52 weeks in public health research, part 25

Posted by Becki Langford, Micky Wilmott and Jean Adams

From Becki Langford and Micky Wilmott: There's been a lot of debate recently in the news about the potential benefits and harms e-cigarettes. While they may be able to help people give up smoking, do they renormalise smoking? Here are two photos we snapped in Cardiff and Derbyshire of shops marketing e-cigarettes

From Jean Adams: I went on a little jaunt to Manchester a few weeks ago for a meeting of the Executive Committee of the UK Society of Behavioural Medicine (I'm secretary). A series of unfortunate events meant I missed my train and so spent longer than anticipated standing on the platform hoping the next train might somehow be early. In case you've ever wondered, this is the New Castle in Newcastle. The trains go 'round it, not through it - although through would be pretty cool.

From Jean Adams: Newcastle-Manchester, via York for coffee and toilet stop. This is the window on the ceiling of the Ladies at York station. It's a photo of the stunning York Minister. But why in a window frame, on the ceiling?

From Jean Adams: and this is the reason I was late for my train in the first place. No, not taking this picture (took it on the way home). The bike racks at Newcastle Station have been moved a few times over the last few years. Their final resting place seems to be here - right at the furthest reaches of one of the non-east coast mainline platforms, miles from anywhere. Every single time I have to traipse down there I want to scream at someone about how important bikes are and how we need to make them welcome, not hide them in the furthest corner we can find. Obviously I know this is where the bike racks are and how long it takes to get to and from them. I just have a mental block on taking this into account in my journey planning

Weird Science

Posted by Joel Halligan

Recently I was chatting with a friend who researches bacterial proteins. My friend was somewhat taken aback by the research methods used in the study I’m working on (questionnaires, food diaries and the like) and, compared to his research, the effort required to collect data. This amused me somewhat: “How else would we do it?” I asked him. He um’d and ah’d but didn’t have an answer. In his mind our research seemed ‘messy’ because our research subjects didn’t behave in as predictable a fashion as his bacteria. Our subjects, being human, are subject to whims and fancies and emotions and, well, real-life; his research subjects don’t require a recruitment strategy with ten phases, they fit snugly on the head of a pin and they don’t eat at McDonalds. I suppose I had to agree with him that, by comparison, our research was indeed ‘messy’, but that in my opinion that’s what makes the research I’m working on much more interesting and enjoyable than his lab-based research.

I reflected on the data collection that I’ve been involved in for the past 8 months and how alien it may seem to somebody like him, with the very same job title as me but working in a very different field of research. My participants have IDs but they also have names. When I visit them or talk to them on the phone to ask them about what they had to eat the day before (part of the research!) they chat to me and, as I’m human, I will chat to them too. This means I don’t just have to remember the protocol and what I need to ask them to make sure I collect the right data, but I also need to remember that they’ve just bred a litter of German Shepherd pups (and how are they all doing?), or that they’ve been somewhere nice on holiday (did you have a nice time?), or that last time I spoke to them their oven broke (and has it now been fixed?). When I arrange to meet them I have to text them to remind them and be prepared to be stood up or rearranged because, surprisingly, the research they’re involved in is less important to them than it is to me. When I visit people at home I have to contend with hairy and excitable Japanese Akitas and ringing phones and doorbells and kids that want to constantly interrupt. I also end up drinking a lot of tea. My friend has none of these issues in his research, the lucky devil, although being plied with tea isn’t so bad.

My friend also seemed discomfited by the ‘lack of control’ he perceived that we had over the many variables that could potentially influence our outcome of interest - in this case whether a cooking skills intervention can influence diet. Again, I playfully asked for his proposed solution. Lock them all in a darkened room with a knife block, portable hob, organic veg box and a series of Jamie’s 15-minute meals on DVD? I don’t think that’d get past the ethics committee, I said. I explained that we do our best to control for this multitude of other variables by randomising participants to one of two study arms. Do you blind them to their allocation, he asked? Er, no, I replied, would we send them on a cooking skills course but tell them they were going on a knitting course and hope that they didn’t realise? He also argued that by telling people we’re recruiting them to take part in a cooking skills course we might generate effects before we’ve even started, regardless of which arm they’re recruited to. I agreed with him to some extent, but explained that it’s difficult enough to recruit participants even when they have the full information beforehand, so imagine how difficult it would be to recruit people to a ‘mystery intervention’, not to mention that darned ethics committee that would no doubt throw a spanner in the works.

After our chat, my friend concluded that he was glad that he didn’t work with humans in his research because he wanted to do scientific experiments, not quasi-scientific experiments (his words). I concluded that I would prefer the latter any day. In my opinion, people are much more fun than single-celled organisms.

52 weeks in public health research, part 24

Posted by Catt Turney

This week I was tweeter-in-residence for two events - a symposium on health promotion in schools (#SchlHealth) and the launch of the School Health Research Network (#SHRN14). I was busy being proud of myself for keeping to the right account and hashtag, when I noticed that I'd tweeted this photo of our Co-Director upside-down. I deleted, rotated it and tweeted again - still upside-down. Moral of the story: Twitter is four-dimensional, or this photo just really wants to be upside-down. It seemed a shame to deny it that chance, so here it is.

The school health symposium meant I got to have a day of working at home at my grandma's in London. Cue amazing vintage healthy-eating books - full of mostly quite sensible advice, interspersed with the odd bit of quackery and some amazingly 70s recipes.

DECIPHer's Clerical Officer, Natalie, preparing for the SHRN launch whilst modelling a new innovative storage solution that we're trialling here in Cardiff - the cupboard-desk.

I've been enjoying Jenni Remnant's animal photos on the Fuse blog over the last few weeks, so wanted to try and contribute something appropriately cute from my walk home. Unfortunately all I could find were these two scraggy seagulls trying to eat each other.

-------------------

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

The C word V: cooking

Posted by Jenni Remnant and Libby Morrison

We all know that two key elements of public health are what we put in our bodies (food, alcohol, cigarette smoke) and the environment that surrounds us.

When you’re a carer, to a point, you can often find yourself responsible for what someone else consumes, and the effect the environment has on them. Quite a responsibility.

And the way, as carers, we respond to this responsibility is incredibly varied.

Service users in care can be fed unhealthy and highly calorific meals through a desire to ‘mother’ and ‘feed up’. Many mental health service users I’ve worked with live on ready meals (my inspiration for the topic of my Msc dissertation last year) which have been found not to fulfil dietary requirements suggested by the Food Standards Agency.

Though I hate using the word, and emphasising that this is only in my experience, there are a number of carers out there, both informal and paid, that can be quite ‘mumsy’. Meals are often very traditional, and full Sunday roasts with all the trimmings are sometimes enforced, even in single occupancy services.

I have worked with a number of service users with high staff ratios due to ‘challenging behaviour’, and they have been quite similar: the service users are often overweight. This is problematic in terms of the health of the service user and the carer – the regular violence that is often an acknowledged part of a service user’s communication can lead to a carer having to deal with 20+ stone of angry person.

  

In one circumstance, a plan was formed based on improved health outcomes - for the service user and staff involved. All the full-timers at this service were given a specific responsibility, and mine was ‘food and exercise’. I downloaded a copy of the Bristol stool chart (a carers best friend), booked our service user an appointment with a nutritionist and started to write weekly shopping lists and menus. We identified, and were supported by the nutritionist in our assertions, that our service user was heavily constipated, and this was causing them some distress and was likely to be contributing toward some, if not all, of their violent behaviours.

Putting together a healthy living plan was interesting. One of my colleagues was a supremely talented cook, and made unbelievably delicious food, but had a very different idea of what ‘healthy’ was to me. Something I’ve heard a lot at work, and which my brother now believes as gospel, is that pasta is healthy - in any dish and any context. Divine though my colleague’s macaroni cheese looked – it had three cheeses in, butter and sometimes even cream – I’m not sure it ticked all the nutritional boxes one might hope in a meal, and might also go above recommendations in terms of fat. And the portions! Portions so mammoth you’d wince to look at them.

So, very slowly, we started introducing more fibre into the menu, and green things; while also limiting, but not removing, gluten and sugar. There was a rule that every meal must have a minimum of three natural colours in, not including white, beige or brown. I should note here, that this service user, as with most of the challenging service users I have worked with, was non-verbal – and only provided very limited feedback.

There was a lot of criticism. The most common one was that the service user was being made to follow a vegetarian diet without consent. Which I’m afraid I mostly rebutted with ‘so at what point was their consent gained to eat meat?’. Though actually the new diet did contain meat, just far less than before.

Some of the team thought it was wrong – that this person had a life with such few pleasures in it, bar eating, that it was border line cruel to take that away. I found this difficult, because I used a lot of recipes and meals that I ate myself, and felt that any criticism of the food served was a criticism of my personal lifestyle. But it also contained so much assumption – how would we know what this person preferred? We tried very hard to see if there was any difference in the gusto with which a piece of carrot was eaten or a piece of chocolate – and could find none. The only discernible preference, as I’ve often found in services with adults with sensory impairments, was for something with a bit of crunch.

This service user often stared at sweet treats in shop cafes or by tills on the way out of shops (why is it ALWAYS huge mounds of cake? Or chocolate?). Often this would happen and someone on the staff team would say ‘they’ve seen it now; we’ll have to get it’. This service user very soon came to realise that this was an efficient way to get food – because of this we couldn’t go through the checkout with them, without some kind of calorific edible having to be bought and consumed every time. The combination of ‘guilty checkouts’ and staff anxiety ‘created’ this negative pattern of behaviour, which in turn impacted on the healthy eating regime that other staff were trying to implement. This resulted in the loss of the daily interaction of buying groceries.

Eventually, when the team pulled together, with compromises made on ‘both’ sides, the service user lost 3st 4lb in a year, episodes of challenging behaviour went down from 4-8 per week to 1-3, and bowel movements were frequent and far less explosive than they had been. Happiness is a non-explosive bowel movement. The social interaction aspect of grocery shopping for this service user was hugely limited – and at times the staff team totally and utterly divided.

There is no right and wrong in this anecdote. I can say hand-on-heart that I know for sure that the staff team all wanted what was best for our service user; we all just had very different ideas about what ‘best’ was.

Policy within care is full of personal outcomes that centre on choice and independence, which can make public health interventions less accessible. Especially in the example given above, where the service user was written out by our models of ‘best interest’ decision making. I certainly don’t have a substitute model. A significant public health issue is how to engage with carers. Carers can sometimes have absolute control over another human being, no matter how we dress it up to suggest otherwise. How do we make sure that clear public health messages are being communicated and instigated by carers without further surveillance and pressure being placed on an already incredibly pressured role?

52 weeks in public health research, part 23

Posted by Jenni Remnant, Mark Welford, Mark Tully and Jean Adams

From Jenni Remnant: initial contact and consent forms ready to send to potential participants, fingers crossed for a decent response rate!

From Mark Welford (Fuse Communications Officer): Spotted this brand daylight robbery at a generic department store (rhymes with M&M’s) in Newcastle. Not only the Fuse name but also the font! There go our plans to diversify through a Fuse fashion label.

From Mark Tully: spent the morning working on an ethics application at my walking desk. By lunchtime, protocol and 9000 steps were done.

From Jean Adams: Fuse director Martin White enjoying a healthy snack on the patio outside our office. Also marketing his favourite outdoor shop.

-------------------

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

Not necessarily useful, and unapologetic: Speaking out on health equity

Posted by Ted Schrecker

We should now be familiar with some hard facts about health equity. In the United Kingdom, despite rhetorical commitments by the previous government to reduce health disparities between rich and poor, by 2007 such disparities were on many measures greater than at any point since the 1930s. This was before the economic crisis and subsequent austerity measures, which have disproportionately affected the UK’s poorest regions, including of course the North-East.

North end of Stockton high street

Yet in discussions of how to reduce health disparities, a frequent refrain is that the evidence is not strong enough to serve as the basis for new policies that change the conditions in which people live and work. Tobacco control initiatives and encouraging people to eat a healthy diet are fine, but not so challenges to ‘the inequality machine [that] is reshaping the whole planet,’ in the words of the editor of Le Monde Diplomatique. Since (for example) the Canadian experience shows that a healthy diet is often unaffordable for benefit recipients or the working poor, and more than 46 million people in the United States are relying on the government vouchers known as food stamps, that would seem to be a major omission.

Debates about the strength of evidence are hardly new: think about tobacco, or climate change, or any number of environmental and workplace exposures the lethality of which is now widely acknowledged. The ethical and political nature of choices about standards of proof (how much evidence is enough) in these debates is often neglected. I began a recent article on this point with an analogy to the case of former professional athlete O.J. Simpson. Acquitted of the murder of his estranged wife and her friend in a criminal trial, he was nevertheless found liable for damages in a civil proceeding initiated by the survivors of his alleged victims. The difference simply reflects the much higher standard of proof that must be met, in common law countries, in criminal proceedings.

My points were that (a) the concept of a standard of proof is crucial for public health policy; (b) the choice of a standard of proof with respect to social determinants of health, as for environmental exposures, is a matter of public health ethics with respect to which scientists qua scientists have no special competence; and (c) unreflective insistence on a definition of scientific quality organised around avoiding false positives, or Type I errors, can be highly destructive of health, and in particular health equity, under conditions of uncertainty. Waiting for more evidence is itself a decision about risks and benefits. This point has been made in the literature for decades, yet it continues to be either ignored or willfully misunderstood.

A case in point: in The Body Economic, David Stuckler and Sanjay Basu assemble abundant evidence of the destructive consequences of austerity for population health, although much of it is not derived from experimental or quasi-experimental studies. Stuckler and Basu correctly observe that ‘in countries where austerity is ascendant, we’re undergoing a massive and untested experiment on human health, and left to count the dead.’ In ten or 20 years, that experiment may indeed provide answers to some of the questions epidemiologists would like to ask about social determinants of health, although there will always uncertainty because in the real world many things go on in people’s lives at the same time. Whether or not the experiment is justifiable is a matter of public health ethics, although it is seldom recognised as such.

Indifference to the role of competing values in making policy based on scientific evidence, and to the politics of such choices, is a generic problem. It is exemplified by the frequency with which speakers at a recent conference on urban health in Paris talked about the need for research to be useful to decision-makers. Similarly, an article on the relation between health research and public policy exhorts social epidemiologists to concentrate on narrowly defined questions amenable to experimental or quasi-experimental study designs that will generate ‘the kind of evidence wanted by policymakers.’

Anyone familiar with contemporary politics and public policy will realise that the quality of evidence demanded by policymakers – and that term is itself curiously decontextualised – depends entirely on what those in power have at stake. Often, no evidence or fabricated evidence is sufficient; think about the weapons of mass destruction that Iraq was declared to possess, or the nonexistent jobs into which George Osborne wants to herd impoverished under-25s. And in the population health context, what if policymakers have decided that some segments of the population are disposable, even though they cannot state this for public consumption?

I would argue that this is true of many national governments, as demonstrated by the policies they adopt. But even those who disagree should recognise the need for critical (and explicitly normative) perspectives on the relations between researchers and those in official positions outside the academic world. Local-level public health practitioners and organisations trying to reduce health disparities in a hostile environment deserve all the support we can give them. At the same time, progressive health researchers must choose our allies and audiences, and I for one have little interest in whether my findings are ‘wanted’ by David Cameron, Eric Pickles, or Iain Duncan Smith. The most appropriate guidance for health researchers of conscience as they interact with governments is sometimes the three R’s: Resist, Ridicule, and Replace.

All views expressed are exclusively those of the author. 

52 weeks in public health research, part 22

Posted by Jenni Remnant and Jean Adams

From Jenni Remnant: urine neutraliser. Carehome worker's best friend. And it smells like bubblegum.

From Jenni Remnant: that health and safety sign that everyone knows, but no-one's read.

From Jean Adams: I have been working on this paper (on time spent cooking in the UK) in spare half days here and there for about the last six months. The analysis and reading are all done and I've written up the methods and results, but I've been really struggling to get the introduction into any sort of presentable shape. Writing detailed notes long hand eventually sorted me out. NB don't anyone think of nicking this paper idea - the manuscript is now submitted and you can't gazump me! 

From Jean Adams: it's on oldie, but a goodie. Well, only a few months old. I have a growing library of photos featuring Coca-cola branding. This one was taken this winter in the Alps - where Coke marketing is rife. Coke deckchairs strike me as particularly ironic given Coke's recent attempt to change the obesity conversation with the message that chairs are the 'real' cause of obesity.

-------------------

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

The day Fuse duck came to town

Posted by Jean Adams

So you might remember that Fuse duck is going on a road trip around the North East region trying to find out what it is that Fuse researchers do all day. He is not, as some might have you believe, the new ‘marketing intern’ at Fuse. And he is certainly not an unpaid intern. No, you can rest assured that Fuse duck is very well recompensed for his labour. Mostly in cake, only rarely in stale bread.

It was right at the start of May that Fuse duck came to Newcastle to visit the Institute of Health & Society. I looked after him. I quite enjoyed having him. He dragged me around the place desperate to meet everyone and I ended up saying hi to a bunch of people I hadn’t met, or had only half met, before.

After a brief argument with the photocopier preparing for the ‘big meeting’ later in the day, we started out with a brainstorming/planning meeting for the 2015 CREATE workshop that I’ve been asked to co-ordinate. I have got myself a reputation for teaching writing skills. I’m not sure this is in any way justified. Sure, I’ve done a lot of writing and sure, bad writing sometimes annoys me. That doesn’t mean I’m any good at teaching people how to do it well. See Twitter during any football match/episode of Question Time/Strictly for more on this. But, when you’re offered a trip to Cyprus, the 2.5 days of workshop you need to prepare and deliver in exchange sometimes doesn’t feel too much of a drag. It’s more than a year away. It’ll be fine. In the course of an hour my co-facilitators and I worked through three or four different ideas for the workshop, before settling on an outline programme that we hope will be acceptable to the organising committee. We’ll find out in June. 

Next up was a project meeting for the YouCook project. This is a pilot evaluation of Jamie Oliver’s Ministry of Food cooking classes. Very exciting in principle, but harder than it looks in practice. Mostly, surprise, surprise, because recruitment is not that easy. And before you ask, Fuse duck didn’t get to meet Jamie on this occasion. But the main researcher on the project has done. 

Ten minutes to nip to the toilet and swap one pile of papers for another, and before we knew it the ‘big meeting’ was upon us. This was the second of three meetings of the steering group for our project on using parental incentives to encourage uptake of pre-school immunisations. Which astute readers might remember is where this whole blog thing began. The meeting was ‘big’ in that there were at least 10 people around the table. But also ‘big’ in that it involved people from London, Glasgow and Aberdeen - both in person, and on the phone - and clinicians as well as academics and researchers. One of those meetings where you are very aware how much of an effort people have made to come and take part, and how much you’d better make sure that you don’t waste their time.

The ‘big meeting’ went well. The project is going well and generating interesting findings. The discussion was engaging and lively. There were some good suggestions made for future directions. But chairing a two and a half hour meeting that you have been subconsciously worrying about for the last week is exhausting. So after that was done, Fuse duck and I went up to our coffee room and just hung out for half an hour to get stuff back in perspective. But somehow the conversation drifted into food porn and how naïve I was to think that food porn=Nigella Lawson and it felt time to leave.

The last meeting of the afternoon was a one-to-one with a researcher to chat R, data, and Foodscape. Although we do have lots of meeting rooms in IHS, we also have three ‘informal’ tables where both planned and impromptu meetings take place. Contrary to expectations, an informal table is not a post-modern representation of a table that only very loosely resembles the typical structure of a formal table. No, the informal tables are distinctively table-like, with grey rectangular tops and at least four sturdy legs. Their informality comes from the fact that there are not bookable, and not restricted within their own rooms. In fact they are placed in what is essentially an aneurytic corridor - a place that is as important for getting from A to B as it is for housing meeting spaces.

As it turns out, holding a meeting attended by a stuffed duck at the informal tables attracts a little more attention than some other meetings. Before we knew it, students, researchers and even the institute director were chatting to Fuse duck and not about Foodscape work package 4. So we called it a day, packed up and headed for home.

That was the end of the work day, but not the end of the whole day. We still had our 30 minutes of moderate to vigorous physical activity to get in. Fuse duck is sadly lacking in bones, ligaments, tendons and muscles, making his running style fairly floppy. I didn’t mind carrying him and we went for a little plod around the park, stopping to see if there were any ducks around to say hello to in the pond. But all we could find was a prissy swan who just hissed at us and swam off.