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.

Friday, 10 December 2021

Once upon a time in research... the power of storytelling for scientific communication

Posted by Peter van der Graaf, Associate Professor, AskFuse Research Manager & NIHR Knowledge Mobilisation Research (KMR) Fellow, Teesside University

A Christmas story about gifting knowledge (featuring Evidence Man)

It was the week before Christmas. After a long day in the office at her university, Ana Lyst rushed out to do some last-minute Christmas shopping. She had been too busy writing grant applications and journal papers to even think about presents for family and friends. It was already dark, with a stiff, cold breeze and snow started falling around her.

As she approached the high street, Ana noticed a bookshop she hadn’t seen before. It looked rather grand, a bit like an ivory tower, but with more doors. Through large windows at the front, she could spot frantic people in white lab coats running between the shelves, carrying big loads of paper and folders. ‘Bingo!’, she thought: books make great Christmas presents and I can sort out all my gifts in this one shop. She merrily stepped inside and was greeted by a large, vaulted ceiling underneath which stood endless rows of books in all shapes and sizes, reaching all the way to the ceiling. On first impression, the books looked rather dull and colourless, many of them gathering dust, with long, incomprehensible titles edged on their spines in gold.

Undaunted by the ambush of knowledge and people, Ana walked over to the applied research section (which sported a large swirly sign, fusing five different colours) and spotted several books that looked like decent presents for friends. Taking them to the till, she was met by a stern looking clerk, named Pierre View, who inspected the books carefully and with an authoritative tone explained that many of the selected books were not yet ready to leave the bookshop, as they needed more work and review. Could she please come back in 17 years to collect them? The 14% of books that were ready to leave, were neatly packaged in shiny, glossy covers with pictures and key phrases all over them that Ana Lyst was sure would really impress her friends.

However, when she tried to leave, Ana noticed that there were many doors to exit the shop (the entrance was no longer visible) and when she tried the first door in front of her, it wouldn’t open. She went to the next five doors with the same result: all of them were firmly locked, or the ones that did open led to a dead-end. Ana started to panic and her earlier optimism
 quickly melt away, replaced with visions of being stuck in the bookshop over Christmas with not a mince pie in sight.

At that moment, a small backstage door hidden in a corner of the shop opened and a bold bespeckled man stepped out, fully dressed in a superhero outfit with bright blue tights and top (that looked a bit too tight), over which she wore red underpants featuring a large letter ‘E’. Ana Lyst didn’t know what to make of this man, but he looked friendly enough and was walking over to her to offer his services. As the man came closer, he produced a large set of antique brass keys from beneath his cape and began opening several doors. “Are you a bit lost?”, asked Evidence Man (for that is who he was) in an accent with a Dutch lilt. “Stuck between here and the outside world? Not to worry! I know the way out to some safe spaces with a friendly audience who would love to hear all about the books you just bought. They would even be interested in the ones that are not ready yet, and they might have a few books of their own to share with you. Shall we go?”

True to his word, when Ana stepped through the first door unlocked by Evidence Man, she emerged back in the now snow-covered high street, where a group of her friends were waiting and, even better, one of them was carrying a large plate of mince pies! Ana Lyst’s spirits lifted immediately, and she vowed to tell her friends all about the helpful Evidence Man in the bookshop. But when she turned around, the nice man had disappeared and through the windows of the bookshop could be seen flying to assist another confused customer.

The End.

The power of storytelling for scientific communication

I was inspired to write this Christmas tale (and blog) after attending a storytelling workshop at the Fuse end-of- year social event on 3 December, which was led by Duncan Yellowlees. Duncan is a Communications Trainer who works with researchers to improve their communications, confidence, and impact. Take a look at his online COMMunity website (Research Comms … but better) to find out more. 

In an engaging and entertaining way, he took us through the key elements of storytelling: from key principles (putting pictures in people’s heads; construct a narrative of causes and effects), to different types of stories (metaphorical, motivational or monster stories, stories as hooks, and point-of-view stories), their structures (problem, solution and results) and what to include in stories (the point, examples, people, heroes & villains, magical helpers, and tensions & conflicts). Did you spot any of these elements in my story? Scroll down to the bottom of this post for spoilers.

Overall, Duncan provided plenty of tips and tricks on how we can use storytelling as academic researchers to communicate our research findings to wider audiences. And this relates directly to the first point (and story) that he made during the workshop: researchers spend too much time throwing the ball (their research findings) but not nearly enough time on making sure there is someone there to catch it (knowledge users). Find your audience first and make them pay attention before you start talking about your research.

His second point was that all this might seem daunting: so many different techniques, plot lines and structures to think about, how can we ever get any good at this? But when comparing it to learning to drive a car, the same principles apply: keep practicing and it gradually (and sometimes quite quickly) becomes second nature. This is because storytelling is already embedded in everything we do in our daily lives: from telling our family and friends about our everyday experiences, to reading books or ‘binging’ on Netflix series.

Finally, Duncan suggested some simple techniques for storytelling in science communication: making stories relatable and relevant (e.g. stress before Christmas) by including named people and adding details (e.g. dark, snowy high streets and describing the interior of the bookshop), which start to paint a picture in people’s heads. Most importantly, start with a hook: a story to draw in your audience, so they want to hear more, or use a question or bold statement as bait (e.g. only 14 percent of research makes it into practice and policy after 17 years).

My story might not have been all you hoped for this Christmas, but the Fuse social event brought some useful gifts for the Fuse Communications toolkit and much needed festive cheer at the end of another challenging academic year. 

Merry Christmas everyone and happy storytelling!

Spoiler alert:
  • The point: knowledge mobilisation between academia and practice is facilitated by a knowledge exchange broker. Plus some points about the time it takes and difficulties faced by researchers when trying to get research into practice and policy.
  • Heroes: academics producing research and papers, while running between bookshelves.
  • Villain: Bookshop clerk (Reviewer 2).
  • Magic helper: Evidence Man (Knowledge Exchange Broker)
  • Tensions & conflicts: research dusting away on bookshelves or not being ready to leave the building, while access to knowledge users is restricted or confusing.
  • Type of story: metaphorical story, overlapping with stories as hooks (to introduce this blog and talk about the storytelling workshop).

Friday, 19 November 2021

Tackling stereotypes, stigma and self-help: What 'BoroManCan' is doing for the health and wellbeing of Boro Men

Posted by Shelina Visram, Senior Lecturer in Public Health, and Mabel Lie, Research Associate, from Newcastle University

It’s that time of year again… No, we’re not talking about Christmas. Today is International Men’s Day! If you’ve got no idea what this is, you may want to read the Fuse blog we wrote on the same day last year. The theme for 2021 is ‘Better relations between men and women’, recognising the need to promote gender equality for women as well as men. Which sounds good to us, as two female researchers who’ve been working on a men’s health project for the past year.

In last year’s blog we mentioned being awarded funding from the NIHR ARC NE&NC to conduct research into the BoroManCan campaign, which aims to inspire positive change around men’s health and wellbeing in Middlesbrough and Redcar & Cleveland. Colleagues from Public Health South Tees were keen to know which elements of BoroManCan were working and where improvements could be made. In collaboration with academics from Durham and Teesside Universities, we interviewed staff, representatives of partner organisations and other key stakeholders to capture their views on BoroManCan. We also trained and supported three peer researchers to gather insights from local men (and one woman). They chose to conduct interviews to explore men’s health and wellbeing needs, to help us understand whether BoroManCan could be doing more to improve their access to health services and other sources of support.

The interviews provided valuable insights into barriers to men’s help-seeking behaviour. To start with, Teesside’s industrial heritage has led to an expectation that the stereotypical ‘Boro man’ should be tough, resilient, and able to fulfil the roles of household provider and protector. Industrial decline, increasing unemployment and job insecurity were felt to have impacted negatively on men’s mental health. There was a general perception that men are not as likely as women to talk about their feelings or their health, and that there is a particular stigma to discussing mental health problems. Rather than accessing formal services, many Boro men prefer to avoid embarrassment by attempting self-help or using coping strategies such as excessive alcohol consumption and substance misuse. Apart from wanting to maintain their masculine image, there were also practical hurdles around demands from employment and the benefits system.

Two of the three peer researchers, Matthew (left) and Neil (right)
But it’s not all doom and gloom. We also identified a number of factors that were felt to impact positively on men’s health and wellbeing and their likelihood of seeking help. These included: having support from a partner or family members; activities such as Men’s Sheds that value life skills; creating male-friendly spaces; and providing opportunities to spend time outdoors. Some interviewees emphasised the importance of sport and particularly football as a way to connect with other men. What was clear was that apart from addressing men’s health within existing services, male-specific interventions such as BoroManCan were needed. The campaign was viewed positively as a way of sharing inspirational stories from others who have dealt with their own challenges, as well as signposting to relevant activities. Online elements such as the website and podcast were key to the campaign, particularly during the pandemic. However, staff and stakeholders were keen to return to offline elements such as the men’s health champion training and showcase events. Local men believed that the campaign needed to be promoted more widely to ensure it was reaching all those who might benefit.

Here's what our stakeholders had to say about the campaign:
"So I think one of the really good things about it [BoroManCan] is it's very specific to Middlesbrough. And obviously when you look at the stats, you know, you look at suicide rates and mental health in Middlesbrough, they're really high and I think men do struggle to engage. But when local men that are very similar to them are engaging, I think it helps other people." (Stakeholder 1)
"When people feel anxious, they're feeling alone. And BoroManCan, it was a way forward for them not to feel alone and to be able to share their story and find a way forward. 'Cos BoroManCan, it leads onto other things. If you share your story, you’re finding you're not alone. You find out how other people have pain, depression and anxiety and you can follow suit. It leads you to find help." (Stakeholder 7)

Today we’re hosting a webinar to share and discuss our research findings in more detail. For anyone who can’t make it, the webinar will be recorded and shared via the BoroManCan YouTube channel. Please get in touch if you’d like to know more about the campaign or the research; we’d be happy to share our final report once this is ready for publication. And watch this space for future blogs on this subject from our practice partners and peer researchers.

Below are links to support organisations relating to the issues raised in the post: 

Friday, 5 November 2021

Cookies, coffee and co-production during Covid

Posted by Emma Adams, Fuse/NIHR School for Public Health Research (SPHR) Pre-doctoral Fellow at Newcastle University, in collaboration with Experts by Experience from Fulfilling Lives Newcastle Gateshead and #HealthNow Newcastle

Photo taken by Jeff Parker (one of the individuals with lived experience involved in our
co-production) of the masks he made for each of us at our first face-to-face meeting. 
COVID-19, has forced all researchers to re-think engagement and how we work with people with lived experience. I like many, have been navigating how best to do this within my study that aims to explore and understand access to community-based mental health and substance use support in Newcastle and Gateshead for those experiencing homelessness during the pandemic.

Since March 2020 I have been collaborating with five people with personal experience of homelessness, mental health, and/or substance use to co-produce the analysis for this study. During that time we have discovered a very helpful approach (albeit with an imposing name) - Interpretative Phenomenological Analysis.

Here comes the science…

This approach was very reflective and recognised that we were trying to understand how our participants made sense of what had happened to them. We wrote exploratory comments to reflect on the word-for-word text from interviews and then used both to develop themes. This approach lent itself really well to our analysis, as we found it was less rigid than other coding-based approaches (such as thematic analysis) and had more opportunity for reflection. 

The saying ‘no two things are alike’ describes how we ran our co-production meetings given COVID-19 restrictions. We sent out printed packages with anonymised transcripts for comments, held Zoom meetings to discuss our comments and thoughts, hosted in-person meetings with sticky notes and marker pens to develop themes and unpick key ideas, and used physical and virtual highlighters to identify our top quotes. Accompanied with a healthy amount of coffee, baked treats, and fruit, we set our sights on trying to understand our data. We broke down each analysis into three sessions, with the first session focussed on reviewing the transcripts and writing comments, the second focussed on developing some initial themes, and the third focussed on identifying and refining all the themes and key quotes.

Friendship, findings and reflections

We are now starting to share initial findings and determine creative ways to present the information. Having built a strong friendship, we reflected on how much we enjoyed the collaborative co-production experience, despite the circumstances created by COVID. We also reflected that not all co-production is positive. Here we share a few thoughts from the experience.

Why did you become involved in the study?
Everyone in our group felt motivated by the opportunity to have their voices heard and make a difference.
"Because I am interested in how the pandemic has affected people and am a member of the Experts by Experience and would like to change things for the better" – Joanne
"I wanted to do a different sort of user health research having done some last year in Newcastle for Crisis and Groundswell. Getting involved in analysing the anonymised data was a fantastic opportunity for myself" – Tony

What did you enjoy and learn?
Everyone enjoyed being involved as the research continued to grow and their continuous involvement meant we could develop friendships.

"Actually being involved from start to finish, Emma baking" – Jeff

"Analysing some of the data and the group! I feel new friendships have been made" – Fiona

 Although different learnings were shared, it was clear that everyone enjoyed working in a team to try out new things and have a ‘behind the scenes’ peak into doing research.

"One day I would really like to do more of this work in a permanent position as part of my continuing personal development. So it was very nice to get the opportunity to find out what this sort of work entailed and whether or not I would enjoy doing it too" – Tony

"Co-production can really work if it's formulated with an organic and lived experience perspective at the heart of the study, the information gathered was not lost in translation and the language from participants' interview was not tampered with" – Des

What did you find challenging and wish researchers knew?
Forcing ourselves to think about some of the things we all found challenging, we realised it is important to touch base with people involved in co-production to understand what they are struggling with and how they can be better supported.

"Biggest problem I have is getting to a venue, I have anxiety issues travelling by bus" – Jeff

"Emma would send me a gentle reminder a few days before work was due and it would spur me to either start, or finish off and get the work sent in. This really helped me" – Fiona
What would you say to a friend about getting involved in research?
Across the board, everyone said they want to continue to be involved in research projects and would encourage friends to do so.
"At first it might fly over the top of your head, but give it time and you will learn things you never knew you were capable of" – Joanne

"Go for it, maybe you can help affect change that will help others who have been through what you have. Plus, you’ll make some new friends and may enjoy yourself too" – Jeff

What are you most excited about?
When asked about what they were most looking forward to and anything else they wanted to share, responses ranged from gaining specific experience, to celebrating successes.

"It made a nice change to be more involved and now I’m doing more research with Crisis its helped me to help them shape how it can be done and how sense making is carried out" – Jeff

"The biggest rush of the project was to receive an email from the Lancet after we submitted a piece on the work. If it gets published, I’m throwing a party" – Fiona

"Emma has kept us updated throughout and involvement moving forward looks bright … and on the back of this there is confidence to come back to the university and vice versa in other research projects" – Des

Lessons learned from a researcher perspective

The depth and richness gained through co-producing my analysis is something I could have never done on my own. I learned that it is okay to admit when you are feeling a bit lost about the best approach, as that allows for an open dialogue to determine what can be done to make things better. Through our co-production, I realised how to make findings more accessible and engaging for everyone. The pandemic has meant that we have all missed out on in-person contact. Listening to our group I was shocked and humbled by how much the little touches mattered; well-timed cookies or an invite for a coffee chat can make a big difference. These small touches allowed me to develop relationships with everyone and have frank and honest conversations. From this experience, I have learned that you do not need to wait until you have findings to make a difference, rather you have a chance through co-production to make lasting impacts across the span of your research project.

Emma's study 'Exploring and understanding access to community-based mental health and addiction services in Newcastle and Gateshead' is NIHR School for Public Health Research (SPHR) ResNet funded.

This project is funded by/ supported by the National Institute for Health Research (NIHR) School for Public Health Research (Grant Reference Number PD-SPH-2015-10025). 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, 29 October 2021

Are zero and low alcohol alternative drinks just a drop in the ocean when it comes to tackling the real harms of alcohol?

Posted by Professor Peter Anderson, Professor Eileen Kaner and Dr Amy O’Donnell, Newcastle University

We’ve come a long way since Becks Blue was your go-to if you were looking for an alcohol-free alternative to beer.

The drinks industry now caters for a growing number of adults who are looking to reduce their alcohol consumption, or not drink at all.
‘Sober-curious’ and ‘Quit-Lit’ are buzzwords of our time, and Sober October and Dry January are now firm calendar fixtures for many.

Supermarkets offer shelves full of zero alcohol gin, 0% craft beer, prosecco – and more. A non-alcoholic Cobra with your curry? No problem. Even Guinness now offers an alcohol-free version.

They’re all a great alternative if you want to reduce or stop drinking, especially if you still want to ‘feel’ like you’re having a drink.

But who is this helping?

Our latest research has found that you’re more likely to buy zero or low alcohol alternatives if you’re younger, you fall into a higher earning bracket and you’re well-educated.

And that’s probably unsurprising, given that non-alcoholic alternatives aren’t cheap - and can sometimes be more expensive than their ‘normal’ equivalents.

For example, at the time of writing, a UK supermarket was selling a litre of Gordon’s Gin (37.5% ABV) at £15.99 a litre, alongside the new 0.0% version at £20 a litre. So if you want to switch, you’re going to have to pay a bit more.

It’s a similar story when it comes to other health-related behaviours, such as eating good quality, fresh food or having a gym membership, where those who are more affluent will lead the way – possibly because they can simply afford to.

Which leads to further questions – are zero or low alcohol drinks only able to make a small difference when it comes to harmful levels of drinking across all groups, including those who are economically disadvantaged? And - does the price and accessibility of these alternatives create some inequality in itself?

Headline findings from our study – do low or no alcohol drinks increase health inequalities?

We wanted to find out whether the purchase and consumption of zero or low alcohol beers differs by demographic and socio-economic characteristics.

To do so, we looked at purchase data from almost 80,000 households and surveys from over 100,000 adults, provided by Kantar World Panel.

We found that zero alcohol beer was more likely to be bought and drunk by younger people and more socio-economically advantaged consumers.

We also saw higher purchase levels in those who generally bought and drank the most alcohol – and this was higher in men, younger adults, and those with higher incomes.

Households that were more likely to buy low alcohol beer were also heavier buyers of alcohol overall, and more likely to be middle-aged (45-64 years).

We also found that for every purchase of a low or no alcohol alternative, there were just under 46 purchases of the alcoholic equivalent – so buying and drinking levels of the low or no alcohol products are still relatively low.

Proportion (%) of households that reported at least one purchase of zero alcohol beer (green, left vertical axis), low alcohol beer (orange, left vertical axis) and all other beer (red, right vertical axis) for any day that a household made an alcohol purchase by study day, 2015 to 2020. Data points: daily.

What does this mean?

The increasing availability of low or no alcohol alternatives might be a useful tool to reduce overall drinking in the more socially advantaged groups in society, but not so beneficial for the rest of the population.

Zero or low alcohol alternatives are great if you can afford them, but they’re not the whole answer when it comes to addressing the real issues around drinking alcohol – including some of the deeper and wider reasons that drive people to drink so much in the first place, the ready availability of alcohol, and its relatively low price.

In conclusion, we believe that promoting zero and low alcohol alternatives is not enough to address the harm done by alcohol, including alcohol-related health inequalities.

Additional evidence-based policy measures - such as a Minimum Unit Price and improved funding for alcohol treatment and intervention and prevention services - are needed to lessen harms of alcohol which are experienced by the most disadvantaged people in our society.


This blog is based on a paper published in September 2021 in the International Journal of Environmental Research and Public Health- ‘Is buying and drinking zero and low alcohol beer a higher socio-economic phenomenon? Analysis of British survey data, 2015-2018 and household purchase data 2015-2020.’ – by Peter Anderson, Amy O’Donnell, Dasa Kokole, Eva Jane Llopis, Eileen Kaner.

Professor Eileen Kaner, Professor Peter Anderson and Dr Amy O’Donnell are based at Newcastle University and members of the NIHR ARC North East and North Cumbria. This blog was produced by the NIHR ARC North East and North Cumbria on behalf of the report authors.

You can read the full paper, here.

Other linked research that may be useful for readers:

Friday, 22 October 2021

Misinformation, data uncertainty and the cat scale of wellbeing - global lessons on knowledge exchange during a pandemic

Posted by Peter van der Graaf, Associate Professor, AskFuse Research Manager & NIHR Knowledge Mobilisation Research (KMR) Fellow, Teesside University and Roland Bal, Professor of Healthcare Governance at Erasmus University Rotterdam

While the evidence base on successful practices in knowledge exchange is growing rapidly, the COVID-19 pandemic presents unprecedented global challenges. During an online taster event for the upcoming Fuse international conference on knowledge exchange in public health, international experts shared their learning from the pandemic.

Perhaps the biggest challenge during the pandemic has been communication. Governments demanding quick access to the latest scientific evidence to inform their decision making in the fight against COVID-19; researchers dealing with a lack of data and uncertainty in interpreting emerging data on spread of the virus and risks to health; and both struggling with the spread of misinformation on social media and in other places of power

In spite of these challenges, awareness of public health and research evidence has increased significantly during the pandemic. Some public health figures, such as England's chief medical officer Chris Whitty, have become household names ("next slide please") and ‘R numbers’ are now common knowledge. We learned to be more flexible in funding, designing and conducting collaborative research, with gold-standards being replaced by ‘good enough’. 

Maureen Dobbins from the National Collaborating Centre for Methods and Tools within McMaster University in Canada, demonstrated how they were able to develop new synthesis methods and dissemination plans with local government to mobilise evidence for decision making within less than a month. For example, they conducted a rapid review on household food insecurity for the Public Health Agency of Canada with support from Public Health Advisor Leanne Idzerda. They dealt with uncertainty in these rapid reviews by grading the evidence by asking: ‘How likely are the findings to change with more evidence?’

As professionals, we learned to deal with the uncertainty of data by making better use of our personal connections. Roland Bal from the School of Health Policy and Management at Erasmus University in Rotterdam showed how Dutch clinicians mobilised their informal network of colleagues at the local, regional and national level to coordinate beds for COVID-19 patients across hospitals in the Netherlands and reduce uncertainty about available intensive care unit capacity. This resulted in a dedicated bus service for transporting patients between hospitals.

Existing monitoring and coordinating structures between hospitals no longer worked in the pandemic and were replaced with new informal ones, in which emotions and politics played a much larger part. Roland dubbed this the importance of ‘relational epistemology’ and also drew attention to the ‘dark side’ of these new coping strategies, where people outside these relational structures were seldom heard and the patient voice and experience not included. 

However, researchers also developed new ways of engaging with their partners in research. For example, Jane Powers and Mandy Purington from the Bronfenbrenner Center for Translational Research at Cornell University, USA engaged with youth workers and health care providers in their ACT for Youth project by transitioning to innovative remote and virtual formats, including game and role play, using avatars. Part of these formats is an acknowledgment of the emotional impact that the pandemic has on partners and therefore the need to create a space in these activities to check in on partner wellbeing. Perhaps their greatest innovation is the ‘cat scale’ which Heather Wynkoop Beach from the Bronfenbrenner Center introduced during the event - which cats represent you today?

Finally, policy makers, professionals and researchers have had to learn to deal with misinformation about COVID-19. Peter Lurie, President of the Center for Science in the Public Interest, in Washington, D.C., USA showed that the actual amount of primary misinformation about COVID-19 is very small but can do plenty of damage, due to many people simply referring to it online. Of the 479,225 articles he found in his review on COVID-19 vaccines in a wide range of media outlets, only 3.7% contained misinformation, and of those only 3% contained what he called ‘primary misinformation’, with the vast majority of articles simply referring to a very small number of primary sources of misinformation. However, some of these articles were sent to more than 400 million subscribers, indicating that the reach of misinformation can be vast!

C-WorKS: COVID-19 Consequences – Want it? or Know it? Share it!
To counteract misinformation and lack of knowledge, Mia Moilanen, who works as an Analytical Programme Manager at Public Health England* in the UK, demonstrated an online knowledge sharing platform called C-WorKS, which was developed during the pandemic. On this platform, health professionals, service commissioners and academic researchers across North East England and Yorkshire share knowledge, expertise and resources on the non-COVID consequences of COVID-19 (e.g. delayed representation of other health conditions, mental health and increasing health inequalities). So far, over 700 members have shared more than 300 resources through C-WorKS.

What the pandemic has taught us more than anything, is the importance of collaboration: to work together to find solutions and that, during public health crises, we need to find new ways of connecting knowledge users, producers and brokers. This requires flexibility in roles, structures, research methods and funding arrangements, which will have a lasting impact on the future of knowledge exchange in public health. We hope to address the complex challenges faced during the pandemic, what we have learned about knowledge exchange, and how we can use this knowledge to improve research and practices in the future at the Fuse conference next year in June in Newcastle, UK. We can’t wait to see you there!

*Public Health England has been replaced by UK Health Security Agency and Office for Health Improvement and Disparities

Watch a recording of the online taster event below


  1. Capture from the BBC News website, 19 December 2020. Covid at Christmas: 'Chris Whitty is more popular than Britney Spears'. Source: TWISTED PICKLE.

Friday, 8 October 2021

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

Posted by Katie Beresford, undergraduate student, Durham University

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

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

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

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

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

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

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

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

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

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

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

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

  1. Photo by Markus Spiske on Unsplash
  2. The Tortoise and the Hare. From Childhood's Favorites and Fairy Stories, by Various. Project Gutenberg etext 19993 From Wikimedia Commons: