Friday, 30 July 2021

The Sound of Sirens

Posted by John Mooney FFPH, Consultant in Public Health, NHS Grampian @StandupforPHlth

Easily my most notable memory from the first Covid-induced lockdown was the unmistakable and disconcerting shriek of ambulance siren calls, regularly piercing the ‘lockdown’ silence of largely empty streets. Prompted by the memory of the mythical origins of the word ‘siren’, in which enchanting songstresses lured sailors and their ships to a rocky destruction, it struck me that the lure and temptation of ‘freedom day’ on which all Covid-19 constraints on social and other gatherings are no longer mandatory might yet similarly have an unfortunate aftermath. While I expect that risks placing me firmly in the ‘doomster’ camp, it seems I am in good company after the letter in last week’s Observer from some of our most eminent public health leaders who were at pains to point out that “living with Covid is not the same thing as letting it rip”.

This is now my third Fuse blog about Covid, in what is sadly proving to be a rather prescient series of posts about the pandemic. I set out in the first (published in February 2020), that as a newly emergent single stranded RNA virus, Covid-19 would be genetically unstable and undergo mutations which could influence its epidemiological characteristics including virulence and transmissibility. To say therefore that the present situation was not foreseeable (given my rudimentary grasp of evolutionary genetics), is clearly not that convincing. It’s probably even more self-evident that the more transmissible variants will be the same variants that are most transmitted, because this is the essence of viral survival strategy. Even with that knowledge however, the speed with which the Delta variant became the dominant strain (from under 10% to over 90% in a matter of weeks and now accounting for 99% of identified cases), was fairly breath-taking even by viral standards. 

A particular concern just now of course must be that the UK’s success in achieving a high vaccination uptake creates a new ‘selection pressure’ of its own, in that any newly emergent strain with the capacity to evade vaccine induced immunity will have an enormous selection ‘advantage’ in a population which has the combined characteristics of a high vaccination rate plus a high level of circulating virus. It’s easy to appreciate then how such a new variant could assume a ‘delta-style’ trajectory towards dominance, leaving even the fully vaccinated vulnerable once more. This is of course not a reason for reducing vaccination efforts which have been critical in protecting vaccinated age groups, thereby reducing the proportion of the population susceptible to new infections. If I could squeeze in one final take-home vaccine basics key message: the more infectious a particular variant, the higher proportion of a population needs to be vaccinated to mitigate transmission. This has prompted some commentators to expect that the holy grail of ‘herd immunity’ will always prove elusive for Covid.

The very real challenge for those of us in practice settings (having recently returned to NHS public health myself), is how best to advise local populations and relevant agencies in order to keep reducing the levels of circulating virus. The mechanisms that work here are very much those that are already in place combined with ongoing vaccination and access to local testing. The extent to which people might be willing to submit to testing that could sacrifice a long-coveted holiday, versus their readiness to isolate away from work, might begin to explain a divergence in the surveillance data in some health-board areas between declining numbers of cases and relatively stable hospital admissions (even allowing for the two week lag). The latter of which has already led to cancelled elective procedures in ours and other regions. We also know that infections in younger age groups are more likely to be mild / asymptomatic taking away the ‘illness prompting’ rationale for seeking a test.

Receiving supplemental oxygen in A&E
 6 months after initial Covid symptoms
 (mask displaced to drink)

At this point it would be useful to highlight the relevance of the second blog in this series as then it all looks impressively planned! (Spoiler alert: it wasn’t!). In that article, I described my experience with Long-covid which I was unfortunate enough to develop very early in the first wave and which included an unscheduled hospital stay and fast track angiogram (think X-ray to check heart blood vessels) thanks to a “dangerous ECG”. Thankfully 18 months on I am much recovered, but remain very conscious that there was more than one false dawn over the course of the illness, although later episodes were milder. The inescapable parallel from a population standpoint is that Covid-19 can prove a truly mercurial adversary, lulling you into a sense of comfort and security, just like the mythological Sirens, before dashing you against the rocks of reality once again. The attached illustration above: ‘Ulysses and the Sirens’ is an 1891 painting by Pre-Raphaelite artist John William Waterhouse. In the words of the Wikipedia description:

"The work depicts a scene from the ancient Greek epic the Odyssey, in which the Sirens attempt to use their enchanting song to lure the titular hero Odysseus and his crew towards deadly waters. As per the Odyssey, Odysseus' crew had already blocked their ears to protect themselves from the Sirens' singing, but Odysseus, wanting to hear the Sirens, had ordered his crew to tie him to the mast so that he may have the pleasure of listening without risking himself or his ship."

In other words, the measures clearly employed were distancing and personal protective equipment! [Note the bound ears of the crew]. Perhaps the fact that the new variants are being ascribed Greek lettering might help persuade us to take a leaf from these mythological mariners and maintain some of our protective measures just a little longer while vaccine roll-out continues. In keeping with worrying reports from our clinical colleagues and as anecdotal as this could certainly be described, I have increasingly of late been hearing much more of the sound of sirens… 

John is currently employed as a consultant in public health with NHS Grampian and has a background in respiratory infectious disease epidemiology. 

1. John William Waterhouse, Public domain, via Wikimedia Commons

The views expressed in posts are those of the authors and do not necessarily reflect those of Fuse (the Centre for Translational Research in Public Health) or the author's employer or organisation.

Friday, 23 July 2021

Find the gap: where is the healthy, enjoyable human body in policy?

Posted by Rachel Kurtz, PhD researcher at Durham University

Balancing varied and sometimes conflicting priorities within a large geographical area and between multiple departments is not a job to be envied. Ensuring the detail is suitably deliberated while also holding in mind how a policy affects other interests must be attempted but cannot possibly be achieved to perfection. My role on behalf of County Durham Sport was much easier. Over three weeks in June, I reviewed Durham County Council documents and the priorities of the Area Action Partnerships (AAPs) to identify areas of local strategy that did (or did not) address the issues of physical inactivity and the climate emergency. As an environmentally-informed, lifelong dancer-turned-researcher, I simply had to view the documents from two perspectives in which I am already personally invested and consider possible changes. Some interesting things emerged.

As you might expect, topics are viewed through whatever lens highlights policy concerns in that area. For example, the County Durham Plan understands physical activity functionally, through land use, waste, and movement of people, advocating for active travel (walking, cycling etc.) and providing and improving recreational areas. Meanwhile, the Joint Health and Wellbeing Strategy considers the environment as either beneficial or detrimental to public health, e.g. air quality. Thinking that is limited by departmental divisions can make it difficult to link overlapping policy areas. Consequently, councils are attempting to increase communication and collaboration by forming multi-disciplinary teams to create joint policy and consider issues from multiple perspectives. The County Durham Health and Wellbeing Board (author of the previously mentioned strategy) is one such team. This ongoing shift towards a collaborative approach is already countering siloed thinking and Durham County Council is taking a systems perspective through its work in Mental Health, from its strategic partnership both within and outside the council to delivery vehicles like the AAPs (which give local people and organisations a say on how services are provided). Nonetheless, a change of perspective inevitably exposes assumptions and raises new challenges, and this was no exception.

Encouragingly, some of the documents reviewed, such as the 2018 Open Space Needs Assessment, comprehensively address both focus areas, however in most cases the environment features more prominently than physical activity. A Physical Activity Strategy is still being developed, therefore gaps in this area might be expected and indeed in many cases the human body was entirely absent from policy. However, what was most noticeable was the underlying attitude where physicality was mentioned. Almost none of the policy documents feature the healthy, enjoyable human body. To cite a specific example: while addressing a rising mental health crisis, the Health and Wellbeing Strategy implicitly regards bodies as problems to be solved. This is particularly noticeable in the section on older people who are seen as frail and in need of preventative and remedial support. The framing of the strategy is already being addressed in this case but overall, any focus on the impact of health and wealth inequalities on the body tends to see physical inactivity as a problem rather than an opportunity. There were exceptions at delivery level (e.g. the Healthy Weight Action Plan and some AAP interventions, both of which are very much about enrichment) but at the strategic level, bodies are overwhelmingly framed as problematic. This is true even where you might expect an enrichment perspective such as the Children and Young People’s Strategy and Strategic Walking and Cycling Delivery Plan.

As a dancer and embodiment researcher this outlook is all too familiar, and I understand it as cultural rather than a failing of the council. In the main bodies are accommodated, objectified and treated as problems to be solved, while the sensual, experiencing body is largely ignored. Unfortunately, when we take this deficit perspective, we lose important, humanising opportunities for productive fun. Policy could be very influential in this respect. If we choose instead the underpinning belief that bodies are an incredible gift through which we explore and enjoy an endlessly engaging world, we automatically find more playful and interesting solutions. Suddenly new possibilities abound, like generating power from playground equipment or a dancefloor made with kinetic tiles. When we remember our sense of fun, urban environments become play spaces for curious bodies. Street furniture is for parkour, roller blading or skateboarding as well as resting. Outdoor games and gyms spill out of parks and line the route of our walking commute. Community growing spaces (already a popular solution to poor diet, food miles, climate change preparedness, physical inactivity, social isolation and low income) are no longer confined to small allotment plots but proliferate around the city alongside the begonias, encouraging healthy eating and a pedestrian habit.

Negotiating such varied needs and uses does of course require extensive consultation and consideration, which again highlights the importance of a partnership approach through which all voices are heard, but as I said at the outset, policy making is inevitably a difficult job. The bonus of reframing in this way is that by using strategies that are intentionally enjoyable rather than those that feel worthy or obligatory, uptake is likely to be far higher and as a result there is a better chance of achieving positive outcomes. Surrounded by the richness of creative human expression and snacking on free, community-grown fruit as we walk, jog, cycle or even dance our way to work and school, why would we choose to drive? 

1. Photo by Anthony Fomin on Unsplash
2. Photograph 'Exercise Machines' (2103264189_e26de7ba22_z) by Catherine via Flickr © 2007: (CC BY 2.0) Adapted (cropped)
3. Photo by markusspiske on Pixabay

Friday, 16 July 2021

(Re)taking liberties: Reclaiming positive freedom as a public health argument

Posted by Jack Nicholls, Lecturer in Social Work at Northumbria University

At the time of writing, the government intends to lift most remaining Covid restrictions still in place in England on July 19, widely touted as 'Freedom Day'. 

I recently passed my PhD viva defending a thesis that was concerned with the diverse ways a contested value concept is understood by human welfare professionals (in my case, 'social justice' and newly-qualified social workers). As a result of that undertaking, I am now habitually critical of the ways in which ethical and moral language is used and claimed for particular agendas. In the looming shadow of so-called 'Freedom Day', I have been thinking about how caring professions and health and wellbeing researchers might reclaim the word 'freedom' for ourselves.

Possibly in contrast to many of my wonderful colleagues in the caring professions and their associated research wings, I am in broad terms a libertarian rather than a collectivist*. Individual rights and freedoms - the ability to live as one chooses unfettered without just cause, to be different, to not fit or conform - are close to sacred to me. While I can be persuaded by arguments advanced by those of a more communitarian mindset, it is always despite, rather than because, they are communitarian. When, as I will here, express concern about the speed and totality of the easing of Covid restrictions, I do so from a liberty-minded philosophical position.

The 'Freedom Day' discourse draws almost entirely on the concept of negative liberty and is emblematic of a long-established idiolect that frames freedom (with personal responsibility) in a zero-sum game against statutory entitlement to and provision of help. Negative liberty refers to the absence of constraint and control. As an idea, it is of profound importance for those of us who believe rights and freedoms are inherent to personhood, and that it is for the state to uphold them, not hand them down as bounties and favours.

Sir Isaiah Berlin 
Alongside negative liberty however sits the concept of positive liberty (both liberty concepts were set out by Sir Isaiah Berlin (pictured right) in his 1958 lecture and subsequent written works). Positive liberty refers to the idea of freedom being enabled by active action and the provision of resources, facilities and support. The two work in tandem and, for the kind of libertarian I am, they are equally important and necessary for one another. Covid restrictions have impacted both our negative and positive liberties - the former by restricting our movement, travel and association, the latter, at least for many people, by restricting our incomes, our ability to access welfare, social security, safe transport, childcare and informal support networks.

The rationale for these actions, a rationale that was broadly accepted by the majority, can be understood as a trade-off with other positive freedoms, most notably seeking to keep as many people as possible, and particularly those at most risk of developing serious or fatal Covid symptoms, free from infection. It is a trade-off I would make again in a heartbeat under similar circumstances. That is part of why the present language about 'Freedom Day' is so galling, because for many, particularly those with high-risk health conditions, their families, and those who have not yet been able to be vaccinated, July 19 will not signal any kind of freedom. I can't tell you how much I'm looking forward to my first liberated Guinness, enjoyed in the hostelry and company I choose, with all the health risks confined to the pint glass. I can't do that on July 19, because the decision has been made to prioritise the negative liberty of those of us who can enjoy it over the positive liberty of those still at particularly serious risk. We aren’t choosing freedom; we are choosing some people’s freedom over that of others.

This situation behoves health and social service practitioners and researchers to consider whether we can reclaim the concept of freedom, particularly positive freedom, as a full and proper part of our value base and lexicon. I argue that we both can and should, for what are we if not participants in endeavours for more positive freedom through greater knowledge and better health and wellbeing. Freedom 'from' is fairly hollow and useless without meaningful freedom 'to', and though many who share my philosophical persuasion see an overbearing state as a legitimate risk to freedom of all kinds, no less important is freedom from preventable illness, pain, anxiety, suffering, burden, loss of control, and the wider contributors to health inequities, not least poverty and postcode.

Our professional fields, with the best of intentions, often couch our arguments in terms of the community or public good. Without besmirching the place and value of those arguments, it is my view that were we to speak also in terms of freedom, including individual freedom, we would do so with complete intellectual coherence and legitimacy. Rather than being unjustly tagged as over-cautious and dictatorial, we could put our criticism of the end of restrictions in pro-positive freedom language. Beyond that, we could reframe and bridge the unfounded but perceived gap between individual choice and public wellbeing, all while avoiding the former being reduced to callous responsibilisation, and the latter being unfairly painted as nannying control. We might even unlock a new set of tools for persuading individuals and institutions who are rarely engaged by welfarist, collectivist or even duty of care arguments about public health concerns. We've done it before; we rarely talk about the smoking ban nowadays, rather we refer to pubs and train stations being smoke-free. Likewise fat-free, alcohol-free - it's a nice word, and an effective one.

At this moment, whatever their diverse feelings about the end of restrictions (I should caveat, the end for some) freedom is high in the public consciousness. Let us who are concerned for public wellbeing liberate our arguments and reclaim the concept of freedom, particularly positive freedom, for ourselves.

*Collectivism: a social pattern in which individuals construe themselves as parts of collectives and are primarily motivated by duties to those collectives. More here:

2. Sir Isaiah Berlin by Rob C. Croes (ANEFO), CC0, via Wikimedia Commons

The views expressed in posts are those of the authors and do not necessarily reflect those of Fuse (the Centre for Translational Research in Public Health) or the author's employer or organisation.

Friday, 2 July 2021

Intersectionality: buzzword or key to tackling health inequalities?

Posted by Dr Daniel Holman, Professor Sarah Salway, Dr Andrew Bell, University of Sheffield

Intersectionality – the idea that multiple axes of inequality overlap and interact – arguably holds great potential to understand and tackle health inequalities. But what do researchers and those working in policy and practice in this area actually think about the approach? What do they see as the key challenges and opportunities? We held a professional stakeholder workshop and consultation survey to find out. Our findings indicated a ‘cautiously optimistic’ view of an intersectional health perspective.

A growing interest in intersectionality and health

Intersectionality is currently something of a buzzword. A search of the scientific literature reveals an explosion in interest, with an eight-fold increase in papers mentioning the term in the last ten years, and a twenty-fold increase for those mentioning both ‘intersectionality’ and ‘health’:

Figure 1 - SCOPUS documents mentioning both 'intersectionality' and 'health' in title, abstract or keywords

The interest in applying intersectionality to health research, and specifically health inequalities research, has now also been fuelled by the pandemic. Ethnicity, deprivation, and age strongly influence Covid-19 outcomes. Calls for intersectional analysis of Covid-19 have now been published in BMJ Global Health and The Lancet.

Yet recent events have indicated significant political barriers. The Sewell Report essentially explained away ethnic health inequalities with reference to socioeconomic factors – anathema to intersectionality – and last year the UK Government declared itself ‘unequivocally against’ Critical Race Theory (within which intersectionality is rooted).

Further, policy-making is a process of dialogue, negotiation and ‘knowledge interaction’, with power relationships, varied sources of ‘evidence’ and competing drivers clearly at play. So, we should not expect the concept to straightforwardly impact how health inequalities are understood and addressed.

Theory vs. practice

In theory, intersectionality offers a critical, innovative approach for understanding and tackling diverse health inequalities. It essentially concerns the power structures and processes that drive these inequalities, and seeks to highlight how unjust systems of discrimination such as racism, sexism and classism operate in tandem to result in unequal, unfair life chances. The animation video below gives an overview of the approach:


Putting intersectionality to work entails a number of practical challenges. Many of our participants thought the term sounded like just another buzzword, questioning what it adds. Concerns were raised about the complexity of intersectionality both as a conceptual and methodological framework. For resource-strapped public health teams this was felt to be a particular barrier. Complexity can sometimes inhibit action because policy making processes support simplicity and certainty.

Methodologically, intersectionality includes a danger of over-disaggregation. Working with finer and finer categories to produce a granular picture of inequalities risks losing sight of the processes of disadvantage that impact across groups of people. Questions were also raised over how we can reveal mechanisms including discrimination, use mixed methods and participatory approaches, include marginalised populations, and access large, high quality datasets that intersectional analyses might require.

How might intersectionality actually be implemented? We asked respondents to consider two suggestions

First was the idea of using intersectionality to target and tailor interventions and policies. This raised numerous concerns that it potentially takes focus away from structural changes; assumes that all those in a particular intersection are the same; excludes those who do not fall into the targeted category, and; reinforces deficit and stigmatising narratives. Nonetheless, respondents thought that targeting could have value if marginalised groups were included in the process. They also suggested that geography should be considered when targeting as it is a key aspect of social context.

Second was the idea of monitoring and evaluating the impact of policies and programmes on different sub-groups. This approach was more popular, with participants keen to be able to demonstrate differential and unanticipated outcomes of initiatives. Again, the importance of meaningful engagement of marginalised groups and careful attention to understanding mechanisms, were highlighted.

What is the way forward? Our participants emphasised some key principles and points of action:
  • Ensure a clear focus on systems of social discrimination and how they structure access to power, resources and life chances, especially via social institutions (such as schools).
  • Wherever appropriate, participatory and co-productive approaches - entailing more equitable knowledge-production – should be used.
  • Carefully consider complexity; arguably intersectionality’s biggest asset and challenge. What constitutes the right level of complexity and in which context? Trade-offs are inevitable.
  • Develop clear methodological guidelines, possibly in the form of a toolkit, to help with implementing intersectionality, especially for non-academics with limited research resources.
  • Big datasets with well measured social variables are essential.
Intersectionality holds much promise. It has the potential to help ensure that those experiencing multiple discrimination are not further disadvantaged by the Covid recovery phase. Acknowledging and addressing potential pitfalls and limitations of the approach is therefore crucial. Marginalised populations, researchers, policy and practice professionals all need to be part of the conversation.

To read more about the project from which this research originated, please take a look at the project website:

Friday, 18 June 2021

When, what and how to engage and disseminate research evidence during a pandemic?

Posted by Peter van der Graaf, Teesside University, Jenni Lynch, University of Hertfordshire, and Liz Such, University of Sheffield, three NIHR Knowledge Mobilisation Research Fellows

In this blog, we share lessons from working with local authorities on the development of action learning sets (bringing people together to reflect on research evidence) when they are faced with the many challenges of COVID-19.

Why do we need action learning? 
(Best-laid plans)

We know that local authorities value research evidence to improve their decision-making about public services in times of austerity; however, making evidence fit for purpose and getting it actively used in local government remains challenging.

So, we decided to test a potential new approach to knowledge mobilisation by convening and supporting action learning sets (ALS) across three local authorities (Hertfordshire, Gateshead and Doncaster Councils). This was supported by the NIHR Centre for Engagement and Dissemination (NCED), which not only aims to share knowledge and outputs from NIHR-funded research, but to develop the evidence base about “what works” in knowledge mobilisation.

The ALS would bring together a group of approximately 15 stakeholders in each local authority, including public health and social care commissioners, front-line practitioners, third-sector representatives, service users and local academics to reflect on research related to a priority topic of their choice. Using deliberative dialogue, including structured questioning and reflection, participants explored different types of knowledge and relationships between knowledge producers, users and mobilisers. By applying this approach, the ALS aimed to help mobilise research and other forms of knowledge on wellbeing and equity in local government into collectively agreed action plans.

As we started discussions with our local authority partners in Spring 2020, the full implications of the COVID-19 pandemic hit. Despite various attempts to start the ALS we regrettably had to decide to abandon the project in its current form. In this blog, we share our lessons from working with the local authorities on the development of ALS during a pandemic and what this means for future knowledge mobilisation activities from NCED when engaging with public health and social care. Our reflections focus on the when, what and how of knowledge mobilisation with local authorities.

Research capacity during a pandemic: unethical conversations? (When)

What the pandemic taught us is that when public health and social care research is most needed (e.g. to inform the response to COVID-19), capacity for using this research is very limited. With local authority staff being spread thin and reassigned to other parts of their councils, it was not feasible and even borderline unethical to ask them to join and prepare for action learning set (ALS) meetings. In particular senior staff within local government, who are key participants for the ALS, were in some cases absent from our early conversations. A serious question was posed: 
"How could we mobilise research evidence to help local government in their response to COVID-19, when they hadn’t got the time or mind space to even look at a one-page summary brief?"
We tried to make the process more accessible by moving the ALS meetings online, involving smaller groups to optimise interaction (five instead of 15 participants) and shorter sessions, with individual activities and reflection time between sessions. This helped to some extent to engage with local authority partners, but the capacity problem remained and even short online meetings where often not feasible for senior staff. However, it illustrated the value of a blended approach to ALS with a potential combination of online and face-to-face sessions to allow stakeholders to engage differently at various times in the process. We also urged them to consider topics that were immediately relevant to their current situation, e.g. working virtually through the pandemic.

The need for relevant evidence (What)

The Hertfordshire County Council Social Work team chose to reflect on how to interpret the Mental Capacity Act and apply strengths-based approaches when discharging patients from hospitals into the care of local authorities (discharge to assess pathways). Strengths-based approaches are a collaborative process between service users and providers to determine an outcome that draws on the person’s strengths and assets. We found a small number of NIHR funded studies but also identified useful knowledge from other sources, such as a Health Services and Delivery Research (HS&DR) Evidence Synthesis Centre Topic Report, which provided a systematic review of evidence on different strengths-based approaches within adult social work, and guidance documents produced by a law firm.

Knowledge Mobilisers Assemble!
Similarly, Gateshead Council selected the topic of community-based approaches to public health, focusing on how to implement these approaches with staff within the Council across different departments by applying a whole system approach. We were able to identify relevant work through our network of NIHR-funded Knowledge Mobilisation Research Fellows. For example, researchers at the University of Hertfordshire had teamed up with Hertfordshire County Council to set up a whole systems programme team and developed a joint masterclass on the topic that summarised the latest evidence.

This illustrated a need to tap into a wide range of databases that included studies and evidence from sectors beyond health and links to a network of knowledge mobilisers to access ongoing work and publications that were not routinely published on scientific databases. We plan to support this in the development of our own website as Knowledge Mobilisation Research Fellows united in the Knowledge Mobilisation Alliance.

Localising and tailoring of evidence: the value of dialogue (How)

Thirdly, our conversations with partners about the planning of the action learning sets (ALS) demonstrated that local authority staff value conversations with academic researchers about the meaning of research and how-to tailor evidence to their local needs. Evidence is made fit for local commissioning and planning purposes by localising it (relating evidence to local context and needs) and tailoring it (presenting actionable messages). ALS provide a mechanism for this translational activity and a collaborative space for local authority staff to take time out from their busy jobs and reflect on research evidence (and other types of knowledge).

Constructive dialogue was seen as most useful in supporting decision
 making, instead of researchers parachuting in with findings   
Various staff members in local government who we talked to were already research active, engaging with research through conferences and some by undertaking PhD studies themselves. They were already mobilising local intelligence, national data and tacit knowledge in their decision making. Instead of academic researchers parachuting in with their research findings, constructive dialogue about the meaning of different types of knowledge - and where researchers and practitioners worked together as equal partners - was seen as most useful for supporting local government decision making. Facilitated conversations over a series of meetings would enable them to effectively blend different types of knowledge together to inform the commissioning of health and social care services.

Being humble and open to challenge and dialogue are key components of any knowledge mobilisation strategy for engaging with local authorities and dissemination of health research findings.

More commentary on action learning sets and engaging with local authorities in knowledge mobilisation below:
  • Van der Graaf P, Cheetham M, Redgate S, Clare H, Adamson A. Co-production in local government: process, codification and capacity building of new knowledge in collective reflection spaces. Workshops findings from a UK mixed methods study. Health Research Policy and Systems. 2021 Jan;19(12).
  • Van der Graaf P, Blank L, Holding E, Goyder E. What makes a ‘successful’ collaborative research project between public health practitioners and academics? A mixed-methods review of funding applications submitted to a local intervention evaluation scheme. Health Research Policy and Systems. 2021 Jan;19(1):1-3.

  1. "… of Mice And Men …" by Kristian Bjornard via, copyright © 2010: (CC BY-SA 2.0)
  2. Pat Loika, CC BY 2.0, via Wikimedia Commons

Friday, 11 June 2021

Things I wish I’d known when I started my PhD… (part 2)

Posted by members of the Population Health Interventions Programme at the MRC Epidemiology Unit

This is Part 2 of our PhD SURVIVAL GUIDE. In Part 1 we found out that doing a PhD (or any research) is challenging but the ‘this might be okay’ stage always comes; continuously comparing your work, and yourself, to others is the thief of joy; and research is a team sport and you're the boss so start channelling your inner Arsène Wenger!

Like most research groups, ours comprises an ever-changing cast of early, mid and senior career researchers. Our training is in a variety of academic disciplines and we all have different short, medium and long term life and career aspirations. While our experiences of public health research are naturally individual, we have noticed some commonalities. We share these here to provide reassurance to those new to the game that whatever they’re feeling is almost certainly ‘normal’. Challenging experiences are often interpreted negatively, particularly when they are first met. We propose that they can often be reassessed and reframed in ways that make them positive parts of a continuous learning and career development journey. Other people might have different experiences, this is ours…


Licensed to YouTube by: UMG (on behalf of Walt Disney Records); UNIAO BRASILEIRA DE EDITORAS DE MUSICA - UBEM, ASCAP, AMRA, LatinAutorPerf, Walt Disney Music Company (Publishing), LatinAutor - SonyATV, LatinAutor - UMPG, CMRRA, UMPI, and 15 Music Rights Societies

4. We’re all in this together – don’t take it personally

It is impossible to overstate the importance of not taking feedback personally. Opening a document containing feedback from your supervisor or peers and seeing a page full of colourful tracked changes and comments can sometimes feel like personal criticism. It’s all too easy to see this as a setback but in reality, this is what teamwork looks like. Your supervisor is there to ask the difficult questions, and to stretch you intellectually. All feedback is intended to be helpful, so you can produce a stronger output.

Trust us, your supervisor doesn’t expect perfection. Think they don’t receive similar feedback from their colleagues? Think again. But they’ve learned from experience that falling short of perfection is okay. Few imperfect ideas are that imperfect!

Also, what does perfect look like? There’s rarely a ‘right’ answer to any question, and there are different but equally valid ways to approach most things. Different is not necessarily better. Although you’re bound to immediately presume what you’ve done is ‘wrong’, our advice is to take a breath, remind yourself why you did what you did, and be prepared to defend that. This will be an essential skill for your viva! But remember to respect the time it took for someone to really consider your work, by reciprocating and carefully considering their ideas.

Your supervisor wants to see you succeed because your success is also theirs. Seeing your student flourish is immensely gratifying. It rewards everyone’s intellectual contribution to the work, and validates that seedling of an idea, planted by your supervisor, which has since blossomed under your care. Lastly, don’t forget that as much as you’re learning from them, they’re learning from you, too. You wouldn’t be doing that systematic review if they knew the answer already. 

"Piled Higher and Deeper" by Jorge Cham
5. A PhD is a job, not a way of life

For most of us, reaching the start of a PhD represents lots of hard work and effort. It is tempting to think that means you should pour your life into research, and nothing but research, for three or more years, to do justice to that opportunity.

But your PhD can benefit from some down time. Giving yourself a mental break from research means you can return to work with renewed enthusiasm. Time away can also offer clarity and sometimes inspiration! Setting boundaries between research and the rest of your life can make the entire PhD process more sustainable and ultimately, more enjoyable. It can be easier to work efficiently and effectively in distinct working hours (even if those aren’t 9-5), with the incentive of doing something else that you enjoy at the end of it.

However, intending to take time off work and actually doing it are two very different things. During busy periods, it is easy to prioritise your PhD over other areas of life. It also becomes harder to switch off thoughts like “should I read that extra paper?” or “maybe I should do that analysis?” while you are trying to relax.

There are simple ways you can give yourself a better chance of achieving the elusive ‘work-life’ balance. Scheduling time – and protecting that time – to do a particular hobby, sport or social activity can help. It is much easier to rearrange a “hope to do yoga at some point this week” than a class you have booked at 7pm on Wednesday. Similarly, committing to doing things with other people is a great way to cultivate new friendships with colleagues, enjoy their company, and follow through with a plan. At times of self-doubt, it is also a good reminder that there are many other things you are capable of, and that life isn’t all about the PhD! 

6. Some bad things may happen that are not okay

A healthy PhD experience should be challenging, yes, but if this starts to have a negative impact on your physical or mental health and affects how you would normally function, something could be wrong. There are fantastic resources on the Mind website which are a great starting point to help you be more aware of your feelings. Struggling with mental health is very common in life and you are not alone. Seeking help and support is important though. Don’t be afraid to tell your supervisor if you’re struggling.

Sometimes though, the cause of these struggles can be external, and in particular, your relationships with supervisors. Supervisors are responsible for challenging you but also encouraging and supporting you. If there is a problem with your relationship, it is always wise to talk to your supervisor if you can, as they may not realise there is a problem. People are not always immediately compatible in their working styles; this is okay and can be worked through.

If a dysfunctional relationship is caused by a supervisor who is behaving inappropriately, this is not okay. Harassment or bullying of any kind should be escalated through the proper channels in your university. Speak to fellow students you trust candidly about your experiences too; you may not be the only one suffering and they could help support you through it.

The student always becomes the master
7. Enjoy every step of the journey

The good things that come from doing a PhD are not necessarily what you might expect. For some, the highest high is indeed right at the end, the crescendo, when the thesis is submitted. But for many this can feel like an anti-climax. The more you can learn to embrace and enjoy the process, and the less you anticipate what you think will be the good things, the more good things will come your way. A breakthrough with your data collection, your first set of meaningful results, mastering a new skill, or even just a meeting with your supervisor that goes particularly well, are all cause for celebration. Each milestone is a block that forms the foundation of your PhD and each one is a vital move towards your end goal. There is nothing more rewarding than the sense you are on the right track.

As you progress, you will also start noticing that people begin treating you like the expert you are becoming. You might not feel like it, but the student always becomes the master. As strange as these moments feel, you should enjoy them. They are an external reminder that you know more than you think you do. 

Occasionally you will sit back and realise, "I'm doing a PhD! And that’s pretty cool". Stop thinking that you need to have all the answers, or even that you know where your research is going, and instead realise you are there to learn and there to explore, wherever that takes you.

That’s it!

We hope that these points have been helpful, and that you are able to look back at these blog posts when it feels like everything is going wrong. Trust us, it most probably isn’t. We have all been where you are and have lived to tell the tale. Most of us would love to be in the position you are right now again, even just to spend time reading those papers that we still can’t get around to. Try your best to enjoy this incredible experience. You’ve got this!

Authors: Catrin Penn-Jones, David Ogilvie, David Pell, Dolly Theis, Emma Lawlor, Hannah Forde, Jean Adams, Jenna Panter, John Rahilly, Kate Ellis, Martin White, Matt Keeble, Nina Rogers, Rich Patterson, Roxanne Armstrong-Moore, Tom Burgoine, Yuru Huang.

Song: We're All In This Together (From "High School Musical"/Soundtrack Version)
Artist: High School Musical Cast
Writers: Robbie Nevil, Matthew Gerrard
Licensed to YouTube by: UMG (on behalf of Walt Disney Records); UNIAO BRASILEIRA DE EDITORAS DE MUSICA - UBEM, ASCAP, AMRA, LatinAutorPerf, Walt Disney Music Company (Publishing), LatinAutor - SonyATV, LatinAutor - UMPG, CMRRA, UMPI, and 15 Music Rights Societies

1. "Piled Higher and Deeper" by Jorge Cham

Friday, 4 June 2021

Things I wish I’d known when I started my PhD… (part 1)

Posted by members of the Population Health Interventions Programme at the MRC Epidemiology Unit
“By three methods we might learn wisdom: first by reflection, which is noblest; second by imitation, which is easiest; third by experience, which is the bitterest.” 
Like most research groups, ours comprises an ever-changing cast of early, mid and senior career researchers. Our training is in a variety of academic disciplines and we all have different short, medium and long term life and career aspirations. While our experiences of public health research are naturally individual, we have noticed some commonalities. We share these here to provide reassurance to those new to the game that whatever they’re feeling is almost certainly ‘normal’. Challenging experiences are often interpreted negatively, particularly when they are first met. We propose that they can often be reassessed and reframed in ways that make them positive parts of a continuous learning and career development journey. Other people might have different experiences, this is ours…

1. Research is challenging but you’ve got this

"Piled Higher and Deeper" by Jorge Cham
Research is certainly challenging. One of the first hurdles of the PhD will be trying to figure out how your research will contribute new knowledge to the area - this is one of the toughest challenges! Stick with it, because thankfully it does get a bit easier over time as you immerse yourself in the research and build your specialist knowledge. But even the most accomplished still find research hard. All the papers you read are from months (often years) of thinking, hard work, and negotiating multiple barriers - it doesn’t happen overnight. As a PhD student, you have the additional challenge of trying to do this in a short time frame, and it doesn’t always go to plan (which is usually out of your control). But, if good research was easy, anyone could do it.

An obvious interpretation of experiencing something as being difficult is to think that we, as individuals, are not up to it. The cycle of creativity suggests, rather glibly, that all projects are associated with a thought cycle that goes something like: this is awesome, this is difficult, this is terrible, I am terrible, this might be okay, this is awesome. We are not sure that we routinely experience the second ‘this is awesome’ stage. But push through because the ‘this might be okay’ stage always comes.

If you have been selected to pursue the PhD, your supervisors think that you are capable. You wouldn’t be on this journey if there were any real doubts about your ability. Encountering difficulties and making mistakes is normal and expected. Even those researchers you admire the most have moments of self-doubt, numerous journal and grant rejections and bad days when nothing goes right.

2. Comparison can be the thief of joy

Academic research is often experienced as highly competitive. In many ways it is. There is competition for limited research, studentship and fellowship funding; limited space in ‘prestigious’ journals; and limited podium time at conferences. This leads to the tendency to continuously compare your own work, and yourself, to others - and to experience a feeling of falling short.

It’s worth pointing out the selection bias present in the successes others share, and how most of the time we’re not seeing the full picture. Despite knowing this, we understand it is sometimes hard to see everyone else seemingly thriving, while you feel you’re just about surviving! Keep in mind that everyone’s PhD is different, and our successes will run to different timelines. And remember, you bring to your PhD your own unique skills and experiences. We’re confident that others are comparing themselves to you, too…

However, rather than continuously comparing yourself to others, we recommend trying to learn from them. If others appear to be succeeding where we are not, what, if anything, can we learn from their approach? Sometimes this will lead to the conclusion that there are better ways of doing things. Other times it might lead to the conclusion that the sacrifices required to achieve a particular outcome are not something we as individuals are willing to make. Or, indeed, that the outcome is not something we want.

We suggest being clear about what our own success criteria are and trying to stick to judging ourselves by those alone. These criteria can be set alone or with others in the context of formal or informal regular appraisals and personal review. At the risk of getting too SMART*-arsed, they should, at a minimum, be realistic.

Rather than interpreting others’ achievements as indicators of our own lack of success, we propose embracing and celebrating them. Informal and formal research group meetings achieve many things, but we see the sense of community that they build amongst ourselves as one of the most important. By embracing each other’s achievements we can support and build each other up, rather than letting comparison get us down.
Channel your inner Arsène - "Le Professeur"
3. Research is a team sport and you’re the boss

Completing a PhD might be seen as a lonely, individual pursuit. But while the end result is your own, you aren’t alone on the journey. In fact, research is a team sport.

Your home team is the one you share with your supervisor(s), and you’ll revel in the highs (and lows) of your PhD experience together. In this team you’re the captain. Lead from the front and manage your supervisors by communicating clearly with them, arranging supervision meetings and keeping them up to speed with your progress. As the captain, you make the final decisions related to your research and you are responsible for defending them. If you don’t agree with your supervisor then you should say so, and explain why. Your supervisor doesn’t want you to nod along, as the idea is to learn from each other and make better research (i.e. win) as a team. This can often feel really hard, especially early on while they’re still the experts, but they expect you to take the lead.

In other teams to which you’ll belong, you might play a different role but still make an impact. For example, you might run a writing group, attend group meetings or present in a seminar series; these are all important aspects of teamwork and becoming a valued member of the research community. You are also a member of teams that are less obvious. You probably aren’t sure now how the Facilities or IT department are going to help you achieve your PhD, but when you need a new chair or an obscure software package installed, be glad that you have them as teammates.

In part 2 next week: learning how not to take things personally, life isn't all about the PhD, bad things may happen that are not okay, and enjoying every step of the journey.

Authors: Catrin Penn-Jones, David Ogilvie, David Pell, Dolly Theis, Emma Lawlor, Hannah Forde, Jean Adams, Jenna Panter, John Rahilly, Kate Ellis, Martin White, Matt Keeble, Nina Rogers, Rich Patterson, Roxanne Armstrong-Moore, Tom Burgoine, Yuru Huang

*SMART Goals: Specific, Measurable, Assignable, Realistic, and Time-related

1. "Piled Higher and Deeper" by Jorge Cham
2. Mr. Alexander Ottesen, CC BY-SA 2.5 <>, via Wikimedia Commons