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 www.phdcomics.com
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.


Video: 
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

Images:
1. "Piled Higher and Deeper" by Jorge Cham www.phdcomics.com

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.” 
Confucius
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 www.phdcomics.com
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

Images:
1. "Piled Higher and Deeper" by Jorge Cham www.phdcomics.com
2. Mr. Alexander Ottesen, CC BY-SA 2.5 <https://creativecommons.org/licenses/by-sa/2.5>, via Wikimedia Commons

Friday, 28 May 2021

What came first, food insecurity or severe mental illness?

Posted by Heidi Stevens, Research Associate, Teesside University, and Jo Smith, Consultant Dietitian and Clinical Academic, Tees, Esk and Wear Valleys NHS Foundation Trust 

Well before the current COVID-19 pandemic hit our shores, it was already apparent that food insecurity was an emerging issue in the UK. In 2014, the Children’s Society presented evidence to an All-Party Parliamentary Group (APPG) to raise awareness of the issue. Four years later after a visit to the UK, Special UN Rapporteur Sir Phillip Alston highlighted the increase of people depending on foodbanks across the UK. Despite these high-profile reviews of the evidence, it has taken a pandemic and the persistent efforts of a professional footballer to thrust the circumstances of food insecurity in children firmly into the spotlight. 

Marcus Rashford has led campaigns to end child food poverty over the course of the pandemic






























While the issues around food insecurity and the longer-term detrimental implications of this for children are now well documented, the implications of food insecurity in other vulnerable groups have been seldom considered. Research has documented the effects of food insecurity on mental health, but less is known about the impact of food insecurity specifically on those with existing severe mental illnesses (SMI) (ie. bipolar disorder and schizoaffective disorders). For example, research has shown that people with a mental health diagnosis face an income gap as high as £8,400 per year compared to the general population. Additionally, almost 25% of food banks have reported an increase in the number of people with mental health conditions accessing them. However, this does not distinguish between mental health conditions and severe mental illness which can be complex to manage often impacting every aspect of a person’s daily life.

Public health guidelines encourage a balanced diet, for a healthy lifestyle. But when faced with financial constraints, food purchases are often restricted to poorer quality foods which are more accessible on lower budgets. Research by Jones et al. (2014) found an average price disparity of £2.50 per 1000kcal of less healthy food products versus £7.49 for more healthy food products. The study classified food products in their data set (basket of food) according to the Eatwell Guide to include carbohydrates (bread, pasta), fruit and vegetables, dairy, protein (meat, beans) and high fat/sugary foods.

Cheaper foods may often be high in salt, saturated fat and/or sugar, the effects of which on long-term health are well documented. However, for people with SMI there are also additional health risks because they may already be at risk of weight gain due to psychiatric medication. Additionally, for those taking prescribed lithium for bipolar disorder, too much salt in a diet can be very dangerous.

UN Sustainable Development Goal 2.1 ‘Zero Hunger’ challenges us to ensure access to nutritious and sufficient food for everyone but in particular poorer people and those in vulnerable positions. This certainly will not happen until we take a “Marcus Rashford approach” and use the current impetus from the COVID crisis to highlight the issue of food insecurity in other vulnerable groups of people, such as those with SMI. The syndemic nature of having severe mental illness in conjunction with food insecurity means these two factors may interact to further marginalise and disempower people with SMI and yet this remains an under-researched area worldwide. This potentially leads to food insecurity in those with severe mental illness being under-managed and under-supported in mental health practice. In order to achieve parity of esteem between physical and mental health it is essential that we understand the issues relating to food insecurity in this population group.

To this end, we are currently working on research aiming to assess the prevalence of food insecurity in adults with a diagnosis of SMI and explore their experiences for better understanding and increased exposure to the issues they face. Preliminary findings of our review of the available research on this topic (a systematic review) show a lack of targeted measurement for this group of people who are sometimes included as part of wider studies. The issue of cause and effect (or causality) is also often referred to; what came first, food insecurity or SMI? We hope our overall findings later this year will provide an overall picture of food insecurity in people with severe mental illness and potentially a basis for affirmative action.


Supporting authors: Lauren Bussey, Emma Giles and Amelia Lake from the School of Health and Life Science, Teesside University.



Image: 'Rashford Mural' by Rathfelder via Wikipedia, copyright © 2020: https://en.wikipedia.org/wiki/File:Rashford_Mural.jpg (CC0 1.0)

Saturday, 15 May 2021

Is it ethical to promote quitting smoking to patients with mental health issues?

Posted by Susan Jones, Research Associate, Teesside University

Smoking rates and levels of dependency are high in people with psychiatric problems and, it has been argued, that smoking helps people with mental health disorders to cope with the struggles in their lives (Malone et al., 2018). On the other hand, the National Institute for Health and Care Excellence (NICE, 2013) argues that introducing a smokefree culture into NHS Trusts offers an opportunity for patients and staff to benefit in terms of physical and mental health and is achievable with appropriate support. Certainly this viewpoint was supported in our research:
"I think for some of our patients because it’s actually a learning disabilities hospital but obviously a lot of them have mental health issues as well, it increased their confidence and self-esteem. A lot of our patients had poor self-esteem and they actually achieved something by stopping smoking, they achieved something that was extremely difficult and I think it made them think, if we can do that we can do other things as well." 
Frontline Staff, Trust B
Nevertheless, by taking this position, NICE have highlighted a contentious issue. In our research we found that the patients and healthcare community were still divided about introducing smokefree policies and supporting patients and staff to quit smoking (Jones et al., 2020). There was a lot of passion on both sides! In some wards (mostly those with non-acute patients, such as those with learning difficulties or associated with forensics) staff and patients took on the challenge to change their environment and behaviours and embrace a smokefree way of life. They were creative in how they prepared for quitting and even made it fun, with games and decorations.

In other areas e.g. acute services, the challenges were different and there was much more scepticism about the ethics and value of offering support to quit smoking. Although awareness raising and training in smoking cessation was available, the role of choice and a pro-smoking narrative was widespread. 

Normalisation of smokefree policies

In mental health, smoking is an established cultural norm both in the community and in healthcare settings. We found that it is seen as an acceptable, even beneficial, coping mechanism for people who suffer from mental health disorders.

Research evidence would argue the converse; that the physical and mental benefits are far greater than continuing to smoke (Harker & Cheeseman, 2016). People with psychiatric problems tend to be highly addicted and there is a definite need to push through the initial stages of withdrawal from nicotine, which can be harder due to greater dependency, and more complicated due to interactions with psychiatric medication. Nevertheless, the evidence shows that people still want to be physically healthier, free from the downsides of addiction and supported to achieve these goals (Harker & Cheeseman, 2016).

Promoting normalisation through collective action

Perseverance is required to change any norm; old habits and perspectives die hard and continual reinforcement of new patterns are needed for success (Jones et al., 2020). This applies at an individual level but also at the organisational level.

Role of context

Our environment is so important in enabling or blocking behaviour; or even ‘nudging’ it in a certain direction (Ratschen et al, 2011). If a hospital is smokefree, then patients who don’t smoke will be able to maintain their status as non-smokers more easily. Alternatively, a smoking environment legitimises and encourages continued smoking. 

Sustainability

Maintaining changed behaviours, like smoking, is known to be challenging; however there is an inherent contradiction in implementing smokefree policies on-site only. Patients and staff move between hospital and community and it is all too easy for this to be seen as abstaining while in hospital, rather than quitting for good.

What we found 

Two mental health trusts in North East England - Northumberland Tyne and Wear NHS Foundation Trust and Tees, Esk and Wear Valleys NHS Foundation Trust - went smokefree in March 2016. In our research to evaluate the implementation of smokefree policies within the trusts, we found that:
  • Inroads had been made in changing an entrenched, smoking culture into one that was smokefree on Trust sites. However, there remained variations across specialities and challenges to full implementation.
  • Once there was sufficient ‘buy-in’ to a non-smoking culture it was anticipated that the issues relating to enforcement and perceived risk would diminish.
  • Long-term perseverance is required to establish smokefree sites in participating mental health trusts, supported by robust, routine, data collection.
  • Normalisation Process Theory and logic modelling are helpful in increasing understanding of the dynamic implementation process. 
Policy relevance and implications
  • Careful use of language is needed to encourage smokefree policies to be seen positively.
  • When interpretation of the term ‘patient leave’ was left open for leave to be used for smoking, it led to inconsistent practice.
  • Consistency of enforcement is key to success.
  • There were many details that needed to be worked out following the introduction of the policies; suggesting a requirement for ongoing review and response in a timely manner.

Read more about Sue's research in this Fuse research brief: Introducing smokefree policies into hospital mental health services.


References:

Harker K, Cheeseman H. The mental health and smoking action report: the

Jones, Susan E; Billett, A; Mulrine, S; Clements, H; Hamilton S. (2020) Supporting mental health service users to stop smoking: findings from a mixed method evaluation of the implementation of nicotine management policies into two mental health trusts. BMC Public Health, 20:1619

Malone V, Harrison R, Daker-White G. Mental health service user and staff
perspectives on tobacco addiction and smoking cessation: a meta-synthesis
of published qualitative studies. J Psychiatr Ment Hlt. 2018;25(4):270–82. https://doi.org/10.1111/jpm.12458

National Institute for Health and Care Excellence. Public health guidance 48:
smoking: acute, maternity and mental health services. London: NICE; 2013. https://www.nice.org.uk/guidance/ph48

Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for
change. Brit J Psychiat. 2011;198(1):6–7. https://doi.org/10.1192/bjp.bp.110.081372


Images:

1. “Smoke-Free Bench” by Michael Coghlan via Flickr.com, copyright © 2011: https://www.flickr.com/photos/mikecogh/5645977385/in/photostream/ (CC BY-SA 2.0)

2. Copyright © South Tees Hospitals NHS Foundation Trust: https://www.southtees.nhs.uk/news/services/trust-to-go-completely-smokefree/ (2019)


The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

Friday, 7 May 2021

Children’s exposure to junk food advertising: can the UK hold firm in the face of industry resistance?

Posted by Chris Baker, primary school teacher and distance learning tutor at the London School of Hygiene and Tropical Medicine

Growing up in a sweet shop was, as you can imagine, an absolute dream. Who wouldn’t want an entire store of confectionery under their own roof? It was the 1990s and I didn’t realise how lucky I was - living above a newsagent run by my parents. I’d get home from school, give a cursory wave to my mum behind the counter and immediately grab a chocolate bar, or an ice cream. It was the best.

Clearly, it wasn’t a recipe for good health. I was continuously surrounded by the bold and colourful logos, the marketing strategies and the special offers - all designed to hook me into habitual consumption. I paid little attention to the nutritional contents of the things I was snaffling (this was long before front-of-package labelling came along). My physical health (particularly my teeth) paid the price.

Cut to 2020 and I find myself thinking back to that era - before the internet, before screen-time, before social media. I am now a primary school teacher (with experience in public health) committed to promoting children’s health and well-being. I see that the relationship between children and junk food today has not changed all that much. There are still products high in fat, sugar and/or salt that kids crave. And what’s helping them to connect with these products? Digital marketing.

I teach ten and eleven-year-olds in an international school, so the demographic group I am most familiar with is not representative of the UK. However, I believe there are important similarities. Many children of this age now have smartphones and use apps intended for older audiences. Through these apps, they are exposed to new and sophisticated marketing strategies, unheard of by older generations.

Fortunately, there are plans to address this. Last year the UK government proposed a total ban of online marketing for foods high in fat, salt and sugar. Not a restriction, or a tightening of rules: a total ban. The preamble to this consultation suggests that completely reducing exposure to ‘endless prompts’ to eat offers the best way forward. The government’s response to the consultation, with an accompanying plan of action, is due to be published this Spring.

The scope and scale of this proposal are noteworthy. To date, no countries have successfully implemented a complete ban (there are strong restrictions in Chile and French-speaking Canada). Implementation of the government’s proposal would place the UK firmly at the front of the pack, delivering strong policy action with the potential for significant public health benefit.

Unsurprisingly, industries affected by such a ban have been critical of the proposals. In an open letter, a consortium of food companies and advertising agencies called for a rethink. Their arguments are predictable and are representative of a cross-industry playbook, seen repeatedly in recent years across several other industries interested in unhealthy commodities. They claim the proposal is disproportionate. They claim the evidence is lacking in detail. They distance themselves from the issue and play down their role. They demand a meeting with the government to discuss ‘alternative’ (but unspecified) approaches.

A total ban would be an entirely appropriate response in the face of an industry that has altered considerably in recent years. An earlier attempt to merely limit adverts for unhealthy foods in and around children’s tv programming (as well as other non-broadcast media) was found to expose children to no less advertising. Artificial separation of children’s media and adult media is a fallacy, and doesn’t reflect the reality of tv consumption nowadays.

More importantly, this proposal addresses the issue of children’s developing ability to distinguish an advert (and its provenance). Research suggests that over a third of 12-15 year olds are not aware of the financial arrangements behind promotional posts. Astroturfing - the artificially-created “buzz” around a product, designed to look authentic and spontaneous - can be difficult to identify, especially when delivered by a relatable vlogger or influencer, who may not have disclosed endorsement arrangements.

Most schools nowadays (mine included) encourage “digital citizenship”. As a teacher, I am responsible for helping my students navigate the risks and benefits of the internet. Often, I hear children referring to spurious news stories, and am reminded of the sophisticated ways even adults can be tricked into believing something.

Age restrictions for social media platforms, often put forward as a robust mechanism to shield children from inappropriate content, are weak and inconsistently controlled. Parental control settings on popular sites are not widely understood or implemented and the rapid changes in children’s media habits is named as a key driver in the government’s desire to strengthen legislation.

I believe that young people should have the freedom to use television and the internet for enjoyment and education. Exposure to insidious marketing that promotes and profits from the development of unhealthy eating habits should not be a price to pay for this. The UK government has proposed a bold course of action. In the face of strong opposition from industry, they should stay firm with their intentions; the health of future generations stands to benefit.

Friday, 30 April 2021

Can putting distinct services under one roof prevent mental illness? We (cold) called in the experts to find out

In today's Fuse blog post, Fiona Duncan, Postdoctoral Research Associate from Durham University, writes about co-locating services to improve mental health and the perils of pulling together an expert panel during a pandemic. 

'Cold Calling' by Darren Tennant
This past year has been tough for many of us.  Financial worries, feeling socially isolated and lonely, facing unemployment, and missing opportunities for physical activity are just some of the things that have impacted on mental health and wellbeing during the pandemic.  This means that finding ways to improve mental health and prevent mental illness in our communities is more important than ever.

Over the past few months, I have been working on a NIHR School for Public Health Research (SPHR) project which aims to investigate how “co-located” services based in the community can be used to promote wellbeing.  A co-located service is where two or more distinct services are in the same physical space and the staff of each service interact with each other, either formally or informally.  Co-located services are often found within traditional health services like GP practices when welfare, legal and/or mental health services are delivered in the same building.  The project will investigate the benefits and disadvantages of co-locating in community spaces, rather than within traditional health services.  For example, a debt service within a faith institution, a welfare service in a library, a mental health support service in a sports centre, or a money advice service within a foodbank.  We are interested in finding out exactly how co-location helps to improve mental health and whether they work for all people in all circumstances, or just some people in certain circumstances. For instance, does co-location increase access, reduce stigma, or encourage a higher quality of service by allowing professionals to work together better?

To start this research, I was given the task of setting up and facilitating an expert panel workshop. The idea being that if we want to gain a deep understanding of how co-located services may or may not work then we should ask the people who actually design, fund or deliver these services in the real world.  We hoped that this workshop would consist of service practitioners, policy-makers, and commissioners at local authorities and people who work for organisations that provide funding for community projects. 

My first challenge in setting up the workshop was getting people to take part.  Where was I going to find these experts and would they be able to give up two hours of their time in the middle of a pandemic?  I was planning on the workshop being small (5-8 people) but, in the circumstances, I realised that I was probably going to have to ask a lot of experts to even hit this target!

I used a variety of approaches to find my experts.  I asked members of the wider research team to email any suitable contacts, we approached the other NIHR Schools and we advertised the study on twitter.  I also personally contacted some people that had participated in a previous research project and my colleague, Dr Emily Oliver from Durham University, mentioned the workshop during a webinar at which she was presenting. Through these methods, three experts signed up.  To get a few more people, I then started to ‘cold call’ potentially suitable people and organisations, including almost 40 local authority Directors of Public Health in England.  Despite the pressures that this group of people are currently under due to COVID, this ‘cold calling’ led to three more people agreeing to attend.

Having six people confirmed still felt like a very precarious position to be in, and it turned out that I was right to be nervous, as one person unfortunately had to pull out on the morning of the workshop. However, luck was on my side as at the last minute another expert who had found out about the workshop from a colleague at one of the organisations I had contacted, asked if they could come along.  Panic over!

Selfridges
The nerves kicked in again at the start of the event, as I had never facilitated a Zoom workshop before and it was clear that some of our experts were feeling nervous too.  This could have been a problem as we wanted them to freely and openly talk about the benefits and disadvantages of co-located services.  Luckily, Gillian Samuel, a member of our research team from the McPin Foundation, was able to facilitate a brilliant icebreaker exercise.  She asked everyone to talk about something that we all had in common, specifically, what we are looking forward to most when lockdown ends?  Everyone had some great answers to this question (the re-opening of Selfridges was my personal favourite answer) and this made for a more relaxed atmosphere.

This almost certainly helped the workshop discussions flow as our experts provided rich and detailed information about co-located services.  However, in some ways the workshop did not go as I had expected.  I thought the experts would talk about the benefits of their co-located services and the mechanisms involved in how these services work. I had prepared a long list of questions to prompt such a conversation, but it soon became clear that the panel had a lot to say about how co-located services quite often don’t work.  They were all clearly very passionate about what they do but expressed frustrations surrounding service delivery.  One theme to emerge was that co-located services are dependent on different types of professional working together, but the reality is that they often don’t communicate well with each other at all.

Although I wasn’t expecting the panel to say these things, I’m glad they did.  It helps us to understand how co-located services are working, or not, and is very important if we want to improve services and therefore improve mental health and prevent mental illness in our communities. This information will also be very helpful in the next part of our study where we will be interviewing people who work at and use selected co-located services.


Fiona works on the NIHR School for Public Health Research (SPHR) Public mental health programme through Fuse's membership of the School.


Images:

1. 'Cold Calling' by Darren Tennant via Flickr.com, copyright © 2014 (Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0)): https://www.flickr.com/photos/10678076@N03/16001016758

Friday, 23 April 2021

How do we improve diversity in research?

Posted by Vicki McGowan, Research Associate, Newcastle University

Public involvement and engagement in research is not a new concept. Without members of the public engaging with our work as participants, we would not have advanced our knowledge and understanding of the social world over the last few hundred years. More recently the Covid-19 vaccination would not have been so rapidly produced without generous support from the public in giving up their time (and bodily fluids) to advance our understanding. What seems to be a more relatively recent idea is the involvement of the public in developing the research itself and setting the agenda based on their experiences. Newer still is the idea that there should be a diversity of voices at the table where these decisions are made. In 2014 the Due North report made a series of recommendations to address inequalities between the North and South of England.


In order to take forward these recommendations academics across the North developed the Fuse led Equal North network which aimed to build a community of academics, policy makers, and practitioners across the region to work collaboratively on addressing the North-South health divide. This community came together in workshops to identify priorities for addressing this spatial inequality, and around 250 professional participants highlighted poverty, austerity, and unemployment as key research areas to ‘level up’ the northern regions (Addison et al, 2019).

Equal England academic and practitioner priority setting workshop hosted by Fuse

But, this was only one part of the story.

It was an important side of the story, and I’m sure many members of the public would agree that poverty, austerity, and unemployment were – and indeed are – priority topics, but we needed their perspectives to ensure we were developing research that addresses these drivers of inequality and doesn’t widen them further.

But also, we’d been talking about tackling inequality at the same time as maintaining unequal access to decision-making by not including all key stakeholders in the discussion. So, when the NIHR School for Public Health Research funded the expansion of Equal North to become Equal England, we increased our practitioner membership to over 800, but we also ensured that we could take forward recommendation 3 from Due North: 
“Share power over resources and increase the influence that the public has on how resources are used to improve the determinants of health”
The Equal England Public Network was born in late 2019. Following the practitioner model developed in Equal North, we aimed to create a space for members of the public to share lived experiences and influence the work that we do and undertake some public priority setting exercises to see how these align with the Equal North work. We’d also share information about key events, new evidence, and generally keep people updated with health inequalities research as we do the practitioner network.

That was the plan, now the action. How do you develop a diverse network to engage with members of the public with lived experience of poverty, austerity, and unemployment?

One option could be to contact the numerous, and brilliant, existing Public and Patient Involvement (PPI) groups that operate across the country. Why reinvent the wheel? If that wheel only comes in one style and doesn’t fit my bike then we may have a problem. These established groups might not accurately represent the diversity we see in our communities.

Also, these can be established groups that by their tenure already have the confidence and capacity to exert influence over research agendas and I wanted to make sure we had representation from people who don’t usually have their voices heard in the communities that are affected by the priority areas identified through Equal North.

To ensure we were accessible to a diversity of voices we aimed to pilot the network in North East England to build on the Equal North findings and implement three phases:

Phase 1: Connect with local grassroots groups that are embedded in their communities, promote the network at relevant community events, generally get out into communities across the North East and get to know people, develop trust and sign people up to our mailing list.

Phase 2: Invite members to a series of local conversations, present the findings from Equal North and discuss whether people thought these were important for their communities, whether there were other priorities, and what we needed to do to address them.

Phase 3: Co-develop research proposals around these priorities and dissemination activities with academics and practitioners – making sure the public experiences were disseminated widely and incorporated into future planning.

By February 2020, Phase 1 was going well with 35 members of the public signing up to the network. And then…


We were forced to cancel all face-to-face activities due to Covid-19. The country shut down and the vast majority of people I’d engaged with over the past few months were now focused on supporting their communities through the crisis.

People are furloughed and so volunteer at food banks, people lose their jobs, they lose loved ones to the virus, the grassroots level is not interested in me trying to encourage them online to talk about inequalities that PRE-EXISTED the virus and are now being made even worse. The public network gets locked down and we pause activity thinking it won’t be long before we’re back chatting over coffee.

A year later and we’re still not able to get together in person and our coffees are stone cold! However, during this time of crisis I focused on maintaining the network rather than trying to grow it. I kept in contact with our members via the mailing list and shared opportunities for engagement and to participate in, and develop, research. It didn’t seem right to actively pursue growth during a pandemic but, as our members represent wider groups within their communities, they have shared these opportunities and this has resulted in more members of the public signing up. We now have 57 official members from across the country who have been supporting and influencing the work we do. Amazingly during a pandemic, our public partners have supported the development of several health inequalities projects, contributed to covid-related inequalities research and influenced decisions over national priority funding around inequalities and prevention from the NIHR Applied Research Collaboration (ARC).

Key messages for ensuring diversity in research 

Identify trusted partners


Engage with your existing networks but identify people who are already trusted in their community. These people are probably the most important, whether we’re in a Covid or non-Covid world. Find them and work with them. Approach grassroots organisations, church leaders, sports groups, charities, hang out in coffee shops, community centres, pubs (when permitted!).

Actively seek out diverse groups

Don’t assume members of diverse groups will respond to your advert on Twitter, you must actively engage with groups and organisations that represent marginalised communities. If you’re unsure use tools like PROGRESS+ and HIAT as a guide to check you’re providing equity of access for members of diverse communities (these consider ethnicity, LGBT+, rural/urban, age, disability, economic disadvantage etc.).

Boots on the ground

Leave the comfort of your (home) office! Opportunity does not knock at your door, you need to go out and seek it. Pre-Covid this means being present in community spaces, libraries, coffee shops, markets and schools. During Covid this means using existing networks, online sessions, and setting up WhatsApp groups.

Give something back

Always give something back, that may be reimbursing people for their time or providing opportunities for training and skills sharing – and here I don’t just mean assuming we have skills that they want, perhaps members of the community want to share their skills with us. Develop reciprocal relationships, don’t just take from communities to boost your career!

Be patient

Developing trusted, meaningful, and reciprocal relationships takes time. Be patient. Do not underestimate how long it can take – I’ve been working with some groups for 6 years!

Manage expectations

But if you don’t have 6 years, be honest with people that your work is time sensitive and clearly articulate what you need and how people will be reimbursed if they’re able to help you. Don’t promise the moon on a stick if you can’t deliver!

Finally, blogs are also a great way to connect with diverse groups so don’t forget to add some shameless promotion: if you’re a member of the public reading this and would be interested in joining our network you can sign up here.

For more information about the development of the network, and other experiences of improving diversity in research, you can view a recording below of a recent joint NIHR School for Public Health Research / School for Primary Care Research webinar.