How our ‘test & learn’ prototypes are strengthening Social Prescribing

Posted by Ang Broadbridge, Head of Implementation at Ways to Wellness, on #SocialPrescribingDay

Evaluation is often something that happens at the end of a project, but what if we built learning into the process from the very start?

At Newcastle-based charity Ways to Wellness, we believe that embedding a culture of learning from the outset helps social prescribing link workers share real-time insights, refine approaches, and ultimately improve support for the communities we serve.

One area where this model has been used is in maternal mental health

Co-designing for impact

A core part of our work is connecting with local communities to shape and refine prototypes that align with our mission:

• Improving health and wellbeing
• Tackling health inequalities
• Reducing demand on NHS services

To ensure our link workers could share learning, develop key messages, and highlight gaps in services, we adopted the Learning Communities model. As described in the Learning Communities Handbook, these are:

"A group of peers who come together in a safe space to reflect and share their judgements and uncertainties about their practice and to share ideas or experiences to collectively improve."

To embed this approach into recruitment and training, we:

• Included an expectation for link workers to actively engage in Learning Communities
• Encouraged participation in ‘test and learn’ approaches
• Provided ongoing support and facilitation to foster a sense of ownership and belonging.

This approach helped link workers collaborate across different host organisations, spanning locations across the North East and North Cumbria.

Extending learning into maternal mental health

One area where this model has been used is in maternal mental health. After eight months of Learning Community meetings, we expanded this approach through a series of external learning events. These events:

• Shared early insights from our maternal mental health prototypes
• Brought in new partners to co-develop next steps
• Strengthened cross-sector collaboration

A key learning was that while social prescribing is well known in GP practices, it was midwives and health visitors who played a crucial role in referring parents to our prototypes - roles that hadn’t previously collaborated with link workers.

By opening up new referral pathways, we helped develop best practices for integrating link workers into maternal healthcare settings.

Turning insights into action

Our Learning Communities aren’t just discussion spaces - they drive change. Link workers use them to:

• Identify barriers in accessing social prescribing
• Test new ways to connect people with support
• Share insights at external events and policy discussions

The impact has been tangible. For example, after testing different approaches, some link workers are now based in health appointment clinics - an innovation that has improved system-wide connectivity and access to services.

Why this approach matters

By embedding a culture of continuous learning, we are:

• Strengthening partnerships across health and care sectors
• Ensuring services are designed with communities, not just for them
• Maximising the impact of social prescribing

At Ways to Wellness, we believe that the voluntary sector, healthcare services, and community organisations must work together to tackle health inequalities.

That’s why we’re committed to testing, learning, and adapting - so that social prescribing continues to evolve, improve, and reach the people who need it most.

Find out more at: waystowellness.org.uk

Image credits: Ways to Wellness Limited company number: 08798423

Should pregnancy 'be incentive enough' to quit smoking?

Guest post by Susan Jones, Research Associate, Teesside University

I have seen many people on twitter express the view that thinking about their baby should make pregnant women automatically quit smoking. Indeed many women when they decide to try for a baby or find out they are pregnant do quit smoking. However, it does seem illogical - and shocking - to many that this is not always the case.

 

Just searched #smoking #pregnancy #incentives - struck by many tweets that say 'pregnancy should be incentive enough' to quit smoking. Clearly the stats tell a different story for a significant minority - the question surely is why and what can be done? @ASH_LDN @FreshSmokeFree

— Dr Susan Jones (@Susan_E_Jones) December 10, 2020

For those who do continue to smoke, it is perhaps more of a hint of a complex web of reasons behind their smoking behaviour, rather than any greater willingness to harm their baby. Smoking throughout pregnancy is often associated with environmental and social deprivation, which gives us a clue. Hilary Graham’s seminal work into women’s smoking and its association with family health, published in 1987, opened the door to a new understanding of what some of the reasons might be for this apparently illogical and paradoxical behaviour on the part of pregnant women from deprived communities. Graham concluded that:

"The study suggests that, for a significant minority of mothers, poverty and caring combine with low levels of physical and emotional energy, with sleep problems and with feelings of social isolation. In this context, smoking appeared to provide a way of coping with caring-in-poverty: a way of coping alone with the demands of full-time caring and with the struggle of making ends meet."

This work revealed that there were other, stronger reasons to continue smoking, which counteracted any impulse to quit.

Guilt and shame

An earlier study of ours heard pregnant smokers confess to feeling guilty and ashamed of smoking in pregnancy and how they are very aware of the stigma associated with their behaviour:

“But then once I lit it up and had half of it I felt guilty. But it took that edge away, but I still felt guilty. So if I felt even more guilty I probably mebbees wouldn’t have touched it, but I feel weak because I have had to do it.”

“I think the kids always make it like, they have more effect on you than what anyone else does, because they're, well you feel guilty if you're letting them down and doing something they don't want you to do.”

We also found that sometimes it can be a distrust of public health messages combined with a real lack of knowledge about the mechanics of how smoking affects the developing baby. Nevertheless, it must be acknowledged that, for whatever reason, not everyone says they want to quit; but of those who do want to quit, some say they do not feel able to. For the sceptics out there, this may seem only subtly different to choosing to smoke, alternatively it may be a real barrier to quitting. Graham’s work would suggest the latter. More recent research has built on her findings and investigated what methods of support may work for these pregnant women, who do not quit, and for whom the health outcomes are comparatively worse for themselves and their babies.

What can be done?

Research over several decades has shown that there are ways to support pregnant women to quit smoking, focusing on:

• Referring to stop smoking support services
• Offering support to change behaviour
• Support through medication.

It is clear now that opt-out approaches to referral and carbon monoxide monitoring and much more personalised support are also helpful to women (see our short video below).

   

Work has been undertaken to implement these supports more fully; e.g. the Local Maternity Systems (LMS) in North East England designed the Maternity Pathway and have led the work across the organisational systems to integrate these mechanisms. Becca Scott, the North East Local Maternity Systems Public Health Prevention Lead says:

"The LMS have led North East organisations and service users to contribute to the target of 5% or less women smoking in pregnancy by 2025. That would mean 2723 fewer women smoking at time of delivery across the North East since 2018. It does this by offering all expectant mothers, and their partners, a multiagency-developed, smoke-free pregnancy pathway and minimum service standards (as detailed in each of the Maternity providers bespoke plans). The impact of the engagement with the work has seen prioritisation throughout all Local Authority Health and Wellbeing boards, as well as consistency in the way smoking in pregnancy is identified and supported, which is demonstrated in significant improvement in adherence to NICE Guidance."

What more can be done?

The results of this partnership work are encouraging. Is there anything else that can be done? The evidence for the effectiveness and cost-effectiveness of financial incentives to support pregnant women to quit has been building. Trials have been conducted which have found that there is "substantial evidence for the efficacy of incentives for smoking cessation in pregnancy" – however this idea has encountered significant public scepticism and opposition.

ash. Smoking in Pregnancy Challenge Group Webinar - Incentive schemes

Although there has been more balanced reporting too and more recently, the headline below suggests the idea has become more acceptable.

Capture from The Sun online (09/03/21)

Modelling financial incentives in smoking in pregnancy

A team of us (details below*) have been awarded funding from the NIHR Applied Research Collaboration (ARC) North East & North Cumbria Open Funding Competition to look into an alternative way to take into account the views and responses from all stakeholders, including staff, pregnant women, and the public. We will also be building a mathematical model based on Evolutionary Game Theory (EGT). EGT is a mathematical framework of contests, strategies and analytics into which Darwinian evolution can be modelled. It is designed to capture the strategic interactions between stakeholders, because ultimately these interactions will drive health behaviour. Incentivisation will be modelled to see how it affects some behaviours and in what contexts. We hope the model will be able to guide commissioning and provision, so that any intervention is as effective and cost-effective as possible, without having to conduct further lengthy and expensive trials beforehand. Watch this space!

*Associate Professor Emma Giles (Teesside University), Professor Falko Sniehotta (Newcastle University and University of Twente), Dr Jean Adams (University of Cambridge) and other partners working in NHS Trusts and local authorities. Colleagues in the School of Computing, Design and Digital Technologies, Associate Professor The Anh Han and Tedy Cimpeanu from Teesside University.

Perseverance and Public Health: creating a cultural shift takes time

Guest post by Susan Jones, Research Associate, Teesside University

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

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

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

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

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

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

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

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

• Saving babies’ lives: reducing stillbirth and neonatal death: a care bundle (NHS England, O'Connor and Gould, 2014)[5]
• Tobacco Control Plan: Delivery Plan 2017 - 2022 (Department of Health and Social Care, 2018)[6]
• Hiding in Plain Sight; treating tobacco dependency in the NHS (Royal College of Physicians and Tobacco Advisory Group, 2018)[7]
• Not to mention ongoing lobbying from the Challenge Group (2018)[8], a coalition of likeminded, stop smoking, activist organisations, with their ‘Review of the Challenge’.

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

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

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

Fuse Complex Systems research programme

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

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

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

References: 

1. Jones, S. et al. (2019) What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory. BMC Health Services Research. Available at: https://rdcu.be/bA4fK (Accessed: 20th May 2019).
2. Beenstock, J. et al. (2012) 'What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England', Implementation Science, 7(1), p 1. 
3. National Institute for Health and Care Excellence (2010) Public health guidance 26: Quitting smoking in pregnancy and following childbirth. London: NICE. 
4. Bell, R. et al. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control. Available at: http://tobaccocontrol.bmj.com/content/early/2017/02/10/tobaccocontrol-2016-053476 (Accessed: 20th May 2019). 
5. NHS England, O'Connor, D. and Gould, D. (2014) Saving Babies Lives: reducing stillbirth and neonatal death: a care bundle. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (Accessed: 10th April 2019). 
6. Department of Health and Social Care (2018) Tobacco Control Plan: Delivery Plan 2017 - 2022. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/714365/tobacco-control-delivery-plan-2017-to-2022.pdf (Accessed: 20th May 2019). 
7. Royal College of Physicians and Tobacco Advisory Group (2018) Hiding in plain sight: Treating tobacco dependency in the NHS. Available at: https://www.rcplondon.ac.uk/projects/outputs/hiding-plain-sight-treating-tobacco-dependency-nhs (Accessed: 11th April 2019). 
8. Challenge Group (2018) Review of the challenge 2018. Available at: http://ash.org.uk/information-and-resources/reports-submissions/reports/smoking-in-pregnancy-challenge-group-review-of-the-challenge-2018/ (Accessed: 10th April 2019). 
9. Moore, G. et al. (2014) Process evaluation of complex interventions: UK Medical Research Council. Available at: https://mrc.ukri.org/documents/pdf/mrc-phsrn-process-evaluation-guidance-final/ (Accessed: 10th April 2019).

Image:

1. 'Smoking when pregnant' by johndavison883 via Flickr. Public Domain Mark 1.0.

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

Guest post by Susan Jones, Research Associate, Teesside University

"I was 12 years old when I started to smoke. I wasn’t thinking long-term, about my future, about the adult world I would one day join … I just wanted to look cool among my peers, be accepted and act grown up. Then I really did grow up and I was still smoking. Then I became pregnant … and I was still smoking. I didn’t exactly choose to be a smoker when I was pregnant but here I am ... addicted and not really wanting to give it up, or even if I wanted to, I don’t think I could – even for my baby.

"My mam smoked when she was pregnant with me, and I’ve turned out all right; all my family smokes, all my friends smoke, my partner smokes too; in fact smoking is a part of all my close relationships, especially with my partner, we smoke together, it is part of how our relationship works."

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

A composite from interviews with pregnant smokers and maternity staff.

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

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

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

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South Tees Hospitals NHS Foundation Trust took part in the evaluation of the implementation of the babyClear© package and works closely with its local stop smoking service. As Joanna Feeney, the Smokefree NHS Strategic Manager, says:

"South Tees is a great example of how Stop Smoking Services and Maternity Services can work together to help support Pregnant women to have Smokefree Pregnancies. 

"Most women who smoke during their pregnancy may know that smoking is bad but they are not aware of all the risks to them or to baby, they are also not aware of the help and support that is available to quit, including treatments such as Nicotine Replacement Therapy. 

"Implementing advice and treatment as part of routine Maternal care that is continued outside of hospital with the Stop Smoking Service helps ensure that babies are given the best start in life. 

"Last year in South Tees there were 334 more babies born Smokefree compared to 2012, and this year following the great work done on the wards at James Cook University Hospital the numbers are continuing to reduce but we recognise that there is still more to be done to ensure that every baby is born smokefree."

The Maternity and Stop Smoking Services reviewed the referral pathway and developed an online referral system that not only makes it easier for midwives but increases the speed with which women are contacted and given an appointment with the Stop Smoking Service.

Image courtesy of South Tees Hospitals NHS Foundation Trust

The Stop Smoking Service provides regular feedback to Maternity on the outcomes of women referred, enabling Maternity to offer bespoke interventions to those women who do not engage with treatment.

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

And now, a year on, Kay Branch, Consultant Public Health midwife, South Tees Hospitals NHS Foundation Trust says:

"We are still really proud to have led the way towards a smokefree Trust. Our staff have noticed a reduction in the presence of anyone smoking outside entrances. 

"We continue to work collaboratively with the local stop smoking service to ensure a streamlined service for women and their partners. Nicotine replacement therapy is available to all of our patients and is widely used across maternity. 

"Our smoking at time of delivery reflects our hard work and passion for smokefree families."

Maternity’s lead has inspired the whole Trust to implement a systematic approach to treating tobacco dependency with Maternity being the model ward.

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

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

References:

1. Chamberlain, C., O'Mara-Eves, A., Porter, J., Coleman, T., Perlen, S. M. et al. (2017) Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews. Accessed on 18/03/19 at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001055.pub5/epdf/full
2. Bauld, L., Graham, H., Sinclair, L., Flemming, K., Naughton, F. et al. (2017) Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study. Health Technology Assessment, 21(36). https://www.journalslibrary.nihr.ac.uk/hta/hta21360#/abstract
3. National Institute for Health and Care Excellence (2010) Quitting smoking in pregnancy and following childbirth: public health guidance 26. NICE: London https://www.nice.org.uk/guidance/ph26/resources/smoking-stopping-in-pregnancy-and-after-childbirth-pdf-1996240366789
4. Bell, R., Glinianaia, S. V., Van der Waal, Z., Close, A., Moloney, E., Jones, S., Araujo-Soares, V., Hamilton, S., Milne, E., Shucksmith, J., Vale, L., Willmore, M., White, M., Rushton, S. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control, 27: 1. Accessed on 18/03/19 at: http://tobaccocontrol.bmj.com/cgi/content/full/tobaccocontrol-2016-053476
5. Jones, S.E., Hamilton, S., Bell, R. Araújo-Soares, V., Glinianaia, S.V., Milne, E.M.G., White, M., Willmore, M., Shucksmith, J. What helped and hindered implementation of an enhanced package of measures to reduce smoking in pregnancy: process evaluation guided by Normalization Process Theory. BMC Health Services Research [In press]

Would you accept money to be healthier?

Guest post by Emma Giles, Senior Research Lecturer in Public Health, Teesside University

As newspaper headlines have shown, the issue of encouraging individuals to adopt healthier lifestyle behaviours by paying them is controversial. Whilst many of us know that we should do a bit more physical activity, eat our five-a-day fruit and vegetables and even attend our vaccination and screening appointments, we don’t always do this. Many barriers prevent us from fully engaging with these healthy behaviours, and these barriers are often complex, individual, and are not always easily surmountable. These barriers range from living away from green spaces which would allow outdoor exercising, to deep-seated social norms that stop individuals from engaging in healthy behaviours because they are not well accepted by family, friends or the wider community.

In recent years there has been a growing body of research looking at paying people to be healthier. This essentially means providing individuals or groups with cash, shopping vouchers or gifts in return for the adoption of healthier behaviours. Such schemes include the Pound for Pound weight loss incentive scheme, the Give it Up for Baby scheme, and offering incentives for breastfeeding.

In order to hear recent research evidence, and to provide a forum for friendly debate, I organised the recent Fuse Quarterly Research Meeting, which focused on payment for health behaviours. Last Wednesday (22 July), policymakers, practitioners, and academics came together to hear presentations from four academics and practitioners working in the broad field of incentives. As Claire Sullivan, a Consultant in Public Health from Public Health England mentioned in her opening address as Chair of the meeting, often incentives can take various forms – including paper pants for Chlamydia screening!

In terms of specific incentives, Professor Pat Hoddinott, Chair in Primary Care, Nursing Midwifery and Allied Health Professions Research Unit at the University of Stirling, presented research which focused on incentives for breastfeeding and to quit smoking in pregnancy – the BIBS study. Key findings suggest that tailoring of incentives is important to meet local needs, but that they show promise to encourage these behaviours.

Professor David Tappin, Professor for Clinical Trials in Children within the School of Medicine at the University of Glasgow, followed Pat by showcasing data from the CPIT trial – a smoking cessation in pregnancy trial in its second phase. Results showed that there was a 14% increase in quit rate and further analysis showed that there was a 150g increase in birth weight of babies born to mothers who quit smoking. Findings suggest that financial incentives were found to be acceptable by the women involved, and may double the quit rate when used with existing smoking cessation services.

A practitioner perspective was provided by Mr Andrew Radley, Consultant in Public Health Pharmacy, NHS Tayside, who talked about operationalising the use of financial incentives in a stop smoking programme within a community pharmacy setting. In particular, 393 women in Tayside engaged with the smoking cessation services, and incentives were found to be effective. Of note was the finding that mothers preferred receiving their incentives on a weekly basis.

I spoke last and presented qualitative data exploring the acceptability of incentives. The findings suggest that incentives are more likely to be accepted if they are provided to certain population groups including pregnant women and those on a low income, but not for those who may have alcohol or drug problems. The ‘perfect’ incentive has yet to be identified, but it will need to be shown to be cost-effective for it to be accepted on a wider scale.

The presenters were then joined by Peter Kelly, Director of Public Health Stockton Borough Council, Jim Beall, Health and Wellbeing Board Chairman, and Dr Jean Adams NIHR Research Fellow at CEDAR for a panel discussion. The audience raised many questions and comments around the use of incentives, with particular concerns around incentives increasing health inequalities, aggressively placing the blame of poor health on individuals, and that incentives may result in moral implications when individuals are rewarded for their behaviour. The debate suggested that more research evidence is needed to discover what type of incentive works for whom, and in what setting, and to better explore group (rather than individual) incentives.

What is obvious is that paying people to be healthier is an emotive topic, a highly contested intervention approach, but at the same time, it also shows promise to encourage individuals to adopt healthier lifestyle behaviours. It certainly provides food for thought…how many of us would accept money to be healthier?

Follow this link to find out more about the Fuse Quarterly Research Meeting ‘Payment for health behaviours: the case of health promoting financial incentives’ on the Fuse website.

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How active are pregnant women? Measuring the methods

Posted by Louise Hayes and Cath McParlin 

Louise and Cath are presenting on the subject of physical activity in pregnancy at the Fuse Phyical Activity Workshop tomorrow (15 May) at Sunderland University.

So we all know we should move a bit more to be more healthy and reduce our risk of getting diseases like diabetes. For a long time pregnancy was seen as a time when a woman could put her feet up, take it easy and ‘eat for two’. But not any longer! Guidance published over the last few years recommends no ‘pregnant pause’, but rather that pregnant women should aim to achieve at least 30 minutes of activity of at least moderate intensity activity on most days of the week - just like the rest of us.

Part of the justification for this is that physical activity might help to reduce the risk of gestational diabetes (GDM) – that’s a type of diabetes that is diagnosed in pregnancy and (usually) resolves after the pregnancy. However, to some extent, the jury’s still out on whether or not being active when you’re pregnant really does reduce GDM.

Partly this is because we don’t really know how to measure physical activity accurately in pregnant women. The more precisely we can measure physical activity, the more accurately we can establish the relationship between it and GDM and other health outcomes.

Physical activity measurement is fraught with difficulty in any circumstances – it’s a challenge to measure such a complex and multi-faceted behaviour. Pregnancy brings additional challenges. With the development (and increasing affordability) of numerous objective methods for measuring physical activity – pedometers, heart rate monitors, accelerometers - objective measurement of physical activity in epidemiology is increasingly common. For pregnant women, however, the validity and acceptability of these methods remains unclear.

We have agonised over how best to measure physical activity in a pregnant population. What effect does the increasing size of the ‘bump’ have on the validity of waist-worn monitors? How good are monitors at recording low-level activity, common in pregnant women? What are appropriate cut-offs for different activity intensities in pregnant women?

The choice of measurement method has a huge influence on conclusions we draw about how active women are during pregnancy. We have compared questionnaire methods and accelerometry using different criteria to define activity intensity and found that, depending on the method used, we identify anything from 12% to 65% of pregnant women to be meeting the current guideline (30 minutes of at least moderate activity per day) in the first half of pregnancy.

We’re looking forward to discussing the whys and wherefores of different methods of assessing physical activity with the experts attending the Fuse PA Group Workshop at Sunderland University tomorrow (Friday 15 May).

No time to run: is role overload contributing to physical inactivity in parents?

Posted by Caroline Dodd-Reynolds

Last night during a Twitter exchange, it somehow came about that I would write a #fuseblog on barriers to physical activity and a healthy diet in working mums. Interestingly, my one-year-old daughter had just gone nicely to bed at this point and so my husband and I treated ourselves to a healthy(ish) home-cooked dinner, albeit at 9pm. Normal service was resumed however at 12.30am when we were woken by the sound of the one-year-old vigorously banging on her cot and shouting, ‘Is DARK!’ (yes, it’s the middle of the night). So here I am typing this blog with two hours of sleep under my belt. Primarily this is why I no longer do very much exercise-based physical activity, or indeed eat as healthily as I used to. I am sure there are many who can relate to this sleep-deprived existence. Certainly the transition to parenthood can be an experience of life-changing proportion. For me, the transition back to work after months of no sleep and complete displacement from my previous identity was interesting.

There is guilt at leaving my little one at nursery and then there is the race through the day so that I can leave early enough for us to have an hour of (potentially active) play before bedtime. There is guilt at not being able to attend the evening functions at work, the interesting lectures that I know would be pure luxury to immerse myself in. There is pressure to succeed at work, not so much to prove that I can be both a parent and an academic, but more that if I don’t, then there is little point in having endured the guilt. And what of physical activity? Well, please see my previous points as to why this takes a seat so far back that I can barely see it.

The Chief Medical officers recommend 2hr 30min moderate-vigorous physical activity (MVPA) per week for adults; an individual is classed as inactive if achieving less than 30min moderate physical activity per week. Time spent engaged in MVPA declines with age and in 2012, 67% of men and 55% of women aged 16 years and over were meeting recommendations. These data were self-reported and objective monitoring methods suggest these figures are inflated. Guidelines for reducing sedentary behaviour are less clear but should involve avoiding prolonged periods of sitting. I am a full-time Lecturer in Physical Activity and Nutrition and so the irony of spending hours (sitting) writing lectures on the perils of sedentary behaviour and energy-dense snacks, is not lost on me. I did a quick PubMed search including physical activity and working mums as key terms and found a lonely but slightly reassuring 10 articles.

One article describes succinctly and astutely the fact that much is known about motherhood as a transitional influence on the physical activity habits of new parents, but actually very little about those new parents (or indeed any parents) who work. Emily Mailey and her colleagues, from the Dept of Kinesiology at Kansas State University, talk about ‘role overload’ and how this is associated with negative health outcomes such as elevated stress, depression and anxiety. I am starting to feel better here. The 25 mothers and fathers who participated in focus groups for this study reported barriers such as ‘scheduling constraints’ which I think many working parents may identify with – for me it is the Outlook calendar that keeps me on track and I know that if I schedule 30min into it on a Tuesday, I do have time to nip out for a run and I am more productive for it. But then what if someone requests a meeting or tutorial? Interestingly, ‘prioritising’ is noted as a facilitator. One mother comments that she had to get up at 5am to fit her physical activity into her day. Indeed this is a thought that often crosses my mind. Another, is that working parents may well comprise a special population in terms of physical (in)activity habits and sedentary behaviour; when I was on maternity leave I was certainly more active than I am now.

Anyway, I’m writing this on a Friday (thank goodness for the weekend). I really must clean the bathroom tomorrow, and the car needs a good wash, these will get my activity counts up, great. Oh but then there is that paper I need to write, and next week’s lecture I have yet to prepare. I know realistically what I will be doing this weekend – and it may not comprise any minutes of MVPA, nor help my preparation for next week at work, but I know it is the finest choice and that my little girl will laugh out loud with delight when she sees the animals on the farm.

Feeling slightly more awake after some strong coffee, I have just read this blog back and am sad that it sounds rather negative. It isn’t meant to, but it has made me think a little more about how I spend my days (and the potential to ask for a standing desk at work). And in case you were wondering, I would not swap my little girl for any amount of physical activity. Mailey and co. talk about being a role model and being active with your children. In a good week with no illness, sleepless nights or marking, we probably do manage to achieve this to an extent. And my little girl is happy, active and eats a healthy but balanced diet (vegetables and chocolate included) so perhaps we are doing things right after all?

52 weeks in public health research, part 42

Posted by Peter Van Der Graaf and Mark Welford

From Peter Van Der Graaf: The Fuse stand before the maternal, infant and child health conference held in the Legends Lounge at The Riverside Stadium, home of Middlesbrough Football Club.

From Peter Van Der Graaf: The audience for the event was broad: from pharmacy, marketing and child nutrition to maternal mental health, smoking and alcohol misuse, and immunisation.  Key message: we need clear and consistent messages across all health professionals.  But what about 'pleasures' of unhealthy behaviours and structural inequalities in accessing opportunities to change behaviours?

Meanwhile in Sheffield...

From Mark Welford: A sister Fuse stand at the National Institute for Health Research School for Public Health Research (NIHR SPHR) Annual Scientific Meeting.  The ASM showcases the School’s research priorities and themes and sets out the School-wide programmes of research. 

From Mark Welford: Established in April 2012, the SPHR is a partnership between eight academic centres, including Fuse, with excellence in applied public health research in England. The School aims to build the evidence base for effective public health practice.  

Bonus pic from Mark Welford: No '52 weeks...' post would be complete without the obligatory food image.  It's a close run thing between the muffins and fruit in the refreshment break popularity contest.

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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.