Thursday, 27 October 2016

Mapping collaboration and constructing a compass

Guest post by Lindy Turnbull, Senior Lecturer, Faculty of Health and Life Sciences, Northumbria University

Collaboration is promoted as a key aspect of commissioning and delivery in public health (NHS England, 2016) and health care (NHS England and NHS Improvement, 2016). Joint working and integration of services are seen as the way forward for the future NHS with new integrated models of care at the forefront of service redesign, and collaboration core to managing increased demands with diminishing resources. Although collaboration is a familiar concept and has been the subject of research and discussion it is still an area of practice which is poorly understood. It is striking that existing definitions of collaboration identify professional sharing with the focus on patient care, yet there is little representation of patients in most studies and the role of patients in collaboration seems to be missing from the existing theory.

I began my research after leading the development of Outpatient Parenteral Antimicrobial Therapy (OPAT) a new model of care which required collaborative working across secondary and primary care to deliver treatment in patient homes. The development of this service was challenging and required strong collaborative relationships to overcome the organisational barriers to integration. Having experienced the challenges of collaborating to develop an integrated service I wondered if these difficulties continue into the delivery of the service in practice, and how collaboration takes place within the challenging environment of the constantly reorganised NHS.

The aim of my research was to develop substantive theory about what collaboration means in the delivery of integrated care, the way it is manifested in day-to-day practice and how it is shaped by the situation in which it takes place. I viewed patients and professionals as participants in collaboration and interviewed three patients and 21 professionals. I have used a social constructionist approach to grounded theory (Charmaz, 2008) and a range of situational mapping techniques (Clarke, 2005)1 to map collaboration within the situation of integrated care delivery. Analysis was a fascinating and absorbing experience as I used mind mapping software to analyse and compare the perspectives of those involved in collaboration and then to combine perspectives to map and analyse the complexity of the situation.

Participants expressed a number of interactive mechanisms (trusting, communicating, co-ordinating and rehearsing) which were influenced by a range of situational co-ordinates (goals, limits, certainty, uncertainty and power) and these were used together to navigate the complexity of the healthcare situation and direct the process and outcomes of collaboration. The capability of individuals to act, or interact was informed by their interpretation of the situation and this directed the capacity for collaboration within the care situation. Positional mapping techniques identified four directions of collaboration: developing, maintaining, limited and disrupted, and I found that limiting factors were significant in changing the direction of collaboration. The communication of some social limitations such as terminal illness, professional roles or work requirements altered an individual’s capability to collaborate and the capacity for collaboration within the situation.

My analysis has constructed a collaboration compass which is used to navigate the situation and direct the collaboration experienced by patients and professionals. I am in the process of writing up and still fighting my enthusiasm to write about everything I found and learned during my study; there simply aren’t enough words!

  1. Clarke, A. (2005). Situational analysis: Grounded theory after the postmodern turn. Thousand Oaks, CA: Sage.
Health Research Authority summary: The Meaning and Manifestation of Collaboration in Domiciliary Outpatient Parenteral Antibiotic Therapy: A Grounded Theory Situational Analysis.

Thursday, 20 October 2016

Who wins: the tortoise or the hare in the race for health benefits?

Posted by Liane Azevedo, Fuse staff member and Senior Lecturer in Physical Activity and Public Health, Teesside University

At the 63rd American College of Sports Medicine Annual Meeting in Boston, USA this year, an interesting debate took place which was titled ‘Who Wins: the Tortoise or the Hare?'. The debate discussed the latest research findings on a hot topic in physical activity research: what is better for your health; high intensity exercise or reducing sedentary behaviour in favour of light to moderate exercise? I was expecting a heated debate; however, the session was quite balanced with both sides presenting the pros and cons of their approach, followed by a talk on the middle ground by Tim Church suggesting that the best is exercise in moderation (the benefits of regular moderate-intensity exercise).

Let’s start with the arguments for reducing sedentary behaviour. The sedentary behaviour ‘defence’ was presented by Genevieve Healy from the University of Queensland. She talked about a study which showed that a reduction in sitting, in favour of more standing or stepping, could both promote cardio-metabolic benefits (concerning heart disease and metabolic disorders such as diabetes) to improvements in glucose and lipid metabolism (the synthesis and breakdown of glucose and fatty acids). Similar results were shown in other presentations at the conference with a number of studies also showing that interrupted sitting with walking (rather than just standing) can improve insulin response, resting blood pressure and lipid concentration. Moreover, Genevieve provided a number of examples of interventions for the workplace and for older populations, such as Small Steps, Stand Up For Health and Stand Up Australia, which have all shown to be effective

I presented evidence of this argument myself at the conference in a poster about a systematic review which we conducted on sedentary behaviour interventions for children. We found that sedentary interventions are mostly ineffective to reduce BMI (body mass index) in a mixed-weight population but can be effective for treatment of an overweight or obese population.

In the case of sedentary behaviour major questions still remain, for instance, are the risks of sedentary behaviour for cardiovascular diseases independent of physical activity? In other words, if you have a job like mine that requires you to sit for long hours and you try to compensate for this behaviour at the end of the day by doing 30-40 mins of moderate to vigorous physical activity, does this mean that you still have the same cardiovascular disease risks as, for instance, someone who does not exercise? The answer appears to be no; the risk seems lower (phew … ). However, the data in the literature is still contradictory. But it was interesting to see well known scientists in the field like Charles Matthews recognising that these behaviours might not be as independent of each other as it was originally thought when it relates to health risks.

The case for the opposite argument - that high intensity exercise is more important for your health - was made by Professor Ulrik Wisløff from the Norwegian University of Science and Technology. He presented a number of studies which showed the additional benefits of vigorous activity compared to moderate or total physical activity on a number of health indicators, such as all-cause mortality, improvement of maximum aerobic capacity and in endothelial (the inner lining of blood vessels) function, and as an effective treatment of arterial fibrillation (abnormal heart rhythm) in unhealthy patients.

The audience questioned Professor Wisløff about the risk of injury when doing high intensity exercise, how to translate these findings into physical activity guidelines, and the long term sustainability of this type of exercise. Wisløff said that in their studies there were no report of injuries, but admitted that long term sustainability still needs to be investigated. A starting point for demonstrating the feasibility of high intensity exercise in a real-life setting can be found in the study completed by Dr Kathryn Weston at Teesside University. In the study she investigated the effect of a school-based high-intensity interval training on cardio-metabolic health. She found that the high intensity exercise did not only improve some cardio-metabolic parameters but was also delivered as intended.

Therefore, I would say that the answer to the question ‘who wins the tortoise or the hare?’ is that both are winners. For some people high intensity exercise can be the most exciting way to exercise, while for others just the substitution of sedentary to light and moderate is the suitable (also it doesn’t need to be one or the other). The most important point is to choose something that will encourage you to do physical activity, because the health benefit is there for both.

Acknowledgment: Liane Azevedo would like to thank Fuse and Teesside University for the support to attend this Conference.

Photo attribution: “Image from page 216 of "St. Nicholas [serial]" (1873)” by Internet Archive Book Images via

Thursday, 13 October 2016

Bridging the gap between (mental) health services and needs: negotiating power and political values

Guest post by Dr Angus Forsyth, Senior Lecturer in Mental Health Nursing, Northumbria University

As Monday was World Mental Health day, there will be familiar messages in the media about the barriers faced by people with mental health problems when seeking appropriate care and treatment. These include (but are not limited to) the difficulties that children and young people face in accessing local services, not to mention specialist services, such as support for young people who may experience eating disorders. For adults the suicide rate has increased, and there are more and more pressures on crisis services and in-patient beds. As overall funding within the NHS is further reduced, mental health services face additional financial cuts as their funding is diverted to other clinical groups whose needs have been identified as more of a priority. 
Steve McDonald (Simon Gregson) battled depression in Coronation Street

As if lack of access to mental health services is not problematic enough, people with mental health problems are also more predisposed to physical health disorders due to the combined effects of certain medications, lifestyle factors, such as smoking and lack of exercise, contributing to obesity and other metabolic disorders. This contributes to early mortality for people with long standing mental health diagnosis such as schizophrenia, having a reduced lifespan of 20 years. Despite these inequalities the Department of Health’s guidance (2011) recommended parity of esteem for people with mental health problems to have the same level of access to services as those with physical illnesses. And even this recommendation has yet to be achieved. 

On the positive side, there has been a relative increase in coverage of mental health related issues within the media and society, either through celebrities disclosing personal issues, storylines in popular TV dramas; magazines, and social media. However, there still persists a stigma associated with the experience of mental ill-health, for example that people with Schizophrenia are unpredictable and predisposed to violence (Houses of Parliament 2015).

Whilst fear and lack of understanding are factors that maintain stigmatising beliefs and attitudes, power inequalities are also evident when exploring the above barriers to meaningful services. These power imbalances can lead to the development of oppressive social systems and organisational practices where the exercise of authority or power can lead to the marginalisation of specific groups. An example of this is the implementation of government policy, for example the reduction of resources and the subsequent allocation of funding by commissioning agencies (as servants of government), can result in further disadvantaging of citizens as in the case of young people attempting to access mental health care. In the majority of these cases, care can only meaningfully be accessed when there is a serious risk to self and others and is provided under the legislative procedures of the mental health act and in locations far from the individual’s home. This example illustrates how healthcare is provided in an oppressive system.

This brief summary of the challenges in accessing comprehensive care and resources that are available to people with mental health issues highlight that as the expression of mental health becomes more dominant, service provision and resource allocation has not kept pace with increasing need and demand for services. This is particularly in light of mental and physical ill-health co-existing and becoming common bedfellows in chronic disease management. Let’s hope that World Mental Health Day not only highlights issues related to the experience of mental health but acts as a catalyst to mobilise meaningful social actions such as:-
  1. Reviewing the public and political structures to include the meaningful involvement of service users at all levels of the decision making process (Rethink 2016). This would further highlight inequalities and disadvantage experienced by individuals and meaningfully influence the development of comprehensive mental health service provision.
  2. Reorganise health and social care structures around the holistic needs of service users rather than in the functional silos that currently operate.
  3. Use World Mental Health Day to evaluate the impact of service delivery for vulnerable groups to identify meaningful changes and clarify further challenges.

Thursday, 6 October 2016

A nation stood still for 25 years: Can we find solutions for action in policy and practice?

Guest post by Ben Rigby (pictured), a postgraduate student in Durham University’s School of Applied Social Sciences and Associate Member of the Wolfson Institute of Health and Wellbeing Research

Fourteen – the number of pieces of legislation published since 1991 which specifically state ‘physical activity’ (PA) in the context in which Public Health England presents as a problem needing a long-term solution. That is, an unsustainable burden on the UK economy, resulting from diminished health and well-being, which may be alleviated by increasing population-level PA.
I want to help do something about this problem. For the next few years, I will be undertaking a North East Doctoral Training Centre ESRC-funded PhD to research how PA-related practice, evidence, and policy interact to benefit or disadvantage different population subgroups. This project will be supervised by both Dr Emily Oliver and Dr Caroline Dodd-Reynolds, co-directors of Durham University’s Wolfson Institute Physical Activity Special Interest Group. 

Although advances in public health policy and evidence have emerged, not least through the work of the Fuse’s Physical Activity Group on improving evaluation and translation, for example, there remains a clear disconnect between use of evidence, proper evaluation and the influence (and interference) of policy and politics in decision making and the provision of activity opportunities. Having worked for Hampshire’s County Sport Partnership for the past year, these are issues I have experienced first-hand.
As a practitioner, it was often difficult to translate available evidence into viable practice. Reasons for this were numerous, though included funding issues, difficulty in physically accessing research, as well as in understanding complex ideas of theory and evaluation, within the particularly vague policy context by which one was guided. Emerging literature also highlights issues in policy, such as failing to consider local implementation barriers, persistent participation inequalities or the intricacies of behaviour change.
The aim of my research will be to identify systems and opportunities that facilitate a more integrated relationship between PA evidence, policy and practice. In order to garner a holistic appreciation of these factors, it is vital to understand how policy makers receive, adapt and adopt evidence; how organisational factors constrain or facilitate its adoption and importantly, recognise values and interests of those influencing responses to the evidence or policy problem. A particularly neglected policy research topic has been individual or organisational capacity to act upon evidence.
Previous research has perhaps been somewhat one dimensional in these areas. Alternatively by employing a mixed-methods approach and my applied social sciences background, I will be able to generate a much-needed complex understanding of the extent that local, regional and national stakeholders use evidence in PA policy design and implementation, and review factors associated with successful policy implementation. Whilst building upon existing literature, it is intended that this will offer a unique interpretive perspective on people, practices and policy processes (both locally and nationally), enabling and supporting policy development and implementation.
Does sitting and talking, and a lack of progressive
 policy action, promote our sedentary society?
Specifically by investigating the following two core propositions initially, I propose that it may be possible to find equitable solutions for progress in increasing physical activity and provide an important contribution to the field of public health research:
  1. Weak evidence results in inherently conflicting and ambiguous PA policy, thus constraining implementation efforts
  2. Political entrepreneurs may offer more effective solutions for policy development and implementation 
Being a fledgling researcher
One of my relatives (a PhD recipient herself), once told me that doing a PhD will be the hardest thing I ever do. I am under no illusions about the task before me, the complexity of which may be compounded by investigating one of society’s most entrenched problems. However I welcome the challenge and cannot wait to get stuck in, even if a little part of me wonders if I have what it takes to make a difference in the world, as I am sure many new Social Policy researchers before me have. I hope that my research will land well and have impact in the academic sense, but also in tangible real life outcomes for local communities in time.
I am not alone in this quest, and hope over the coming years to work closely with Fuse and its focus on Translational Research; specifically, the Fuse Physical Activity group offers an important platform for me to engage with physical activity policy makers, practitioners and academics who I hope will engage with me in developing this programme of work. I believe research evidence should be free and accessible wherever possible, an issue I have already raised. I wish to experiment with how better to present evidence to make it attractive to both policy makers and practitioners. At the same time, I am conscious of having to develop my academic reputation and profile and balancing this with experimentation is something I am wary of at this stage. 
I wish to build networks within local institutions with like-minded students and academics to share ideas and findings. My aim is to disseminate throughout my project and beyond. I hope to be able to present to Fuse research fora, access advice and support from the group’s members, as well as contribute to this blog. I welcome any feedback on this post. In particular I would be delighted to hear from individuals, practitioners or groups who:
  • have shared research interests
  • are responsible for PA-policy production locally
  • research health inequalities
  • had difficulties implementing policy guidance and evidence
  • believe research in this area may benefit their line of work
Ben can be emailed at He is also on Twitter, LinkedIn and has a blog.

Notes and References:

  1. Figure taken 27 June 2016 – using the search term ‘physical activity’ at Between 1991 and this date 72,088 pieces of legislation were published. Results were manually screened and filtered for ‘physical activity’ as recognised by the World Health Organisation as benefitting health, well-being and personal and social development.
  2. Bowen and Zwi.2005. Pathways to evidence-informed policy and practice: a framework for action.

Sunday, 2 October 2016

Giving Grandmothers a Voice

Guest post by Roz Rigby, a Health Improvement Practitioner at Newcastle City Council and Doctoral student in Public Health at Northumbria University

Today is Grandparents’ Day, a day which celebrates the contributions of grandparents to families and
society overall. Grandparents can have important roles in the health related decisions of families and my research is looking at the influence of grandmothers on introducing solid food. Much of the literature describes grandmothers in a negative light, suggesting they may advise their daughters to start solids before the recommended six months. I found that there was very little research that addressed this from the perspectives of grandmothers’ themselves, and therefore I set out on my research journey with the intention of finding out ‘how do grandmothers make sense of the role they play in introducing solid foods to their grandchildren?’

 I am using constructivist grounded theory methods based on the works of Charmaz (2014)1, and am still finding new meaning in my data, as I try to write up my findings. I am finding this an exciting time in the research, after the arduous task of trying to understand the terminology in qualitative methodology! I must admit that I expected to find grandmothers defending the older methods of introducing solids, which was generally started at around four months, but I actually found that they were open to change and generally accepted the new guidelines. I have also uncovered a complicated web of dynamic family interactions in which grandmothers can struggle to come to terms with competing values of the wider family that they find themselves in. Some grandmothers expressed how marginalised they feel, as they do not have access to the latest information, except through their daughters or daughters in law, and yet, they are often providing extensive childcare.

One of the issues that this research has highlighted for me, is the contested levels of responsibility that grandmothers face. On the one hand they are ‘proxy’ parents, making autonomous decisions about the food that they offer their grandchildren, whilst on the other hand, this can compete with the parents’ decisions and parenting styles (which may in turn be influenced by the other grandparents). Being able to switch this responsibility on and off can cause tension and conflict, particularly if there is a feeding issue. The problems of having a fussy eater can cause parents and grandparents immense distress, with issues of power and control coming to the fore. Grandmothers often worry about conflict within the family and are wary about raising their concerns, for fear of fracturing relationships and possibly losing contact with their children and grandchildren.

Of course it’s not all doom and gloom, as they all report feeling immense love for their grandchildren and a similar nurturing feeling that they had for their own children. They get tremendous satisfaction from these relationships, and I hope that my research will help practitioners to have a better understanding of the issues grandmothers face. I am looking forward to using the findings to develop an intervention that will help families navigate potential intergenerational conflicts and find ways of developing collaboration within families, as they all have the best interests of the children at the heart of what they do.

  1. Charmaz, K. (2014) Constructing Grounded Theory (2nd Edition). Sage