The booze, the binge and the bulge

Guest post by Cassey Muir, Research Assistant, and Alice Graye, MRes Student, Newcastle University.

Drinking behaviours and eating behaviours in young adults have been widely studied separately, but our research - FOrwaRD; exploring FOod and Risky Drinking behaviours in young adults aged 18-25 - takes a novel perspective to try and understand how drinking and eating behaviours interact and the implications for interventions.

We hope that intervening in early adulthood, when these linked unhealthy patterns emerge and are prominent, may prove beneficial in reducing the risks associated with obesity and heavy drinking. From our formative research, there seems to be an unquestioned norm that drinking alcohol and eating unhealthy food link together in the lives of young adults. There are a number of ways in which drinking and eating behaviours may interact, for example, some young adults may eat a takeaway after a night of drinking and a fry-up the next day, some may choose not to eat prior to drinking and some may drink alcohol alongside a meal (look out for research on this soon to be published by Dr Stephanie Scott and colleagues). 

While the answer to how these behaviours link together may vary, it is clear that young adults are provided with a social benefit from their linked eating and drinking patterns. A benefit that seems to be the biggest barrier for intervening with these linked behaviours.

Alice and I recently organised a Fuse Quarterly Research Meeting. The event kicked off with three inspiring talks. Firstly, Sharon Hodgson the Shadow Minister for Public Health, gave her thoughts on young adult alcohol use and eating patterns from a policy perspective. This was followed by Fuse Associate Director Dr Amelia Lake, a Reader in Public Health Nutrition who delved into the obesogenic environments that today’s young people live in, with particular emphasis on the high rates of energy drink consumption in the UK. The current research findings of the FOrwaRD project were presented by Dr Stephanie Scott and the team. These findings led into the workshop activities for the day, with attendees giving their views on young adult associated eating and drinking habits and intervention strategies. The meeting was attended by over 50 delegates responsible for policy or service delivery for young adults; this included people from Local Authorities, voluntary sector organisations and Higher Education Institutions from across the North East, as well as three young adults involved in patient and public involvement. 

Sharon Hodgson, Shadow Minister for Public Health, at the
Fuse Quarterly Research Meeting

For the workshop activities, attendees visited ‘FOrwaRD’s Food and Alcohol Big Market’ in which there were tables representing ‘venues’ and everyone had time to socialise in two venues, one bar and one takeaway shop. At each venue there was a topic to be discussed, which were:

1. Young adult eating and drinking patterns
2. Current support for young adults
3. Developing an intervention
4. Recruiting young adults at risk

There was lots of energy and positive discussions throughout the workshop activities and a clear opinion voiced that young adults should be better supported when it comes to safer drinking and healthier eating and the link between the two. Ideas to support this focused on both individual and population based approaches. Firstly, young adults may benefit from a change in policy around the food and alcohol environment. This could include; reducing the amount of alcohol and food promotional offers, restricting development of fast food and alcohol venues (for example, on and around student campuses), or setting up activities that do not revolve around food or alcohol. While these discussions mainly focused on the environment in and around Higher Education campuses, this approach may be beneficial more widely.

“We need to have a shift in the way that we approach planning and licensing around universities or colleges. Obviously, it’s harder to do because there are a lot of people who don’t go to university and college who you wouldn’t reach with that.” Group 1

Indeed, in earlier interviews with young adults, it was also found that linked food and alcohol pricing, and the night-time environment could be target areas for change.

In addition, attendees also discussed the importance of targeting a young adult’s social network, tailoring the motivational hook and goals to the individual, whether that be to lose weight, save money, to improve their appearance or mental health awareness, and that we offer healthier - and just as social - alternative behaviours.

“Perhaps finding more avenues for socialising as well that don’t involve eating and drinking. There are plenty of other things to be doing.” Group 5

“The important thing is your hook and what motivates them, because if you don’t get that then you’re not going to.” Group 3

While student eating and drinking behaviours were seen as problematic, there was a view throughout discussions that these behaviours may change or improve upon graduating, and that going into employment may act as a buffer against these behaviours escalating. Whereas, young adults who do not go to university may benefit from an intervention in the long-term. One way of accessing young adults may be to start within the community setting and approach services that support them.

At the event we made fantastic connections to discuss our findings with other young adults within community settings such as the YMCA, Balance North East, Matrix, and the Young Health Commissioners.

Do you know of any organisations who work with and support young adults and who would like to find out more information or get involved with our research project? If so, then please contact me, Cassey Muir (cassey.muir@newcastle.ac.uk). We are aiming to run workshops over the summer with young adults to get their views on how we can support them to drink safe, eat well and be social.

#DrinkSafeEatWellBeSocial

Cassey and Alice are part of a multidisciplinary research team working on the FOrwaRD project. Cassey is an early career researcher running the day-to-day activities of the project and Alice is an MRes student working on the project, exploring students’ experiences.

Do councils have what they need to help tackle obesity?

Guest post by Michael Chang, Project and Policy Manager, Town & Country Planning Association

The new revised National Planning Policy Framework (NPPF) is published by the Ministry for Housing, Communities and Local Government this week (24 July). It now provides the policy basis for planning healthy communities (Section 8 Paragraphs 91 and 92). In this context, here I want to explore whether there are enough planning powers to successfully tackle fast food outlets. At a Fuse event earlier this year on ‘Planning for Healthier diets: restricting hot food takeaway proliferation’, I also highlighted interesting results of recent planning policy developments and planning appeal decisions.
 

Back to the future… again?

Firstly it should be stated that concerns about the physical built environment and food environment in relation to people’s health and wellbeing are not a new trend. There has long been an understanding (with increasing supporting academic evidence) of the negative implications of food deserts and extant planning policies to tackle the negative environmental impacts from food outlets such as smells, noise, opening hours, litter and traffic generation.

The Foresight Tackling Obesities report was published in 2007 which, in the context of addressing the issue through a whole system approach, suggested two actions in which urban planners can effect change in the living environment, one of which refers to food and drink access and availability[1]. But a year earlier, the Royal Commission on Environmental Pollution, an independent standing body established in 1970 to advise the Queen, the Government, Parliament and the public on environmental issues, had already highlighted availability and cost of healthy food as an environmental determinant to cardiovascular risk in its seminal 26th report on The Urban Environment[2].

Is there an enabling policy environment to tackle obesity?

Given the weight of evidence, research and high-level recommendations in the last decade, in 2018, do planning practitioners working in local authorities have the right policy tools to do something about it? The main indicator is whether local plans, which each local authority across England have created, have the right policies? Local plans are powerful because in addition to setting out the council’s long-term vision and pathway for creating sustainable local communities, they are the basis with which decisions on planning applications are made from extensions to your house, to opening new shops on the high street to the creation of a complete new neighbourhood.

CEDAR (Centre for Diet and Activity Research) will publish more extensive results on local plans and fast food outlet policies so I will focus on the wider issue of tackling obesity. As part of the Planning Healthy Weight Environment work in 2014[3], the Town & Country Planning Association (TCPA) undertook an extensive policy review of local plans in England. Forty-one percent (41%) did reference obesity but generally only in the introductory paragraphs where they identified that obesity was a problem in the area. Only 17% followed through to the policy sections, but always in the supporting text rather than in the policy text. In statutory Joint Health and Wellbeing Strategies, only 31% make specific links to the built environment as one of the wider determinants of obesity. 

There is no reason, if supported by evidence and needs assessment, for councils not to have relevant policies such as on active travel, open space and food environment with a specific objective to help reduce local obesity rates. Recent planning inspector reports on draft local plans, before they are approved by councils, indicate a growing positive picture of a more welcoming stance on restricting fast food outlet policies including greater acceptance of the exclusion zone approach.

Have planning appeal decisions been favourable?

How are councils actually faring when they apply these policies in defending their decisions to refuse planning permission for new fast food outlets? The picture is more mixed with some councils successfully defending their decisions while many others have their decisions overturned by planning inspectors. The justifications by planning inspectors are not as you might expect.

"...this is politics, it's not medicine..." - 24 TV series

To illustrate the way planning appeals have been decided for and against planning applications for new fast food takeaways, take for example a scene from the hit American drama ‘24’. President Palmer’s advisor Wayne Palmer said to the President’s doctor Anne Packard: “It’s he said, she said, you see this is politics, it’s not medicine, so do me a favour and stay out of it”. 

Most, if not all the recent judgements I have seen (but there would need to be a more systematic review), do reference national guidance and support the obesity crisis as a valid planning reason. The health and medical arguments appear to have been won, but other wider considerations including local ‘political’ issues come into play and only evidence presented on the day are valid. This scene underlies the tension in planning decisions, which is why in its three reports into the government’s Childhood Obesity Plan in the last three years, the Health and Social Care Select Committee[4] has consistently called for health to be a material planning consideration in an arena of competing considerations from economic to employment.

What does this all means?

There needs to be more research done in the area to better understand the implications of proliferation of fast food outlets on population health from the health inequalities lens. There also needs to be more applied research to understand why practitioners could not effectively implement policies and what the real barriers are. Evidence and aspiration can only go so far. It is time we all take a breather from pursuing perfect evidence to properly supporting practitioners at the coal-face.


Michael Chang is a Chartered Town Planner at the Town and Country Planning Association (TCPA), leads on TCPA’s Reuniting Health with Planning Initiative and currently undertaking a part time Master by Research at Leeds Beckett University on using planning powers to promote healthy weight environments.


References:

1. Foresight, 2007, Tackling Obesities: Future Choices: https://www.gov.uk/government/publications/reducing-obesity-future-choices  
2. Royal Commission on Environmental Pollution (RCEP), 2006, The Urban Environment: http://webarchive.nationalarchives.gov.uk/20110322144101/http://www.rcep.org.uk/reports/26-urban/documents/urban-environment.pdf
3. Town & Country Planning Association (TCPA), 2014, Planning Healthy-weight environments: https://www.tcpa.org.uk/Handlers/Download.ashx?IDMF=7166d749-288a-4306-bb74-10b6c4ffd460
4. Health and Social Care Select Committee, Childhood obesity inquiries reports 2015, 2017 and 2018: 

• https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/inquiries/parliament-2015/inquiry/publications/, 
• https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/inquiries/parliament-2015/childhood-obesity-16-17/publications/, 
• https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/inquiries/parliament-2017/childhood-obesity-inquiry-17-19/

Images:

1. "318-365 Year3 On Our Way Home" by John Garghan via Flickr.com, copyright © 2011: https://www.flickr.com/photos/johngarghan/6351566649
2. By The original uploader was Tuxo at German Wikipedia. [Public domain], via Wikimedia Commons: https://commons.wikimedia.org/wiki/File:24-Logo.svg

How can governments reduce health inequalities in high-income countries?

Guest post by Dr Katie Thomson, Institute of Health and Society, Newcastle University

In recent months, there have been high profile stories of how governments can influence public health. The Scottish minimum unit price for alcohol introduced on the 1 May 2018, and more recently the publication of Chapter 2 of the Government’s Childhood Obesity Plan. This update proposed measures to address children’s exposure to junk food advertising on television and online, and called for a ban of price promotions on products that are high in fat, salt or sugar.

20mph zones were shown to increase inequalities in cycle accidents and

 rates of death between more and less deprived neighbourhoods

Such policies have great potential to improve public health, by shifting the distribution of health risk and addressing the underlying social, economic and environmental conditions (Hawe and Potvin, 2009)1. However, it is imperative to understand the impact of these policies on health across the entire social gradient. Thereby ensuring the most marginalised, are not adversely effected by policies which aim to improve health overall.

I have been part of a group of academics which recently completed an umbrella systematic review (‘review of reviews’) which aimed to understand the effects of public health policies in high-income countries. You can read about the research in a handy two-page Fuse research brief. As part of the Health inequalities in European welfare states (HiNews) project, we found evidence of 29 reviews (comprising 150 unique primary studies) which detailed the evidence of how fiscal (government revenue), regulatory, education, preventative treatment and screening approaches can be used by governments to influence health inequalities across eight key domains.

Conceptual framework of population-level preventative public health policies to reduce health inequalities

Our review highlighted 13 key interventions which were demonstrated to reduce health inequalities. These include taxes on unhealthy food and drinks; food subsidy programmes for low-income families; incentive schemes linked to immunisation status; proof of immunisation for school admission; tobacco advertising control measures; traffic calming measures; oral health (water fluoridation and tooth brushing campaigns); some nutritional and cancer education programmes; universal and targeted vaccinations for indigenous populations; and targeted and population screening interventions.

Worryingly, we also found evidence of interventions that were shown to increase health inequalities – potentially leading to so-called 'intervention generated inequalities’ (Lorenc et al., 2013)2. For instance, lowering alcohol tax by 33% was shown to increase inequalities in rates of death amongst disadvantaged groups in Finland. Environmental interventions, including 20mph and low emission zones, were also shown to increase inequalities in cycle accidents and rates of death between more and less deprived neighbourhoods.

Our research also demonstrates that for some potentially important interventions, such as for policies to control alcohol, there is a lack of robust evaluations highlighting the effects on different groups of people.

Given the volume of literature we found on the effects of government-led policies on health overall, it was disappointing that we could only identify 29 reviews that reported data on health inequalities. Going forward, those tasked with evaluating such policies must report how health outcomes differ for specific interventions by subgroup as standard. Furthermore, reviews should incorporate sufficient information on how the intervention was implemented and enforced to be useful for policy makers thinking of adopting such approaches. We also found many of the reviews and their primary studies were US-based, which could potentially limit the transferability of interventions from one country to another.

Undertaking a systematic review is not without its challenges. When published, the article reads like a definitive narrative when in reality it comprises a multitude of subjectivities – which reviews to include? Which primary studies are relevant? Which outcomes are most appropriate? And how to summarise the state of evidence in a particular field given multiple studies/reviews? The methodology is designed to be systematic, but as it uses human interpretation there is always an element of judgement. Umbrella reviews assess the state of the evidence across a wide area of interest, and are therefore worth the blood, sweat and tears which goes into producing them.

Upstream public health interventions involving state or institutional control offer great hope to improve health for all. However, a comprehensive understanding on the effects of different interventions is a necessary first step to ensure policies have an equitable benefit for all members of society and therefore are worthy tools at the disposal of governments tasked with improving health.


The Health inequalities in European welfare states (HiNews) project is a collaboration between the universities of Newcastle, York, Trondheim, Siegen and Harvard and funded by the New Opportunities for Research Funding Agency Cooperation in Europe (NORFACE).

References:

1. Hawe, P., Potvin, L., 2009. What is population health intervention research? 100, I8-I14.
2. Lorenc, T., Petticrew, M., Welch, V., Tugwell, P., 2013. What types of interventions generate inequalities? Evidence from systematic reviews. Journal of Epidemiology and Community Health 67, 190-193.

Photo: © Albert Bridge (cc-by-sa/2.0)

Putting the 'occupation' in Occupational Therapy and debating its role in Public Health

Guest post by Andrew Graham, Registered Occupational Therapist and PhD Candidate, Teesside University

Having recently made the move from NHS clinician into academia (I started my PhD at Teesside University in December 2017), I arrived in Belfast for the Royal College of Occupational Therapy Annual Conference with an appetite to hear new and interesting research in the profession.

In my welcome pack, I received a copy of the RCOT’s Strategic Intentions which represent the leadership response to the challenges of the changing landscape of health and social care. The principle that stood out for me was to ‘position the Profession, and our members, for the 21st century’.

With my background in amputee rehabilitation I have seen first-hand the impact of socio-economic inequalities and lifestyle trends on amputation rate in North East England. For example, the amount of amputations due to diabetes, and more shockingly intra-venous drug use, has spiked in the past 10 years or so. As an Occupational Therapist (OT), I view the person holistically and always try to take into account the social and psychological not just physical barriers they will need to overcome post amputation. My focus will always be on what the person needs and wants to do. The person’s meaningful activities (occupations).


The pledge tree

During the conference, we were asked to make a pledge about how we would do our part to ensure the new strategic intentions are met. The pledge tree seemed to have a recurring theme of ‘ensuring occupation is central to my work’.

My own pledge was to better explain ‘occupation’ and its meaning within occupational therapy to a range of audiences.

So, my attempt at articulating ‘occupation’? I’ll go with ‘doing things that we need to do and want to do (meaningful activities), which enable a sense of self-meaning and improved health and well-being.

I feel as a profession we are experts in using occupation as a goal (top down approach) and/or a means (bottom up approach) to ensure provision of high-quality, client centred services. Utilising the OT process from information gathering to evaluation we strive to enable growth, confidence and self-meaning.

Despite OTs generally being able to better define what they do and what the outcomes can be, it was a bit of a shock to see that the debate at the conference highlighted that the profession is still unsure about its stakeholders. The topic up for discussion was ‘This house believes that Occupational Therapy needs to be predominately based in public health, not in secondary or tertiary services’.

From my experience, this issue had been debated and answered years ago. My pre-registration training saw me working in the NHS, community mental health teams, a special needs school and a charity. The OTs all had a prominent and effective role in these sectors, so as intrigued as I was to hear the debate, I knew which way I would be voting!

For the purpose of this blog I’d like to highlight the case for OTs working in Public Health. A starting point would be the statement by the professional body, which points out that the Public Health Agenda has been of increasing importance and relevance for occupational therapists, who facilitate health promotion through working with people of all ages to enable their participation in meaningful occupations (RCOT 2004).

The evidence base is also pretty strong. A systematic review of Allied Health Professions and Health Promotion (Needle et al 2011) reviewed 28 studies related to occupational therapy and Public Health, and found related interventions in the areas of mental health, arthritis, pain and fatigue, pulmonary rehabilitation, stroke, drug and alcohol problems, and falls prevention.

Not only are OTs already working with people on aspects of Public Health and health promotion activity, but there is an expectation that this focus will form part of the delivery of all occupational therapy interventions in the future. For example, I remember reading about the ‘make every contact count’ campaign when working on an acute stroke ward and making sure I asked about smoking and drinking habits as part of my OT assessment.

So, it was with no surprise that the result swung against the motion at the conference. A particularly convincing rebuttal speech was given by Professor Diane Cox and Dr Jenny Preston, clearly showing the professions ability to address Public Health matters but also reach a wider audience through demonstrating outcomes in secondary and tertiary services.

Overall, I left the conference with a sense that the profession has strategically positioned itself to demonstrate that it is making a difference and will continue to make a difference to the health and well-being of people in the 21st century. It is time for OTs working in Public Health and other services to be proud. In my favourite quote of the conference….‘we are not the jack of all trades, rather we are the masters of human occupation’.


Andrew Graham is investigating ‘Sensory Discriminating Training for Phantom Limb Pain’, as a PhD candidate in the School of Health and Social Care at Teesside University.

Game of Thrones: King in the NoRTH… Workshop is coming… but has anyone actually read the books?

Dr Sonia Dalkin, Senior Lecturer in Public Health and Wellbeing, Northumbria University

Unless you’ve been living in a box since 2011, it’s likely that you will have heard of the series Game of Thrones. For those of you still in your boxes – Game of Thrones is fantasy drama television series created by David Benioff and D. B. Weiss. It is an adaptation of A Song of Ice and Fire, George R. R. Martin's series of fantasy novels, the first of which is called A Game of Thrones. The series has been acclaimed for many things including its acting, complex characters, story, scope, and production values. Notably, it has also received praise from both The Guardian and The Times for what is perceived as a sort of medieval realism. Here, I want to talk about a different type of Realism, that of Scientific Realism, or more specifically Realist Approaches to Research.

What is realist research?

Just as Martin’s novels rely on believable characterisation and relatable motivation to create enough suspension of disbelief to enter a world of dragons and sorcery, realist research focuses on social interventions to explain not only whether an intervention works or not, but for whom and under which circumstances. The focus therefore embraces and explains the complexity of social interventions. It aims to understand the responses people have to programme resources, therefore understanding the reasoning and motivations behind their actions. In order to do this, we focus on programme theory and utilise context, mechanism and outcome configurations. It provides rich findings, explaining why interventions work in some contexts, but not in others. For example – why is Daenerys impervious to fire when others are burnt? Because she’s a decedent of House Targaryen. Context is important, people! Alongside context is its trusty friend mechanism – similar to Ghost (an albino dire wolf) and Jon Snow – they go hand in paw. Mechanisms can be referred to as a combination of intervention resources and participant reasoning. More information is available on mechanisms here.

Altogether, the analytical tools of realist evaluation described above are used in the following way: Intervention resources are introduced in a context, in a way that enhances a change in reasoning. This alters the behaviour of participants, which leads to outcomes.

The methodology is not without its difficulties. Often realist researchers describe feeling that they are in a ‘realist swamp’; going down different alleyways, trying to understand and explain how a programme works, for whom and in which circumstances, but not getting too far. Often in this phase, realist researchers are similar to the White Walkers (an ancient race of humanoid ice creatures who really aren’t too friendly), in both looks and temperament. This phase can be frustrating, but like Arya against The Waif (acolyte of the Faceless Men), in most projects there is a sudden moment of clarity, where the dark alley becomes your friend, it all comes together, and you come out fighting.

Here at Northumbria University we have engaged in many projects using realist methods and want to help other realist researchers beat The Waif as quickly as possible, where possible. In order to do this, we’ve engaged a three-pronged approach as sharp as Arya’s sword, ‘Needle’:

1. Realist research Team Hub (NoRTH)

We felt it was time to highlight ourselves as key players in the realist game and to create a hub of realist research. What does every hub need? An acronym! We are now the Northern Realist research Team Hub (NoRTH).

NoRTH’s priorities will be to: advance the implementation of the methodology; collaborate with others focusing on realist research; contribute to and host realist education platforms; support PhD students in realist research; and continue to offer methodological expertise to those who seek it.

One thing of importance to note here is that we don’t feel we are the only big players in the North in terms of realist research – The Starks (University of Leeds) are obviously the long term true Kings of the North, with Professor Ray Pawson at the helm (our Jon Snow) for many years, and Nick Emmel, Joanne Greenhalgh, and Ana Manzano (Bran, Sansa and Arya) now fighting strong. But being ‘Northumbria University’, the acronym NoRTH seemed too good to resist… please take this blog as a token of our affection and don’t give us a fate like that of the Red Wedding!

2. Winter’s coming… along with a workshop in realist approaches

Winter is coming and soon we’ll have dark nights and frosty mornings, but never fear; alongside winter we have a brilliant offer of a Realist Approaches Workshop. Like Daenerys, mother of dragons, we wanted to educate others and decided one way to do this would be to provide a workshop. Whilst we can’t promise dragons, rebirths in blood and fire, or steamy scenes with Jon Snow, we can offer a fantastic line up of realist researchers, ready to take you on an exciting methodological journey.

Day 1 of the workshop will focus on Basic Principles of Realist Research, whilst day two will focus on contemporary developments such as realist ethnography and realist economic evaluation. To find out more and to book, check out the website.

3. ‘Doing Realist Research’ – a new book

As much as a lot of people claim to be Game of Thrones fans, how many of them have actually read the original books? TV series and films can bring whole worlds to life before our eyes, make characters into living people, but books take you into the detail, the nooks and crannies of the story. For example, the maps in Martin’s book displaying the geography of the mythical Kingdom aren’t as well portrayed in the TV series, despite efforts in the opening titles. Books provide the details that are often overlooked yet important in really understanding the overall story or the characters. Thus, if interested in realist research, I would like to suggest you read the new book ‘Doing Realist Research’, available to pre-order now), which provides much more detail on realist approaches, covering topics such as: realist review problem-solving, literature searching for realist reviews and mechanisms at higher levels of abstraction.

Edited by Nick Emmel, Joanne Greenhalgh, Ana Manzano (The Starks), Mark Monaghan and myself, this book celebrates the possible ways in which realism can contribute to researching complex social puzzles, providing practical advice on the ‘how to’ of realist methods.

Similar to Game of Thrones, so far, it’s received rave reviews, like that from Professor Kieran Walshe, (University of Manchester): “I wish all social science researchers would read this book”. Best of all, it has absolutely no Game of Thrones references – and that’s a promise (similar to that of Ned Starks to Lynna Stark in the infamous Tower of Joy Scene)…



Acknowledgements

Many thanks to Dr Phil Hodgson (Northumbria University) for helping me in identifying so many obvious Game of Thrones parallels with realist research…


Image: "Game of Thrones. Xbox One. 1080.P. 😁 Gameplay Part.04.-06. On my YouTube Channel 😁 https://youtube.com/playlist?list=PLwsjII0MclEGZnmdii3LZb9FZLby_iP4Q 😁 by Rob Obsidian via Flickr.com, copyright © 2015: https://www.flickr.com/photos/65092514@N08/18679295525

Why we must stop using the F-word in relation to Gypsies & Travellers

Posted by Natalie Forster, Senior Research Assistant at Northumbria University and Fuse, and Helen Jones, CEO, Leeds Gypsy and Traveller Exchange

Fascination. Not the word you expected? Then read on to find out why we find it so problematic when people say they are ‘fascinated by’ Gypsy and Traveller Communities.

We frequently hear ‘fascination’ cited as a motivation for
 working with Traveller Communities by practitioners

There is certainly a captivation with Traveller Community ‘lifestyles’ in society. The numerous Gypsy and Traveller autobiographies and television programmes devoted to Traveller Communities (perhaps best exemplified by the Channel 4 ‘Big Fat Gypsy Weddings’ phenomenon) have led Gypsy and Traveller life to be described as a ‘bestseller’, with little sign that this interest is fading. Television programmes are often badged as an exposé on Traveller Community lives, starting with the premise that Traveller Communities are hidden, closed-off and exotic. The Channel 4 Big Fat Gypsy Weddings series for example, promises a ‘Revealing documentary series that offers a window into the secretive, extravagant and surprising world of Gypsies and Travellers in Britain today’ (emphasis added). This language is not value free, and seems to foster a sense of intrigue or fascination in order to appeal to viewers.

Traveller Community members have a lack of opportunities to shape their own image in popular culture. A complete absence of Gypsies or Travellers among the proposed cast for an upcoming BBC Film adaption of Mikey Walsh’s memoir ‘Gypsy Boy’ recently drew attention to the exclusion of Traveller Community voices in the film industry. The understandable reluctance of many Gypsy and Traveller Community members to disclose their ethnicity for fear of racism and discrimination also means there are a lack of images or stories to counter the negative stereotypes peddled within mainstream media. That said, younger Traveller Community activists in particular are increasingly making use of forums through which they can challenge these portrayals.

What though are the implications of this issue for health practitioners, researchers and the public? Of course, we recognise that many of our colleagues share our aversion to programmes such as Big Fat Gypsy Weddings and the hugely problematic representations of communities that these advance. Yet, the underpinning premise of these shows remain unchallenged by many, and we frequently hear ‘fascination’ cited as a motivation for working with Traveller Communities by practitioners.

Why do we feel uncomfortable when someone says they are ‘fascinated by’ Traveller Communities? The use of ‘fascination’ echoes the voyeuristic sentiment of many television programmes and reinforces notions of Traveller Community members as exotic and worthy of special attention or interest. When mentioning working with Traveller Communities, the very reference to these groups often appears to prompt greater interest, but why should this be the case?

It is problematic, we think, in its divisiveness; in the impression it gives of Traveller Communities as mysterious and ‘other’, and a community that ‘outsiders’ can only look into. This downplays the possibilities for seeing commonalities between Traveller Communities and other sections of society – Gypsies and Travellers are seen less as people ‘like us’, facing similar experiences or challenges in life, and more as groups we should find out ‘about’ or gather information ‘on’.

A sense of fascination also seems to shift the motivation away from the interests of Gypsy and Traveller Communities themselves, and towards fulfilling the agenda of those working with these groups. A desire to satisfy one’s own curiosity about Traveller Communities can result in questions that are insensitive, such as those about the cost of someone’s caravan, or aspects of culture that are unconnected with the purpose of a visit.

It is for these reasons that we call for the reconsideration of the use of ‘fascination’ in relation to Traveller Communities and other groups who are seldom heard, as well as for greater questioning of the assumptions that lie behind this term, and the interests it truly serves.

Image: "Seeing My World Through a Keyhole" (4592429363_292aec80c9_z) by Kate Ter Haar via Flickr.com, copyright © 2010: https://www.flickr.com/photos/katerha/4592429363

Public health isn’t good politics (part 2)

Knowledge exchange lessons from the spotlight event at the University of Sunderland

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University and John Mooney, Senior Lecturer, University of Sunderland

In our last blog, we reported on the 4th Fuse international conference on knowledge exchange in Vancouver, B.C. Provocative speakers explained that public health is, at best a hard sell to policy makers and at worst impossible to influence decision making. Luckily, they also presented short cuts for making it more likely that public health evidence would be heard by policy makers.

Sharon Hodgson, Shadow Minister for Public Health, speaking
at the Spotlight on Public Health event in Sunderland

These challenges and the potential short cuts were clearly present at the University of Sunderland spotlight event that we attended, which aimed to increase the visibility of public health research at the university.

Sharon Hodgson, the Shadow Minister for Public Health, opened the afternoon session with a passionate plea for introducing a minimum unit price for alcohol in England, following the example of Scotland. However, she made it clear that the Scottish choice for a 50p unit price would be a hard sell to both her voters and the Labour party. Labour colleagues simply dismissed the policy as a ‘tax on the poor’ and voters would feel the pinch on their already austerity squeezed household budget.

This ignited a lively debate with researchers in the room, who highlighted the research evidence that is available in favour of a 50p unit price. While statistical models consistently demonstrate that this would have the biggest impact on reducing alcohol related harm, such as liver disease, the Shadow Minister was concerned with how the price selected might impact on her voters. Specifically, she felt it was more important that increased costs to people living in more deprived communities were not dismissed, but instead presented as a health improvement incentive.

Having visited various supermarkets in her constituency to check the prices of different types of alcohol in order to work out the impact of different MUP limits, her conclusions sided with the views of the voters and Labour peers: 50p would hit all the different types of alcohol and not just the cheap ciders and therefore penalised not just the heavy drinkers but also the moderate drinkers in deprived communities. Instead, she argued for a 40p unit price, which would mostly affect the price of cheap ciders, and therefore target only the problem drinkers and not the other drinkers in her constituency. What counted as the most important evidence for the Shadow Minister was quite different from what the researchers in the room perceived as the best evidence to inform policy.

When an audience participant also tried to make the economic case by suggesting that the 50p tax would generate a better return for the Government that could be used to finance alcohol addiction services, the Shadow Minister remained unconvinced.

What did start to sway her was another suggestion to change the narrative from a ‘tax on the poor’ (which might be used as a stick by Conservative party members to beat their Labour colleagues), to a ‘tax for the wellbeing of all’. This narrative framed the 50p MUP as a policy that would affect all walks of life and could encourage a change in drinking cultures among all ages and classes, with the money raised being reinvested across a range of policy areas.

Shanon Hodgson agreed that this might make for an ‘easier sell’ and perhaps more importantly serve as the basis of a future health legacy that she could leave for her voters. By reframing the narrative from a small group problem (problem drinkers in deprived communities) to an emotive public issue of damaging drinking cultures, better policy and voter engagement might be secured.

Paul Cairney presenting at the 4th Fuse International
Conference on Knowledge Exchange in Public Health  

The evidence that she really needed were stories to demonstrate meaningful (personal) health gains and cultural change across different sectors of society. This requires a new type of evidence. It does not mean dismissing academic research and all the rigorous evidence it generates, but it does require a careful consideration of the policy system and process in which it is used and a willingness to adapt the messages and narrative to that context and the other types of evidence that are prevalent in that context. This is neatly summarised in the top tips from political science offered by Paul Cairney in his presentation at the 4th international Fuse conference:

1. Find out where the action is (‘actors’) 
2. Learn the rules (‘institutions’) 
3. Learn the language/ currency (‘ideas’) 
4. Build trust and form alliances (‘networks’) 
5. Be entrepreneurs, exploit ‘windows of opportunity’

Public health researchers operating as political entrepreneurs might be a hard sell to academic institutions but they have a world to win when trying to get evidence into decision making where it matters and creates impact.