A week and a day in the life of an embedded researcher

Posted by Mandy Cheetham, Fuse Post doctoral Research Associate and embedded researcher with Gateshead Council Public Health Team

Standing to deliver my presentation at the UKCRC Centres of Excellence conference recently held at the Royal College of Physicians last week, I felt oddly out of place. I was describing my experiences of embedded research in a community centre in an estate characterised by high levels of poverty, health inequalities and persistently high rates of childhood obesity. The contrast between this setting and the auspicious environment of the RCP was marked. The lecture theatre represented an entirely different world.

Presenting at the UKCRC Public Health Research Centres of Excellence Conference

At the pre-conference dinner, I’d had lively discussions with researchers and practitioners from the four corners of the UK about different approaches to, and experiences of knowledge exchange and about advocacy. Presenters earlier in the day were clear that advocacy was not part of their role. And yet, it felt at the heart of my role as an embedded researcher as a way to affect change.

As my presentation began, photos of the community centre, the events and activities I’ve been involved in, beamed on to the enormous screen, and gave a flavour of the different worlds we inhabit as researchers. One of the slides showed a picture of the international athletics stadium near the estate where I’m based. I explained how during the research, local people said they didn’t feel the stadium was for people like them. Some had never been inside, despite growing up on the estate just across the main road.

Back at the community centre on Monday, I talked about the conference. I had invited the stadium manager for community lunch and was full of anticipation about the possibilities of exploring closer links. He arrived, chatted to community members and staff, and stayed 2 hours. He was really receptive and people shared plenty of ideas. It’s the start of a dialogue. Who knows where it will lead.


Working with the community to involve children in cooking and trying healthy options

I love this aspect of my job, the variety, the networking. The rest of my working week involved a focus group with the steering group of the community centre and another with year 4 children from the local school. My role as a researcher is many and varied. The organisation where I’m embedded, and the public health team who commissioned the research, have been extremely receptive and welcoming, open to scrutiny, feedback and learning. Collaboration requires multiple skills, which are not always taught or easily learned, including sensitivity, diplomacy, tenacity and assertiveness, recognising the nuances of the local context and existing relationships in place. Researchers can contribute by offering new perspectives and working alongside existing stakeholders as equal partners.

If we are to make progress in efforts to turn the tide on entrenched health inequalities, I believe we need to work differently as researchers. Embedded research offers opportunities to engage communities who would rarely volunteer to take part in formal university research projects. It involves co-producing public health research with communities and researcher users, sharing knowledge, identifying and generating solutions together, and including children and young peoples’ views as part of that, as experts by experience. As academics, we are not the experts. Children and adults who have participated in the research process are only too aware of what makes us fit and healthy and the constraints on their choices and decisions. The opportunities to act on that knowledge are limited by their environment and sometimes by the assumptions of others. As researchers, I believe we have a responsibility to challenge some of those limiting assumptions and collaborate with others working proactively in community settings to facilitate positive change where we can. By co-producing and combining different types of knowledge we can create meaningful impact, both in communities experiencing health inequalities and in auspicious academic lecture theatres.


Photo courtesy of the National Children's Bureau (NCB) report (p10): 'Working together to reduce childhood obesity' authored by Emily Hamblin, Andrew Fellowes and Keith Clements (May 2017)

Researching holiday hunger

Guest post by the Healthy Living Lab team, Faculty of Health and Life Sciences, Northumbria University

“Summer is here and the living is easy ….” well for most people it might be. However, for many families on low incomes, school holidays are challenging times. Over the past few years, the Healthy Living Lab at Northumbria University has undertaken research into the holiday clubs providing support to these families. We have had the privilege of working with clubs right across the UK from Scotland to the South of England. We have visited clubs based within a range of settings including schools, food banks, church halls and community centres. Research by the Healthy Living Lab is providing a significant insight into the location of holiday clubs, and crucially identifying gaps in provision and the outcomes for families and children attending the clubs.

During the school term, free school meals (FSM) act as a safeguard for children from low income families, but there is no additional state provision for these children during the school holidays. The term ‘holiday hunger’ has been used to describe the hardship that children and families on low incomes face during the summer break; when they do not have access to a free school lunch. Moreover, the increase in financial pressures during the school holidays has a more general impact on the quality of children’s lives, as families lack money for entertainment, socialising and educational or developmental activities (Gill & Sharma, 2004; Graham et al., 2016; Kellogg’s, 2015).

School holiday clubs can help to bridge this gap by providing food, activities and support. Many holiday clubs are staffed by volunteers, who have given up their summer to make sure that something important happens; that children have access to nutritious meals when free school meals aren’t available. There is also a good chance there will be activities happening within holiday clubs, and that the children attending are having a great time.

Research from the Healthy Living Lab team ascertained a need for holiday club provision for families on low incomes (Defeyter, Graham, & Prince, 2015). We have spoken to parents and children at holiday clubs, many of whom live below or just above the poverty line. Our findings highlight that, for many low-income families, the school holidays are difficult, especially the longer summer break. A member of staff at one holiday club breakfast club indicated that it wasn’t just children who benefited from the the holiday breakfast club as well, saying:

“Main thing is for the kids, but I think it’s really benefitted the adults as well, so urm yeah just making sure every-one’s getting food, which is really important ‘cause breakfast, the most important meal of the day (Female staff member; Club 5) (Defeyter, Graham, & Prince, 2015, p.5)

Whilst parents strive to ensure that their children are fed, many find it more difficult to manage during school holidays, as food bills increase and thereby the risk of low-income families experiencing food insecurity also increases. Moreover, we have spoken to staff and volunteers from school holiday clubs, who have told us that their clubs provide food, in addition to social, learning and support opportunities (Graham et al., 2016). Our research shows that holiday clubs not only provide financial support to low income families, through the provision of a free meal, but also provide a social outlet for parents and their children, as well as wider benefits for the community (Defeyter, Graham, & Prince, 2015).

Researching this area is challenging as it involves talking to families about sensitive issues such as their food and financial situation. But, this work is also invaluable as it draws directly on the experiences of parents, children, and holiday club staff ensuring their voices are heard.

The Healthy Living Lab Team is:

• Professor Greta Defeyter, Faculty Associate Pro Vice-Chancellor (Strategic Planning & Engagement), Faculty of Health and Life Sciences, and Director of Healthy Living
• Dr Pamela Graham - Vice Chancellor's Research Fellow
• Dr Louise Harvey-Golding - Senior Research Assistant
• Emily Mann - PhD Researcher
• Jackie Shinwell - PhD Researcher

References:

1. Gill, O., & Sharma, N. (2004). Food Poverty in the School Holidays. London.
2. Graham, P. L., Crilley, E., Stretesky, P. B., Long, M. A., Palmer, K. J., Steinbock, E., & Defeyter, M. A. (2016). School Holiday Food Provision in the UK: A Qualitative Investigation of Needs, Benefits, and Potential for Development. Frontiers in Public Health, 4(April 2014), 1–8. http://doi.org/10.3389/fpubh.2016.00172
3. Kellogg’s. (2015). Isolation and Hunger : the reality of the school holidays for struggling families. Manchester. Retrieved from http://pressoffice.kelloggs.co.uk/Going-hungry-so-their-children-can-eat-Third-of-parents-on-lower-incomes-have-skipped-meals-during-school-holidays
4. Defeyter, M. A., Graham, P. L., & Prince, K. (2015). A Qualitative Evaluation of Holiday Breakfast Clubs in the UK: Views of Adult Attendees, Children, and Staff. Frontiers in Public Health, 3(August). http://doi.org/10.3389/fpubh.2015.00199

Photo courtesy of Children in Scotland: http://www.childreninscotland.org.uk

What does a hung parliament hold for the future of Public Health?

Posted by Fuse Senior Investigator David J Hunter, Professor of Health Policy and Management & Director, Centre for Public Policy and Health, Durham University

The June general election threw a lot of things up in the air but resolved little. We are living in a suspended state awaiting resolution of what is clearly an unstable political landscape and a government hobbled by its own tensions and contradictions. Uppermost among these is of course Brexit. This will continue to consume all of government as it has already done for much of the past year. No part of government will be left untouched by it. The upshot is that other domestic policy areas are likely to receive minimal attention. This includes public health which rarely features high on the policy agenda.

Earlier in June, the Faculty of Public Health President, John Middleton, in a British Medical Journal editorial urged the next UK government ‘to make health central to all its policies’ (BMJ 2017, 2 June doi:10.1136/bmj.j2676). He concluded that just as local government had adopted a health in all policies approach, ‘national government must now become a public health government’. There seems little chance of that happening in the current febrile political climate.

Of course one can argue the merits of putting health into all policies as distinct from putting all policies into health which might hold more appeal for those who are suspicious of, or are opposed to, health imperialism. But the central point is valid. Most, if not all, of what government does impacts on the public’s health. Indeed, much of the support for political parties calling for an end to austerity was driven by a perception that the unrelenting assault on the public realm since 2010 was having unacceptably negative consequences for people’s health and wellbeing. It’s a small consolation that what has happened in regard to widening inequalities was predicted by the public health community.

So if we cannot look to national government for public health leadership in the foreseeable future, and that seems a forlorn hope given that the former public health minister lost her seat in the election and her successor is unlikely to make an impact anytime soon, what does the immediate future hold for public health? And where is the action likely to occur?

Having a disabled or incapacitated national government may not be entirely a bad thing if it allows local government and other agencies to go about their business without being subjected to a constant outpouring of policy initiatives and ministerial announcements and directives which invariably offer only distraction.

This suggests a need for the public health community to engage more vigorously than it has done hitherto in driving the 44 Sustainability and Transformation Plans (STPs) in England. Though flawed, deeply so in some cases, and poorly communicated with minimal public engagement, STPs and related developments like Accountable Care Systems (ACSs) offer an opportunity (perhaps the only one for the time being) to put public health centre stage in developing place-based approaches to improving population health.

STPs are underpinned by the Triple Aim (Berwick et al 2008Health Affairs 27(3): 759-69) which comprises: improving population health, focusing on patient-centred care, and achieving more efficient per capita spending. STPs and many of the other health system transformation activities underway, and being actively promoted by NHS England with back-up as appropriate from Public Health England, are aimed at managing demand on health care services.

This is not a new agenda – the Wanless reports from 2002 and 2004 commissioned by the last Labour government eloquently argued the case for making the NHS a health rather than a sickness service – but the drive for a systemic transformation has perhaps never been so evident.

The opportunity to bring about a much needed shift in health policy should not be lost and public health should be at the centre of STPs. They offer the best prospect of taking on the big beasts of the acute hospital jungle and wresting resources from them to put into public health. Yet, as research being carried out by colleagues in the Centre for Public Policy and Health (CPPH) at Durham examining the public health changes introduced in 2013 demonstrates, with few exceptions Directors of Public Health in Local Government and their teams and Health and Wellbeing Boards are failing to provide the system leadership that is urgently needed1,2.

Since New Labour introduced foundation trust status for hospitals, compounded by the Coalition government’s misconceived and unnecessary Health and Social Care Act 2012, the NHS has been bedevilled by fragmentation and an ethos of competition in place of collaboration. STPs and associated reforms including ACSs are an attempt to mitigate the worst features of the various reforms since the turn of the century.

It is vital that STPs succeed and bring about the whole system, place-based approach to health and wellbeing that they promise. But we are some way from reaching that goal and the risks are considerable especially when budget cuts affecting public health make it less likely that the necessary changes can be realised.

However, we must not make too much of the budget cuts invoking them to argue that it demonstrates how misconceived it was to relocate public health to local government. Had public health remained under the NHS, it is almost certain that it would be in an even poorer state than is the case at present. Those who remember the days of PCTs will recall the frequency of raids on public health budgets to offset overspends and prop up hospitals. At least public health under local government control remains visible and there is evidence despite the impact of austerity of authorities making serious efforts to become public health organisations and take health improvement and wellbeing seriously.


References:

1. Commissioning Public Health Services - Centre for Public Policy and Health (CPPH), Durham University: https://www.dur.ac.uk/public.health/projects/current/cphs/
2. Evaluating the Leadership Role of Health and Wellbeing - Centre for Public Policy and Health (CPPH), Durham University: https://www.dur.ac.uk/public.health/projects/current/prphwbs/

Photo attribution: "Exactly." by Sam Rodgers © 2017: https://www.flickr.com/photos/samrodgers/34779376735