Friday 31 January 2020

Does reaching the ‘hard-to-reach’ mean leaving traditional academia at the door?

Angela Wearn, PhD Researcher, Department of Psychology, Northumbria University

“You tend to find the ones that are protesting and telling you to go and get your smears are the ones that have their cushy little jobs and that lovely flash car that they can just jump in and dive down to the doctors”

From all the conversations I’ve had throughout my research career, this is one of the quotes that has stuck with me the most. For over three years I have been working on my doctoral research, conducted across Newcastle, which explores barriers to cervical screening participation in areas of high relative deprivation. We know that uptake rates tend to be lower in areas of socioeconomic disadvantage, but reviewing existing literature showed very little insight from women who lived within these communities themselves. Incidentally, I am one of these women. I grew up, and still live, within a neighbourhood which, according to the Index of Multiple Deprivation, falls within the 10% most deprived areas in the country. It’s therefore no accident that I ended up with a programme of research which aimed to prioritise the voice of this community.

Graffiti walls can be a simple and effective way of starting conversations
Initially, I had dreams of a wonderfully participatory project, where I formed a steering group and we worked together to find answers and seek solutions. As often happens in research, time ticked on and it didn’t work out the way I had planned. My participatory ideals had to take a backseat for a less time-consuming participant-researcher approach. I suspected my ‘insider’ status might open doors for me and to be fair, it did. I found myself being able to quickly connect and build a rapport with others when I discussed my own background and why I wanted to do this project. However, getting to the point of even having these conversations was by no means easy. I spent days, weeks, months trying to speak to community groups, charities and community members about my research. Some were very open and interested, others were not. I attended community get-togethers handing out cakes alongside research information, making ‘graffiti walls’ with post-its, even chatting about life over freshly made biryani at a cookery club. Actually, these were the most rewarding and enjoyable moments over the past three years, but the more I did this the more I felt I was straying from what academia expected of me. I also began to feel my status as an academic researcher was a hindrance to what I was aiming to do at community level. For a lone PhD researcher, bringing together these two worlds, at times, felt completely impossible.

"community get-togethers...were the most rewarding and enjoyable moments over the past three years, but the more I did this the more I felt I was straying from what academia expected of me"

Attending community events was a great way to connect with 
people who were otherwise unfamiliar with research
The quote at the beginning of this blog was when it all clicked into place. Although we were talking about cervical screening, I acknowledged something that I had already known all along - the same issues of accessibility and trust apply to involvement with academic research. If I put my working-class hat on for a minute, academic research feels neither accessible nor promotes interpersonal trust. From the outside, academia appears to be filled with people who think they know better than you, patronising you, sometimes even using you to showcase the poor decisions people make in life. I had to work hard to reassure people that I wasn’t there to pass judgement on their screening status. I’m still not sure many believed me. ‘Eat a healthy diet’, ‘Stop smoking’, ‘Engage in physical activity’, ‘Attend your screening appointments’. These are the messages that come through, focusing on the individual and discounting all the structural and social barriers that exist for people living in communities like mine. If you are trying to figure out how to afford the weekly food shop, the kids have come home with a tear in the coat you only bought a fortnight ago and you’re worried about not getting enough work from your zero hours contract, there is no mental space for ‘living your best life’ (and certainly no space for sitting with a stranger from some university taking part in a research study).

Those living in socioeconomically disadvantaged areas are often described as ‘hard-to-reach’. This often implies that despite best efforts to reach out, these groups are disinterested and disengaged. I tend to believe the reverse is true. Some groups are hard to reach because academic research is too disengaged from the community. I know of many academics who are so obviously committed to tackling the avoidable and unjust disparities in health, and for this reason I do feel positive for the future. However, as someone who is positioned in between the ivory towers of academia and the working-class neighbourhoods at home, I know there is still a lot of work to do. There is a long history of mistrust and marginalisation to put right. If we are serious about tackling inequality and involving so called ‘hard-to-reach’ groups in research, then we need more focus on developing trust and togetherness…and occasionally, this might mean leaving traditional academia at the door.

Friday 24 January 2020

Is Exercise Referral fit for a new decade?

Posted by Coral Hanson, Emily Oliver, Caroline Dodd-Reynolds and Paul Kelly

“Exercise referral doesn’t work”. We have heard this said time and time again, particularly by those who are peripherally aware of the field, but perhaps most worryingly by commissioners and those involved in public health policy. We’ve argued that this is simply not true. A different interpretation is that the exercise referral evidence-base, and the way it is used, hasn’t been working.

The term ‘exercise’ conjures images of Mr Motivator-style aerobics in eye-searing 1990’s lycra

Exercise referral is a decades-old process where professionals in primary care (GP/practice nurse) or secondary care (specialist doctor/physiotherapist) refer patients to a community-based physical activity scheme - often delivered by a leisure provider. National policy guidance (NICE, 2014) recommends that referrals are made where a patient is otherwise inactive or sedentary (both different parameters and not simple to classify in a primary care setting such as a GP surgery) and additionally has an existing health condition, or is at risk of having one.

Traditional evidence-generation for exercise referral has tended to be single-site studies that are then condensed using systematic-review-based methods. Given the considerable variation in how schemes are designed, delivered and evaluated at local level, this is problematic. Vague policy guidance and limited evaluation funding means that most scheme iterations are unsuitable for inclusion and interpretation in this outcome-driven way (Oliver et al., 2016). Collectively, the findings of such overviews are rather underwhelming.

Consequently, during times of tightened public health spending and commissioning, many UK exercise referral schemes have been de-commissioned. This seems misguided, given evidence that some schemes work, for some individuals, in some contexts. Understanding these nuances is at odds with the ‘best practice’ and ‘scaling-up’ that is so often seen as desirable within physical activity policy. Evidence must (and thankfully is starting to) account for consideration of local tailoring and best fit for a given community. Incorporating such evidence into policy is a different matter, of course.

To assist with collating evidence that can meaningfully inform policy and commissioning decisions in this area, our recent editorial in the British Journal of Sports Medicine proposes a sea change in how exercise referral is considered, categorised and reported. The term ‘exercise referral’ is outdated in 2020. ‘Physical activity referral schemes’ more appropriately describes the innovative and extensive range of programmes being delivered, and allows for other types of referral including self-referral, social prescribing and group-based needs assessments, to potentially contribute to the evidence base.
Personally, we’re not keen on the term ‘exercise’; it conjures images of Mr Motivator-style aerobics in eye-searing 1990’s Lycra. It sounds so imposed and constrained
You may have noticed we have replaced ‘exercise’ with ‘physical activity’ – surely a more inclusive term for what is ultimately a behaviour – and one which we are trying to change. Traditionally exercise referral schemes were mainly gym-based and we think that this image probably persists when we think of exercise referral today. Personally, we’re not keen on the term ‘exercise’; it conjures images of Mr Motivator-style aerobics in eye-searing 1990’s lycra. It sounds so imposed and constrained. Even a simple phrasing change can have far-reaching implications, and hopefully for the better in this case.

In the editorial, we propose a simple way of identifying, classifying, and recording key information about physical activity referral schemes that will enable better understanding of what exists and what is working. Our new reporting checklist (or taxonomy) encompasses all physical activity schemes that:
  1. have the primary aim of increasing physical activity,
  2. have a formalised referral process, 
  3. are provided for individuals who are inactive/sedentary, and/or have or are at risk of a health condition. 
The classification framework can be seen in figure 1 (below). The full reporting checklist can be found in the editorial. We propose that this be used by commissioners, practitioners and researchers alike: for auditing and monitoring, to capture service delivery and in generation of evidence reviews.

Figure 1
We are very keen to hear from anyone working in exercise/physical activity referral of any kind as we move forward with refining this idea. The model was proposed to policy-makers, practitioners and academics at a consensus event in late 2019, and we are currently refining it by undertaking a Delphi Survey. We are inviting further comment, critique and engagement to make the final version as accessible and ‘fit for purpose’ as it possibly can be, so please get in touch with Coral, Caroline, Paul, or Emily via twitter or email - details below.

Coral Hanson, Research Fellow, Edinburgh Napier University @HansonCoral /

Emily Oliver, Associate Professor, Director of Research in the Department of Sport and Exercise Sciences, Durham University @_EJOliver

Caroline Dodd-Reynolds, Associate Professor, Department of Sport and Exercise Sciences, Durham University @carolinedod /  

Paul Kelly, Lecturer in Physical Activity for Health, The University of Edinburgh @narrowboat_paul 


  1. Mr Motivator 2’ by Dave Tett via Flickr. Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0): © 2007.
  2. 'Figure 1' reproduced from Hanson, CL, Oliver, EJ, Dodd-Reynolds, CJ & Kelly, P (2019). We are failing to improve the evidence base for “Exercise Referral” How a PhysicalActivity Referral Scheme Taxonomy can help. British Journal of Sports Medicine Published Online First: 17 December 2019. doi: 10.1136/bjsports-2019-101485 with permission from BMJ Publishing Group Ltd.

Friday 17 January 2020

School food research and teenage diets mean sleepless nights and a mountain to climb

Posted by Kelly Rose, Graduate Tutor/PhD researcher at Teesside University

In the spirit of the commencement of the New Year, I thought it the perfect timing to write a second Fuse blog post reflecting on my first year of PhD study. Also, driven by my waking at 2am, Monday of the first week back in a cold sweat, realising I am more baffled than ever!

In my first blog post, I described myself as feeling at the bottom of a mountain…

Now a year and a half in, I can report some relief at successfully passing my annual review, confirmation that I have the capability. This is definite progress, and a sure sign of having climbed at least a little higher towards the summit. A few days ago I also celebrated my 44th birthday, and I suppose the coinciding of a new decade brought a significantly reflective mood (in the most positive sense). This past year has tested me in so many ways that I had never expected. If you want to know yourself at a deeper level, I think a PhD certainly would be the recommendation. I started this journey with the attitude (that I was always telling my students and children) that anyone can do anything they set their mind to. This mantra has definitely helped in times of significant self-doubt.

Progress update

So far, I have completed a systematic review, had a paper of the political timeline of food policy published in the Nutrition Bulletin, shared my research in a conference, and was boosted by an article I contributed to the being shared in the Independent online.

What have I learned?

I left secondary school teaching in July 2018 with a strong sense that more was needed to improve adolescent nutrition. Today, with more of a grasp on the research, I am even more incredulous as to why more is not being done by policymakers.

The evidence is clear, teenagers have the poorest diets of any other age group in the UK. The Lancet commission stated we can reap huge benefits from improved health policies, focusing on the global adolescent population, after all they are our future parents and workforce. As I found in the political timeline research and systematic review, there are many examples of good practice with regards to implementing and evaluation of school food standards, whole school policy and health interventions. But still no priority being placed on consistent evaluation and of policing school food provision in England.

Waking up at 2am questions
  • Why is our school food provision failing to improve adolescent nutrition?
  • Why does the Childhood obesity strategy (part 2) make the assumption that all schools in England are following the national school food standards when there is no evidence that most schools are? #pizzaandcookies. 
  • Why the inertia and lack of prioritising teen diets, when the evidence points to the impacts of diet on mental health and school performance? 
Of course, it’s just not that easy, because, this is a multilevel issue, and the problem is much more complex than just implementing a policy or three. There are significant barriers to challenge, as we see the commercial determinants to health as a major part (defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (Kickbusch et al 2016)).

One of the factors I want to focus in on over the next two years, is the social aspect of teen diets. It is becoming more and more an accepted ‘norm’ that teenagers have a poor diet, and food choice is a major factor in fitting in with peers, with healthy food choices often ridiculed. A low risk perception of unhealthful food choice seems to be a barrier in improving the health of the next generation. I wonder how we can flip this influence.

With all the reflecting done, I am ready to move forward into 2020. This year the plan is to see my systematic review published, to plan and conduct research in building a picture of experiences, views and what is happening in a range of schools in the North East. And with this public declaration I aim to keep momentum and to contribute to the body of research moving forward.

Keep believing and achieving.

"Junk fast Food illustrations infographics editorial" by Svajune Garnyte is licensed under CC BY-NC 4.0

Friday 10 January 2020

Now that's what I call blogging 2019

Posted by Mark Welford, Fuse Communications Officer, Teesside University

Happy New Year – can I still say that or have we reached peak-greet when this obligatory salutation is no longer required in email, phone, or awkward fleeting corridor exchange?

This time of year is all about numbers: the 12 days of Christmas, the pounds you’ve gained (lbs) or lost (£), counting steps, units, the 31 days of Dry January, Veganuary, or the point at which you can grant yourself a run free day.

It therefore seems fitting that the Fuse blog has a countdown of its own.  Last year was a fine vintage for blog posts but you may not have had the opportunity to read all 40 of them.  To save you time we have had a look back and created a Top 5 Chart of the ‘bestsellers’.

So without further ado, here’s our chart toppers:

5. The provocatively titled Can cancer ever be a good thing? in which Fiona Menger (@slt_fi) revisits the writing of 'cancer columnist' John Diamond while working on a head-and-neck cancer research study with a focus on a phenomenon called post-traumatic growth.

Page views: 585.  Posted: 31 May 2019 

4. In What old crisp packets dig up Duika Burges Watson (@debedub) gets hands on to unpack the mystery of the humble crisp.  What is their continued value as ‘food’ and can we still enjoy them as a cultural icon without creating so much waste and damaging our health?

Page views: 640.  Posted: 22 February 2019

Still from the animation
3. Why do some women continue to smoke when they are pregnant?  Sue Jones (@Susan_E_Jones) shares research findings on overcoming barriers to implementing NICE guidance on supporting pregnant women to quit smoking.  The blog includes a short animation which was developed based on the findings.

Page views: 663.  Posted: 10 May 2019

2. If at first you don’t succeed, try, try, try & try again...  Suzanne Moffatt (@SuzanneMoffatt) reflects on 58 months of knock backs in her efforts to secure ‘the big grant’ because multiple failures before success is often untold and sometimes persistence pays off.

Page views: 686.  Posted: 15 February 2019

Courtesy of Children's Future Food Inquiry via twitter
1. "It’s time to act!  It’s time this country gave every child the right to food!"  Pamela Graham (@PamLGraham) begins her blog post with this powerful statement from Corey (pictured right), a 15-year-old Young Food Ambassador who sat on a stage in Westminster and bravely told an audience about her experiences of food insecurity.  With more than double the views of its nearest competitor, Young people taking a stand for their #Right2Food takes the crown as most popular blog post in 2019.

Page views: 1474.  Posted: 03 May 2019

So there you have it, the top five Fuse blog posts from 2019. Can we can do any better in 2020? If you fancy giving it a go, please find out what we are looking for and how to take part here.

P.s. perhaps we need to look more closely at what's going on in February and May!?

  1.  'Now That's What I Call Music! 1989' by brett jordan via Flickr. Attribution 2.0 Generic (CC BY 2.0):