When stigma came to town: why a quick fix can never work with a life-long problem

Posted by Ian Treasure, Programme Manager, Changing Futures Lancashire and Cassey Muir, Research Associate, Newcastle University

“When you point a finger, three point back,” a member of our Lived Experience panel said while discussing stigma. Stigma is often invisible, yet it shapes how people perceive themselves and are perceived by others. This saying reminds us that before we judge others, we should first reflect on our own behaviours, actions, and beliefs.

 

The Changing Futures Lancashire Programme and taking a trauma-informed approach

The Changing Futures Lancashire (CFL) programme was one of 15 areas in England chosen to receive funding to test and learn approaches to supporting adults experiencing multiple disadvantage. Anyone experiencing three of the following five conditions were able to access our services:

• substance misuse
• homelessness
• criminal justice involvement
• poor mental health
• domestic violence

CFL was a follow on from Fulfilling Lives which also supported this cohort. CFL was different as it was funded through local authorities in an attempt to gain more traction for system-wide change needed to support a seldom heard group. The funders were Ministry for Housing Communities and Local Government (MHCLG) and The National Lottery Community Fund.

Nationally, we focused on measuring improvements for the people we support, how well services work together, and how decisions are made at a higher level. The aim was to create significant changes in the system so that people with complex needs can access the support they need more easily. We adopted a trauma informed approach in the way we offer and provide support. For example, we understand that individuals who may appear aggressive could actually be scared, confused, or reliving past trauma. This non-judgmental approach not only shapes how our providers assist individuals with complex needs but also affects how the adults we support view themselves.

The majority of beneficiaries (90%+) in the Changing Futures programme face poly-substance use (using more than one substance at a time) as the main condition that developed into multiple disadvantage. Many have shared how chronic drug use often leads to involvement with the criminal justice system, poor mental health, and eventually homelessness. Alongside these challenges, many individuals have experienced parental abuse or neglect. Their negative school experiences, often tied to undiagnosed learning disabilities or other barriers, have also shaped their struggles. Over time, our beneficiaries have developed coping strategies to survive—tools they rely on to navigate a world that often feels unsupportive.

Shining a light on stigma

The CFL Programme has made significant strides in supporting individuals facing multiple disadvantage. However, as we delved deeper into the challenges faced by our beneficiaries, we uncovered an invisible yet pervasive barrier: stigma. This insight shifted our focus and prompted us to ask: 

how can we tackle the stigma that often prevents people from seeking the help they need?

People with lived experience helped shape the CFL model, ensuring that it addresses the needs of those who understand these challenges best. During conversations with our beneficiaries, we found that many initially hesitated to seek help because of the trauma and judgment they felt during comprehensive assessments. We responded by removing this entry barrier, focusing instead on the sharing of information between services followed by a more conversational approach that helps build trust without the fear of interrogation. This small change proved to be a key turning point for many individuals, making them feel more comfortable returning for support.

 

 

Across Lancashire we also have started to shed light on the issue of stigma. We created the powerful and thought-provoking film above featuring people with lived experience and other professionals sharing their stories, which has been viewed thousands of times. One case study highlighted a single mum afraid to visit the pharmacy near her child’s school for fear of being seen picking up methadone by another parent, and the stigma she faces as a result. Another featured a man who is street homeless, sleeping in a public toilet, only to be kicked out by the cleaner in font of commuters. These are painful reminders of some people’s situations and how different they feel from everyone else. It became clear that it wasn’t enough for us to only think about how we tackle stigma across our services, we also had to ask ourselves: what else can be done to prevent stigma and to reduce its impact on individuals?

The CFL board agreed that we should do some credible research into the topic. We sent out an enquiry of interest form and Fuse researchers responded.

Reducing stigma: research findings and key recommendations

The project between the CFL programme and Fuse was to conduct a review of the research into what can be done to reduce stigma for adults who experience multiple disadvantage.

At the heart of our work are the people with lived experience who have been instrumental in shaping our approach. Their first-hand insights have been invaluable not only in designing effective services but also in guiding our research on stigma. Many panel members shared how they overcame their own stigma through achievements like gaining employment, while others still face the stigma of past criminal convictions – something that remains a barrier to moving forward. Their voices are central to the research and the recommendations we’ve developed.

We brought together 51 review papers and found that most focused on reducing mental health stigma. Fewer studies addressed stigma related to drug and alcohol use. There was limited research on stigma linked to domestic violence, homelessness, criminal justice involvement, and poverty. Our panel felt that the findings would be relevant across various forms of disadvantage, reflecting that poor mental health or alcohol and drug use often serve as the primary ways people come into contact with services.

The research we reviewed found that stigma reduction approaches typically focused on:

• individuals experiencing disadvantage and stigma
• practitioners who provide support
• the public

There was little research on system-level changes, such as policy changes, that could address stigma more broadly.

We found that social support, particularly through peer-led or group-based approaches, was highly effective in reducing self-stigma among people facing multiple disadvantage. Peer connections helped individuals build stronger and more positive identities and gain confidence, breaking down feelings of isolation.

Additionally, we discovered that combining educational strategies with contact-based training was a powerful way to reduce stigma amongst practitioners and the public. Educational efforts - such as presentations or information addressing misconceptions about disadvantages - were most effective when paired with opportunities for practitioners and the public to meet and learn from people with lived experience. This combination allowed for a deeper understanding of the challenges faced by those with multiple disadvantages and proved more effective than using either method alone.

We engaged with our Lived Experience panel to discuss and explore recommendations. They came up with eight key recommendations to advance this work into practice:

1. Facilitate peer connections: Provide opportunities for individuals experiencing disadvantage to connect with others who share similar lived experiences. This can help reduce isolation, foster mutual support, and reduce feelings of shame and embarrassment.
2. Promote peer leadership and advocacy: Encourage individuals with lived experience to take on leadership roles or act as advocates within services. This could help challenge stigma and provide role models for others facing similar challenges.
3. Incorporate lived experience in service design and delivery: Actively involve individuals with lived experience in the design, development, and delivery of services to ensure they are relevant, responsive, and inclusive.
4. Embed trauma and stigma informed practices throughout the organisation: Apply both a trauma and stigma informed approach across all levels of the workplace. Training should not only be limited to frontline staff but also extend to managers, supervisors, and directors to ensure everyone is stigma-aware.
5. Ensure long-term commitment to anti-stigma efforts: Integrate anti-stigma interventions into ongoing practice, ensuring they are not one-off sessions. Offer regular refresher courses to reinforce learning and maintain long-term impact.
6. Foster collaboration across services: Promote collaboration between all services to ensure they adopt stigma-aware practices. This includes working together across sectors, such as housing, mental health, and other support services, to create a cohesive approach to addressing stigma.
7. Engage the community: Work on community outreach to raise awareness about stigma and its effects, helping to foster a more inclusive and empathetic environment in the wider community.
8. Implement system-wide change: Advocate for policy changes that address the root causes of stigma, such as social inequalities, and promote fair access to services for all individuals, regardless of their background or circumstances. System-level changes are crucial because stigma isn’t just about individual attitudes; it’s embedded in our systems, policies, and institutions.

We need your help

The insights from the Changing Futures programme and our research are clear: tackling stigma requires a holistic, multi-level approach. By prioritising peer support, lived experience, and trauma-informed practices, we can make real, lasting change. Now, we need your help. Join us in challenging stigma, watch and share our videos, and support this movement. Together, we can create a more inclusive, empathetic society where everyone has the chance to thrive.


Take the next step (useful resources):

• Join the anti-stigma network
• See the presentations from the recent Fuse and Changing Futures Lancashire event - Understanding the impact of stigma and multiple disadvantage, A call to action
• Watch the Changing Futures Lancashire video on stigma
• Watch an animation by Newcastle City Council Adults Safeguarding and Fuse Researchers - Stigma, A Call for Action
• Find out more about Changing Futures Lancashire

Going beyond bricks and mortar to 'Up' awareness of healthy homes

Posted by Natalie Forster, Philip Hodgson, and Alex Kirton from Northumbria University

“It’s just a house”. Words famously uttered by Mr Fredricksen in the much-loved film, ‘Up’. But does this really do justice to the complicated relationships we have with our homes?

There’s a steady stream of evidence now showing that housing characteristics (including issues like overcrowding, poor insulation, damp and mould) can impact on physical and mental health. And far from being just a house, we know that where you live can make a big difference to how socially connected you are, the services you can access and how safe you feel.

This increasing awareness of home as a social determinant of health has led to many local authorities introducing initiatives to address housing-related issues. Yet, evaluations often look at the effects of specific housing enhancements in isolation, and more understanding is needed of how healthy homes services can tackle housing issues in their widest sense.

The Healthy Homes service in South Tyneside is an advice and signposting-based service that aims to address people’s home-related health needs. As Fuse researchers we set out to explore its benefits for residents. We worked with the service to create a data collection tool to help capture the financial benefits of advice given, alongside interviews to explore the experiences of those who used the service.

So, what did we find?

Our analysis showed that the service was reaching people with multiple and complex housing needs, including those related to health conditions, low income and age. We found the personalised approach taken by the service to be especially successful in engaging proactively with older homeowners (like Mr Fredricksen!) who often presumed they wouldn’t qualify for housing improvements, didn’t want to be seen to be asking for help or didn’t want to lose their independence. And without this support they would have otherwise put off seeking help until a crisis hit.

Some participants were keen to swap their bricks and mortar entirely and relocate to a more suitable home or area. For others, longstanding and deep psychological connections to homes and areas meant a move would be too painful. In these circumstances, changes to home environments made through the service (like getting extra bannisters or a stairlift, and support to address cold, damp and mould) helped reduce worries about housing problems and avoided the need for unsuitable coping strategies like coming down the stairs backwards. Participants described how small housing modifications – even getting a different lightbulb when you’re worried about your electricity bills – made a difference both practically and emotionally, helping them resume ordinary and taken-for-granted aspects of life like going to bed upstairs with your partner. Yet, for many, the service also worked on a different level, with the face-to-face interaction and warm and friendly manner of staff helping people feel heard and cared for.

Ultimately, the project illuminates the complex and varied issues and feelings people have around their homes. It underscores the importance of services which see beyond the bricks and mortar of houses and consider the importance of people’s “homes”, such as those offered by South Tyneside Council, but also the crucial role that other (non-home focused) services can play in addressing the interactions between homes, health and wellbeing. Many people we spoke to were unsure of what support they are entitled to and so there’s a need to raise awareness and take up of healthy home enhancements before problems escalate. Finally, both the stories of our participants and Mr Fredricksen demonstrate how our relationships toward our homes can shift and change over time, highlighting a need for long-term and sustainable models of housing care and support.

Natalie Forster, Assistant Professor, Social Work, Education and Community Wellbeing, Northumbria University and co-lead of the Fuse Health Inequalities Research Cluster

Philip Hodgson, Assistant Professor, Nursing, Midwifery and Health, Northumbria University

Alex Kirton, Research Fellow, Northumbria University

Image by Pascal Laurent from Pixabay

Amplifying voices to tackle inequalities in South Asian and Muslim communities

Posted by Zeibeda Sattar, Assistant Professor in Health Policy, Northumbria University

L-R: Greta Defeyter, Humaira Khan and Zeb Sattar 

I recently had the opportunity to chair the Health Inequalities Symposium hosted by the Centre for Health and Social Equity (CHASE) at Northumbria University, in collaboration with Fuse. It was an incredible event that brought together over 100 people, including researchers, policymakers, healthcare providers, and community members, all focused on tackling the pressing health challenges facing South Asian and Muslim (SAM) communities. The main goal was clear: to find ways to bridge the gap between research and real-world impact.

The presentations were enlightening and underscored how critical it is to engage with minority communities effectively to shape public health services. Each speaker highlighted a different, but equally important, health issue impacting SAM communities. Public partner Humaira Khan, who co-chaired the symposium, pointed out that the mental health challenges facing South Asian and Muslim are often misunderstood and stigmatised. Hearing her talk about the need for culturally competent healthcare really hit home. Her words - “researchers are warriors; they don’t fight for themselves - they amplify the voices of the people” - perfectly captured why events like this matter.

“researchers are warriors; they don’t fight for themselves - they amplify the voices of the people” 

Humaira Khan, public partner

Dr Sarah Croke from the University of Manchester spoke about the language and cultural barriers that often lead to untreated health issues. This can leave community members struggling because healthcare services aren’t designed with South Asian and Muslim needs in mind. Dr Saeed Ahmed from Sunderland Royal Hospital took on the tough topic of organ donation disparities. He pointed out the harsh reality: SAM communities are in desperate need of organ transplants but are also among the least likely to donate. His call to raise awareness and educate was powerful, especially when he reminded us that one donor can change up to nine lives.

There were also discussions about everyday barriers that many of us face but rarely see addressed. Professor Defeyter from Northumbria University talked about the lack of culturally appropriate meals, like halal options, in schools. It was a reminder of how even things like food choices can create a sense of exclusion for our children and why legal changes to recognise cultural diversity are long overdue.

I found Simon Luddington’s (SearchNewcastle) presentation about the West-End Befrienders project particularly inspiring. It’s easy to forget how isolating language barriers can be and how vital social connections are for our wellbeing. Their work in bringing people together, especially in helping with access to primary care and breaking down isolation, felt like a model that should be replicated.

One of the more challenging discussions was around drug and alcohol use in our communities. Lydia Lochhead’s (Northumbria University) research laid bare the stigma that prevents so many from seeking help. It’s a tough conversation to have, but hearing about Mushtaq Dakri’s community-led approach to addiction support was a beacon of hope. They offer a holistic service - combining therapy, physical activity, and spirituality - and it’s designed by and for the SAM community. Knowing there’s a women-only support space now available shows their commitment to evolving and meeting community needs.

Fuse Associate Director Dr Floor Christie and Dr Rawand Jarrar from Sunderland University, wrapped up the day with their work on improving cancer screening uptake among Muslim women. Their workshops have reached over 260 women, and it’s encouraging to see how culturally sensitive approaches can genuinely improve health outcomes. This was a reminder of how vital it is to build services that reflect our communities.

As I reflect on the symposium, it’s clear to me that these health inequalities are not just about accessing services - they’re about how these services are designed and delivered. The urgency to address these gaps cannot be overstated. The event reinforced the need for services that truly understand and respect South Asian and Muslim communities, going beyond just offering a service to creating environments where people feel welcomed, understood, and valued.

Leaving the symposium, I felt hopeful. Change is possible, but it won’t happen without consistent engagement with our communities. Trust needs to be built, and community voices must be represented and acted upon. The gap between research and impact can be bridged if we keep pushing for culturally relevant, accessible, and respectful health services.

Plans are already in place for a follow-up symposium in November, focusing once again on the health inequalities that continue to affect SAM communities. I urge everyone to get involved. This is our chance to be part of the change and to make our voices heard in the ongoing fight for a more equitable health system. Sign-up details will be shared soon, and I hope to see more of us there - because turning these conversations into action is how we create a healthier future for all of us.

How can Local Authorities help shape healthier food environments?

Posted by Amelia Lake, Claire O'Malley and Helen Moore, Fuse researchers from Teesside University

This week I joined other health professionals across the country in signing an open letter from the Obesity Health Alliance (OHA) to the Prime Minister, giving our support for new policy reforms, allowing the planning system to better support the creation of healthy, active local communities and reduce health inequalities. The letter was issued alongside the OHA's Local Government Position Statement: “Empowering Communities to Create Healthier Local Food Environments”, which contains a list of recommendations and a supporting package of evidence.

In support of the OHA statement paper and on the back of the news that the government plans to ban junk food TV adverts before 9pm next year, here we highlight the need to make it easier for local authorities to control their local food environments.

Why we need to act now

It’s essential to create healthier environments that make it easier for people to access nutritious food and engage in physical activity. With the cost of living rising, more people are facing food insecurity, and obesity remains a major health issue. Local authorities have a crucial role in shaping healthier communities, but they face challenges due to funding cuts. Despite these difficulties, professionals across the country are working hard, but they need clearer national policies to support their efforts.

The role of National Planning Guidance

Planning guidance should clearly prioritise public health. While policies often focus on individual responsibility, local governments can work with their communities to promote healthier lifestyles. Our research has shown how local authorities can shape healthier environments by collaborating with various stakeholders, from community members to policy makers.

Everyone’s responsibility

Creating healthy food environments requires collaboration among many professionals within local governments. When it comes to handling appeals for fast-food outlets, our research found that good communication between teams is key to defending decisions. It’s also important to understand how fast-food outlets affect communities and health over the long term. To improve the process, professionals should be trained in accessing relevant data and records.

Using regulations to improve the food landscape

Local authorities can use planning regulations to limit the number of fast-food outlets and promote healthier options. For example, in North East town Gateshead, limiting new fast-food outlets near schools, in areas with too many, or in places with high childhood obesity rates has reduced fast-food outlet numbers by 17.5% in just four years. This shows how strategic planning can make a real difference in promoting healthier food choices.

Working with the planning inspectorate

The National Planning Policy Framework supports the idea of “healthy communities,” and local governments can reject fast-food applications if they threaten local health goals. However, these decisions are often appealed, and the Planning Inspectorate makes the final decision. Our Fuse research shows that having a Local Plan in place helps local authorities reject such applications, but even with additional planning documents, success isn’t guaranteed. It's important for new planning guidelines to support public health and ensure that the Planning Inspectorate works with local authorities to meet health priorities.

Regulating outdoor food advertising

We support extending regulations on unhealthy food and drink ads beyond TV and online to outdoor spaces like bus stops. After London banned junk food ads on public transport, local governments began reviewing their advertising policies with the help of Sustain: the alliance for better food and farming. Our research in the North East found that almost half of bus shelter ads were for food, and 35% of those were for unhealthy options. Many of these ads appeal to children, which is concerning. Although local governments face challenges due to complex contracts with advertisers - and research has explored the advertising of unhealthy commodities (e.g. tobacco, alcohol, less healthy foods and gambling) - more work is needed to reduce the impact of unhealthy advertising.

The changing food landscape

A recent study in North East England showed that after a new fast-food outlet opened, visits by 11- to 16-year-olds increased significantly within the first nine months. The young people said they were attracted by the taste, low prices, socialising and free Wi-Fi. While this isn’t covered by current fast-food restrictions, it shows the need to look at the entire food system and where outlets are located. Policies that prevent students from leaving school during lunch could also help reduce fast-food consumption.

Another growing trend is "dark kitchens," which only prepare food for delivery services like Deliveroo and Uber Eats. While these kitchens bring economic benefits, they raise public health concerns, especially in low-income areas. Local authorities need to stay informed about this trend and address the challenges it presents, such as the increase in unhealthy food options. Some professionals worry that current regulations for fast-food outlets don’t work well for dark kitchens, so there’s a need to adapt the system to ensure public health is protected.

Monitoring and evaluation

It's important for local authorities to regularly review the food environment and assess how well their policies are working. By collecting and analysing data, they can identify areas for improvement and make sure their strategies are effective and responsive to community needs.

Focusing on these areas will help local governments create environments that support healthy choices and improve the overall wellbeing of their communities. With thoughtful planning and strong community involvement, they can significantly impact public health. To do this effectively, local authorities need clear understanding of planning policies, support from senior management, adequate staff, and the right resources to handle cases efficiently.

Amelia Lake is Professor of Public Health Nutrition at Teesside University, Associate Director of Fuse, the Centre for Translational Research in Public Health, a dietitian and public health nutritionist.

Dr Claire O'Malley is a Research Associate at Teesside University and a Fuse Associate member

Helen Moore is an Associate Professor at Teesside University and a Fuse Associate member

Adapted with thanks to the Obesity Health Alliance

Photo by Erik Mclean on Unsplash

Food insecurity in pregnancy is putting women’s health at risk and babies at a health disadvantage. That is unfair and unjust

Posted by Zoë Bell, Postdoctoral Research Fellow, King’s College London

In the three years since we started this project a lot has changed, and nothing has changed at the same time. Just as the pandemic was leaving a shadow behind us, we entered a new chapter of social and economic challenge; notably, the Russian invasion of Ukraine and Brexit fuelling a cost-of-living crisis with huge impacts on our food system and food prices. These events, in their own unique ways, have left households more vulnerable to experiencing poverty, and the topic of this blog, food insecurity.

During this time, we’ve witnessed food insecurity become a more prominent feature in the news with the help of celebrity advocates and mutual aid groups which brought communities together to support one another. Headline examples are Marcus Rashford’s campaign supporting the extension of free school meals over the summer holidays, and most recently, Taylor Swift’s donation to food banks in cities across the UK as part of her tour. Within the context of a decade long erosion of the social security safety net, the charitable sector has stepped in to provide food relief; but it’s clear this is just a sticking plaster.

As fans gathered at @MurrayfieldStad on Friday for the first of three record-breaking gigs, we found out that @taylorswift13 would be making a donation to support foodbanks across the city 🪩Thank you so much Taylor 🫶
Want to help? Donate £13 (#IYKYK): https://t.co/itIShHqprD pic.twitter.com/zVh2zfbZ42

— EdinburghFoodProject (@EdinFoodProject) June 10, 2024

While temporary economic, social and nutrition policies were put in place during the pandemic to support vulnerable families, long-term commitment has been lacking.

Time is ticking and it is the most vulnerable who are paying the price. Indeed, pregnancy is a time when the consequences of inadequate support come at a premium cost.

We know how important it is for pregnant women to eat a nutritious and well-balanced diet for their own health and for their developing baby. This is where our research fits in. We set out to pull together all the available evidence to explore whether there are differences in pregnancy risks for women and babies when they experience food insecurity.

Our two new reviews of the evidence around food insecurity in pregnancy and the links with maternal weight, diet, and pregnancy health show worrying results, including both physical and mental health risks. While we were expecting to see some health implications, the extent of the risk for poorer health was shocking. Pregnant women experiencing food insecurity were significantly more likely to have poor mental health, obesity, poor quality diets, develop Gestational Diabetes and dental problems.

Infographic to translate the review findings co-designed with experts by experience during an engagement workshop in Newcastle
Upon Tyne, North East England. Funded by Tilly Hale a Newcastle University Faculty Medical Sciences Engagement fund.

Noticeably, these reviews lacked studies from the UK with studies mainly from the USA. You might ask does this matter? Yes. Why? Because the USA has long-standing nutritional support for pregnant women, with evidence of having beneficial impacts on women's diet and health. This embedded support might have reduced or completely masked some of the associations that food insecurity has with pregnancy risks reported in these studies. Whereas in the UK nutritional programs are not as extensive and women lack support. This means we might find that the risks are worse and the need for support is greater than we currently think it is in the UK.

We acknowledge these reviews are based on observational data, exploring association rather than causation. Women experiencing food insecurity are likely living with multiple other causes of stress that could be contributing to food insecurity and pregnancy risks. Nevertheless, we see from the evidence to date that these women are at risk and need more support. Our ongoing work exploring experiences of food insecurity during pregnancy also suggests that current support initiatives are not doing enough, and further policy-related intervention is required, further emphasising the need for action now.

Our new reviews show that food insecurity during pregnancy contributes to health inequalities, putting women’s health at risk, and babies at a health disadvantage from before a they are born. For example, when babies are exposed to gestational diabetes or maternal obesity, they are more likely to develop type 2 diabetes or obesity themselves later in life. That is unfair. That is unjust. So, we ask, how much more evidence is needed before urgent policy action is taken to mitigate food insecurity?

Much more support from government is needed to make sure that women and babies are protected from food insecurity during pregnancy. Only time will tell if tides will turn under this new Labour government.

So, what do we suggest?

First, an uplift in the value of the Healthy Start scheme, a policy directly related to nutrition during pregnancy and early years. Second, greater integrated care across multiple sectors for women during the pregnancy period. Thirdly, considering the wider interlinked, structural barriers for families living in poverty (and based on our broader research program) removal of the two-child benefit cap, continued expansion of childcare support and of free school meals. These policies would relieve financial pressures on households with young families.

In the meantime, watch this space as our research team has two ongoing reviews exploring pregnant women and people's experiences of food insecurity and its relationship with breastfeeding and infant feeding. Some of our other ongoing studies are exploring the experiences, risks and support needs of women during pregnancy and in the postnatal period after birth, and their families across a diverse UK population in Gateshead, Coventry, Middlesbrough, Lambeth and Bradford.

If you are inspired to help add evidence and advocate for food security amongst mothers and children, then please consider becoming a member of our Nourishing Futures Network. This was established by Fuse members working with international colleagues. The network’s mission is to lead knowledge exchange and generate knowledge in this emerging field around food insecurity before and during pregnancy and in the first 2001 days of life.

Find out more

This research has been summarised in the following:

• News item: Unaffordable food putting mums-to-be at risk
• Research brief: What impact does food insecurity have in pregnancy? - with key findings and policy relevance & implications
• Read the papers in full:
• Associations between food insecurity in high-income countries and pregnancy outcomes: a systematic review and meta-analysis
• Food insecurity during pregnancy in high-income countries, and maternal weight and diet: A systematic review and meta-analysis

From crisis to collaboration: Transforming support for people experiencing homelessness in North East England

Posted by Steven Thirkle, Research Associate, Newcastle University

People experiencing homelessness often have multiple and complex health and social care needs that require support from many services. However, accessing and coordinating this support can be difficult when services are disconnected geographically or relationally. Often the person who is experiencing these challenges is the one who has to reach out for help, and this can be extremely hard for someone also managing day-to-day homelessness.

During our workshop, More Than Minutes visually captured our discussions, providing a dynamic summary. These visuals encapsulate key insights and recommendations, offering an engaging snapshot of our collective journey towards transforming support for people experiencing homelessness.

Over the past two years, our team has been working with services that provide support to people experiencing homelessness in rural and coastal areas of North East England. Our goal has been to explore innovative ways to improve access to care and support for these vulnerable people. Here, we share our research findings, shed light on the challenges faced by people experiencing homelessness and present our co-produced recommendations for creating a more effective and holistic (whole person) support system.

What does hospital data tell us?

To understand why people experiencing homelessness in the North East often turn to emergency care services in rural and coastal areas rather than seeking alternative forms of support, we examined hospital data on people attending emergency care services who had no recorded address. We discovered that there are many contributing factors, including struggles with alcohol and drugs, mental health issues, and challenging social situations. These challenges often occur at the same time, exacerbating their complexity and approaches to treatment.

What is stopping homeless people accessing services?

While this numerical data provided valuable insights, it did not uncover the underlying reasons behind the lack of engagement with other support services. To gain deeper insights, we interviewed people experiencing homelessness as well as those providing support in rural and coastal areas. The interviews aimed to explore experiences with emergency care services, overall health, social lives, and past traumas. They revealed significant barriers to accessing services, such as limited resources, transportation challenges inherent to rural areas, and the isolation often felt in coastal communities. Additionally, rigid service criteria and thresholds prevented people from receiving the support they urgently needed, further compounded by the sparse availability of services in these regions.

What is the current picture?

A comprehensive and integrated approach tailored to the rural and coastal context was needed to provide effective support to people experiencing homelessness in these areas, so we mapped out existing services and their collaborative relationships in the areas. Our findings showed a fragmented system, with many services operating independently and lacking essential connections to the core network of services necessary for addressing the unique challenges faced by people in rural and coastal areas.

How do we address the gaps?

In response to these gaps, we organised a workshop at the Community Hub in Cramlington, Northumberland, bringing together over 70 people including professionals from health, housing, social services, local authorities, law enforcement, emergency response, and third-sector organisations, as well as people with lived experience of homelessness and mental health issues in these regions. Together we developed recommendations for a more effective and collaborative approach to supporting people experiencing homelessness in rural and coastal areas. Seven key areas for recommendations were identified:

1. Long-term funding and resources: Campaign for sustained funding and increased resources to support comprehensive and ongoing assistance for homeless people.
2. Coordination, connectivity, and communication: Establish robust ways to coordinate, foster better connectivity between services, and improve communication channels to ensure a seamless and integrated support system.
3. Accessible services - pathways to support: Develop clear and accessible pathways for homeless people to access a wide range of support services, including health, housing, social services, and mental health resources.
4. Building trust and co-developing services with lived experience: Foster trust and inclusivity by actively involving peoples with lived experience of homelessness in the design, development, and evaluation of support services.
5. Trauma-informed practice: Implement trauma-informed approaches across all support services, recognising and addressing the underlying trauma experienced by homeless people.
6. Improved data sharing: Establish efficient data-sharing agreements for support services to ensure comprehensive and up-to-date information, enabling better coordination and informed decision-making.
7. Staff retention and wellbeing: Prioritise the wellbeing of support staff by providing resources, training, and support to prevent burnout and turnover, fostering continuity of care.

We have developed a handy two-page Fuse research brief which pulls out the key findings and recommendations for practice and policy co-developed with people with lived experience. 

Follow this link to read the brief

Animating practitioners to take action on stigma

Matty Starforth, Public Health Practitioner-Harm Reduction and Social Inclusion Portfolio, Newcastle City Council

“Stigma, stated simply, is a set of negative and often unfair beliefs. Stigma can be experienced on a societal, structural and personal level. It is employed largely unconsciously but at times also consciously”. 

Anti Stigma Network

Stigma is often a word that is associated with harm but it is important to recognise that stigma can have a huge impact on individuals and groups in society. From my own professional experiences, I am aware, like many of my colleagues and partner services are, that the harms of stigma can include and are associated with inequality, disadvantage, discrimination. Stigma increases stress, shame, depression, isolation, and can lead to the avoidance of healthcare and decreases treatment engagement and retention for individuals and groups.

 

It’s clear that there is a need to address stigma and embed an ‘anti stigma approach’ as part of the work we do to tackle inequalities, but doing so can be challenging. While people tend to be generally aware of the term stigma and how this can affect individuals, there is often less understanding of the depths that people go through to avoid and overcome the stigma they experience, such as not attending appointments or seeking the help or support they deserve. There is also less awareness of the steps that we can all take as individuals to not only avoid stigmatising people through our language and practices, but also actively speak out and promote an anti-stigma approach more widely.

What we are doing about it

To address this, we have had several areas of work in Newcastle upon Tyne looking to raise awareness and address some of the harms of stigma on others. This started with the publication of Drugs, Identity and Stigma and ongoing discussions about changing how we focus on people who use drugs or alcohol and the language we use for those facing multiple disadvantage and exploitation. Academics, policy makers, public health and key stakeholders, from working together on various research, came together to deliver a practitioner conference, improve practitioner training, development and networking and production of a practice briefing, stigma animation and a planned education package. All of this has been informed by lived experience.

In May 2023 we worked with partners to hold a conference to over 320 practitioners, service providers and community members from across the region. The Stigma, Trauma, Substance Use and Domestic Violence Conference involved a range of international, national and regional researchers and academics including a keynote talk from international anti-stigma lead, Professor Carla Treloar. The Conference was designed to promote knowledge exchange and good practice of Anti-Stigma work from across the region. A practice briefing that was developed from the event can be found here. A key theme in the discussions has been around vulnerability and exploitation, and partners have worked together, from research developed by the University, to produce animations around exploitation and home takeover. Research into practice improvement. Two artists were employed to capture the key themes and discussions of the conference as a visual (see below) which could then be shared with services.

Visual capturing the key themes and discussions of the conference

Developing the stigma animation

From this work, we explored how we can explain the ongoing theme of stigma and its impact. A recent project that I have coordinated, in collaboration with university colleagues, is the production of a stigma animation which you can see above. Aimed at practitioners and volunteers, this will help raise awareness and become a key resource to support the work and objectives we have within Newcastle Public health, and also the wider local authority. The animation has involved consultation and input from a range practitioners, service users and individuals with lived experience of stigma. At each stage of the animation production, I have attended the Newcastle Service User and Carer forum. Inclusion of those with lived experience of stigma was essential in these discussions and has been key in helping to shape the direction and design of the animation, particularly in relation to service needs and solutions.

A key challenge during this work has been ensuring we produce an animation which doesn’t unintentionally stereotype or stigmatise individuals through the imagery used. There has been a lot of thought-provoking conversations and discussions which have led to both personal and professional reflections. For example, figures in early storyboard drafts of the animation which were uniformly male and able bodied were subsequently changed to be more inclusive and represent a diverse range of bodies. Throughout the process there have also been a lot of discussion in relation to the language that we use to support the imagery. Some key insight was gained from the Newcastle Service User and Carer forum where participants identified examples of where they had felt stigmatised through language and how potential changes could have changed outcomes. These examples have been included within the animation to highlight the impact of language.

We plan to share the animation across a range of practitioners working within fields such as drug and alcohol, mental health and wider health and social care roles. This will support the drive to encourage sign up to the Anti-stigma network and prompt organisations to develop an anti-stigma strategy for their workplace. Alongside this we wish to support practice improvement by developing a stigma education package, which the academics are leading on, and which we hope to eventually deliver through an educators by experience model.

Addressing stigma will require individual and collective action from all of us, and so we urge you to please watch and share the animation, use the resources available, sign up to the Anti-Stigma Network and help us to spread an anti-stigma approach.

Background and context

Addressing stigma is a key priority in Newcastle upon Tyne. In 2022 the Director of Public Health report stipulated that policy and practice should ensure health improvement is free from stigma. This issue is also gaining National traction, with the Office for Health Improvement and Disparities (OHID) recently announcing the project ADDER stigma indicator programme and currently adapting Professor Carla Treloar’s (University of New South Wales) Australian stigma indicator and monitoring model for the UK. The NHS Alliance Stigma Kills campaign has recently been rolled out, with the North East and North Cumbria Integrated Care System (ICS) backing this campaign for our region. The Anti Stigma Network has also recently formed to raise the profile and awareness of stigma, especially the impact on people who use or have issues with drugs and/alcohol.

How volunteering at 'biscuit club' helped me build bridges between parents and researchers

Posted by Ella Anderson, Fuse Public Involvement and Engagement Manager, Newcastle University

 

“volunteering feels like the morally right thing to do – we can’t just ‘take’ from groups and not offer something in return”

 

MumSpace volunteers together

Supported by the Newcastle University’s staff volunteering scheme and Fuse colleagues, I had the opportunity to volunteer with MumSpace. As Fuse’s Public Engagement and Involvement Manager, this meant that I could spend some time away from my desk learning more about the voluntary sector within a grass roots organisation, build sustainable community relationships, collaborate with volunteers who have valuable connections to local communities and, above all, help out in a way that was specific and useful to the needs of the community group.

What is MumSpace?

MumSpace is a warm, welcoming and inclusive community group for parents, carers and their little ones. Here, the focus is on building supportive networks and providing children with a safe space to play. MumSpace is part of Parents and Communities Together (PACT), set up by Citizens UK. PACT was first set up in London as a community-led social support project and has since been successfully piloted in North Tyneside too. The project aims to empower parents and improve the health and development of young children.

The community group meets twice a week in North Tyneside during term-time. There is no cost to attend, although it’s possible to leave a small optional donation that goes towards drinks and snacks.

Toy time at MumSpace

Why did I choose to volunteer with MumSpace?

There are both personal and professional reasons why MumSpace was an obvious choice as a place for me to volunteer. On a personal level, I was lucky enough to attend MumSpace myself with my two children, in particular with my little boy. I always found this to be a welcoming space, no matter how I was feeling or what kind of day I was having. It was a place where you could chat with other parents and carers or just have a quiet cuppa whilst your little one whizzed about and played. I have made some brilliant friends at this group and I witnessed first-hand the value groups like this have on people’s wellbeing. It felt like the natural thing to do to give something back.

When I joined Fuse in 2021, I was already a regular at MumSpace with my son. Every week, there would be new faces and new people to speak with. It was evident that everyone’s experiences and backgrounds were unique - the one constant was that we were all caring for a little person. Each parent or carer has their own story, and it shows beautifully how one person alone cannot represent all thoughts, feelings and experiences of an entire parenting community. It was this diversity of experience that I could see would be a valuable addition to the Fuse Public Partner Network, as we seek to celebrate and share a wide range of voices and experiences in public health research.

In some ways, it felt like a natural next step to see if the group organiser, Wendy McConnell, might like to talk about involvement in public health research. Nevertheless, I admit that I felt a little nervous speaking with Wendy about a possible collaboration with Fuse, not least because I didn’t want to change the general feel of this space that felt miles away from my ‘work life’. But I needn’t have worried. Wendy and I chatted easily about our respective roles, about Fuse more generally, and about how there might be opportunities for working together. It felt a bit strange to be talking about work whilst at the same time chasing after my 4 year-old and trying to encourage him to play with the toys rather than steadily work his way through all of the biscuits on offer. After all, this was the group he fondly called “biscuit club”...

Looking back, I suspect that it was this informal and gentle approach - building on an existing foundation of trust and knowing one another - that in turn has made the relationship between Fuse and PACT more meaningful and fruitful.

MumSpace disco

How has MumSpace been involved with Fuse?

Wendy, PACT and the MumSpace parents and carers have played a significant role across a number of public health research projects. Wendy, for example, originally joined as a Fuse Public Partner in a personal capacity. But her role as a Parent and Community Organiser also lends itself well to building bridges between members of community groups and researchers. For example, parents and carers from MumSpace are collaborating on a project around poverty-proofing maternity services, have contributed to research around barriers to returning to work and childcare costs, and a researcher will be visiting the group in May 2024 to discuss a new project relating to food insecurity during pregnancy. Wendy has also spoken at a Fuse Public Involvement and Engagement Group meeting to share what it was like to belong to a community group involved in health research and to reflect on the associated benefits.

Mam’s time

What have the benefits of involvement in research been for the group?

Wendy explained that benefits of involvement have included the feeling of empowerment for parents and carers, feeling ‘heard’ and making positive changes, for example to services. There have also been benefits from collaboration with researchers, for instance, the development of a formal evaluation of MumSpace. This evaluation played a key role in securing new funding* to continue running the group. This demonstrates that research relationships can be positive for all involved. It also shows how reward and recognition for involvement can extend beyond remuneration – there can be other ways for university-based researchers to usefully and meaningfully ‘give back’. Volunteering can fall into this category too.

Arts and crafts

Has volunteering been useful for building relationships within community groups?

There have been notable benefits to Fuse and wider health research as a result of the volunteering and community engagement activities with MumSpace. It has helped to build trust; shows a commitment to truly listening to people and their stories; acts as a gentle stepping-stone towards the inclusion of diverse voices and perspectives within the Fuse Public Partner Network; and offers a greater sense of transparency about what involvement in health research is and what it can look like. It aligns with many of the core principles of the NIHR Community Engagement Toolkit. Newcastle University have also added PACT as an organisation who university staff and students can volunteer with in the future, so even after I have left there will be opportunities for continuity. In short, volunteering feels like the morally right thing to do – we can’t just ‘take’ from groups and not offer something in return.

What has it been like to volunteer?

Volunteering has been an incredibly positive and rewarding experience. To be on the ‘other side’ of the group and helping to set up, offering people what would often be their first teas and coffees of the day, and welcoming new people to the group and then seeing them return the following week has been brilliant. I can still only remember a maximum of two drink orders at a time (!!) but I hope people have felt as welcome and included as I did when I first joined.

Want to find out more? Get in touch!

For more information, please email Ella Anderson, Fuse Public Involvement and Engagement Manager on eleanor.anderson@ncl.ac.uk.

For more information about MumSpace, PACT and Citizens UK in particular, email Parent and Community Organiser Wendy McConnell: wendy.mcconnell@citizensuk.org

New faces are always welcome at the group:

Tuesdays – 12.30pm to 2pm at St. Luke’s Church, 10 Frank Street, Wallsend NE28 6RN
Thursdays – 9.15am to 11.15am at St. Cuthbert’s Church, Albion Road West, North Shields NE29 0JB


*From March 2020 to August 2023, MumSpace was funded by Comic Relief and, following a successful funding bid, it is now funded by Public Health North Tyneside.

"We need happy memories"

How people who have experienced homelessness are redesigning support

Professor Monique Lhussier & Dr Christina Cooper from Northumbria University, and an Experts by Experience panel

Fuse researchers at Northumbria University were recently awarded £1.4m for a project looking to understand connections between trauma, health and homelessness in the North East. Here the research leads share how they have previously worked to embed community voices to improve health and reduce disparities for people with experience of homelessness.

The link between trauma and homelessness has been well documented, with recent evidence showing that 94% of people experiencing homelessness have experienced trauma. In the majority of cases the trauma was complex and reoccurring, with 65% having experienced four or more traumatic experiences.



In 2023 we received funding from the Arts and Humanities Research Council to develop a network to better support people who had experienced homelessness. We were fortunate to work with eight Experts by Experience (EbEs), or Experts by ‘Disaster’ as Barnie (one of our EbEs) suggested; people who had experienced homelessness, and the complex multiple needs and exclusions that frequently co-occur. The nine months project aimed to develop integrated ways of working, embedding community voices into the system to improve health and reduce disparities for People with Experience of Homelessness (PEH).

Discussions, which were led by EbE throughout the project, reiterated that trauma was common and often started in childhood, and followed by further re-traumatising events. Karl commented that while he remembered in vivid detail what had happened to him as a child, he often could not recall what he had been doing last week, highlighting the lasting impacts of trauma. Further discussions highlighted negative impacts throughout life, from relationships, education, employment to mental illness, suicide and addiction.

We reflected as a group that PEH are often viewed through a lens that considers only their immediate needs; shelter, clothing, food, and healthcare. Drawing on Maslow’s hierarchy of needs we considered that only the bottom two tiers are the most consistently met, but belonging and esteem much less so. The Experts by Experience felt that people need to be given a chance to grow in more holistic ways across all tiers of the hierarchy in order to become healthier and happier.

Tonkin’s model of grief proposes a way to see a happy and meaningful future focusing on growth around the grief. From these discussions, we collaboratively designed the graph below, which superimposes Maslow’s hierarchy of needs with and adapted version of Tonkin’s, in a model to inform ongoing and future work.

We have begun to explore this model through three core project strands:

1. an innovation fund for which EbE were responsible;
2. participation in an accredited Northumbria University module, and
3. through understanding the impacts of involvement with the project.

The innovation fund pilot involved the development and implementation of five creative projects providing sustainable and varied opportunities for self-care, learning, and physical activity for People with Experience of Homelessness. One of those, the Hope Project, gave opportunities for 189 PEH to take part in new creative, social, or physical activities. Steven designed the Hope Project on the premise that ‘people need happy memories’, which those who have experienced trauma do not always have, to draw on when the going gets tough. Barnie explained that often people lose the motivation and ability to cook for themselves when they have lived on the streets. He designed cookery classes with a train the trainer model, meaning that many people have since benefitted from eating healthier food that they had cooked themselves. Lee set up a bike repair workshop so people can take part in physical activity and be more self-sufficient.

Being given the opportunity to manage a budget, help others and having the status of university student (“I have been called many things; it was nice being called a student!”), stood out as having had a positive impact for many of the Experts by Experience. Lee and Porl said that opportunities to shape the project and develop their skills as researchers led to them feeling trusted and valued as equal members of the project team. Further to this, involvement in the project gave a sense of purpose and belonging, and increased confidence for many EbE.

This supported the notion that it is possible to grow around trauma when we attend to people’s experiences, hopes, talents, potentials and ambitions, as well as their basic needs. It also challenged us, as researchers, to think of research not solely as a detached enterprise, but as an inherent part of a system that can support people to grow and have more positive and valuing experiences.

*This blog has been written in memory of Ben

References:

• Irving, A. & Harding, J. (2022) The prevalence of trauma in people who have experienced homelessness in England. Available at: https://www.oasiscommunityhousing.org/wp-content/uploads/2022/10/The-prevalence-of-trauma-among-people-who-have-experienced-homelessness.pdf
• Maslow, A. H. (1954). Motivation and Personality. New York, NY: Harper & Row Publishers.
• Tonkin, L. (1996). Growing around grief – another way of looking at grief and recovery. Bereavement Care, 15(1), 10-10.

Image:

1. Photo by Matt Collamer on Unsplash