Friday, 28 April 2017

From the office to Eastern Africa: how digital technologies can be used to assess diet

Guest post by Emma Foster, Lecturer in Public Health Nutrition, Human Nutrition Research Centre, Newcastle University

Life in academia can be tough at times. It can be difficult to switch off, the list of tasks can seem never ending and just when you think things are going to quieten down along comes that call for proposals that you simply can’t miss.

I’ve worked at Newcastle University for almost 20 years now and throughout that time my research has focused on improving how we measure dietary intake. In the early years this involved going into school and talking to children and parents, which was always good fun. More recently we’ve been working with adults developing online systems for measuring intake along with colleagues at Open Lab. The work is really interesting and I’m enormously proud of the system we have produced but life is predominantly office based now.

Earlier this year though, my enthusiasm for work was suddenly re-ignited with a slight change in focus for my research. For 12 days in February I left behind my 6 year old son (bad mummy!) and my husband and headed off to do some research looking at how digital technologies could be used to assess dietary intake in Africa. Along with my colleague - research associate Maisie Rowland - I headed to Tanzania to learn about the food environment there, looking at the range of foods available, and the way things are cooked, served and eaten. We also looked at the uptake of technology such as use of smartphones and internet access. We started our visit in Moshi near Kilimanjaro (every time I say Kilimanjaro I still break into a smile). The weather there was lovely and warm and the people were too. We’d been put in touch with a school teacher, Amina who showed us around two primary schools and one secondary school in the area. Seeing the cooking facilities at the schools was really eye opening. The schools all cooked over wood fires.


I was amazed at the secondary school kitchen; this was what I had expected to find in the homes in poorer rural communities but not in a large (700+ pupils) secondary school. Yet the staff managed to cook enough food to feed all of the students and had taken the time to provide information for us on the common local foods.

Every day for school lunch the children got maize and beans, one of the schools added oil to the mixture to make sure the children got some fat in their diet. Children brought a bowl, plate or other container (some had margarine tubs) and most ate with their hands. The children ate their food outside. Amina invited us over for dinner one evening. “I thought I’d cook you banana stew and elephant leg” she said, monitoring our faces for a reaction. Politely we said “that sounds lovely” but we clearly looked a bit worried before Amina roared with laughter and told us that elephant leg was a vegetable….it just got its name because it apparently looks a bit like one!

Before we left Moshi we got to tour the local food markets, where people buy the majority of their food. There was very little in the way of pre-packaged foods consumed.

Our next stop was Dar es Salaam where we worked with the Tanzanian Food and Nutrition Centre (TFNC). We conducted two workshops, one with nutritionists, dietitians, food technologists and public health workers at the TFNC, which Maisie and I ran in English, and one with a rural community group which the TFNC researchers ran in Swahili. Through the workshops we gathered lots of information about the foods consumed and how these differed between regions, the time of year, celebrations and droughts, and how people would share recipes and consume foods. We learned that African power cuts can last a whole day - the workshop at the TFNC was done in 35 degree heat with the power (and therefore air conditioning) off! We discovered that the foods we were served for breakfast at the hotel were usually only reserved for celebrations for the local population.

We took our research very seriously and ate at a wide variety of restaurants, cafes and street food stalls. The food over there was really tasty. For breakfast every day we had an amazing beef stew that we got the recipe for. I’ve tried to re-create it but mine isn’t quite up to scratch, I think it’s probably to do with the way that they rear the cows rather than my cooking skills....

We plan to work with the staff at TFNC to put in a proposal to the Global Challenges Research Fund with the aim to develop a technology based method of assessing dietary intake that will enable them to run what would be the first National dietary survey for Tanzania.

….Now back to the office for some proposal writing to get us back out there. Next time I might even take the family with me!

Friday, 21 April 2017

Sleepless in the slammer

Charlotte Randall, Higher Assistant Psychologist and MSc student, Northumbria University

The current prison population is 85,641 and around 50% of this population suffers from symptoms of insomnia. While this is similar to the general population there are a limited amount of resources to help treat this disorder in prisons.

Having worked in prisons for seven years, I am all too familiar with the problems that a lack of sleep can have on an offender's ability to engage with the prison regime, and the impact this has on their mental health. Due to the high prevalence of mental health problems, substance misuse and personality disorders in the prison population, the issue of sleep is often side-stepped and the importance of obtaining and having a healthy sleep practice can be forgotten about.

I am part of the Mental Health In-reach team in a prison in the North East, and have witnessed first-hand the effect poor sleep can have on an offender’s mental health. As this is an under-researched area, I decided it would be interesting and beneficial to conduct research on insomnia in the custodial setting. The aim of the study was to see whether a 60-70 minute session of Cognitive-Behavioural-Therapy for Insomnia (CBT-I) with an accompanying self-help pamphlet was an effective treatment in reducing the symptoms of insomnia in male prisoners.

As I work in the prison Mental Health Team full time, I thought this would be a simple project to undertake, however there were several hurdles along the way. Firstly I was required to gain ethical approval from several different organisations; NHS; National Offender Management (NOMS); and the University. Offenders are classed as a vulnerable population for research purposes, and therefore there is heightened scrutiny from ethic boards as a result of this. This process was lengthy; I had to complete three separate documents explaining the project’s benefits for each organisation. Once submitted, I was required to attend a full Research Ethics Committee (REC) where the research protocol and IRAS (Integrated Research Application System) form were discussed and additional questions were asked. It was then a waiting game to see whether the study had been granted ethical approval. As with any research project there was a deadline of September 2016, in which my dissertation needed to be submitted. Ethical approval was granted in June 2016, after recommendations had been made by the NHS and NOMS ethic boards and an amendment report was submitted.

On the other hand, recruitment for the study was relatively easy, which surprised me! Although it also identified the need for insomnia interventions in the custodial setting and confirmed that this research was important. The offenders were keen to engage, due to the lack of pharmacological (drug related) and psychological interventions for insomnia they were eager to find something that helped them sleep.

Results from this research were positive and highlighted that there was a significant reduction in insomnia related symptoms after completing the 60-70 minute session of CBT-I, with the accompanying self-help pamphlet with category C adult male prisoners. This research is the first of its kind to assess whether an adapted versions of CBT-I is effective in the prison population, where there are limited interventions and resources to help aid sleep disturbances. Although the results were positive, they have to be taken with caution as the prison where this research was undertaken has a unique regime and all prisoners are in single-cells which allowed them to complete certain aspects of CBT-I e.g. sleep restriction.

My experience of completing this research was positive; I enjoyed the prospect of analysing an undiscovered area and hopefully informing academia and practice within a public health setting. I did however find it hard in the early stages of this project, specifically going through the ethics process and length of time this took. A written report has been disseminated to NOMS highlighting the findings of this research. It also identifies how this research could be taken forward and inform future research opportunities. The single session of CBT-I is being delivered in the prison where the research was completed, more data is being gathered and will hopefully be published in 2017.


Photo attribution:
  1. “sans horizon” by poirpom via Flickr.com, copyright © 2015: https://www.flickr.com/photos/poirpom/16479845789/
  2. “prison” by erin via Flickr.com, copyright © 2007: https://www.flickr.com/photos/insunlight/1037277952
  3. “Insomnia” by Ben Harrison via Flickr.com, copyright © 2011: https://www.flickr.com/photos/48755144@N02/5564362009

Friday, 14 April 2017

Life inside foodbank Britain

Post by Kayleigh Garthwaite, Research Associate at Newcastle University and Fuse Associate Member

For the last three years, I’ve been a volunteer and a researcher at a Trussell Trust foodbank in central Stockton, North East England, finding out how a foodbank works, who uses them, and why. My new book ‘Hunger Pains: life inside foodbank Britain’ tells the stories of the people I met inside the foodbank over an 18 month period. The experiences throughout the book offer a serious challenge to persistent myths that foodbank users are simply seeking emergency food as a result of flawed lifestyle choices.

Every week, I prepared the three days’ worth of food that goes into each food parcel. I dealt with the administration of the red vouchers required to receive food, making sure that anyone who needed further support was signposted to where it could be obtained. I weighed kilograms of food in and out. I volunteered at the collections at Tesco supermarkets, asking people to add an extra tin to their weekly shop. Most importantly, I sat and listened to the stories of the hundreds of people who came through the foodbank doors for emergency food.

The idea that more people are using foodbanks because there are more foodbanks is a popular one. But, in reality, people are using foodbanks as a last resort, when the benefit delays, sanctions, debt and low pay have finally caught up with them. My research, as well as that of other academics, charities and frontline professionals showed that a major reason for people using foodbanks was the impact of welfare reform. It was common for people to have experienced significant problems with benefit delays and sanctions, which led to lengthy periods without income for themselves and their families. Other reasons that brought people through the foodbank doors were ill health, bereavement, relationship breakdown, substantial caring responsibilities, precarious jobs, and redundancy.

Although research has repeatedly emphasised the link between foodbank use and welfare reform over the past five years, the Government denies that a connection between the two exists. Instead, it chooses to dismiss foodbank use as a lifestyle choice of those who are unable to budget properly or who would rather spend their money on cigarettes, flat screen televisions, alcohol, and iPhones. Perhaps unsurprisingly, I found that this political rhetoric had a strong influence on beliefs about foodbank use and deservingness, and could lead to stigma, shame, and embarrassment for the people who needed to use them. As a result, people would postpone asking for foodbank support until they were truly desperate.

The big challenge is ensuring that ‘emergency’ food support continues to be seen by the public as a consequence of food poverty and inequality, rather than a permanent solution. We need to listen to the stories and the voices of people foodbanks so that we can understand who uses them, why, and what it feels like. Perhaps these messages are reaching a wider audience now with Ken Loach’s latest award winning film I, Daniel Blake, which has been called ‘a rallying cry for social justice’ with its depiction of the inefficient and often cruel bureaucracy of the benefits system. It is hard to not feel empathy when watching lead character Katie in the haunting foodbank scene, or in witnessing Daniel’s day-to-day struggles in applying for job after job, despite being unfit for work.

But it is hugely important to make sure that the messages in the film, as well as the messages of the book, are heard not just by people who are sympathetic to what the research is saying, but also by people who don’t quite believe that the benefits system is really that bad, or who are adamant that poverty is a lifestyle choice.

Kayleigh’s book ‘Hunger Pains: life inside foodbank Britain’ was placed second in the British Sociological Association / BBC Radio 4 Thinking Allowed Award for Ethnography 2017.

Saturday, 8 April 2017

Passionate Advocacy versus Dry Evidence

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University

Should public health researchers be passionate advocates of their work when engaging with policy makers or should they present their findings in the most neutral way possible, sticking to the facts only (and preferably economic figures) to encourage take up of their research? This question was the focus of a heated debate at the recent national School for Public Health Research Annual Scientific Meeting, bringing together researchers from eight different centres of excellence across the UK and a selection of senior health practitioners at the Royal Society in London.

Chris Whitty: academics should present their findings neutrally
to politicians without making any advocacy statements
The tone for the debate was set by Professor Chris Whitty, Chief Scientific Adviser for the Department of Health, who challenged the audience to be more ambitious in their public health goals. At the same time, he warned academics to play to their strengths: if they wanted to ensure impact of their work, academics should present their findings neutrally to politicians without making any advocacy statements, as this would deter politicians. Advocacy should be reserved for politicians, who in turn are supported by economic advisors. Therefore, academics would do well to present their data in terms of opportunity costs and trade-offs; without solid economic back-up, any evidence claim would be quickly dismissed by politicians, according to Whitty.

This provoked strong reactions from audience members and particularly on Twitter, where a lively discussion ensued throughout the rest of the day. People questioned whether it is possible or even desirable to leave advocacy at the door when dealing with politicians. Some argued that, from a social science perspective, there is no such thing as neutral evidence and that it is our duty as public health scientists to take a stand and advocate against increasing health inequalities. Others disputed the need from politicians for dry evidence, stating that purely evidence based approaches can leave politicians cold without a persuasive narrative. Instead, emotionally informed and narrative research was important to persuade local government. Researchers needed to align themselves with local government concerns and cultures and acknowledge the importance of context to have any impact.

Duncan Selbie: academics should be more ruthless, coordinated and angry
in the interactions with policy makers to get them to act on the evidence
Duncan Selbie, Chief Executive at Public Health England, poured oil on the fire in the afternoon by appealing for the exact opposite to Chris Whitty’s call for more neutrality: academics should be more ruthless, coordinated and angry in the interactions with policy makers to get them to act on the evidence that academics have generated. He encouraged public health researchers to make more use of behavioural science to help policy makers take notice and implement their findings. This provoked several reactions, with some participants highlighting the role that advocacy played in the public health fight against the tobacco industry, while others made passionate pleas on soapboxes for the re-politicising of public health science, arguing that it was unhelpful to divide science and politics into two separate worlds.

The storm seemed to settle towards the end of the day, when Twitter users and audience members started suggesting solutions for the debate, which was dubbed “Passionate Advocacy vs. Dry Evidence”. One suggestion was that public health researchers should develop a ‘horses for courses’ approach: at certain times some people needed to be passionate advocates, while others at different times needed be neutral scientists to get the listening ear of politicians. The different approaches were related to different levels at which politicians operate: local politicians were more persuaded by narratives emerging from research and advocacy, while national politicians valued neutrally presented evidence and data.

Others suggested the use of intermediates to make the advocacy case for public health, such as voluntary community organisations that represent the will of the people, and by focusing research on the key questions that front line workers are struggling with. Or even better, persuade policy makers to become advocates of research evidence!

Overall, participants agreed that science needed to be pushed more up the policy agenda, as research is currently losing out to politics and economics. Therefore, in some circumstance researchers need to consider accept that submitting good enough evidence quickly is better than waiting too long for perfect peer reviewed publications. Furthermore, we need to be aware that different kinds of evidence are used in decision making processes.

My favourite solution was proposed by Professor John Frank, Director of the Scottish Collaboration for Public Health Research & Policy: if you want good policy influencers, you need to change the academic model to produce them. The biggest barriers to knowledge mobilisation are structural and often in academia. As long as we don’t train public health students in engaging with policy and practice partners, fail to teach and reward them in how to use different types of evidence and do not involve them in collaborative research, we will keep returning to this debate for many Annual Scientific Meetings to come.

Friday, 31 March 2017

Do public health practitioners make good fire fighters?

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University

Given ongoing budget cuts and diminishing local capacity, one might be forgiven for thinking that soon public health practitioners will only be responding to emergencies, such as disease outbreaks and substance abuse epidemics. Fighting these public health fires would leave little time and resources for prevention and working with other public organisations. An event co-organised by Fuse, Durham County Council and Darlington Fire & Rescue Service recently proved quite the opposite: fire fighters and other public organisations are very capable of ‘doing’ public health.

Can public health researchers learn a trick or two from fire fighters?
The increasing focus of the Fire and Rescue Services on prevention over the last 10 years has seen the development of innovative approaches that support public health: from helping people with dementia, to tackling child obesity and getting people active (for some excellent examples, see the Local Government Association (LGA) report Beyond fighting fires).

In Durham, the Fire and Rescue Service implemented so-called Health and Wellbeing Visits. As part of home visits to check fire safety, fire fighters ask residents questions about their health and wellbeing (e.g. about falls, smoking and alcohol use, heating and loneliness and isolation) and provide them with advice or signpost residents to relevant services to address any health concerns.

Over the past year (Feb 2016 – Jan 2017), no less than 15,732 Health and Wellbeing Visits have taken place with over 1,800 referrals to various services in Durham and Darlington, accessing vulnerable residents that are often not on public health’s radar. Because of their trusted reputation, the Fire and Rescue Service can get behind the front doors of these people and help them access health services. Perhaps not surprisingly most referrals relate to loneliness and isolation, with an ageing population keen to live at home independently but with a social care system lacking resources to support these people in and outside their homes.

Even the police is getting in on the act of public health prevention with partnerships being established between health and the police across the UK to support, among others, suicide prevention and reduce alcohol-related harm, as was recently illustrated in a Public Health England paper.

In turn, public health practitioners are taking on new activities that were previously deemed outside of their scope. For instance, the Durham County Council’s public health team is actively supporting energy efficiency improvement schemes (such as Warm and Healthy Homes), in recognition of the link between excess winter death and cold houses. Poor quality housing, low incomes and high energy costs result in residents having to choose between food or fuel. To prevent residents from having to make that choice, council officers are providing tenants at high risk (e.g. people with cardiovascular and respiratory conditions) with new central heating, boiler repairs, home insulation and energy saving advice.

This blurring of boundaries between public professionals is not new, but public health moving back into local authorities has created opportunities for linking prevention activities across a wider range or organisations. The event provided many other examples of this, e.g. GPs prescribing boilers to patients with long-term conditions and Citizens Advice providing welfare rights advice to elderly residents.

This new boundary blurring builds on existing policy initiatives, such as Making Every Contact Count and Health in All Policies, which all involve the wider public health system. Participants at the event made it clear though that this is not a simple cost-saving exercise, allowing councils to pass the public health buck to other parts of the system. Instead, these new partnerships are characterised by a genuine exchange of knowledge and practices between public organisations at the front-line. It highlights a new way of working that recognised joint priorities and the values of other professions to achieve these priorities through the sharing of resources and by taking on new roles. As Professor David Hunter outlined in his presentation at the start of the event, these new partnerships require a different form of leadership, which is less hierarchical and formal, not so much concerned with Key Performance Indicators and commissioner-provider splits, but more focused on the value of relationship building, trust and 'soft' skills.

The event provided a platform for looking at these new partnerships and the evidence for their effectiveness. If anything, it highlighted a challenge for public health academics to research these new partnerships: how to make sense of the contribution of each partner in a system where boundaries are rapidly blurring? Maybe public health researchers can learn a trick or two from fire fighters.

Find out more about the event: Creating Healthy Places in the North East: the Role of Fire and Rescue Services and Fuel Poverty Partnerships

Photo attribution: "Rochdale Fire Station Opening Day" by Manchester Fire via Flickr.com, copyright © 2014: https://www.flickr.com/photos/manchesterfire/13288225965/

Friday, 24 March 2017

Beyond bricks and mortar: re-thinking home and health

Dr Philip Hodgson, Senior Research Assistant, Northumbria University

In a time of continued public spending cuts, policy drivers to age in place (to grow old in the home or in a non-institutional setting in the community) and an increasing ageing population, the challenge to ensure that people can live longer and healthier in their own homes is growing. Yet, solutions for this, when a host of other factors – the development of housing to meet commercial rather than health pressures, future generations with little equity in housing that can be used to fund future care, the prevalence of a belief in a “forever home” – are difficult to identify.

That was one of the core messages discussed at the first ‘Home and Health’ research group hosted by Northumbria University and Fuse (via the pump-priming research fund) last month. This brings together researchers, practitioners and policy makers interested in the impact of housing on health. The seminars aim to foster a core working group, culminating in the development of concrete plans for collaborating on further research in this area. Building on insights from previous Fuse Quarterly Research Meetings (‘Creating Healthy Places in the North East’ in October 2015 and ‘Reuniting Planning and Health’ in April 2016), the seminars aim to take stock of existing evidence on how housing conditions can promote or impede healthy ageing, and identify gaps for further research. Our first seminar explored priorities for research from a policy perspective and we were thrilled to welcome Gill Leng (National Home and Health Advisor to Public Health England) to present.

Gill Leng, Public Health England, presenting at the Fuse research meeting
Gill highlighted the need to think about ‘homes’ (a term which people identify with and encompasses emotional connections to a place of living) rather than just ‘housing’ (a term used when referring to the workforce and describing bricks and mortar). While evidence and action often focuses on the risks posed by unhealthy homes, little is done to address unsuitable or precarious housing. Although most older people own their homes, these are not necessarily healthy. The challenge we face is to identify an approach to housing which allows its support to develop and mirror our own changing health needs through the life course. This is not just a case of using adaptations and facilities, but reframing how we conceptualise the home as a physical location, a part of a wider social environment and a personal / psychological space.

The conceptual spaces of home illustration used in the seminars 
Group discussions focused on this issue (among others). At the personal level, a tension was found between the maintenance of private life and the role of external sources of support. Current policy relies on care delivered by family members, but this can in turn cause problems for individuals without these links. Also, how do we develop mechanisms that initiate people’s thoughts on the best accommodation for them before they reach a point when they’re in crisis / a change is urgently needed and driven by necessity rather than choice (e.g. when people with dementia still have capacity to make an informed choice)? At the level of buildings and services, these problems take on a more concrete form, where the permanence, inconvenience and cost of a housing adaptation to support health is seen more as an obstacle to avoid rather than an enabler in the future. Meanwhile, within social and environmental factors, the current focus of housing policy on volume, rather than quality of public space, and a decrease in social cohesion were both noted as linked factors that could influence health as the population ages. The depth of discussion at each of these levels highlighted the importance of issues of home and health. But to address it we need to move beyond the ideas of bricks and mortar, and consider how we think about and use our homes to facilitate our health and wellbeing as individuals and a wider society.


Our first seminar explored priorities for research from a policy perspective
All of these issues will be picked up in future sessions, which will focus on good practice, existing research in the field and funding opportunities. We’ll be continuing to blog about each of these events and their outcomes, so please check back for more information soon.

If you are interested in joining the group and attending future seminars, please contact Phil Hodgson philip2.hodgson@northumbria.ac.uk

From left: Peter van der Graaf, Monique Lhussier, Natalie Forster, Phil Hodgson
and Dominic Aitken; organising team for the home and health research interest group

Friday, 17 March 2017

Food as a job, life and research: the many meanings of what we eat

Posted by Amelia Lake, dietitian and public health nutritionist & Fuse Lecturer in Knowledge Exchange in Public Health, Durham University

Food is my job. As an academic dietitian and public health nutritionist I spend my time questioning why people eat what they eat, and thinking about what we can do to change behaviours. As a mum, I also spend a lot of time at home wondering why a 4-year-old and a 17-month-old eat what they eat!

Its nutrition and hydration week, which aims to highlight, promote and celebrate improvements in the provision of nutrition and hydration locally, nationally and globally. So this is an excellent opportunity to explore the many roles of food in public health.
Top shelf material

Food is life. We need nutrition and hydration for life and to maintain health.

Food is a thread that moves through every aspect of our life from the everyday to the special occasion.

I read somewhere that the origin of culture was when raw ingredients were cooked. The importance of this event was not so much in how food was prepared but in the organisation of individuals around meals and meal times.

Food has shifted populations and started wars; think of the thirst for sugar, tea and coffee (also known as the ‘hot drinks revolution of the eighteenth century’) and the impact that had on various countries and their populations.

Food is our culture and identity; it is an intrinsic description of who we are and where we come from. For example, I am a complex mixture of Persian dishes, Indonesian dishes and some Northern Irish wheaten bread and Tayto crisps.

Food is our comfort. That dish your mother made, it’s a warm familiar blanket; it evokes memories, both good and bad. It is a way in which we show others that we care for them and are thinking of them.

The party bag horde - a focal point for arguments
Food is a focal point for arguments: “No you can’t have any more sweets from the party bag…” A conversation every parent has at one point or another.

Our social media feeds provide us with ‘food porn’, hands that whizz up magical results in seconds. Additionally, social media and the press provide us with self-styled food and nutrition 'experts' presenting us with spiralised courgette and clean eating advice.

Food continues to dominate our life and the public health agenda on a global scale.

The World Health Organization’s global targets for 2025 to improve maternal, infant and young child nutrition tackle a range of issues from obesity to stunting and wasting.

In this country we are familiar with the concept of our obesogenic environment; an environment in which calories are easily accessible and available and with little opportunity to expend that energy. In an attempt to tackle the obesity problem in this country our government will follow Mexico and introduce a sugar levy.

Despite the issues of over-nutrition and the seemingly endless opportunity to buy food, food poverty is a term we have become more familiar with. Despite it sounding like it belongs to another era, it’s a very real issue for a significant proportion of our population. Oxfam estimates that 500,000 people in the UK are now reliant on food parcels. Foodbanks provide nutrition to those who struggle to feed themselves and their families and have sadly experienced rapid growth in recent years, especially in the UK.

How can research help to address these global and local problems?

Free fruit with every purchase
Within Fuse ‘food’ runs through a number of research themes, from behaviour change to healthy ageing. As part of the national School for Public Health Research, a team of Fuse researchers has evaluated a food training programme run by Redcar and Cleveland Council. To promote the findings from this research we decided to create a short film and this week were filming in a small sandwich shop in the market town of Guisborough, where you were offered a free piece of fruit with every purchase. This small business owner’s focus is food. She provides food to customers every lunch time. This owner had attended the training course run by the Council and decided to make a difference by providing more healthy food.

This is an important step, supported by research. On this nutrition and hydration week, I am sure you will agree that there is still much to be done on this important and vast topic across many disciplines and on a global scale.