Beyond stats and diseases: my summer internship in Public Health

Posted by Bethany Henshaw, NIHR School for Public Health Research (SPHR) Intern in Fuse, undergraduate at Newcastle University

The NIHR School for Public Health Research (SPHR) recently asked its members (including Fuse) if we would like to host an internship this summer. The summer internships are aimed at undergraduate students with an interest in a career in public health research. The internships offer support for 6-8-week projects supervised by SPHR Early Career Researcher (ECRs), Fellows and PhD students. 

In this post, Beth (pictured right) tells us about her internship experience last year at Gateshead Council. 

When you think of the term ‘public health’ what comes to mind? According to the World Health Organization, it is:

“the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society.” 

If you had asked me this question in early 2023, I would probably have given a very general, slightly muddled answer which was focused on the disease aspect of the field. What my answer would have highlighted was that I had very little understanding of just how broad and wide ranging the field of public health is.

Last year I undertook a NIHR School for Public Health Research (SPHR) summer internship in Fuse, looking at the perspectives of social prescriber link workers (who connect people to community-based support) on the promotion of active travel. Active travel refers to modes of travel that involve a level of physical activity such as walking and cycling. I was interested in understanding how social prescriber link workers felt the prescription of this to their patients would impact them.

The findings will be used to inform the development of an active travel pilot in Gateshead. The internship was a fantastic experience in many ways: it enabled me to develop my qualitative research skills, for example, I developed a topic guide for the social prescriber link worker focus group, and gave me valuable insight into professional working life. However, my biggest take-away was the insight it gave me into career options within public health.

Behind the stats are real people with their own unique story

As a biomedical science undergraduate, I spent two years studying topics like physiology, pharmacology, and immunology largely at the molecular level. I understand how many different diseases invade the body and make a patient ill. However, for a while now I have been interested in understanding disease at a population level. Rather than the cellular mechanisms of disease, I have grown more interested in why some people are more susceptible, and how we can reduce this disparity and prevent further people from becoming ill in the future. Before my internship, I mainly considered public health from a disease related perspective and thought that health protection covered the vast majority of the field. However, by speaking to both researchers and members of the Public Health team at Gateshead Council, it became clear to me that it covers significantly more than this! Issues such as environmental health, health services and health improvement are all things I previously wouldn’t have thought about when trying to define what I considered public health to be.

Something that surprised me during my internship was just how central recognising the individuality of each patient’s situation is in public health. I came to the realisation that when I had read research papers on disease outbreaks or rates of chronic disease as part of my degree, I had been overlooking this important detail: that behind the stats are real people with their own unique story. Talking to members of the active travel social prescribing team at the Council, made me realise just how individual and unique the journey is for each patient. Summarising, for example, how many patients continued to regularly use active travel for the time period they were prescribed it as a percentage does not reflect the reality of what these patients go through, something that will only be understood by talking to the patients to understand their experience. I found this outlook on viewing patients as people and not just statistics to be incredibly refreshing, and it has provided me with a new perspective to take into my final year of university and beyond.

My internship offered me a view of what life could be like working within public health research and the broader field. My understanding of what public health is, has been challenged and has been significantly changed from the disease focused perspective I had before. However, one of the main things I will take away is that behind all the statistics we see in the news and read in research papers regarding rates of disease, it is vital to remember that each statistic is a patient whose own unique experience should not be undermined.

Image:

2. Photo by cottonbro studio: https://www.pexels.com/photo/woman-with-red-light-on-face-5473950/

Getting creative to make research more accessible and inclusive

Posted by Victoria Bartle, Fuse Public Partner

We were throwing balls of wool around, picking picture cards to describe ourselves and having a thoroughly inspiring time. This was not your typical research conference!

It was day one and keynote speaker Pam Burnard was encouraging us to challenge the system using creative methods to subvert common assumptions.

Many of the researchers at the International Creative Research Methods Conference in Manchester are independent, not linked to a specific university or funder and this allows them to approach research from a variety of unusual and unfamiliar angles.

The conference is the brainchild of Dr Helen Kara: independent researcher, author, teacher, speaker and creative research methods (CRM) expert. Helen’s vision was to bring together the global CRM community to share knowledge, promote understanding, enable networking and have fun!

After the first day's keynote, I went to see Nicole Brown, a researcher looking at fibromyalgia, a condition that I also have. She had asked people living with fibromyalgia to collect objects to describe how the condition made them feel. One person had taken a photo of her chair - a really comfortable armchair, with a blanket, a table beside it holding drinks, snacks and distractions. This could have been a picture of my own living room! Due to chronic pain and fatigue I have what I call my 'nest'. I have reclining sofas with a side table with all of my remotes, chargers, creams, spare meds, thermostat, drinks, snacks, book, switch, lip balm (etc.) just so that everything I need is within reach and I don’t have to move too much or cause myself too much pain. I found the picture really impactful and saw the potential for objects, artwork and abstract thinking to be able to describe conditions like fibromyalgia which is extremely difficult to explain to someone who doesn’t have it. Using objects as data to assess and evaluate was really interesting and a methodology that I wasn’t previously aware of.

We were then given the task of picking some cards to describe ourselves as researchers.

These are the lego cards I chose to describe me during the sessions by Nicole Brown, who works with objects as data in research.

The skydiver because I feel like I just ask to do things and hope for the best, the singer because I like to present and talk about PPI (Patient and Public Involvement) in research. 

Black widow because she’s a superhero and fights for people who can’t and Rocket because he’s been made up with tech and I felt like he’s a disabled superhero :)

Jargon buzzing

On day 2 the Lawnmowers Theatre Company, run by and for people with learning difficulties, brought out jargon buzzers which were amazing! The characters pressed the buzzers every time someone used a term or word that they didn’t understand. I really want to use these in PPI meetings in the future, but we might not get anything done having to explain all the acronyms and research language that is often used!

Making a 'zine'

I didn’t know anything about zines and wasn’t aware of the Madzine project to help people with mental health conditions to explain how they feel, get things out and be creative. The session was really interesting giving us some history on zines before we were able to create our own. I made one about a project that I have been working on using some paper with stars on to represent the PPI Group members. A black page for accessibility as we all had different barriers to involvement and some of them were difficult to address, hidden or unknown. Some of the zines that they showed us were amazing: creative, visual, unusual, thought provoking and touching. They plan to create a mobile Madzine library that tours around the country so that people can read the zines and share in the experiences of the creators to increase awareness and understanding of living with mental health conditions.

Board games, rockpools and podcasts  

Kath McGuire (University of Exeter/NIHR School for Public Health Research), led our session talking about working with creative methods, public involvement and research dissemination. I briefly introduced the Fuse podcast and explained the collaborative approach to creating it. People were then able to take a look around the room at the variety of creative outputs that we had brought with us, and a video about how we have creatively communicated research in Fuse (see below). We had a snakes and ladders game to be used with PPI groups, or groups of researchers to evaluate their projects: snakes were barriers and challenges and ladders were successes and wins. We also took posters created by Fuse researchers showing their project results (Emma Adams) and Kath had a Blue Health Rockpool from another project. We took questions and explained how we created the podcast, what its impact had been and answered lots of technical questions about equipment, hosting and distribution. Hopefully accurately!

Attending the conference really broadened my view of research and public involvement. Lots of researchers at the conference felt that by making their work more creative it made it more inclusive. By reducing or removing established barriers to involvement such as language, terminology, education level and academic preconceptions they were able to engage with a wider, more diverse group of people. They could still be academically rigorous and produce research that stands up to peer review and meets publication standards whilst including more people, accessing people with appropriate lived experience of their topic of study and making involvement engaging, interesting and fun!

I have come away from the conference wanting to make Patient and Public Involvement meetings more creative, use games and objects to describe feelings and opinions, implement the jargon buzzer and design engaging dissemination methods that are relevant to the target audience of the study, drawing on the skills of the researchers and PPI teams.

A special thanks to Kath Maguire, Daniel Mutanda and Heather Boult (University of Exeter/NIHR School for Public Health Research), and the Fuse colleagues: Lesley Haley, who helped me with the podcast aspect of the workshop 'market place'; Ella Anderson for preparing the workshop activity; and Mark Welford for producing the Creatively communicating research video that we used in the session.

What is the best way to reduce the amount of meat we eat?

Posted by Jack Hughes, PhD Candidate in Behavioural Science; Mario Weick, Professor of Behavioural Science; and Fuse Associate Milica Vasiljevic, Associate Professor of Behavioural Science, from Durham University

The science is clear that eating meat can be bad for our health; eating meat has been linked to an increase in cardiovascular risks, diabetes, stroke, cancers, and even dementia. Meat is also bad for the planet, with the livestock industry being estimated to be responsible for up to 15% of greenhouse gas emissions. Eating meat is also surprisingly closely connected to the risk of pandemics, with zoonotic diseases (caused by harmful germs that spread between animals and people) much more easily spread from eating animals.

Governmental policy and legislative choices play an important role in our excessive meat consumption. The Committee on Climate Change has recommended a 20% reduction in UK meat consumption by 2030 if we want to hit our net zero targets. Additionally, the Department of Health and Social Care recommends eating no more than 70g of meat a day, but average meat consumption in the UK is closer to 90g. So, what is the best approach? Do we advocate for a ‘nanny state’ that bans meat or imposes hefty taxes? Or do we advocate for a removal of all subsidies for meat farming and just let the market and people decide how much meat we consume under the hopes that awareness of the dangers of meat will drive down consumption?

There are of course significant problems with both approaches, but maybe there is a third option. One that can be applied not just to meat but to all society’s destructive large-scale behaviours, from alcohol to tobacco to ultra-processed foods to sedentary lifestyles.

In 2003 Richard Thaler and Cass Sunstein coined the phrase Libertarian Paternalism. Essentially arguing that the best way to produce policy is to design interventions that change behaviour without affecting people’s right to choose. So, you can still eat as many steaks as you like but policy will build an environment that unconsciously discourages eating an excessive amount. This idea could be argued to balance individual and government responsibilities, the government is nudging people to healthier choices, but the individual still gets to make the final decision.

For example, in a recent study of ours we found that sticking a graphic warning label (similar to those you see on cigarettes) onto meals could reduce the amount of meat chosen. Not only were the labels effective, leading to between a seven and 10 percent reduction in meat meals chosen, but the idea of introducing them as policy received fairly neutral responses. Which, let’s be honest, makes it more popular than most policy proposals!

When we look at recent research we can see that a variety of interventions have shown promising effectiveness on reducing meat consumption. Whether changing the ratio of meat to non-meat meals on offer, making meat meals less appealing by using less flattering descriptions, changing which meals appear at the top of the menu, or adding eco and warning labels to discourage the selection of meat meals, there are many ways of changing the environment without reducing the freedom of choice consumers ask for.

The question is though: is this approach the best or the worst of both arguments? Does Libertarian Paternalism thread the needle between governmental and personal responsibility? Others might say the approach is too hands off, or too hands on. If we accept that as a society we would benefit from eating less meat, which policy strategy do you support? The ‘nanny state’, the free market, or the libertarian paternalist approach?

The paper described in this blog-post can be accessed here:

Hughes, J. P., Weick, M., & Vasiljevic, M. (2023). Impact of pictorial warning labels on meat meal selection: A randomised experimental study with UK meat consumers. Appetite, 190, 107026. https://www.sciencedirect.com/science/article/pii/S0195666323024881

Should researchers act as disruptors?

Learning from the Dutch Academic Collaborative Centres

Posted by Peter van der Graaf, Associate Professor in Public Health & AskFuse Research Manager, and Mandy Cheetham, Research Fellow, from Northumbria University

While Storm Babette was wreaking havoc in the UK, a team of international delegates from Tranzo, scientific centre for care and wellbeing of Tilburg University visited Fuse. The visit focused on sharing learning on how to develop and maintain collaborative research partnerships between policymakers, health practitioners, communities and academic researchers.

Great visit from @TilburgU_Tranzo to the North East yesterday hosted by @fuse_online @gateshead and @EdbertsHouse to share international learning on #collaborative research partnerships between policymakers, health practitioners, communities and researchers. #KMb pic.twitter.com/iTCMggC1hG

— Peter van der Graaf 🇪🇺🇳🇱🇬🇧 (@pvandergraaf75) October 21, 2023

Tranzo works in Academic Collaborative Centres (ACCs),which are sustainable partnerships between Tilburg University researchers and health and care organisations at both a regional and national level, including (local) government, third sector organisations and other research institutes. Tranzo hosts in total 11 ACCs, each with a different topic area: ranging from mental health, addiction, intellectual disability, to public health, youth, work & health, social work, care for older adults, and technological and social innovations for mental health. Each centre could be compared to a research cluster within Fuse and is led by an academic lead.

Despite the diversity in topics addressed in each centre, there are five underlying research themes:

1. health-related behaviour, health care policies and societal influences; 
2. social inequality and inclusivity; 
3. mental health care, capabilities and recovery; 
4. client perspective and participation, experiential expertise, and; 
5. the (health) care system.

We could call these cross-cutting themes, and this is something Fuse could consider to integrate research across clusters. For example, translational research could act as a cross-cutting theme within Fuse.

The ACCs work in a similar way to Fuse: they connect science, lived experience and professional practice in the domain of health and wellbeing in the Netherlands through co-creation of research and knowledge exchange. These diverse sources of knowledge are valued equally. The principles of establishing long-term partnerships, based on equality, personal relationships will also sound familiar to Fuse members.

During the discussions on the day, we reflected on the importance and challenges of blurring boundaries and the need for ‘living bridges’ between partners organisations. Personal and trusted relationships and a commitment to reciprocity were identified as key for this, but also the need for systems that support and incentivise collaborative working. Unfortunately, universities and research funding programmes are often not set up for this way of working, or narrowly confine knowledge exchange to commercial spin-off companies.

Blurring boundaries, science practitioners, and the fourth-generation university

One of the ways in which Tranzo has tried to blur boundaries is by developing science practitioner roles, which are practitioners who take up a temporary post in universities to develop their research skills and act as boundary spanners for the knowledge they co-create within their practice organisations. These roles can be funded by the health and care organisations (in kind), as they recognise the importance of using more evidence to inform their decision making, by blending scientific knowledge with the knowledge and expertise from practitioners and service users. But sometimes also external funding (grants) is available for co-creation projects with science practitioners. Sometimes it is a combination of in kind and grant funding.

This makes science practitioners the flip side of embedded researchers in Fuse: instead of academic researchers co-locating temporarily in a practice organisation (for example a public health team in a local authority) practitioners spend time in academia, (partly) paid for by their organisation and supported by academics to develop their own research. Both roles help to blur boundaries and therefore science practitioners, which go beyond short-term placements, could be a valuable role to consider for Fuse.

To support this two-way traffic between researchers and practitioners, Tranzo has defined itself as a ‘developing towards a fourth-generation university’: an open network university reaching out and working on innovation with partners and citizens in an ecosystem. While first generation universities are focused on education and second generation universities combine education with research, third generation universities embrace entrepreneurship and try to market their knowledge. However, this happens solely within the space of the university (Steinbuch, 2016).

In contrast, fourth generation universities see themselves as only one space within a wider knowledge eco-system that requires close collaboration with all participants in this eco-system, including policymakers, professionals and service users, but also private organisations, arts and creative industries and international collaborations. Interestingly, the function of senior leaders within fourth generation universities is not to manage processes and structures, but to disrupt them. By disrupting existing practices, ways of thinking, and valuing and using different types of knowledge, more value can be created within the eco-system.

This perspective suggests an extended new role for Fuse: not only trying to be a bridge between different worlds (research and practice) or between different research infrastructures and networks within the North East and North Cumbria - Applied Research Collaboration (ARC), Health Determinants Research Collaborations (HDRCs), and Research Support Service (RSS) - but actively disrupting the status quo by building structures and processes to enable the creation of value through new collaborative partnerships and by stimulating multi-actor innovation.  

The new value that could be created in this way was clearly visible during the two site visits on the day, when we were welcomed by staff and community members at Edberts House and Gateshead Council. Embedded research roles have shone a light in Gateshead on the importance of control for residents, whose lives are often defined by a lack of control and influence over decisions affecting their lives. Research helped them to learn from a community-centred approach and use this learning to inform future planning. Council staff felt more confident and skilled to develop their own research and evaluations and implement solutions using this knowledge and the connections it helped to create with external partners.

It was inspiring to hear from our colleagues in Tranzo and share examples of our collaborative research. We had positive and fruitful exchanges about our experiences, challenges and shared interests including training in the craft of knowledge exchange, mentoring, engagement and impact. We look forward to continuing the conversations and would be interested in any readers' thoughts on how we can be more disruptive as Fuse researchers?

The view from Tranzo

Reflections from Prof. Dr. Ien van de Goor, Program leader Academic Collaborative Center Public Health, Tranzo and Tilburg University

On behalf of the Tranzo delegation, first of all many thanks for the very warm welcome on this stormy day in October. We were impressed by the introductions in the morning program on how translational research within Fuse is taking form. There were some very nice examples of how knowledge exchange can help to increase the flow of evidence into public health practice. And how push and pull factors in this process are taken into account in the Fuse knowledge exchange model. It was very interesting to hear about the co-creation process where research was translated in a book for children with parents suffering from addiction problems. As was the report on the relation between the Covid-19 pandemic and health inequities. Both resonated with Tranzo’s way of working: a diversity of themes and different ways of making an effort to do impactful research.  

Next in the afternoon program we were invited to Edberts House and the Gateshead Council. The way the voice of the community is a driving force in making Edberts House into a successful and valued community project, was impressive to experience (as was the lovely lunch offered!).

The program was finalised by meeting with representatives of Gateshead Council. The enthusiasm of the members from the Council's Public Health team and the Fuse researchers was striking and made clear that direct collaboration and co-creation between academic research and local authorities can contribute significantly to the uptake of evidence in public health policy and practice.

So for Tranzo it was a very insightful and inspiring visit learning about Fuse collaborating with practice and sharing our ways of working and trying to be impactful with scientific research. We really look forward to exploring further opportunities to collaborate, co-create and share our thoughts on finding ways to be disruptive (for the better!)

The Power of Partnership

Our Top Tips for co-production with inclusive and meaningful Public and Patient Involvement and Engagement 

Posted by Rosemary Nicholls, Patient and Public Involvement and Engagement (PPIE) member, and Charlotte Parbery-Clark, Fuse researcher at Newcastle University and Public Health Registrar

This image was co-produced with members of the public, researchers and film production company Kaleidoscope CFA as part of the UNFAIR research programme. You are welcome to use and share the animation or images whilst acknowledging the source (https://bit.ly/UNFAIRstudy) when doing so. 

Earlier this year, members of the public with researchers at Newcastle University launched an animation that explores public views of health inequalities. The animation was created as part of the UNFAIR project, which is funded by the National Institute for Health and Care Research (NIHR).

Here Rosemary and Charlotte share their experiences as co-applicants on the project and give some top tips for members of the public and researchers.

Rosemary

"A key factor in the success of this project was the leadership style of the professional UNFAIR researchers. Their excitement and commitment to the study and to us as members of the Patient and Public Involvement (PPI) advisory team was infectious. The timely exchange of emails kept us all informed of progress and involved in deciding next steps. There was ongoing respect for what we had to offer.

"I was confident in my views and sometimes doubtful about the practicalities of what was being proposed, thinking: “This isn’t going to work.” But I found various methods much more successful than I expected and I learned through my surprise that I’d been wrong!

"A risk of consulting people in disadvantaged settings is that they may assume that the researchers will be able to effect immediate improvement in their circumstances, so it’s important to be clear from the outset about the aims and likely outcomes of a project and I feel we succeeded in this. The people we met in community groups emphasised how vital it is for them to be treated with respect and I’m confident that we put their needs at the top of our agenda when we asked them questions.

"There were occasions when we had to reassess our approach and resilience became a useful quality. The excellent teamwork that Charlotte and I had developed over previous months enabled us to undertake a successful review of our methods and move forward."

Charlotte

"When the opportunity came up to co-lead the project, I was excited but also a bit apprehensive as I was new to this type of work and was unsure about how to 'get it right'. One thing I was sure of was that I wanted to involve members of the public throughout the project in a meaningful way and avoid it being 'tokenistic'. So, the start of my PPIE journey involved lots of reading and reflecting about how to approach it!

"Co-leading with Rosemary and working with the UNFAIR PPIE contributors was invaluable as we could bounce ideas off each other and consider a variety of perspectives. They kept me right with the 'academic speak' I would sometimes slip into. I learnt so much with so many firsts, such as applying for funding for this type of work (and being successful!), creating flyers, navigating remuneration, as well as being involved in creating an animation."

 

Top tips for members of the public (especially if considering a co-applicant role)

• Applying to be a co-applicant or public contributor can involve being selected from a group of interested people. Don't let that put you off as there are lots of opportunities. The Research Design Service (RDS) including Creating Connections, or People in Research are good places to start.

• Be confident about taking up the role, if you would like to do it. The researchers have asked you because they’re confident you can contribute relevant skills and experience.

• Check that you have the time to commit to being a co-applicant. In terms of hours, the commitment may not be very great, but being able to respond to emails quickly (within 48 hours) and to attend online and in person meetings at arranged times can be important. It’s likely that you will be consulted about suitable times, perhaps by doodle poll, but there may be occasions when you need to prioritise the project to ensure continuity and re-arrange your diary. Ongoing dialogue between you and the researchers to figure out the best approach together works well.

• Each stage of the project will be well-planned and costed in advance by the researchers and the lay co-applicant is paid by the hour in my experience, depending on the nature of the work. However, there may be occasions when lay co-applicants feel that they can offer further insights and they should feel freely encouraged to check that comments outside the box will be welcome and if so, volunteer their thoughts to the researchers by email.

• Be willing to ask questions of the researchers and put your point of view across with confidence, but be prepared to find that your assumptions may be proved wrong as the project progresses. Remember that it’s a learning process for us all. Be resilient when necessary and work together to keep the project on track.

Top tips for researchers

Ways of working:

• Decide how you will involve public contributors at each stage of the project in line with your budget.

• If working with a specific group of PPIE contributors on a project, decide together how you would like to work. There are tools to help you with this, such as Working Together.

Diversity and inclusion:

• Remove barriers for involvement as much as you can. For example, provide options such as different online and/or in-person sessions on different days/times, go to community groups and be flexible about timings to ensure it suits public contributors (not expecting people to come to you), or use online platforms, such as Padlet, for people who want to be involved but can't attend the session.

• Language is really important, be as clear and as simple as possible.

• To increase diversity of public contributors, networks can help promote the opportunities particularly in public health research compared to disease related research as public health research typically has a wider remit.

Time:

• Building relationships is key and takes time. It is good practice to keep people updated and adapt according to need where you can.

• Make sure you know how to remunerate public contributors in your organisation before any PPIE sessions to reduce delays.

• Build in extra project time for unforeseen events.

Challenges:

• Any challenges that may come about with PPIE work or co-production are opportunities to make the project even better, see them as gifts.

• Sometimes, what is feasible in the time/resources available may not align with the feedback so be clear that you may not be able to act on all suggestions at the outset. Compromise as well as sharing why you have not been able to act on certain suggestions is useful. Have a way of deciding what you will do if the feedback conflicts with others' feedback is important.

Involving members of the public is incredibly worthwhile strengthening the project in so many ways. Also, undertaking PPIE and/or co-leading provides opportunities for rich learning and skill development for both researchers and public contributors. There is lots of support especially if this is your first time doing this type of work, as either a member of the public or researcher. To find out more about PPIE or public co-applicants, the following resources may be useful:

Guidance:

• NIHR guidance on PPIE including guidance for public co-applicants and PPIE remuneration
• NENC RDS Public Involvement Guidance
• UK Standards for Public Involvement
• NIHR RDS Community Engagement Toolkit
• Working Together

Opportunities for public involvement:

• Contact your local Research Design Service (RDS); in North East and North Cumbria, opportunities for involvement are available, for example, through the RDS Consumer Panel and/or Creating Connections
• People in Research

 

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Rosemary Nicholls is a Patient and Public Involvement and Engagement (PPIE) Representative and Consumer Panel Member, National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East North Cumbria (NENC) and one of the UNFAIR PPI members.

We would like to thank the UNFAIR PPIE and research team, members of staff who helped facilitate the online workshop as well as everyone who took part in the workshops.

This project was funded by the Tilly Hale Award from Newcastle University and the National Institute for Health and Care Research (NIHR) (ref CA-CL-2018-04-ST2-010).The views expressed in this blog are of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

A public partner’s guide to podcasting

Posted by Victoria Bartle, Fuse Public Partner, with tips for guests from Cassey Muir, Fuse & NIHR School for Public health Research (SPHR) funded PhD Researcher from Newcastle University

Everyone seems to have a podcast these days and there are lots discussing research, but how many can say that they are totally led by the public? I have been participating in public involvement in research since 2016 and believe that it is a vital part of improving everybody’s health, but find that getting other people involved and informing the public about research projects is really difficult.

I was excited to be involved with the Fuse podcast Public Health Research and Me as I’ve wanted to start my own for a while now, and felt as if this would be a perfect opportunity to learn about podcasting and give it a try, as well as being part of creating a platform to help engage the public in research and hopefully increase awareness and involvement. I joined the podcast team made up mainly of other public partners and took part in some excellent training which went through equipment, hints and tips for selecting guests, how to phrase and deliver questions, different podcast formats, as well as recording and editing. I was buzzing after the training and keen to get started.

 

I was lucky enough to be selected to be the first host for the podcast and was matched with Cassey Muir, one of the Fuse researchers who is working with children and young people who have been affected by parental substance use. Her work is fascinating and I was soon enthralled reading everything I could to prep for the interview and come up with a very long list of questions. As brevity is not my forte the rest of the team helped to cut these down to around five or six questions which is about all that you need to create a 30 minute podcast.

We then had a pre-record meeting with Cassey, where we discussed the questions. Talking to her about her work helped me to edit and refine the questions for the interview. Once the questions had been finalised and approved by the podcast team and Cassey, we set a recording date.

I was quite nervous before the record. I’d been a panel member on a podcast before and had so many technical issues that I was really stressed and anxious by the time I managed to get everything sorted. So for this recording I made sure I had tried all of the equipment and was all set up with my notes, drinks, tissues and cough medicine…because of course I had a cold! Recording when one of the presenters keeps coughing is really difficult for the editor, but Cassey was a pro and kept pausing whenever I coughed so that we would have a second or two to edit it out. We talked for ages and the record went really well. I was able to bring in some of my own lived experience of the topic and this helped to make the conversation more natural and less like me firing questions at Cassey, although I did say “wow” and “that’s amazing” a lot which I was determined not to do as much the next time.

Now to the technical part! Although we had had some training on editing podcasts, the team decided to use an external editor as we wanted it to sound as professional as possible, and none of us were confident in using the software just yet. Listening to the edited version we were able to make requests for changes, but I felt that it generally sounded great, and asking to cut out all of my embarrassing “wows” was my own issue and not necessary. We had to write our bios to go with the podcast, an overview of what it was about, and make sure that the projects and references that we discussed were all available for the listeners to link to directly from the podcast page.

Going live was exciting, I sent the link to all of my friends and family, it was tweeted on the Fuse twitter feed and is also on the Fuse website so everyone can access it. We’ve had over 100 listens and the bonus video has had nearly 300 views so far. I’ve had lovely feedback from my friends and family who said they found it really interesting. My Mum was especially impressed as she now has something that she understands to tell people when she’s trying to explain what public involvement in research is and what I do.

Round two  

The second recording went a bit differently. I had loads of background information to read about Eugene Milne, his career history, his involvement in establishing Fuse, his role in public health and his recent MBE which was all very exciting. I had lots of questions about all of the different projects that he had been involved in, their impact on public health in the North East, as well as his plans for retirement, but during the pre-record chat I decided to take a more focused direction as his responses to some of the topics were just so interesting. We narrowed it down to his involvement in establishing Fuse, what his initial expectations were and how he feels it has developed over the past 15 years; the impressive results from the public health initiatives that he oversaw (including North East tobacco and alcohol control programmes Fresh and Balance); as well as responding to Covid-19 during his time as the Director of Public Health for Newcastle.

Again the public partner team reviewed the questions and the theme of the podcast and we went ahead with the recording. This time I didn’t have a cough which made recording much easier, but I still responded with lots of “wow’s” and “that’s amazing” as I found Eugene very engaging and his career so interesting. I then got myself a bit confused towards the end of the record. I’d skipped a question as it didn’t fit with how the conversation was flowing, but I wanted to come back to it at the end. I’d already said the outro lines so I had to pause for a second or two, ask the missed question, and then remind the editor to swap the order of the last two sections around. I was a bit embarrassed about this, but it was absolutely fine and you can’t tell in the final version.

Things don’t always go to plan

The third recording with PhD student Joanne McGrath has been different again. We had already decided to focus on one of Joanne’s current projects looking at women experiencing homelessness as it fitted in with International Women’s Day and an event that Fuse was hosting for the occasion. This meant that I had a bit less reading to do while prepping the questions this time. They were approved by the podcast team and Joanne, and she steered the direction of the podcast from the outset as she knows her research best and which areas are being focused on currently. The recording has been beset with challenges, technical issues, diary clashes and unavoidable life events that have meant that we have had to postpone the recording three times. Is it cursed!?

These challenges actually led us to writing this blog, as well as the hints and tips below. We have all learnt so much from the first three podcasts and as I pass the hosting responsibilities to the next public partner we wanted to make sure that we were learning from our experiences. At the point of writing this blog, we have now managed to record Joanne’s episode, so keep an eye out for it. Her work with women experiencing homelessness is so important and will benefit an often overlooked group of people by supporting positive changes in their lives.

Our top tips for podcasting

For hosts

Preparing for the podcast:

• Give yourself enough time to read through all of the guest’s work and discuss with them and the team the possible theme of the interview.
• Write down all the questions you can think of; you can always edit and rearrange the order later.
• Have a pre-record meeting with the guest; this helps you and your guest to feel comfortable, and to try out the microphone and recording platform. This can also help to define the questions and theme of the podcast.
• After the guest and the team have reviewed the questions and decided on five or six to use, arrange them in an order that should flow like a conversation.
• Write your own intro, a couple of sentences about yourself to introduce you to the listeners and practice this a few times so that you are familiar and comfortable saying it.
• Also practice the intro and outro sections that have already been created, changing some of the words if it fits better with how you speak.

The podcast recording:

• Login to the meeting for the record early, have everything you need set up around you, and make sure you have all devices on silent so you won’t be disturbed.
• Check the mic in advance, you may need a USB port to attach to your computer and headphones with a connector jack. If you use an Apple Mac (or similar) you may have to use a USB adapter.
• Place the mic approximately 15cm (6”) in front of you.
• Find a small quiet room that is preferably well furnished to absorb any echo.
• Have a little chat with the guest, try to make them feel comfortable and start when you’re both ready.
• Mute yourself if you need to cough, sneeze or drink etc.
• Avoid rustling any paper or notes that you may have prepared.
• Turn off non-essential devices using wifi and reduce the tabs/windows on your device. This will reduce the likelihood of buffering during the Zoom/Teams call.
• If you do cough, sneeze or make a mistake then pause for a second or two and start again (or mark by saying “edit point”), this gives the editor a space to remove the noise.

After the recording:

• Re-record any sections you feel necessary, or let the team know if you think a section will need to be moved, cut or edited and they can pass this on to the editor.
• Once the edited version comes back, with the “umms”, “aaahhhhs”, coughs (etc.) removed, you will be able to listen through and request any further edits that you’d like.
• Write a bio and provide a photo to go on the podcast platform.
• Help with any promotion through your own networks, and enjoy listening!

For guests

Preparing for the podcast:

• Identify and share your relevant publications, resources, and information with the host and podcast team, which allows them to focus the conversation and questions (e.g., do you want to provide a wide variety of resources or only those on a specific topic?).
• Help clarify any specific points of interest or themes you would like to get across about your work as this will help with determining relevant questions.
• Pre-record meetings and/or emails are helpful, which can take away some of the nerves by building a relationship with the host or testing out the equipment.
• Ask for a copy of the questions if you would like to make notes and think about your answers ahead of time.

The podcast recording:

• This should be/is a fun experience where you get to talk about your work with someone who is keen to listen and explore different topics with you. It is a great chance to discuss your research in a way that you might not normally and possibly from a different viewpoint, so try to ease into it and enjoy it. If you lose your train of thought or stumble over your words it is okay, that is the benefit of editing and not being live.
• If you have made them, have your notes to hand, either printed (but not rustling) or on the screen to help you remember important points that you want to make during the podcast.
• As this is meant to be somewhat conversational, remember to go with the flow of questioning as some of your answers may spark interesting follow-up questions that you are unprepared for.

After recording:

• Ensure you have provided links to the important items you discussed during the podcast, which can then be shared alongside the podcast.
• You get to listen/watch through the edited podcast before it goes live, which is your chance to highlight any changes you would like to be made (although the editing team do a fab job, so there may be no necessary changes at this stage).
• Once the podcast is live, this is a great opportunity to share your work and the podcast with relevant networks and/or on your social media.
• Enjoy listening or watching the podcast!

Treats: a helpful reward, or to be approached with care?

Posted by Anita Attala, Lead Adult Weight Management Dietitian from Northumbria Healthcare NHS Foundation Trust, and research team from Teesside University

We all like to have a ‘treat’ and to give ‘treats’ to others. Indeed, the use of food, and in particular what we in public health call ‘high fat, sugar, and salt’ containing foods or ‘HFSS’, are often chosen as rewards. The notion of food cultures is certainly a social anthropological (study of humans) concept, with an example being the use of food in positive reinforcement; using ‘treat’/HFSS foods to reward children in particular. Taken at ‘face-value’ such treats may appear harmless, however repeated use of HFSS in this way has been shown to physiologically influence the human food reward system, and impact on our ability to regulate how much food we eat. This, together with other detrimental impacts, has led to advice not to regularly use food as a reward. Research has also shown that using food rewards in adults can hinder healthy weight management, especially from a psychological perspective.

But what exactly is a ‘treat’? Why do we feel the need to ‘treat’ someone? Are ‘treats’ always a positive experience or can they be used in a detrimental or harmful way?

While working in a forensic service I saw patients gain weight, and often gain this weight very rapidly. I also noted that some staff seemed frustrated and concerned about the weight gain some patients experienced. However, I also noticed that HFSS food was frequently used as part of patient care. This sparked my interest in wanting to understand this apparent conflict.

Forensic services provide care for people with a severe mental illness or learning disability, who have committed a crime but are too vulnerable to be in prison. For example, they are high risk either to themselves or the public, and therefore are unable to live in the community. People in these environments are often here for a long time and are reported to die 15-20 years prematurely, often from avoidable diseases. There are often restrictions imposed on the person and their environment. These restrictions will depend on the level of security required and the risk posed by the patient, and can be directed by the Ministry of Justice. An example of a restriction might be the person is not able to leave the ward.

Limited research seems to have been undertaken around the use of HFSS food ‘treats’ for adults, let alone adults who are in hospital. Yet, it is something many of us seem primed to do – bring (HFSS) food to someone when they’re ill.

The word ‘treat’ conjures up a particular thought of food – which is often high in calories, high fat and high in sugar. What you view as a ‘treat’ and how to ‘treat’ can often have been learnt in childhood and can differ from person to person. But, while it is entirely possible to have a non-food ‘treat’, it’s often harder to think of one and can be more difficult to provide while in hospital (particularly one with restrictions such as forensic wards).

You could argue that ‘treats’, by definition, can only be a ‘treat’ if you don’t consume them on a regular basis. As research shows, regular behaviours of any kind, can soon develop into habits.

Wanting to learn more about the use of ‘treats’ to show care and kindness, particularly in a hospital setting, I applied for research funding from my Trust (Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust). Also, in 2020, I was successful in obtaining a clinical academic internship with Health Education England (HEE) and the National Institute for Health and Care Research (NIHR). Both awards enabled me to research the use of treats in forensic inpatient care settings.

Using this funding, I decided to focus on whether ‘treats’ were being used to prompt a particular behaviour from a person, while in inpatient care settings; whether these ‘treats’ impacted on a person’s weight and physical health; and why treats were chosen and if it was related to ideas of care and kindness. Certainly, from my observations this is what seemed to be happening - often perhaps unconsciously – but this research allowed us to evidence what may be happening.

What we found

Our research into treats in the health care sector has now been published. It found that treats were used for a number of reasons including:

• Being an affordable way to reward someone
• An incentive to encourage patients to participate in activities, and
• A way to express love/care for someone.

Of course, food as a bonding mechanism is not a new phenomenon, and the idea of certain foods providing comfort is well-established.

It’s entirely possible to have ‘treats’ as part of a healthy balanced diet, and that the origin of using HFSS as treats may be from a place of nurture, but the advice is that food treats should be infrequent and limited in quantity. While it would appear ‘easy’ to say that those working in institutions, like in NHS care services, need to be mindful of how food is being used, our research findings suggest that it may take a much bigger system/cultural change to reduce the use of HFSS as treats in services. I think the idea of a ‘positive food culture’ is useful here. One where the focus is on preserving and nurturing good health and wellbeing through the use of healthy, positive, food behaviours, attitudes and values.

Authors:

Anita Attala, Lead Adult Weight Management Dietitian from Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, and postgraduate student from Teesside University.

Jo Smith, Consultant Dietitian (Clinical Academic) from Tees, Esk and Wear Valleys NHS Foundation Trust, and PhD student from Teesside University

Amelia Lake, Fuse Associate Director and Professor of Public Health Nutrition from Teesside University

Dr Emma Giles, co deputy-lead of the Fuse Behaviour Change Theme and Associate Professor Public Health from Teessside University

References:

1. Alonso-Alonso M, Woods SC, Pelchat M, Grigson PS, Stice E, Farooqi S, Khoo CS, Mattes RD, Beauchamp GK. Food reward system: current perspectives and future research needs. . Nutr Rev 2015;73(5):296-307. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477694/
2. Roberts L, Marx JM, Musher-Eizenman DR. Using food as a reward: An examination of parental reward practices. Appetite 2018;120:318-326. https://doi.org/10.1016/j.appet.2017.09.024
3. Hsu A BA. Designing for Psychological Change: Individuals’ Reward and Cost Valuations in Weight Management. J Med Internet Res 2014;16(6). https://www.jmir.org/2014/6/e138
4. Attala A, Smith J, Lake AA, Giles E. Investigating ‘treat culture’ in a secure care service: a study of inpatient NHS staff on their views and opinions on weight gain and treat giving for patients in a forensic secure care service. J Hum Nutr Diet 2023; 1-13. http://doi.org/10.1111/jhn.13129
5. Human Relations Area File. Craving comfort: bonding with food across cultures. 2023; Available at: https://hraf.yale.edu/craving-comfort-bonding-with-food-across-cultures/
6. Mingay E, Hart M, Yoong S, Hure A. Why We Eat the Way We Do: A Call to Consider Food Culture in Public Health Initiatives. International journal of environmental research and public health 2021; 18(22) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8623951/

Public Health at a crossroads again: meeting the challenge of a reformed system in England

Posted by David Hunter, Newcastle University, Peter Littlejohns, King’s College London, and Albert Weale, University College London



With health policy understandably preoccupied with the pressures on, and changes occurring in, the NHS arising from the impact of COVID-19, implementation of the Health and Care Act 2022, and various strikes among the workforce, it is imperative not to overlook the public health system reforms in England.

Public Health England’s (PHE) sudden demise in August 2020 followed mounting criticisms of its performance during the early stages of the pandemic and general unpreparedness.1 Rather than consider how PHE might be reformed, the government rushed to replace it with two new bodies: UK Health Security Agency (UKHSA), and Office for Health Improvement and Disparities (OHID). Like PHE, the UKHSA is an executive agency with close ministerial oversight while still permitting ‘independence in the delivery of policy advice’. It will act as a ‘system leader’ for health security with responsibility for pandemic preparedness and external threats across the UK while bearing in mind that health is a devolved responsibility.

PHE’s remaining functions in respect of the wider public health, including health improvement and population health, lie with OHID. Located within the Department of Health and Social Care (DHSC) and jointly accountable to the Secretary of State for Health and Social Care and the Chief Medical Officer for England, it enjoys even less independence than the UKHSA. Building on the work of PHE, OHID’s priorities include tackling obesity, improving mental health, promoting physical activity and other population health issues, notably inequalities.

There is merit in taking stock to identify any lessons which might be gleaned from the mixed life of PHE and whether the new bodies offer hope to do things better.2

Learning the lessons

The findings from a research project to explore the circumstances surrounding the rise and fall of PHE may assist with the learning process.3 Five broad underlying issues were identified in the research which contributed to PHE’s demise.

• 

  PHE did not possess the capacity to undertake a testing regime
   of the size and complexity required by the pandemic

  Severe funding cuts in public health spending, nationally and locally, since 2010 meant that PHE functioned with reduced capacity when the pandemic struck
• PHE did not possess the capacity to undertake a testing regime of the size and complexity required by the pandemic, the absence of which was the basis of the case against the organisation
• The governance of PHE as an executive agency meant it lacked independence
• While decisions made by PHE at the start of the pandemic were later considered mistakes (and judged outside the law by a judicial review) at the time there was little information about the nature and possible effects of the virus and limited capacity in the health system which required tough prioritisation decision to be made
• The sudden closure of PHE without any consultation was widely reported to be due to blame-avoidance behaviour on the part of key actors, principally Dominic Cummins (as former Chief Advisor to the Prime Minister, Boris Johnson) and Matt Hancock (as former Secretary of State for Health and Social Care). There was also a view that the decision was based on policy favouring use of the private sector and contracting out functions like test and trace.

Key lessons from these findings centre on two major areas of concern: the respective remits of the new bodies, and their governance.

Remits

The respective remits of UKHSA and OHID need to be clearer and more transparent if the risk of fragmentation is to be avoided. A welcome feature of PHE was its attempt to bring together the key public health functions that had previously operated in separate silos. As things now stand, separating communicable diseases (CDs) from non-communicable diseases (NCDs) is a retrograde move since, as the pandemic highlighted in stark terms, close links exist between them when it comes to those groups and communities which suffered most in terms of illness and death. A syndemic understanding of diseases and their underlying social factors is pivotal in preventing disease in the future and avoiding fragmentation.4

Governance

Governance of the new public health bodies requires careful attention. As an executive agency, PHE was criticised for its lack of independence from government which restricted its ability to ‘speak truth to power’. Given UKHSA enjoys the same status, it remains unclear how it intends to avoid a similar fate. The problem is a deep-seated and pervasive one within government. The idea that OHID being housed in the DHSC will allow it to exercise greater influence and have a closer collaboration with ministers could be a good move, or, more likely if history is any guide, it may be overly optimistic. There is a risk that OHID may disappear into Whitehall and become invisible, lacking even the limited degree of independence PHE had. To succeed, OHID has to be visible and have allies inside government.

A further issue concerning the governance and working style of both agencies, especially OHID, centres on their ability to operate effectively across government. Public health comprises numerous ‘wicked issues’, that is, multi-faceted problems that are complex and for which there are no simple or single solutions. Confronting them will be especially challenging for a government which, for all its rhetoric about ‘levelling up‘, remains topic- and department-focused, operating in silos rather than concerned with cross-government issues.5

OHID has a steep hill to climb if it wants to lead a transformational agenda across the wider determinants of health which demands a whole-of-government approach. The hill just got steeper following government delays in tackling child obesity and its failure to implement a national food strategy. In keeping with the prevailing political ethos, there is a renewed focus on individual behaviour change and lifestyle choices rather than tackling the influence on health of commercial interests via taxation and regulation.6,7 If significant inroads into the population health agenda are to be made, then confronting powerful vested interests in, and lobbying from, the food and drinks industry and their ’friends’ in government engaged in what has been termed ’institutional corruption’ cannot be avoided.8 Whether OHID has either the backing from government or competences for such a struggle remains doubtful in the extreme.

Conclusion

Public health once again finds itself at a crossroads. It can either continue to ‘muddle through’ with a broken political and public policy system that is not fit for purpose.9 Or there is an opportunity to construct a strong and confident public health system that is well-placed to confront the challenges facing it. The aftermath of COVID-19 should make the choice of options self-evident. However, as things stand, it is unlikely that the UK’s broken political system with its focus on short-term fixes is up to the challenge. Without major systemic change aimed at overhauling the UK’s political system, a risk of further deterioration in the state of the public’s health may be unavoidable.

References:

1. Calvert J, Arbuthnott G. Failures of state: the inside story of Britain’s battle with coronavirus. London: Mudlark, 2021. https://harpercollins.co.uk/products/failures-of-state-the-inside-story-of-britains-battle-with-coronavirus-jonathan-calvertgeorge-arbuthnott?variant=39528280391758
2. Vize R. Controversial from creation to disbanding, via e-cigarettes and alcohol: an obituary of Public Health England. British Medical Journal 2020; 371:m4476 http://dx.doi.org/10.1136/bmj.m4476
3. Littlejohns P, Khatun T, Knight A, Hunter DJ, Markham S, Coultas C, Kelly MP, Ahuja S. (2022) Lessons from the demise of Public Health England: where next for UK public health? London: NIHR ARC South London. https://arc-sl.nihr.ac.uk/sites/default/files/uploads/files/public-health-report-sept-2022-final.pdf
4. Horton R. Offline: COVID-19 is not a pandemic. The Lancet 2020; 396: 874. https://doi.org/10.1016/S0140-6736(20)32000-6
5. Pope T, Shearer E, Hourston P. What levelling up policies will drive economic change? The need for a long-term focus on skills and cities. London: Institute for Government, 2022. https://www.instituteforgovernment.org.uk/publications/levelling-up-policies?
6. British Broadcasting Corporation (BBC). Junk food: obesity strategy falling apart, Jamie Oliver says. 15 May 2022 https://www.bbc.co.uk/news/uk-61449921
7. Ralston R, Smith K, O’Connor CH, Brown A. Levelling up the UK: is the government serious about reducing regional inequalities in health? British Medical Journal 2022; 377:e070589 https://doi.org/10.1136/bmj-2022-070589
8. Draca M. Institutional corruption? The revolving door in American and British politics. SMF-CAGE global perspectives series: 1. 2014. http://www.smf.co.uk/wp-content/uploads/2014/10/Social-Market-FoundationInstitutional-Corruption-the-revolving-door-in-American-and-British-politics.pdf
9. Ricketts P. Hard choices: the making and unmaking of global Britain. London: Atlantic Books, 2022. https://atlantic-books.co.uk/book/hard-choices

David J Hunter, Emeritus Professor of Health Policy and Management, Population Health Sciences Institute, Newcastle University

Peter Littlejohns, Emeritus Professor of Public Health, Centre for Implementation Science, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

Albert Weale, Emeritus Professor of Political Theory and Pubic Policy, University College London

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Newcastle University, King’s College London, University College London, or Fuse, the Centre for Translational Research in Public Health.