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.

Friday, 17 May 2019

The toxic mix of Universal Credit, austerity and widening inequalities

Concerns about the mental health impact of government reforms under austerity are growing and emerged in Universal Credit research commissioned by Gateshead Council which is soon to be published in BMJ Open[1].


Mandy Cheetham, Research Associate at Teesside University, posts on Mental Health Awareness Week.

The invitation to present the findings at Newcastle University’s recent conference on human rights, health and welfare made me reflect on the multiple ways in which Universal Credit drives inequalities and undermines claimants’ rights.

Panel members (Mandy, pictured furthest right)
Want, Disease, Ignorance, Squalor & Idleness: Beveridge’s 5 giants

As part of a panel discussion, I was struck by the powerful comments of my fellow panel members who framed the rising need for food banks as a failure of social security. They described the “uncomfortable truth” of food poverty, the “violence of austerity” and the need to start from a position of love and care, offering people dignified, not demeaning responses to crises.

The sense of exclusion, shame, embarrassment and stigma surrounding food insecurity and the use of foodbanks was clearly articulated by the Universal Credit claimants in the study we did in Gateshead and Newcastle. One participant with a long term health condition commented:
"I think the most degrading thing about Universal Credit was that I had to go to foodbanks. I couldn’t afford to eat" (Claimant interview)
Universal Credit claimants and staff supporting them recognised the political choices which undermine people’s basic rights to food and social security, which are fundamental to health and wellbeing.
"It seems to be government policy at the moment to punish people for being poor" (Staff interview)
It is hard to see these choices as accidental when Amber Rudd, the Secretary of State for Work and Pensions, acknowledges that the rise in food banks is at least in part due to the roll out of Universal Credit. It is brutal and unrelenting in its effects.

Last week, I attended a thought provoking seminar by Guy Standing (co-founder of the Basic Income Earth Network), who reflected on the benefits of securing a basic income for all and described his view of the modern giants blocking transformative progress, including precarity: creating ‘supplicants’ with no rights, asking for favours from friends, family and bureaucrats, reliant on charity with no sense of agency or freedom. 

Digital exclusion, delays, deductions, intensified work related requirements, arbitrary risk of sanctions and maladministration by the Department for Work and Pensions associated with Universal Credit, all combine to maintain the precarious existence of claimants, undermining their rights to financial and material security, and social inclusion required for health and wellbeing.

This is not new. In a paper entitled ‘First do no harm’, Barr et al (2016)[2], found the programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. The authors suggest that the policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

The four year welfare benefits freeze, austerity and implementation of Universal Credit is a toxic combination that has truly terrible consequences for those reliant on the state leaving people without enough money to fund the basics essential to participate in society. 

Piecemeal changes announced by government to phase out “unnecessarily long” three year sanctions under Universal Credit, for example, are welcome but do little to address the wider concerns raised about the continuing hardship which people experience on Universal Credit (Dwyer P. 2019)[3]

There are increasing calls for public health to respond in the face of mounting evidence of the harm to people’s physical and mental health which Universal Credit is causing. If government Ministers and policy makers were guided by the principles of “First Do No Harm”, it would be hard to see how the continued roll out of Universal Credit could be justified in the name of ‘welfare reform’. Public health needs to be at the forefront of efforts to address concerns about rising inequalities in different dimensions – income, work, mental and physical health, families and relationships, which were highlighted this week by the Institute for Fiscal Studies (Joyce and Xu 2019).

  1. Cheetham M, Wiseman A, Moffatt S, Addison M. (2019) The impact of Universal Credit in North East England: a qualitative study of claimants and support staff BMJ Open (in press).
  2. Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Whitehead M. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study Journal of Epidemiology and Community Health, 70:339–345
  3. Dwyer P. [editor] (2019) Dealing with welfare conditionality, Bristol, The Policy Press. 
  4. Joyce R. and Xu X. (2019) Inequalities in the twenty-first century: Introducing the Deaton Review, Institute for Fiscal Studies and Nuffield Foundation, London, UK
  1. Courtesy of Newcastle University Law School:
  2. Courtesy of Ruth Norris (@ruthpnorris): 
  3. Courtesy of the Institute For Fiscal Studies:

Friday, 10 May 2019

Why do some women continue to smoke when they are pregnant?

Guest post by Susan Jones, Research Associate, Teesside University
"I was 12 years old when I started to smoke. I wasn’t thinking long-term, about my future, about the adult world I would one day join … I just wanted to look cool among my peers, be accepted and act grown up. Then I really did grow up and I was still smoking. Then I became pregnant … and I was still smoking. I didn’t exactly choose to be a smoker when I was pregnant but here I am ... addicted and not really wanting to give it up, or even if I wanted to, I don’t think I could – even for my baby.
"My mam smoked when she was pregnant with me, and I’ve turned out all right; all my family smokes, all my friends smoke, my partner smokes too; in fact smoking is a part of all my close relationships, especially with my partner, we smoke together, it is part of how our relationship works."

"I feel guilty, oh so guilty, but I can’t, I really can’t give up – I simply do not have the confidence to do it. I know that ‘smoking is bad for my baby’; I care for my baby and don’t want to do anything that would cause harm, and I’m really looking after myself, eating well, not drinking any more. I’ve cut down but I hardly dare think about quitting smoking, how on earth would I cope? And my partner, he’s not willing to change his smoking habits, or at least he’s agreed he’ll just not breathe over me when he’s been smoking, but he’s not even prepared to cut down – all he does is tell me, you must quit for the sake of the baby."
A composite from interviews with pregnant smokers and maternity staff.

Smoking is highly addictive and habit forming; many people enjoy the feeling it brings too[1]. Nevertheless the damage from smoking to the developing baby is well documented and the high level of smoking in pregnancy is still a major public health concern[2]. The National Institute for Health and Care Excellence (NICE) Public Health Guidance 26 (2010)[3] sets out all the trial-based evidence relating to the activities health professionals should take to support pregnant women to quit smoking. BabyClear© is a programme that supports health professionals to implement NICE guidance and provides standard training for them in order to carry out the activities in the most effective ways[4].

When we evaluated the implementation of the babyClear© package during its roll-out across North East England, we found that, for healthcare practitioners to challenge smoking behaviour amongst pregnant women, there needs to be a whole support system in place for both the professionals and the women whose behaviour they seek to change[5].

We recently developed an animation, based on our findings, which you can watch here:

South Tees Hospitals NHS Foundation Trust took part in the evaluation of the implementation of the babyClear© package and works closely with its local stop smoking service. As Joanna Feeney, the Smokefree NHS Strategic Manager, says:
"South Tees is a great example of how Stop Smoking Services and Maternity Services can work together to help support Pregnant women to have Smokefree Pregnancies. 
"Most women who smoke during their pregnancy may know that smoking is bad but they are not aware of all the risks to them or to baby, they are also not aware of the help and support that is available to quit, including treatments such as Nicotine Replacement Therapy. 
"Implementing advice and treatment as part of routine Maternal care that is continued outside of hospital with the Stop Smoking Service helps ensure that babies are given the best start in life. 
"Last year in South Tees there were 334 more babies born Smokefree compared to 2012, and this year following the great work done on the wards at James Cook University Hospital the numbers are continuing to reduce but we recognise that there is still more to be done to ensure that every baby is born smokefree."
The Maternity and Stop Smoking Services reviewed the referral pathway and developed an online referral system that not only makes it easier for midwives but increases the speed with which women are contacted and given an appointment with the Stop Smoking Service.

Image courtesy of South Tees Hospitals NHS Foundation Trust
The Stop Smoking Service provides regular feedback to Maternity on the outcomes of women referred, enabling Maternity to offer bespoke interventions to those women who do not engage with treatment.

A further example of how South Tees Hospitals NHS Foundation Trust has moved towards a whole support system and worked in close partnership with stop smoking services is an initiative they undertook last year to redecorate the entrance to their maternity unit using eye-catching posters with a strong, stop smoking message.

And now, a year on, Kay Branch, Consultant Public Health midwife, South Tees Hospitals NHS Foundation Trust says:
"We are still really proud to have led the way towards a smokefree Trust. Our staff have noticed a reduction in the presence of anyone smoking outside entrances. 
"We continue to work collaboratively with the local stop smoking service to ensure a streamlined service for women and their partners. Nicotine replacement therapy is available to all of our patients and is widely used across maternity. 
"Our smoking at time of delivery reflects our hard work and passion for smokefree families."
Maternity’s lead has inspired the whole Trust to implement a systematic approach to treating tobacco dependency with Maternity being the model ward.

I would encourage you to take a look at the animation above and publications relating to the roll-out of the babyClear© intervention package across the North East region. Please do share them with commissioners and providers of services, but also your colleagues, family and friends and any pregnant smokers you know.

More information on our evaluation work can be found here on the Fuse website.

  1. Chamberlain, C., O'Mara-Eves, A., Porter, J., Coleman, T., Perlen, S. M. et al. (2017) Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews. Accessed on 18/03/19 at:
  2. Bauld, L., Graham, H., Sinclair, L., Flemming, K., Naughton, F. et al. (2017) Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study. Health Technology Assessment, 21(36).
  3. National Institute for Health and Care Excellence (2010) Quitting smoking in pregnancy and following childbirth: public health guidance 26. NICE: London
  4. Bell, R., Glinianaia, S. V., Van der Waal, Z., Close, A., Moloney, E., Jones, S., Araujo-Soares, V., Hamilton, S., Milne, E., Shucksmith, J., Vale, L., Willmore, M., White, M., Rushton, S. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control, 27: 1. Accessed on 18/03/19 at:
  5. Jones, S.E., Hamilton, S., Bell, R. Araújo-Soares, V., Glinianaia, S.V., Milne, E.M.G., White, M., Willmore, M., Shucksmith, J. What helped and hindered implementation of an enhanced package of measures to reduce smoking in pregnancy: process evaluation guided by Normalization Process Theory. BMC Health Services Research [In press]

Friday, 3 May 2019

Young people taking a stand for their #Right2Food

Guest post by Dr Pamela L Graham, Vice Chancellor’s Senior Research Fellow, Northumbria University

Image courtesy of Children's Future Food Inquiry via twitter 
“It’s time to act! It’s time this country gave every child the right to food!” Such a powerful statement. But, these aren’t the words of a politician addressing Parliament or a celebrity on a new mission to make a difference. These are the words of Corey - a 15-year-old, Young Food Ambassador who sat on a stage in Westminster and bravely told an audience about her experiences of food insecurity. As a carer for her disabled mum, Corey takes responsibility for making sure her family have access to food by collecting food parcels when needed and sharing her own meals to make sure there is enough food to go around.

This was just one account shared at the launch of the Children’s Future Food Inquiry report on 25 April 2019. As a researcher involved in work around food insecurity, I was invited to attend this event. I’ve been fortunate enough to attend lots of fantastic events on children’s food in recent years, but this one was by far the most thought-provoking.

The event attracted some high profile speakers, including Children’s Future Food Inquiry Ambassador, Dame Emma Thompson. She spoke passionately about the need for us as adults to listen to what children are saying about their circumstances and take action to make a change. Children and Families Minister, Nadhim Zahawi, also addressed the audience acknowledging the importance of children’s views. But then came what Dame Emma Thompson described as “the real VIPs” and six Young Food Ambassadors took to the stage and I was blown away!

Image courtesy of Dr Philippa Whitford via twitter 
I was struck by the confidence and clarity with which these young people spoke. They weren’t there telling their stories to gain sympathy; they meant business and were there to demand action. They gave accounts of parents who struggled to make ends meet, working yet still unable to attain a healthy diet. They questioned the motives of a society where unhealthy food is promoted to them through shiny promotions and easy access. They highlighted the stigma associated with food insecurity and the need to reduce this within food systems set up to support them. These young people know what they should be eating but have had enough of not being able to access it.

The young people highlighted policies and practices that hinder their access to healthy food. Policies and practices that were probably implemented by adults. As adults, I think we have a responsibility to use the knowledge, skills and resources we have to support young people to make a change, but this needs to be done with input from the young people who are affected by these changes.

Young Food Ambassadors talk about their experiences

A great example of the difference that can be made when children are listened to was described by Richard ‘Beef’ Frankland from Prospex Youth Centre (who stars in the film above). He talked about how the staff at the youth centre began providing toast and progressed to cooking full meals, all at the request of the young people. The young people are also growing herbs, trying new foods and learning about where their food comes from in response to their queries about why the vegetables being prepared for cooking at the youth centre are covered in soil. From research I’ve worked on previously around breakfast and holiday clubs, I know that Beef’s work is just one example of the difference school and community groups are making by listening to the needs of those they are working with.

I left the event wanting to do more. Reading the Children’s Future Food Inquiry report on the way home, I found that research I’ve been involved in with the Healthy Living lab at Northumbria University had been cited. It’s always nice to see your work cited, knowing it’s not filed away unread, but this occasion was bitter sweet. Children are still going hungry and missing out on valuable nutritious food so there’s still more work to do. Going forward, I’m keen to do more research around food insecurity involving young people and people like Beef, who know their communities and are committed to making a difference.

Friday, 26 April 2019

Could collective community power direct future public health research?

Guest post by Liam Spencer, Research Assistant, Institute of Health & Society, Newcastle University

The Tyne & Wear Citizens are a local division of Citizens UK, a community organising group, which comprises of schools, universities, faith groups and charities. The group launched a ‘Commission on Mental Health’, which aimed to map problems, and identify solutions around mental health services in the region. In early 2018, The Tyne & Wear Citizens approached AskFuse [Ed – Fuse’s responsive research and evaluation service] in order to identify researchers to contribute to the analysis and production of their final report, ‘Living Well: Mental Health and Public Life in the North East’.

Through Professor Eileen Kaner (Newcastle University/Fuse), I had previously been involved in another AskFuse-supported project called ‘PROMOTE:NE’, which looked at young people’s mental health across the North East, and we met with Dr Peter van der Graaf and Lesley Haley from AskFuse to discuss this piece of work. Following this, I met with Revd Dr Simon Mason and Dr Joe Barton from the Tyne & Wear Citizens, and they were very happy to have me working with them, with supervisory support from Eileen.

The Commission had collected over 300 individual written ‘testimonies’ from people across the region, who articulated what was good, and what was not so good about mental health services in the region. It was these testimonies, which formed the basis of the Living Well report, and helped shape what the Citizens were asking local politicians and organisations to commit to. Prior to being involved in this piece of work, I had no understanding of what community organising was, and initially it was a challenge to grasp the concept of what the Commission were aiming to achieve, and how I could best contribute to this. In order to gain a better insight, I attended one of the Mental Health Commission Public Hearings in Durham, where key themes were discussed in front of a public audience, and a meeting of the Mental Health Action Team, where the group refined the ‘asks’ of the report.

Due to my interest in mental health, and experience in this area of research, I wrote the ‘Context’ section of the report, which aimed to set the tone, and provide the audience with relevant information about mental health in the region, and further afield. I was also able to provide relevant literature for, and make comments on the themed sections of the report, which were written by the editor.

Coming from a qualitative research background, it was interesting to learn about the methodologies employed by the Citizens for this piece of work. Community organising is a process where people who live locally come together into an organisation that acts in their shared self-interests. This method was used in order to best capture the voices of those who may not engage with traditional methods of research. This was one of the most fascinating insights I gained from the process, and I believe this method of collective power from the community, could be utilised in directing future public health research, and that groups such as these may well be a starting point for meaningful patient and public involvement work. 

The Citizens had a small pot of money to support our involvement, and seven working days were costed for me to undertake the work. The biggest challenge I faced was the tight timescale. I was working full-time across other projects, and was in the process of writing my MSc dissertation, so the work had to fit around these existing commitments, which meant working outside of normal work hours.

The final report was launched in November 2018, at an event attended by over 500 people at Newcastle’s Civic Centre. Eileen and I were delighted to attend and speak at the event, and it was fantastic to see so many individuals interested in finding out about the work. Although the timescale was tight, I thoroughly enjoyed the opportunity to be involved in this important and innovative piece of work. I had a great working relationship with Simon and Joe, and was well supported by Eileen and Lesley. 

I am passionate about mental health research, and I am proud to have played a part in the production of a report, which aims to improve the lives of those in my home region.

Find out more about the work on the Citizens UK website.

Friday, 12 April 2019

Making the rural a bit more idyllic

Guest post by Christina Dobson, Research Associate, Institute of Health and Society, Newcastle University

Ah, the countryside. The home of all that is natural and healthy, the epitome of the ‘good life’. Where you can stroll down the lane to collect fresh eggs or veggies from your neighbour, simply dropping your money in the honesty box left at the end of their drive. I grew up in a rural area, and still live in one now. I love that I only have to walk (more like dawdle - I have a very curious and distractible three year old!) for 10 minutes (five minutes without said three year old) from my front door and I am in the North Yorkshire Moors National Park.

And it seems that living in a rural area could actually be good for you in a number of ways. You are likely to be more satisfied with your life, experience better health overall, and live an average of two years longer than people in urban areas. Maybe it’s the un-polluted air, the connection between land and food, the sense of belonging and community? Or maybe that is just a myth, sold to us all through Postman Pat?

Because, actually, living amidst the beautiful rolling hills may not be so good for you if you develop cancer. In fact, it may even put you at greater risk of developing certain cancers and make you less likely to survive your cancer. With roughly 20% of the population of England living in a rural area, this poses a serious public health problem.

However, we don’t really know why rural patients are facing poorer survival rates than urban patients. One of the strongest factors is that cancer is often diagnosed at a more advanced stage in rural patients, limiting the treatment options available to them. We know that delays in diagnosis are strongly linked to advanced stage cancers, and, as such, encouraging early diagnosis has been central to UK cancer policy for over a decade.

When we begin to think about where diagnostic delays may be occurring for rural patients, it seems that they are investigated and diagnosed just as quickly as urban patients, after referral to hospital for specialist assessment. It follows then that there may be problems prior to referral to hospital that are slowing down rural cancer patients’ diagnoses, either in the way patients respond to symptoms, or the way they are managed in primary care.

Thanks to funding from Yorkshire Cancer Research, and alongside colleagues from Aberdeen and Glasgow, we are starting to look for answers to some of these questions. This study will involve interviewing people in rural Yorkshire to understand their experiences of bowel cancer symptoms and decisions around if, how, and when to seek help about them. The findings from these interviews will be used to work with local communities to think about what interventions we may be able to design to encourage people in rural areas to present to their GP and, hopefully, increase the likelihood that their cancer is diagnosed at an earlier stage and that they will survive.

It is an exciting study, as there is so little known about symptom experiences in rural populations, with lots of issues to explore. For instance, availability and regularity of public transport, provision of health care services in rural areas, hidden poverty, cultural beliefs and experiences of ill health and employment, to name but a few. And then there’s the messy complexity of defining the ‘rural’, or maybe we should be looking to instead describe the multitudes of ‘rurals’? Plenty to keep me busy!

With the arrival of National Bowel Cancer Awareness Month it’s been valuable to reflect on the importance of this study and the opportunities and challenges that lie ahead. Understanding some of the barriers to timely presentation that exist for rural populations, and devising ways to overcome them is our challenge for the next two years, and beyond. Maybe, longer term, we can help to make the ‘rural’ a bit more idyllic.

Friday, 5 April 2019

What fairy tales and pinball machines can tell us about using research

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

Once upon a time... the UK Knowledge Mobilisation Forum 2019 took place in Newcastle at Seven Stories, the National Centre for Children’s Books. The Forum brings together practitioners, researchers, students, administrators and public representatives who are engaged in the art and science of sharing knowledge and ensuring that it can be used. This year I was part of the organising group and we deliberately chose Seven Stories as location for the Forum with its focus on stories, which are an important mechanism for exchanging knowledge.

5 points awarded to Dan Wolstenholme of House Gryffindor 
The Centre, spread out over seven floors, provided plenty of exercise to get to the different rooms for interactive poster sessions, knowledge fayres, fishbowls and workshops. The Harry Potter themed conference room also allowed me (not pictured right) to dress up as a Ravenclaw student while serving coffee. But the real highlight of the conference for me were the stories being shared by the key note speakers, Ishbel Smith from Heart in Mouth, who reflected on her practical experiences, and Andree le May and John Gabbay from the University of Southampton, who provided an in-depth research perspective. I will relate two of their stories: the first involves a house made of sweets, the second is about a pinball machine.

The power of stories is often underestimated in research but has gained some traction in academia, particularly for evaluating new interventions and because they make great impact case studies. At the same time, it has proven notoriously difficult to capture any impact in a story: we don’t really know what happens to research findings once they leave academia and trying to trace impact is like Hansel and Gretel clinging onto tiny bread crumbs in a large wood.

This brings me to the first story. Ishbel Smith used the story of Hansel and Gretel to highlight that the siblings missed the blindingly obvious (a house made of sweets is too good to be true and likely to be a trap), because they were too focused on the breadcrumbs and did not see the wider picture or context in which they were walking (a deep dark wood inhabited by a hungry witch). As knowledge mobilisers it is vital to understand where we are in a given situation to be able to unlock the relevant knowledge in that context.

Ishbel reiterated that contextual knowledge is just as important as content. Understanding the context in which research evidence is used and, perhaps more importantly, what happens to that evidence in a practice or policymaking context, is vital for mobilising it. To clarify this, Andree Le May and John Gabbay, told a story about how research evidence is transformed by using the analogy of a pinball machine.

In this second story, research evidence gets batted around across various groups of people within organisations as they interact with it. In each interaction, the evidence is slightly changed: people put their own spin on it and adjust it slightly for their own needs. The evidence literally receives a battering but in this process the evidence is made fit for a particular context and socially reconstructed. Like the pinball getting batted around inside the machine, with every contact the evidence changes shape. Perhaps not noticeably at first but you end up with something quite different and unrecognisable from the research evidence that you put into the dissemination process at the start. This means that, if you don’t understand as a researcher that your research findings will be transformed when it is being used by practitioners and policy makers, then you will never be able to find and follow it for your impact case studies.

Andree and John persuasively pointed out that the craft of knowledge mobilisation is not only using the right skills to get evidence into practice, but also to be able to be part of the story of how evidence is used. This requires not only technical skills (which are mostly studied by implementation science) but also the use of soft skills, such as the striking the right tone and style, being able to get your message across and contextualise knowledge; for example, do we know what the right problem and the right solution is for the context in which we are trying to mobilise knowledge?

Perhaps the most important skills we can develop for mobilising knowledge is how to enable learning: what did work and didn’t work in this context? How can we help others to apply research evidence into their own context? Stories provide a powerful tool for this: not to highlight what we have achieved as research institutions in the next REF submission, but to create a space to reflect on our experiences of using research evidence in different practice and policy context. To make these stories impactful, they have to be told by the people who used the research evidence. And we as researchers have to be willing to listen and be able to reflect on them with the evidence users.

Monday, 25 March 2019

Are you making the most of your public health budget.............? There's a tool for that

Over the last few months researchers from Fuse based at Newcastle and Northumbria universities have been undertaking an independent evaluation of one of Public Health England’s published resources, the Prioritisation Framework. In the guest blog below Brian Ferguson and David Gardiner, both of whom were closely involved in the development of the Framework, comment on the evaluation’s findings.

How PHE’s Prioritisation Framework was developed

Public Health England is committed to supporting local systems to make the best possible investment decisions. With this in mind, in March 2018 we published the Prioritisation Framework, a product aimed at helping local authorities to make the most of their public health budgets. The project to develop the Prioritisation Framework traces its roots back to Shifting the Gravity of Spending? (2015), an academic report detailing how more systematic decision making could be made across public health. From there, the idea was picked up and developed through joint working between Directors of Public Health in the North East of England and their local PHE Centre. After successful prioritisation exercises had taken place in South Tyneside and Gateshead, the foundations of what would be the Prioritisation Framework were taken on by PHE’s Health Economics team to be developed at a national level.

Throughout the development of the Prioritisation Framework there has always been a strong emphasis on user engagement, evaluation of progress and continuous learning. This led to several rounds of user testing throughout the development of the Framework, and we see this latest evaluation by the NIHR School of Public Health Research as another step in helping to shape further work in this area.

How PHE sees the Prioritisation Framework

While the Prioritisation Framework has been developed to be as simple and supportive as possible, it is still easily misunderstood. As you read through the full evaluation report, we encourage you to consider why the Framework was developed, and how it can be used flexibly to reflect local context and needs.

Overview of prioritisation process
One misunderstanding that we often come across is the assumption that the Prioritisation Framework is a ‘health economics’ tool. This is not the way we typically describe it, as the consideration of economic concepts such as cost-effectiveness is only a small part of the information brought together to make prioritisation decisions. Instead, the Prioritisation Framework provides structure and guidance for local decision makers to agree the outcomes they see as important, in a transparent process, that can be tailored and controlled by the users themselves. Any criteria that can be defined and agreed upon by stakeholders, such as equity and political acceptability, can be included and considered. Furthermore, through appropriate facilitation there is the opportunity for effective stakeholder engagement, developing consensus and building influence. In this sense it is much more of a strategic tool, recognising that consideration of the evidence (on both effectiveness and cost-effectiveness) will only be one part of the overall decision making process.

In addition, there is a risk of over-emphasis on the act of assigning numerical scores to the evidence. While this is an important step, it is only a means to an end. More important than the scores themselves are the conversations that run alongside them, where people have a chance to air their views, challenge the assumptions of others and agree on the best course of action through consensus. Capturing these discussions means that the process is transparent, informed and robust.

Users therefore have a significant degree of control when using the Prioritisation Framework. The Framework guides users on how to approach each step, but all the key decisions remain in their hands. This flexibility is critical as ultimately local areas need to have ownership of the process. This also means that each time the Prioritisation Framework is undertaken, the outcomes will be completely unique to the area and the individuals taking part.

The results of the evaluation

The evaluation report yields valuable insights into how the Prioritisation Framework has been and could be used at a local level. Overall, the results are very encouraging and supportive of this type of systematic process. The feedback helps to validate the effort that has been dedicated to developing and implementing the Prioritisation Framework. This effort has extended well beyond the core project team, to the PHE Centres and Local Knowledge & Intelligence teams who have provided support to the early adoption sites, and of course the staff within the sites themselves. We hope that the Prioritisation Framework will continue to be used in these local authorities, and that they continue to provide feedback on their experiences over the longer term.

In addition to thanking the test sites for their kind words, we also want to acknowledge the areas for development identified by the evaluation participants. One issue identified was the time commitment needed. While it is true that the process can be resource-intensive in terms of people’s time, it is robust and evidence-based and is designed to ensure buy-in from key decision makers to help them to make the best use of their public health resources locally. To that extent the work involved can be seen as an investment that should pay off in terms of being clear (for example) about the outcomes that matter to the organisation. This will be particularly true where there is engagement and ownership from senior leaders within the organisation, as acknowledged in the report. There will always be a trade off between rigour and speed, and a balance clearly needs to be struck here. In order to help streamline the process as much as possible and reduce local workloads, the Prioritisation Framework is already heavily supported through guidance and signposting to useful resources.

Some of the other development issues identified have already been taken on board. The thoughts and comments of the early adopters have been instrumental in helping us understand how to better support prioritisation processes. As such, we feel that both the Prioritisation Framework itself, and the associated support from PHE Centres, are in a much stronger position now than when the test sites first took on the challenge. In particular, the guidance and communication on what the Framework can and cannot do are much clearer.

Future developments

Here, several users and developers of the framework discuss how it has supported decision-making in local authorities

Looking to the future, we will continue to make the changes that have been highlighted in the feedback to date in order to further improve the Prioritisation Framework and the support offer. This will include an exploration of how the Framework could be used more widely within local organisations to inform resource allocation decisions broader than the public health budget. We therefore see the Prioritisation Framework as a developing product that will evolve and change over time to keep pace with the needs of local systems. Central to this is understanding over time what impact there has been on outcomes: has using a tool like this actually delivered more value from the limited budgets that are available to improve population health and reduce health inequalities?

About the authors:
Brian Ferguson, Chief Economist, Public Health England
David Gardiner, Health and Wellbeing Programme Lead, Public Health England’s North East Centre