Holidays!

Is it holidays yet? Oh thank goodness.

The blog has spent the last few weeks hanging on to every scrap of work-related motivation it can find for dear life. It seems like everyone apart from the blog is on holiday. Facebook is full of holiday snaps. Twitter is packed with advice from Public Health England on how to cope with hot weather. But the blog has been diligently heading into work every day, ploughing through the to-do list, keeping the in-box under control.

But now it's holiday time!

The blog has a couple of friends who've rented a flat near Chamonix for the summer and the blog's off to join them for a month of rock, glaciers, ropes, crampons, snow in summer, and painstaking deciphering of French weather forecasts.

See you in September.

Photo by Matthieu Lienart

52 weeks in public health research: part 30

Posted by Amelia Lake, Martin White and Jean Adams

From Amelia Lake: My messy desk as I try to analyse data from our NIHR food environment project. Some tidying required!

From Martin White: I recently stayed at the Royal College of General Practitioners where the NIHR Public Health Research Funding Board held its June meeting. It has rather swanky hotel accommodation with well appointed meeting rooms, but what I liked most was the sympathetic architectural treatment, bringing together old and new, with light and airy atria and retention of period details. So much nicer than a drab hotel chain - indeed positively uplifting. I wonder if it affected our decisions? Now there's a study that needs doing...

From Martin White: The most recent Fuse Quarterly Research Meeting was held at the National Glass Centre, which is now owned and managed by Sunderland University. Offering a range of exhibits on the history of glass and examples of glass as art, the centre also boasts some excellent meeting rooms and a huge and airy café/restaurant - with glass on three sides (yes, more great architecture). This photo shows an exhibit in a show case on a galleried walkaway above the café. Outside the huge windows the river Wear is reflected in a curved mirror backdrop. I think we'll be using this venue again...

From Jean Adams: Arty shot of my academic gown and hood. There are a few tasks that academics are required to do that took my a little by surprise. One was that we 'must' take part in the academic processions that occur at all graduation ceremonies. There are about 20 academics at each ceremony, so if everyone is nice and takes their turn, each person only has to do this once every couple of years. The first few times I was bored. This year I attended one of the MBBS congregations. A few of my tutees and other students who have worked with me were graduating. Sir Paul Nurse was awarded an honorary doctorate and gave a great acceptance speech. His advice to the new graduates: don't loose your curiosity, your passion, or your sense of humour. The university's chancellor, Sir Liam Donaldson, spoke about the advances in medicine (nicely expressed in epidemiological terms), he has seen in his career and encouraged the graduates to go forth and advance the field some more. It turned out to be an uplifting 90 minutes away from my desk to reflect on why we do science, medicine, and teaching and how to keep doing it well.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

52 weeks in public health research: part 29

Posted by Jemma Hawkins, Jenni Remnant, Shelina Visram and Emily Henderson

From Jemma Hawkins (photo credit: Natalie Richards): When compiling the promotional material for a seminar we are organising on 'Tackling Workplace Sedentary Behaviour' we decided that it would be better to create our own image rather than using a stock one. One quick tidy of a colleague's stand-up desk, another colleague's smartphone and me as 'model' donning the famous DECIPHer t-shirt and hey presto!

From Jenni Remnant: Sat down to eat at a Knowledge Exchange conference last week run by the LSE and this was on the table.

From Shelina Visram: This picture was taken in County Durham after a meeting to discuss a pilot project on supporting lifestyle changes amongst people newly diagnosed with a chronic condition. I recently ran some focus groups in the community centre across the road, which required several telephone conversations with a local caterer about what I meant by a ‘healthy buffet lunch’. Thankfully their salad did not contain lard.

From Emily Henderson: It *might* have been said once or twice in the history books that academics are *sometimes* overworked and underpaid, but there are definite benefits. In June I had the pleasure of attending the EvaluatingComplex Public Health Interventions short course at DECIPHer. We were off the leash in the evenings, and I got very lucky with the weather! An evening picnic in Sofia Gardens along the river Taff, Cardiff, Wales. With the latest addition of 'The Lady' mag, white wine and cheeses.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Knowledge exchange

Posted by Jenni Remnant

Last week I went to a residential in Birmingham run by the London School of Economics. The theme for discussion and workshops was ‘Knowledge Exchange (KE) and Impact’, and had a focus based in social care and social work.

In terms of public health, impact is arguably a necessity and not something to tap on a grant proposal as an add-on. I would suggest that there is no point to public health research if the health of the public is not impacted upon (positively).

So as part of this residential we discussed stakeholder focus groups, partner organisations and dissemination. We discussed REF, academic and policy impact.

We discussed all the snazzy ways to tart up our findings and pitch them to people in an accessible way. These included videos, infographics, twitter and blogs amongst other things. We also learnt how to engage with journalists and the press.

And then on the last day, we learnt about the #JusticeForLB campaign – an incredible shout of anger that grew and was cultivated through Twitter. The campaign, started by the Mother of a young dude called Connor Sparrowhawk, has gained amazing momentum – and for me, personally, is many of the things KE and impact should be.

For a start – it was born from a real issue, as identified by people involved in the real issue.

Connor Sparrowhawk was in a specialist unit called Slade House, an NHS assessment and treatment unit in Oxfordshire. He had autism and epilepsy. Connor was in the unit for 107 days before he died by drowning in one of the baths. The cause of death was initially recorded as ‘natural causes’.

Secondly – the real issue was focused within and around the people it directly affected, and may directly affect in the future. The academics that did become involved in this became involved because it was clear something needed to change, and they cared.

Thirdly – it had, and has, impact: immediate tangible impact; demand from the Sparrowhawk family and support from the campaign meant that the death was subsequently found to be preventable, the unit has been closed down and there has been an inquest.

Finally – this campaign reached out; there were blogs, activities, sponsorships and endless tweeting.

Totally amazing and inspiring.

This might seem really far removed from what we do as researchers, but there is a pattern there that is not so different from what we do;

1) Identify an issue that needs further scrutiny
2) Scrutinise it.
3) Work out what it means, or what the implications are, and then
4) Work out recommendations to go forward with

The reason the #JusticeForLB campaign did such a spectacular job in doing this is in part, I think, due to the lack of any academic-type goals and limitations placed around it. REF was unimportant; impact ratings, finding a niche and career progression were not foregrounded. There was no traditional model to adhere to.

I’m aware that this story has a strong narrative, with irrefutable social justice at the heart of it that may capture interest in a way that some public health doesn’t – but it doesn’t (or shouldn’t) hurt to occasionally think outside the box with research. Even if that box is in another box.

It would be cool to see more research instigated by, committed to and partnered with the people affected by whatever the issue it is. It seems a bit counterproductive to take an issue, decontextualize it through research, and then struggle to communicate the findings back to the ‘stakeholders’ at a later date. Especially if we are then going to lament how people haven’t enacted the lifestyle/policy/ [insert other] change advised in the research.

As useless as ever, I don’t really know how to implement changes that involve remodelling the academic research model – but the residential was definitely an excellent place to broaden the horizon.

I do hope to organise an unconference in the not so distant future though, as a start…so watch this space I guess!

Definitely check #JusticeForLB out on twitter if you get the chance, and spend just over 4 minutes looking at their animation – gifted by an illustrator as part of the campaign – it’s exquisite.

52 weeks in public health research, part 28

Posted by Catt Turney, Bronia Arnott and Jean Adams

From Catt Turney: I've been thinking a lot recently about the role of place, space and environment in public health, and thought this smoking area at Paddington station was a nice example of a very simple space-related intervention. It's effectively a little cage around some chairs - the sign reads 'Smoking is only permitted in the area designated by barriers around this notice'. The station was busy but this area was completely deserted - a sign it's failing, or working as intended?

From Bronia Arnott: At Newcastle central train station to travel to Leeds for the UKCRC Public Health Research: Centres of Excellence Conference a couple of weeks ago to talk about developing interventions to promote active travel.

 

From Bronia Arnott: Being a parent can make you feel as if you are part of a government experiment that you never consented to at times. This week my daughter brought home this leaflet from school advertising the collaboration between Disney and Change4Life which you can read more about here. The idea is that by working together they will encourage children to increase their physical activity during the school summer holidays. As a developmental health psychologist I can't help but wonder if this intervention is being evaluated?

From Jean Adams: despite my Coke-marketing photo-obsession, my soft-drink of choice is in fact Diet Coke. So this can of Diet Pepsi was a novelty. Sometimes I wonder if people who put their name and face to junk food marketing campaigns think about the implications at all. Maybe Messi thought this was okay because it was Diet Pepsi and not the real thing (which I can understand, but might argue with). Or maybe he didn't think about it at all - it was just another photo shoot that his agent arranged for him.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Fuse duck flies into the University of Northumbria

Posted by Barbara Harrington

Fuse Duck arrived at Northumbria University on 30th May for a few weeks with me, Barbara Harrington, a researcher and lecturer in public health and patient safety. He quickly settled in having a cup of tea with his new friend, Stress Penguin from Redcar. Stress Penguin was liberated from Redcar whilst doing some interviews around Healthwatch, looking at the role of the new patient and public involvement organisations in the North East.

By Tuesday 3rd June and a lot of switching between PDFs, Excel Files, SPSS and SurveyMonkey for a Delphi project, something stronger than tea was called for. Fortunately Lesley Geddes (in the background), a principal lecturer with a particular interest in health promotion, behaviour change, and social marketing for health, was on hand to provide corrective public health messages about responsible drinking.

On Wednesday, 4th June, Fuse Duck joined in the celebrations when copies of Reforming Healthcare appeared written by Profs Ian Greener, David J Hunter, Russell Mannion, Martin Powell - and me! This is a major critical overview of the research published on healthcare reform in England from 1990 onwards. As you can see, Fuse Duck is riveted, considering the implications of this research for current debates about healthcare reorganisation in England.

Also on Wednesday, Fuse Duck attended our theory discussion seminar - the highlight of the month for many research staff, PhD students and other academics months. Here, staff from different disciplines within the faculty read and discuss some of the key theoretical texts from the social sciences. The seminars are led by Mick Hill, Robbie Duschinky, and Ian Robson. So far we have looked at chapters from Foucault’s Psychiatric Power lecture series, and Bourdieu’s Misrecognition and Symbolic Violence. These are always well led and interesting, discussing theory in relation to the times they were written and how relevant they continue to be. 

In June, we discussed Goffman’s Presentation of Self – Chapter 1. As usual the discussion was wide ranging including references to Hamlet, as well as presentation of self in relation to higher education teaching and health, social work, and education practice. With Fuse Duck attending, there was also a discussion about whether he had inadvertently disrupted the expected setting and consequently the personal fronts people displayed in this seminar. It was in fact a very apt seminar for Fuse Duck to attend. Here he is Ian Watson and me getting to grips with some of the finer points of Goffman.

52 weeks in public health research, part 27

Posted by Catt Turney, Amelia Lake and Bronia Arnott

From Catt Turney: Being in an office when the weather is glorious can be a bit grotty. Luckily, the healthy-snack opportunities posed by summer almost make up for having to be inside rather than frolicking in the sunshine.

From Catt Turney: We recently had an unofficial DECIPHer social climbing Pen y Fan, a little mountain in South Wales. This greeted us at the end - apparently, even up a mountain, you can't get away from the idea that it's only a fun day out if there's junk food or alcohol.

From Amelia Lake: my pass from my first high level steering group meeting for the food responsibility deal - watching policy in practice & the negotiations & complications of food policy.

From Bronia Arnott: I was at the Sage Gateshead with my daughter for a performance called "At the Seaside". It was aimed at young children and parents and involved singing and dancing along to seaside-related songs. I was very impressed that they even made up a song about the importance of sun protection! Hopefully the catchy, repetitive, action song meant that at least some of the children went home remembering the importance of 'slip, slop, slap, seek, slide' - slipping on a t-shirt, slopping on some suncream, slapping on a hat, seeking shade or shelter, and sliding on some sunnies! 

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Social policy and public finance: Are possibilities for health equity shrinking?

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

With the publication of Thomas Piketty’s massive book Capital in the Twenty-First Century, the acceleration of economic inequality has belatedly begun to receive the attention it deserves. His is, in fact, just one of several indispensable recent treatments of the topic. Another, which has received less publicity, is Hard Times: The Divisive Toll of the Economic Slump, by Guardian editorial writer Tom Clark and sociologist Anthony Heath – a meticulously researched treatment of how the recession has affected the United States and the United Kingdom. Readers too impatient to read Capital’s elegantly written 655 pages can find a highly condensed summary of much of Piketty’s work in the 23 May 2014 issue of Science. The summary is especially valuable for a conclusion that comes through more emphatically than it does in the book: ‘Inequality does not follow a deterministic process. …. There are powerful forces pushing alternately in the direction of rising or shrinking inequality. Which one dominates depends on the institutions and policies that societies choose to adopt’.

This is not new to those of us concerned with the social determinants of health; consider the WHO Commission on the topic and its focus on ‘the inequitable distribution of power, money, and resources’. Against this background, what are we to think of a new report on The Condition of Britain from the Institute for Public Policy Research? Since it was released in the same week as initial findings from the Project on Social Exclusion indicating that the proportion of British households living with multiple forms of material deprivation has doubled in the past three decades, one might have expected recommendations for a frontal assault on the elements of economic inequality that are most destructive of health to be the centrepiece of the IPPR report.

Not so. Instead, we get prescriptions for a ‘richer version of equality [that] is more complex than one focused purely on the distribution of material resources’ (p. 16) and the priceless statement that: ‘Like many other countries, Britain has experienced an unwinding of the postwar compression of market inequalities, and its tax and benefit system has had to work increasingly hard to reduce disparities in wealth and income. Fiscal constraints will limit the scope for post-tax redistribution in the years ahead, while tendencies towards greater wealth inequality may intensify (Piketty, 2014)’. This goes on for almost three hundred pages.



Crisis, what crisis?

In a jurisdiction that taxes huge incomes and accumulations of wealth as lightly as the United Kingdom, talk of fiscal constraints and the limited scope for post-tax redistribution is, to put it politely, nonsense. I prefer a stronger term, but Fuse probably doesn’t. The imperative of eliminating the deficit cannot be ignored, but as George Monbiot recently pointed out, on the revenue side the options include financial transactions taxes, wealth taxes and ‘a progressively banded council tax’. The most straightforward option is a return to much higher marginal tax rates on the personal incomes of the ultra-wealthy, which were the norm in many countries until quite recently. Thomas Piketty and his long-time collaborator Emmanuel Saez have themselves suggested this. (All these observations are also relevant to the proliferation of nonsense about the crisis of financial sustainability supposedly facing the NHS, now being regurgitated even by people who should know better.) On the expenditure side, massive welfare programmes for the propertied and the arms traders like HS2 and Trident replacement could be rethought.  

None of this would matter much – the IPPR report could be dismissed as an uninformed and unfortunate reprise of the discredited Third Way – except that the report apparently will shape much of the Labour Party’s agenda for 2015, and if elected thereafter. In other words, it represents the current limit of permissible official discourse, what one might call the frontier of political possibility for reducing inequality, and the message is clear: too bad, it can’t be done.

A week is a long time in politics, and the location of the frontier could change – not least in response to spirited advocacy for considering public finance and its equity implications as a public health issue. In the absence of such change, Johan Mackenbach’s gloomy 2010 conclusion that ‘reducing health inequalities is currently beyond our means’ will turn out to have been spot-on. We must be very clear, in private and in public, about the implications: the best that can be hoped for is a reduction in the pace at which health inequalities are growing, and even that is uncertain. Harsh words, but the times demand them. To quote Bob Dylan, ‘let us not talk falsely now, because the hour is getting late’.

All views expressed are exclusively those of the author.

52 weeks in public health research, part 26

Posted by Lynne Forrest and Jean Adams

So, week 26. That's half way. We haven't missed a week and there's been a full complement of four pictures each and every week. People, we are doing great. Only 26 weeks to go!

From Lynne Forrest: this is my family Saturday food shopping. I think it demonstrates the current confusion around healthy eating perfectly. The trolley contains fruit and muesli (good), fruit juice (used to be good but now the sugar is a concern), butter and cheese (used to be bad but fat is now potentially rehabilitated), as well as crisps, biscuits and pizza (definitely bad, and I'm clearly letting the public health side down here, but as they're from Marks and Spencer it's good quality bad food – does that make it any better?!)

From Jean Adams: My great uncle died recently. Although I'd never met him, I found myself tasked with finding his birth certificate in order to register his death. After looking absolutely everywhere else in his flat for it, I final flung open the kitchen cupboards in despair thinking maybe there was a secret stash of important documents under the bread. This is what greeted me: Morrison's saver's tinned soup, mushy peas, custard and fruit. I wasn't quite sure whether to laugh or cry. I finally found the birth certificate in a shared cupboard in the hallway of his apartment building.

From Jean Adams: Yeah, I didn't really find this funny. Yeah, I get that it's hilarious that 'pushy health types' like me don't even have a sense of humour. Yeah, I enjoyed a bag of crisps on the train with a cup of tea - what of it?

From Jean Adams: this supermarket convenience store isn't near a school. But this is some pretty heavy store-front alcohol marketing I'd say.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Alcohol marketing at the school gates?

Posted by Mark McGivern, Specialty Registrar in Public Health, Balance

[Editor's note: this post describes a piece of work conducted by Mark and Balance. Just for the avoidance of doubt, we thought we should point out it hasn't been formally peer reviewed.]

I’m a reluctant supermarket shopper at the best of times. If possible we try and do most of our shopping online or using local shops or the market (at least, that’s my excuse for not having noticed the scale of alcohol displays in our supermarkets).

However, in the first week of working at Balance, the North East Alcohol Office, a colleague came back from a lunchtime visit to a supermarket, somewhat vexed at the labyrinth of alcohol displays they had walked through in the store.

This sparked an idea for a piece of work studying the promotion and provision of alcohol by our supermarkets, which we hope to publish in the near future.

The Government’s public health responsibility deal (PHRD) is a partnership between government, industry, academic and voluntary sector experts aimed at developing voluntary agreements to address specific public health objectives.

Within the PHRD, the five largest supermarkets (‘Top 5’- Tesco, Asda, Sainsbury’s, Morrisons. Co-Op) have made a series of pledges regarding alcohol, which including the following:

A6. We commit to further action on advertising and marketing, namely…. not putting alcohol adverts on outdoor poster sites within 100m of schools…..
There could obviously be some debate as to whether a self-imposed exclusion zone of 100m constitutes a responsible attitude towards alcohol promotion by supermarkets. In theory, I suppose it shows intent at the very least, but does it go far enough? If you take the guidance on planning applications for takeaways which recommends an exclusion zone from schools of 400m, then the alcohol advertising exclusion zone pales into insignificance by comparison.

Making this pledge is all very well, but there was also no mention of whether the Top 5 applied the same standards to their own store-front advertising as part of the pledge. I wanted to see whether it would be possible to demonstrate compliance with this pledge by visiting stores throughout the North East to look at the extent to which the Top 5 stuck to their pledging guns.

To look into this 100m exclusion zone further, I visited a number of stores across the region and, as part of the wider study, assessed the Top 5’s compliance with this pledge.

The 378 postcodes of the stores of the 5 major supermarket retailers were entered into a GIS system and mapped against all primary and secondary schools to identify those that were within 100m of a school. Initially, 18 primary schools and two secondary schools were identified as potentially being within 100m of a supermarket. This was narrowed down to 10, once inaccuracies in the postcode address file were accounted for.

So, ten stores were identified as being within 100m of schools. After visiting these, it became clear that a number appeared to be contravening the alcohol pledge. Three had on-site, outdoor alcohol advertisements. Another had an alcohol advert in a window that was intended to be visible outside.

Examples of storefront alcohol advertising within 100m of a school premises in the North East of England

Clearly, as with all advertising, there is a seasonal aspect to take into consideration. At the time of carrying out the research, it was close to Mother’s Day. Whilst most of the adverts related to non-alcohol related gifts & seasonal products, there were also a number of adverts promoting wine. For those with good eyesight, I should stress that I am not suggesting fabric softener is an appropriate mother’s day gift!

Perhaps, if the same stores were revisited now, during the World Cup, the likelihood of there being more adverts associated with alcohol consumption would be much higher too.

This research has highlighted that there may still be some way for the Top 5 (and retailers and manufacturers more broadly) to go when it comes to taking the Public Health Responsibility Deal seriously. After all, a pledge means nothing if it isn’t seen through. And if it isn’t seen through, then people lose confidence in it.

There have also been a number of other examples of alcohol advertising in the North East that wouldn’t meet with the responsibility deal pledges, like advertising alcohol at school bus stops for example.

Examples of alcohol advertising within 100m of a school premises in the North East of England

There is a body of evidence that suggests exposure of children and young people to alcohol advertising increases initiation of drinking and also encourages heavier drinking among existing drinkers. 

Advertising in such close proximity to schools is something that most major producers and retailers have committed not to do, but this limited investigation has shown otherwise.

These are unlikely to be isolated examples and we’d like to try and compile some more examples from across the North East, and beyond. We know elsewhere in the country there have been successful objections to such practises. Next time you take your kids to school, if you see any alcohol advertising at the school gates, please send us a picture with details of the location to: info@balancenortheast.co.uk or tweet it to @BalanceNE.

The debate about appropriate restrictions & guidelines on alcohol advertising will continue. However, if we don’t highlight the apparent lack of compliance by the retail and manufacturing sector with their current pledges, it may be assumed that the current controls are not only being observed, but are enough. By demonstrating that this isn’t the case and taking a stand on alcohol advertising, we can take a small, but significant step in the right direction.

52 weeks in public health research, part 25

Posted by Becki Langford, Micky Wilmott and Jean Adams

From Becki Langford and Micky Wilmott: There's been a lot of debate recently in the news about the potential benefits and harms e-cigarettes. While they may be able to help people give up smoking, do they renormalise smoking? Here are two photos we snapped in Cardiff and Derbyshire of shops marketing e-cigarettes

From Jean Adams: I went on a little jaunt to Manchester a few weeks ago for a meeting of the Executive Committee of the UK Society of Behavioural Medicine (I'm secretary). A series of unfortunate events meant I missed my train and so spent longer than anticipated standing on the platform hoping the next train might somehow be early. In case you've ever wondered, this is the New Castle in Newcastle. The trains go 'round it, not through it - although through would be pretty cool.

From Jean Adams: Newcastle-Manchester, via York for coffee and toilet stop. This is the window on the ceiling of the Ladies at York station. It's a photo of the stunning York Minister. But why in a window frame, on the ceiling?

From Jean Adams: and this is the reason I was late for my train in the first place. No, not taking this picture (took it on the way home). The bike racks at Newcastle Station have been moved a few times over the last few years. Their final resting place seems to be here - right at the furthest reaches of one of the non-east coast mainline platforms, miles from anywhere. Every single time I have to traipse down there I want to scream at someone about how important bikes are and how we need to make them welcome, not hide them in the furthest corner we can find. Obviously I know this is where the bike racks are and how long it takes to get to and from them. I just have a mental block on taking this into account in my journey planning

Weird Science

Posted by Joel Halligan

Recently I was chatting with a friend who researches bacterial proteins. My friend was somewhat taken aback by the research methods used in the study I’m working on (questionnaires, food diaries and the like) and, compared to his research, the effort required to collect data. This amused me somewhat: “How else would we do it?” I asked him. He um’d and ah’d but didn’t have an answer. In his mind our research seemed ‘messy’ because our research subjects didn’t behave in as predictable a fashion as his bacteria. Our subjects, being human, are subject to whims and fancies and emotions and, well, real-life; his research subjects don’t require a recruitment strategy with ten phases, they fit snugly on the head of a pin and they don’t eat at McDonalds. I suppose I had to agree with him that, by comparison, our research was indeed ‘messy’, but that in my opinion that’s what makes the research I’m working on much more interesting and enjoyable than his lab-based research.

I reflected on the data collection that I’ve been involved in for the past 8 months and how alien it may seem to somebody like him, with the very same job title as me but working in a very different field of research. My participants have IDs but they also have names. When I visit them or talk to them on the phone to ask them about what they had to eat the day before (part of the research!) they chat to me and, as I’m human, I will chat to them too. This means I don’t just have to remember the protocol and what I need to ask them to make sure I collect the right data, but I also need to remember that they’ve just bred a litter of German Shepherd pups (and how are they all doing?), or that they’ve been somewhere nice on holiday (did you have a nice time?), or that last time I spoke to them their oven broke (and has it now been fixed?). When I arrange to meet them I have to text them to remind them and be prepared to be stood up or rearranged because, surprisingly, the research they’re involved in is less important to them than it is to me. When I visit people at home I have to contend with hairy and excitable Japanese Akitas and ringing phones and doorbells and kids that want to constantly interrupt. I also end up drinking a lot of tea. My friend has none of these issues in his research, the lucky devil, although being plied with tea isn’t so bad.

My friend also seemed discomfited by the ‘lack of control’ he perceived that we had over the many variables that could potentially influence our outcome of interest - in this case whether a cooking skills intervention can influence diet. Again, I playfully asked for his proposed solution. Lock them all in a darkened room with a knife block, portable hob, organic veg box and a series of Jamie’s 15-minute meals on DVD? I don’t think that’d get past the ethics committee, I said. I explained that we do our best to control for this multitude of other variables by randomising participants to one of two study arms. Do you blind them to their allocation, he asked? Er, no, I replied, would we send them on a cooking skills course but tell them they were going on a knitting course and hope that they didn’t realise? He also argued that by telling people we’re recruiting them to take part in a cooking skills course we might generate effects before we’ve even started, regardless of which arm they’re recruited to. I agreed with him to some extent, but explained that it’s difficult enough to recruit participants even when they have the full information beforehand, so imagine how difficult it would be to recruit people to a ‘mystery intervention’, not to mention that darned ethics committee that would no doubt throw a spanner in the works.

After our chat, my friend concluded that he was glad that he didn’t work with humans in his research because he wanted to do scientific experiments, not quasi-scientific experiments (his words). I concluded that I would prefer the latter any day. In my opinion, people are much more fun than single-celled organisms.

52 weeks in public health research, part 24

Posted by Catt Turney

This week I was tweeter-in-residence for two events - a symposium on health promotion in schools (#SchlHealth) and the launch of the School Health Research Network (#SHRN14). I was busy being proud of myself for keeping to the right account and hashtag, when I noticed that I'd tweeted this photo of our Co-Director upside-down. I deleted, rotated it and tweeted again - still upside-down. Moral of the story: Twitter is four-dimensional, or this photo just really wants to be upside-down. It seemed a shame to deny it that chance, so here it is.

The school health symposium meant I got to have a day of working at home at my grandma's in London. Cue amazing vintage healthy-eating books - full of mostly quite sensible advice, interspersed with the odd bit of quackery and some amazingly 70s recipes.

DECIPHer's Clerical Officer, Natalie, preparing for the SHRN launch whilst modelling a new innovative storage solution that we're trialling here in Cardiff - the cupboard-desk.

I've been enjoying Jenni Remnant's animal photos on the Fuse blog over the last few weeks, so wanted to try and contribute something appropriately cute from my walk home. Unfortunately all I could find were these two scraggy seagulls trying to eat each other.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

The C word V: cooking

Posted by Jenni Remnant and Libby Morrison

We all know that two key elements of public health are what we put in our bodies (food, alcohol, cigarette smoke) and the environment that surrounds us.

When you’re a carer, to a point, you can often find yourself responsible for what someone else consumes, and the effect the environment has on them. Quite a responsibility.

And the way, as carers, we respond to this responsibility is incredibly varied.

Service users in care can be fed unhealthy and highly calorific meals through a desire to ‘mother’ and ‘feed up’. Many mental health service users I’ve worked with live on ready meals (my inspiration for the topic of my Msc dissertation last year) which have been found not to fulfil dietary requirements suggested by the Food Standards Agency.

Though I hate using the word, and emphasising that this is only in my experience, there are a number of carers out there, both informal and paid, that can be quite ‘mumsy’. Meals are often very traditional, and full Sunday roasts with all the trimmings are sometimes enforced, even in single occupancy services.

I have worked with a number of service users with high staff ratios due to ‘challenging behaviour’, and they have been quite similar: the service users are often overweight. This is problematic in terms of the health of the service user and the carer – the regular violence that is often an acknowledged part of a service user’s communication can lead to a carer having to deal with 20+ stone of angry person.

  

In one circumstance, a plan was formed based on improved health outcomes - for the service user and staff involved. All the full-timers at this service were given a specific responsibility, and mine was ‘food and exercise’. I downloaded a copy of the Bristol stool chart (a carers best friend), booked our service user an appointment with a nutritionist and started to write weekly shopping lists and menus. We identified, and were supported by the nutritionist in our assertions, that our service user was heavily constipated, and this was causing them some distress and was likely to be contributing toward some, if not all, of their violent behaviours.

Putting together a healthy living plan was interesting. One of my colleagues was a supremely talented cook, and made unbelievably delicious food, but had a very different idea of what ‘healthy’ was to me. Something I’ve heard a lot at work, and which my brother now believes as gospel, is that pasta is healthy - in any dish and any context. Divine though my colleague’s macaroni cheese looked – it had three cheeses in, butter and sometimes even cream – I’m not sure it ticked all the nutritional boxes one might hope in a meal, and might also go above recommendations in terms of fat. And the portions! Portions so mammoth you’d wince to look at them.

So, very slowly, we started introducing more fibre into the menu, and green things; while also limiting, but not removing, gluten and sugar. There was a rule that every meal must have a minimum of three natural colours in, not including white, beige or brown. I should note here, that this service user, as with most of the challenging service users I have worked with, was non-verbal – and only provided very limited feedback.

There was a lot of criticism. The most common one was that the service user was being made to follow a vegetarian diet without consent. Which I’m afraid I mostly rebutted with ‘so at what point was their consent gained to eat meat?’. Though actually the new diet did contain meat, just far less than before.

Some of the team thought it was wrong – that this person had a life with such few pleasures in it, bar eating, that it was border line cruel to take that away. I found this difficult, because I used a lot of recipes and meals that I ate myself, and felt that any criticism of the food served was a criticism of my personal lifestyle. But it also contained so much assumption – how would we know what this person preferred? We tried very hard to see if there was any difference in the gusto with which a piece of carrot was eaten or a piece of chocolate – and could find none. The only discernible preference, as I’ve often found in services with adults with sensory impairments, was for something with a bit of crunch.

This service user often stared at sweet treats in shop cafes or by tills on the way out of shops (why is it ALWAYS huge mounds of cake? Or chocolate?). Often this would happen and someone on the staff team would say ‘they’ve seen it now; we’ll have to get it’. This service user very soon came to realise that this was an efficient way to get food – because of this we couldn’t go through the checkout with them, without some kind of calorific edible having to be bought and consumed every time. The combination of ‘guilty checkouts’ and staff anxiety ‘created’ this negative pattern of behaviour, which in turn impacted on the healthy eating regime that other staff were trying to implement. This resulted in the loss of the daily interaction of buying groceries.

Eventually, when the team pulled together, with compromises made on ‘both’ sides, the service user lost 3st 4lb in a year, episodes of challenging behaviour went down from 4-8 per week to 1-3, and bowel movements were frequent and far less explosive than they had been. Happiness is a non-explosive bowel movement. The social interaction aspect of grocery shopping for this service user was hugely limited – and at times the staff team totally and utterly divided.

There is no right and wrong in this anecdote. I can say hand-on-heart that I know for sure that the staff team all wanted what was best for our service user; we all just had very different ideas about what ‘best’ was.

Policy within care is full of personal outcomes that centre on choice and independence, which can make public health interventions less accessible. Especially in the example given above, where the service user was written out by our models of ‘best interest’ decision making. I certainly don’t have a substitute model. A significant public health issue is how to engage with carers. Carers can sometimes have absolute control over another human being, no matter how we dress it up to suggest otherwise. How do we make sure that clear public health messages are being communicated and instigated by carers without further surveillance and pressure being placed on an already incredibly pressured role?

52 weeks in public health research, part 23

Posted by Jenni Remnant, Mark Welford, Mark Tully and Jean Adams

From Jenni Remnant: initial contact and consent forms ready to send to potential participants, fingers crossed for a decent response rate!

From Mark Welford (Fuse Communications Officer): Spotted this brand daylight robbery at a generic department store (rhymes with M&M’s) in Newcastle. Not only the Fuse name but also the font! There go our plans to diversify through a Fuse fashion label.

From Mark Tully: spent the morning working on an ethics application at my walking desk. By lunchtime, protocol and 9000 steps were done.

From Jean Adams: Fuse director Martin White enjoying a healthy snack on the patio outside our office. Also marketing his favourite outdoor shop.

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

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

Not necessarily useful, and unapologetic: Speaking out on health equity

Posted by Ted Schrecker

We should now be familiar with some hard facts about health equity. In the United Kingdom, despite rhetorical commitments by the previous government to reduce health disparities between rich and poor, by 2007 such disparities were on many measures greater than at any point since the 1930s. This was before the economic crisis and subsequent austerity measures, which have disproportionately affected the UK’s poorest regions, including of course the North-East.

North end of Stockton high street

Yet in discussions of how to reduce health disparities, a frequent refrain is that the evidence is not strong enough to serve as the basis for new policies that change the conditions in which people live and work. Tobacco control initiatives and encouraging people to eat a healthy diet are fine, but not so challenges to ‘the inequality machine [that] is reshaping the whole planet,’ in the words of the editor of Le Monde Diplomatique. Since (for example) the Canadian experience shows that a healthy diet is often unaffordable for benefit recipients or the working poor, and more than 46 million people in the United States are relying on the government vouchers known as food stamps, that would seem to be a major omission.

Debates about the strength of evidence are hardly new: think about tobacco, or climate change, or any number of environmental and workplace exposures the lethality of which is now widely acknowledged. The ethical and political nature of choices about standards of proof (how much evidence is enough) in these debates is often neglected. I began a recent article on this point with an analogy to the case of former professional athlete O.J. Simpson. Acquitted of the murder of his estranged wife and her friend in a criminal trial, he was nevertheless found liable for damages in a civil proceeding initiated by the survivors of his alleged victims. The difference simply reflects the much higher standard of proof that must be met, in common law countries, in criminal proceedings.

My points were that (a) the concept of a standard of proof is crucial for public health policy; (b) the choice of a standard of proof with respect to social determinants of health, as for environmental exposures, is a matter of public health ethics with respect to which scientists qua scientists have no special competence; and (c) unreflective insistence on a definition of scientific quality organised around avoiding false positives, or Type I errors, can be highly destructive of health, and in particular health equity, under conditions of uncertainty. Waiting for more evidence is itself a decision about risks and benefits. This point has been made in the literature for decades, yet it continues to be either ignored or willfully misunderstood.

A case in point: in The Body Economic, David Stuckler and Sanjay Basu assemble abundant evidence of the destructive consequences of austerity for population health, although much of it is not derived from experimental or quasi-experimental studies. Stuckler and Basu correctly observe that ‘in countries where austerity is ascendant, we’re undergoing a massive and untested experiment on human health, and left to count the dead.’ In ten or 20 years, that experiment may indeed provide answers to some of the questions epidemiologists would like to ask about social determinants of health, although there will always uncertainty because in the real world many things go on in people’s lives at the same time. Whether or not the experiment is justifiable is a matter of public health ethics, although it is seldom recognised as such.

Indifference to the role of competing values in making policy based on scientific evidence, and to the politics of such choices, is a generic problem. It is exemplified by the frequency with which speakers at a recent conference on urban health in Paris talked about the need for research to be useful to decision-makers. Similarly, an article on the relation between health research and public policy exhorts social epidemiologists to concentrate on narrowly defined questions amenable to experimental or quasi-experimental study designs that will generate ‘the kind of evidence wanted by policymakers.’

Anyone familiar with contemporary politics and public policy will realise that the quality of evidence demanded by policymakers – and that term is itself curiously decontextualised – depends entirely on what those in power have at stake. Often, no evidence or fabricated evidence is sufficient; think about the weapons of mass destruction that Iraq was declared to possess, or the nonexistent jobs into which George Osborne wants to herd impoverished under-25s. And in the population health context, what if policymakers have decided that some segments of the population are disposable, even though they cannot state this for public consumption?

I would argue that this is true of many national governments, as demonstrated by the policies they adopt. But even those who disagree should recognise the need for critical (and explicitly normative) perspectives on the relations between researchers and those in official positions outside the academic world. Local-level public health practitioners and organisations trying to reduce health disparities in a hostile environment deserve all the support we can give them. At the same time, progressive health researchers must choose our allies and audiences, and I for one have little interest in whether my findings are ‘wanted’ by David Cameron, Eric Pickles, or Iain Duncan Smith. The most appropriate guidance for health researchers of conscience as they interact with governments is sometimes the three R’s: Resist, Ridicule, and Replace.

All views expressed are exclusively those of the author.