School's out for stigma: Understanding the mental health needs of LGBTQ+ youth

Posted by Liam Spencer, Fuse Associate and Research Assistant at Newcastle University

February is LGBTQ+ History Month, an annual month-long observance of lesbian, gay, bisexual and transgender history, and the history of the gay rights and related civil rights movements. The 2024 theme celebrates LGBT+ peoples’ contribution to science and medicine both historically and today. 

In this blog, Liam reflects on his research of LGBTQ+ young people’s mental health.

As LGBTQ+ History Month unfolds, it offers us an opportunity to reflect on the strides we’ve made, the challenges we still face, and the incredible diversity within our communities. This month holds particular significance for me – a chance to not only honour the struggles of those who came before us, but also to celebrate the progress we’ve achieved and recommit to the work that lies ahead.

With a background in youth and community work practice, my research interests are primarily focused on children and young people’s mental health, particularly early and preventative interventions, and school-based interventions. My journey as a member of the LGBTQ+ community and as a researcher has been intertwined with a deep sense of purpose – to shed light on the unique mental health challenges faced by LGBTQ+ individuals. This is a mission born out of personal experience, and a desire to contribute meaningfully to the wellbeing of this community. 

I have recently been involved in several Fuse projects funded by the NIHR School for Public Health Research (SPHR) Public Mental Health programme, and I’ve had the privilege of being able to delve into the complex dynamics of LGBTQ+ mental health, particularly in school environments. One of these projects, led by Professor Liz McDermott, aimed to investigate the impact of school-based interventions on LGBTQ+ young people’s mental health.

In the first phase of our study, we did a realist review (a type of evidence review that assesses the specific contexts in which a certain intervention may or may not work) of published evidence and identified positive interventions that supported LGBTQ+ mental health in school environments. However, the focus tended to be upon outcomes and studies rarely detailed underlying processes. The second phase of our study aimed to develop a theory that explained how, why, for who, and in what context school-based interventions prevent or reduce mental health problems in LGBTQ+ young people, through participation with key stakeholders.

We interviewed LGBTQ+ young people aged between 13 to 18 years attending secondary schools; intervention practitioners; and school staff in the UK. We then analysed this data to identify relationships across different interventions that improved mental health outcomes. The theory we produced explains how school-based interventions that directly tackle dominant cisgender and heterosexual norms can improve LGBTQ+ pupils’ mental health. Specifically, our theory proposes three interventions that may improve these outcomes:

1. Interventions that promote LGBTQ+ visibility and facilitate usualising, school belonging, and recognition.
2. Interventions for talking and support that develop safety and coping.
3. Interventions that address institutional school culture (staff training and inclusion polices) that foster school belonging, empowerment, recognition, and safety.

Ultimately, our research underscores the importance of providing a school environment that affirms and normalises LGBTQ+ identities, promotes school safety and belonging, and addresses systemic issues within educational institutions. By implementing evidence-based interventions informed by our theory, we can pave the way for improved mental health outcomes for LGBTQ+ pupils.

This month serves as a powerful reminder of our collective resilience, our shared struggles, and our unwavering commitment to justice and equality. Let us continue to push boundaries, challenge norms, and advocate for a world where difference is celebrated and all are embraced for who they are – within academia, our personal lives, and beyond.

Adapted with thanks to the PHSI EDI Committee Newcastle University

Images:

Image 1: courtesy of Schools OUT LGBT+ History Month 2024

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/

How can we fail more intelligently?

Posted by Peter van der Graaf, Northumbria University; Amanda Purington Drake, Cornell University; and Ien van de Goor, Tilburg University

We don’t like talking about failures, as it signals loss of time, resources and reputation, but failures present opportunities for learning in knowledge exchange. 

However, this requires a ‘failure culture’ in academia and policy, in which failures are no longer avoided but actively encouraged. To learn how to turn failures into successes, we need to share and publish our failures, have early engagement with all stakeholders in the knowledge exchange process, and make more use of boundary spanners.

There are plenty of academic papers celebrating successes in knowledge exchange, but not many researchers and policy makers talk openly about their failures. But learning from failures is just as important, if not more crucial, than celebrating successes. Allowing partners to reflect in a safe space on knowledge exchange practices and research projects gone wrong, in which communication broke down, partners did not engage or dropped out, and evidence was not taken up or ignored, will provide important lessons on how knowledge exchange practices and research can be improved.

Paul Iske. Chief Failure Officer, speaking at the Fuse conference in 2022  

At the 5th Fuse Conference on Knowledge Exchange in Public Health in 2022, we created such a space in Newcastle by bringing together over 100 academic researchers, policy makers, practitioners, and community members to share and reflect on their failures and how to turn them into success. Don't miss the 6th conference in the US ! 

Our Special Issue: Learning from failures in knowledge exchange published this month in journal Evidence & Policy brings together selected papers from the conference and papers that were submitted in response to an open call afterwards. From 23 original submissions from 14 different countries (including the UK, USA, Canada, Norway, Switzerland, Kenya, Chile, South Korea, and Portugal) and from a range of disciplines and areas of focus (Public Health, Primary Care, Oral Health, Sociology, Anthropology, Public Management, Policy-Making, and Community and Voluntary Sector), we invited four research papers and three practice papers for full submissions.

This includes a paper from Fuse Associate Mandy Cheetham and her practice colleagues on the challenges of co-production. They reflect on the failed performance of a theatre play to mobilise the research findings of a qualitative study into the health and wellbeing effect of major social security reforms (Universal Credit) in the North East of England. They argue that academics fail to appreciate emotional engagement of stakeholders in knowledge exchange.

The point about emotional labour in knowledge exchange and research is further developed (and flipped) by Louise Warwick-Booth, Ruth Cross and James Woodall. They reflect on data generated from three evaluation studies across different Voluntary, Community and Social Enterprise (VCSE) interventions in the North of England. In their paper, they expose the conflict between the research teams and evaluation partners, structured around five key features of co-production to highlight the emotional costs and labour involved for researchers.

The seven papers highlight different ways of defining and conceptualising failures in knowledge exchange, ranging from mis-implementations, to setbacks, pitfalls, unproductive interactions between stakeholders, conflicts in co-production, and deviations from expected and desired results. Using different theories and frameworks, the papers in this special issue demonstrate that failures are complex problems, involving many actors at different levels across various organisations and networks. These organisations and networks are in turn influenced by a range of determinants, from workforce instability, leadership challenges, and lack of adequate funding to practical, everyday issues, such as logistical, technical, and buy-in considerations.

Each paper offers a different perspective on relational barriers and structural stressors contributing to failures, but all authors agree that failures offer opportunities for learning, particularly small failures. We tend to focus on large catastrophic failures, but small failures are often the early warning signs, which can help to avoid larger failure in the future. To support this learning, we need to talk more openly about failures and create a culture where talking about and sharing of failures is more accepted and, even better, actively encouraged. Therefore, we argue for more deliberate experimentation in organisations and partnerships to allow for failures that provide rich insight and learning. How can we fail more intelligently? And how do we create spaces and time for reflection on failures between evidence producers, brokers and users to share this learning and support them in turning failures into successes?


This blog post is based on the article, ‘Learning from failures in knowledge exchange and turning them into successes’, which introduces the Special Issue: ‘Learning from Failures in Knowledge Exchange’. Adapted with thanks to Evidence & Policy.

Authors

Peter van der Graaf is an Associate Professor in Public Health at Northumbria University and Research Manager of AskFuse - the responsive research and evaluation service run by Fuse. Peter is interested in the interface between research, practice and policy making and how this interface facilitates (or hinders) social improvement processes at local, regional, national and international levels. He conducts research on knowledge mobilisation in public health, with a focus on the wider determinants of health (e.g. housing, health landscapes, urban regeneration) and how they affect people’s health and wellbeing.

Amanda Purington Drake, PhD, is the Director of the ACT for Youth Center for Community Action at the Bronfenbrenner Center for Translational Research and a research collaborator with the Social Media Lab, both at Cornell University, USA. Amanda has a passion for using research and evaluation to help communities to promote and support the health and wellbeing of youth. Her work in the Bronfenbrenner Center has focused on promoting positive youth development, investigating non-suicidal self-injury in general populations of adolescents and young adults, and evaluating the effectiveness of large-scale adolescent sexual health initiatives. She has co-developed and evaluated interventions to develop youth social media literacy and to promote parent-teen communication about sexual health. Amanda works to bridge research and evaluation with practice and policymaking to prevent youth risk-behavior and promote healthy development.

Ien van de Goor (MSc, PhD) works as endowed professor and program leader in Public Health and Prevention at Tranzo, Faculty of Social and Behavioral sciences, Tilburg University, in the Netherlands. She has a background in health sciences with many years of research experience in evidence-informed public health. Central areas of interest are healthy behaviour in relation to the environment, poverty and vulnerable groups, and monitoring and public health policy.

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Fuse, the Centre for Translational Research in Public Health.

A new social contract for Public Health

By David Hunter, Newcastle University; Peter Littlejohns, King’s College London; Albert Weale, University College London; Jacqueline Johnson, public health and management consultant; and Toslima Khatun, King’s College London

Air pollution is widely recognised as a serious health hazard while Covid-19 shone a spotlight on the weaknesses of the UK’s public health system

The UK is in the grip of a public health crisis. With depressing regularity, new research shows the growing deterioration of the public’s health. Improvements in life expectancy have stalled, health inequalities have widened, obesity and alcohol misuse are placing an increasing strain on health services, and air pollution is now widely recognised as a serious health hazard. While Covid-19 shone a spotlight on the weaknesses of the UK’s public health system, they had existed for some time. Indeed, as Michael Marmot has argued, most of the deterioration in health stems from 2010 and the Coalition government’s austerity policy. This resulted in cuts to public spending with local government, which is responsible for public health, suffering some of the deepest.

Despite the wealth of evidence testifying to the parlous state of public health and with many studies offering solutions that are both cost-effective and for which there is robust evidence, there remain significant political and organisational barriers to the realisation of an effective public health system. Unless these are confronted, the chances of progress are slim.

A new social contract for public health

We support the case for a new social contract in which health policy is truly public. Public health policies are often criticised by those of a neoliberal persuasion for restricting individual choice and for ‘nanny statism’. We refer to this form of liberalism as ‘vulgar individualism’. Big government and state overreach are viewed as problems which stifle personal freedom and hinder private sector growth on which the economy depends.

In fact, a much bigger problem is state underreach and a failure to take up and apply policies and policy instruments that are known to be effective in order to improve health. But as long as governments continue to subscribe to the view that the health of individuals is a matter of personal responsibility then action of the kind needed will not be forthcoming. Over the past 13 years or so, successive governments have subscribed to this view ignoring all the evidence which demonstrates the flaw at the heart of such thinking, namely, a belief that that government is best which governs least.

In place of such a stunted political ideology we propose a new social contract for public health incorporating the principles of what might be termed ‘social individualism’, that is, a commitment to using the instruments of collective political authority to create the conditions for individual choice and fulfilment.

What are the elements of the new social contract for public health?

First, and importantly, a social contract for public health would focus on prevention, reflecting the significant body of evidence demonstrating how a wide range of public health measures would prevent more serious conditions developing. But while it is easy to state all this, as indeed numerous academics and analysts have done over many years, unless political leadership is in place to confront the challenges the prospect of change happening is slim.

A particular challenge is the tension arising from the urgent driving out the important. With an NHS under extreme pressure in respect of growing waiting lists and staff shortages, for electoral and other reasons, politicians are most likely to prioritise addressing these to the exclusion of longer-term public health measures. Yet, as the Hewitt Review of Integrated Care Systems points out, ‘we have mistaken NHS policy for healthcare policy’.

Second, a new social contract requires a precautionary state, paying attention not only to known hazards but also to remote and uncertain ones. If the pandemic taught us anything, it was the need to be prepared and have sufficient resources in place to enable swift and effective action to be taken. Sadly, for a government emerging from the debacle over Brexit and trapped in a mindset of short-termism with a focus on campaigning rather than governing, adopting a policy of precaution does not come naturally.

Third, social solidarity is required in the face of health inequalities. Social individualism recognises that policies for the most vulnerable are not policies for a particular group in society, but policies for all of us when in need. What is required from public policy is the support to resilience over the life cycle.

Fourth, a new social contract requires a different approach to government and governance. In particular, addressing the short-termism that pervades our politics has to be challenged and replaced by a more sober acknowledgement of how governments need to function. A populist politics that wishes away the need for planning and relies on easy, facile slogans to attain and retain office – ‘the unbearable lightness of politics’ as the historian, Tony Judt, put it – undercuts the seriousness that is needed for effective government.

Above all, a new social contract sees a central role for an active state. To this end, we set out a manifesto to frame the approach to public health that is needed in the hope that it might inform the political debate as preparations get underway for a general election due over the next year.

A manifesto

Much that needs to be done already exists and is supported by a sound evidence base as well as by the main UK public health bodies. The Hewitt Review’s plea for priority to be given to population health matched by new investment is also worth acting on. Some measures could be swiftly adopted by a new government if it so chose. Others will take longer but making a start by implementing what be done quickly would make most sense in tackling the crisis facing public health.

Above all, regardless of the particular topic demanding attention, at the heart of public health policy is the need to work in a cross-organisational and cross-sectoral way. This will not happen without strong political leadership, but to embed a cross-government commitment to public health requires new legislation to place a duty on all government departments to respect in their policies the claims of public health. To monitor how policy is taken forward and implemented, there is a strong case for making the publication of health impact statements obligatory.

If the winds of change blowing through the country offer a turning point in the public’s health, then the incoming government has no time to lose in seizing the opportunity.

For an extended discussion of the issues raised go to our new book: Littlejohns P, Hunter DJ, Weale A, Johnson J and Khatun T (2024) Making Health Public: A Manifesto for a New Social Contract. Bristol: Policy Press

Bristol University Press | Making Health Public - A Manifesto for a New Social Contract, By Peter Littlejohns, David J. Hunter, Albert Weale, Jacqueline Johnson and Toslima Khatun

Authors

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 Sciences, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

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

Jacqueline Johnson, pubic health and management consultant

Toslima Khatun, teaching fellow, King’s College London



References

The answer starts with austerity, The Guardian, 10 August

https://www.theguardian.com/commentisfree/2020/aug/10/england-worst-covid-figures-austerity-inequality

Hewitt P (2023) The Hewitt Review: An independent review of integrated care systems, GOV.UK https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf

Judt T (2010) Ill Fares the Land. Harmondsworth: Penguin Books 

https://www.penguin.co.uk/books/178939/ill-fares-the-land-by-judt-tony/9780718191412 

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Fuse, the Centre for Translational Research in Public Health.

Image:

Image by Jacques GAIMARD from Pixabay.

Energy drinks may be commercially lucrative but what is more valuable than the health of our children?

Posted by Amelia A Lake, Professor of Public Health Nutrition at Teesside University, and Shelina Visram, Senior Lecturer in Public Health at Newcastle University

As we prepared our new review on the health effects of the consumption of energy drinks by children and young people, we have been dwelling more and more on the Commercial Determinants of Health.

The Commercial Determinants of Health are defined by the World Health Organisation (WHO) as: 

“...the private sector activities that affect people’s health, directly or indirectly, positively or negatively.”

The WHO definition goes on to expand on how these activities might include the private sector influencing:

“...the social, physical and cultural environments through business actions and societal engagements; for example, supply chains, labour conditions, product design and packaging, research funding, lobbying, preference shaping and others.”

Now cast your mind back to pre-Covid… a Government consultation on the banning of energy drinks had a 93% backing to restrict the sale of these drinks to under 16s. There was even a Green Paper proposing this. Yet, there has been inaction (helpfully summarised here by Sustain: the alliance for better food and farming).

What is causing this inaction? Is it a turnaround in evidence that suggests these drinks are not as harmful as previously thought, or is there something else going on...? Perhaps, instead there are some pretty significant commercial interests at stake; but what could be more valuable than the health and wellbeing of our children and young people?

Energy Drinks are VERY commercially viable. They have been the fastest growing sector of the soft drink market for some time. In 2020 the global market was worth $45.80 billion and this is projected to grow at an annual rate of 8.2%. In an article in December 2023, The Grocer described the hydration drink and energy drink market as “buoyant”.

Research has found that around one in three young people (under 18) say that they regularly consume energy drinks, typically containing high levels of caffeine and sugar in combination with other ingredients known to have stimulant properties. On average, young people in the UK consume more energy drinks than those in other European countries.

You may be familiar with the labelling on energy drinks:

Image courtesy of www.parliament.uk (by URL)

‘‘High caffeine content. Not recommended for children or pregnant or breast-feeding women’’

Under current labelling rules, any drink, other than tea or coffee, that contains over 150mg of caffeine per litre requires this label and should state the amount of caffeine in milligrams per 100ml of the drink.

Yet why do we see these drinks unrestricted and available to children and young people, not just in the UK but globally? Some countries have attempted to regulate energy drinks (see our research for more on this).

Our new review of the global evidence around energy drinks and the health impacts on children and young people shows a worrying increase in the types of health outcomes associated with their consumption. This includes mental as well as physical health behaviours. Not only health impacts but wider impacts around sleep and educational attainment.

This new review is the latest of many which have highlighted the impacts of these products to our younger population.

We accept the evidence is from mostly cross-sectional studies, exploring association rather than causation. Experimental studies to establish causation have both ethical and feasibility issues. We have argued before that the precautionary principle should be applied. This country bans the sale of a number of items to young people (fireworks, crossbows, knives) presumably these don’t have the large commercial interests or lobbying groups that the energy drink industry has?

Why are we applying a higher standard of evidence to energy drinks, if it isn’t around their commercial value?

The evidence is here, the labels clearly say these drinks are not suitable for children. How many more studies are needed before policy action is enacted?

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Fuse Podcast about this Energy Drinks research

Listen to the latest episode of the Fuse podcast ‘Public Health Research and Me’, in which host and Fuse Public Partner Cheryl Blake chats with Amelia and Shelina about their research, to cut through the confusion and ask some the questions that you want to know about Energy Drinks.
> Listen now

Find out more

• News item on the latest research
• Research paper in full
• Research brief (2-page summary)
• Timeline of Fuse energy drink research activity and impact
• Original review in 2016

Images:

2. Courtesy of www.parliament.uk (by URL) > Parliamentary business > Publications & records > Energy drinks and children > 4 Labelling and advertising: 

https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/821/82107.htm#_idTextAnchor031

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

Using board games to increase inclusion in research - a trivial pursuit?

Posted by Lesley Haley, AskFuse Research Associate, Teesside University 

Did you play any board games over the holidays? As we scrabble into 2024, have you ever thought about how they could be used as a way to engage people in your research?

I hadn’t, until I went to a recent Creative Methods in Research conference, where Kath Maguire (University of Exeter/NIHR School for Public Health Research) showcased how using board games in research was anything but trivial! Kath demonstrated the concept of using board games in public involvement and engagement can increase participation by reaching people less comfortable with standard formats of engagement or data collection, such as interviews or questionnaires.

Kath brought examples, like a “pairs” game used with public partners to break down barriers of understanding around the jargon used in research. Pairing research jargon, concepts or acronyms (‘randomised control’, ‘double blinded’, ‘SPHR’, ‘NIHR’ for example) with their plain English explanations allowed all participants to probe the underlying assumptions and constructs, and perhaps to reduce the power imbalance between the knowledge giver (usually researchers) with the knowledge receiver (usually public partners). And of course this game can be used to redress that balance by public partners sharing their knowledge with researchers.

However, the most surprising game that Kath has used in increasing involvement was the repurposing of that classic multicultural game, Snakes and Ladders.

While AskFuse (the responsive research and evaluation service run by Fuse) created the pictured Snakes and Ladders game as an interactive way to explore successes (Ladders) and setbacks (Snakes) of getting research knowledge used in practice, Kath has taken the game to a whole new level.

Kath has a wealth of experience in using board games as a creative method of inclusion to reach people less comfortable with more literacy-based research methods. They bring a blank paper board and a variety of stick-on snakes and ladders as a visual prompt to generate discussion and reflection using the metaphor of the game to explore a range of experiences. The aim is not necessarily to play the game, but to use the building of a bespoke “game” to reflect and “illustrate” narratives and experiences.

Participating in Kath’s interactive workshop was, for me, a real game changer. We explored how using snakes and ladders enabled discussion, reflection and inclusion. We could design our own individual game to tell our story, or do it collaboratively. We used the game layout as a metaphor for exploring changes through time or to illustrate a “journey” (for example, exploring access or barriers to health services). It allowed us to describe and reflect on different pathways or starting points. Being a physical representation of our narrative meant that, at times, “gaps” emerged which led to questions around “what was happening here?” and “what are we missing?” The grid could also used to reflect emotional journeys in response to a given (research) question or situation. We explored how focussing on a game allowed for different viewpoints to emerge and for less vocally confident people to engage without having to “carry” a conversation or justify their experience. The game squares could be filled with comments, contributing factors, and ideas. We reflected that the snakes and ladders could be reconfigured for creative re-imagining of time/place/situations - “what would happen if we did this”? And of course the complexities of the research process can be illustrated through the metaphor of Snakes and Ladders.

At the end of the session, there was a tangible product and graphic representation of the research question, the process and the outcomes of the exploration. We reflected that over several sessions, the game would perhaps change and this progress could be captured in photos. The “game” could also then be used creatively to disseminate the research (Coon et al 2022).

We also explored the risk that a gaming method for engagement or data collection, especially in the “Snakes & Ladders” format, could be seen by some people as trivialising the serious business of research, as in the UK it is perceived as a child’s game. However the game is not all it appears. Originally known in “Moksha Patamu”, it was a philosophical game of actions and consequences for adults developed in ancient India (Museum of Gaming 2015). Over time and locality, the game has evolved into other versions, with snakes transformed into “drainpipes” or “chutes (Start the Week 2023). So the game has a tradition of being adapted and re-purposed and perhaps we should not be shy of re-purposing it to make research more accessible?

Since Kath’s workshop, I’ve had a quick look around to see if there are other researchers using gaming. While there is literature on using board games in health education and promotion (Nakao 2019) and public health policy (Spitters 2018) there seems less on the use of board games in public involvement and engagement in health.

Of course, snakes and ladders doesn’t have the monopoly on being the only board game that can be used. So, do you use board games in your research to engage with people and communities? What's been your experience of what works for who? How do you pitch it? What have you found the setbacks and successes of using board games as a creative way of engaging people and communities?

As you scrabble to fit all the board games back into the cupboard after Christmas, maybe it’s time to reflect that participatory board games in research could be for the rest of the year too, not just for Christmas.

With thanks to Kath Maguire for the interactive workshop and to SPHR for funding attendance at the conference.



References:

Coon, J.T., Orr, N., Shaw, L. et al. (2022) Bursting out of our bubble: using creative techniques to communicate within the systematic review process and beyond. Syst Rev 11, 56 https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-022-01935-2

Kath’s work:

Museum of Gaming Newsletter (2015) Issue 2 Snakes and Ladders History. Accessed 2 Jan 2024 Available at: https://www.museumofgaming.org.uk/documents/Newsletter2.pdf https://www.museumofgaming.org.uk/index.cfm

Nakao M (2019) Effects of board games on health education and promotion” board games as a promising tool for health promotion: a review of recent literature BioPsychoSocial Medicine (2019) 13:5 https://doi.org/10.1186/s13030-019-0146-3

Spitters H.P.E.M , van de Goor L.A.M, Juel Lau C, Sandu P , Eklund Karlsson L , Jansen J, van Oers J.A.M (2018) Learning from games: stakeholders’ experiences involved in local health policy Journal of Public Health | Vol. 40, Supplement 1, pp. i39–i49 | doi:10.1093/pubmed/fdx149 https://academic.oup.com/jpubhealth/article/40/suppl_1/i39/4925598

Start the Week: Playing Games (2023) BBC Radio 4 Monday 4th December 2023 09.00 Available at: https://www.bbc.co.uk/sounds/play/m001t2xq?partner=uk.co.bbc&origin=share-mobile (Accessed 8 Dec 2023)

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!)

Pulling the PINS on takeaways

Creating healthier food environments through the planning system

Posted by Callum Bradford and Claire O'Malley, Research Associates, Teesside University

Obesity continues to be significant health and social problem, especially due to its links with cardiovascular disease, diabetes, and certain cancers. One potential solution is to change our environment so we are better equipped to make healthier food choices, however, as you can imagine, this is easier said than done!

A tool that can be used to help shape the environment with help from Local Authorities is the Planning System. Many of our towns and cities are full of hot food takeaway outlets and unless you are made of stone (or perhaps a public health researcher?), there will come a day when your motivation is low and you don’t have time to cook a meal, making the local takeaway feel like the obvious solution. But, if we can limit the number of takeaways and improve access to healthier food, we can encourage individuals to make healthier choices.

Research has shown that just over half of Local Authorities in England use the planning system to limit the number of hot food takeaways in their area, with 34% doing so with public health in mind. The most well-known example of this policy is setting a minimum distance a new takeaway must be from local schools, usually set at 400-800m away.

However, when a newly proposed takeaway is rejected, the owner has the right to appeal the decision. This appeal moves the decision from the Local Authority to the Planning Inspectorate (PINS) on behalf of the Secretary of State.

Our research looked at the ins-and-outs of this process. Specifically:

• What are the influences behind a decision by the Planning Inspectorate?
• How is the Planning Inspectorate perceived by professionals involved in the process?
• What barriers do Local Authorities need to overcome to win a case?
• What factors make for a better chance of success?

To explore this, we spoke to local planners and public health professionals, including the Planning Inspectorate to get a greater insight into the process.

The main findings from our interviews were that:

1. there was a discrepancy between what public health professionals, planners and the Planning Inspectorate considered to be public health evidence; and
2. how public health professionals countered this with their enthusiasm to try and shape healthier environments.

The Planning Inspectorate was viewed by all as fair and neutral. However, public health professionals believed they had to go out of their way to ‘state the obvious’, in that new takeaway outlets would likely be harmful to local health. Conversely, planners and the PINS were keen to point out that public health is just one small aspect of planning policy.

“I think there seems to be an expectation from the public health side of things that planning will provide policy…like restricting take-aways will be the end of it from a health point of view, and of course planning is not actually designed to do that.”    

Planning Officer

This perceived constraint that health-based evidence was not given enough weight in decisions was offset by the enthusiasm of public health professionals to limit hot food takeaways in their area. They were often very proactive in defending appeal cases, stressing the importance of communication across a Local Authority, finding robust statistical evidence (as opposed to ‘anecdotal qualitative evidence’), and having good knowledge of their local area. Having this information in a Local Authority’s Local Plan (this guides decisions on future development proposals and addresses the needs and opportunities of the area) supported this activity and removed the need for re-researching the area for each application.

“It's all well and good having the policy but it needs the evidence as well to back it up. So, having access to the public health team and the public health evidence is a really, really relevant part of the appeals process” 

Public Health Professional

Planning policy can be used to successfully limit the number of takeaways within a local area. However, if such policies are to be used reliably to prevent their spread in our towns, public health professionals need adequate support to defend appeals, and planning needs to give greater consideration to public health evidence.

Read the research paper here: Regulatory mechanisms to create healthier environments: planning appeals and hot food takeaways in England

How to choreograph a dance between policy makers and academic researchers?

Posted by Peter van der Graaf, Associate Professor in Public Health at Northumbria University and AskFuse Research Manager

Dancing is a key move in public health, particularly if you want to make an impact with your research. Knowledge exchange is not just a science or even an art, but very much a dance between researchers and policy makers about the use of research evidence. To complete this dance successfully and get evidence used in decision making, both partners need to follow certain steps. However, learning the steps (science) or performing them perfectly (art) is not sufficient: it requires instinct and feel for where you are in the dance and why you are doing it.

To develop a dance plan for your interactions between policy makers and academic researchers, Fuse hosted a special session (or dance class) at the European Implementation Event in Basel, Switzerland on 8 June. The EIE2023 brought together over 300 implementation scientists, practitioners and funders from across health, social welfare, education and other sectors in Europe. Over two days through fishbowls, science slams, workshops, inspiring keynotes and oral presentations, participants explored how to create a new normal for implementation science in society.

Our session explored dance challenges (e.g. moving too slow, bad timing, outfit malfunctions, and unsynchronised performances) and new routines in response (see: ‘What did we learn?’ below) that we have developed in Fuse over the last 15 years collaboratively with our partners. In the session, we highlighted examples of creative communication (the art of knowledge exchange), research performance both backstage and frontstage (AskFuse), and dancing together (embedded research) to set the scene for a discussion about what makes a successful dance between policy makers, health practitioners and academic researchers. We invited conference participants to share their own reflections of dance routines they have developed to support knowledge exchange and implementation of research evidence in practice and policy making.

What did we learn? 10 dance lessons

Fuse knowledge exchange model

1. Academic researchers need to learn four basic steps for dancing with policy makers (see the Fuse knowledge exchange model):

• Raising awareness, using creative communication.
• Knowledge sharing through joint events.
• Making evidence fit for purpose (localising and tailoring).
• Supporting uptake and implementation (e.g., capacity, co-production, linking activities).

2. A deviant knowledge broker can help to facilitate backstage conversation and protect policy makers and academic researchers from missteps.

3. Go with the music: as the context and process in which evidence is useful changes constantly, it is an important skill for researchers to be able “to go with the music” based on ongoing relationships with policy and practice partners.

4. Emotional engagement between researchers and policy makers is essential to get a better feel for the music. A heart-to-heart or moaning about bad performances helps you to improve dance routines and hide missteps. Don’t forget the power of cookies!

5. Embedded research helps to develop an instinct for the dance, based on a better understanding of each other’s organisational contexts. Embedded research allows you to be part of solutions, developed with the communities affected, not just report on the effect on interventions and their implementations.

6. Public health is political; lobbying and advocacy are a core part of the embedded research roles.

Choreographing your own dance routine

We presented participants with the following questions to help develop their own dance routines: 

In response, conference participants started to develop their own dance metaphors for describing their experiences with collaborative research between academics and policymakers. Someone referred to their routines as a ‘silent disco’, where academics and policymakers were dancing to different pieces of music without knowing what the other where listening too. Other participants emphasised the need to spend time together first before you start picking music, to get a better understanding of each other’s musical tastes (classical meets punk?).

Overall, participants felt inspired to start to think more deeply about their own dance plans. How would you answer the above questions and what would your dance plan look like? 

Full house at the #EIE2023 @fuse_online Special Session! @pvandergraaf75 and Mandy Cheetham choreographing a dance between policymakers and researchers. Creative communication at it’s best! 💃🏽🕺🏼 pic.twitter.com/7ej4Kr29LG

— Leah Bührmann (@LeahBuehrmann) June 8, 2023