How to get the evidence message across

Guest post by Katie Cole

The mantra of “but there’s no evidence for it!” is one I’ve said or thought many times, both in my work, discussions with family and friends, or when shouting at the BBC Today programme.

But as an early-career academic, I’m increasingly aware there is a complex web of considerations when trying to translate evidence into policy, and that there are times when chanting our mantra may do more harm than good.

I recently attended a Royal College of Physicians/Alma Mata seminar on alcohol advocacy. At one point, a panel member suggested that social norms interventions to address excessive alcohol consumption on university campuses “sounded very promising” and policy-makers were considering it. I’ve looked into US research into these interventions: a national evaluation concluded that they are ineffective in reducing alcohol consumption. Whilst I could have made this point, I felt it was more complex than that. Don’t we need to test the policy in the UK drinking context to make a more robust contribution to the debate? Shouldn’t we seek to support policy-makers to integrate evaluations into pilots, or to finance full-scale trials?

Another challenge I’ve had was during a placement at a Primary Care Trust. I was involved in the Individual Funding Request process, where the PCT considers funding treatments and procedures not normally available on the NHS. I worked up a number of cases, looked at the evidence base and presented the case to a panel of clinicians and non-clinicians. In most cases, the evidence base was of poor quality: finding a case series for the exact condition and treatment in question represented a minor professional achievement. Usually, the case series found that, lo and behold, most cases improved, which often sparked disproportionate optimism that we had a justification for funding the treatment. In contrast, when I found a randomised controlled trial with only modest results, the panel were more inclined to propose not funding the treatment. Here I was challenged to explain the difference between the strength of the evidence base, and the strength of the effect size; whilst at the same time, acknowledging the difficulty of decision-making against a poor evidence base.

A final challenge has been in developing The Lancet UK Policy Matters website, which includes short summaries of the evidence underpinning a range of UK health-related policy changes. In developing the format of the summaries, we had to be very clear to authors that statements purporting the intended benefit of the policy should not be included in the ‘evidence’ sections of the summary – this was reserved for peer-reviewed research or evaluations. Our experience in guiding authors highlighted to us how meticulous we as professionals need to be in the choice of language we use when drawing on our scientific expertise.

Above all other lessons, these experiences have taught me that advocating for evidence in policy making is challenging, complicated and requires skill. It demands an understanding of the evidence itself – its strengths and limitations – but also of the policy making process. Whilst these issues can be difficult to reconcile, the above experiences have only strengthened my drive to communicate effectively with all actors in the policy making process.

Katie Cole co-founded The Lancet UK Policy Matters website with Rob Aldridge and Louise Hurst.

The joys of systematic reviewing

Posted by Dorothy Newbury-Birth

I’m often asked what my methodological expertise is. Hmmmm, expertise aye…..

Well, I love a randomised controlled trial – the more complex and difficult the better. But I have grown to love systematic reviewing aswell. As funding becomes harder to get, funders are looking more at systematic reviews and meta-analyses (and modelling) to get to grips with what research is already out there.

As with most things I fell into my first systematic review (which was actually a rapid review so not quite as difficult) on alcohol and liver disease. My role was to manage the team and I found the process fascinating. It was all about preparation and organisation.

I am the module leader on a 10 credit MSc module in Systematic Reviewing. The first thing I tell anyone who asks about how to do a systematic review is that it’s important to do get your team around you. You wouldn't do a trial without a statistician and a methodologist, so we shouldn’t do a systematic review without the necessary expertise. I’m sure I could come up with a half-decent search strategy but I know that our Information Specialists can do it much better than me. I could make a half-decent attempt at meta-analysis (I’ve been on a course you know!) but there are statisticians who can do it far better.

First thing's first: get your team together

So the first thing to do is get your team around you, and then work out what you want to know and how you’re going to do it. Write a protocol like you would for any research work. Importantly, scope the literature, find out what’s been done before. You really don’t want to get half way through and realise someone else has done the work that you are doing or, even worse, not find anything because your question is so obscure. Have regular team meetings to discuss progress. Divide the work into sections – writing the protocol; designing the search strategy; first sift of the data; second sift of the data etc. Draw a gantt chart and be realistic with it – ask other people for their advice on time frames.

Stay positive, lots of people will tell you horror stories of the process of carrying out a systematic review but that is really not the case. It’s like anything, if you go in negatively you will hate it, but if you are positive you will enjoy it.

Finally, be organised, use Endnote as your management tool and make it your friend, make it work for you.

Enjoy.

How to improve your productivity: don’t read this blog

Posted by Jonathan Ling

One of my first office mates was Roger.

He was an older academic who had just been recruited by my department. As I helped him carry boxes of books into our room, I noticed that at the top of one of them was a book with his name on the cover. I was impressed – I was sharing my office with an author! I told him how great it must be when someone said to him: “I’ve read your book”. He agreed that it was a nice feeling, but what felt even better was when, having written a couple more books, he was able to say: “Which one?”

I’d never really thought about writing a book myself, until I was asked a couple of years ago to co-author a short textbook. It was on a topic I knew a bit about, but I’d never met the co-author who came from a university at the other end of the country. The editor suggested that the process would be reasonably straightforward and fairly speedy. As he had written several books himself I thought he obviously knew what he was talking about.

With hindsight I now realise he must be significantly more methodical in his approach to writing than I am.

I eventually finished my part of the book and it was published last year. Mostly by trial and error, I learnt a few things as I went along:

1. Have a writing routine. Take time out of every day to write. If you don’t block out a specific time each day to write (and stick to it), you won’t get anything written. It doesn’t matter when it is (I work better in the afternoons), just hang a “Do not disturb” sign on your door, or around your neck, and get going.

2. Don’t get side-tracked. See point 1. Your writing time is for writing – it’s not time for admin, catching up with emails, fitting in meetings or reading engaging and erudite blogs.

3. Seek feedback from your target audience. Unless it’s your diary, everything you write is for an audience. Think about who the audience is, and make sure they get a look at it. For a textbook, this was undergraduate students and other lecturers. For a journal article, most likely it would be fellow academics, as well as practitioners or policy makers.

Egg timer, by Martin Lopatka

4. When all else fails, get an egg timer. There were some parts of the book where I really struggled – topics I was unfamiliar with, that required lots of reading and which I wasn’t particularly interested in. But I just had to grind these sections out. In one of my more (possibly only) fruitful side-tracks, (see point 2), I came across the Pomodoro technique. In essence, this is just working on your chosen task for 20 minutes (no email, no looking out of the window – just work!) and then having a 5 minute break before another 20 minute session. Try it sometime – it did the trick for me.

Eventually, with the help and support of my co-author, editor and publishers, the book was finished, proofread and published. It is nice to have a book on the shelf with my name down the spine. But it was a huge amount of work, on something that’s not REF-able. So it’s not something I can see myself doing again.
Although, in my weaker moments I can’t help but think that one day it might be quite nice to say “Which one?” when someone tells me that they’ve read my book….

Turning the corner

Posted by Jean Adams

In university research there are two sorts of jobs: research jobs and academic jobs.

Research jobs are all about getting a particular research project done. Contracts are time-limited and you do research – collect data, analyse results, write reports. Academic jobs tend to be permanent and involve the classic triad of research, teaching and administration. The research bit is more about leadership than in research jobs – submitting grant applications, and supervising researchers employed on your projects. But there is also classroom teaching and student supervision. And let’s just not talk about the admin.

You can see why many people might aspire to an academic position - for the job security if nothing else.

Turning the academic corner

I wouldn’t be an academic if I didn’t now say “well, that’s actually a bit of an oversimplification, really – but it gives you an idea, doesn’t it?”.

Even before I finished my PhD I wanted an academic position. I wanted to ‘lead’. I wanted to teach. And after all those years as a full-time student (n=9), you betcha I wanted a nice, healthy pay-check every month forever.

I spent four years as a post-doctoral researcher before getting my first academic position. Less time than many, and for this I am very grateful. Now, a further four years on, it occurred to me recently that only now am I actually doing the job.

Although I knew all that stuff about the difference between research and academic jobs, when I first made the transition myself it seemed like nothing changed. Yes it was nice to stop getting those letters telling me that my contract was due to expire in three months. Yes it was nice to get a little bump in my salary with promises of more in due course. Yes it was nice to put “Lecturer in Public Health” in my email footer. But that was about it. My day-to-day job was pretty much the same. I analysed data, wrote papers, suggested ideas for projects to senior colleagues, shied away from any real responsibility.

And then I got scared. I wouldn’t be the “new lecturer” able to hang on the coat-tails of more senior colleagues forever.

And then I got more scared. I knew I had to get some grant funding, make sure my post-grad students flourished, and deliver good teaching. I tried to do all these things. But I didn’t seem very good at any of them. My grant applications were rejected. My post-grads seemed unable to tie down their research questions, let alone do some research. The big lecture theatre petrified me.

But, you know, it does seem true what they say. Once you’ve started, it gets easier; you just have to start. I got a little grant funded. Then I got another, bigger one. Then I got another. My post-grads are making their own, individual, journeys towards completion. I look forward to teaching seminars (although not preparing them) and whilst the big lecture theatre still scares me, I don't think it shows so much anymore.

So here I am just starting to think that I have finally turned the corner and might truly be doing the job I’m paid to do. And guess what? From August, they've promoted me.

Venice

Posted by Dorothy Newbury-Birch

I’m at a conference in Venice and I think it's the most beautiful place I've ever been to. But, with a bit of time on my hands (there’s no English TV in the apartment I’m staying in), I'm wondering why we come to conferences. I've probably been to about 50 conferences, heard around 300 speakers and seen hundreds of posters. I can only remember a handful of any of them.

We’re told that its important for us to attend conferences and disseminate our work. But as I stood in front of my carefully crafted poster today for an hour and a half in the baking heat and spoke to a grand total of three people I wondered just how much dissemination was happening. I once gave an oral presentation in America to three members of my research team and someone who I think was in the wrong room but felt too bad to leave. I have, of course, also given presentations in front of hundreds of people.

So why is it so important and why do I keep coming to conferences? Well the reason is that by coming to these conferences I ‘connect’ with other like-minded people from around the world. I chat with people about their research and my research and we talk about how we can perhaps collaborate on future work.

I sat on the boat to the conference venue today (yes in Venice it's a boat not a bus!) and talked with an academic from Kansas about research in schools - a really useful conversation for a project I'm currently working on. During lunch, I chatted with some colleagues from Barcelona about a European project we are involved in. Over coffee yesterday I talked with someone from Cardiff about complex methodologies and had a chat with a member of the steering group for a recent UK trial we worked on. On the boat back from the venue, I chatted with a researcher from the USA about the differences in obtaining ethical approval in America and the UK.

These are just a few of the many conversations I have had in the last two days. I have also been introduced to some important people in the field who I didn't know before.

I know others find this whole networking thing really difficult. Anyone who knows me will know that my two greatest loves are talking and biscuits, so for me it's fantastic. But it's more than just chatting. These events give me time to think about past, present and future research and to explore ideas with others who are giving themselves the time to do the same.

They give me time to ponder and that's a good thing and that's why I come to conferences.

What happens when you put fresh fruit & veg in local corner shops?

Posted by Jean Adams

This post is about a research paper that is published on-line today. Writing about research findings is a new venture for the Fuse Blog. Let us know if you want to see more results write-ups like this by leaving a comment below, or tweeting me @jeanmadams

In 2008, the Department of Health in England decided that one way to get people to eat more fruit and veg was to make it more readily available in local, corner shops.

The rationale was fairly simple – corner shops are less likely to sell fruit and veg; people who live in poorer neighbourhoods are less likely to have cars; thus they probably shop more at local corner shops and so probably have less opportunities for buying fruit and veg than people who have a car and use it to shop at a big supermarket.

Simple, but perhaps flawed. But let’s not talk about that for now. 

The corner store initiative was part of the all-singing-all-dancing Change4Life campaign. In our region, the North East, 17 stores were selected for an intensive intervention that involved part funding for a brand new chiller cabinet, a partial store re-fit to allow fruit and veg to be displayed more prominently, a funky little fruit and veg stand on wheels, and lots of Change4Life branded ‘merch’ – posters, stickers, shelf strips, you name it. A further 70 stores got just the stand and the merch. All stores were given various written materials to help them make more of fruit and veg.

Launch of a new Change4Life store in Portsmouth

There was a lot of publicity around the intervention and lots of shops got in their local papers. Which was great. But the point was to encourage people to eat more fruit and veg. Did it?

We spent a lot of time and effort trying to get funding to do a full-on outcome evaluation of this intervention. Sadly, although we did initially get awarded funding, it was withdrawn at the last moment (a story for a different post). Instead we did a small, process evaluation. Around two years after initial implementation, we looked at whether the stores were still using the intervention materials. We also asked 10 people who had been involved in the intervention in different capacities how it had gone.

What we found was that less than half of the stores were still using the campaign materials – apart from the funded chillers, which were all still in place. Shopkeepers told us that the merch just didn’t last very long and they didn’t know how to get replacements. They also thought that the campaign had been intended as a short-term initiative and were a bit surprised that we were still interested two years on.

Lots of shopkeepers and managers complained about a lack of communication with the intervention team. They didn’t have a clear idea what the intervention was aiming to do, or how to keep it going after the initial fanfare of its launch. DH was aware of this, and they tried to maintain the momentum by linking shops to local health workers and primary schools in the hope that schools and other community organisations might choose to buy their fruit and veg from Change4Life stores. Unfortunately, this never really worked and there were some tensions between the ultimate commercial aims of shops and health promotion aims of health workers.

As we weren’t able to collect any information on the impact of the intervention on consumption of fruit and veg amongst local people, we can’t ever say for sure whether or not the campaign was effective. But our results do suggest that it was unlikely to have had any sustained impact.

Sadly, lots of enthusiasm and funding seems to have got bogged down by poor communication and a focus on style over substance. The lessons are wide reaching, but perhaps not new.

You can read the full results here.

Can banking help fight health inequalities?

Guest post by Cam Donaldson

In 2010, Glasgow Caledonian University established the Yunus Centre for Social Business and Health. Muhammad Yunus is the 2006 Nobel Peace Laureate, awarded jointly with Grameen Bank for their efforts to relieve poverty, largely through promulgating microcredit. Grameen - 97% owned by its borrowers - issues small collateral-free loans, often for enterprise, to millions of the poorest people in Bangladesh and in several other countries.

Yunus does not fund our Centre. Why, then, is a UK University working with him, and what has microcredit got to do with health? Let me try to explain by bringing together three strands of thought.

Cam, with Muhammad Yunus and GCU Principal Pamela Gillies

First, on health, a more explicit strategy of inclusion combined with fair loan provision - essentially what Grameen promote - could facilitate health improvement. Gaps in life expectancy between the richest and poorest areas of Glasgow have grown to 28 years. We already have a world class NHS, so solutions do not lie there. Even public health policy seems more like “products chasing diseases”. We identify ‘risk factors’ and then target products (mainly drugs) at them. Either that or we tell people to exercise more, eat less fatty foods, give up smoking and drink less. But, can health be ‘compartmentalised’ like this? Further away from diseases and risk factors are the root causes - it is low income, societal exclusion and hopelessness that kill people. Without working on the ‘causes of the causes’ more-conventional attempts at public health improvement will have limited impact.

Second, on banking, the sector has been bolstered by national bailouts and quantitative easing. The bonus culture continues. Banks pander to middle class ‘trendies’ with more flexible opening hours (a 1980s phenomenon on which they had cut back!) and the entry of flash providers like Metro and Virgin. As we argue whether regulation goes far enough, the poorest are largely ignored – many trapped on benefits, which, despite being squeezed, people still cannot get off because, whilst raking in billions from QE, banks will not go near such people or their business ideas.

Government matches this lack of support, not allowing the welfare system to become a facilitator. They could do this by permitting schemes allowing income from welfare to taper off gradually whilst that from private sources grows - providing a minimum income overall and a guarantee of a return to welfare if such businesses fail. No less a guarantee than the banks have had, and one with much less risk – if a business is a success, one more person is off welfare and likely creating jobs for others. If it fails, then, at worst, we are merely back where we started, although it is thought that having tried and failed still enhances future job prospects. Money is placed more directly in the hands of those more likely to spend, contributing in a small way to getting the economy moving.

Third, on the ‘Big Society’, implementing some of the above would mean society could truly claim to be big, ensuring enhancement of well-being amongst the worst off. So far, many examples of the Big Society merely show it being captured by the middle class to their own advantage – with many more schemes in affluent as opposed to more-deprived areas, despite notable exceptions.

So here it is. To create a truly Big Society, and enhance the health and well-being of the poor, there is a role for banking. Examples are now spreading to the West – Fair Finance in London, started up by the son of Bangladeshi immigrants, is an excellent case. But we need more and they need more strategic support. Hence, the attempt to bring Yunus’ ideas to the most deprived areas of Scotland and the creation of our research centre to assess its impact. 

If it can be done in Bangladesh, why not here?

How can I help you help me?

Posted by Dorothy Newbury-Birch

I’ve never failed to get practitioners on board for a research project.

I’m not bragging (oh okay I am a bit). Some of the projects have been really difficult environments to do research: Accident and Emergency Departments, prisons, probation, magistrates courts, crown courts, youth offending teams, police stations, schools, GP surgeries. But I see people struggling with engaging practitioners and I wonder why. It’s by no means easy – actually getting someone to answer the phone or respond to your email can be really difficult but there are ways around that. Don’t believe what people say about it being more difficult elsewhere in England either – we’re often told that its much harder in London to engage but I don't agree: it is harder to get around London for meetings, but not harder to engage. I’ve done it – I know!

So what are my tips for success in engaging practitioners?

1. Send an email followed up by a telephone call about a week later where you tell them you’re following up on your email will probably get you somewhere. If you are a Dr. or working with a Dr. saying this helps.

2. Use current contacts to help you – however remember if you say that ‘Dorothy’ suggested I call you that you are using my reputation, so use it wisely.

3. When arranging to meet, ask what suits them best. Making it clear that you will come to them,  out of hours if necessary, usually works.

4. NEVER say you want to arrange a meeting (even though you do). Always say something like, ‘have you got time for a coffee and a chat about some research I’m working on which I think you would be really interested in’.

5. When you do meet (for a coffee!) find out very quickly if they are the right person to talk to about the research – they may be the PI but it may be someone else that you will be liaising with. Get the first person to introduce you to the next person.

6. Don’t go the meeting (coffee) with a huge list of things you need them to do. Tell them about the research and go through the main things – the list should come later (although you should never have too long a list).

7. When you get to meet the team (there is usually a team) my years of research experience tell me that ONLY providing blueberry muffins works. For some reason, chocolate ones don’t work the same.

8. Offer solutions to problems. In one trial I worked on with probation where I wanted them to fax me something each day, they said that they didn’t have time. So I offered to set the fax up to send me the list at the same time that they HAD to send it to someone else.

9. Listen to their solutions. They know their systems much better than you.

10. Keep them updated with what is going on throughout the research. THIS IS REALLY IMPORTANT not just for your research project, but for others that may come after.

11. Ok, I know I have 11 tips and 10 sounds better but this one is important. Involve the people you’re working with in the design, carrying out and the dissemination of the work (if they want to) it really makes for much better research.

On realist approaches

Posted by Monique Lhussier

Whilst I was originally educated as a scientist (an engineer in biological processes), many years later, I wrote a PhD thesis in… Nomadology.

This is not only about the kind of nomadism that describes the life of Bedouins in North Africa. It’s also about a flexibility of the mind, which allows us to accept that all research paradigms have a point, but rejects the fact that any single one of them could provide answers for everything at all times. The approach is postmodern and offers perspectives that most, at best, consider iconoclastic. It is as far from science as one can go, but I found it liberating. My PhD journey was one of discovery and intellectual indulgence that we rarely have the opportunity to engage in. This, for me, is what working in academia is all about. In fact, my ambition in life is to reach a stage where I am paid to think and do little else…that unlikely dream is what keeps me interested. 

The hampter wheel career stage

After my PhD, I went through a hamster-on-the-wheel stage. Work needed to be done to attract funding, deliver, attract more funding and deliver some more, with little time to build some kind of cumulative knowledge. 

Then, in the past few years I discovered realist approaches (evaluation, synthesis), which are about building theories of understanding. Understanding of how things work, for whom and in what circumstances. The kind of theory that isn’t a million miles away from the realities of life, but explains it in a way we might not have thought about before. It talks about the way in which contexts interact with underlying mechanisms to produce favourable outcomes. 

I recently attended a seminar on realist approaches, where the presenter illustrated this beautifully. Imagine a tennis ball in a hand. On earth, if the hand releases its grip, the ball falls. The action of the opening hand is only the visible part of what made the ball fall, though, as it is gravity that attracts the ball to the floor. Take that hand in outer space and, when it opens, the ball floats. The same visible thing happened (hand opening), but gravity has ceased to work. Take that hand under water and the ball goes upwards, towards the water surface. Gravity still applies, but is outweighed by buoyancy. Take the same action in three different contexts, and it leads to three different outcomes. 

How relevant is this in public health? Unless we can understand what really happens as a result of a public health intervention, we have no chance of replicating its successes and avoiding its pitfalls. I am currently undertaking a realist synthesis. Existing theories provide me with potential ‘menu’ of forces that may, in isolation or combination, explain published outcomes in any given circumstances. We constantly operate a toing and froing from theories to published data, until we feel we have developed a comprehensive enough explanatory framework. This process forces us to step out of our normal modus operandus of understanding (engaging in some kind of nomadism), to develop a new area of knowledge that can readily be translated. 

That knowledge is also beginning to instil conceptual sense in many other things I have done – whilst unfortunately not all I do, I at last am being paid to think my way out of the wheel.

Happy birthday health economics, from public health!

Guest post from Cam Donaldson, Kenny Lawson, Helen Mason and Emma McIntosh

UK Health economics is 40 years old this year. Well, more accurately, the Health Economists’ Study Group is 40 years old. This is to be celebrated in itself – few areas of applied economics have been as successful in terms of sustainability and influence, as well as contributing significantly to our parent discipline of economics.

Ironically, health economics concepts can be traced back to Adam Smith’s pronouncements on public health:

“In some parts of Lancashire it is pretended, I have been told, that bread of oatmeal is a heartier food for labouring people than wheaten bread, and I have frequently heard the same doctrine held in Scotland. I am, however, somewhat doubtful of the truth of it. The common people of Scotland, who are fed with oatmeal, are in general neither so strong nor so handsome as the same rank of people in England, who are fed with wheaten bread. They neither work so well, nor look so well; and as there is not the same difference between people of fashion in the two countries, experience would seem to show that the food of the common people of Scotland is not so suitable to the human constitution as that of their neighbours of the same rank in England.”

We say ‘ironically’ because, despite the claimed successes of health economics and public health, growing health inequalities within nations remains an outstanding societal challenge, and one with significant health economic consequences. The main challenge, of course, is in devising effective and efficient interventions to reduce such inequalities. For health economics, the question then becomes one of whether our tools, which have been so successful to date, are up to the task of economic appraisal of public health interventions.

Indeed the dominant rubric of ‘cost per quality adjusted life year’ seems to present something of a moral dilemma for health economics when it comes to assessing public health interventions. The cost-per-QALY metric has served well the assessment of health technologies, but, amongst others, has the following limitation: all that is measured (and hence valued) are health gains for health care resources expended.

Public health economics: more than just cost-per-QALY?

On the cost side this is limiting, given that many public health interventions will, by their nature, be multi-sectoral, thus requiring more of a ‘societal approach’. Likewise, on the benefit side: although one may wish to assess the output of public health interventions in QALYs, what about other outcomes such as ‘improving life chances’ as well as enhancements in quality of housing and built environment, dignity, esteem and capabilities? Many community-based public health interventions also have spill over effects on their communities which need to be captured. The reductionism of the now-dominant health economics evaluation approach does not match what needs to be measured in evaluating public health. A broader and longer time horizon is required to fully capture all impacts.

This becomes a moral dilemma because, given that so many interventions previously evaluated by bodies such as NICE have been assessed using cost-per-QALY, should we permit others to be appraised via a broader societal approach which now takes these ‘other broader attributes’ into account?

There are two answers to this question. First, if the general scientific principle of working from ‘broad to specific’ were adhered to in health economics, no such moral dilemma would exist. We could start off our evaluations by thinking broadly and then either remain so or work to something more specific (e.g. cost per QALY) depending on the issue at hand. Just because health economics has come at this principle the wrong way round - specific to general - should that be allowed to limit our evaluations by leaving out the measurement of important potential impacts?

Secondly, and following on from this, a broader societal approach actually takes us back to the origins of economic evaluation, which was designed to:

“...identify relevant options for consideration; enumerate all costs and benefits to various relevant social groups; quantify as many as can be sensibly quantified; not assume the unquantified is unimportant; use discounting where relevant to derive present values; use sensitivity analysis to test the response of net benefits to changes in assumptions; and look at the distributive impact of the options”

So, public health has given health economics a birthday present - the opportunity to return to a societal perspective, which many, even in health economics itself, have been advocating for some time.

Hopefully, we can take advantage of this coming together of health economics and public health in measuring and valuing what is relevant and so implementing effective and efficient public health solutions to reduce health inequalities in the communities we all seek to serve.


Cam, Kenny, Helen and Emma run the Economics of Public Health blog, hosted by the Glasgow Centre for Population Health

Communicating science

Posted by Jean Adams

Not so long ago, I promised never to do another degree again. This came after finally completing an MSc in Psychology and Health in London. For 20 long weeks I caught the early flight to London each Thursday morning, attended lectures for two days, and then struggled to make it back to Newcastle before midnight on Friday evening. I learnt some stuff. I did an interesting dissertation that I’m still pretty pleased with. But overall, the effort was not worth the gain.

But another fellowship application, and another blank ‘training plan’ section, and I found myself thinking that the only thing I needed to do to become an ‘independent researcher’ was a Postgraduate Certificate in Science Communication – at the University of the West of England, in Bristol. A PGCert isn’t a degree anyway. So it’s not like I was breaking a promise.

Love the box hedge logo at UWE Frenchay campus

So let’s be clear: Bristol is further from Newcastle than London is. The travelling was longer, more expensive and more arduous this time; each trip was three days, rather than two. But, I only had to make six trips. And, most importantly, I learnt so much more during those six trips than I did from the 20 I made to London.

In a nutshell, I learnt that it’s all about story. Communicating stuff is about narrative. Communicating difficult science to people who aren’t necessarily that interested in it, is about telling a good story. You catch people’s attention with a compelling tale, then once you’ve got them hooked, you can slip in whatever you want – complex methods, difficult concepts, mashed swede, whatever.

Which is not exactly rocket science. But, you know, the science communication field is full of used-to-be scientists – if they were rocket scientists, they might have stayed in science.

I also got to do some pretty cool other stuff. I edited a (pretend) travel magazine, I set up a blog, I recorded and edited a podcast, I got totally over-excited in the Knit-a-Neuron workshop, I bought a copy of The Sunday Telegraph – for research purposes (which wasn’t that cool, but it’s certainly something I’ve never done before). In order to complete my writing portfolio, I attended a conference and pretended I was journalist, not a researcher. At the end of each day I wrote a 500 word news article on something I had heard. It made the whole experience a whole lot more immediate and exciting.

Which is all well and good, Dr. Adams, and we are certainly trying to encourage our staff to do more in the way of 'public engagement', but not at the expense of research excellence and impact.

I think this stuff is important for research excellence and impact too. Good research papers also tell good stories. Not necessarily in the same way that a newspaper or novel does, but without narrative your paper is just a series of facts (or, if you’re a social scientist, just a series of 'facts'). That's why you remember some research papers so much better than others. Ditto good grant applications, teaching sessions, and conference presentations.

So, I’m thinking about doing a degree in creative writing.

Only joking.

Nothing personal

Posted by Peter Tennant

When I was four feet tall, and each year felt like a Chinese dynasty, certain annual events used to really standout. The first hot day of summer. That strange day when there were flying ants everywhere. And the day when young adults would cry in the streets.

Apparently they had 'A-levels'. Or more accurately, they didn't.

These days, I find it harder to notice anything among the blur. Christmas is a long lunch. Summer a short weekend. But every now and again, grown men and women can still be found crying. The tears are usually less visible. But there’s no doubt about it, Fellowship applications are the A-levels of the early career researcher.

Vladimir Putin, after hearing he didn't get his fellowship

In a recent post, Fuse director Martin White listed personal funding (in particular getting a Fellowship) as one of 10 "easy" steps to achieve "rapid and effective progression" in a research career. It reminded me of one of those weird logic puzzles. If Andrea is lazier than Beth, and Catherine is greedier than Delia, how many cakes will Delia eat before Andrea has woken up? In short, getting a Fellowship may make career progression easier, but it's certainly not easy to get one. At least not in my experience.

At this point, my academic enemy would probably volunteer a simple explanation. Like the overly-blunt PE teacher to the short fat boy (sorry, boy of below average height and above average weight) who doesn't understand why he's so rubbish at the high-jump. But as much as we might blame my own academic physique, the statistics tell a bruising story. For every 5-10 applications, only one will be successful.

On the surface of it, this doesn't sound too bad. At least not in a world where there are hundreds of applications for any one academic position. But firing off a job application and applying for a Fellowship are like chalk and cheese. Occasionally cheese may have a chalky texture. But I guarantee, the chalk and pickle sandwich will never catch on.

To start with, Fellowship applications belong to that special category of things that completely take over your life. Partly because they take up so much time – I reckon I did about 200 hours on my NIHR Fellowship application, not to mention the countless time staring into space 'thinking' about it. And whenever I did stop thinking about it, a friend would usually ask: "Have you heard about your Fellowship yet?".

But it's the personal focus that makes a Fellowship application so uniquely challenging. Yes, the project needs to appear excellent. But so do you. And, sadly, not just in the eyes of your Mum (sorry Mum, but I'm afraid 'having good A-levels' isn't quite enough any more). Which means there's lots to write about how great you are and why you deserve the money more than anyone else. There's no place for modesty. So if I ever come across like a egotistical jerk, I'm just practising for my next application. Honest.

Before finishing, I would like to offer some advice. Some magic formula that boosts those slim chances of acceptance. But as a twice-reject, you might as well ask McDonald's to help solve the obesity epidemic. All I can advise, is you try to keep your emotional distance. They might call it personal funding, but (believe it or not) rejection is nothing personal.

If it ain’t fixed, broker it

Guest post from Oliver Francis, Centre for Diet and Activity Research

Before I applied for my current job, I’d never heard of a Knowledge Broker. I’d always described what I did as ‘communications’. But a year in, this role has confirmed that the word 'communication' doesn’t really cover the challenges of linking public health evidence with policy and practice. In this time I’ve also met a couple of other ‘Brokers’ so I’m now a little less embarrassed about telling people my job title at parties.

As the recent Geek Manifesto reminds us, there are plenty of voices clamouring for more evidence-based policy making, so why does all this knowledge need brokering at all? Surely academics just need to publish their findings and they’ll be automatically taken up by policymakers and practitioners who want to do a good job.

Well, put simply, the world isn’t built like that. There are many barriers within the complex world of public health research translation. To take just one, there are often big gaps between the evidence that individual studies generate and the broader information that policymakers use to make their decisions. There are the practicalities of implementation, there’s money, ideology, politics, public opinion, the media. Or to put it another way: how many purely evidence-based decisions do you make in a day? Thought so.

Research translation: not so simples

One thing academics can do to help is make our research more available and easier to digest. So at CEDAR we’re producing short summaries of our research findings. Hopefully these Evidence Briefings are a step in the right direction. Indeed, these sorts of documents are increasingly common outputs from research groups, in addition to the wider syntheses of evidence coming from organisations such as NICE and (soon) Public Health England.

So, writing engaging and straightforward summaries of emerging, nuanced and complex evidence in no more than two pages… Simples! Well, actually, not so simples. For instance, how do we deal with expressing uncertainty for those who need to make clear cut decisions? How do we produce something that’s short enough to hold attention, but long enough to convey all the important information without a hundred web links? How do we convince a local authority in Newcastle to pay attention to findings generated in Cambridgeshire? People love case studies, but as we know, the plural of anecdote is not data. How can we make sure we tell only ‘true stories’?

Or should we just face up to the fact that there is a limit to what researchers can contribute to this process? Is the job of academic institutions just to produce summaries of the evidence in plain English, and then leave it to others to interpret them in the light of the demands of the so called ‘real world’?

I’d love to hear your thoughts. Have a look at the first Briefing in the series about physical activity and schools, and take our quick survey to tell us what you think of it. Or post here, or contact me directly if you’ve something to share. Even if you don’t work in this particular area, your views can help us improve future Briefings on other topics, and hopefully make sure that as little as possible gets lots in translation.

Older and wiser? Musings from a ‘mature’ PhD student

Posted by Amy O'Donnell

Recent posts from Martin White and Dorothy Newbury-Birch have sent me musing (and no, before you ask, this isn’t yet another PhD distraction, I promise!).

On the one hand Martin’s first tip in his "From PhD to PI in ten easy steps" is to do your PhD young; on the other, Dorothy writes convincingly about how you might juggle 'mature' study with the domestic stuff that grown-ups tend to have to manage.

So where does this leave me I wondered? I've just turned forty, have two school age children, five pets (do they count?) and to throw into the mix, am currently facing a somewhat challenging time due to my partner's (lack of) employment situation.

Times are indeed tough. And believe me I often look at my younger, child-free peers rather enviously, imagining all the amazing progress I’d achieve if I didn't have after school activities to organise four nights out of five, weekends packed with football matches and Stagecoach, and general mortgage related-stress.

But when I seriously ask myself - “Should I have done this sooner? Could I have done this sooner?” - the answer to both questions is a resounding "No".

For starters, I think that the long and confused path I've taken to get this far has provided me with an invaluable skillset and bundles of what they call ‘life’ experience. I've worked in public affairs so I have a keen sense of the need to stay policy-relevant; I used to manage the BBC corporate diary (yes really) so bureaucracy and seniority doesn't faze me (mostly); and I spent most of my thirties at the rough end of the contract research wedge: bid-writing and mega-quick project turnarounds were my bread-and-butter.

Along the way, I think I've become a better and more seasoned writer and I've developed a deep-rooted passion for tackling social and economic inequalities. In particular, as a mother, I feel a sense of urgency to see things change for the better before my boys have to go out and face the big bad world. Personally, I really don't think I was ready before now. And I also think that with the current focus on translational research, those of us who have actually worked outside academia might have a valuable role to play in bridging the cultural divide.

Of course I understand this will undoubtedly limit my long term opportunities (unless I plan on working to 80…which is possibly not too ridiculous a prospect under the current government). Things haven't always gone quite to plan with the PhD either, so I haven't (yet) rattled off those all-essential publications. But, future academic employers, I do think I've still got lots to offer. Come January 2013, let's hope someone else does too.

Coral Triangle Day

Posted by Duika Burges Watson

June 9th is Coral Triangle Day. The Coral Triangle is a region in South East Asia that covers just 1% of the world’s surface but contains 30% of its coral reefs, 76% of coral reef-building fish species, 9 of the 10 species of giant clam and is home to 100 million people. Celebrating Coral Triangle Day might not sound like an important public health issue for people in the UK, but my reading tells me it is fundamental. I am fortunate to have the opportunity to demonstrate how, as recipient of the 2012 Neville Schulman Challenge Award (with Dr Johanna Wadsley), through our Indonesian research exchange and expedition, Hugging the Coast.



Sometimes topics in public health leap out at you because you are motivated by an issue or concern that really grabs you. Hugging the Coast is a title that resonates on so many levels, and it is one that clearly touched not just us but the many supporters and sponsors that have provided gear, money, expertise, and time to help make the expedition possible.

In August 2012, our international team of six women sea-kayakers and social scientists will traverse the 250km length of the volcanic islands that reach from the northern tip of Sulawesi, Indonesia, to Sangihe in the Celebes Sea - at the edge of the Coral Triangle. We will be documenting and engaging with life in one of the world’s ‘liminal zones’, confronting key contemporary public health issues in relation to climate change and sea level rise, food security and ecology, and how what we ‘do’ at home is not isolated from what happens in other parts of the world.

Our project resonates with the major challenge to public health that is presented in Lang and Raynor’s recent publication Ecological Public Health: Reshaping the Conditions for Good Health. At its core, they argue that public health needs a major overhaul, we need to transform relationships between people, circumstances and the biological world of nature and bodies. They stress that we need better ways to understand and account for major transitions – be they demographic, epidemiological, urban, energy related, economic, nutritional, biological, cultural or political; any conditions involving interactions between human eco-systems and health.

Scenarios developed for the Coral Triangle suggest that in the next century the biological diversity of this ‘Amazon of the seas’ may be destroyed, the resilience of coastal environments will deteriorate and food security – already an issue with climate change and El Nino events – will force migration, urbanisation and even greater depletion of environmental resources. In Hugging the Coast we will confront the lived experience of transitions related to climate change.

But part of the Coral Triangle Initiative, and what Coral Triangle day is there to celebrate, is that there are opportunities to avoid this worst-case scenario – reducing greenhouse gas emissions and building resilience back in with new approaches to agriculture and aquaculture; international investment to ensure that economic growth, food security and natural environments are maintained. On this, a key focus for our expedition and research is the role that seaweed farming might play as an exemplar of ‘climate smart’ agriculture: as an alternative livelihood, reducing fisheries pressures and for carbon sequestration.

The seaweed farmed in the Coral Triangle, is not used there. The product ‘carrageenan’ is extracted from the seaweed and, amongst other uses, is employed in processed foods and fat-reduced products, in toothpaste, as an active ingredient in HIV/AIDs prevention technologies, as an anti-viral agent to protect against HPV and swine flu, and to encapsulate important drugs (for example for novel diabetes drugs). In many applications, public health is a driver of use. In Hugging the Coast we will be exploring a ‘liminal’ zone between land and sea, but also one between the global East and West.

Hugging the Coast offers us an opportunity to map out interactions between human eco-systems and health; to ‘test drive’ an ecological public health approach. It will inevitably be a complex picture, and one that you can follow and contribute to on our blog or on twitter @hugindo

What do you get if you mix a scientist and a mother?

Posted by Bronia Arnott

I came across a headline on the way to work a few weeks ago “The data confirms: If you want to stay in science and see your children grow up, don’t have children before you have tenure”. As a post-doctoral science researcher, who doesn’t yet have tenure, and is already a mother of one did I dare read on?

The headline was the title of a post on the LSE Impact Blog. It referred to the findings of a study which found that childless women are “paid, promoted and rewarded equivalently to their male peers” but mothers are “far more likely to move out of the research-professor pipeline…”.


So for those just starting out who want a career and kids, they just have to wait until they have tenure to have kids. Right? But what if you get tenure and then find out that you’ve missed your biological window of opportunity? I can’t imagine many people regretting not getting tenure on their deathbed, but I can imagine the years of heartache that come with not being able to have the children you wanted.

And I’m not convinced that once you have tenure you can sit back and relax. All the professors I know are always talking about how busy they are! REF papers and successful grant applications don’t write themselves.

So what about me? Should I just give up and go home?

I wasn’t convinced so I thought I would do what I do best and do some further research… I found a piece in the Guardian suggesting that the proportion of women in science is much lower in the UK low compared with the United States. The article suggested that the problem wasn’t getting women into science, but getting them to stay. Apparently they often drop out to start families. This was beginning to sound familiar.

I got my coat.

But wait…on my way out of the door I remembered I had attended my first full institute meeting of the Institute of Health and Society, at Newcastle University. There was the usual IT updates and grant successes, but then they started talking about the Institute being awarded the Athena SWAN Silver Award, and suddenly the meeting got a whole lot more interesting. Some of the staff even put down their knitting needles.

This award scheme recognises good employment practices for women working in science and related fields in higher education and research. The Silver award recognises efforts, above and beyond university-wide policies, to identify challenges faced by women and implement effective solutions.

Professor Judith Rankin, who led the application, said that the Institute “has always strived to introduce good working practices to ensure that those women who wish to combine a family with a career can”. Professor Eileen Kaner, Institute Director, said: "Success in achieving this award acknowledges the considerable work to make working in science an attractive career option for women."

Did you notice that? Two quotes from two women, both Professors, one the director of the Institute! In fact the Institute is full of examples of successful women, including those who have children, some who even had their children before they got tenure!

On my way to pick up my daughter later that day the whole issue was still playing on my mind. While I was boosted by the news that there was such great work going on in the UK to support women in science, I realised that is was a sad reflection of the existing inequalities. Surely we should be better at supporting men AND women in their careers AND in their family life?

From PhD to PI in ten 'easy' steps

Posted by Martin White

Recently I’ve been reflecting on what it takes to make it in academia. In part, this was prompted by an invitation to take part in an event at the UK Society for Behavioural Medicine conference last year. ‘Senior’ academics from a range of disciplines formed a panel to take questions informally over lunch from a baying mob of PhD students and post-doc researchers.

The baying mob: El dos de Mayo de 1808, by Fancisco de Goya y Lucientes

The questions primarily focused on career development and how to achieve rapid and effective progression. The members of the panel were readily able to identify ways in which their careers had been atypical. But despite our idiosyncrasies, we agreed on many pieces of advice.

Here's my top ten tips for success:

1. Get a doctorate early on in your academic career – preferably while you are young and need less sleep, and while you can tolerate a student stipend for 3-4 years.

2. Learn to work independently, demonstrating that you have an enquiring mind and are able to define original research questions. This is the foundation of academia and one of the X-factors which will set you apart as PI material.

3. Learn how to write well, for both scientific and non-academic audiences. Get advice or training on how to do this. Practice every day (e.g. by writing blog posts - Ed.).

4. Publish your work. Start while you are doing your PhD - leaving these papers until later creates a backlog which you may never be able to tackle. Writing papers before the relevant thesis chapters will help you develop a concise, clear style for your thesis and prove it is of a 'publishable standard'.

5. Get a mentor. Identify an academic ‘hero’, or at least a good role model. Look outside your institution and don’t be afraid to ask very senior  people. They will be flattered and pleased to help shape someone else’s career. Meet with them at least once a year.

6. Be genuinely interested in your subject area; choose carefully! A lack of enthusiasm shows through any veneer you put on for project meetings or interviews.

7. Sell yourself. Think carefully about how you can make a case for your future employment. Make yourself indispensible and demonstrate how you can add value to any team. Take every opportunity to present at conferences, workshops, select committees, etc.

8. Get personal funding. While post-doc research posts, working on other people’s projects, will earn your crust and keep you busy, they provide limited opportunities to hone your skills as a PI. Fellowships are available at every level and will give you incredible freedom to develop and shine as an independent researcher.

9. Collaborate. Spread your wings and make new relationships with the most interesting and brightest people you can find. Involve policy and practice partners in your research whenever possible to help bring relevance and impact to your research.

10. Learn to love criticism – she's your best mate. You will not get anywhere unless you welcome objective peer review and understand how to give and receive it. The best way to learn this is to become a peer reviewer for journals and grant funding bodies. This also carries esteem and will open up doors for you through the contacts you make.

Lastly, enjoy yourself and don’t be afraid to break the rules!

Let’s get out of the office and see what’s really happening

Posted by Dorothy Newbury-Birch

When putting bids together for research we have to think carefully about how a project can happen ‘in the field’. We look at the evidence to date and often ask people who are working in said 'field' for advice on how things can work. But is this enough?

I would argue not always – for us to really understand what we are asking people who take part in research to do, we need to get out there and look for ourselves how things could work in practice. For example if I am working on a project where I would like ambulance staff to screen patients for alcohol use disorders how can I really know what normal practice is like without observing it for myself?

Hanging out with an ambulance crew - good fun, good research

I have, to date, carried out observational work for these very reasons, in an Accident and Emergency Department (AED) on black Friday - the Friday before Christmas. I quickly realised that asking AED staff to ask lots of questions about alcohol wasn’t really a good idea. In fact, just getting a cup of coffee that night was barely feasible. However, using a shorter questionnaire, perhaps at the triage stage, might be.

I also spent two weekends with an ambulance crew and learned that paramedics make small talk in the back of the ambulance with a lot of patients whilst they are being transferred to the AED. This makes it an ideal opportunity for research to take place. I also realised that quite a few people who paramedics are called to see, are not transferred to hospital. The paramedics were frustrated about not being able to do anything with these people (another opportunity for research).

I spent a night with the maxillofacial team in AED where I learned that they are slightly separate to the core AED staff and in the main do have more time (yet another opportunity for research). Finally I spent a couple of nights on a project with police and paramedics where I’m not sure what I learned, but it was fun.

Of course, there are loopholes to get through in order to do observational work like this, forms to be filled in (including risk assessments). I am always honest about my reasons for doing the work with the people I’m working with and this is important for good relationships. I always, always take goodies for the team (blueberry muffins, cherry bakewells).

Ultimately I think this observational work means we end up with better research. And it's really, really, really good fun. So give it a try.

Routine Secondary Data

Posted by Lynne Forrest

We all know what a nightmare it is trying to recruit participants for research studies. So if you only have to get hold of some routine data that’s just sitting there, well, that’s going to be much simpler, isn’t it? You’d think....

The plan for my PhD was to look at inequalities in cancer care by linking cancer registry and Hospital Episode Statistics data for lung cancer, and also linking to audit data. This is routine data that has already been collected and so I naively assumed it was just a case of getting ethical approval to access the data, finding someone to cobble the data together and off we go. I wrote an optimistic project timetable where I would get my hands on the data about seven months into the PhD. Eighteen months in I’ve finally got hold of some unlinked data and I’m still waiting for the rest.


I don't work for News International, so what's the problem? Photo: Christian Sinibaldi

So, what went wrong?

I think my first mistake was assuming that just because the data was there it would be easy to get hold of. There are a lot of hoops you have to jump through first.

I thought that what I wanted to do was simple but it turns out that it’s not. This is apparently the most complicated linkage that the cancer registry has undertaken and the bottom line was, nobody wanted to do it. I spend a lot of time begging people to speak to me and basically being fobbed off, in the nicest possible way. Luckily I eventually found a newly-joined analyst who was willing to give it a go. I’m not sure that she’s thanking me now...

Issues then arose of whether the data I wanted might be identifiable. Variables such as date of birth and death are classed as identifiable and individual records are ‘potentially-identifiable’, even if they don’t include identifiable information (which is an excellent catch 22 – they are identifiable even though they are not identifiable...)!

Finally it seemed like it was all coming together. I’d agreed with the registry that they would supply me with anonymised data containing ages rather than dates, I’d made it through ethics, and I’d got some data. But, on checking, not exactly the data I wanted. So, currently I am discussing with the registry how it will be possible for me to calculate survival time if they won’t allow me to have data on the number of days from diagnosis to death. Survival from lung cancer is short and rounding to the nearest year isn’t going to identify survival differences with any degree of accuracy.

The sticking point is that although they are not supplying me with date of death I could theoretically work it out from this information and that makes the data (aaagh!) ‘identifiable’. However, as I don’t have an NHS number, date of birth, or place of death, I don’t know how I would identify anyone from the 140,000 records I have. Plus I’m a researcher, not a News International journalist, and I’m not interested in anyone individually, so I’m not going to attempt to do this.

Can’t I just sign something to that effect and have the data I need please?

Should I do a PhD mum?

Posted by Dorothy Newbury-Birch

I’m about to have a grandchild and am so unbelievably excited about it! My daughter is thinking that she might like to do some postgraduate studies after her baby is born and is starting to worry about how she will manage to be able to do this and have a child. This made me think about what advice I should give her.

I began my PhD in 1997 (not that long ago!) when my youngest was four and the eldest (the now pregnant daughter) was eight. My husband and I made a decision from day one to treat my PhD as a job. I also learnt that the only thing that was going to get me through it all was good, changeable, project management.

At least once a week, the diary would be put on the kitchen table and decisions made about who would do the drop offs (mainly me), who would do the pick ups (mainly me) and who would look after the girls at weekends so I could do some work (mainly him).

Dot's girls. Some time ago.

We didn’t have family locally so negotiations would happen in the school yard about me looking after friends' kids after school one day if they could look after mine another. School holidays were negotiated with friends the same way: I would have their kids for a couple of days (or from 3pm onwards) and they would have mine opposite times. These summer holiday days were fab: I would have three or four kids, we would go off for the day early and be back by about 3pm, then I would go up to the university for a few hours work.

I also wrote five papers during my PhD and attended a few conferences. I can honestly say, that from day one I worked at least 8 hours a day on my PhD - mostly in the office, sometimes at home. In the last year, of course this wasn’t enough and I did have to work at nights and every weekend.

Of course there were sacrifices: I didn’t spend nearly enough time with the kids when they were young. But this was a decision I made and if I hadn’t done a PhD, I would have needed to work anyhow. The money was terrible and there were at least three conversations in the three years about whether I should continue because of money worries. In the end I got a pub job for a few months at nights.

So my advice to my lovely daughter who is contemplating this? Pick a subject and topic that you really believe in, that you are going to be interested in for the time needed. Make a commitment to it and treat it like a job. Remember that your child (my precious grandchild) is a fact and not an excuse for working. You have support on your doorstep from family that a lot of people (including me) didn’t have. Go for it....