Friday, 13 May 2022

Planning for a healthier future?

Posted by Tim Townshend, Professor of Urban Design for Health, Newcastle University

Can we plan for a healthier future by intervening in the built environment? You may be surprised to find out this is not a new idea! Indeed, the very concept of Town Planning emerged in the last quarter of the 19th Century out of a concern for public health and to help prevent the spread of infectious diseases such as cholera.

Ebeneezer Howard - ‘slumless, smokeless’ garden cities

The resulting Victorian terraces, with fresh water supplies and internal toilets may seem unimaginative, but they were a huge improvement on what went before - and did indeed prove a boon to public health. What’s more many still provide decent homes today.

Early planning thinking was also dominated by a vision that the physical health attributes of the countryside – access to open space, clean air and fresh food could be combined with social and economic (mental health) benefits of the city – including opportunities for education, access to culture and wider social contacts. Such thinking is typified by the Garden City Movement associated with Ebenezer Howard and realised - at least in part - in towns such as Letchworth in, Hertfordshire.

Health was at the core of planning for much of the 20th century, however, in the post-war period it became eclipsed by other issues - particularly the need for economic regeneration. Consequently, the health and well-being impacts of the way our towns and cities were developing was not considered carefully enough.

“...primarily designing around the needs of the private car - rather than humans - has been a disaster.”

In retrospect, primarily designing around the needs of the private car - rather than humans - has been a disaster.  Busy roads now cut noisy polluted swathes through communities; poorer neighbourhoods find themselves served by ‘toxic high streets’ – a deadly mix of nutritionally poor food, subprime financial services, betting shops and other potentially harmful outlets; and vast tracts of poor-quality new build housing - devoid of adequate open space, or local services - have been constructed in the suburbs.  At the same time rates of obesity (and associated health/well-being consequences), respiratory and so-called ‘lifestyle’ diseases have all soared. Moreover, these impacts are not felt equally across all neighbourhoods, and health inequalities unjustly burden the poorest in society.   

 Interlinked themes explored in Healthy Cities? Design for Well-being
It does not have to be this way, however. We can plan for a healthier future and create places that support individuals and communities to take healthier lifestyle choices. In ‘Healthy Cities? Design for Well-being’ I explore five inter-related topics and the ways in which the goal of a healthier future can be achieved.

There is for example a large and robust evidence base around our need for urban greenspace (as was highlighted so graphically during the COVID-19 lockdown period). Green (and blue) spaces in our cities not only facilitate physical activity and socialisation (positive for physical health and mental well-being) but can mitigate against issues such as, air and noise pollution, ‘heat islands’ (the significant heat increases in urban areas as compared to their surroundings) and alleviate flood risk. Crucially, however, greenspaces have also been shown to reduce stress levels and help restore cognitive capabilities - for example concentration levels - just by being there.  

Planning policies can also be used in conjunction with public health goals to tackle specific health issues. A great example of this, is the development of planning guidance and regulation to tackle the further spread of hot food takeaways – a key component of my ‘toxic high street’ concept, which I explore in more detail in the book.  While planning cannot tackle existing businesses it can limit further spread, especially in sensitive areas – for example near schools, as research has proven the link between hot food availability and overweight/obesity in older children. Issues we will explore at the Fuse Research Programme Meeting “Planning for a healthier future: Priorities and Practicalities” on May 18, 2022, at Teesside University (and available online).

Therefore by encouraging those aspects of the built environment that support healthy lifestyle choices, while constraining those aspects we know are linked with less healthy lives, healthier places are within our grasp – but this can only be achieved if we collaborate across disciplines and garner the political support required to make it happen!

Healthy Cities? Design for Well-being is available to order now


1. Howard, Ebenezer. "Diagram of a group of slumless smokeless cities.". 1898. From Ebenezer Howard, "To-morrow: A Peaceful Path to Real Reform" [London, 1898]. Web. 12 May. 2022.

Friday, 1 April 2022

Breaking down barriers in End of Life care

Posted by Colette Hawkins, Consultant in Palliative Medicine, South Tees NHS Foundation Trust

Health research achieves extraordinary things. There are countless examples of life-changing, disease preventing or curative treatments. These are rightly celebrated and have shaped our society, as well as our expectations, around health and illness.
Break Through 1995 "Walls break hearts, hearts break walls" by 
Pierre Marcel via Flickr © 2011 (CC BY-NC-ND 2.0)

But what about people living with a life-limiting illness and those approaching end of life? Health professionals often struggle to move away from an interventional, disease-focussed approach to a more holistic, person-centred approach. This risks unwanted intervention and missed opportunities for choice. This is mirrored by health research. In the UK, just 0.21% of health research is focussed on palliative and end of life care.

The reality is that people living towards end of life really struggle and whilst this may be directly related to ill-health, it is often issues of daily life which incapacitate them. These are generally overlooked by health professionals.

Since 2017, I have been involved in running research on legal needs in life-limiting illness. One element of this is social welfare legal needs (SWL): matters of daily life for which the law defines rights, entitlements and protections. In the context of life-limiting illness, the ‘big three’ are issues relating to money, employment and housing. These are prevalent, impacting most people in some way. However, their greatest impact is on people who are already disadvantaged, for example those experiencing homelessness, financial insecurity or debt, socially excluded or marginalised groups and people with multiple physical and/or mental illness. These people experience the most SWL needs, are most affected by them and are least likely to access support successfully.

Social welfare legal needs will often be presented to health professionals, wrapped up in a person’s physical complaints, but missed in favour of a focus on disease. So where else could they go? Our foundation research scoped the system of support for these issues. A wide range of services beyond health and social care provide advice and support for SWL needs, including charities, community groups, advice sector, legal services, social services, Jobcentre, housing groups, social prescribing, statutory organisations and more.

But if we took months to map the system (and it’s still growing), can we expect people in vulnerable and difficult situations to find their way?

Funded by the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC), our research has engaged members of the public with lived experience, as well as service providers in Gateshead, to find an effective system response to social welfare legal needs. We used Human Learning Systems, an approach which accepts the complexity of a system and supports co-produced responses to need founded on continuous learning.

Engagement of people with lived experience of life-limiting illness and SWL needs proved critical to the value of this project. Focus group discussions revealed the scale of the challenge to manage SWL needs. The walls they faced included not feeling heard, not knowing where to go for help, lack of information to help themselves, lack of responsibility from professionals or services, poor communication between services and long delays to resolution (or non-resolution). These insights, along with those of service providers, told us that the ideal system response should be founded on relationships and offering information, problem solving and a joined up approach. This seems quite obvious and appropriate, so why are there so many walls?

Attitudes and structures 

The walls come from two main sources: professional attitudes and structures. Attitudes obstruct when they use labels, stereotypes or assumptions, treat illness, not people, miss opportunities for honest discussion, restrict choice through failing to listen to priorities and wishes, overlook responsibility for holistic needs and forget to work in partnership. Structures maintain silos and fragmentation of care with the lack of clear routes to advice and support, boundaries to access through geography, referral criteria or social context, expectations that patients and carers will self-advocate and navigate themselves and missed opportunities to capitalise on the expertise of others. These walls obstruct identification and management of social welfare legal needs and amplify inequalities in care towards end of life.

We believe interprofessional learning is a route to breaking down these walls. We use short stories of experience instead of ‘sterile’ clinical cases, and facilitate discussion to explore what matters most, and the approaches to meeting needs in an inclusive, respectful and effective way. Initial pilots have shown that this is a route to closer integration of services, although the latest pilot, within the ARC project, also highlighted the challenge of engagement with online learning, accentuated by the pressure and workplace fatigue linked to COVID-19. Feedback showed that people felt too busy to attend or just didn’t turn up on the day.

We have secured a NIHR End of Life Partnership grant which we are using to co-design a research strategy for evaluation of system-wide learning around SWL needs in life-limiting illness. We are re-evaluating what we mean by ‘end of life’, pushing beyond traditional views and including people at risk of premature death. We are broadening our insight into the inequalities and prejudices embedded within care of people who may be living towards end of life. We can see the walls; our task is to break them down.

This project ‘Integrating care to meet social welfare legal needs in life-limiting illness. Qualitative investigation of a multi-agency, complexity-informed intervention’ has been funded by by the National Institute for Health Research (NIHR) [Applied Research Collaboration North East and North Cumbria (NIHR200173)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Image: Break Through 1995 "Walls break hearts, hearts break walls" by Pierre Marcel via Flickr © 2011: (CC BY-NC-ND 2.0)

Friday, 25 March 2022

Is a picture truly worth a thousand words?

Posted by Emma Adams, NIHR ARC NENC Mental Health Fellow at Newcastle University, and Experts by Experience from Fulfilling Lives Newcastle Gateshead & #HealthNow Newcastle

An illustration of me! Taken from one of the images
below created by Siân from More than Minutes
We have all heard some variation on the saying “a picture is worth a thousand words”, and yet often information is shared through large reports with thousands of words and few images. A 2019 paper published in Nature Communications highlighted that with all the information people can read, gaining people’s attention is increasingly difficult.

Take the image of me (right), it tells you about my hair colour, glasses, outfit, that I'm partial to a tea or coffee and that I am sitting at a table. If I had written a description of everything that you can get from the picture, it would have likely taken up far more space. If it were me, I would probably only have skimmed the text. As a public health researcher, part of my job is finding ways to share research findings in a way that will engage people to want to learn more and have a conversation (something we in Fuse like to call knowledge translation).

Alongside my Experts by Experience (individuals with lived experience of homelessness, mental ill-health, and/or substance use) we began to ponder how to share what we learned from our NIHR School for Public Health Research (SPHR) funded study exploring access to community based mental health and substance use support during the COVID-19 pandemic for individuals experiencing homelessness and those providing support. We had finally reached a point where there was a light at the end of the tunnel, as we moved away from understanding to sharing the findings. Yes, we figured we would write a couple of papers, attend some conferences, and likely write a report, but the bigger question was would the people in policy and practice and individuals experiencing homelessness read those documents? While trying to be nice, one person levelled with me and said Emma, “I’m probably not going to share a PowerPoint with a friend” and another said, “I don’t even know what that journal is”. Quickly the realisation sunk in that we were going to have to come up with a better solution for sharing our findings.

I began to think about visuals but realised my failed attempts at drawing stick people meant I probably would not be able to do this on my own. Two of the Experts by Experience spoke about a visual they had seen designed by More than Minutes for a peer research study around barriers to accessing care and treatment for people experiencing homelessness (#HealthNowManchester). I realised in that moment we had found our answer. Suddenly the Zoom call was abuzz with energy as everyone got excited about what story our visual might tell. As one person said, “it’s aimed at people who can’t read or write, or have a disability - someone like my brother”. Perhaps even more insightful was the comment that, “it [a visual] could have a different meaning for each person depending on their own experience”. 

We met with Siân (an illustrator from More than Minutes) and began planning the image and figuring out how to depict our endless pages of ideas into a visual that was engaging without being overwhelming. Over the next few months, we had a bit of back and forth on what we were envisioning. When the initial pencil sketch arrived, we were shocked at how the images captured so much of what we wanted to share without being a visual overload. Like kids at Christmas, we sat in suspense waiting to see what the final colour version would look like. We knew it captured exactly what we wanted when we saw the coloured versions. It was the physical depiction of everything we had learned and would proudly adorn our homes and offices! Through working with Experts by Experience and having input from colleagues in practice, we believe we have created a poster that depicts the experiences without some of the stigma we often see. Each of us saw something a little bit different in the poster, and we could not wait to share it with friends, colleagues, and providers. 

Created by Siân from More than Minutes; See the full images on the NIHR School for Public Health Research website.

Having had the experience of seeing words and quotes come to life, I cannot wait to do it again. Although we will continue to write papers and reports, the ability to share the images from our phones or by email with anyone has made us think about other creative ways to communicate research in the future.

So, I end this post with a question for you, do these pictures tell a better story of the findings than a one-page summary would have? Between you, me, and our Experts by Experience, we will be returning to this visual time-and-time again whereas the paper and report might not have the same reach and engagement. 


To make this visual freely accessible, we would welcome organisations printing their own copies. If you are printing the poster, please print it in its entirety and email Emma Adams so we can see all the places sharing our findings. A limited number of printed posters are available directly from Emma for pick up from Newcastle University.

Initial findings from Emma’s study have now been published in the International Journal of Environmental Research and Public Health.

Fuse Research Programme Meeting is planned to share more information about Emma’s study. Stay tuned for the save the date and further information. 


Emma is a Mental Health Fellow for the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC) and a previous NIHR School for Public Health Research (SPHR) Pre-Doctoral Fellow.  Her study 'Exploring and understanding access to community-based mental health and addiction services in Newcastle and Gateshead' is NIHR SPHR ResNet funded.

This project is funded by/supported by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR) (Grant Reference Number PD-SPH-2015-10025). Emma was supported by the NIHR SPHR Pre-doctoral Fellowship Funding Scheme (Grant Reference Number PD-SPH-2015). Emma is now supported by the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC) (NIHR200173). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Friday, 11 March 2022

Universal Credit experiences and research co-production

Introduction by Mandy Cheetham, Research Fellow in the Applied Research Collaboration North East and North Cumbria (ARC NENC), Northumbria University

I contacted David in my role as public involvement lead for the NIHR funded study on Universal Credit. As a research team, we made a commitment to include the views of people with experience of claiming Universal Credit as part of our public involvement and engagement activities. David very kindly offered his assistance and has been one of the contributors who have helped shape the study so far.


Posted by David Black, Fuse Public Partner and Expert by Experience

David takes part in a wide variety of public involvement and engagement activities  
I had noted many observations during my experience of engaging with the Universal Credit system and had a little experience of welfare benefits in a previous roll assessing applications for legal aid. As I'd been involved in co-production work relating to clinical research and healthy ageing in a number of patient and public involvement roles, I knew what would be expected of me in terms of sharing my perspectives about Universal Credit with the research team. Preparation prior to the initial meeting was key to getting my messages across, so I made some notes and checked out dates and relevant facts about the benefit online.

The messages I wanted to share about Universal Credit related to my direct experience and also what I'd see at local libraries when other people had been trying to use computers to apply for the benefit and respond to requests from the Department for Work and Pensions (DWP) that were expected to be done online. Some of the people trying to use computers were clearly struggling and I found myself and the librarians were regularly asked for assistance. I'm a helpful kind of person, so I would try my best to assist. Many of the people I met did not have the basic computer skills necessary to complete what was requested and with a time limit on computer access at the library, it was often a struggle.

As part of my co-production work I shared my experience of the initial application process and explained to the researchers that I had to go to my local library with all of my personal data in document form in order to complete the online application. It took me an hour and I was concerned that I had all the information to complete the form in full in one go. One of the frustrations I had related was the process of proving your identity via an online checking tool. Having initially been relieved once I'd got the main online form completed and saved, I found myself beaten by the simple process of proving who I was! The system simply did not work for me in this regard and after going home and phoning the DWP I was given an appointment to go to a Jobcentre to complete this process manually.

It was clear to me what information I wanted to share with the researchers and the fact that they were good listeners and gave me the time and space to explain my experiences helped a great deal. In the past I'd always found the process of seeking help from the unemployment benefit system to be relatively easy, but Universal Credit was a disaster for me. Not only did the DWP assume all claimants had access to the internet all of the time - something that I did not have until the pandemic started, which was years after my experiences of Universal Credit - but a constant stream of text messages in relation to Universal Credit created a state of panic and worry for me.

An important message I got across to the researchers was that ultimately I was deemed to not qualify for Universal Credit and left without any help or assistance. Something I'd never experienced when I'd previously reached out for help from the state system. Continuing my co-production work with researchers in this area of study has given me an immense sense of pride and satisfaction. I hope that in working on this research in some small way I can assist in the future understanding of how changes to benefits and the wider government welfare system can have real impact on the lives and wellbeing of people.

If you are interested in becoming a Fuse Public Partner, please visit the Public Involvement page on the Fuse website.

Friday, 11 February 2022

Dressing as a tomato and meeting the CMO - all in a day's science

Elsie Widdowson, British nutritionist
Posted by Amelia Lake, Professor of Public Health Nutrition at Teesside University and Associate Director of Fuse

In this blog on International Women's Day, Amelia tells us about the pioneering female scientist who inspired her career in nutrition science.

When I was at University studying for my degree in Human Nutrition and Dietetics in the mid 1990s our ‘food tables’ were in books – actual books that you held.

We worked out nutritional content of food using books and calculators. Now-a-days this is all done by software without the need for the hard copy of the books. The book we all had was a copy of the ‘McCance and Widdowson’ Food Tables. I still have my well thumbed copy and the book is the the basis of the modern software systems that nutritionists and food scientists use.

Although as an undergraduate I didn’t really give the names McCance and Widdowson much thought it was later on in my career, thanks to the British Nutrition Foundation and my colleagues, that I really learned about Elsie Widdowson. She was born in 1906 and died in 2000 having spent a long and productive life as a pioneering female scientist. Along with her colleague Robert McCance, Elsie Widdowson was at the forefront of the Nutrition effort after World War II.

Elsie studied Chemistry at Imperial Collage London and in 1931 completed a PhD in Chemistry also at Imperial. Elsie met Robert McCance in the kitchens at Kings College Hospital in 1933, when she was studying to become a dietitian and he a junior doctor. Here, in the hospital kitchens, began a partnership that would last for 60 years!

It was at Cambridge, where they both worked, that the book I mentioned earlier was developed: a publication pivotal to nutritional science. But it wasn’t just for the development of this book that she has my respect - it was for the pioneering work around vitamin and mineral fortification, the rehabilitation of severely starved individuals and malnourishment around the world and important work on infant diets. This was an incredible female scientist who paved the way for nutrition scientists like me.

                           My inaugural Professorial lecture - challenging the food environment

I recently spoke about today’s nutrition challenges in my inaugural Professorial lecture. Preparing for this lecture I had to reflect on the work I have been doing in the field of nutrition research starting from 1998, looking at ‘the influence of Western Food on a Traditional Diet’ in Western Sumatra Indonesia for my first degree, through to my PhD studies on longitudinal dietary change and then finding my field around Obesogenic Environments and Food Environments. Similar to the ever changing Food Environment, which I study, the field of nutrition science is ever changing - in line with our changing diets and behaviours. There remain many challenges not least around food insecurity which, according to a new report by the Food Foundation, continues to increase. The current cost of living crisis puts food and eating into the spotlight. 

One of the challenges of Nutrition Research is around communicating. Doing this clearly around the noise of misinformation about food or food products is a challenging job! Throughout the twenty-three years that I have worked in nutrition, I have spent a significant amount of time communicating. Sometimes, that involves dressing as a tomato for a public lecture to children (see picture) and sometimes that involves meeting the chair of The House of Commons Science and Technology Committee (Sir Norman Lamb) or even the Chief Medical Officer (Professor Chris Whitty). But most of the time it is about exchanging knowledge between professionals and communicating to the public about the ‘latest’ nutrition fad or ‘superfood’ (spoiler - there is no such thing as a superfood).

Dialogue is important, food is important and nutrition science has much to do. I think I am going to be kept busy in my line of work for a few more years!

The other issue I reflected on during my inaugural lecture was my career breaks (3 in total) and the fact that I have worked part time (3-days per week) since having my second son Auden in 2012. My eldest son David died from a rare disease called Alveolar Capillary Dysplasia in 2011 and, along with my husband we run a charity called The David Ashwell Foundation raising money for research into this usually fatal lung condition affecting newborns. In 2020 I was recognised by TimeWise as a Power Part-Timer. Since doing my lecture, I have received a number of emails thanking me for talking about working part-time and for acknowledging the army of helpers it requires to be a working parent.

If you want to help make a difference in people’s lives I can recommend a career in nutrition science….

#InternationalWomensDay #IWD2022 #BreakTheBias

Now that's what I call blogging 2021

Posted by Mark Welford, Fuse Communications Manager, Teesside University

Let’s all channel British novelist E.M. Forster and play a little game of Only Connect. What connects the things below?

“Yes of course, they can all be a type of list” (said in the friendly yet ever so slightly patronising manner of host Victoria Coren Mitchell)
I think it's fair to say that we all love a list. I mean, the premise of another very popular BBC gameshow is basically to list pointless stuff.

So here again (a little later than advertised) is our annual list of the most-viewed Fuse blog posts of 2021!

You'd be forgiven for thinking that this would be dominated by Covid and the pandemic as we saw in the 2020 list.

Obviously, we had our fair share of pandemic related posts. Blogs about misinformation, food insecurity, malnutrition, obesity and what children made of it all. How it impacted on work and engagement with public partners, parents, decisionmakers, practitioners, policy-makers and commissioners. How it affected our mental healthour liberties and even inspired a song and a cat-scale of wellbeing!

But as you can see from the list below it didn't dominate the top 5 chart-toppers of 2021. Perhaps a little escapism goes along way...


Katsushika Hokusai: The Great Wave off Kanagawa
5. The other third wave: a mass epidemic of very individual pain

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

Lockdown restrictions were beginning to ease in the UK. But after the jubilation, what if you don't feel the way you think you should?

A very personal post by Jack Nicholls on the long-term mental health consequences of the pandemic, of lockdown and social restrictions, and of its easing. 

*Content/trigger warning: mental health, depression, suicidal feelings.

Page views: 938
Published: 16 April 2021.


4. Patient and Public involvement with Parents during a Pandemic: the four ‘P’ challenge

Posted by Hannah Batten, Food and Human Nutrition undergraduate student at Newcastle University. Hannah was on a placement year with the Population Health Sciences Institute, as part of the MapMe study aiming to help parents assess child weight.
Body image scales on the MapMe website are being updated for MapMe2
"Most importantly, is to say to our participants that we are extremely grateful for their time and input, particularly during these uncertain times."
Hannah tells us how she and the MapMe study team met the challenges involved in recruiting and running an online Parent Involvement Panel (PIP) to help review documents and study materials, when parents were already dealing with a global pandemic. 

Page views: 1,029
Published: 5 March 2021.


3. Should pregnancy 'be incentive enough' to quit smoking?

Posted by Susan Jones, Research Associate at Teesside University

In this blog post on #NoSmokingDay, Dr Jones explored deprivation, guilt, shame, stigma and the complex web of reasons behind smoking behaviour.

Page views: 1,155
Published: 10 March 2021.


2. 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

Research doesn't happen overnight, avoid comparison and channel your inner Arsène Wenger ("Le Professeur"). In our second most popular blog post, the early, mid and senior career researchers at University of Cambridge share their tips for PhD survival.

Here is part 2 which interestingly received only half as many views despite including a High School Musical reference.

Page views: 1,347
Published: 4 June 2021.


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

Posted by Katie Beresford, undergraduate student at Durham University

With more than 2,700 views this is our most read post of 2021 by some distance!

In it Katie explores growing up in the Lake District, embracing nature, finding school restrictive and struggling academically in her early years.

Nearly two decades later she is completing a Fuse summer internship with the NIHR School for Public Health Research and is tasked to review literature discussing the effectiveness of Forest School as a public health intervention.

Why not grab a coffee and take a walk with Katie into the woods to find out what she discovered...

Page views: 2,746
Published: 8 October 2021.


So there you have it, the top five Fuse blog posts of 2021. Congratulations to Katie who wins a rare and coveted Fuse paperweight!  

Fantastically both Katie and Hannah's blog posts were part of our Fuse blog Student Series which we launched last year! This showcases posts by students who have been challenged to write a blog as part of their studies. The authors may be new to blogging and we hope to provide a 'safe space' for the students to explore their subject and find their voice in the world of public health research. Hopefully this will encourage other students to take the plunge!

As always, many thanks to our loyal readers and fantastic contributors.

Can we do any better in 2022? If you fancy giving it a go, please find out what we are looking for and how to take part here. All contributors receive a much sought-after Fuse badge.

2. Image: Katsushika Hokusai, (CC0 1.0), via Wikimedia Commons
4. Mr. Alexander Ottesen, CC BY-SA 2.5, via Wikimedia Commons

Friday, 28 January 2022

Science, and the art of communication

Posted by Louis Goffe, Research Associate, NIHR Policy Research Unit in Behavioural Science

Brian Deer - Copyright cleared
“He’d found no cure for Crohn’s, or remedy for autism, no vaccine, no nothing in medicine. But now he was a man delivering fear, guilt, and disease to everywhere with an internet connection.”
Brian Deer, The Doctor Who Fooled the World


It wasn’t a scientist, not a medical doctor, nor an esteemed health institution, but Brian Deer, an investigative journalist, who researched, compiled, and detailed to the world ‘The fraud behind the MMR scare’. While the adjective to his profession alludes an expectation to the discovery of truth, it’s his journalistic craft that effectively communicates with passion and clarity how the now struck off doc and his associates formulated the non-existent relationship between MMR and autism.

Health promotion takes more than good science, there is
 an art to the delivery.  Photo by Jon Tyson on Unsplash

Deer lays out the complete narrative in his book The Doctor Who Fooled the World. It’s as gripping as your favourite thriller, though with the added heart-sinking poignancy that it is not a work of fiction. While I was keen to write a book review, others do this better, I considered what’s the take-home for those of us in translational research in public health.

I’m a researcher for the NIHR funded Policy Research Unit in Behavioural Science, where we ‘use behavioural science evidence, theory and methods to support decision-making’. Our approach is rigorous and grounded in scientific theory. However, the pandemic has brought into sharp focus that health promotion takes more than good science, there is an art to the delivery. I mean, how else have the sceptics convinced so many that wearing a face covering could be detrimental to health?

Prior to the Medicines and Healthcare products Regulatory Agency approval of the first COVID-19 vaccines, research institutions, health, and Government bodies had been virtually silent on the development process. Some were also critical of how the initial results were released to the world. This reservation to engage with a non-academic audience is partially understandable, we deal in uncertainty and it’s much more than simply crossing the i's and dotting the t's. No researcher worth their h-index wants to put something out into the world that they can’t back-up empirically. The sad fact is though, if we’re not on the front foot keeping the public informed of the vaccine trial process and approval milestones, then there’s a flock of 'quacks' more than happy to work their grift.

To their credit, they work with the religious zeal of a missionary, flooding every corner of the internet knowing our vulnerability to the illusory truth effect. While promotion is focused on social media, their word is also preached in podcasts and proliferated through e-commerce. Take a look at Amazon. Their charitable programme AmazonSmile has reportedly donated thousand of dollars to a vaccine misinformation soil pipe, and high ranking books on “vaccines” include: ‘Anyone who tells you vaccines are safe and effective is lying’, ‘The COVID vaccine: and the silencing of our doctors and scientists’, and ‘Vaccine-nation: poisoning the population, one shot at a time’. There is also the subtly titled: ‘******’s review of critical vaccine studies’, that gives the allusion of a systematic review (though don’t expect it to be listed in the Cochrane Library) but shares a publisher with the essential intergalactic phrasebook ‘Ambassador between worlds’ that provides answers to: What do extraterrestrials think about our religious beliefs, sexual attitudes, and goals in life? But most depressing of all, prominence is given to the book authored by the struck off doc, the man at the centre of Deer’s investigation.

Before the first COVID-19 shots were available, to understand vaccine attitudes my Unit delivered a survey using belief-based statements in adults living in England who did not want, were yet to consider, or were not sure whether to vaccinate against COVID-19. This included their agreement to some of the more 'out-there' theories, including our own fictionalised theory that “Mass coronavirus vaccination is a ploy by environmental lobbyists to sterilise billions of people to reduce population growth”, to which 117 (7%) of respondents agreed to. While my literary intention here is to shock, I suspect that the pandemic has made you immune to such statistics. The problem is that once such views have taken root the typical counter arguments using facts are insufficient, and potentially detrimental in combating misinformation.

The vaccine rollout has been the biggest, most ambitious immunisation programme ever in the UK. It’s a historic achievement by the NHS, ably supported by the Vaccine Taskforce. But as we now reflect, it’s my view that if the Government, healthcare providers and research institutions had provided a cohesive, timely, and responsive informative service that detailed and provided a status update on vaccine development, this would have gone a long way to allay many people's rightful concerns. Sadly this reticence to comment continues as speculation increases over approval of jabs for younger children.

The public has shown an enthusiasm to learn a wealth of terminology during the course of the pandemic. My Unit’s work on the comprehension of antibody testing has shown that this isn’t easy, but it’s something that we shouldn’t shy away from. Patient and public involvement in research is vital to ensure that our lay outputs are fit for purpose and we should all consider how we can be better at science translation. Speaking on camera or on live radio is incredibly nerve-racking and not for all, but as I recently discovered following a two-hour training course, you don’t need a degree in design to produce a half decent infographic.

While I am advocating for your individual action, we also need to consider what systems, for example the new UK Health Security Agency, could put in place to fulfil the role that was missing during the pandemic. Most pressingly on our horizon is the delayed childhood vaccine strategy. The struck-off doc will be feeling emboldened. He understands and has mastered the artistic skill of communication, delivering his message with the gentle assured cadence of a BBC continuity announcer. In the absence of substantiated evidence, he expertly sows doubt and fear to the masses, and as the infodemic has shown, he is not alone. This is a huge challenge for us in public health research and the online vitriol is scary. But building the evidence-base isn’t enough, we all need to work on at least one aspect of the artistic craft of research promotion. Because if it’s not you, you can be assured that someone else most certainly is.

The views and opinions expressed by the author are those of the author and do not necessarily reflect those of the Policy Research Unit in Behavioural Science, the NIHR, the Department of Health and Social Care, Newcastle University or Fuse, the Centre for Translational Research in Public Health.

The Policy Research Unit is funded by the National Institute for Health Research (NIHR) [Policy Research Programme (Policy Research Unit in Behavioural Science PR-PRU1217-20501)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.


1) Lourenço Veado, CC BY-SA 4.0, via Wikimedia Commons
2) Photo by Jon Tyson on Unsplash

Friday, 17 December 2021

The way the Government talks about ‘childhood obesity’ is flawed. Should we even be talking about it at all…?

Posted by Naomi Griffin, Fuse SPHR Post Doctoral Research Associate, Sport and Exercise Department, Durham University

‘Childhood obesity’ has been a key public health priority area for those with an interest in challenging health inequalities among children and young people. This is because we can see, at a population level, that children living in the most deprived areas in England are twice as likely to measure as ‘obese’ than children in the most affluent groups (as measured by Body Mass Index (BMI)*). The gap between the most and least deprived is growing.

Logic may suggest that if certain children are more likely to be categorised as ‘obese’, we should focus on ‘childhood obesity’. However, when exploring wider evidence, it is clear that this approach misses out important pieces of the puzzle. Our research used an approach to policy analysis developed by Professor Carol Bacchi called 'What’s the problem represented to be?', whereby the researcher infers what the policy makers are implying the ‘problem’ to be addressed is by looking at what is proposed. For example, if a policy calls for teacher training, the problem is represented to be: teachers lack training. We used this approach to investigate the way UK government ‘childhood obesity’ policy (which I will call ‘The Policy’ from this point) frames the ‘problem’ of ‘childhood obesity’ in relation to health inequalities.

What we did in our research

Firstly, we looked at the way ‘obesity’ is defined in the policy. The Policy’s definition of ‘obesity’ focuses on child weight status, rather than presence of health problems, where the determinants of change are calories consumed vs energy expended: 
at its root obesity is caused by an energy imbalance: taking in more energy through food than we use through activity’ (Chapter 1, p.3).
However, the causes of ‘obesity’ (as defined by BMI) are embedded in an extremely complex biological system that interact with cultural, structural and economic contextual factors, none of which exist in isolation. In truth, BMI is a rather crude measure of height versus weight. BMI data can tell us about population level trends in BMI, but it is not complex enough to tell us about individual health status. It is also not a particularly appropriate measure for children as it was designed for use in adults.

Food bank volunteer
Secondly, The Policy proposes ideas around ‘choice’ and ‘informed decisions’, implying the ‘problem’ is a lack of information or poor choices. For example:

I want to see parents empowered to make informed decisions about the food they are buying for their families when eating out.’ (Chapter 2, p.5).

However, it lacks consideration of the accessibility of a balanced diet due to: affordability of food, practical considerations on physical cooking equipment and energy costs of preparing and cooking food, skipping meals, needing to use food banks, or varied availability of healthy food options.

Thirdly, in The Policy, ‘stigma’ was given as a reason for the need for a childhood obesity policy, as children deemed ‘obese’ are likely to experience:
bullying, stigmatization and low self-esteem’ (Chapter 1, p6). 
However, there was no targeted response to stigma itself. The attention paid to stigma is necessary. The physical and psychological harms caused by stigma, and the negative impact that stigma can have on the quality of healthcare has been evidenced. Not only is stigma and misinformation about ‘obesity’ likely to impact an individual’s health and wellbeing, it also causes barriers to appropriate and timely treatment of many health concerns, not just those that have been linked to weight status. By framing stigma as the result of ‘obesity’, rather than a problem to challenge head-on, The Policy supports individual behaviour change and responsibility, rather than addressing the wider determinants that are necessary to understand these social trends and the negative impacts of weight stigma.

Challenging inequality

So, is ‘childhood obesity’ really the policy ‘problem’ we should be addressing in order to challenge health inequalities? I don’t think so. We propose that inequality itself is the ‘problem’ we need to challenge. For example, the unequal distribution of wealth that leaves millions of children in poverty, increasing food insecurity, unequal access to healthy food and green spaces, and unequal opportunities for physical activity. Policy decisions that have drained public services and policy approaches that unfairly tip the scales of responsibility for addressing the effects structural inequalities onto individuals must be challenged.

The proposals in The Policy, and the evidence bases drawn on (and those absent), reflect a broader ideological trend in government policy on health to move from addressing social/structural dynamics to focussing on individual responsibility. The Policy reflects ideological decisions which are difficult to challenge. The notable absence of the impact of austerity on health budgets and spending on child health inequalities in The Policy is evidence of this.

With Chapter 3 of The Policy potentially delayed due to COVID-19, I hope that government will revisit and review the aims of The Policy with a focus on structural dynamics like health inequality and poverty. At the very least, the government must work to remove barriers to healthy eating and physical activity, regardless of socioeconomic or weight status, for healthier outcomes for all young people.

Failing this, the government’s messaging about ‘obesity’ directly impacts the wider conversation and so I feel that it is the duty of those of us working in public health to challenge the ineffective proposals and damaging narratives that have been put forward in these policies, especially where we cannot change the policies themselves. I hope that our review can be used to challenge and strengthen future policy development, pushing for effective action against health inequalities and policy/intervention-generated inequalities in child health.

Reference: An open access research article detailing the project which informed this blog post is available via BMC Public Health.

For further information on the research project, please visit the NIHR School for Public Health Research website.