Friday, 6 September 2019

Health inequalities in rural and coastal areas

Last November we, a team of Fuse academics, were successful in winning competitive funding from Public Health England (PHE) and given just four months to complete a rapid evidence review investigating health inequalities in older populations in coastal and rural areas. The team from Northumbria University and led by myself, consisted of Professor Katie Brittain a Social Gerontologist and Dr Sonia Dalkin Co-lead of the Fuse Healthy Ageing Research Programme (HARP). Read a case study about the review on the HARP pages of the Fuse Website.

The short timescale and vast quantity of literature made this a challenging project from the outset but the evidence was urgently needed to provide recommendations for taking an asset-based approach to reducing inequalities and promoting productive healthy ageing in rural and coastal areas. We worked closely, consulting and collaborating, with stakeholders including PHE Centre leads, Knowledge and Libraries Service, the Health Inequalities Team and Director of Public Health representatives from rural and coastal authorities. Key partners were approached from the start to recommend grey literature and case studies.

One hundred and eleven studies later the report is finally published and launched by our colleagues at Public Health England with this great blog showing how we age is strongly influenced by our environment, including where we live.

Katie Haighton, Associate Professor in Public Health, Northumbria University

How we age is strongly influenced by our environment, including where we live

Helen Brock - Programme Manager for Adults & Older Adults at Public Health England
Dr Rashmi Shukla - Director, Midlands and East of England at Public Health England

The impact of where we live

The long-term trend in life expectancy in the UK has been upwards; however, our experience of getting older varies across the nation. Some people have good physical and mental health well into old age, whereas others become frail or ill.

How we age is strongly influenced by our environment, including where we live. For both men and women, there is a 19-year difference in healthy life expectancy between those living in the most and the least deprived areas of the country.

Whether or not we live in an urban setting can also make a difference. While many of our country’s rural and coastal areas are picturesque, they can present significant challenges to protecting the health of the local population.

Our new evidence review builds on the existing evidence and suggests that older people living in rural or coastal areas may experience specific inequalities in their physical and mental health.

With almost 10 million of us living in rural areas, and older people making up a growing number of this group, it is important to understand why these health inequalities exist so that we can help to tackle them.

The evidence review aims to provide a synthesis of the evidence to support leaders in local areas in their efforts to reduce health inequalities.

Why are there public health inequalities in rural and coastal areas?

There are several drivers of health inequalities in rural and coastal areas.

One significant factor is social exclusion and isolation. Research suggests that loneliness can increase the risk of premature death by 30%.

Rural and coastal areas can face infrastructure challenges, with many villages and small towns lacking frequent and reliable public transport and high-speed internet. Having sufficient numbers of healthcare workers and carers in certain areas is an additional problem.

However, living in a rural or coastal area also has benefits. Rural places often have a strong sense of community, easier access to green space and lower crime rates than urban areas. ONS figures indicate that a higher proportion of people living in rural areas feel a sense of belonging and safety in their neighbourhood compared to people living in urban areas. Coastal environments may also provide benefits, through increased opportunities for physical activity as well as the restorative and stress-reducing impact of blue space (water).

What can we do to reduce these inequalities?

Local government and NHS partners, alongside the voluntary and community sectors, play a key role in taking action to improve the health and wellbeing of their populations.

PHE and NICE recognise that local interventions which bring communities together are some of the most valuable in addressing rural public health challenges.

Good social relationships and engagement in community life are necessary for good mental health and can help people become more resilient. By providing and maintaining community areas, green spaces and promoting public and community transport, councils can help to create a positive local environment and tackle social isolation.

Creating communities

Community activities such as lunch clubs can encourage older people to socialise and participate in community life. Bringing groups together in a village hall or other community space also provides the opportunity to reach older people with services, helping them to look after their wellbeing.

It is important to encourage social connections and contact for those in marginalised groups, who may be particularly affected by social exclusion. Involving older men who often find it harder than women to make friends later in life and may be reluctant to engage in community activities or social groups can also be a challenge.

Men’s Sheds is a programme that provides a place for older men in rural communities to participate in physical activities and projects such as gardening, woodwork and model-building. The initiative helps older men to meet, socialise and learn new skills, alleviating social isolation and creating a sense of purpose. With over 480 Sheds open in the UK, and more than 100 in development, it’s estimated that over 11,000 ‘Shedders’ are benefitting from Men’s Sheds across the country.

Promoting physical activity and making use of natural assets

There is potential for coastal and rural areas to use their natural assets to promote physical activity and reduce social isolation, for example, through volunteer-led walking groups or outdoor activities.

‘Stepping into Nature’ is a project led by Dorset Area of Outstanding Natural Beauty using Dorset’s natural and cultural landscape to provide activities and sensory-rich places for older people, including those with dementia and their carers. It seeks to increase physical and mental wellbeing, to reduce social isolation and loneliness, and to increase confidence and motivation for people to access the countryside.

Promoting and normalising physical activity as part of the experience of daily living for older people living in sheltered housing or residential care settings can result in further benefits.

In rural Norfolk, Active Norfolk – a partnership of organisations working to encourage people to participate in sport and physical activity – trialled Mobile Me, a physical activity programme for older people funded through Sport England.

For ten weeks, Mobile Me visited 65 sheltered housing and residential care homes to encourage them to get moving through games such as bowls and table tennis. The programme helped to reduce older peoples’ sedentary behaviour and fear of falling as well as increasing overall wellbeing.

Harnessing technology

Technology can be useful for providing care services to older people in the country’s most remote areas.

NHS Highland recently trialled video conferencing in remote care homes to allow doctors to speak to dementia patients in a familiar setting without the need for extensive travel.

The technology enabled care home residents to be assessed and reviewed more quickly and monitored more regularly. Video conferencing also helped care home staff to access specialist knowledge and advice more easily, helping them to feel more confident and actively involved in their residents’ care.

However, it’s important to find a balance between remote and direct face-to-face contact that many older people value.

Supporting local areas

With advances in healthcare and a greater understanding of how healthy lifestyles, supportive communities and environments can help us to live longer, enabling older people to lead fulfilling lives for as long as possible is more important than ever.

Recognising the health inequalities faced by people in different areas of the country, including rural and coastal places, is a crucial step to ensuring that all older people have the opportunities and care relevant to their needs, no matter where they live.

PHE’s evidence review seeks to share what is known about these issues, so that through Locality Plans, local Health and Wellbeing Strategies and other mechanisms, local authorities and the NHS locally are supported to prioritise work to address the health inequalities that exist within and between coastal and rural areas.

To find out more you can read the full report: An evidence summary of health inequalities in older populations in coastal and rural areas. You can also read our rural health report produced with the Local Government Association: Health and wellbeing in rural areas, and our recent health inequalities report: Place-based approaches for reducing health inequalities.

Reproduced with thanks to Public Health England and Exposure:


Thursday, 1 August 2019

School's out for summer

The blog will be back, refreshed and raring to go, on Friday 6th September 2019.

To be the first to hear about new posts in the autumn, follow @fuse_online.

Just because the blog is on holiday, doesn't mean you should be too. We always need your posts.

Please continue to send your 600-800 word posts to and they will be published just as soon as the blog is back in the office.

Here's how to take part and why you should blog.

Image: Ross Halfin [CC BY 3.0], via Wikimedia Commons

Friday, 26 July 2019

By invitation-only, at a secret location, with no agenda - this is Sci Foo ‘unconferencing’

Amelia Lake, Associate Director of Fuse and Reader in Public Health Nutrition at Teesside University

I’ve been back home from Sci Foo for more than a week. I’m not missing the Californian sunshine as the North East weather has actually been rather seasonal, but I am missing two things; the incredible Google micro-kitchens and the people I had the good fortune to meet.

Before the email arrived - which incidentally, I almost deleted thinking it was another spam invitation to a fictional conference in some far flung location - I hadn’t heard of Sci Foo. Thankfully, I forwarded it to our University Director of Corporate Communications and Public Relations, who was suitably excited.

That was April.  Fast forward to July and I’m on a 10-hour flight to San Francisco (feeling very relieved that I don’t have to entertain the kids on such a long haul). At this point I’m still not that clear what an ‘unconference’ conference is.

When I arrive, I have to download Uber to my phone (not a necessity when living in rural north Yorkshire) and I find my destination with only jet lag to contend with - a theme common throughout my three days at Sci Foo. To be fair, I had jet lag before getting here courtesy of a three-year-old.

On Friday evening, we are bused to the top secret Google X complex and it starts – as all good things should – with food. I can’t remember the last time I went to an event where I didn’t know anyone at all other than some vaguely recognisable faces from the twittersphere.
But with food came conversation. 
Participant-driven 'rugby scrum' 

At around 8pm the conference started (bearing in mind that I had been awake since 3am) and the message was clear. Be inclusive, be kind, be curious and talk to people from as many diverse fields as possible. That was very easy, as I soon discovered, most people were doing or studying things I hadn’t heard of, or had zero comprehension. It was awe inspiring.

I soon discovered that an ‘unconference’ is completely participant-driven and from a distance this looked a bit like a rugby scrum.                                 

       But with encouragement from my new found food friends I joined the pack and put down a session on ‘silencing science’ - discussing whether our role as scientists is to be neutral or advocates. I met Prof Shaun Hendy and Dr Siouxsie Wiles both phenomenal science communicators from the University of Auckland, New Zealand and we devised a session for Saturday morning based on the range of experiences Shaun had collated in his book ‘Silencing Science’.

The rest of the day was incredible – from sessions on trust in science, to the future of scientific publishing – and did I say that the food was great?! Sleep deprivation is nothing when you have access to kettles with higher and lower temperatures depending on the type of tea you select.

On Sunday morning it was my turn to give a ‘lightening talk’ on our Fuse energy drink research, alongside a handful of other presenters. Speakers one and two were incredible with amazing graphics, audio and visuals. My more low-tech approach highlighted the powerful words of our young respondents, illustrating what the consumption of energy drinks means to them.

Sci Foo was only three days but it felt longer, in a good way. There were many highlights, including holding a Woolly Mammoth’s actual tooth during breakfast [add photo], discussing galaxy formations with cosmologist and Prof of Physics Risa Wechsler and attending a session on ‘fully automated luxury feminism’!

There can’t be many conferences – no make that occasions in life - where you can share the same room with the most influential skateboarder in history, Rodney Mullen and a Nobel Laureate.

I hit a conference high attending Sci Foo. It was incredible and lots of people worked very hard to make it such a brilliant event. Particularly Cat Allman, the team from O’Reilly Media, Digital ScienceNature Publishing Group and Google Inc.

My take home message is: if you ever get invited to one of these ‘Foo’ events, say yes - you won’t regret it.

2: Courtesy of Alex Cagan:
3: Amelia Lake with Prof Shaun Hendy
4: Quotes from the young people involved in Fuse energy drinks research
5: Amelia Lake with a Woolly Mammoth tooth 

Friday, 19 July 2019

Struggling to see a way through your data? Try a different lens

Posted by Peter van der Graaf, AskFuse Research Manager / Fuse Knowledge Exchange Broker, Teesside University

“Having trouble analysing your qualitative data? Are you lost in the sheer amount of data you have collected and don’t know where to start?”

This was the strapline of a course at Kings College London last week, called ‘Ethnography Language and Communication’ and a big reason why I attend the summer school. Within my NIHR Fellowship research, I have collected big piles of observation notes, interview transcripts and meeting minutes and struggled to make sense of them. So did the course deliver?

Over five days, we were presented with a range of analytical tools borrowed from linguistics and applied to qualitative data (interview transcripts and video recording of job interviews and classrooms) with an ethnographic lens. In essence, this means trying to understand how meaning is constructed in social interactions by studying text and recordings generated from these interactions in fine detail. First from the perspective of the specific situation in which these texts were constructed, but with an explicit aim to make valid statements about the wider social structures in which these interactions are embedded.

The course leaders* have even come up with a name for this academic discipline: ‘linguistic ethnography’. Linguistic ethnographers acknowledge that texts are representations of social actions and, therefore, that to understand these texts you need to closely investigate the social interactions that produced them.

However, they also explore how these interactions are embedded in institutional contexts and are closely linked to social interactions elsewhere, both in time and location, adding a historic and place perspective. Sociological concepts of power, social class, inequality and identity feature eventually in these analyses but are not presumed and not used in the first instance. The specific context of the social interaction is initially key for understanding what is going on.

The course attracted speakers and participants from across the globe, including the UK, US, China, Spain, Germany, Austria, Belgium, Turkey, Israel and many more. This international gathering aligned nicely with the aims of the course: being highly interactional, working across different contexts with different types of data and approaches coming together to co-create a better understanding of their data.

Although we discussed many theoretical concepts, the course was also practical and gave us the opportunity to experiment with a range of analytical tools (or what Ben Rampton preferred to call ‘sensitizing concepts’): from micro-analysis (a form of Goffmanian conversation analysis: applying a dramaturgical lens (life is a stage!) to data interpretation) to discourse genres featuring The X Factor, multi-modal analysis (looking simultaneously at different modes of communication such as language, gaze and gestures), semiotic landscapes (e.g. how shop signs in neighbourhoods communicate change) and trans-contextual analysis (how text moves and changes across contexts and interactions). If you are confused by the plethora of terms and concepts, you feel exactly as we did during the course!

However, this was also the point: gaining experience of applying a range of tools that overlap or sometimes contrast with our data to find new insights that we wouldn’t otherwise have discovered. If it is helpful, use it; if not, try another tool or a combination of tools. In this sense, the course was very pragmatic. And this also applies to the role of being a linguistic ethnographer. You do not need to do X, Y and Z as a minimum, with a potential dusting of C to call yourself a linguistic ethnographer. Instead, you prescribe to a set of principles about the nature (social interaction), context (multi situational) and structure (institutional framing) of texts and recordings, that help you to choose from and apply an analytical toolkit.

Applying a different lens
Did it help me make more sense of the qualitative data I collected for my research project? No (at least not yet), but the course provided me with a starting point for analysis. It also helped me realise that trying to incorporate and do justice to all the data that I collected is simply not possible. Instead, applying a linguistic ethnographic lens to my data will help me to identify instances of text that signify social interactions that are critical for my understanding. This will ultimately help me to build an argumentative structure for my papers.

I will still need to go through all my qualitative data in detail but have a better sense of how to navigate this now.

*Ben Rampton, Kings College London; Adam Lefstein, Ben-Gurion University of the Negev; Jan Blommaert, University of Tilburg; Jeff Bezemer, University College London; and Julia Snell, University of Leeds

Friday, 12 July 2019

Managing difficult conversations at work; ambulances, snow ploughs and submarines

Posted by Peter van der Graaf, AskFuse Research Manager / Fuse Knowledge Exchange Broker, Teesside University

We all face difficult conversations in our work; whether as a PhD student trying to tell a supervisor that they are not very helpful, or as post-doctoral researcher, explaining to your line manager that you really don’t want to take up any more teaching responsibilities. Or even as a practitioner having to point out to an esteemed researcher that their pet project is not relevant at all for your practice.

Like most people, I try to avoid these conversations as much as I can and prefer ‘flight’ rather than ‘fight’. Best to give in and avoid confrontation than have an uncomfortable row that will keep me up at night.

But could confrontations also be useful, and if so, how could you manage them in a way that they benefit you? This was the aim of the Courageous and Compelling Conversations Masterclass I attended in London as part of the NIHR Leadership Development Programme. Before starting the masterclass, I had to complete a self-assessment of my preferred response mode to confrontational conversations, which neatly confirmed my ‘flight’ status and gave me new labels for it: 60% Give In; 20% Run Away; and 20% Compromise.

What the masterclass taught me was that confrontation is not about preparing well for the other’s potential responses; for instance, by endlessly scripting clever and rational dialogues to counteract every accusation that a person could throw at me.

Instead, the course focused on better understanding my own response style in relation to other people. My light bulb moment was the realisation that you can’t control the response of the person you are talking to, but that you can manage yourself on how to respond, and take time to formulate this response during the conversation. Therefore, my nights (more preferably work hours) would be better spent understanding what I want to get out of the confrontation (outcome) and plan my conversations accordingly, instead of worrying what the other person will say and need.

During the course we were split into three groups, according to our preferred Motivation Value Style, with each group given its own emblem in the shape of a transport vehicle. Apparently, I am an ambulance, which is the symbol of the ‘carer’ group, who are motivated by the protection, growth and welfare of others. We prefer to ensure that everyone is happy, relationships are good and don’t want to be a burden to others. As an ambulance, I am responsive to other people’s needs and therefore go into conversations where I am needed (with blue lights if possible!).
In contrast, the ‘driver’ group (snow ploughs) - motivated by task accomplishment and achieving results - prefer to exercise persuasion. The third group, technicians (submarines) are different again in that they are motivated by meaningful order and thinking things through; they want to be practical and fair.

Although, these three styles feel quite stereotypical, I was surprised to see how much each of us on the course was conforming to these styles when explaining their behaviour in difficult conversations. We discovered that we incorporate elements of each style into our conversations but have a natural gravitas to a particular style. Realising your preferred style and working out the preferred style of your conversation partner, proved really helpful.

For example, someone who prefers to be a submarine (technician style), does not respond well to pressure to make an on the spot decision. Forcing them to agree to a solution at the end of the conversation will only escalate the confrontation. Instead, agreeing to give them time to mull the problem over and come back with a response later, will likely result in a much more favourable response and implementable solution.

Under stress, people tend to respond in either of two ways: they become more extreme in their preferred style (dig their heels in) or switch to a different style. What we were encouraged to do during the training course, was to play with different styles and practice switching during a confrontational conversation to a different style that would be more attuned to the person we were speaking to. In that sense, we are better able to manage ourselves and the responses we get from the person we are confronting.

A key part of this switching of styles was being assertive; not shouting over the other or ignoring what they say, but quite the opposite: taking more time to listen to the other and trying to understand what they say and where they are coming from. Are we really hearing what the other person is telling us or are we too busy trying to contain our emotions and constructing our next argument in our heads? Armed with this understanding, you will be better prepared to say what you think and feel, and, most importantly, what you want to happen.

As an ambulance, I need to be patient with submarines and focus on the practical, while being more competitive and assertive with snow ploughs, or team up with submarines to create new opportunities in joint conversation with snow ploughs.

  1. 'Arguments' by Jeff Eaton via Flickr. Attribution-ShareAlike 2.0 Generic (CC BY-SA 2.0):

Friday, 28 June 2019

Universal Credit and survival sex – a hostile policy in practice?

Post by Laura Seebohm, Changing Lives, Executive Director – Innovation and Policy

I recently provided evidence to the Work and Pensions Select Committee on the relationship between Universal Credit and survival sex. By both shining a light on this important issue, and promoting the terminology of ‘survival sex’ – sex work conducted to meet basic needs in the absence of other options - the Committee had a significant opportunity shape the public policy debate on this issue.
Changing Lives first coined the term ‘survival sex’ when we supported women who had experience of selling sex to carry out peer research, interviewing 86 of their peers across Tyne and Wear back in 2007. The findings highlighted the overwhelming correlation between selling sex and poverty, deprivation and social exclusion. Women disclosed they were turning to survival sex to meet their immediate needs; to pay for food, for a place to stay, laundry, to fund an addiction, and often to support their children. We have repeated this methodology in other towns and cities over the past 12 years and the findings have not changed.

What has changed quite significantly is the number of women faced with destitution. They see selling sex as their ‘only option’ when faced with unprecedented levels of financial hardship. They tell us time and time again that this relates to welfare reform - specifically the roll out of Universal Credit.

Changing Lives has five specialist services for people involved in survival sex, sexual exploitation and sex work across the North and Midlands, supporting nearly 700 people at any one time. Most of the women we work with come to us with a range of vulnerabilities, alongside survival sex. Many report trauma and abuse as children continuing into adulthood, poor mental health and addiction, poor education and employment opportunities, homelessness and experience of the criminal justice system. Most also present as courageous, amazingly resilient and articulate, with an array of talents and strengths that see them through.

However, they are severely disadvantaged by Universal Credit. This is a system which appears to be designed to be alienating and impenetrable for people who need it most – those with little money, living on tight budgets and with limited financial capability. It is exacerbated for those who have low levels of ‘social capital’; they do not have people in their lives who they can turn to for support when times are hard.

Key issues our services consistently report are:
  • People frequently have no formal ID, no bank account, and are not digitally literate and have no access to the internet – making it impossible to claim Universal Credit.
  • The timescale for processing a new claim is commonly five to six weeks - but delays can take up to 11 weeks. 
  • It is possible to access Advance Payments while a claim is processed. But the rates of repayment are excessive and non-negotiable, leaving people in extreme financial hardship. 
We know of people who have been given £250 as an advance payment with no indication of how long this should last (six weeks). If this does not cover rent (which it often doesn’t) homelessness is inevitable. The difference with Universal Credit is that any deductions are taken from the one ‘universal’ benefit, so there is no capacity to protect rent, for example (as the old system would have provided with a separate housing benefit entitlement).

Survival sex can feel like the only avenue available. And when benefits are reinstated with deductions of £150 including the advance payment, people are left with such small amounts to live on that it is impossible to sustain their health or welfare at even the most basic level. It is of no surprise that people sell sex in order to survive, especially those with children to care for.

We see women doing this for the first time; we see women returning to sex work years after they have left; we see up to a third of women we support choosing not to apply for Universal Credit at all. They all say selling sex is their ‘last resort’. As Heidi Allen MP, Vice Chair of the Committee said, “if the system is not a safety net, you run out of options”.

There was a concern raised by a number of women giving evidence to the Committee that dehumanising processes and subsequent levels of poverty we see resulting from welfare policy have been deliberately built into the administration of Universal Credit. There is a suggestion that there has been a deliberate act of making people poorer by using the welfare system as a hostile tool. The widespread shared experience of all of us giving evidence would certainly suggest that this is the case.

Work and Pensions Committee: Universal Credit and Survival Sex - oral evidence

Since the Committee a number of us who gave evidence were invited to meet with Secretary of State Amber Rudd and Will Quince MP at the Department of Work and Pensions (DWP). They are adamant that there is no policy or directive ‘from the top’ to deliberately create a system that is impenetrable for people in need. They also accepted that the evidence provided by women we support is not ‘anecdote’ (as previously claimed in a DWP letter to Frank Field and his Committee) but genuine cause for concern.

The following day Will Quince MP, Minister for Family Support, Housing and Child Maintenance made some conciliatory steps to further demonstrate this point. He apologised for the initial response by DWP, and concluded that ‘We need to make sure people’s lived experience matches our policy intent’.

It is the responsibility of Changing Lives, and the many other organisations who gave evidence, to work with the Committee to hold the government to account on this matter. We need to make sure we never tolerate a system where survival sex is ever anyone’s last resort.

About Changing Lives

Changing Lives helps over 17,000 people change their lives for the better each year. We are a national charity dedicated to supporting people with the most complex needs to make meaningful and lasting improvements to their lives. We have around 100 projects in England and over 500 dedicated staff, supporting people experiencing homelessness, domestic violence, addictions, long-term unemployment and more.

Friday, 21 June 2019

Is there life beyond the PhD?

Posted by Priyanka Vasantavada, PhD researcher, School of Health and Social Care, Teesside University

Living my Jane Austen fantasy
Don’t ask me if there is? It’s not afterlife. Or is it? But it is a question every PhD student has wondered about during the ups and downs of their PhD journey (unless you have a permanent job and are doing a part-time PhD). So how do you deal with it when this sort of ‘limited existentialism’ strikes? What do you say when the world around you repeatedly asks, “what next?”.

I just curl up in my bed and binge watch screen adaptations of Jane Austen novels or any good costume drama, science fiction series or even fantasy; for what can be better than some good old escapism? Does it answer the question? No! Does it help me forget it? Yes!

So last summer when I received an email from the Graduate Research School of my university regarding a Life Beyond PhD conference being held at Cumberland Lodge, Windsor; I jumped with excitement. I knew I wanted to go for it the moment I saw the pictures of the Lodge. Not unlike Pride and Prejudice protagonist Ms Elizabeth Bennet who started seeing Mr Darcy in a favourable light after visiting Pemberley. Don’t get me, or Ms Bennet, wrong for we both saw the merit in the conference and Mr Darcy respectively, but their residences certainly recommended them.

Cumberland Lodge, Winsor Great Park
Here was an opportunity blending my fantasy and reality - a four night residential conference with hospitality in the actual former residence of a real-life princess…. hello Disney! What more could I have asked for? (*cough*… Cumberland Lodge Scholarship …*cough*). The conference programme was designed to highlight the value of PhDs (both within academia and industry) and it also promised opportunities for sharing research and career aspirations, exploring collaborative and interdisciplinary ways of working, and presenting to a diverse, non-expert audience.

My supervisor considered it to be a good opportunity for me; owing to the nature of my PhD which marginally borders on public engagement in research and public health. She was kind enough to recommend me to the school for sponsorship and I daydreamed my way to the Windsor great park on a balmy summer afternoon.

Conference delegates
All the delegates were welcomed and given a tour of the historical building by the education officer of the lodge. The tour was followed by a session on research culture in the UK topped with a drinks reception. A delicious dinner was served shortly thereafter, and the delegates had fun in the group games session which included a pop quiz, table tennis, and snooker. I don’t think I ever made so many friends in such a short period of time!

The second day centred around PhD researcher development with sessions on self-leadership, speaking and writing techniques, and wellbeing and mental health. Unsurprisingly the session on mental wellbeing: research-based thoughts, issues and toolkit commanded most delegate participation, as the mental health of a PhD researcher is almost always never considered in academia. The conference drew delegates from disciplines across science, art and literature and yet everyone identified with mental health issues in PhD life!

Me and fellow Teesside University
PhD researcher David Oluwadere
On the third day, delegates were divided into four groups and were given the opportunity to present their project to their group mates who were of a different subject background. Every delegate received feedback from their peers on their overall presentation skills and comprehension of content. My colleague David Oluwadere, studying Environmental Sciences at Teesside University, presented on agronomic biofortification technique as a means of increasing zinc concentration and bioavailability in wheat using seaweed. I presented my project on the public perception of community water fluoridation in the UK. The presentations were followed by sessions by PhD graduates on their life after PhD and on public engagement in research.

The fourth day focussed on interdisciplinary research and working in designated groups we were challenged to address a problem by developing interdisciplinary research proposals within the day. These proposals were pitched to a panel of judges in order to seek funding. This was an exercise in developing our collaborative skills and emphasised the importance of interdisciplinary approaches to problem solving. It also demonstrated how a problem is viewed differently by people from various disciplines. Humble brag, but the team I was part of, won the proposal contest and were gifted a box of chocolates.
Winners of the interdisciplinary research proposal contest 

The conference closed with a session on, “Why is a PhD worth it?”. In addition to the conference presentations which were highly informative and relevant, I will always remember the experience for living in a historic aristocratic building, ‘taking a turn’ about the Windsor great park (channelling heroines of Jane Austen and Charlotte Bronte), the late night banter with friends in the sitting rooms of the lodge, playing games and striking the keys of an out of tune piano in the basement in evenings, and being served dinner in a fashion reminiscent of Downton Abbey.

If you feel that this is something for you (fantasising is optional), visit the the Cumberland Lodge website to find out more.

Getting a job after PhD is subject to availability and visa status, but life beyond PhD is open to endless possibilities. So, I believe that instead of speculating about the future, we should try to live in the moment and savour the #phdlife while it lasts!


Friday, 14 June 2019

Battle planning to reduce childhood obesity

Michael Chang, Co-founder, Health and Wellbeing in Planning Network

Latest statistics show that obesity prevalence is highest in London, the West Midlands and the North East and there is a significant gap in children living in the most and least deprived areas. So I am supportive of Local Planning Authorities (LPAs) using relevant planning powers at their disposal to promote a healthier food environment to help reduce childhood obesity levels and close the inequalities health gap.

Here I want to reflect on efforts by councils to introduce planning policies and guidance to manage unhealthy food environments around schools and other educational settings. It follows on from a previous blog on whether councils have what they need to help tackle obesity?

The context of this blog is the recent session from the draft New London Plan examination on draft Policy E9 C which seeks to control proposals containing hot food takeaway uses (A5 class use in planning terminology) within 400 metres walking distance of an existing or proposed primary or secondary school. Many other local authorities are proposing similar policies and undergoing similar stages of the local plan in the North East and other parts of the country.

The London Plan is the Mayor of London's strategic planning document and sits above individual borough Local Plans. It sets out 'issues of strategic importance' (note terminology used) for all of London while individual borough issues are dealt with at borough level. It is a powerful and influential planning document for borough level planning policies and planning decisions across the 32 London Boroughs and the City of London. It is as upstream as you can get in terms of policy influence. Other areas with Combined Authorities or joint planning units will also be developing these strategic planning documents.

London Plan examination held at London City Hall
What is an examination?

Draft policies need to be tested through an ‘examination’ before they can be adopted by councils. Don't let the terminology put you off - essentially an independently qualified person(s) from the Planning Inspectorate carries out an inquisitorial process on whether to accept, suggest revisions or reject the proposed policies. Often policies on takeaways fall at this hurdle and are subsequently watered-down or deleted altogether.

Policy approaches to managing fast food takeaways

Fast food takeaways, in planning terms in England (Wales, Scotland and Northern Ireland will have their own variations of the use class classification), is a specific use class - A5 - for selling food to be consumed off the premises. Planning permission is needed for change of use to A5 from other uses such as a hairdressers. There are many 'planning' approaches to managing fast food takeaways and only recently have the approaches been influenced by a need to tackle public health issues such as obesity. Latest research by Keeble at al. found 50.5% of LPAs had a policy specifically targeting takeaways with 34.1% focused on health. Planning Practice Guidance, Health and Wellbeing Paragraph 6 sets out examples of approaches for consideration including over-concentration and proximity to certain activities.

Opposing arguments

There are opponents to takeaway policies who believe them to be overly restrictive. Their arguments have some merit, particularly against economic reasons in areas desperate for economic activity. I would suggest policies can be justified as part of a package of policies to tackle unhealthy environments as well as prosperous diverse local economies. Common themes from those opposing include:
  • "The policy does not meet National Planning Policy Framework (NPPF) soundness tests"
  • "There is no objective evidence for any link between the incidence of obesity and the proximity of hot food takeaways to schools" 
  • “Obesity is complex and you can’t narrow it down to just takeaways”. 
  • "The local area has the lowest percentage of overweight or obese children" 
  • "There are unintended consequences for local jobs and employment" 
  • "The policy would limit consumer choice and access to retail" 
  • "The policy would also ban healthy takeaways and does not address unhealthy food sold in other non-A5 outlets".

Hold your ground: defending a 'sound' takeaways policy

This singular policy issue or public health intervention of managing takeaways is deceptively complex, and battles are taking place up and down the country as councils defend the soundness of policies against objectors as well as the probing questions from inspectors. When defending a takeaway policy, there should be a combination of the following:
  • Valid consideration: Be confident that efforts to tackle obesity through the environment can be a material planning consideration.
  • Planning basis for obesity: Recognise that the NPPF requires planning to consider all three social, economic and environmental factors equally. But make sure there are priorities on tackling obesity through the environment in local health strategies. 
  • Local evidence: Do your research and build up a local evidence base, including the use of up to date data and mapping to demonstrate the scale and location of the problem. This should also include knowing the background of those who operate local businesses – independent or chain. 
  • Whole systems approach: Take a corporate approach by referring to programmes such as promoting healthier catering, food growing and education to demonstrate the action is part of a cross-council initiative. Also demonstrate you are planning for a healthy weight environment, and that the takeaways policy is an important part of the jigsaw. 
Researchers, local government and national agencies are aware of these practical challenges hindering local action to make it less easy for kids to become overweight. Concerted efforts and peer support are needed so let’s keep the conversations going.


Friday, 7 June 2019

Take it away: a masterclass in healthy takeaways

Post by Scott Lloyd, Advanced Public Health Practitioner at Public Health South Tees and Karen PearsonCatering Monitoring & Advisory Officer at Redcar & Cleveland Council

Whether it is the Golden Cod or the Taste of India, independent hot food takeaways get a bad rap in Public Health circles. They serve food and drink that is predominantly higher in fat, salt and sugar and may contribute to noise pollution and other environmental ills. Furthermore, they may not be the best option for our beleaguered high streets as they tend to be shuttered up during the daytime.

Up to March 2018, for a variety of reasons (including health), 164 out of 325 Local Authorities (50.5%) have introduced powers through Local Plans or Supplementary Planning Documents (SPD) that aim to restrict the proliferation of hot food takeaways (Keeble et al. 2019)[1].

Watch this video to find out more about how we worked with takeaway owners
(click here if the video doesn't appear above)

But let’s be honest – that horse has already bolted. Analysis by Public Health England has shown that there is an average of 96.1 hot food takeaways per 100,000 population in England (Public Health England, 2018)[2].

Where we work in Redcar and Cleveland, the Local Authority introduced a SPD in 2008 that restricted the percentage of hot food takeaways (A5 class use in planning terminology) in any commercial centre to no more than 5% - but even then, each commercial centre already had more than 5% hot food takeaways.

So we have to accept that hot food takeaways are here to stay – at least for the foreseeable future. Many Local Authorities have implemented interventions such as award schemes that engage these businesses to support them to improve the healthiness of their food offerings, but with limited evaluation (Hillier-Brown et al. 2017)[3]. Indeed, we have a Food4Health award in Redcar and Cleveland, which is open to all out-of-home caterers. We were doing OK in engaging hot food takeaways but we wanted to try something different.

In 2015, the Foodscape team organised a Fuse Quarterly Research Meeting on developing interventions with out-of-home caterers. One of the presentations was by Louise Muhammad from Kirklees Council on the healthy takeaway masterclass that they had developed and delivered to over 20% of the eligible businesses on their patch. The masterclass was described as a three-hour session in which hot food takeaway owners and managers learn about the small, sustainable changes they can make so their food is a little healthier without costing a huge amount or that will actually save them money/generate new custom.

A few months later, we travelled down to Huddersfield to watch a masterclass being delivered. It was clear from the start that this was something that engaged businesses and had potential. The decision to repeat it in Redcar and Cleveland was easy.

Takeaway owners and managers learning about small changes to make their food healthier
We worked with the teams from Kirklees and Foodscape to deliver our first masterclass in May 2016. In line with what Kirklees do, we invited hot food takeaways with a food hygiene rating of three or above – the feeling was that any outlets with less than this really needed to concentrate on food hygiene first. In total, 181 invitations were sent out and 18 attended, representing 10% of those eligible – a figure that we practitioners were happy with (if not all the academics!).

The Foodscape team conducted a mixed methods evaluation to explore the acceptability and feasibility of the masterclass intervention (Hillier-Brown et al. 2019)[4]. The takeaways businesses that attended made a variety of pledges – the ones that required less effort and cost (e.g. reducing salt and sugar in pizza dough) were implemented more so than other more potentially costly or difficult changes (e.g. stocking reduced sugar tomato ketchup).

Pledging to use healthier alternatives
Has this work made the hot food takeaways in Redcar and Cleveland healthy? No it hasn’t. Like the rest of us, businesses owners have a living to make and will cater to what their customers want. But as an example, Carol - the owner of a sandwich shop in Guisborough who stars in the film above - pledged to take 10% of the sugar out of her baking. Did her customers notice? No. Did, this make her flapjacks ‘healthy’? Of course not but they are now a little healthier. Hence, has the masterclass via all the pledges made their food offerings a little healthier? Probably.

We have since delivered a further six masterclasses, with the offer extended to other out-of-home caterers such as restaurants. About 30% of all eligible takeaways in Redcar and Cleveland have now attended a masterclass, with follow up support provided by the Food4Health award.

Engaging with hot food takeaways can be difficult. We are now struggling to attract new businesses onto the masterclass and may hit a saturation point at 35% or 40% of those who are eligible. Some owners have other priorities and some may not accept the healthy eating messages. Also, some hot food takeaway owners are not even resident to the UK so engaging them is nigh on impossible. But we have to continue to try.

Another key learning point is that we need to work more closely with suppliers. The majority of masterclass attendees pledged to start using healthier alternatives, such as reduced sugar tomato ketchup or reduced salt soy sauce but they were unable to source these items from suppliers at a reasonable cost or not at all. Hence, wider work is needed with suppliers which, as one of the other Foodscape projects showed, is possible (Goffe et al. 2019)[5].

But the masterclass is an acceptable and feasible intervention to engage a good proportion of hot food takeaways. We will continue to deliver it once or twice a year as long as there is sufficient demand. We’re hoping to run the next class in September, so lookout for that.

What the masterclass doesn’t do is engage the big operators such as McDonald’s and Just Eat, accepting that the latter works mainly through local independent takeaways (but what requirements can the national corporation specify on their local deliverers?). It’s likely that national work is needed with those corporations, continuing the good work of Public Health England and others.

We also need to be mindful of the potential impact of “dark kitchens” – potentially the “satanic mills of our era”. But I’ll save that for another time…

Read our handy Fuse research brief to find out more about the Foodscape study.

  1. Keeble, M., Burgoine, T., White, M., Summerbell., C., Cummins. S., Adams, J. (2019). How does local government use the planning system to regulate hot food takeaway outlets? A census of current practice in England using document review. Health & Place, 57, 171 – 178.
  2. Public Health England (2018). Fast Food Outlets: Density by Local Authority in England. Available at: [accessed 27 May 2019] 
  3. Hillier-Brown, F.C., Summerbell C.D., Moore, H.J., Wrieden, W.L., Adams, J., Abraham, C., Adamson, A., Araújo-Soares, V., White, M., Lake, A.A. (2017). A description of interventions promoting healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England: a systematic mapping and evidence synthesis. BMC Public Health, 17 (1), 93.
  4. Hillier-Brown, F. C., Lloyd, S., Muhammad, L., Goffe, L., Summerbell, C., Hildred, N. J., ... Araújo-Soares, V. (2019). Feasibility and acceptability of a Takeaway Masterclass aimed at encouraging healthier cooking practices and menu options in takeaway food outlets. Public Health Nutrition.
  5. Goffe, L. Hillier-Brown, F., Hildred, N., Worsnop, M., Adams, J., Araújo-Soares, V., Penn, L., Wrieden, W., Summerbell, C.D., Lake, A.A., White, M., Adamson, A.J. (2019). Feasibility of working with a wholesale supplier to co-design and test acceptability of an intervention to promote smaller portions: an uncontrolled before-and-after study in British Fish & Chip shops. BMJ Open, 9 (2), e023441.

Friday, 31 May 2019

Can cancer ever be a good thing?

Post by Fiona Menger, Research Associate, Institute of Health and Society, Newcastle University

Dr Menger blogs about how she was inspired early in her career by Times Journalist John Diamond and has recently returned to his writing while working on a study on the positive consequences of having cancer.

John Diamond, author of “C, Because cowards get cancer too”
As a newly qualified speech and language therapist in the late 90s, I was an avid reader of Times journalist John Diamond’s weekly columns on his experiences of being treated for head and neck cancer. Diamond was one of the UK’s first ‘cancer columnists’, writing about his reaction to his diagnosis and treatment, and the correspondence he received from his thousands of concerned readers. His columns became two books, a documentary, a play, a TV drama, and were followed by many other cancer survivors writing about their experiences in the media or on personal blogging platforms.

John Diamond conveyed to his readers not only that it was ok to write about personal experiences of cancer, but that it was positive to share his story. He was adamant that he was neither brave nor strong, but that he was, in his own words, ‘a coward’, a passenger on a journey where he had very limited control. For me, John’s strength lay in his writing and his reflection. He was simultaneously eloquent and rude. Each day when the radiologist would ask, “How are you today?” he would grumpily reply, “Well, since you ask, I’ve got cancer.” I loved that about him. He was honest and funny and had a natural ability to convey the serious level of crap he was living through. He also taught me a great deal about viewing care from a patient’s perspective, something I have tried to carry with me throughout my career.

I recently returned to John Diamond’s writing because, twenty plus years later, I find myself working on a head and neck cancer-related project with a focus on a phenomenon called post-traumatic growth. Around 20 years ago, psychologists began to investigate post-traumatic growth in survivors of traumatic experiences such as natural disasters or accidents, but more recently the concept has begun to receive attention within the cancer research community. The principle of post-traumatic growth is that a person can, over a period of months and sometimes years, come to perceive positive benefits as a result of their trauma (in this instance, cancer). It might mean, for example, that a person feels emotionally stronger, that they appreciate their life and relationships more, or that they feel they have renewed focus and direction. The researchers who coined the term report that to experience post-traumatic growth, a person must go through a process of rumination and reflection. They write that it is necessary to work through a period of recurrent thinking about the event with the aim of trying to make sense of what has happened, to problem solve and to reminisce. These were skills that John Diamond demonstrated in spades. In the final chapter of his book, ‘C – Because cowards get cancer too’, Diamond recounted a conversation with his wife, the chef and author Nigella Lawson:

‘It’s such a strange time, isn’t it?’ I said.

‘How so strange?’

‘Oh you know. Strange in that I’ve never felt more love for you than I have in the past year, that I’ve never appreciated you as much, nor the children. In a way I feel guilty that it should have taken this to do it, I suppose. But it is strange, isn’t it?’

For the first time, I found myself talking like this without resenting that it had taken cancer to teach me the basics, without resenting that there was part of me capable of talking like a 1950s women’s magazine article without blushing.

I still don’t believe that there is any sense in which the cancer has been a good thing but, well, it is strange, isn’t it?
Quote from: Diamond, J. C. Because cowards get cancer too. Vermillion. 1999

So, is there ever any sense in which cancer can be a good thing? Research across different types of cancer survivors suggests that post-traumatic growth is a common occurrence but that it doesn’t happen for everyone. There is also some limited evidence to suggest that people with cancer who experience higher degrees of post-traumatic growth may have better health-related quality of life. What we don’t understand is what helps or hinders people to experience these positive changes. This is what our project – “Life after Head and Neck Cancer” aims to determine. We plan to interview people who have finished treatment for head and neck cancer and have had time to reflect on their experiences. We will explore coping mechanisms, support systems and beliefs about the impact head and neck cancer has had on people’s lives. Why is it important to better understand post-traumatic growth? Well, if researchers can somehow identify and understand how people develop post-traumatic growth, this could inform the development of services to support people to have more positive outcomes after cancer.

This Sunday (2 June) marks National Cancer Survivors Day. We are hopeful that, if post-traumatic growth can in some way be encouraged and supported, more and more cancer survivors can live well following their experiences. This work is in its very early stages, but I am extremely proud to be part of it.

John Diamond died in 2001, following a recurrence of his throat cancer.

Figure image: reproduced with permission from: Diamond, J. Close encounters of an alternative kind. BMJ 2000; 321:1163

All articles posted on this blog give the views of the author(s), and not the position of Fuse, the Centre for Translational Research in Public Health; the five North East Universites in the Fuse collaboration, or funders.

Friday, 24 May 2019

Perseverance and Public Health: creating a cultural shift takes time

Guest post by Susan Jones, Research Associate, Teesside University

I spoke to a young woman the other day who had moved to North East England recently. She already had a little boy, just coming up 2 years old, and was now well on in her next pregnancy. Because I had been involved in evaluating babyClear© - an intervention to help support expectant mothers to stop smoking - I asked her whether the midwives had enquired if she smoked, (she doesn’t). “Oh yes”, she said, “they’re much more into keeping a close eye on you here”, as compared with the region where she lived before.

This buy-in by maternity staff, and the change to practice, is reflected in our paper, recently published in BMC Health Services Research (Jones et al., 2019)[1], in those Trusts that facilitated the intervention most successfully.

It is crucial, yet difficult, to answer questions about the effectiveness of initiatives like these. It takes time and perseverance t
o identify the questions, conduct the research and bring in the system and practice changes, which in turn support behaviour change in patients.

How do we go about answering questions about effectiveness of interventions designed to support people to change their behaviour and to become healthier?

It was in 2012, that the findings from interviews with midwives were first published (Beenstock et al., 2012)[2] and the search for new ways of embedding National Institute for Health and Clinical Excellence (NICE) Public Health Guidance 26 (2010)[3] more thoroughly, began. As a result, babyClear© was initially implemented across North East England from 2013 to 2015.

Fundamentally, interventions like babyClear© can be shown to be effective in certain circumstances (NICE, 2010; Bell et al., 2018)[4] but our latest paper found that these changes required specific contexts and cultures in the implementing organisation to maximise their effectiveness and potentially their sustainability and transferability.

These changes in staff practice and patient behaviour do not happen in isolation; the external context is important too and, in this case, the national context has become increasingly supportive.

For example, there have been a number of new pieces of legislation, guidance and reports during this time, all pushing in the same direction:

Clearly, there is an appetite to find solutions to the health problems that smoking causes; however, imposing regulation, without understanding and dealing with the causes, is never going to be hugely effective in a democracy like ours.

So what we see is a lot of different ‘scatter gun’ approaches all dedicated to the same aim – typical of lots of health and social interventions – but is this the best approach?

It is being recognised more and more that intervening in complex systems, such as the NHS, is both necessary and – at the same time – problematic. Largely, the problems come from a lack of understanding of the multiple complexities of the contexts and the effect of cultures upon outcomes. New ways of combining research methods are required to investigate these complex systems and find appropriate answers (Moore et al., 2014)[9]. Updated guidance from the Medical Research Council on evaluating complex interventions is being drafted as I write.
Fuse Complex Systems research programme

Only when the links – or active ingredients – between the different elements of an intervention are identified, and proper attention is given to the contexts and cultures surrounding it, will we be able to understand the necessary environment and resources for it to thrive, ensure its sustainability and maximise outcomes.

Our paper is one step in this direction but there is much more to do. Fuse has a Complex Systems research programme, because the researchers know how important it is. They will soon be publishing their plans for the future direction of their research on this topic.

This is an area where research and evaluation are moving fast, as they attempt to get to grips with the way health and public health are changing in the lives of staff and patients.

  1. Jones, S. et al. (2019) What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory. BMC Health Services Research. Available at: (Accessed: 20th May 2019).
  2. Beenstock, J. et al. (2012) 'What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England', Implementation Science, 7(1), p 1. 
  3. National Institute for Health and Care Excellence (2010) Public health guidance 26: Quitting smoking in pregnancy and following childbirth. London: NICE. 
  4. Bell, R. et al. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control. Available at: (Accessed: 20th May 2019). 
  5. NHS England, O'Connor, D. and Gould, D. (2014) Saving Babies Lives: reducing stillbirth and neonatal death: a care bundle. Available at: (Accessed: 10th April 2019). 
  6. Department of Health and Social Care (2018) Tobacco Control Plan: Delivery Plan 2017 - 2022. Available at: (Accessed: 20th May 2019). 
  7. Royal College of Physicians and Tobacco Advisory Group (2018) Hiding in plain sight: Treating tobacco dependency in the NHS. Available at: (Accessed: 11th April 2019). 
  8. Challenge Group (2018) Review of the challenge 2018. Available at: (Accessed: 10th April 2019). 
  9. Moore, G. et al. (2014) Process evaluation of complex interventions: UK Medical Research Council. Available at: (Accessed: 10th April 2019).
  1. 'Smoking when pregnant' by johndavison883 via Flickr. Public Domain Mark 1.0.