Are zero and low alcohol alternative drinks just a drop in the ocean when it comes to tackling the real harms of alcohol?

Posted by Professor Peter Anderson, Professor Eileen Kaner and Dr Amy O’Donnell, Newcastle University

We’ve come a long way since Becks Blue was your go-to if you were looking for an alcohol-free alternative to beer.

The drinks industry now caters for a growing number of adults who are looking to reduce their alcohol consumption, or not drink at all. ‘Sober-curious’ and ‘Quit-Lit’ are buzzwords of our time, and Sober October and Dry January are now firm calendar fixtures for many.

Supermarkets offer shelves full of zero alcohol gin, 0% craft beer, prosecco – and more. A non-alcoholic Cobra with your curry? No problem. Even Guinness now offers an alcohol-free version.

They’re all a great alternative if you want to reduce or stop drinking, especially if you still want to ‘feel’ like you’re having a drink.

But who is this helping?

Our latest research has found that you’re more likely to buy zero or low alcohol alternatives if you’re younger, you fall into a higher earning bracket and you’re well-educated.

And that’s probably unsurprising, given that non-alcoholic alternatives aren’t cheap - and can sometimes be more expensive than their ‘normal’ equivalents.

For example, at the time of writing, a UK supermarket was selling a litre of Gordon’s Gin (37.5% ABV) at £15.99 a litre, alongside the new 0.0% version at £20 a litre. So if you want to switch, you’re going to have to pay a bit more.

It’s a similar story when it comes to other health-related behaviours, such as eating good quality, fresh food or having a gym membership, where those who are more affluent will lead the way – possibly because they can simply afford to.

Which leads to further questions – are zero or low alcohol drinks only able to make a small difference when it comes to harmful levels of drinking across all groups, including those who are economically disadvantaged? And - does the price and accessibility of these alternatives create some inequality in itself?

Headline findings from our study – do low or no alcohol drinks increase health inequalities?

We wanted to find out whether the purchase and consumption of zero or low alcohol beers differs by demographic and socio-economic characteristics.

To do so, we looked at purchase data from almost 80,000 households and surveys from over 100,000 adults, provided by Kantar World Panel.

We found that zero alcohol beer was more likely to be bought and drunk by younger people and more socio-economically advantaged consumers.

We also saw higher purchase levels in those who generally bought and drank the most alcohol – and this was higher in men, younger adults, and those with higher incomes.

Households that were more likely to buy low alcohol beer were also heavier buyers of alcohol overall, and more likely to be middle-aged (45-64 years).

We also found that for every purchase of a low or no alcohol alternative, there were just under 46 purchases of the alcoholic equivalent – so buying and drinking levels of the low or no alcohol products are still relatively low.

Proportion (%) of households that reported at least one purchase of zero alcohol beer (green, left vertical axis), low alcohol beer (orange, left vertical axis) and all other beer (red, right vertical axis) for any day that a household made an alcohol purchase by study day, 2015 to 2020. Data points: daily.

What does this mean?

The increasing availability of low or no alcohol alternatives might be a useful tool to reduce overall drinking in the more socially advantaged groups in society, but not so beneficial for the rest of the population.

Zero or low alcohol alternatives are great if you can afford them, but they’re not the whole answer when it comes to addressing the real issues around drinking alcohol – including some of the deeper and wider reasons that drive people to drink so much in the first place, the ready availability of alcohol, and its relatively low price.

In conclusion, we believe that promoting zero and low alcohol alternatives is not enough to address the harm done by alcohol, including alcohol-related health inequalities.

Additional evidence-based policy measures - such as a Minimum Unit Price and improved funding for alcohol treatment and intervention and prevention services - are needed to lessen harms of alcohol which are experienced by the most disadvantaged people in our society.

References

This blog is based on a paper published in September 2021 in the International Journal of Environmental Research and Public Health- ‘Is buying and drinking zero and low alcohol beer a higher socio-economic phenomenon? Analysis of British survey data, 2015-2018 and household purchase data 2015-2020.’ – by Peter Anderson, Amy O’Donnell, Dasa Kokole, Eva Jane Llopis, Eileen Kaner.

Professor Eileen Kaner, Professor Peter Anderson and Dr Amy O’Donnell are based at Newcastle University and members of the NIHR ARC North East and North Cumbria. This blog was produced by the NIHR ARC North East and North Cumbria on behalf of the report authors.

You can read the full paper, here.

Other linked research that may be useful for readers:

• Impact of low and no alcohol beers on purchases of alcohol: interrupted time series analysis of British household shopping data, 2015–2018 – BMJ Open, October 2020
• Effectiveness of brief alcohol interventions in primary care settings – Cochrane Review, 2018
• The relationship between alcohol-related hospital admission and specialist alcohol treatment provision across local authorities in England since passage of the Health and Social Care Act 2012 – Cambridge University Press, July 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Watch a recording of the online taster event below

 

Images:

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

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

Posted by Katie Beresford, undergraduate student, Durham University

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

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

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

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

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

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

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

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

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

Taking the scenic route to academic attainment

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

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

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

Part of our Fuse blog Student Series

The Fuse blog Student Series showcases posts by students who have been challenged to write a blog as part of their studies at one of the universities in the Fuse collaboration, the NIHR School for Public Health Research, or perhaps further afield. The authors may be new to blogging and we hope to provide a 'safe space' for the students to explore their subject and find their voice in the world of public health research.

Images:

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

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

 Posted by Laura Basterfield, Research Associate, Newcastle University

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

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

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

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

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

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

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

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

I hope you enjoy their film.

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

Funding from EngageFMS at Newcastle University supported this project. 

Originally written for VOICE.