Misinformation, data uncertainty and the cat scale of wellbeing - global lessons on knowledge exchange during a pandemic

Posted by Peter van der Graaf, Associate Professor, AskFuse Research Manager & NIHR Knowledge Mobilisation Research (KMR) Fellow, Teesside University and Roland Bal, Professor of Healthcare Governance at Erasmus University Rotterdam

While the evidence base on successful practices in knowledge exchange is growing rapidly, the COVID-19 pandemic presents unprecedented global challenges. During an online taster event for the upcoming Fuse international conference on knowledge exchange in public health, international experts shared their learning from the pandemic.

Perhaps the biggest challenge during the pandemic has been communication. Governments demanding quick access to the latest scientific evidence to inform their decision making in the fight against COVID-19; researchers dealing with a lack of data and uncertainty in interpreting emerging data on spread of the virus and risks to health; and both struggling with the spread of misinformation on social media and in other places of power. 

In spite of these challenges, awareness of public health and research evidence has increased significantly during the pandemic. Some public health figures, such as England's chief medical officer Chris Whitty, have become household names ("next slide please") and ‘R numbers’ are now common knowledge. We learned to be more flexible in funding, designing and conducting collaborative research, with gold-standards being replaced by ‘good enough’. 

Maureen Dobbins from the National Collaborating Centre for Methods and Tools within McMaster University in Canada, demonstrated how they were able to develop new synthesis methods and dissemination plans with local government to mobilise evidence for decision making within less than a month. For example, they conducted a rapid review on household food insecurity for the Public Health Agency of Canada with support from Public Health Advisor Leanne Idzerda. They dealt with uncertainty in these rapid reviews by grading the evidence by asking: ‘How likely are the findings to change with more evidence?’

As professionals, we learned to deal with the uncertainty of data by making better use of our personal connections. Roland Bal from the School of Health Policy and Management at Erasmus University in Rotterdam showed how Dutch clinicians mobilised their informal network of colleagues at the local, regional and national level to coordinate beds for COVID-19 patients across hospitals in the Netherlands and reduce uncertainty about available intensive care unit capacity. This resulted in a dedicated bus service for transporting patients between hospitals.

Existing monitoring and coordinating structures between hospitals no longer worked in the pandemic and were replaced with new informal ones, in which emotions and politics played a much larger part. Roland dubbed this the importance of ‘relational epistemology’ and also drew attention to the ‘dark side’ of these new coping strategies, where people outside these relational structures were seldom heard and the patient voice and experience not included. 

However, researchers also developed new ways of engaging with their partners in research. For example, Jane Powers and Mandy Purington from the Bronfenbrenner Center for Translational Research at Cornell University, USA engaged with youth workers and health care providers in their ACT for Youth project by transitioning to innovative remote and virtual formats, including game and role play, using avatars. Part of these formats is an acknowledgment of the emotional impact that the pandemic has on partners and therefore the need to create a space in these activities to check in on partner wellbeing. Perhaps their greatest innovation is the ‘cat scale’ which Heather Wynkoop Beach from the Bronfenbrenner Center introduced during the event - which cats represent you today?

Finally, policy makers, professionals and researchers have had to learn to deal with misinformation about COVID-19. Peter Lurie, President of the Center for Science in the Public Interest, in Washington, D.C., USA showed that the actual amount of primary misinformation about COVID-19 is very small but can do plenty of damage, due to many people simply referring to it online. Of the 479,225 articles he found in his review on COVID-19 vaccines in a wide range of media outlets, only 3.7% contained misinformation, and of those only 3% contained what he called ‘primary misinformation’, with the vast majority of articles simply referring to a very small number of primary sources of misinformation. However, some of these articles were sent to more than 400 million subscribers, indicating that the reach of misinformation can be vast!

C-WorKS: COVID-19 Consequences – Want it? or Know it? Share it!

To counteract misinformation and lack of knowledge, Mia Moilanen, who works as an Analytical Programme Manager at Public Health England* in the UK, demonstrated an online knowledge sharing platform called C-WorKS, which was developed during the pandemic. On this platform, health professionals, service commissioners and academic researchers across North East England and Yorkshire share knowledge, expertise and resources on the non-COVID consequences of COVID-19 (e.g. delayed representation of other health conditions, mental health and increasing health inequalities). So far, over 700 members have shared more than 300 resources through C-WorKS.

What the pandemic has taught us more than anything, is the importance of collaboration: to work together to find solutions and that, during public health crises, we need to find new ways of connecting knowledge users, producers and brokers. This requires flexibility in roles, structures, research methods and funding arrangements, which will have a lasting impact on the future of knowledge exchange in public health. We hope to address the complex challenges faced during the pandemic, what we have learned about knowledge exchange, and how we can use this knowledge to improve research and practices in the future at the Fuse conference next year in June in Newcastle, UK. We can’t wait to see you there!

*Public Health England has been replaced by UK Health Security Agency and Office for Health Improvement and Disparities

Watch a recording of the online taster event below

 

Images:

1. Capture from the BBC News website, 19 December 2020. Covid at Christmas: 'Chris Whitty is more popular than Britney Spears'. Source: TWISTED PICKLE. https://www.bbc.co.uk/news/uk-55333205

Can Forest School inspire the next generation to be happy & healthy?

Posted by Katie Beresford, undergraduate student, Durham University

Katie completed a 6-week NIHR School for Public Health Research (SPHR) internship with Fuse based at Durham University in summer 2021. She was supervised by Fuse / NIHR SPHR PhD student, Sophie Phillips.

Richard Louv, in his book Last Child in the Woods, theorises that lack of connection to nature is causing a plethora of health problems in children. Can reconnecting children to the natural world provide a holistic solution to health and developmental issues?

Growing up in the Lake District, I spent my childhood climbing trees, swimming in rivers, and making mud pies. Embracing nature and enjoying letting my imagination reshape the world around me was part of my everyday life. In contrast, I found school restrictive and struggled academically in my early years – often being described as a ‘late developer’.

While completing my NIHR SPHR summer internship within Fuse, I reviewed literature discussing the effectiveness of Forest School as a public health intervention. One article titled: The hare and the tortoise go to Forest School: Taking the scenic route to academic attainment via emotional wellbeing outdoors struck me as similar to my own story, describing how children considered ‘behind’ their peers could catch up, like the tortoise in Aesop's fable. Now nearly two decades later and about to go into my final undergraduate year at University, I truly believe in the power of the outdoors to inspire children to be curious and healthy individuals.

Forest School is a child-led educational practice, whereby children spend time in a Forest or woodland under the guidance of a trained Forest School practitioner. The ethos and philosophy of Forest School is based on a rich heritage of outdoor learning. This ranges from whole movements such as the romantic movement, which exalted the sublimeness of nature as a push-back against the industrial revolution, to the work of individuals such as the great educationalists like Steiner and Montessori. However, the concept of ‘Forest School’ emerged originally from Scandinavia, where in many cases children spend their entire early years education playing outdoors.

The practice developed in the UK in the early 1990s and is ubiquitous across the country today. Although much of the practice in the UK places emphasis on freedom and play, often activities are incorporated into the sessions designed to connect the children to the natural world. Forest School aims to be beneficial for the holistic development of children, offering a wide range of social, emotional, cognitive, and physical benefits.

My summer internship consisted of writing up a literature review which drew on both the current research on Forest School and the thoughts of practitioners and stakeholders in the field. I considered both the effectiveness of Forest School on the health and development of children and the accessibility of the programme.

Due to its rapid growth, there is still much work to be done on improving the evidence base for Forest School, but in general there is huge enthusiasm from researchers and practitioners alike on the effectiveness of the practice. Forest school appears to equip children with social skills such as teamwork and collaboration; emotional skills such as resilience and self-esteem and cognitive skills like problem solving. There is evidence that it also increases children’s levels of physical activity and improves their appreciation of nature.

But, perhaps the most striking finding was that Forest School not only had an impact during the session itself, but long after the children stopped attending the Forest School. Through the pure enjoyment of being outside and not bound up by the norms of classroom behaviour, the children were inspired to be curious about the world around them. They started asking questions and thinking creatively and collaboratively.

Taking the scenic route to academic attainment

Some studies found that through attending Forest School, children who were academically behind their classmates caught up to a similar level of academic attainment since their interest in learning had increased. Forest School impacted children’s overall wellbeing, as it encouraged them that physical activity and spending time in the outdoors could be fun and rewarding. The children were therefore more likely to want to exercise and complete similar activities to Forest School in their own time – asking parents to take them to local natural spaces after school and at the weekend. Conversations with practitioners showed that this was pivotal to challenging the cultural lifestyle of families, especially in more deprived areas, improving perceptions of what it means to be healthy.

In a changing world, where children spend far less time outside as a result of factors like the increase of technology and availability of entertainment, Forest School offers an innovative and holistic approach to reconnecting children with nature. Through this, we can hope to inspire the next generation to be the curious, positive, and healthy individuals of tomorrow.

This project was funded and supported by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR), Grant Reference Number PD-SPH-2015. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.


Images:

1. Photo by Markus Spiske on Unsplash
2. The Tortoise and the Hare. From Childhood's Favorites and Fairy Stories, by Various. Project Gutenberg etext 19993 http://www.gutenberg.org/etext/19993. From Wikimedia Commons: https://commons.wikimedia.org/wiki/File:The_Tortoise_and_the_Hare_-_Project_Gutenberg_etext_19993.jpg

“Next slide, please!” Newcastle children’s reflections on the pandemic

 Posted by Laura Basterfield, Research Associate, Newcastle University

Often in research, once we’ve collected the data, analysed and published it, we don’t have the opportunity to go back to the participants to discuss what we found. When children are involved, we may give a feedback presentation at a school assembly, but let’s be honest it can be difficult to make Powerpoint fun!

I’ve worked closely with Walkergate Community School over the last few years on my research into children’s physical fitness and mental wellbeing and I wanted to deliver my feedback in an assembly that the children would enjoy. I thought the best way to do that might be to let them do it themselves, as who knows what children like better than other children? And I am so pleased I did; it was a fascinating process. 

The ‘Young Science Communicators’ project was due to have taken place in June/July 2020, but had been delayed due to the COVID-19 school closures. Whilst I was initially disappointed last year, the realities of the past 12 months brought an added dimension, intensity and poignancy that would not have been there otherwise.  

There weren’t many rules, but the assembly should include some of the results of the study, including both the physical and mental benefits of physical fitness and activity. Other than that I was happy for the children to take the assembly wherever they saw fit. To start, thirteen Year 6 pupils (aged 10-11 years) discussed with me the project specifically, fitness in general, and about the impact the COVID-19 lockdowns and school closures had on them and their families. Then I taught the children some of the key skills they would need to do my research. I wanted them to really understand why I do what I do, and what better way than to then practice on your friends?! There were some wonderful comments from the children about how they liked the experience: “I enjoyed it because I want to do your job when I’m older” and “I liked being in control!” (which must be quite unfamiliar at 11 years old), and they quickly learned both the techniques and how to talk politely to their class-mates! 

The following week it was over to the children and their ideas. The goal was for them to create an assembly, film their performance, and share it with the rest of the school – all within three days. Scott and Claire are practitioners with local theatre company Mortal Fools and they led the children on a games-based journey to increase their confidence, public speaking and team-working skills. The children were all totally engaged and willing to share their thoughts, feelings and experiences to create a collegiate and supportive atmosphere. For me as an observer at this point, I was struck by the children’s recreations of the school closure periods and how they articulated their feelings: “I had no motivation to do anything”, “I was lonely”, “frustrated”, “isolated”. This was especially the case for those without their own mobile phone – some were unable to speak to friends for weeks. They also showed a mature insight into how the adults in their life had been affected, acting out money worries, family health issues, the stress of getting children to do schoolwork and go to bed on time, when there was nothing to get up for the next day…

As the group moved on to the awkwardness of meeting up with people after such a long time “Errr… so have you been up to much?!”, to their joy and excitement of seeing family, friends and teachers again, the whole process felt reflective and cathartic. Claire and Scott’s skill was evident as the children’s confidence grew before my eyes. Along the way the children had us in stitches with impressions of Boris Johnson, ‘next slide please’, and Joe Wicks.

Finally, they got to film their creation with the help of a proper film-maker. Most scenes only took a couple of takes, and the children showed incredible focus and concentration throughout. The final co-produced 9-minute film is informative, funny and affecting, and the children should be incredibly proud of their efforts. We still weren’t able to completely escape COVID, as three children missed the filming day due to a positive case in their class, but their input on the previous days made it a true team effort. 

The process showed me how important it is that we involve children not just in our research but in everything that affects them – simply asking children how they are, what they are feeling, and what they would like to be involved in gives us a hugely important insight into their world. 

I hope you enjoy their film.

Thanks go to all the children and staff at Walkergate Community School; Scott Wilson, Clare Rimington and Helen Ferguson at Mortal Fools, and Matt Jamie the film-maker. Permission to share this film has been granted by the parents and school of the children involved. 

Funding from EngageFMS at Newcastle University supported this project. 

Originally written for VOICE.

The Sound of Sirens

Posted by John Mooney FFPH, Consultant in Public Health, NHS Grampian @StandupforPHlth

Easily my most notable memory from the first Covid-induced lockdown was the unmistakable and disconcerting shriek of ambulance siren calls, regularly piercing the ‘lockdown’ silence of largely empty streets. Prompted by the memory of the mythical origins of the word ‘siren’, in which enchanting songstresses lured sailors and their ships to a rocky destruction, it struck me that the lure and temptation of ‘freedom day’ on which all Covid-19 constraints on social and other gatherings are no longer mandatory might yet similarly have an unfortunate aftermath. While I expect that risks placing me firmly in the ‘doomster’ camp, it seems I am in good company after the letter in last week’s Observer from some of our most eminent public health leaders who were at pains to point out that “living with Covid is not the same thing as letting it rip”.

This is now my third Fuse blog about Covid, in what is sadly proving to be a rather prescient series of posts about the pandemic. I set out in the first (published in February 2020), that as a newly emergent single stranded RNA virus, Covid-19 would be genetically unstable and undergo mutations which could influence its epidemiological characteristics including virulence and transmissibility. To say therefore that the present situation was not foreseeable (given my rudimentary grasp of evolutionary genetics), is clearly not that convincing. It’s probably even more self-evident that the more transmissible variants will be the same variants that are most transmitted, because this is the essence of viral survival strategy. Even with that knowledge however, the speed with which the Delta variant became the dominant strain (from under 10% to over 90% in a matter of weeks and now accounting for 99% of identified cases), was fairly breath-taking even by viral standards. 

A particular concern just now of course must be that the UK’s success in achieving a high vaccination uptake creates a new ‘selection pressure’ of its own, in that any newly emergent strain with the capacity to evade vaccine induced immunity will have an enormous selection ‘advantage’ in a population which has the combined characteristics of a high vaccination rate plus a high level of circulating virus. It’s easy to appreciate then how such a new variant could assume a ‘delta-style’ trajectory towards dominance, leaving even the fully vaccinated vulnerable once more. This is of course not a reason for reducing vaccination efforts which have been critical in protecting vaccinated age groups, thereby reducing the proportion of the population susceptible to new infections. If I could squeeze in one final take-home vaccine basics key message: the more infectious a particular variant, the higher proportion of a population needs to be vaccinated to mitigate transmission. This has prompted some commentators to expect that the holy grail of ‘herd immunity’ will always prove elusive for Covid.

The very real challenge for those of us in practice settings (having recently returned to NHS public health myself), is how best to advise local populations and relevant agencies in order to keep reducing the levels of circulating virus. The mechanisms that work here are very much those that are already in place combined with ongoing vaccination and access to local testing. The extent to which people might be willing to submit to testing that could sacrifice a long-coveted holiday, versus their readiness to isolate away from work, might begin to explain a divergence in the surveillance data in some health-board areas between declining numbers of cases and relatively stable hospital admissions (even allowing for the two week lag). The latter of which has already led to cancelled elective procedures in ours and other regions. We also know that infections in younger age groups are more likely to be mild / asymptomatic taking away the ‘illness prompting’ rationale for seeking a test.

Receiving supplemental oxygen in A&E
 6 months after initial Covid symptoms
 (mask displaced to drink)

At this point it would be useful to highlight the relevance of the second blog in this series as then it all looks impressively planned! (Spoiler alert: it wasn’t!). In that article, I described my experience with Long-covid which I was unfortunate enough to develop very early in the first wave and which included an unscheduled hospital stay and fast track angiogram (think X-ray to check heart blood vessels) thanks to a “dangerous ECG”. Thankfully 18 months on I am much recovered, but remain very conscious that there was more than one false dawn over the course of the illness, although later episodes were milder. The inescapable parallel from a population standpoint is that Covid-19 can prove a truly mercurial adversary, lulling you into a sense of comfort and security, just like the mythological Sirens, before dashing you against the rocks of reality once again. The attached illustration above: ‘Ulysses and the Sirens’ is an 1891 painting by Pre-Raphaelite artist John William Waterhouse. In the words of the Wikipedia description:

"The work depicts a scene from the ancient Greek epic the Odyssey, in which the Sirens attempt to use their enchanting song to lure the titular hero Odysseus and his crew towards deadly waters. As per the Odyssey, Odysseus' crew had already blocked their ears to protect themselves from the Sirens' singing, but Odysseus, wanting to hear the Sirens, had ordered his crew to tie him to the mast so that he may have the pleasure of listening without risking himself or his ship."

In other words, the measures clearly employed were distancing and personal protective equipment! [Note the bound ears of the crew]. Perhaps the fact that the new variants are being ascribed Greek lettering might help persuade us to take a leaf from these mythological mariners and maintain some of our protective measures just a little longer while vaccine roll-out continues. In keeping with worrying reports from our clinical colleagues and as anecdotal as this could certainly be described, I have increasingly of late been hearing much more of the sound of sirens… 

John is currently employed as a consultant in public health with NHS Grampian and has a background in respiratory infectious disease epidemiology. 

Image:

1. John William Waterhouse, Public domain, via Wikimedia Commons

The views expressed in posts are those of the authors and do not necessarily reflect those of Fuse (the Centre for Translational Research in Public Health) or the author's employer or organisation.

Find the gap: where is the healthy, enjoyable human body in policy?

Posted by Rachel Kurtz, PhD researcher at Durham University

Balancing varied and sometimes conflicting priorities within a large geographical area and between multiple departments is not a job to be envied. Ensuring the detail is suitably deliberated while also holding in mind how a policy affects other interests must be attempted but cannot possibly be achieved to perfection. My role on behalf of County Durham Sport was much easier. Over three weeks in June, I reviewed Durham County Council documents and the priorities of the Area Action Partnerships (AAPs) to identify areas of local strategy that did (or did not) address the issues of physical inactivity and the climate emergency. As an environmentally-informed, lifelong dancer-turned-researcher, I simply had to view the documents from two perspectives in which I am already personally invested and consider possible changes. Some interesting things emerged.

As you might expect, topics are viewed through whatever lens highlights policy concerns in that area. For example, the County Durham Plan understands physical activity functionally, through land use, waste, and movement of people, advocating for active travel (walking, cycling etc.) and providing and improving recreational areas. Meanwhile, the Joint Health and Wellbeing Strategy considers the environment as either beneficial or detrimental to public health, e.g. air quality. Thinking that is limited by departmental divisions can make it difficult to link overlapping policy areas. Consequently, councils are attempting to increase communication and collaboration by forming multi-disciplinary teams to create joint policy and consider issues from multiple perspectives. The County Durham Health and Wellbeing Board (author of the previously mentioned strategy) is one such team. This ongoing shift towards a collaborative approach is already countering siloed thinking and Durham County Council is taking a systems perspective through its work in Mental Health, from its strategic partnership both within and outside the council to delivery vehicles like the AAPs (which give local people and organisations a say on how services are provided). Nonetheless, a change of perspective inevitably exposes assumptions and raises new challenges, and this was no exception.

Encouragingly, some of the documents reviewed, such as the 2018 Open Space Needs Assessment, comprehensively address both focus areas, however in most cases the environment features more prominently than physical activity. A Physical Activity Strategy is still being developed, therefore gaps in this area might be expected and indeed in many cases the human body was entirely absent from policy. However, what was most noticeable was the underlying attitude where physicality was mentioned. Almost none of the policy documents feature the healthy, enjoyable human body. To cite a specific example: while addressing a rising mental health crisis, the Health and Wellbeing Strategy implicitly regards bodies as problems to be solved. This is particularly noticeable in the section on older people who are seen as frail and in need of preventative and remedial support. The framing of the strategy is already being addressed in this case but overall, any focus on the impact of health and wealth inequalities on the body tends to see physical inactivity as a problem rather than an opportunity. There were exceptions at delivery level (e.g. the Healthy Weight Action Plan and some AAP interventions, both of which are very much about enrichment) but at the strategic level, bodies are overwhelmingly framed as problematic. This is true even where you might expect an enrichment perspective such as the Children and Young People’s Strategy and Strategic Walking and Cycling Delivery Plan.

As a dancer and embodiment researcher this outlook is all too familiar, and I understand it as cultural rather than a failing of the council. In the main bodies are accommodated, objectified and treated as problems to be solved, while the sensual, experiencing body is largely ignored. Unfortunately, when we take this deficit perspective, we lose important, humanising opportunities for productive fun. Policy could be very influential in this respect. If we choose instead the underpinning belief that bodies are an incredible gift through which we explore and enjoy an endlessly engaging world, we automatically find more playful and interesting solutions. Suddenly new possibilities abound, like generating power from playground equipment or a dancefloor made with kinetic tiles. When we remember our sense of fun, urban environments become play spaces for curious bodies. Street furniture is for parkour, roller blading or skateboarding as well as resting. Outdoor games and gyms spill out of parks and line the route of our walking commute. Community growing spaces (already a popular solution to poor diet, food miles, climate change preparedness, physical inactivity, social isolation and low income) are no longer confined to small allotment plots but proliferate around the city alongside the begonias, encouraging healthy eating and a pedestrian habit.

Negotiating such varied needs and uses does of course require extensive consultation and consideration, which again highlights the importance of a partnership approach through which all voices are heard, but as I said at the outset, policy making is inevitably a difficult job. The bonus of reframing in this way is that by using strategies that are intentionally enjoyable rather than those that feel worthy or obligatory, uptake is likely to be far higher and as a result there is a better chance of achieving positive outcomes. Surrounded by the richness of creative human expression and snacking on free, community-grown fruit as we walk, jog, cycle or even dance our way to work and school, why would we choose to drive? 

Images:

1. Photo by Anthony Fomin on Unsplash

2. Photograph 'Exercise Machines' (2103264189_e26de7ba22_z) by Catherine via Flickr © 2007: https://www.flickr.com/photos/30325243@N00/2103264189 (CC BY 2.0) Adapted (cropped)

3. Photo by markusspiske on Pixabay

(Re)taking liberties: Reclaiming positive freedom as a public health argument

Posted by Jack Nicholls, Lecturer in Social Work at Northumbria University

At the time of writing, the government intends to lift most remaining Covid restrictions still in place in England on July 19, widely touted as 'Freedom Day'. 

I recently passed my PhD viva defending a thesis that was concerned with the diverse ways a contested value concept is understood by human welfare professionals (in my case, 'social justice' and newly-qualified social workers). As a result of that undertaking, I am now habitually critical of the ways in which ethical and moral language is used and claimed for particular agendas. In the looming shadow of so-called 'Freedom Day', I have been thinking about how caring professions and health and wellbeing researchers might reclaim the word 'freedom' for ourselves.

Possibly in contrast to many of my wonderful colleagues in the caring professions and their associated research wings, I am in broad terms a libertarian rather than a collectivist*. Individual rights and freedoms - the ability to live as one chooses unfettered without just cause, to be different, to not fit or conform - are close to sacred to me. While I can be persuaded by arguments advanced by those of a more communitarian mindset, it is always despite, rather than because, they are communitarian. When, as I will here, express concern about the speed and totality of the easing of Covid restrictions, I do so from a liberty-minded philosophical position.

The 'Freedom Day' discourse draws almost entirely on the concept of negative liberty and is emblematic of a long-established idiolect that frames freedom (with personal responsibility) in a zero-sum game against statutory entitlement to and provision of help. Negative liberty refers to the absence of constraint and control. As an idea, it is of profound importance for those of us who believe rights and freedoms are inherent to personhood, and that it is for the state to uphold them, not hand them down as bounties and favours.

Sir Isaiah Berlin 

Alongside negative liberty however sits the concept of positive liberty (both liberty concepts were set out by Sir Isaiah Berlin (pictured right) in his 1958 lecture and subsequent written works). Positive liberty refers to the idea of freedom being enabled by active action and the provision of resources, facilities and support. The two work in tandem and, for the kind of libertarian I am, they are equally important and necessary for one another. Covid restrictions have impacted both our negative and positive liberties - the former by restricting our movement, travel and association, the latter, at least for many people, by restricting our incomes, our ability to access welfare, social security, safe transport, childcare and informal support networks.

The rationale for these actions, a rationale that was broadly accepted by the majority, can be understood as a trade-off with other positive freedoms, most notably seeking to keep as many people as possible, and particularly those at most risk of developing serious or fatal Covid symptoms, free from infection. It is a trade-off I would make again in a heartbeat under similar circumstances. That is part of why the present language about 'Freedom Day' is so galling, because for many, particularly those with high-risk health conditions, their families, and those who have not yet been able to be vaccinated, July 19 will not signal any kind of freedom. I can't tell you how much I'm looking forward to my first liberated Guinness, enjoyed in the hostelry and company I choose, with all the health risks confined to the pint glass. I can't do that on July 19, because the decision has been made to prioritise the negative liberty of those of us who can enjoy it over the positive liberty of those still at particularly serious risk. We aren’t choosing freedom; we are choosing some people’s freedom over that of others.

This situation behoves health and social service practitioners and researchers to consider whether we can reclaim the concept of freedom, particularly positive freedom, as a full and proper part of our value base and lexicon. I argue that we both can and should, for what are we if not participants in endeavours for more positive freedom through greater knowledge and better health and wellbeing. Freedom 'from' is fairly hollow and useless without meaningful freedom 'to', and though many who share my philosophical persuasion see an overbearing state as a legitimate risk to freedom of all kinds, no less important is freedom from preventable illness, pain, anxiety, suffering, burden, loss of control, and the wider contributors to health inequities, not least poverty and postcode.

Our professional fields, with the best of intentions, often couch our arguments in terms of the community or public good. Without besmirching the place and value of those arguments, it is my view that were we to speak also in terms of freedom, including individual freedom, we would do so with complete intellectual coherence and legitimacy. Rather than being unjustly tagged as over-cautious and dictatorial, we could put our criticism of the end of restrictions in pro-positive freedom language. Beyond that, we could reframe and bridge the unfounded but perceived gap between individual choice and public wellbeing, all while avoiding the former being reduced to callous responsibilisation, and the latter being unfairly painted as nannying control. We might even unlock a new set of tools for persuading individuals and institutions who are rarely engaged by welfarist, collectivist or even duty of care arguments about public health concerns. We've done it before; we rarely talk about the smoking ban nowadays, rather we refer to pubs and train stations being smoke-free. Likewise fat-free, alcohol-free - it's a nice word, and an effective one.

At this moment, whatever their diverse feelings about the end of restrictions (I should caveat, the end for some) freedom is high in the public consciousness. Let us who are concerned for public wellbeing liberate our arguments and reclaim the concept of freedom, particularly positive freedom, for ourselves.

*Collectivism: a social pattern in which individuals construe themselves as parts of collectives and are primarily motivated by duties to those collectives. More here: https://plato.stanford.edu/entries/culture-cogsci

Images:

1. Courtesy of Pixabay: https://pixabay.com/illustrations/bird-cage-aviary-freedom-flying-730478

2. Sir Isaiah Berlin by Rob C. Croes (ANEFO), CC0, via Wikimedia Commons

The views expressed in posts are those of the authors and do not necessarily reflect those of Fuse (the Centre for Translational Research in Public Health) or the author's employer or organisation.

Intersectionality: buzzword or key to tackling health inequalities?

Posted by Dr Daniel Holman, Professor Sarah Salway, Dr Andrew Bell, University of Sheffield

Intersectionality – the idea that multiple axes of inequality overlap and interact – arguably holds great potential to understand and tackle health inequalities. But what do researchers and those working in policy and practice in this area actually think about the approach? What do they see as the key challenges and opportunities? We held a professional stakeholder workshop and consultation survey to find out. Our findings indicated a ‘cautiously optimistic’ view of an intersectional health perspective.

A growing interest in intersectionality and health

Intersectionality is currently something of a buzzword. A search of the scientific literature reveals an explosion in interest, with an eight-fold increase in papers mentioning the term in the last ten years, and a twenty-fold increase for those mentioning both ‘intersectionality’ and ‘health’:

Figure 1 - SCOPUS documents mentioning both 'intersectionality' and 'health' in title, abstract or keywords

The interest in applying intersectionality to health research, and specifically health inequalities research, has now also been fuelled by the pandemic. Ethnicity, deprivation, and age strongly influence Covid-19 outcomes. Calls for intersectional analysis of Covid-19 have now been published in BMJ Global Health and The Lancet.

Yet recent events have indicated significant political barriers. The Sewell Report essentially explained away ethnic health inequalities with reference to socioeconomic factors – anathema to intersectionality – and last year the UK Government declared itself ‘unequivocally against’ Critical Race Theory (within which intersectionality is rooted).

Further, policy-making is a process of dialogue, negotiation and ‘knowledge interaction’, with power relationships, varied sources of ‘evidence’ and competing drivers clearly at play. So, we should not expect the concept to straightforwardly impact how health inequalities are understood and addressed.

Theory vs. practice

In theory, intersectionality offers a critical, innovative approach for understanding and tackling diverse health inequalities. It essentially concerns the power structures and processes that drive these inequalities, and seeks to highlight how unjust systems of discrimination such as racism, sexism and classism operate in tandem to result in unequal, unfair life chances. The animation video below gives an overview of the approach:

 

Putting intersectionality to work entails a number of practical challenges. Many of our participants thought the term sounded like just another buzzword, questioning what it adds. Concerns were raised about the complexity of intersectionality both as a conceptual and methodological framework. For resource-strapped public health teams this was felt to be a particular barrier. Complexity can sometimes inhibit action because policy making processes support simplicity and certainty.

Methodologically, intersectionality includes a danger of over-disaggregation. Working with finer and finer categories to produce a granular picture of inequalities risks losing sight of the processes of disadvantage that impact across groups of people. Questions were also raised over how we can reveal mechanisms including discrimination, use mixed methods and participatory approaches, include marginalised populations, and access large, high quality datasets that intersectional analyses might require.

How might intersectionality actually be implemented? We asked respondents to consider two suggestions

First was the idea of using intersectionality to target and tailor interventions and policies. This raised numerous concerns that it potentially takes focus away from structural changes; assumes that all those in a particular intersection are the same; excludes those who do not fall into the targeted category, and; reinforces deficit and stigmatising narratives. Nonetheless, respondents thought that targeting could have value if marginalised groups were included in the process. They also suggested that geography should be considered when targeting as it is a key aspect of social context.

Second was the idea of monitoring and evaluating the impact of policies and programmes on different sub-groups. This approach was more popular, with participants keen to be able to demonstrate differential and unanticipated outcomes of initiatives. Again, the importance of meaningful engagement of marginalised groups and careful attention to understanding mechanisms, were highlighted.

What is the way forward? Our participants emphasised some key principles and points of action:

• Ensure a clear focus on systems of social discrimination and how they structure access to power, resources and life chances, especially via social institutions (such as schools).
• Wherever appropriate, participatory and co-productive approaches - entailing more equitable knowledge-production – should be used.
• Carefully consider complexity; arguably intersectionality’s biggest asset and challenge. What constitutes the right level of complexity and in which context? Trade-offs are inevitable.
• Develop clear methodological guidelines, possibly in the form of a toolkit, to help with implementing intersectionality, especially for non-academics with limited research resources.
• Big datasets with well measured social variables are essential.

Intersectionality holds much promise. It has the potential to help ensure that those experiencing multiple discrimination are not further disadvantaged by the Covid recovery phase. Acknowledging and addressing potential pitfalls and limitations of the approach is therefore crucial. Marginalised populations, researchers, policy and practice professionals all need to be part of the conversation.

To read more about the project from which this research originated, please take a look at the project website: http://intersectionalhealth.org