Thursday, 26 November 2015

Housing and health: aligning stars or weathering a perfect storm?

Posted by Peter van der Graaf, AskFuse Research Manager

Last Wednesday I attended the annual conference of the Housing Learning and Improvement Network (LIN), which explored how the housing and health sectors can work more closely and effectively together.

The case for this partnership was well made by the keynote speakers: not only are there already strong historic roots but the present day challenges faced by both sectors make them obvious partners. With the recent move of Public Health to Local Authorities, the central message from the Marmot review - improving social determinants is central to improving population health and wellbeing - has taken on a new significance for public health commissioners faced with the needs of other local government departments.

Housing is one of the key social determinants and has received much attention in recent Government policies that seek to redefine the remit of health. For instance, the Care Act outlines an overarching vision for adult social care and emphasises various housing solutions that can help to support the integration of health and social care.

The NHS has also recognised the role of housing and has proposed a new care model around housing in its Five Year Forward View, such as the Healthy New Towns initiative. As Neil Revely from Sunderland City Council and Chair of the Association of Directors of Adult Social Services (ADASS), proclaimed: “the stars seem to align once more to bring housing and health together”. For this reason, ADASS has worked closely with NHS England to develop a Memorandum of Understanding on Housing and Health.

However, the same politics that bring both sectors together could be stumbling blocks for the partnership to take off. As members of the audience pointed out, prevention services have been hardest hit by austerity measures and many local authorities have decommissioned the services that are now most needed. With a growing and ageing population, demand is likely to increase while resources are more likely to decrease with continued budget cuts. Moreover, the ageing population means an increase in complex needs that cannot be addressed by a prevention agenda alone and in which (supported) housing is just one part of the solution.

In short, the current political and financial climate might provide a perfect storm, making it difficult for housing and health to work effectively together. The balance might be decided by the ability of the partnership to access new resources and powers, for instance, by claiming a stake in the North East devolution plans, mirrored on the success of the Greater Manchester Devolution Agreement that includes an MOU on Health and Social Care worth £6bn each year (see also the Fuse blog post by Patrick Vernon on this topic).

To make the business case for these claims, the partnership will need to build the evidence base around the impact of a joint housing and health programme in the North East. An abundance of data is available to highlight the problem areas and populations, supporting the call to arms, but limited evidence was presented at the conference on what housing providers, public health teams and care providers can effectively do to address these problems and populations. Much of the current evidence is anecdotal and in the format of case studies.

The need for more evidence of the impact of the home/housing on health and wellbeing was also reiterated by Gill Leng from Public Health England (PHE) and this is an area where Fuse could provide helpful support. What research evidence do we have available within our Centre to support the North East partnership between housing and heath? What support can we provide in developing the monitoring and evaluation framework for their programme? The recent Fuse Quarterly Research Meeting (QRM) and corresponding research brief on health and housing is a first step in this direction and the upcoming QRM in April 2016 on planning and health another, but more practical evidence is required to align the stars of local policy, practice and research and help the North East health and housing partnership to weather the current political and financial storm.

Photograph 'Incoming Storms No. 2' by Mike Lewinski via © 2013:

Monday, 16 November 2015

Alcohol Awareness Week: just who are those risky drinkers?

Posted by Dorothy Newbury -Birch, Professor of Alcohol and Public Health Research at Teesside University.

It's national alcohol awareness week and I've been asked to write a blog about it and as I sit and wonder what I would like people to be ‘aware’ of, one thing comes to mind. It’s the thing that I say in every lecture I give and hope that it’s the one thing that people take away with them: “Its not a them and us issue when it comes to alcohol-related harm”. What do I mean by this? Well we know that around 30% of people (any people) who go to the GP will screen positive for risky drinking (an alcohol use disorder). That’s 30% of folk you see walking down the street and in shops – that’s us – not those people over there. If we realise this then we become more aware of how risky drinking is affecting all of us. If I were to screen everybody who is reading this blog then around 30% of you would screen positive for risky drinking and about half of you would have no idea that you had an alcohol use disorder. You don’t believe me do you? Well here is an alcohol screening questionnaire – have a go...

If you score 5 or more than you would be classified as a risky drinker. So, I hear you ask, what is a unit? Well this is a massive problem as a lot of us don’t know what a unit (or standard drink) is. Did you realise that a bottle of wine has around 9 units? Did you realise that a man drinking more than 4 units and a women more than 3 units in one go is classified as a ‘binge drinker’? Did you know that the recommended drinking units are 3-4 per day for men and 2-3 per day for women, with two days free per week? All sounds rather complicated doesn't it?

So what can we do about it if we are drinking too much? Well you've done something already by realising it – remember I said a lot of us don’t realise. Small things make a massive difference. We can keep an eye on what we are drinking; we can think about having a soft drink in between a glass of something; don’t drink in rounds (it’s much easier to drink more when in a round) and remember you can leave some wine in that bottle for another night. 

Alcohol-related harm costs the UK around £21 billion a year. Alcohol is a causal factor in more than 60 medical conditions including cancers, high blood pressure, cirrhosis of the liver and depression. Alcohol-related hospital admissions have increased by 35% in the nine years to 2011/12 when there were 1.2 million admissions related to alcohol. Alcohol is implicated in, or responsible for around 30% of visits to primary health care and around 70% of A&E attendances from midnight to 5am at weekends. These are well known statistics but who do they relate to? The Alcohol and Public Health Team at Teesside University is carrying out research to reduce the harm caused by risky drinking. This includes research with young people in the school setting (SIPS JR-HIGH) and the Accident and Emergency Setting (SIPS JR) and work in the criminal justice system.

If you want more information then have a look at the following websites: 
If you want to find out more about the research, myself and the team that are involved, you can follow TeamAlpha’s research on and @TeamAlphaTees

Thursday, 12 November 2015

Sublime and ridiculous: the glamorous life of a public health researcher

Guest post by Rebekah McNaughton, Research Associate in Public Health and Lecturer in Research Methods at Teesside University 

They say that variety is the spice of life and that is certainly true in my line of work. When I started my career as a public health researcher I understood that a great deal of my time would be spent reading other people’s research, doing fieldwork and writing numerous reports. That has certainly been true of the last 10 years of my career. What I didn't expect was the huge variety that I would come to love.

Doing fieldwork is by far my favourite aspect of the job. I'm naturally quite inquisitive and I'm really lucky to get paid to do something I enjoy- being nosey! So far, I have worked on projects with children and young people, parents, teachers, public health professionals and patients. You name it: I've probably worked with them. And, to be honest, it has ranged from the sublime to the ridiculous…
Crowd control: Some research participants refused to be quiet for the focus group
Yes, I've done focus groups in schools and community venues. I've sat on people’s sofas having a cup of tea and a biscuit. I've been challenged by young people determined to embarrass me whilst talking about sex and relationships education. All of this I expected as part of the ‘routine’.

What I didn't expect, however, was trying my hardest to concentrate on asking ‘the right questions’ whilst the washing machine was screaming in the background on the extended spin cycle. Or being mauled by a rather ‘licky’ dog and trying to make sense of the tape afterwards. I didn't expect to need crowd control skills when trying to carry out work with 24 new mums and their 28 babies and toddlers, all wriggling on the floor and not one of them being courteously quiet for the tape. However, today took the biscuit. I went to talk to two health visitors, at their place of work. Nothing out of the ordinary, or so I thought. In need of some privacy, I was led into a tiny windowless room (a cupboard), a cupboard lined with patient notes and not enough room to swing a cat. The three of us huddled around a mop and bucket, like women dancing around their handbags in a club circa 1989, whilst I held out the voice recorder. At the same time I was trying desperately not to drop it in the murky water swimming at the bottom of the bucket. Oh, the glamorous life I lead…

Would I change it? Absolutely not! No two projects are the same. Meeting participants is by far the best aspect of my job; it brings obstacles and challenges but most of all it makes my job a lot of fun!

Photo attribution:, Anthony J, 'Six pack', The results of the 'final project' in our childbirth class, (Left to right: Sienna, Maguire, Sophia, Ethan, Claire and Noah)

Wednesday, 4 November 2015

Too stressed for words? Involving those experiencing stress in research

Guest post by Natalie Forster, Senior Research Assistant, Northumbria University and Sonia Dalkin, Lecturer in Public Health at Northumbria University

On this National stress awareness day, we wanted to take the opportunity to reflect on the ethics of involving those experiencing stress in research.

Fuse researchers are currently undertaking a realist evaluation to understand how, when and for whom, Citizens Advice Bureau (CAB) interventions improve people's health. CAB provide independent, impartial, confidential, and free advice to everyone on their rights and responsibilities. This includes advice on debt, benefits, employment, housing and discrimination.

Changes to physical health take a long time to show, and are therefore difficult to capture in the evaluation timescale. The impact of CAB on stress therefore forms a core focus of the study. As we know already that stress is linked to many mental and physical health outcomes, determining if and how CAB services reduce stress should enable us to project the potential health impact of CAB.

At the point when people approach CAB, they are often under considerable strain. Two in three people accessing CAB services report feeling stressed, depressed or anxious as a result of the problem or problems that they are experiencing, more than one in five people have had to move home or are worried about losing their home, and almost one in five are experiencing difficulties in relationships with other people.
We have had much discussion as a research team, together with CAB staff, around how to design the research in a way that generates sufficient data to assess the impact of the service, but which remains sensitive to what clients are experiencing. Imagine a scenario for example, whereby you approach a service for help already under significant stress, you are anxious to resolve a financial problem, yet before you can start to address the issue you're asked to fill in a lengthy questionnaire about your health. Furthermore, CAB have projects specifically designed to support those diagnosed with cancer. In the case of CAB clients who are currently undergoing treatment for, or supporting a family member with cancer, stress is likely to remain in spite of addressing financial concerns, and to ask if their health has improved would be inappropriate.

These are just some of the issues we've been grappling with and which have informed our decisions about which client groups we invite to participate, when we contact potential participants, and what they can reasonably be asked to take part in. A decision was made for instance, not to include a project for patients and families with cancer among those being evaluated. Baseline questionnaires will not be delivered before, but rather during or just after clients’ initial appointments. The number of questionnaires clients will be asked to complete has been carefully considered and where possible, shorter versions of questionnaires have been used in order to avoid over-burdening participants.

That said, we're also conscious of the risk of excluding people from taking part by making too many presumptions about participant preferences. We have often reflected during involvement with previous research on how generously people have shared their time and experiences even when undergoing difficult circumstances. We therefore continue to consider the balance between participant protection and autonomy when recruiting potentially stressed participants. In research with people experiencing difficult circumstances, involving potential participants and organisations working with them in designing data collection strategies is key to ensuring their appropriateness.

Photo attribution: Photograph ‘Anxious 1’ (File ID #1431663) by Joana Croft via, copyright © 2007:

Thursday, 29 October 2015

Not just a can of pop: the social meanings of energy drinks

Posted by Mandy Cheetham, Fuse Research Associate at Teesside University

Children and young people can sometimes be conspicuous by their absence in public debates about sugary drinks, so I’ve enjoyed reading the series of blogs posted since September, which describe research and activities involving young people. As children and young people are the predominant consumers of sugary drinks, it is claimed they are one of the groups whose health will benefit most from efforts to control or reduce their consumption (FPH 2015), such as the introduction of a duty on sugary drinks advocated by PHE (2015) and popularised by Jamie Oliver.

Our study on energy drinks showed that cost was one of the major influences on young people’s choices. The mapping exercise we did with Year 6 and Year 9 students in their local area showed walls of cheap, appealing, attractive displays of multiple flavoured energy drinks to tempt young people, with ‘buy one, get one free’ offers to share with friends. As important as the economic considerations are, the social meanings of energy drinks also have a major role to play. These are often misunderstood or ignored by adults planning public health interventions to reduce the risks of obesity.
Young people described the social spaces in which they drink energy drinks, whether consumed at weekend sleepovers, whilst gaming, hanging out with mates in the park, or on the way to or from school. Shared, swapped, and exchanged, energy drinks, and the sponsorship, branding and marketing associated with them, are woven in to the social fabric of young people’s lives. Energy drinks are part of the construction and maintenance of particular gendered identities, associated with extreme sports, alien elimination, looking hard, sophisticated and / or attractive. They offer young people opportunities to conform to certain ideas about what girls and boys like and do, and become part of the currency of young people’s daily interactions. In short, social meanings matter.

In Wendy Wills’ presentation at the Sweetness, Social Norms and Schools seminar in September, (CPPH/Wolfson Seminar - Sweetness, social norms and schools: factors influencing children and young people’s food and drink practices), I was struck by the similarities in young people’s comments about the importance of social relationships, interactions with friends, and the value of friendly respectful exchanges with local retailers, informing their lunchtime decision making. Young people were keen to be involved in efforts to improve the school food environment. Young people in our study were similarly fired up to make positive changes, and questioned why and how energy drinks companies can target young people under 16. They had ideas about what would make a difference and were realistic about the challenges of restricting sales of energy drinks to young people.

In September, Fuse welcomed Professor Helen Roberts, a self confessed fan of evidence informed public health advocacy, to deliver a knowledge exchange seminar prompting debates about our role as academics and advocates. Constrained by restrictions placed on us by funders, some appear nervous about compromising assumed notions of independence. If we want our research to have impact, should we not frame public health debates in ways which make sense to those who participate in our research? Rather than simply highlighting the health risks of energy drinks, this means understanding the social meanings of young people’s food and drink choices and more critical engagement with the industry that promotes them. Our efforts would be further strengthened by encouraging young people and colleagues to connect with other campaigns such as RRED and GULP.

To download the Fuse Energy Drinks report click here, or the Fuse Brief can be viewed here.

Wednesday, 21 October 2015

Back to the Future: health and housing working together

Guest post by Patrick Vernon, Health Lead, National Housing Federation

The launch of the Due North report in September 2014 was a rallying cry for greater priority around tackling health inequalities with a manifesto in how all stakeholders and system players can recycle effectively the £136 billion in public spend for transforming services. Since May 2015 we have a new Government with a clear agenda on austerity, public sector reform and the revitalisation of the devolution agenda with the mantra of the "Northern Powerhouse". In the middle of this maelstrom has been the Government's approach to tackling the housing crisis with the immediate reduction of 1 per cent in rents over the next four years, the extension of the Right to Buy and the ongoing impact of welfare reforms. These changes have become a major turning point in the history of the social housing sector along with the changes in supported housing.

Although there is an emotional, political, moral and (increasing) evidence base for the links between poor housing and health, the gap between fact and reality still feels light years away. There is a clear role for the social housing sector to work with the NHS, social care and employers in transforming services and care pathways to meet demographic, lifestyle and morbidity changes in the population. A step in the right direction is the Memorandum of Understanding (MoU) to support joint action on improving health through the home which was signed by all stakeholders in the health and housing sector in Autumn 2014. The document highlights at a strategic and national level the key principles and actions around a collective approach around delivery. However, what is currently missing is a regional approach that is embedded in the devolution agenda. This is already happening in Greater Manchester as part of DevoManc (giving greater powers to the combined authority working in partnership with a directly-elected Mayor). In the North East we need to ensure that housing and health are part of the devolution plans.

Thus the Fuse Quarterly Research Meeting (QRM) ‘Creating Healthy Places in the North East: the Role of Housing’ on Tuesday (20 October) in Darlington is the start of another important chapter in the health and housing trilogy (or may be pre-sequel) on how health, social care and housing can work together in meeting the needs of local communities in a period of austerity. All the speakers at the event had - in essence - the same message: a need for strengthening partnerships and system leadership along with collating, translating and communicating the evidence for cost-effective interventions.

The event not only had international examples from the Netherlands and New Zealand but also local case studies from a number of housing associations such as Thirteen Group (Middlesbrough Recovering Together project), Gentoo Housing (Boilers on Prescription), Home Group (social prescribing), Tyne Housing (working with homeless people in the community) and South Tyne side Homes (sheltered accommodation for residents with dementia). The case studies illustrated how better commissioning and service integration can make a difference to the lives of people.

The challenge in a period of reduced budgets and further potential cuts in the forthcoming Comprehensive Spending Review is how we make the business case and get the right people in the room to transform services, building on the spirit and vision of the Due North report in tackling health inequalities and achieving greater health equity.

I think one of the key outcomes of the QRM is for Fuse to act as broker between service providers, commissioners and service users in creating a strong North East dialogue between the health, social care and the housing sector. This can be achieved by networking, sharing good practice, supporting development of the evidence and, finally, an advocacy role in influencing the devolution agenda.

Thus, if Marty McFly and Doc Brown pop out of their DeLorean DMC-12 again in the future, we can share with them the successful journey that we have undertaken in ensuring that the housing sector is a valued, respected and key partner in delivering better health and social care services and an integral agent in tackling the public health agenda.

For more information visit the National Housing Federation website or read the Fuse research brief accompanying this event: Creating healthy places in the North East - the role of housing.

Photograph 'Back to the Future DeLorean Time Machine' by AdamL212 via © 2007:

Thursday, 15 October 2015

Obesity: How neoliberalism made us fat

Posted by Ted Schrecker, Fuse Associate Member and Clare Bambra, Fuse Associate Director

A 2010 editorial in the Journal of the American Medical Association warned: “If left unchecked, overweight and obesity have the potential to rival smoking as a public health problem, potentially reversing the net benefit that declining smoking rates have had on the US population over the last 50 years”. Obesity increases the risk of developing cardiovascular disease (CVD), certain types of cancer, Type 2 diabetes, and orthopaedic problems. At the end of the 1970s it was estimated that 15% of US adults were obese. By 2012, this had more than doubled, to 35%. Among adolescents the increase is even more striking – from 5% at the end of the 1970s to 20% in 2012. In the UK, it is estimated that obesity nearly tripled between 1980 and 2002, from 6% amongst men and 8% amongst women to 23 percent and 25 percent women respectively. Amongst children in England, obesity has increased from 11% among boys and 12% among girls in 1995 to around 20% today.

In our book Neoliberal Epidemics: How Politics Makes Us Sick we argue that obesity in high–income countries is partly the result of political and economic choices made since the 1980s. Since the early 1980s, neoliberalism or “market fundamentalism” has dominated politics and economics across much of the globe, perhaps nowhere more conspicuously than in the post-Thatcher UK. Obesity is a neoliberal epidemic – one of four, along with austerity, stress, and inequality. They are neoliberal because they are associated with or exacerbated by the rise of neoliberal politics. They are epidemics because they are on such an international scale and have been transmitted so quickly across time and space that if they were a biological contagion they would be seen as of epidemic proportions.
North American contrasts between rich and poor urban areas, less than a mile from one another
Photo: T. Schrecker
Other high-income countries have also experienced increases in obesity. Obesity has no single cause; the many influences include changes in the food environment (including advertising, marketing, accessibility and affordability); the growth of sedentary work occupations and leisure time activity, such as television viewing; changing settlement patterns, notably the rise of a privatised approach to planning organised around driving rather than walking or the provision of public transportation; and changes in the built environment that reduce the safety and attractiveness of physical activity, especially for those who do not live in leafy places. However, countries that have gone farthest down the neoliberal road, the UK and the US in particular, have experienced greater increases in obesity – suggesting that neoliberalism has magnified and accelerated trends that are present to some extent throughout the high-income world.

Obesity is a neoliberal epidemic for several reasons. These include: (1) economic and social policies that have meant fewer people can afford a healthy and balanced diet; (2) increasing time poverty, as when the demands of work (often on unpredictable schedules), transportation, and (especially for women) child care within ‘flexible’ labour markets are combined, there is not much time or energy left for eating a healthy diet and the attraction of a quick stop at the shopping park’s fast food outlet are strong; (3) the role of aggressive corporate marketing of unhealthy, energy-dense foods, notably as multi-national supermarkets, manufacturers of ultra-processed food and fast food chains expand into developing economies with the lowering of barriers to foreign investment. This helps to explain why overweight and obesity are now also rising rapidly in many middle- and some low-income countries, with prevalence in Mexican adults comparable to levels in the United States.
Corporate food systems and time poverty interact at the shopping park.
Photo: T. Schrecker
A fourth connection was addressed at a groundbreaking workshop at the University of Oxford in 2009: political structures such as welfare state regimes. More specifically, higher levels of economic insecurity – associated with neoliberal policies like the rollback of welfare state protections and opening up labour markets to the “creative destruction” that Joseph Schumpeter extolled as a defining virtue of capitalism – are causally linked with a higher prevalence of obesity through both biological (stress-related) and psychosocial (comfort eating) mechanisms, in addition to the more direct effects on time and food budgets.

Public health researchers, who agree on little else, recognize that reducing overweight and obesity is a formidable challenge. A first step is to avoid the lifestyle trap. A recent literature review on policy interventions to tackle what has been called the obesogenic environment produced by the Scottish Collaboration for Public Health Research and Policy provides some useful directions. Its authors do not shrink from arguing the need for large-scale interventions that may be expensive or challenging to vested interests, noting (for example) that the transport mode split in urban areas is 84% by car versus 9 percent walking in the United States, while it’s 36% by car versus 39% walking in Sweden. “Suffice it to say, it has been a concerted combination of infrastructure provision, integrated transport planning and disincentives for private cars which has helped to bring about the higher active travel rates.” We have no easy solutions, but emphasise that neoliberalism and the associated political choices have exacerbated the obesity crisis. Obesity is an example of how politics makes us sick.

Links: Schrecker, T. and Bambra, C. (2015) Neoliberal Epidemics: How Politics Makes Us Sick, Palgrave Macmillan, available at:

Professors Schrecker and Bambra will be discussing their new book 'How Politics Makes Us Sick' at an event at Durham University on 15 October 2015. For more details click here.

About the authors

In June 2013, Ted Schrecker moved from Canada to take up a position as Professor of Global Health Policy, Centre for Public Policy and Health, Durham University (UK). Since 2002, most of his research has focused on the implications of globalization for health; he also has long-standing interest in issues at the interface of science, ethics, law and public policy. A political scientist by background, Ted worked as a legislative researcher and consultant for many years before coming to the academic world, and co-edits the Journal of Public Health. Among his publications, he is editor of the Ashgate Research Companion to the Globalization of Health (2012) and co-editor of a four-volume collection of key sources in Global Health for the Sage Library of Health and Social Welfare (2011). Ted is also an Associate Member of Fuse. Ted can be followed on Twitter @ProfGlobHealth.

As well as being an Associate Director of Fuse, Clare Bambra PhD is Professor of Public Health Geography and Director of the Centre for Health and Inequalities Research, Durham University (UK). Her research focuses on the health effects of labour markets, health and welfare systems, as well as the role of public policies to reduce health inequalities. She has published extensively in the field of health inequalities including a book on Work, Worklessness and the Political Economy of Health (Oxford University Press, 2011). She contributed to the Marmot Reviews of Health Inequalities in England (2010) and Europe (2013); the US National Research Council Report on US Health in International Perspective (2013); a UK Parliamentary Labour Party Inquiry into international health systems (2013), as well as the Public Health England commissioned report on the health equity in the North of England: Due North (2014). She is a member of the British Labour Party and can be followed on Twitter @ProfBambra.