Thursday, 30 June 2016

Learning to be a researcher

Guest post by Jane Johnson, PhD student at Teesside University

Have you ever had the experience of thrusting your hand into the air, “Oo! Oo! Pick me! Pick me!” and afterwards think, “Uh oh, why did I offer to do that?” Despite being invited to give a poster presentation at CAMSTRAND, the Complementary and Alternative Medicine Strategic Direction and Development Conference hosted by University of Warwick’s Medical School, I felt apprehensive. The topic of the conference was ‘The Application of Qualitative Methods in CAM Research’ and not only is my research mostly quantitative, I have only been doing the PhD for eight months so thought, “how on earth will I hold my own in a room of forty experienced researchers?” My intention to seek out and explore opportunities to learn and to contribute during the limited PhD time frame of 36 months had yet again left me with my hand up, and not in an air-punching Bruce Springsteen Born in the U.S.A. kind of way.

But I was glad to have been brave enough to attend because the experience was invaluable for many reasons. I heard 18 presentations and in addition to learning about the variety and content of on-going qualitative research into complementary therapies, discovered the following:
  • Standing up in front of experienced researchers gave me heartburn but not heart failure.
  • Even experienced researchers don’t always get their point across to the audience in the way they intend.
  • Researchers are curious. They ask questions and reflect on what people say.
  • For the most part, researchers want to share their experiences to help prevent other researchers making the same mistakes.
  • Researchers are solution-focused. They can’t help but start questions with, “have you thought of trying…”
  • Researchers like to network.
  • Everyone presents their posters differently. I made a mental note to make the font size of the title of future posters even larger than PowerPoint’s recommended 24 and to use more yellow.
  • Even as a novice researcher I can contribute. I helped out two attendees who were struggling to understand the concept of ‘coding’, proving that sitting in on Dr Maura Banim’s qualitative methods lessons at Teesside Uni has not been wasted on me.
  • The abstract that got me accepted to CAMSTRAND will be published in The European Journal of Integrative Medicine and the discipline of having to put this together was useful.
Even when you think you are alone at a conference, there are opportunities for surprise and comradery. “Oh you’re that Jane Johnson,” said a woman noting my name badge, “I was looking at one of your books the other day in the library.” I braced myself ready to explain that I didn’t write novels featuring romance in the Moroccan desert. “Posture …something,” she said. I relaxed. “Yes,” I confirmed, “I was that Jane Johnson”, suddenly feeling an affinity for a woman I’d never met and slightly more at ease.

CAMSTRAND is an annual conference organised by the Research Council for Complementary Medicine and I look forward to attending other conferences that provide equally good opportunities for me to learn how to be a researcher.

Thursday, 23 June 2016

‘First, do no harm’: How to think about austerity and public health

Posted by Ted Schrecker, Fuse Associate and Professor of Global Health Policy, Durham University

The current ‘neoliberal epidemic’ of (selective) austerity directs our attention to public health impacts of choices about public finance in several ways. Most fundamentally, anticipated post-2015 public expenditure cuts in the UK will reduce public expenditure as a proportion of Gross Domestic Product (GDP) to the levels of the 1930s, ‘taking the size of the state to its smallest in many generations’, in the words of a 2014 Institute for Fiscal Studies briefing. In fact, on recent projections by 2020 public spending in the UK as a proportion of GDP will be below the figure for the US, despite the latter country’s bloated defence budget. It is implausible that a National Health Service that is free at the point of use can be maintained with pre-World War II levels of public spending. Even a brief conversation with anyone familiar with US health care reminds us just how much that matters.

Meanwhile, the health consequences of social spending cuts that fall disproportionately on the poorest people and regions are beginning to be manifest in rising food insecurity and increased use of food banks – the latter trend probably related to the rising rates at which benefit recipients are sanctioned. Further health impacts, more difficult to isolate epidemiologically but probably at least as significant, are associated with the stresses of chronic insecurity, powerlessness, and lack of ‘control over destiny’.

There is a basic ethical and political point here about the politics of evidence. Sir Michael Marmot and colleagues wrote in 2010 that ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’. Good point.

In a previous blog with Clare Bambra, we demonstrated that politics can make us sick; Clare recently wrote a similar blog highlighting large health divides across Europe, showing that where you live (and the health policies implemented there) strongly affects how long you live. Against the background of austerity and the rising costs of healthy diets, it is indefensible to ask public health professionals and advocates to demonstrate, over and over again, that (for example) inadequate incomes lead to unhealthy diets and poor health. Rather, the burden of proof should be shifted: we must insist on clear and convincing evidence that national governments’ choices about the level and composition of public expenditure first, do no harm to health, except in extraordinary and clearly justified circumstances. This is an important part of the case for (independent, third party, adequately resourced) health impact assessments, especially of policies and programmes outside the health sector. Such a shift in the burden of proof is also congruent with the strong presumption in international law against retrogression (backsliding) with respect to human rights such as the right to health – a presumption that assumes special importance in an era of austerity.
Is corporate tax avoidance a public health issue?
Public finance, then, is a public health issue. This point applies to the revenue side, as well. The publication of the ‘Panama papers’ reminds us of the extent to which cross-border tax avoidance, whether legal or questionably legal, represents one of the ‘fiscal termites’ that can undermine states’ ability to provide everyone with the prerequisites for a healthy life. (Interestingly, the phrase ‘fiscal termites’ was coined by the former director of the International Monetary Fund’s Fiscal Affairs Department.) The question of how maintaining health services free at the point of use and investing effectively in prevention could be financed should be asked as a routine element of public health practice and advocacy – part of a broader strategy of interrogating scarcity. One answer could be using revenues from clamping down on UK corporate taxes avoided by major transnational corporations. In the real world, resources can almost always be found for the purposes of the powerful: think HS2, Trident renewal, and so on.

Choices about public finance are political choices with consequences for health and health inequalities; academics and practitioners must not be shy about pointing out those consequences.

A more extensive list of references is available from the author.  All views expressed are exclusively those of the author.

Photo: Servizi Mediali.  Reproduced under a Creative commons 2.0 licence

Thursday, 16 June 2016

Being critical of how bodies are ‘sinking’ the NHS: Lessons from the University of Wollongong (Part 2 of 3)

Guest post by Stephanie Morris, PhD Candidate at Durham University

My time at The University of Wollongong has been one of the biggest learning experiences so far on my Overseas Institutional Visit to Australia. My conversations with scholars there have led me to think more critically and question the status quo regarding physical activity, health and obesity. I had many conversations with Professor Jan Wright that made me realise the way in which physical activity is often promoted may have some unintended consequences for the health and wellbeing of those whose behaviours public health initiatives constantly seek to change.

The University of Wollongong
Many academics and practitioners stress the importance of understanding the political economy of health and health inequalities yet it appears that the media and other discourses in our neoliberal society remain focused on stigmatising individual bodies and their behaviours. I came across an article in The Spectator (a conservative magazine) recently entitled, Our NHS will sink under the weight of Britain’s fatties. The title alone got my blood curdling but one paragraph written by Dr Dawn Harper stood out in particular. It went as follows:

If you are a woman with a waist greater than 32in (80cm) or a man with a waist greater than 37in (94cm) you are at risk of type 2 diabetes. If you are a woman with a waist circumference greater than 35in (88cm) or a man with a waist greater than 40in (102cm) then your risk is very high… For your sake and for the sake of our beloved NHS, take this as a warning shot across your bow and get yourself on a healthy living plan.

Now, the first thing I thought about this extract was how fear mongering and morally loaded its tone was. The emphasis is put on the individual for being a bad citizen, immorally and self-indulgently sinking the NHS. Yet, causations and prevalence of obesity and diabetes is much more complex than a waist circumference category. The key question that I wish to raise here stems from the work of two critical scholars, Gard and Wright (2005), whose work is part of the literature critiquing the ‘obesity epidemic’, the link between body size and diseases like diabetes, and health education curriculums. They ask whether the prevalence of such obesity discourses are actually more connected with the morality included in cultural attitudes concerning fatness than about the clear communication of objective and conclusive scientific knowledge. I am not suggesting that there is no reason for some focus on body weight and size, nor am I attempting to condemn all quantitative research in this area. However, I am questioning what implications such a focus on the body might have for people, and future research and policy. First, many have argued that focusing on the individual body distracts us as researchers and citizens from looking at wider structural issues and health inequalities that need to be researched and addressed. Second, others show obesity discourses and 'Healthism' (a term coined by Crawford (1980) to describe a discourse where individuals are held morally responsible for their own health. Individuals then self-monitor and manage their health by objectifying the body.) fuel body dissatisfaction, feelings of guilt and eating disorders, thus negatively impacting on the wellbeing of children and young people.

Positive vibes from a hostel in Sydney
Due to these negative consequences on people's wellbeing I ask what we as scholars, practitioners and third sector workers in the field of public health really consider ‘health’ to be? Do we consider 'health' to be “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (The WHO definition)? Or do we view ‘healthy’ as appearing as an active and slim body? There are movements away from focusing on weight and body size, including Health at Every Size (HAES) – which Peter van der Graaf also writes about in this blog post – that focuses on promoting happiness in eating and an enjoyment of movement in life. Although HAES has been critiqued by many I wonder if some of its elements can be valuable. I do not think continually worrying about one’s body or fat composition is a ‘healthy’ way to grow up or live, as I don’t think it helps achieve “physical, mental and social wellbeing”. Moreover, perhaps if we stop fixating on the body and move away from changing individual behaviours we might consider societal inequalities more and help reduce inequalities that constrain people’s daily lives. What do you think?

Thursday, 9 June 2016

Aspiring to new lows in North West waistlines

Guest post by Naoimh McMahon, Postgraduate student, NIHR CLAHRC NWC

In theory weight management is a ‘simple’ balance between consuming enough energy to adequately fuel ourselves and moving enough to ensure that extra energy is used up. However, in reality there is a complex web of influences that determine our eating and activity habits. We are becoming increasingly more sedentary and are prone to consuming more energy-dense foods. This combination is making the energy balance harder to achieve. When it comes to weight management interventions, what works for one individual is rarely guaranteed to work for the next and so there are real challenges to understand what the right mix of actions are to enable people to achieve and maintain a healthy weight.

Last summer, when preparing a doctoral fellowship application I met with providers and service users from a range of local health improvement initiatives in the North West of England. I was really intrigued by one initiative in particular called Aspire. Aspire is a weight loss programme delivered by a local charity. The design of the programme was unlike any other weight loss programme I had encountered and there was a real sense of personal investment in the programme from both the providers and participants. The thinking behind Aspire is that for individuals who have a lot of weight to lose, intensive and ongoing support is needed to make a positive and sustainable change. The programme runs for 26 weeks and each group has 12 participants. Aspire includes all the traditional elements that you would expect to find in a weight loss programme such as advice and education on food and healthy eating. It also supports participants, many of whom have a body mass index (BMI) of over 35, to engage in graded physical activity.

I think what I found most intriguing about this programme was the emphasis it placed on the person, trying to build confidence and esteem to really convince people that they could achieve their weight loss goals. For example one of the activities that participants spoke about with most feeling was a step climb in a local park at the beginning of the programme. The Aspire providers discussed how this activity served two purposes: (i) to act as a ‘shock to the system’ by allowing the participants to really reflect on their current fitness levels and (ii) to provide a goal to work towards and make a commitment that it will never be that hard again. The group returned to this step climb at the end of the 26 weeks with smart phones in tow and there is some really fantastic footage that captures the excitement and pride at the progress they had made along with the disbelief at how it had once taken hours to complete.

There is never a ‘one size fits all’ and any programme will work for some but not for others. It certainly seems like now it is less about finding a single ‘effective’ or ‘perfect’ programme and more about trying to understand what it is about programmes that enable different people to make positive and sustainable changes. I think we will all know people personally who have taken control over their weight by stumbling upon park runs and ‘getting the bug’ or by using commercial weight loss programmes such as Weight Watchers or Slimming World - finding a system that really works for them. Like other weight loss programmes, there were Aspire participants who did not achieve their goal weight and there were participants who regained the weight that they had worked so hard to lose. What is important is not to write-off such efforts as ‘ineffective’ but to get a better understanding of how and why these outcomes came about. Aspire is only one example of a novel approach to enable people to lose weight but there are certainly elements that have been particularly effective for some participants.

Find out more about the programme and how participants felt about what worked for them.

Thursday, 2 June 2016

Boring to Baywatch

Guest post by Jane Johnson, PhD Researcher at Teesside University

The title of this post is perhaps not what you’d expect to hear at an academic conference but then again not all conferences broach the tricky subject of ‘sexy communication’.

The Hoff
This month I was invited - and funded thanks to help from Teesside University and the Royal College of Chiropractors (RCC) - to present an outline of my PhD at the Researchers’ Day of the European Chiropractors’ Union (ECU) Convention in Oslo. The theme for researchers was Down from the Ivory Towers: Breaking Down the Barriers Between Research and Clinical Practice.

As a clinician-turned-researcher and someone who has sat through countless presentations by researchers, this was a theme close to my heart. It felt like a win-win because not only was the RCC getting to see where its money was being spent but - as a fledgling researcher - I gained a valuable insight into the world of research and particularly into the opportunities and challenges presented to us in disseminating what we are doing and what we discover.

President of the ECU Executive Council, Øystein Ogre opened the conference by saying that research has always been a priority for the ECU, not least because chiropractors need a sound evidence base; a concept which, as a physiotherapist, drew me to apply for the PhD on which I am now engaged.

Two speakers from whom I took home important messages were Alice Kongsted and Jørgen’s Jevne. Firstly, Alice suggested that, when presenting our message to clinicians, we should “decide on a clear message” and “drop the details”. She gave examples of PowerPoint slides where the message was unclear and the details many, contrasted to the same information presented in a pared down format. The second take home message was from Jørgen, whose claim to fame could be that he managed to get the word ‘sexy’ into a British Medical Journal publication when they published his article The Sexy Scalpel: unnecessary shoulder surgery on the rise. He said that in getting our message across to clinicians we need to be ‘message brokers’, maximising the use of social media and including images, videos, catchy quotes in our delivery.

Having previously felt anxious about presenting my own work in a highly visual and often interactive way for fear of being criticised as lacking gravitas, I suddenly felt an immense sense of relief. These were experienced researchers and skilled presenters advocating not that we dumb down the content of what we say, but that we change the way we say it. For the first time I felt like I was being given permission to present in a manner that I was drawn to even if it didn’t match the majority of presentations I have sat through. Jørgen’s said that we need make the way we communicate sexy: we need to go “from boring to Baywatch”. I may not have the skill to incorporate images of David Hasselhoff or Pamela Anderson into my slides, but I’m inspired to think more creatively about communication to clinicians.

Photo attribution:, Geoffrey Chandler, "David Hasselhoff":