Thursday, 25 June 2015

Go for the plums!

By Mark Welford, Fuse Communications Officer

The title of this post was the provocative take home message from a session on ‘Writing for the media and Public Health Today’ at the Faculty of Public Health (FPH) conference held at the Sage in Gateshead earlier this week.

Public Health Today is the quarterly magazine for FPH members, featuring a range of articles from topical news items, to in-depth interviews with key public health figures. It is distributed to over 3,300 public health professionals in the UK and internationally.

Led by Richard Allen, Productions Editor of the magazine, the session aimed to give attendees an idea of what he and his team are looking for from contributors. The FPH want to hear about your research, but there are ways in which you can make it more likely that what you provide ends up in the magazine. Much of this also applies to the media and providing journalists with stories through press releases.

As the title says: ‘go for the plums’. Hit readers with the most important, unexpected or unusual fact, anecdote, or quote first. Your top line may not be the most important message but the ‘sweetie on the top’ designed to draw readers in and convince them to read on.

The first sentence should get across the key message and/or provide a brief summary of the research in 20 words. Many articles that the FPH receive start from the beginning. Instead, reverse history and put the background in later with the conclusion first.

Be concise. Richard and his team are looking for articles of 550 words – stick to the word count. Remove the long words and jargon, the public health and management speak. Use everyday language and write acronyms in full in the first instance. The news stories on the BBC website provide a good example of this.

Include short quotes that add opinion or emotion. This humanises the story and brings it to life. Write as though you’re describing your research to an educated friend.

Each issue of Public Health Today is themed. June's edition is on sex. The themes of future issues aren’t easy to find but I did eventually discover them in the latest FPH e-bulletin.

The special features for the other editions in 2015 are:
  • September: Disasters & emergencies
  • December: Healthcare public health
An editorial board decide on the themes for the year ahead at a meeting in December. Could you suggest a theme?

Here are Richard’s top tips in a handy list:
  1. Go for the plums!
  2. Is there anything ‘new’ in my article – what’s current?
  3. Is there anything unusual or unexpected about it?
  4. Would this be of interest and understandable to anyone outside of public health?
  5. What, who, when, where and why?
  6. Reverse history 
  7. Be concise
  8. Keep sentences short
  9. Avoid jargon
  10. Avoid management speak
  11. Avoid acronyms
  12. Use quotes to provide insight, not information
  13. Stick to the word count
  14. No references /footnotes
  15. No multiple bylines
  16. Provide contact details
Richard, like me, was once a journalist and it’s helpful to be reminded of good practice. So I’m going to follow no.13 and keep to the 550 word limit.

Tuesday, 16 June 2015

A Munich alcohol gathering with a difference

Guest post by John Mooney, senior lecturer in Public Health at The University of Sunderland

The mention of the German city of Munich and alcohol in the same sentence normally conjures up the image of a buxom serving wench in traditional Bavarian costume plying glasses of beer during Octoberfest, a prominent component of which is the Munich Beer Festival. Announcing to colleagues therefore that I was attending an alcohol public health conference in the city last week met with a few raised eyebrows – together with enquiries about whether I had got the wrong month!

This was most certainly not the case – for in addition to hosting the G7 conference in the nearby Bavarian mountains at the weekend, Munich was also last week’s venue for the 41st Meeting of the Kettil Brunn Society’s Alcohol Epidemiology conference. Established in 1986, the Kettil Bruun Society (KBS) is an international organisation of scientists engaged in research on the social aspects of alcohol use and alcohol problems. Given that the task of containing alcohol harm is now a truly worldwide public health challenge, the Society aims to promote social and epidemiological research on alcohol in a spirit of international cooperation and information exchange.

As a second time attendee, this year’s conference programme was just as packed and varied as the 2104 meeting in Turin – and the start of summer proper in Southern Germany ensured that temperatures were also comparable! Morning plenary sessions focused on current topical debates such as the relative merits of abstinence over harm reduction approaches, the latter including the controversial Dutch experiment where alcoholics who were resistant to treatment received payment partly in beer for undertaking community work.

The conference setting in the University of Munich’s Institute for Psychiatry and Psychotherapy meant that the psychological and mental health dimensions surrounding alcohol misuse were never far from the surface. Indeed accurately remembering the route to the Alzheimer room (named after the eminent psychiatrist himself who was once based at the Medical School), was going to be the first challenge of my own presentation session!

The luxury of a week-long conference allows for a 10 minute speaking slot for all accepted abstracts (KBS is a poster free zone!). Another unconventional aspect compared to most other conferences is the requirement to submit a full draft paper of your work before the conference. In addition to offering delegates the chance to view your paper through the conference website, this also enables your allocated discussant the opportunity to prepare some constructive criticism of your work (discussants are each allocated two papers in one of the parallel sessions). Most attendees therefore are allocated a discussant slot as well as their own presentation, so the required preparation beforehand is substantially greater than for most conferences where pulling together some slides the weekend before can often suffice!

Among the many highlights of the parallel sessions I attended were the rising public awareness and policy implications of alcohol’s contribution to cancer risk (where frequent drinkers are less likely to perceive the risk); the perhaps unsurprising enthusiasm that the alcohol industry shows towards presenting alcohol predominantly as a ‘lifestyle choice’ as opposed to a risk factor; the usefulness of sewage monitoring for estimating population-level consumption alcohol; and the potential value of reformatting alcohol labels to enhance awareness of drink strengths and associated health risks.

Another annual characteristic of the KBS Conference is a strong presence by the Sheffield alcohol research group, where I had the considerable pleasure of working for two years and on which work (on local alcohol policies) my own presentation was based. Other presentations from the Sheffield Group included gender differences in the effectiveness of alcohol policies; the need for more transparency in setting drinking guidelines; socio-economic gradients in UK alcohol harms across the four constituent countries and also social gradients in specific cancers, attributable to disparities in tobacco and alcohol use.

Now based within the Fuse collaboration at the University of Sunderland, there should be no shortage of opportunities for continuing my research interests in alcohol and fruitful collaboration with expert centres such as Sheffield and the UK Centre for Tobacco and Alcohol Studies (UKCTAS). The North East of England, very much like my native Scotland, is acknowledged to have among the highest public health burdens attributable to alcohol consumption in the UK and is also pursuing some of the most innovative policy solutions such as cumulative impact policies and a late night levy, as well as a very pro-active third sector in the form of Balance North East.

Of course, the Fuse collaboration also includes Newcastle Universities Institute of Health and Society acknowledged for extensive research into the effectiveness of screening and brief interventions for hazardous drinking as well as the alcohol and public health research team at Teeside University (TeamAlphaTees). The North East is well placed therefore for research into all aspects of alcohol harm treatment and prevention, although as yet, it has no October festival – which is probably something else to be grateful for!

Forthcoming events:

Author affiliation
John Mooney FFPH, is a senior lecturer in Public Health at The University of Sunderland. He was previously a research associate with the Alcohol Research Group at The University of Sheffield, funded by the UK NIHR School of Public Health Research, which also funded his attendance and participation at this year’s KBS Conference

Thursday, 11 June 2015

The Troubled families Programme: what's health got to do with it?

Guest post by Stephen Crossley, PhD student in the School of Applied Social Sciences at Durham University

A couple of weeks ago, the expansion of the Troubled Families Programme was formally announced during the Queen’s Speech. This formality came two years after the government itself announced their plans to expand it, around 10 months after they announced further details such as the criteria to be called a ‘troubled family’ under Phase 2 of the programme, and around six months after some local authorities started working with ‘troubled families’ as part of the expanded programme.

Another troubled family?
There have been numerous criticisms of different elements of the Troubled Families Programme since the programme was announced in the wake of the riots in England in 2011, with David Cameron promising to ‘turn around’ the lives of the most troubled and troublesome families in England by the end of the Parliament that finished in May 2015. Ruth Levitas and Jonathan Portes highlighted that the figure of 120,000 ‘troubled families’ used by the government (characterised as ‘neighbours from hell’ in the prime Minister’s launch speech), actually referred to research published four years earlier on families thought to be experiencing multiple disadvantages such as maternal mental health, poverty, material deprivation, poor quality or overcrowded housing. Levitas argued it was a discursive strategy which succeeded in feeding vindictive attitudes towards the poor.

A report carrying a series of interviews with families, written by Louise Casey, the senior civil servant in charge of the programme, was criticised for its lack of ethical process and the government admitted it was a ‘dipstick’ process which didn’t meet the government criteria for research and therefore didn’t require ethical approval. My own investigations revealed that a ‘survey’ used by Casey to highlight the need for ‘radical reform’ didn’t actually exist. In a series of speeches during 2013, Casey told audiences of a survey which showed that, in one deprived area in the North East, not one out of 3000 children had attended a dentist for a routine check-up, but that 300 had presented at A&E for emergency dental care. The survey was, in fact, an anecdote shared during a meeting about a different government programme, which Casey never thought to check before sharing with audiences, preferring instead to tell them it ‘encapsulates the problem’ of ‘troubled families’ in a single example. Casey also told the 2013 RCGP conference that these 120,000 families ‘dominated NHS budgets. That’s the long and the short of it’, which isn’t exactly true either.

To date, however, health has played a relatively minor part in the Troubled Families Programme (TFP) and health issues were not mentioned in either the criteria for families in Phase 1, or the outcomes expected in order for their lives to be considered ‘turned around’. But this is starting to change. The government published a report in July 2014 entitled: ‘Understanding Troubled Families’ which included information on the characteristics of families entering the programme in its early stages (my brief (Mis)understanding Troubled Families is available here). The data showed that the majority of the families being worked with under the banner of the TFP were not particularly anti-social, weren’t serial offenders and most of the children were in education, albeit not all of the time. In fact, the only characteristics that could be applied to a majority of families included in the report were that they were white, they lived in social housing, they had an adult on out-of-work benefits (although we don’t know why) and they had a family member with a serious health issue or a disability. In short, and if any personal characteristic can adequately explain unemployment, these families were probably more likely to be out of work because of health, disability or caring issues than because of any intergenerational culture of worklessness.

In the expanded second phase of the programme, ‘parents and children with a range of health problems’ is included as one of the six criteria for families, who have to hit two of the criteria to be labelled ‘troubled’. Other criteria include ‘children who need help’ and ‘children who have not been attending school regularly’. These vague criteria are open to interpretation and councils will be encouraged to go out and find ‘troubled families’ in order to ‘turn them around’ (or make ‘significant and sustained progress’ in phase 2) and claim the cash bonus, via the Payment By Results process, for doing so. A health bulletin on ‘troubled families’ was also published when the new criteria were announced, highlighting the health related issues some ‘troubled families’ faced, and a ‘leadership statement’ followed shortly after, accompanied by information on skills and training and interim guidance on data sharing amongst partner agencies. With health visitors and school nurses now under the remit of local authorities in England, it is likely that many will become involved with the TFP.

All of these developments should concern health professionals. The TFP assumes that the answer to the families problems lie firmly within the four walls of the family home, with a strong rhetorical focus on ‘getting in through the front door’ and working with the family ‘from the inside out’. In short, there is no room in the narrative for wider determinants of people’s circumstances. Its alleged success has never been proven. There is scant evidence to justify such an approach and it is unlikely that having a determined, non-specialist key worker will make much difference to many of the health problems ‘troubled families’ experience. The programme is a good example of what David Hunter and Jenny Popay and others have called ‘lifestyle drift’, where the focus of interventions drifts towards attempting to change individual behaviour, despite the wealth of evidence pointing to other solutions. But this ‘responsibilization’ strategy is also a punitive, stigmatising discourse which is targeting some of the poorest and most vulnerable families in England, telling them that they are the architects of their own misfortune and that they just need to try harder and follow a routine. A simultaneously fascinating and alarming article in the BMJ recently, exploring the role of psychology in government workfare programmes highlights that this approach is not a unique aspect of the government’s welfare ‘reforms’. Health professionals should tread carefully.

Stephen Crossley's first peer-reviewed article on ‘troubled families’ can be found here.

Thursday, 4 June 2015

Complexity in health organisations: setting ourselves up for chaos or enjoying the simple things in life?

Posted by Peter van der Graaf

Can applying a complexity lens to health organisations be more than an academic exercise with practical applications for service delivery? This question was central to a two-day meeting last week in London at the Health Foundation between researchers, policy makers and health practitioners. The event was organised by The Knowledge to Action Group (KTAG), an international team of senior academics and coordinated by two leading members of Fuse’s Complex Systems research programme, Prof David Hunter and Dr Emily Henderson. The group brought together the crème de la crème of health research and knowledge mobilisation, with about 40 handpicked participants from across the UK to debate a green paper on the topic (which is a tentative government report and consultation document of policy proposals for debate and discussion).

The essence of this meeting was about getting to grips with the consequences of doing research and developing interventions in a world that is inherently complex (which is not to be confused with just being complicated!). The green paper (Knowledge-to-Action: Addressing Complex Problems in Health Systems, May 28/29 2015) described complex systems as non-linear; dynamic; and having no single point of control.  Because of these characteristics, outcomes in a complex system are unpredictable and resistant to interventions. So are health systems really complex? Anyone trying to get research evidence into practice will quickly discover that knowledge mobilisation is prone to all the characteristics outlined above for complex systems.

In one of the breakout sessions during the event the difference between complicated and complex was illustrated with the example of building a rocket versus raising a child.  Building a rocket is complicated but will lead to a predictable outcome (successful launch) if all the different pieces are correctly assembled according to the guidebook. However, raising a child is complex (as many parents will testify) and often leads to chaos in many academic households. This is bad news for academic parents and health service managers: you cannot steer the thing (but you are still accountable for it) and even if you find the solution to a problem in the system it is likely not to work when you try it again. The dynamic nature of systems means that what works in one context or at one point in time may not work the same as the system changes.

How do you work within such a system? Fortunately, the event provided four case studies of research projects where the academics had managed to work within a complex health system to produce change across different areas, often in co-production with policy makers and health practitioners. The authors of the green paper distilled four themes from these case studies to inform future research and interventions:

  1. the balance of central and distributed authority in organisations and systems; 
  2. the importance of emergence (continuous learning and adaptation); 
  3. the need for co-produced knowledge; and 
  4. a range of leadership positions and styles.
These four themes were discussed in more detail in various breakout sessions over the two days.

Participants embraced the spirit of the event and discussed a wide range of topics (from the need for a critical discourse department to finding positive deviants), whose relationships with the four themes were sometimes unclear and mostly unpredictable. Nevertheless, some key messages emerged from the event that will soothe the nerves of academics and service managers. By visualising complex organisations as “patterns of conversations between interdependent individuals” (as quoted in a presentation from Allan Best on the first day), working in complex systems becomes conversation management and engagement. According to the researchers involved in the successful case studies, this works all the better outside the normal context of everyday work by taking commissioners to the pub or baking a cake for a meeting with service managers to get the conversation really going. Isn’t it ironic that to work inside complex systems, one needs to go back to basics in a more simple system?

Thursday, 28 May 2015

52 weeks in public health research – the (very) rough guide

Guest post by Avril Rhodes

Remember the natty idea to take photographs representing a year of working in public health research? Well, how about a quick analysis of what we saw, snapped and submitted? Here are the exciting and indeed revealing results.

After looking at 198, or was it 200, images a portrait of researchers concerns emerges – not exactly Maslow’s hierarchy of needs, so much as the Rhodes' hierarchy of academic obsessions.

Bottom or is it top of the pile comes food. It’s official – no less than 42 pictures, close up and distance shots, ranging from individual snacks, drinks and meals to full size conference spreads and displays. I felt slightly queasy after looking at them all. Feed those academics!

The next most important thing is to feed the mind. Any passing course, lecture, symposium and the like weighing in with 20 pictures. But there’s lots more that get close to the mind-feeding category although making more cameo-esque appearances, such as degree ceremonies, IT, stands and posters, books, theses, work in progress and journal covers. Publication definitely counts. Completing work even more.

The office – no not the TV series, comes next, with 16 images, inflated perhaps with opportunities created by moving office and the delights of standing desks and desks tied to exercise apparatus. I would not have dreamed that taking a picture of the immediate work environment was so important. 

Travel ranks highly but possible to count in different ways. Railway stations are significant at 11 pictures, especially Newcastle Central – of world significance as stations go, but that’s just me. Car travel featured just slightly with a nod to cycling. Active travel (good and bad) is clearly a source both of delight, when stairs get favoured, and frustration, when lifts are promoted. Exercise equipment got a decent look in too. 

Signs and marketing really played on the collective academic mind. Labelling, the impact of shop placements and advertising, spelling mistakes, unintended humour, public health messaging, came in with around 12 images. Some of this felt a bit judgemental, when it came to cheap unhealthy food signs. Not too many wider determinants of health, it has to be said.

Field work related images scored a fairly respectable 9.

Culture kept creeping in. Museum visits, architecture, music, sculpture were all there. Nature played a relatively small part, but researchers did appreciate the cute, the beautiful, office plants and the changing seasons.

Then a whole rag bag of one-offs. Some were clearly novelty items or personal reminiscences, and some seemed like stream of consciousness, or pet concerns.

Curiously, the academic world was quite short of pictures of people, except in crowd shots doing serious lecture type stuff. It looked a camera shy world. So what do we have? A hard working, semi-office bound, nomadic community that likes writing, learning, unable to switch off form public health even when undertaking a leisure activity or just walking around the town, that enjoys high art and longs to sniff a flower. Is this what we are? The camera apparently doesn’t lie.

Tuesday, 19 May 2015

Public Health Post-election: What is its future?

Posted by David J Hunter, Professor of Health Policy and Management, Durham University and Fuse Deputy Director

The Conservatives’ election victory has brought both old and new faces into the ministerial team at the Department of Health. Jane Ellison returns as a junior minister and will retain the public health brief thereby bringing a degree of continuity to the post. She was growing into the post in the run-up to the election and public health insiders speak well of her.

Public Health Minister Jane Ellison
The fact there has been extensive coverage of the other ministerial appointments in health excluding hers might say a great deal not only about the place of public health in the government’s health priorities but about the level of importance the media attaches to the subject.

Clearly the funding difficulties plaguing the NHS will be uppermost in Jeremy Hunt’s (back as Secretary of State for Health) in-tray with the integrated health and social care agenda not far behind. But the new government is also committed to implementing the Five Year Forward View (5YFV) produced by the NHS Chief Executive, Simon Stevens, last October. Herein lies the hope for public health and surely the near certainty that it will occupy a high place on the government’s list of priorities.

Public health did not feature prominently in the Conservative Party’s manifesto and no major new initiatives were promised. None of the parties had much to say about public health during the campaign. And yet the new government is going to come under significant pressure to up its game over the next five years with the call for ‘a radical upgrade in prevention and public health’ featuring prominently in the 5YFV.

Not only that, but Simon Stevens rarely misses an opportunity in public to stress the importance of public health, admonishing successive governments for their failure to implement the Wanless ‘fully engaged scenario’.  Since the NHS failed to heed the warning, it ‘is on the hook for the consequences’. Wanless wanted a transformed NHS that put health and not illness first.

The 5YFV urges the NHS to redeem itself over the wasted years by becoming an advocate for ‘hard hitting action’ on avoidable lifestyle-related illnesses. Because these put added pressure on health care services, tackling them at source has to be a high priority if a universal service free to all at the point of use is to be sustained.

The latest projections from WHO published a week ago show that Europe faces an obesity crisis by 2030 and that urgent action is needed by governments. In the UK, 33% of women are forecast to be obese by 2030 compared with 26% in 2010. For men, the figures are 36% and 26% respectively. The figures are worse in some other WHO member states with only The Netherlands doing better and remaining stable.

As we know, although there is no silver bullet for tackling obesity restricting unhealthy food marketing is regarded as a key policy lever available to governments. Where this leaves the government’s responsibility deal approach to addressing key public health challenges is uncertain. Even if its critics are persuaded that it is working, the key question in the light of the WHO projections is whether it is working fast enough given the urgency of the crisis looming in under 15 years’ time.

Another key development concerns devolution within England and the Northern Powerhouse initiative. Local MP for Stockton South, James Wharton, has been made the first minister for the project. It builds on the DevoManc announcement earlier this year which put local government in charge of the NHS budget for the Greater Manchester region. Chancellor George Osborne, the architect of this experiment, in his first speech since the election will announce today similar devolved arrangements for the City regions, including Newcastle.

The move to devolve power and responsibility could have major implications for public health as local government will be able to pool budgets and adopt place-shaping policies to improve health and wellbeing and tackle the social determinants of health.

But the catch must be that these developments are occurring at a time when local government is on its knees. With no let up to austerity in sight and with further public spending cuts to come which will fall heavily on local government, the question has to be asked: is local government being set up to fail? Whatever the outcome, there will be significant implications for public health which cannot be predicted. Watch this space.

Thursday, 14 May 2015

How active are pregnant women? Measuring the methods

Posted by Louise Hayes and Cath McParlin 

Louise and Cath are presenting on the subject of physical activity in pregnancy at the Fuse Phyical Activity Workshop tomorrow (15 May) at Sunderland University.

So we all know we should move a bit more to be more healthy and reduce our risk of getting diseases like diabetes. For a long time pregnancy was seen as a time when a woman could put her feet up, take it easy and ‘eat for two’. But not any longer! Guidance published over the last few years recommends no ‘pregnant pause’, but rather that pregnant women should aim to achieve at least 30 minutes of activity of at least moderate intensity activity on most days of the week - just like the rest of us.

Part of the justification for this is that physical activity might help to reduce the risk of gestational diabetes (GDM) – that’s a type of diabetes that is diagnosed in pregnancy and (usually) resolves after the pregnancy. However, to some extent, the jury’s still out on whether or not being active when you’re pregnant really does reduce GDM.

Partly this is because we don’t really know how to measure physical activity accurately in pregnant women. The more precisely we can measure physical activity, the more accurately we can establish the relationship between it and GDM and other health outcomes.

Physical activity measurement is fraught with difficulty in any circumstances – it’s a challenge to measure such a complex and multi-faceted behaviour. Pregnancy brings additional challenges. With the development (and increasing affordability) of numerous objective methods for measuring physical activity – pedometers, heart rate monitors, accelerometers - objective measurement of physical activity in epidemiology is increasingly common. For pregnant women, however, the validity and acceptability of these methods remains unclear.

We have agonised over how best to measure physical activity in a pregnant population. What effect does the increasing size of the ‘bump’ have on the validity of waist-worn monitors? How good are monitors at recording low-level activity, common in pregnant women? What are appropriate cut-offs for different activity intensities in pregnant women?

The choice of measurement method has a huge influence on conclusions we draw about how active women are during pregnancy. We have compared questionnaire methods and accelerometry using different criteria to define activity intensity and found that, depending on the method used, we identify anything from 12% to 65% of pregnant women to be meeting the current guideline (30 minutes of at least moderate activity per day) in the first half of pregnancy.

We’re looking forward to discussing the whys and wherefores of different methods of assessing physical activity with the experts attending the Fuse PA Group Workshop at Sunderland University tomorrow (Friday 15 May).