Friday, 17 February 2017

How big food and drink are using sport

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 M√ľnchen'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.

Friday, 10 February 2017

The importance of partnership working to improve priority-setting in public health decision-making

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.

Friday, 3 February 2017

Mannequin challenge: preparing cancer nurses through simulating emergency situations

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.

Friday, 27 January 2017

The first step to an equal North

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

Friday, 20 January 2017

An education in how research influences parliament, policy & practice

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

Friday, 13 January 2017

A prescription for tackling riskier drinking?

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 ©

Thursday, 5 January 2017

Engaging ‘harder-to-reach’ service users - Food as a Lifestyle Motivator

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