Stress is a universal experience, but is it unequally distributed across society?

Posted by Dr Joanne-Marie Cairns and Dr Emily Henderson, Durham University and Fuse.

How are you feeling today? Stressed at all?! If so, you are in good company.

Stress is so pervasive in our society that it contributed to a shocking 9.9 million working days lost in 2014/15(1), which equates to an average of 23 days per person. From an evolutionary perspective, stress is useful to animals such as humans to help us react to physical and social threats, commonly known as the ‘fight or flight’ response. According to Danielsson(2) and colleagues, stress can simply be defined as an imbalance between demands placed on us and our ability to cope with them. But if stress continues over a long period of time then a permanent imbalance may arise between the body’s degenerative (reduced growth) and regenerative (regrowth) functions. Stress can also lead to everyday problems including poor performance at work, low mood, lack of motivation, fatigue, sleep disturbance and chest and muscular pain as well as major life-limiting health problems such as high blood pressure, depression and chronic pain.

In light of these concerns, we organised a Health Summit on inequalities-related stress, with colleagues from the Local Area Research & Intelligence Association (LARIA), the Wolfson Research Institute for Health and Wellbeing, and Fuse - the Centre for Translational Research in Public Health. This event was hugely popular and brought together a wonderful mix of delegates and speakers from policy, practice and academia, from the North East and across the UK. The programme, which includes a list of speakers and a description of the talks, can be found here.

While stress can be a universal experience, it doesn’t manifest equally amongst certain population groups. For instance, Thoits(3) conducted a review which highlighted how unequally high exposure to stress by women and people in lower socioeconomic and minority groups lead to inequalities in health outcomes. Moreover, we see health inequalities accumulate over the life course as a result of this unequal distribution of disadvantage, for example Thoits refers to a study conducted by Turner and colleagues(4) that examined the effect of cumulative stressors in adults. These stressors that accumulated over time, explained a significant 50 per cent of the Socioeconomic status (SES) gap in depressive symptoms.

What are health inequalities then? These are differences in health status or determinants of health between different population groups. There are also intersecting inequalities, for example, if you are a lone parent but also on a low income, living in a disadvantaged area. Moreover, coping mechanisms sometimes adopted to mitigate stress can be health-damaging and lead to other forms of health problems, such as smoking or alcohol misuse. John Watson (Deputy Chief Executive, Action on Smoking & Health (ASH) Scotland) quite rightly argues that smoking IS NOT A LIFESTYLE ISSUE; rather in his words it is a form of medication to society’s maladies. Just think of the current global economic downturn as a societal issue that can be at the root cause of individual depression. As well, unequal access to jobs (at least good jobs that aren’t precarious in nature or that might lack autonomy) or good schools, which already limit an individual’s future prospects and may as a result contribute to psychosocial stress and poorer health highlighting the structural factors that are beyond the individual. Furthermore, stress at the population-level can manifest into geographical health inequalities. Data published by the Health and Social Care Information Centre (HSCIC) shows that the North East Strategic Health Authority (SHA) had the highest admission rate due to anxiety of any of England's 10 SHAs (just under 24 per 100,000 of the population), while South Central SHA had the lowest (at nearly 11 per 100,000), mirroring other health outcomes and shows the stark North-South health divide in England.

‘Lifestyle’ is used ubiquitously in current public discourse, and can be understood as a set of factors that describe a person’s daily living. Obesity-related lifestyle often refers to people’s behaviours and apparent food choices(5). These so-called behaviours are ways in which individuals respond to challenging circumstances. They are not choices in the purest sense of the word. Rather, an individual may be experiencing financial difficulties and, feeling the demands in their life which outweigh their ability to cope, may respond to the situation by smoking, drinking or comfort eating. But what is actually causing the financial difficulty in the first place? Are individuals to blame for reacting to the bleak reality of poverty and the social gradient they find themselves in? The seminal work by Sir Michael Marmot tells us that we instead need to consider the “causes of the causes” of inequality, not just the symptoms. Politics is also important, as we have seen in the government’s release of the new obesity strategy which continues to support healthy choices, and maintains the voluntary efforts by industry by suggesting a 5 per cent sugar reduction in children’s food and drink. The chairwoman of the Health Select Committee, Dr Wollaston, told BBC Radio 5 live that “it does show the hand of big industry lobbyists and that’s really disappointing”(6). A key political talking point relates to the fact that what was a 50-page document was shortened to a mere 10 pages which does not do something as complex as obesity justice – it was “weak and watered down”.

To sum up, the discussions from our Health Summit supported the principle of moving away from individualised and stigmatising conceptions of unhealthy behaviours; after all it is not just poor people that behave poorly!


References:

1. Figures obtained from: http://www.hse.gov.uk/statistics/causdis/stress/ [last accessed 17/08/16]
2. Danielsson M, Heimerson I, Lundberg U, Perski A, Stefansson C-G, Ákerstedt T. 2012. Psychosocial stress and health problems. Scandinavian Journal of Public Health, 40(9):121-134.
3. Thoits PA. 2010. Stress and Health: Major finding and policy implications. Journal of Health and Social Behavior, 51(s):41-53.
4. Turner R, Jay and William R. Avison. 2003. Status Variations in Stress Exposure: Implications for the Interpretation of Research on Race, Socioeconomic Status, and Gender. Journal of Health and Social Behavior,44:488–505.
5. Nettleton S. Lay health beliefs, lifestyles and risk. The sociology of health and illness. 2nd ed. Cambridge: Polity Press; 2006. p. 33-70.
6. http://www.bbc.co.uk/news/health-37108767 [last accessed 19/08/16]

It's April: happy stress awareness month everyone!

Guest post by Dr Emily Henderson, Lecturer in Knowledge Exchange in Public Health and Research Fellow in Complex Systems at Durham University

April is stress awareness month. Why, you may ask? Maybe because it’s tax season. Or because parents have to look after their children during the Easter holidays. Or perhaps it’s to help recover from all the April Fools’ Day jokes, like the poor guy in Canada this year who reportedly collapsed from heart palpitations after his work colleagues convinced him he had to cut his holiday short to meet a deadline that had been moved forward.

 

Whatever the reason, it is happening this month. The Health Resource Network has deemed it so. And we at Fuse think it is a good opportunity to raise awareness about stress.

But I am already aware that I’m stressed, I can virtually hear you reply. Fair enough. Nearly half of UK adults report feeling stressed every day or every few days, according to the Mental Health Foundation. With budget cuts, job insecurity and global crises, just to begin with, we all are stressed.

  

So what am I to do about it? We all have our coping strategies, which are biologically understood responses that humans and animals alike have evolved. Chimpanzees are known to groom each other to cope with threats and re-establish bonds. Stress and suffering are human universals. We can measure stress via stress hormones like cortisol, and there are physiological and some behavioural responses we can predict, like the ‘fight or flight’ response. But some behaviours are not predictable, and do not always make (immediate) sense. For example, Hilary Graham’s ethnographies of low-income single mothers showed us that, paradoxically, smoking was used to cope with suffering and thus improve wellbeing.

You, dear reader, have asked so many good questions up to this point, I have one for you: Considering the ‘causes of the causes’ of ill health, is the actual problem that these women smoked or is it the disadvantage they experienced? We have no choice but to cope in our own ways with stress. After trial and error, I know better now what I need to get perspective and find stillness inside. I am addicted to the oxygen highs I get through practicing yoga, and require connection with nature and people. But as a native to San Francisco, I am under cultural obligations to indulge in wine. Nobody is perfect. And nor should we ever aspire to this elusive ideal. Indeed, evidence for the health benefits of practicing compassion - either compassion for ourselves or for others - is growing. Beyond changing our behaviours, we must change the structures and systems that generate stress.

Spring is actually not about chocolate bunnies, but about renewal. So this April, in addition to trying new ways to cope with stress (see the Huffington Posts compilation of articles for Stress Awareness month, or NHS Choices mindfulness article), maybe get involved in a cause that seeks to alleviate suffering.

Please check out the Stress, Health and Wellbeing special interest group that I run through the Wolfson Research Institute for Health and Wellbeing at Durham University.

Photo credits

1. http://slstpaso.com/wp-content/uploads/2015/03/April-for-email.png

2. http://missinghumanmanual.com/wp-content/uploads/2011/05/grooming-chimps.jpg

3. https://thimesblog.files.wordpress.com/2014/02/keep-calm-make-your-voice-heard.png?w=600

Complexity in health organisations: setting ourselves up for chaos or enjoying the simple things in life?

Posted by Peter van der Graaf

Can applying a complexity lens to health organisations be more than an academic exercise with practical applications for service delivery? This question was central to a two-day meeting last week in London at the Health Foundation between researchers, policy makers and health practitioners. The event was organised by The Knowledge to Action Group (KTAG), an international team of senior academics and coordinated by two leading members of Fuse’s Complex Systems research programme, Prof David Hunter and Dr Emily Henderson. The group brought together the crème de la crème of health research and knowledge mobilisation, with about 40 handpicked participants from across the UK to debate a green paper on the topic (which is a tentative government report and consultation document of policy proposals for debate and discussion).

The essence of this meeting was about getting to grips with the consequences of doing research and developing interventions in a world that is inherently complex (which is not to be confused with just being complicated!). The green paper (Knowledge-to-Action: Addressing Complex Problems in Health Systems, May 28/29 2015) described complex systems as non-linear; dynamic; and having no single point of control.  Because of these characteristics, outcomes in a complex system are unpredictable and resistant to interventions. So are health systems really complex? Anyone trying to get research evidence into practice will quickly discover that knowledge mobilisation is prone to all the characteristics outlined above for complex systems.

In one of the breakout sessions during the event the difference between complicated and complex was illustrated with the example of building a rocket versus raising a child.  Building a rocket is complicated but will lead to a predictable outcome (successful launch) if all the different pieces are correctly assembled according to the guidebook. However, raising a child is complex (as many parents will testify) and often leads to chaos in many academic households. This is bad news for academic parents and health service managers: you cannot steer the thing (but you are still accountable for it) and even if you find the solution to a problem in the system it is likely not to work when you try it again. The dynamic nature of systems means that what works in one context or at one point in time may not work the same as the system changes.

How do you work within such a system? Fortunately, the event provided four case studies of research projects where the academics had managed to work within a complex health system to produce change across different areas, often in co-production with policy makers and health practitioners. The authors of the green paper distilled four themes from these case studies to inform future research and interventions:

1. the balance of central and distributed authority in organisations and systems; 
2. the importance of emergence (continuous learning and adaptation); 
3. the need for co-produced knowledge; and 
4. a range of leadership positions and styles.

These four themes were discussed in more detail in various breakout sessions over the two days.

Participants embraced the spirit of the event and discussed a wide range of topics (from the need for a critical discourse department to finding positive deviants), whose relationships with the four themes were sometimes unclear and mostly unpredictable. Nevertheless, some key messages emerged from the event that will soothe the nerves of academics and service managers. By visualising complex organisations as “patterns of conversations between interdependent individuals” (as quoted in a presentation from Allan Best on the first day), working in complex systems becomes conversation management and engagement. According to the researchers involved in the successful case studies, this works all the better outside the normal context of everyday work by taking commissioners to the pub or baking a cake for a meeting with service managers to get the conversation really going. Isn’t it ironic that to work inside complex systems, one needs to go back to basics in a more simple system?

Collaboration, Intimacy and Revolution

Posted by Emily Henderson

Heartened. How's that for an opener? It was my privilege this past August to present a paper at the European Association for Social Anthropologists biennial conference, hosted by Tallin University in Estonia. The theme was ‘Collaboration, Intimacy and Revolution’, in honour of Estonia’s 25th anniversary of their struggle and success in gaining independence from Russia after the Soviet fall.

Collaboration

The city of Tallin, Estonia

I am particularly grateful for this experience because of the importance of international exchange to my work. The panel I contributed to was entitled ‘Bodies out of bounds: anthropological approaches to obesity practices’. It aimed to rethink common understandings of obesity, and encourage interdisciplinary approaches to such a complex issue. I presented preliminary findings from my Wellcome Trust funded project exploring perceptions of the contribution of psychosocial factors to obesity. In short, I explore how cultural understandings of the causes of obesity and who is to ‘blame’ determines the ways in which all of us decide how obesity is to be addressed. I argue for the anthropological contribution to health interventions because it puts humanness and the human perspective and at the centre of these decisions. An outcome of this panel is an EASA special interest group, which I currently chair.

Intimacy

Brown peaty waters of the bogs, Lahemaa National Park

A shared issue that emerged from our collaboration was our belief that, while the study of obesity can be fascinating from a theoretical perspective, it also must be able to make an impact on health and wellbeing. The field of public health anthropology is considered ‘applied’ research, distinct from ‘pure’ research. This false dichotomy implies in the first that research cannot be both applied and generate theory, and that applied research is somehow ‘impure’. Central to social anthropology is ethnography and the personal contemplation it requires, as well as an emphasis on social justice. The translational research we do at Fuse - in particular through the coproduction model whereby those in policy and practice are equal partners in driving research - requires academics to give up their authoritative power over knowledge. This compels us academics to open up our disciplines to the world which is outside of our ‘pure’ surroundings.

Revolution

Lantern collection at the Kasmu Sea Museum, on the Baltic Sea

The other panel I attended was ‘Anthropology as a vocation and occupation’, which served as a forum for exchange on career prospects at a time when the global economic crisis threatens higher education. A main focus was on the ‘precariat’ researcher who is unable to find jobs or job security, (or more specific to academia, ‘cognariats’) many of whom are ‘early career’ researchers. A little bird told me we should give great thanks to postdocs at Durham University, because their external funding is used to run our offices. It’s a fitting analogy that we supply the lighting around universities. Rather than the term 'young scholars' perhaps a positive spin would be call us 'fresh scholars'. At this conference, I may have received the best professional complement ever: A fellow obesity ‘fresh scholar’ said my work asked the bigger questions; alas for him, he feels only permanent ‘academic staff’ in France have the luxury of thinking deeply. In a setting where The Rule of the Game is ‘Publish or Perish’, free thinking is one of the few remaining perks to being merely ‘research-only staff’ in higher education, and is the life raft to which we cling.

Past, present, future

Life grows out of a deserted Soviet submarine
base, on the Baltic Sea

Finally, Estonia really captured me. Taking a cheeky guided tour to Lahemaa, their largest national forest, I observed first-hand their love of nature, as over half their country remains forested. While cooling our toes in boggy waters, a local employed by Skype, a company created within Estonia, told me all about the cutting edge technology going on in Estonia. Our guide ‘begged’ us that if we were to remember one thing about Estonia, it’s that they are Baltic and Nordic people, distinct from eastern Europe. I was struck by Estonians’ ability to preserve their heritage, and also to innovate and make their mark as a new EU nation. Perhaps one will be their example of conservation. The lesson I took away from my trip was that in order to drive forward, we have to keep looking back. Given the opportunity of reflection on my trip, I felt revived and ready to face challenges forward. Presently, this means cracking on with the business of it.

This trip was funded very generously by Fuse and Durham University’s Centre for Public Policy and Health (WHO Collaborating Centre on Complex Health Systems Research, Knowledge and Action).

52 weeks in public health research, part 43

Posted by Amelia Lake, Emily Henderson, Lorraine McSweeney and Peter Van Der Graaf

From Lorraine McSweeney: It was a proud and surreal moment to see my PhD thesis join eminent academics’ work on the Fuse Director's bookshelf of fame at Newcastle University!

From Amelia Lake and Emily Henderson: Emily has fashioned a temporary standing desk so we, at Durham University's centre for public policy & health, can introduce a bit more activity into our working life!

From Amelia Lake: Halloween a time of... excessive sugar intake? What happened to carving turnips, eating satsumas and the best treat (well in the Lake household circa 1985) a big box of pomegranates!

From Peter Van Der Graaf: Poster presentations at the 1st International Conference on Realist Approaches to Evaluation and Synthesis with two posters from Fuse's Monique Lhussier (see below). A surprising amount of papers and presentations on public health including a keynote address by Professor Mike Kelly from NICE.  Is Fuse missing a trick?

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A reminder from the Fuse blog group:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in most of our lives, we foresee problems compiling 208 images worth posting on our own. So this is going to have to be a group project. Send an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and we’ll post them as soon as we can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Email your posts to m.welford@tees.ac.uk or contact any member of the Fuse blog group.

Context, complexity, mixed methods and multidisciplinarity

Posted by Emily Henderson

As the new Research Associate lead on Fuse’s Complex Systems Research Programme, I was funded by Fuse to attend a training course on Evaluating Complex Public Health Interventions in Cardiff, 25-27 June. It was delivered by our partners in DECIPHer (Development and Evaluation of Complex Interventions in Public Health), one of five UKCRC Public Health Centres of Excellence (PHCoE). As we know from Prof Simon Murphy’s lecture, presented at the Complex Systems Research Programme’s inaugural event last May, DECIPHer have a successful record of doing localised, translational research. So it struck me and Prof David Hunter (Programme Leader, Complex Systems Research Programme and Fuse Deputy Director) as a great opportunity to exchange experiences with other PHCoE.

As a mixed methods medical anthropologist, I was hoping on this course I would 1) make new and interesting acquaintances, which I did, and 2) learn about how the diversity of methods can be best used in addressing complex public health issues. The three-day course, which followed its two-day counterpart on Developing Complex Public Health Interventions, covered: process evaluations, feasibility studies, large-scale effectiveness studies and alternatives to randomisation and data linkage. The DECIPHer approach was clearly outlined as adopting 1) the MRC Framework on developing and evaluating complex interventions; 2) Ecological Thinking, 3) Co-Production Models and 4) Complex Systems Thinking. And echoing the MRC Framework on process evaluation - coming to a theatre near you - that, despite the range in methods that can be adopted, there is “no hierarchy of evidence”.

This was welcome news - given the diversity of methods adopted within Fuse, e.g. embedded ethnography, realist evaluation, economic evaluation of trials - excepting that the focus of the training was exclusively on trials. In certainly what was not an unusual experience for me, I was the odd-(wo)man-out at this event (emphasis on odd). But this lonely position has its rewards, as participant-observer:

“The magic of anthropology is precisely its ability to self-critically live with the almost schizophrenic contradiction of adhering to two worlds simultaneously”. Messac et al. Soc Sci Med 2013. p185

 

It seemed my chummy classmates were by-and-large RCT researchers, and many told me they left the course wanting to re-read the notebooks to apply what they learned to their research. Pfft, over-achievers. The task I left feeling that I needed to address, was to consider in greater depth this question:

‘In adopting socio-ecological models, how can we as public health researchers, if at all, adequately consider context?’

Just last week, I was asked by a medical anthropology PhD student from the University of California Los Angeles to use my PowerPoint slides as a complement to a podcast of a talk I gave at the University of Oxford, which, dear reader, I wouldn’t shamelessly draw your attention to here. This bright and motivated student wanted to illustrate to her undergraduates how anthropologists can address “real world” problems using mixed methods approaches.

 Induced to dig out my own mixed methods lecture (delivered for Durham’s Methods and Analysis anthropology module), I was reminded of the premise I taught: *only* use mixed methods when the sum of methods reveals more than the methods as parts, or some such or other. I used Durham City’s biennial Light Festival as an analogy of how mixing unrelated media (a cathedral, a slide projector and spooky music) can enhance one’s experience of learning about Durham’s history. But why the proviso “only”? Why not have a light festival every night? Indeed Durham City, why not? Because mixed methods approaches also have many drawbacks. They require: added time, added expertise and multidisciplinary working, to name but a few, not to mention the added funding all this entails. 

 

'Lumiere' - Durham Light Festival

 

No, it’s not possible to create time - we as academics know this all too well - but somehow the latter point - multidisciplinary working - seems more challenging. The debate on ‘Realist RCTs’ for example raises the important issue of the researcher’s epistemological lens. The what? That is, the researcher’s understanding of knowledge and how knowledge is constructed. Do you believe reality can be objectively measured, or rather that reality exists only as a subjective experience, or something in between? Disagreements on this fundamental of doing research can make combining methods - for example embedding ‘qualitative’ methods within trials to provide context - a challenge and at times implausible. However, as with epistemological views, there is a continuum of mixed methods approaches, including triangulation - no, not strangulation - where methods complement each other but retain their disciplinary roots.

Given the range in my own multidisciplinary background, from neuroscience to biocultural anthropology to health policy, my tendency is to at least consider, albeit critically, the range of approaches to researching humans and human health. As social animals we are, after all, complex beings (or at least we’re quite happy to get ourselves into a muddle over what it all means), thus one perspective surely cannot paint the entire picture. Enter multidisciplinarity. However, as with all disciplines, multidisciplinary working itself requires skills, training and experience, especially interpersonal skills to facilitate collaboration, or to recognise when this is impracticable. 

All views expressed are exclusively those of the author.

52 weeks in public health research: part 29

Posted by Jemma Hawkins, Jenni Remnant, Shelina Visram and Emily Henderson

From Jemma Hawkins (photo credit: Natalie Richards): When compiling the promotional material for a seminar we are organising on 'Tackling Workplace Sedentary Behaviour' we decided that it would be better to create our own image rather than using a stock one. One quick tidy of a colleague's stand-up desk, another colleague's smartphone and me as 'model' donning the famous DECIPHer t-shirt and hey presto!

From Jenni Remnant: Sat down to eat at a Knowledge Exchange conference last week run by the LSE and this was on the table.

From Shelina Visram: This picture was taken in County Durham after a meeting to discuss a pilot project on supporting lifestyle changes amongst people newly diagnosed with a chronic condition. I recently ran some focus groups in the community centre across the road, which required several telephone conversations with a local caterer about what I meant by a ‘healthy buffet lunch’. Thankfully their salad did not contain lard.

From Emily Henderson: It *might* have been said once or twice in the history books that academics are *sometimes* overworked and underpaid, but there are definite benefits. In June I had the pleasure of attending the EvaluatingComplex Public Health Interventions short course at DECIPHer. We were off the leash in the evenings, and I got very lucky with the weather! An evening picnic in Sofia Gardens along the river Taff, Cardiff, Wales. With the latest addition of 'The Lady' mag, white wine and cheeses.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

52 weeks of public health research, part 13

Posted by Melanie Rimmer, Emily Henderson & Martin White

From Melanie Rimmer: Reminds me of the old days of searching journals by hand, card index files, the smell of old books, dusty shelves festooned with dead flies, and the volume you needed was always the one missing from the shelf. Without doubt computer searching is better, but somehow sterile. I miss the romance (but not the dead flies).

From Emily Henderson: Celebrating our new status as a WHO Collaborating Centre! The Centre for Public Policy and Health at Durham University is now a WHO CC on Complex Health Systems Research, Knowledge and Action, which links with Fuse’s new Complex Systems Research Programme.

From Martin White: It never ceases to amaze me how the irony of juxtaposing public health stories (this one courtesy of our very own Blog Editor) with junk food promotions entirely escapes newspaper editors. Nowhere more than in the free dailies that litter our public transport. This piece about a systematic review on financial incentives is rather good, which makes me think it may even have been written by Dr Adams.

From MartinWhite: When a small glass of coke contains 9 teaspoons of sugar, it is hardly surprising that the Coca Cola Corporation is investing heavily in ‘changing the conversation’. Coca Cola wants us to forget about the sugar and do exercise instead to burn it off. Their marketing is widespread in the Alps, as well as in professional sport, leisure and educational settings. Someone tell them why this isn’t the answer please…

-------------------

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.