our population. Oxfam estimates that 500,000 people in the UK are now reliant on food parcels. Foodbanks provide nutrition to those who struggle to feed themselves and their families and have sadly experienced rapid growth in recent years, especially in the UK.

How can research help to address these global and local problems?

Free fruit with every purchase
Within Fuse ‘food’ runs through a number of research themes, from behaviour change to healthy ageing. As part of the national School for Public Health Research, a team of Fuse researchers has evaluated a food training programme run by Redcar and Cleveland Council. To promote the findings from this research we decided to create a short film and this week were filming in a small sandwich shop in the market town of Guisborough, where you were offered a free piece of fruit with every purchase. This small business owner’s focus is food. She provides food to customers every lunch time. This owner had attended the training course run by the Council and decided to make a difference by providing more healthy food.

This is an important step, supported by research. On this nutrition and hydration week, I am sure you will agree that there is still much to be done on this important and vast topic across many disciplines and on a global scale.

How I overcame my scholionophobia... a clinical pharmacist in an academic world (Fri, 10 Mar 2017 05:59:00 +0000)

By Rachel Berry, Specialist Antibiotic Pharmacist, County Durham and Darlington NHS Foundation Trust, and Health Education England (HEE) and National Institute for Health Research (NIHR) Intern 2016/17

“Scholionophobia* – A fear of school, college or university”

So, I want you to picture the day ….. It was a sunny September morning and there I was, a clinical pharmacist currently working in hospital, standing by the River Tees at Queen’s Campus Stockton about to enter Durham University. And I was terrified. Honestly, the last time I was this scared walking into a university building was in 2004 and I was about to sit my Registration Assessment to become a qualified pharmacist. I was obviously suffering from scholionophobia.


Courtesy of mothmediatech & the creators of The adventures of Worrisome Wilf books

“But why were you so scared?” I hear you ask. Well, the answer is that I was just about to start my Health Education England (HEE) and National Institute for Health Research (NIHR) Integrated Clinical Academic Internship programme.

The HEE/NIHR funded internship is a programme to enable Healthcare Professionals working in clinical practice to gain research experience and skills by working alongside a university academic. I had ahead of me, 30 days away from my clinical commitments that I could use to gain an introduction into clinical academic research.

My fear was based on the fact that I didn't know anything about research or universities. Not one bit. And I definitely wouldn't be able to do it myself. In my mind, research was only done by brilliantly clever people who know everything. I was only a lowly hospital pharmacist. I was pretty sure that I would be the most stupid person there!

Fortunately for me, I was about to meet my amazing academic mentor, and go on an adventure into the unknown world of research. I have gained experience and skills in literature searches and critical appraisal, project design and data collection, statistics, statistical analysis software (SPSS) and writing for publication. I have met so many talented, lovely people who have been interested and willing to help me, even when I probably was the most stupid one there (try explaining Poisson regression and statistics to a person who doesn’t have A-level maths!). It really has opened my eyes to the world of research, and the possibilities for clinical practitioners. My mentor has helped me realise that the skills and experience I have from clinical practice are just as important in clinical research as the skills of doing the research.

I am now coming to the end of my time. I have completed my project, which will be disseminated to local Clinical Commissioning Groups (CCGs) to enable them to focus on key target areas to improve patient safety within antibiotic prescribing. I am also planning on publishing it, and hopefully this will allow the work to have wider impact. I have been able to take what I have learnt about research and its impact on patients back to my clinical work too. This has meant that I am more reflective and research-aware when doing my job. I have also shared this with the colleagues in my department, and hopefully encouraged them to be more research aware and active, to enable us to provide better care to our patients.

In the future I would love to do more research in conjunction with the School of Pharmacy as I have realised that blending our skills and experiences, whether they are clinical or research based, can lead to more relevant patient-focussed clinical research being undertaken. I am also trying to get other members of my department to apply for the Internship next year.

The 30 days spent at Durham University were some of the most challenging, interesting, frustrating and rewarding I have ever spent at work. My scholionophobia has been cured, with no medicines required. If you are a sufferer in clinical practice, I would recommend talking to academics in your clinical speciality and applying for the Internship; there is no need to be scared. And if you are an academic in health research there is a wealth of experience that you could utilise within the clinical teams; they would probably love to be involved, they just might be too scared to ask.


My thanks go to the team at North West Research and Development who ran the 2016/17 Internship Programme on behalf of HEE/NIHR. Also thanks to my managers at County Durham and Darlington Foundation Trust, and especially to Professor Cate Whittlesea and the School of Medicine, Pharmacy and Health at Durham University.

*Also known as Didaskaleinophobian or Scolionophobia.


The challenges (and joys) of evaluating babyClear©: a package of support to help pregnant women to stop smoking (Fri, 03 Mar 2017 06:00:00 +0000)

Guest post by Sue Jones, Research Associate, Teesside University

A team of Fuse researchers from Newcastle and Teesside Universities published findings from the babyClear© study a few weeks ago and I thought that I’d put finger to keyboard to share with you the challenges and joys of evaluating the roll out of this innovative intervention.





















In 2012, I became involved with evaluating babyClear©, a package of support for maternity and stop smoking services, designed to help them to deliver the stop smoking message more effectively to pregnant women. BabyClear© was due to be rolled out regionally across North East England and evaluated throughout, which presented a number of challenges:
  • Challenge 1: different research questions – we wanted to know if this new approach worked and would it help women quit but we knew that this would not be enough; we wanted to understand what influenced those figures, and what healthcare staff need to do to be most effective.
  • Challenge 2: ethical dilemma – ethically we could not deny pregnant women a test like carbon monoxide monitoring that was known to improve outcomes to some degree, so the regional rollout of babyClear© offered a prime opportunity to evaluate the intervention using a natural experiment1.
  • Challenge 3: wide variety of stop smoking delivery models – the extent of austerity measures experienced by the public sector has been far greater than anticipated when the research was envisaged in 2011. At the same time responsibility for delivery of stop smoking services has been moved to local authorities who themselves are under extreme pressure to reduce spending. This has created a wide variety of stop smoking delivery models, all trying to provide a low cost service but with implications for the implementation. For example: babyClear© was designed to be a package that could easily slot into existing services, however it assumed a number of systems were standard when they were not, such as a midwife available at dating scan appointments and a local stop smoking specialist in pregnancy. All those Heinz 57 varieties of stop smoking service delivery models and systems within maternity services, each one different from every other, made it logistically challenging to implement the new pathway, leading to delays of varying lengths in each Trust area.
  • Challenge 4: researching within a changing system – due to ongoing changes largely in the delivery of stop smoking services, but also in maternity, and their impact on the implementation of babyClear©, data collection plans had to be re-thought again ... and again ... and again to reflect what was happening out in the real world! 
We were greatly helped in approaching some of these challenges by the publication in 2014 of the Medical Research Council (MRC) Guidance on process evaluation of complex interventions. Using this guidance, we were able to start re-shaping our thinking in terms of how the qualitative data could be used synergistically with the numerical data. We set about strengthening the methodology with a retrospective logic model, weaving contextual data into the mix and with an eye on the mechanisms of impact.

After overcoming these challenges, along came the joys: the findings of our study proved that babyClear© was not only effective but also cost-effective, which was a great achievement in such a short timescale. This new approach, which supported midwives to offer universal carbon monoxide screening and refer pregnant smokers quickly to expert help, nearly doubled quit rates.



The findings highlighted that we could systematically help women to stop smoking in pregnancy which will result in already well-evidenced outcomes such as:
  • Help mothers have babies who are heavier and healthier than if they continued smoking
  • Help more mothers lead healthier lives
  • Help mothers live longer and see their children grow up
  • Help the children to live and run and grow up surrounded by smoke free air; and 
  • Enable them to not be held back by smoking-related poor health
So have a read of our paper, this has the nitty-gritty of the statistical outcomes.

Importantly, soon we hope to be publishing the details about the how, what, when, where, why questions that were the focus of the qualitative process evaluation. Without this it is difficult to know how to implement it elsewhere to best effect and why it works well in one place and not another.

Celebrate our findings with us; if the maternity and stop smoking services are able to use the babyClear© approach to implement best practice/national guidance it can offer the support that is needed so that more women stop smoking during their pregnancy than did before. So keep your eyes peeled for my next blog – which will focus on the findings from the process evaluation.


Reference:
  1. “A natural experiment is an empirical study in which individuals (or clusters of individuals) exposed to the experimental and control conditions are determined by nature or by other factors outside the control of the investigators, yet the process governing the exposures arguably resembles random assignment”. (Reference: en.wikipedia.org/wiki/natural_experiment)     More info: Craig P, Cooper C, Gunnell D, Haw S, Lawson K, Macintyre S, Ogilvie D, Petticrew M, Reeves B, Sutton M, Thompson S. Using natural experiments to evaluate population health interventions: new Medical Research Council guidance. J epidemiol commun h. 2012 May 10:jech-2011.
Related content:

Two perspectives on arts and public health (Fri, 24 Feb 2017 06:00:00 +0000)

Andrew Fletcher, PhD researcher, Faculty of Health & Life Sciences, Northumbria University

Engagement with the arts and/or creative practice benefits wellbeing in multiple ways. I am a musician and relatively new to public health. This post argues that arts and culture should have greater prominence in health and social care.

Courtesy uk.pinterest.com
So what of arts-based therapies? Compared to Cognitive Behavioral Therapy (CBT) for example, such programmes are not heavily promoted. Perhaps this is right; CBT is cheap and effective, whereas things like music therapy are often reserved for individuals with more complex needs. But this hierarchy contributes to the idea that arts-based therapies are ‘alternative’ – potentially placing them in the same category as, say, homeopathy. This is not a helpful perception, but anyone who’s tried to advocate for creative therapies will know it exists.

Then there’s ‘evidence-based medicine’, which is of critical importance, but whose dominance has been challenged.2,3  This is particularly relevant to approaches to health and wellbeing that are seen as ‘alternative’, which still seem to remain the preserve of those who can afford to try more ‘esoteric’ interventions – thereby reinforcing inequality. So what’s the response? Promote holism*; make arts therapies mainstream; emphasise their part in everyday life; make creativity and cultural engagement as vital as exercise, healthy eating or social interaction. The idea that creativity is intrinsic to wellbeing needs to be established in the early years and beyond, and to neglect this idea is missing a trick.

Courtesy tinybuddha.com
Why do people do art? Usually to express a political statement, to communicate a specific feeling or sentiment, or to satisfy some intangible ‘urge’. Making a painting to hang on your bedroom wall cultivates a more pleasurable living environment; putting your kid’s collage on the fridge boosts self-esteem; and who never listens to music? Creative practice, in one way or another, feeds into numerous wellbeing outcomes. Artists know this instinctively, yet policy around art and culture focuses on tourism and/or entertainment income, and a vague ‘intrinsic’ social value. Lip service is paid to health, but as Tiffany Jenkins says: “If you’re competing with hospitals, you’ll lose”.4

But art and wellbeing are significant components of the lived experience. They make us human. They sit at the apex of Maslow’s hierarchy** and most people understand the inherent value of culture to either social or personal wellbeing. If prevention really is better than cure, we must pay attention to the cultural-wellbeing landscape and the atmosphere these concepts exist in. Perceptions are changed through innovative and creative information delivery – so creativity not only has its own wellbeing outcomes, it’s also the key to shifting arts and culture towards being a major pillar in overall wellbeing.

I can’t help but wonder what the world would be like if the perceptions of arts therapies were different. Stickley (2014)5 outlines one potential scenario as follows:
The year is 2080. A new textbook has been published. The book is called ‘A Century of Healthcare’ and I would like to quote from this book:

"For most of the last century it was unusual for people to be treated holistically. Incredible as it sounds today, healthcare systems separated physical interventions from anything they referred to as "mental". Thus a dualism existed and people were treated as divided objects. At the time, there were many attempts at holism, especially by those who practised alternative or complimentary therapies. However, anything that remotely threatened the domination of the medical model was largely side-lined and researchers gave little credence to anything that was not considered scientific.

We should however give a great deal of credit to those who foresaw the potential contribution that the arts and humanities could make to healthcare and wellness but they operated in a narrow scientific paradigm that gave little acceptance to holism…”
The contexts in which creative practice occurs are complex, but the benefits are multiple and well-known. The key here is changing perceptions. This takes time, but perhaps Stickley’s vision will bear out. I hope so.


Footnotes:
* The idea that the human experience of wellbeing is social, cultural and complex, and extends far beyond medical definitions of health.
** 'Self actualisation' appears at the apex of psychologist Abraham Maslow's 'hierarchy of needs' model and includes in its definition (among other things): "expressing one's creativity".

References:
1. Various demographic data available from www.theaudienceagency.org
2. Greenhalgh, T., Howick, J. & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? BMJ g3725.
3. Stickley, T. (2015). A little rant about evidence, available from: https://ayrshirehealthandarts.wordpress.com/2015/03/31/dr-theo-stickley-a-little-rant-about-evidence/
4. Jenkins, T. (2015). Front Row debate (23rd Feb, 2015). Are artists owed a living? Online: BBC.
5. Monologue delivered at ESRC funded Seminar Series on Arts, Health & Wellbeing, 15th September 2014.

How big food and drink are using sport (Fri, 17 Feb 2017 06:00:00 +0000)

Guest post by Robin Ireland, Director of Research, Food Active and Healthy Stadia

You don't have to do much travelling to realise that the unhealthy alliance between sport and the Food and Drink Industry isn't only an issue in the UK.

I am lucky enough to be visiting New Zealand and Australia at the moment and it's easy to see all the same signs - and very similar marketing campaigns and messaging. Whether it's the All Blacks rugby team being pictured with the product of their "Official Hydration Partner", Gatorade, or the recent Australian Tennis Open full of alcohol advertisements (and I haven't even mentioned cricket), it's clear that the Food and Drink Industry have an international agenda.

Advertising featuring the All Blacks rugby team photographed in New Zealand

In January, the British Medical Journal published an editorial (Ireland and Ashton 2017)1 that I wrote (with Professor John Ashton CBE) about how Coca-Cola's publicity machine was subverting the Christmas message.

If anything, it's even more blatant in sport and we have been aware of it for some time from London's "Obesity Games" (Garde and Rigby 2012)2 to Rio's promotion of ultra-processed foods (Loughborough University)3. Even when spectators want healthier food, this choice is rarely made available to them.

George Monbiot recently referred to "Dark Money" (Monbiot 2017)4 which describes the funding of organisations involved in political advocacy that are not obliged to disclose where the money comes from. In public health terms, we may describe this as Commercial Determinants of Health where industry interests impact on our health. It is often linked to the increasingly sophisticated Corporate Social Responsibility policies being adopted by big corporations.

The latest of these is of course the deal just announced by the English Premier League and Cadburys criticised by the Obesity Health Alliance in a letter to The Times (Obesity Health Alliance 2017)5. Cadburys no doubt will argue that they are taking an ethical position to help educate people. But can we really take a chocolate company seriously that wishes to advise schoolchildren on nutrition, healthy eating and exercise?


FC Bayern München's branded energy drink
It is no coincidence that the mantra parroted by food and drink sponsors is that our diets are down to individual choice and that if we simply took more exercise we wouldn't be having the obesity epidemic now prevalent worldwide. This is rubbish. So called energy and sports drinks should have no part to play in the diet of the average member of the public. Kids do not need more sugar (or more protein for that matter) if they are eating a balanced diet with lots of fruit and veg. But of course the food and drink industry do not make their enormous profits in this way.

It is these concerns - amongst many others - that encouraged myself and colleagues to establish Healthy Stadia in 2005, of which I am a Director. Healthy Stadia takes a holistic and integrated approach to developing sports stadia and clubs as "health promoting settings":
"Healthy Stadia are those which promote the health of visitors, fans, players, employees and the surrounding community" (from Healthy Stadia website)6.

Healthy Stadia's Conference which will be held at the Emirates Stadium, London, in April will be discussing food and drink sponsorship in professional sport among other issues. I anticipate that these topics will come under increasing public scrutiny in years to come, as we develop more awareness of the impact that marketing has on our food and drink choices. (Cairns et al., 2013)7.

Sports fans and public health professionals alike should be questioning how 'Our Beautiful Games' are being manipulated by the Food and Drink Industry to promote ultra-processed food and drink - including alcohol - to audiences, often well populated by impressionable youngsters. Let's see if we can link up the campaigns in different countries to make a louder voice demanding change from the governing bodies of sport.
References:
  1. Ireland R and Ashton John R. (2017). Happy corporate holidays from Coca-Cola. BMJ 2017;356:i6833. http://www.bmj.com/content/356/bmj.i6833. 10 January 2017.
  2. Garde A and Rigby N. (2012). Going for gold – should responsible governments raise the bar on sponsorship of the Olympic games and other sporting events by food and beverage companies? Commun Law. 2012:356:42-9.
  3. Loughborough University Press Release (2016). Loughborough research calls for change in spectator food and drink provision at sports mega events such as Rio 2016. PR/16/158. http://www.lboro.ac.uk/media-centre/press-releases/2016/december/loughborough-research-calls-for-change-in-spectator-food-and-drink-provision-at-.html. 05 December 2016.
  4. Monbiot G. How corporate dark money is taking power on both sides of the Atlantic. The Guardian. https://www.theguardian.com/commentisfree/2017/feb/02/corporate-dark-money-power-atlantic-lobbyists-brexit. 02 February 2017.
  5. Obesity Health Alliance (2017). Letter to The Times – Cadbury and Premier League Sponsorship. Accessed online at: http://obesityhealthalliance.org.uk/2017/02/06/letter-times-cadbury-premier-league-sponsorship/?utm_campaign=Cadbury%20letter. 06 February 2017.
  6. European Healthy Stadia Network. http://www.healthystadia.eu/about.html
  7. Cairns G, Angus K, Hastings, G and Caraher M (2013). Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 2013: 356:209-15. http://www.sciencedirect.com/science/article/pii/S0195666312001511. 03 March 2013.
All views expressed are exclusively those of the author.

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.

References:
  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

References:
  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.

References:
  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)

http://www.fuse.ac.uk/

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