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.

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

Posted by Katie Beresford, undergraduate student, Durham University

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

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

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

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

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

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

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

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

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

Taking the scenic route to academic attainment

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

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

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

Part of our Fuse blog Student Series

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

Images:

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

Not addicted but still having an impact: children living with parents who misuse drugs and alcohol

Guest post by Dr Ruth McGovern, Institute of Health & Society, Newcastle University

There is growing political interest in the misuse of alcohol and drugs by parents and its impact upon children. The newly published Drug Strategy 2017 highlights drug and alcohol dependent parents as a priority group with an estimated 360,000 children living with parents who are dependent upon alcohol or heroin.

As a registered social worker, I have often identified ‘dependent parental substance misuse’ as a risk factor in many ‘child in need’ assessments conducted by Children’s Services. Around half of all child protection cases, recurring care proceedings (repeat children removed and placed into local authority care) and serious case reviews (enquiries following child death or serious injury where neglect or abuse is known or suspected) involve parents who misuse substances. However, the impact of parental substance misuse is not limited to addicts. The number of children living with parents who misuse but aren’t dependent upon alcohol and drugs is likely to be substantially more than the number of children living with those who are addicts. As such, greater harm in the population as a whole is likely to be experienced by these children.

I have been part of a group of academics and clinicians who have recently concluded a rapid evidence review funded by Public Health England (PHE). The review found evidence that parents who misuse, but aren’t dependent on substances, can have a significant impact on the physical, psychological and social health of their child. For instance, in early childhood we found that children of mothers misusing alcohol [1] were twice as likely to suffer a long bone fracture and five times as likely to be accidentally poisoned, than children whose mothers do not drink heavily. Children of mothers misusing alcohol or drugs are also more likely to require outpatient care or to be hospitalised due to injury or illness, and for longer. The impact of substance misuse by parents continues into adolescence, with our review showing an increased likelihood of antisocial, defiant and violent behaviour in late adolescence as well as substance misuse by the child. However, many of these children and families are not identified as being affected by the substance misuse of a parent and subsequently do not receive the help they need in the form of an intervention.

Therefore, our review also examined the evidence for effective interventions to help reduce the numbers of parents misusing alcohol and drugs. Family-level interventions, particularly those that offer intensive case management, or those which provide parents with a clear motivation (such as those linked to care proceedings) show promise in reducing the problem. Unfortunately, there was little research examining the effectiveness of interventions for parents misusing but not dependent on alcohol and drugs.

PAReNTS study logo

To respond to this evidence gap, we designed the PAReNTS study (Promoting Alcohol Reduction in Non Treatment Seeking parents). Within this study we are examining the feasibility and acceptability of alcohol screening (using the AUDIT-C questionnaire [2]) and brief interventions with parents involved in early help and statutory children’s social care services. The brief intervention is an adapted version of the ‘How much is too much?’ programme for parents [3] which combines advice and behaviour change activities and is delivered by both social care practitioners and the local alcohol service. Whilst alcohol brief interventions have been found to be effective in adults who misuse alcohol, little is known about the effectiveness of such interventions for parents with additional and complex needs. This presents unique challenges, for instance, parents may be concerned about the stigma of being labelled as having an alcohol problem, particularly if this could be used as a reason to remove their child from their care. There is clearly a need for a sensitive approach. In future blog posts, I hope to update you on the progress we make with the PAReNTS study and whether it is feasible to deliver early interventions with alcohol misusing parents to improve the wellbeing of children, who are often overlooked in public health.

References:

1. Below the age of 10 years, much of the evidence focuses on mothers with alcohol misuse problems as most caregiving is carried out by mothers during early years. 
2. The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence): https://www.integration.samhsa.gov/images/res/tool_auditc.pdf. 
3. This programme was highlighted by the National Institute for Health and Clinical Excellence alcohol prevention guidance (PH24): https://www.nice.org.uk/guidance/ph24.

Image credits:

• First image: Copyright: Alcohol Concern April 2008. Taken from the report 'Keeping it in the Family Growing up with parents who misuse alcohol'. ISBN number 1 869814 92 4: https://www.alcoholconcern.org.uk/Handlers/Download.ashx?IDMF=399c1dd7-1cb3-407d-a093-b3d486ac034d

Monopoly money, pitching to the converted, and sending Mr Grumpy away happy: doing home and healthy ageing research differently

Dr Philip Hodgson, Senior Research Assistant, Northumbria University

Endings are rubbish, right?  Whether it be a great novel, play, film, TV series – there’s always that feeling that no matter how things are pulled together, it will never be as good as you have pictured in your imagination.  And then, you know, it just ends…

It was perhaps with this in mind that we decided to take a different approach in the last of our four workshops on home and healthy ageing.  Rather than guest speakers being invited to share their knowledge and prompt discussion, the project team attempted to summarise and pitch their ideas for future research back to the group (think Dragons’ Den).  This proved to be challenging, as the previous sessions had been so rich that even synthesising them into brief slides was difficult, never mind placing them in a strategic context for the participants to critique and reflect upon.  Yet, three key themes were identified.  These were in addition to the concept of a ‘home’ being more than just bricks and mortar but personal/psychological, physical and social/environment space(s) – an idea that we used as a starting block in week one and illustrated below.

More than just bricks and mortar
'Home' illustration used in the seminars 

The key themes were:

• Policies and contexts: not only a tension between housing and health policies, but also the need to consider market and narrative factors influencing housing and health decisions;
• The life course approach: the need to think about housing as an individual pathway, in which preventative measures and services are considered before crisis point;
• Transitions and soft services: the need for support to be available as and when people experience key housing and life changes, such as reduced physical health, retirement, or the loss of support networks and being able to navigate different services on offer.

However, this is where we’d like to leave you with a cliff hanger: rather than going through each of themes in-depth (fans of this series will have to wait for our spin off…  er, research papers for that!), we’d instead like to reflect on our process at this stage.  These sessions took a slightly different approach as, rather than being a series of open seminars with presentations that people could dip in and out of, we invited several key individuals to attend each session in turn.  The reasons for this were many, but primarily we wanted to ensure that a diverse range of backgrounds were represented throughout (housing providers, architects, academics, local authority workers, homelessness workers, etc.) to go on a learning journey with us as a research team.  This meant that by the time we reached the final session, there was enough of a shared understanding that we could make the most of the group’s commitment to the project – we would be actually able to start to pin down quite complex concepts, practical issues and, hopefully, future projects.

We tried out different formats to structure the discussions: from world cafés, to games (with Monopoly money!) with researchers pitching ideas to mock panels, which worked to various degrees but always ensured a lively debate.

Do not pass Go. Do not collect £200
Pitching ideas with Monopoly money 

There were, of course, some difficulties.  As I’m sure everyone reading this will know, it is a lot to ask of a practitioner to take one morning out of their schedule, let alone for four seminars.  As a result, engagement had to remain a constant focus and I spent much time nervously lingering by the registration desk hoping for just a few more name badges to disappear before we started!  It was also a challenge in terms of managing the conversations during the sessions: you want all voices to be heard in such a diverse group but we all needed to be pulling in the same direction by the end.

Yet, by the final session, the rewards were immense.  Not only were we able to pitch ideas to a group who had already undergone some of the same learning as us, but this gave everybody the confidence to relate the complex theoretical issues to their own practice (allowing us to capture the breadth of what was possible).  It allowed us to discuss concrete projects, and leave the session with a sense of trust that networks were in place to actually deliver on them.  Perhaps most importantly we found that, what started as a broad idea, was something of relevance across the housing and health sectors.  Even the grumpiest of the project group (naming no names) left the day with a spring in their step.  For that alone, everyone who attended deserves some massive thanks…

So, who needs endings, when we can all just sign up to the sequel?

To be continued…

Photo 2: By James Petts from London, England (Monopoly) [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Researching holiday hunger

Guest post by the Healthy Living Lab team, Faculty of Health and Life Sciences, Northumbria University

“Summer is here and the living is easy ….” well for most people it might be. However, for many families on low incomes, school holidays are challenging times. Over the past few years, the Healthy Living Lab at Northumbria University has undertaken research into the holiday clubs providing support to these families. We have had the privilege of working with clubs right across the UK from Scotland to the South of England. We have visited clubs based within a range of settings including schools, food banks, church halls and community centres. Research by the Healthy Living Lab is providing a significant insight into the location of holiday clubs, and crucially identifying gaps in provision and the outcomes for families and children attending the clubs.

During the school term, free school meals (FSM) act as a safeguard for children from low income families, but there is no additional state provision for these children during the school holidays. The term ‘holiday hunger’ has been used to describe the hardship that children and families on low incomes face during the summer break; when they do not have access to a free school lunch. Moreover, the increase in financial pressures during the school holidays has a more general impact on the quality of children’s lives, as families lack money for entertainment, socialising and educational or developmental activities (Gill & Sharma, 2004; Graham et al., 2016; Kellogg’s, 2015).

School holiday clubs can help to bridge this gap by providing food, activities and support. Many holiday clubs are staffed by volunteers, who have given up their summer to make sure that something important happens; that children have access to nutritious meals when free school meals aren’t available. There is also a good chance there will be activities happening within holiday clubs, and that the children attending are having a great time.

Research from the Healthy Living Lab team ascertained a need for holiday club provision for families on low incomes (Defeyter, Graham, & Prince, 2015). We have spoken to parents and children at holiday clubs, many of whom live below or just above the poverty line. Our findings highlight that, for many low-income families, the school holidays are difficult, especially the longer summer break. A member of staff at one holiday club breakfast club indicated that it wasn’t just children who benefited from the the holiday breakfast club as well, saying:

“Main thing is for the kids, but I think it’s really benefitted the adults as well, so urm yeah just making sure every-one’s getting food, which is really important ‘cause breakfast, the most important meal of the day (Female staff member; Club 5) (Defeyter, Graham, & Prince, 2015, p.5)

Whilst parents strive to ensure that their children are fed, many find it more difficult to manage during school holidays, as food bills increase and thereby the risk of low-income families experiencing food insecurity also increases. Moreover, we have spoken to staff and volunteers from school holiday clubs, who have told us that their clubs provide food, in addition to social, learning and support opportunities (Graham et al., 2016). Our research shows that holiday clubs not only provide financial support to low income families, through the provision of a free meal, but also provide a social outlet for parents and their children, as well as wider benefits for the community (Defeyter, Graham, & Prince, 2015).

Researching this area is challenging as it involves talking to families about sensitive issues such as their food and financial situation. But, this work is also invaluable as it draws directly on the experiences of parents, children, and holiday club staff ensuring their voices are heard.

The Healthy Living Lab Team is:

• Professor Greta Defeyter, Faculty Associate Pro Vice-Chancellor (Strategic Planning & Engagement), Faculty of Health and Life Sciences, and Director of Healthy Living
• Dr Pamela Graham - Vice Chancellor's Research Fellow
• Dr Louise Harvey-Golding - Senior Research Assistant
• Emily Mann - PhD Researcher
• Jackie Shinwell - PhD Researcher

References:

1. Gill, O., & Sharma, N. (2004). Food Poverty in the School Holidays. London.
2. Graham, P. L., Crilley, E., Stretesky, P. B., Long, M. A., Palmer, K. J., Steinbock, E., & Defeyter, M. A. (2016). School Holiday Food Provision in the UK: A Qualitative Investigation of Needs, Benefits, and Potential for Development. Frontiers in Public Health, 4(April 2014), 1–8. http://doi.org/10.3389/fpubh.2016.00172
3. Kellogg’s. (2015). Isolation and Hunger : the reality of the school holidays for struggling families. Manchester. Retrieved from http://pressoffice.kelloggs.co.uk/Going-hungry-so-their-children-can-eat-Third-of-parents-on-lower-incomes-have-skipped-meals-during-school-holidays
4. Defeyter, M. A., Graham, P. L., & Prince, K. (2015). A Qualitative Evaluation of Holiday Breakfast Clubs in the UK: Views of Adult Attendees, Children, and Staff. Frontiers in Public Health, 3(August). http://doi.org/10.3389/fpubh.2015.00199

Photo courtesy of Children in Scotland: http://www.childreninscotland.org.uk

Two perspectives on arts and public health

Andrew Fletcher, PhD researcher, Faculty of Health & Life Sciences, Northumbria University

Engagement with the arts and/or creative practice benefits wellbeing in multiple ways. I am a musician and relatively new to public health. This post argues that arts and culture should have greater prominence in health and social care.

Courtesy uk.pinterest.com

So what of arts-based therapies? Compared to Cognitive Behavioral Therapy (CBT) for example, such programmes are not heavily promoted. Perhaps this is right; CBT is cheap and effective, whereas things like music therapy are often reserved for individuals with more complex needs. But this hierarchy contributes to the idea that arts-based therapies are ‘alternative’ – potentially placing them in the same category as, say, homeopathy. This is not a helpful perception, but anyone who’s tried to advocate for creative therapies will know it exists.

Then there’s ‘evidence-based medicine’, which is of critical importance, but whose dominance has been challenged.2,3  This is particularly relevant to approaches to health and wellbeing that are seen as ‘alternative’, which still seem to remain the preserve of those who can afford to try more ‘esoteric’ interventions – thereby reinforcing inequality. So what’s the response? Promote holism*; make arts therapies mainstream; emphasise their part in everyday life; make creativity and cultural engagement as vital as exercise, healthy eating or social interaction. The idea that creativity is intrinsic to wellbeing needs to be established in the early years and beyond, and to neglect this idea is missing a trick.

Courtesy tinybuddha.com

Why do people do art? Usually to express a political statement, to communicate a specific feeling or sentiment, or to satisfy some intangible ‘urge’. Making a painting to hang on your bedroom wall cultivates a more pleasurable living environment; putting your kid’s collage on the fridge boosts self-esteem; and who never listens to music? Creative practice, in one way or another, feeds into numerous wellbeing outcomes. Artists know this instinctively, yet policy around art and culture focuses on tourism and/or entertainment income, and a vague ‘intrinsic’ social value. Lip service is paid to health, but as Tiffany Jenkins says: “If you’re competing with hospitals, you’ll lose”.4

But art and wellbeing are significant components of the lived experience. They make us human. They sit at the apex of Maslow’s hierarchy** and most people understand the inherent value of culture to either social or personal wellbeing. If prevention really is better than cure, we must pay attention to the cultural-wellbeing landscape and the atmosphere these concepts exist in. Perceptions are changed through innovative and creative information delivery – so creativity not only has its own wellbeing outcomes, it’s also the key to shifting arts and culture towards being a major pillar in overall wellbeing.

I can’t help but wonder what the world would be like if the perceptions of arts therapies were different. Stickley (2014)5 outlines one potential scenario as follows:

The year is 2080. A new textbook has been published. The book is called ‘A Century of Healthcare’ and I would like to quote from this book:

"For most of the last century it was unusual for people to be treated holistically. Incredible as it sounds today, healthcare systems separated physical interventions from anything they referred to as "mental". Thus a dualism existed and people were treated as divided objects. At the time, there were many attempts at holism, especially by those who practised alternative or complimentary therapies. However, anything that remotely threatened the domination of the medical model was largely side-lined and researchers gave little credence to anything that was not considered scientific.

We should however give a great deal of credit to those who foresaw the potential contribution that the arts and humanities could make to healthcare and wellness but they operated in a narrow scientific paradigm that gave little acceptance to holism…”

The contexts in which creative practice occurs are complex, but the benefits are multiple and well-known. The key here is changing perceptions. This takes time, but perhaps Stickley’s vision will bear out. I hope so.


Footnotes:

* The idea that the human experience of wellbeing is social, cultural and complex, and extends far beyond medical definitions of health.
** 'Self actualisation' appears at the apex of psychologist Abraham Maslow's 'hierarchy of needs' model and includes in its definition (among other things): "expressing one's creativity".

References:

1. Various demographic data available from www.theaudienceagency.org
2. Greenhalgh, T., Howick, J. & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? BMJ g3725.
3. Stickley, T. (2015). A little rant about evidence, available from: https://ayrshirehealthandarts.wordpress.com/2015/03/31/dr-theo-stickley-a-little-rant-about-evidence/
4. Jenkins, T. (2015). Front Row debate (23rd Feb, 2015). Are artists owed a living? Online: BBC.
5. Monologue delivered at ESRC funded Seminar Series on Arts, Health & Wellbeing, 15th September 2014.

Social enterprises in health: can you make profit for the greater well-being of all?

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University

Is it ok to make money in public health? This was one of the key questions that that came out of the Quarterly Research Meeting on social enterprise and health last month, which was jointly organised by Fuse and the Institute of Local Governance (ILG), in association with the North East Social Enterprise Network (NESEP). Social enterprises are often involved in pioneering and transformational work that may help reduce pressure on public health providers within local authorities. But are we taking enough notice of their potential and is there an evidence base for such interventions? The event aimed to explore this theme, highlight best practice and identify barriers and opportunities for future work and research in this area.

The key note speakers first engaged in a bit of myth-busting: a social enterprise is not a legal form and does not mean the same as not-for-profit. They are not replacing the NHS or public health, are not promoting budget cuts and are not a form of corporate social responsibility. So what are they then? Professor Cam Donaldson from Glasgow Caledonian University offered the following definition: “organisations that trade for the common good (e.g. addressing social vulnerability) and where the profits of that trade are used for social and community benefit”.

Making profit for a good cause sounds like a good idea, particularly for cash-strapped health and voluntary and community sectors, but the discussions at the event made clear that this comes with a number of strings attached, which can have far reaching and often unintended consequences for organisations. For instance, bidding for contracts can shift organisational focus from addressing local needs. Organisations also have to be size and investment ready, with plenty of larger competitors out there going for the same contracts. And this can be a big ask, particularly for small community organisations that have no interest in developing a business strategy.

 

There is also an ethical dimension to this decision: moving health provision from the public sector to social enterprises means one less link in democratic accountability. Who governs the governors of social enterprises? Cam Donaldson referred to this as “the shadow state”. Is the market also the right model for public health and wellbeing delivery or does it cause further distortion of social priorities? One participant put it as follows: “Although commissioners understand the importance of well-being, they are unlikely to pay for it unless you can demonstrate that it will save them money”. If everything is all of a sudden an asset, where does that leave an ideology of free access to health and social care for all?

In summary, social enterprises in health leave a lot of questions unanswered but can make quite a difference, be it for better or for worse. Unsurprisingly, there was an urgent plea from participants to academics to develop more research in this area. Studies looking at social enterprises in health are rare and particularly their impact on health and the wider determinants of health is unknown.

Interestingly, participants argued for a move away from “REF impact research” and government favoured approaches, such as Social Return On Investment (SROI) analysis. They argued that economic models were less suited for capturing the wider range of health and social outcomes that social enterprises aim to deliver. Outcomes of social enterprises are often produced in co-production between commissioners, providers and service users and, therefore, needed to be measured as such. Therefore, participants advocated a more anthropological approach to impact research for social enterprises that allowed researchers to leave outcomes and their measurement more open from the start of the research to accommodate new meaning of impact along the way.

Would that perhaps be the greatest asset of social enterprises in health: turning co-production of evidence into a profitable approach?

A summary report of this QRM can now be found here.

Picture attribution: www.flickr.com, Tom Simpson, "I've always been able to turn mistakes into big profits!", https://goo.gl/ku0VRG 

Not just a can of pop: the social meanings of energy drinks

Posted by Mandy Cheetham, Fuse Research Associate at Teesside University

Children and young people can sometimes be conspicuous by their absence in public debates about sugary drinks, so I’ve enjoyed reading the series of blogs posted since September, which describe research and activities involving young people. As children and young people are the predominant consumers of sugary drinks, it is claimed they are one of the groups whose health will benefit most from efforts to control or reduce their consumption (FPH 2015), such as the introduction of a duty on sugary drinks advocated by PHE (2015) and popularised by Jamie Oliver.

Our study on energy drinks showed that cost was one of the major influences on young people’s choices. The mapping exercise we did with Year 6 and Year 9 students in their local area showed walls of cheap, appealing, attractive displays of multiple flavoured energy drinks to tempt young people, with ‘buy one, get one free’ offers to share with friends. As important as the economic considerations are, the social meanings of energy drinks also have a major role to play. These are often misunderstood or ignored by adults planning public health interventions to reduce the risks of obesity.

Young people described the social spaces in which they drink energy drinks, whether consumed at weekend sleepovers, whilst gaming, hanging out with mates in the park, or on the way to or from school. Shared, swapped, and exchanged, energy drinks, and the sponsorship, branding and marketing associated with them, are woven in to the social fabric of young people’s lives. Energy drinks are part of the construction and maintenance of particular gendered identities, associated with extreme sports, alien elimination, looking hard, sophisticated and / or attractive. They offer young people opportunities to conform to certain ideas about what girls and boys like and do, and become part of the currency of young people’s daily interactions. In short, social meanings matter.

In Wendy Wills’ presentation at the Sweetness, Social Norms and Schools seminar in September, (CPPH/Wolfson Seminar - Sweetness, social norms and schools: factors influencing children and young people’s food and drink practices), I was struck by the similarities in young people’s comments about the importance of social relationships, interactions with friends, and the value of friendly respectful exchanges with local retailers, informing their lunchtime decision making. Young people were keen to be involved in efforts to improve the school food environment. Young people in our study were similarly fired up to make positive changes, and questioned why and how energy drinks companies can target young people under 16. They had ideas about what would make a difference and were realistic about the challenges of restricting sales of energy drinks to young people.

In September, Fuse welcomed Professor Helen Roberts, a self confessed fan of evidence informed public health advocacy, to deliver a knowledge exchange seminar prompting debates about our role as academics and advocates. Constrained by restrictions placed on us by funders, some appear nervous about compromising assumed notions of independence. If we want our research to have impact, should we not frame public health debates in ways which make sense to those who participate in our research? Rather than simply highlighting the health risks of energy drinks, this means understanding the social meanings of young people’s food and drink choices and more critical engagement with the industry that promotes them. Our efforts would be further strengthened by encouraging young people and colleagues to connect with other campaigns such as RRED and GULP.

To download the Fuse Energy Drinks report click here, or the Fuse Brief can be viewed here.

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Who needs nudging, shoving, and shaming? Individuals or government?

Guest post by Victoria McGowan, Post-Doctoral Research Associate at Teesside Uni, Alcohol & Public Health Research Team

I recently attended International Society for Behavioural Nutrition and Physical Activity (ISBNPA) conference in Edinburgh (see #ISBNPA2015 on twitter). The conference was a great event and I’m very grateful to Teesside University for supporting my attendance.

Conferences have a tendency to be sedentary affairs and can often have limited opportunities for physical activity or even just standing during sessions. However, I was delighted to see that the conference organisers had marked out significant space for standing during sessions. Not only that, but there was the opportunity for yoga and health walks early every morning as well as lessons in ceilidh dancing at lunch time and a walk to Arthur’s Seat as part of the social programme. It was quite a physically active, physical activity conference.

Lunch time ceilidh dancing

However, there were some interesting discussions about whether us delegates were being socially shamed or nudged into partaking in physical activity during the conference. The conference opened with Professor Nanette Mutrie describing how she’d spotted one of her own researchers using the escalator as opposed to the stairs and encouraged delegates to give standing ovations to all speakers in an attempt to get us on our feet more. Although I found the level of physical activity on offer a refreshing change from being largely sedentary, I was slightly unnerved about the underlying social shaming.

I’m a strong advocate for informed choice, I love posters on stairs telling me how many calories I’ll burn by walking up them but I also love having the option of taking the escalator. There were stories of academics taking photos of people using the escalator to shame them for not using the stairs. It was interesting to watch the Mexican wave of delegates standing to applaud, a few individuals would stand and then row after row behind them followed suit… until it came to me and I would sit in defiance. Why did I stay seated? Because I have a choice and honestly, I don’t like being socially shamed into doing something. Yes, I agree obesity, nutrition, and physical activity researchers should not be hypocritical and practice what they preach. However, we also need to be mindful that we’re working with people who are more concerned about paying their rent, whether their children need new school shoes, zero hours contracts, whether they can get an appointment with their GP, the list goes on. Yes, taking the stairs may improve our health if we use them regularly but we have to understand that some individuals choose the unhealthier option due to a whole host of external pressures. Lecturing these individuals about taking the stairs may fall on deaf ears or, as in my case, may lead to defiance. I used the escalator on occasion because it was quicker for me to walk up/down the escalator to dash between sessions and avoid the crammed stairs.

There are other reasons why individuals choose the less healthy option and we need to understand these external pressures rather than shaming people into taking the stairs. As Professor Alan Batterham rightly pointed out in his debate with Professor Stuart Biddle we’re evolutionary predisposed to conserve energy whenever possible so sometimes we may choose the escalator. However, we may choose the stairs if we’re provided with information on why it’s good for our health, or if we alter the environment to make healthy choices easier. But please don’t shame us into choosing one option or the other as this could lead to unintentional detrimental consequences of purposeful rebellion. Yes, I’m aware of the obesity ‘epidemic’, but I’m also aware this is caused by factors which are outside of individual control. Professors Ted Schrecker and Clare Bambra’s book How Politics Makes Us Sick shows how the rise in neoliberal policies in the UK and US are associated with rises in obesity and health inequalities.

Inequalities are having the greatest impact on health

Kylie Ball highlighted this point at the end of her keynote speech, yes we need to help improve nutrition and physical activity BUT we also need to help reduce inequalities in nutrition and physical activity. Inequalities are having the greatest impact on the nation’s health, not occasionally taking the escalator.

It’s time to nudge, shove, and shame our government, not individuals, into reducing health inequalities and improving overall public health.

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A Munich alcohol gathering with a difference

Guest post by John Mooney, senior lecturer in Public Health at The University of Sunderland

The mention of the German city of Munich and alcohol in the same sentence normally conjures up the image of a buxom serving wench in traditional Bavarian costume plying glasses of beer during Octoberfest, a prominent component of which is the Munich Beer Festival. Announcing to colleagues therefore that I was attending an alcohol public health conference in the city last week met with a few raised eyebrows – together with enquiries about whether I had got the wrong month!

This was most certainly not the case – for in addition to hosting the G7 conference in the nearby Bavarian mountains at the weekend, Munich was also last week’s venue for the 41st Meeting of the Kettil Brunn Society’s Alcohol Epidemiology conference. Established in 1986, the Kettil Bruun Society (KBS) is an international organisation of scientists engaged in research on the social aspects of alcohol use and alcohol problems. Given that the task of containing alcohol harm is now a truly worldwide public health challenge, the Society aims to promote social and epidemiological research on alcohol in a spirit of international cooperation and information exchange.

As a second time attendee, this year’s conference programme was just as packed and varied as the 2104 meeting in Turin – and the start of summer proper in Southern Germany ensured that temperatures were also comparable! Morning plenary sessions focused on current topical debates such as the relative merits of abstinence over harm reduction approaches, the latter including the controversial Dutch experiment where alcoholics who were resistant to treatment received payment partly in beer for undertaking community work.

The conference setting in the University of Munich’s Institute for Psychiatry and Psychotherapy meant that the psychological and mental health dimensions surrounding alcohol misuse were never far from the surface. Indeed accurately remembering the route to the Alzheimer room (named after the eminent psychiatrist himself who was once based at the Medical School), was going to be the first challenge of my own presentation session!

The luxury of a week-long conference allows for a 10 minute speaking slot for all accepted abstracts (KBS is a poster free zone!). Another unconventional aspect compared to most other conferences is the requirement to submit a full draft paper of your work before the conference. In addition to offering delegates the chance to view your paper through the conference website, this also enables your allocated discussant the opportunity to prepare some constructive criticism of your work (discussants are each allocated two papers in one of the parallel sessions). Most attendees therefore are allocated a discussant slot as well as their own presentation, so the required preparation beforehand is substantially greater than for most conferences where pulling together some slides the weekend before can often suffice!

Among the many highlights of the parallel sessions I attended were the rising public awareness and policy implications of alcohol’s contribution to cancer risk (where frequent drinkers are less likely to perceive the risk); the perhaps unsurprising enthusiasm that the alcohol industry shows towards presenting alcohol predominantly as a ‘lifestyle choice’ as opposed to a risk factor; the usefulness of sewage monitoring for estimating population-level consumption alcohol; and the potential value of reformatting alcohol labels to enhance awareness of drink strengths and associated health risks.

Another annual characteristic of the KBS Conference is a strong presence by the Sheffield alcohol research group, where I had the considerable pleasure of working for two years and on which work (on local alcohol policies) my own presentation was based. Other presentations from the Sheffield Group included gender differences in the effectiveness of alcohol policies; the need for more transparency in setting drinking guidelines; socio-economic gradients in UK alcohol harms across the four constituent countries and also social gradients in specific cancers, attributable to disparities in tobacco and alcohol use.

Now based within the Fuse collaboration at the University of Sunderland, there should be no shortage of opportunities for continuing my research interests in alcohol and fruitful collaboration with expert centres such as Sheffield and the UK Centre for Tobacco and Alcohol Studies (UKCTAS). The North East of England, very much like my native Scotland, is acknowledged to have among the highest public health burdens attributable to alcohol consumption in the UK and is also pursuing some of the most innovative policy solutions such as cumulative impact policies and a late night levy, as well as a very pro-active third sector in the form of Balance North East.

Of course, the Fuse collaboration also includes Newcastle Universities Institute of Health and Society acknowledged for extensive research into the effectiveness of screening and brief interventions for hazardous drinking as well as the alcohol and public health research team at Teeside University (TeamAlphaTees). The North East is well placed therefore for research into all aspects of alcohol harm treatment and prevention, although as yet, it has no October festival – which is probably something else to be grateful for!

Forthcoming events:

• Future Kettil Bruun Society Meetings: See Website for details
• June 2016 Stockholm, Sweden
• June 2017 Sheffield , UK
• Also for all practitioners and policymakers:
• UKCTAS Alcohol Policy & Practice Course at University of Sheffield / 1-4 September 2015.

Author affiliation
John Mooney FFPH, is a senior lecturer in Public Health at The University of Sunderland. He was previously a research associate with the Alcohol Research Group at The University of Sheffield, funded by the UK NIHR School of Public Health Research, which also funded his attendance and participation at this year’s KBS Conference

The pensiveness of the long distance runner*

Posted by Jean Adams

Have you been following #episongs? It’s like a game. But for epidemiologists. On Twitter. You’ll appreciate this lends it a certain in-crowd, geekiness:

     Bayesian Rhapsody (from @martinwhite33)

     One way or ANOVA (from @soozaphone)

     Geoffrey Rose the boat ashore (from @gingerly_onward)

     You say use StAYta, I say use StAHta (yours truly)

I have been using my running time this week to dream up contributions.

The loneliness of the long distance runner, Dir. Tony Richardson

I run most days. I down tools sometime between 5 and 6pm, gather up my stuff, head down to the toilets in the lobby of our building, where a secret door takes you through to a tiny changing room, and change from smart young professional into Supergirl. Well, more often it is from slightly scruffy climbing hut chic (as my dad once graciously labelled it) into rather smelly day-glo shirt and running tights.

Often I can’t quite be bothered. But I have found that this thought can be turned off long enough to get changed and out the door and by the time it comes back there’s no choice left.

I run because I like to be fit enough to keep up with my climbing hut buddies, because it gives me licence to eat a certain amount of cake, because it gets me outside for at least 45 minutes, and because it allows my brain to think in a different way from normal. I think it keeps me healthy. But it might not.

When I'm running, my thoughts take on a different quality. I don’t have to stop them because I need to focus on getting an abstract down to 250 words, wording an email just right, or so I can work out what exactly the person speaking is trying to say. I can just let them happen. But it’s not like there is a jumble of thoughts. Often it’s just one thing. Going back and forth. Round and round. Upside down.

I have some of my best ideas when I'm running. Ideas for research projects. Ideas for how to solve the problem I've been sweating over all day. Ideas for how to teach the cohort study session without killing everyone in the room with boredom. Ideas for #episongs.

Sometimes I think that the quality of my thoughts is so good when I'm running that running time should be reclassified as working time. Other times, my thoughts are not about work at all and I would feel resentful of having to think about something in particular when I'm running.

I presume the two things are not unlinked: my thoughts happening differently, and the good ideas coming. I presume there’s a technical term for the thoughts thing too. Once when my brother was particularly frustrated about something or other, I suggested he take up running. He said he was going to go on a meditation retreat instead. I suspect they might amount to nearly the same thing.

I'm a bit of a running evangelist  But I try not to be a running bore. Pounding the same loop, or variations of it, day after day is not that interesting of itself. Beyond the occasional wildlife spot, hardly anything interesting happens when I run, apart from in my head. There is not much about running itself to talk about. And, to be honest, I can get the same thought effect from swimming, walking and various other repetitive physical pursuits.

What I really want to get out of running right now is a running related #episong


*with apologies to Alan Sillitoe

Knitty problems

Posted by Jean Adams

My name’s Jean and I’m a knitter.

I am also a crocheter, sewer and quilter. I’ve tried my hand at upholstery and if anyone ever bought me a spinning wheel, I imagine I could get quite into that too.

I do these things because I like making stuff. I don’t always like the things I make. But I really like the process of making. Sometimes I like making things that require all my concentration and attention. Other times I’m happy just to mindlessly plod through a simple pair of socks or ripple blanket.

One of my many crochet blankets

I can totally mindlessly knit a sock and, at the same time, leave substantial brain space free for conversation, watching TV, listening to the radio, or doing the crossword. Obviously I would have to put my knitting down to fill in the crossword, but that’s not impossible. Me and my knitting aren’t absolutely inseparable, you know.

So here’s the question: would it be appropriate for me to knit in meetings?

Obviously, I’m not suggesting that I knit during a meeting that I’m chairing, taking notes for, or being asked to make some other types of substantial contribution to. But those sorts of meetings make up only about half of the things I go to.

Think of all those meetings which you just have to go to, but you learn almost nothing and almost contribute nothing. Knitting in these feels like a sensible option – at least I’ve used the time efficiently. Unlike the next best alternative of playing on my phone, at least when I’m knitting I can also listen, keep track of what’s going on, and contribute if I need to.

Then there are the things like seminars where I often learn something really interesting or useful, but again I don’t really need to contribute anything. Surely it would be okay to knit in those too?

It’s not like there aren’t other people who do crafty things in meetings – with very productive results. There are even other academics who knit in meetings in a very public way. And rules for how to do it right.

Sounds like I’ve almost talked myself into it, doesn’t it?

But the problem is, I’m worried about what other people would think. I guess there might be all sorts of responses to meeting knitting, but the one I’m most worried about is that people might think it’s unprofessional. Somehow playing on your phone can indicate that you’re a very busy person with important other stuff to be doing. Which just reinforces how very professional you are. Whilst knitting indicates that if you weren’t here you might be baking fairy cakes. Which is not what us serious academics should be doing at all.

Network or perish

Posted by Lynne Forrest

If you want to get on in academia you have to get published. That’s ok, I don’t have a problem with that. But there aren’t that many jobs available post-PhD and lots of people chasing them. So that means, as well as writing papers for journals, you’ve got to get out there and sell yourself - which translates as going to conferences and giving presentations. Even worse, you have to go to conference dinners and ‘network’. Just the thought of it is makes my heart sink. 

Networking

When I was growing up, ‘showing off’ was a bad thing so having to stand up and talk about how fabulous your research is, is a real trial. Plus I’m pale and Scottish so I go bright red. For those of us who’d really rather just sit at our desks and play with our data, this whole self-publicity thing is not fun. But I guess it is a necessary evil. You could be doing a brilliant job but if nobody knows about it then what’s the point?

I’m giving a presentation next week. Luckily it’s just an internal one but I’m stressing about it already. I’ve been on the training though. I know what I should be doing to give an effective presentation. But, by the time I’ve remembered to talk slowly and not look at my slides or stare fixedly at one person, I’ve forgotten what it was I was planning to say. Plus I’m presenting the results from my systematic review – I have a lot of data. There’s a danger of boring everyone to death with data overload. That’s a lot of things to stress about.

On the plus side, I am sharing the presentation slot with someone else. Is it wrong to hope that she’ll be rubbish to make me look better?

Actually it probably doesn’t really matter if it doesn’t go well as it’s just to give me some practice for the real thing. I’ve got a few conferences I need to attend this year. So I’ve drafted a couple of abstracts and submitted them. I’ve ticked the ‘poster or oral presentation’ box (because my supervisors made me) but you know that, really, I’m hoping it’ll be ‘poster’.

Dinner

Posted by Jean Adams

In my experience, there are two possible plans of action in that moment between drinks and dinner when everyone hovers around the table wondering if there is a seating plan.

Plan A is to actively manoeuvre to ensure that you sit next to the most interesting people.  Plan B is to hang back and grab the last seat.  Obviously Plan B is the introverts preferred method.  But there is a real risk that everyone else is following Plan A.  Meaning that Plan B’ers find themselves, by default, left sitting next to the very least interesting people. 

The other evening I found myself at a work related dinner where I hardly knew anyone.  I knew the people I probably didn’t want to sit next to.  So I manoeuvred away from them.  But I took my chances with the rest.

I was rather taken aback when, around 20 minutes into the dinner, the man on my right said in a rather loud voice: “Well, I used to be on the monetary policy committee, you know.  I disagreed with Mervyn King about almost everything.” 

Mervyn King

You what?  How did I, a university lecturer in public health, find myself sitting next to an economist who used to be on the MPC?  I am still not quite sure what the answer to this question is.  But it seemed unlikely that it would happen again.  So I decided to find out what I could.

I guess we are all victims of surrounding ourselves with opinions that agree with our own.  I feel quite privileged to work in a professional arena where my political opinions are mainstream, and are almost part and parcel of the job.  It’s nice to work somewhere where you feel your colleagues so strongly agree with your worldview.

So it was a bit of a shock to be at a work dinner with an economist who turned out to be just a little bit to the right of me.  It turned out he lives in New Hampshire – a beautiful part of the world, where the state motto is “Live free or die”.  They don’t have sales tax or state income tax in New Hampshire.  This means there are limited public services.  But it’s okay – because “there’s a market”.  You need your garbage collected – “there’s a market”, you need the snow swept from your drive – “there’s a market”, you need some health care – “there’s a market”.

“So what do the people in New Hampshire who can’t afford those things do?”  I asked.

“They live in Vermont.”

Apparently a new liberal era has washed in and the students are trying to get “Live free or die” replaced with the much more politically correct “Live free or move”.