Little legs

Posted by Linda Penn

I was pleased that the train arrived to take me to Middlesbrough on a freezing January morning, although not so pleased that it was the cold train (heating in this train hasn’t worked for months). By the time I got to Middlesbrough station I was frozen through. Claire picked me up and took me to an annex at the back of what used to be St Cuthbert’s church. In this very cold and rather dark annex was a ‘community gym’ and I was there to interview South Asian women about their physical activity, as part of the evaluation of our preventive intervention feasibility study. By then I was so cold I would have preferred to tramp the treadmill to warm up or maybe even indulge in beginners’ Zumba. However, when the women started talking I forgot to be cold. Qualitative research can be such joy.

St. Cuthbert's Church, Middlesbrough, 1965

St Cuthbert’s church used to be near my uncle’s butchers shop, until the planners bulldozed the community to drive a road through the heart of the town and move people out to a concrete desert. I didn’t know, until my cousin told me recently, but they had apparently sold halal chicken from this shop. So there must have been a Muslim community in Middlesbrough for some time.

My great aunt Minnie’s sweet shop was also somewhere nearby St Cuthbert’s. I think she ran the shop from the front room of one of the little terraced ‘slum’ houses. This house too has long since been reduced to rubble. I only remember going there once and I was very young. Minnie was too old then to keep shop and my sister and I had been warned that Minnie had ‘little legs’. We were not to ask or comment. In fact, we should just pretend we had not noticed. The legs were not at all obvious when we arrived as she was sat in her big chair by the fire, with a rug over her knees. However after a while she got up to fetch the coal from the back kitchen. When she got up she was walking on her knees – the little legs. It was a shock, which must be why I remember. Nevertheless Minnie managed to negotiate down the stone step into the back kitchen to fetch the coal and obviously back up the step with the bucket of coal. I remember watching her. I am sure someone would have offered to go and get the coal for her, but she must have refused with such determination that no-one dared interfere. 

St. Cuthbert's Church, Middlesbrough, 2008

Not until years later did I appreciate that Minnie’s little legs were as a result of diabetes related amputations. That was my first introduction to the nasty, progressive and debilitating disease that is diabetes. It was pure serendipity that this January I was back almost where I started and the prevention message is the same. Although I hope the prosthetics have improved.

The day the media circus came to town

Posted by Jean Adams

Is it more scary when Monty Don slags off your research on Twitter, or when a professor who you respect a lot asks you nicely to be a bit more careful with your not-quite-what-it-was-designed-for use of his carefully developed tool (also on Twitter)? How about both on one day?

What seems like a long time ago now, an MSc student emailed to ask if I’d be interested in chatting about an idea he had for a dissertation project.

His idea was simple: compare the nutritional quality of ready meals to celebrity chef meals. I don’t think the student (now graduate) in question would mind me saying that he’s not unfamiliar with a ready meal, or currently maintaining his weight within the recommended BMI range. Slightly fed up with being told his ready meal habit was bad for him, he was interested in finding out just how bad and whether it was any worse than the alternative that seemed to be in his face whenever he was eating his ready meals – something served up by Nigella, Jamie or Hugh.

In contrast, I and my co-supervisor were backing the celeb chefs. I don’t think I’ve ever eaten a ready meal, and it is possible that I have an affinity for glossy recipe books that has resulted in a collection that outgrew the kitchen bookcase some time ago. Scientists are neutral (not). We might be able to collect and analyse the data objectively, but it was clear what results each member of the research team was hoping to find.

The project was perfect for an MSc dissertation: clear research question, data collection primarily via the web, fairly straightforward analysis, no ethics permission required. We joked in supervision that the BMJ would love it.

And so it came to pass that the student collected and analysed his data, perhaps stretched the use of front of pack labelling for a good gimmicky visual a bit too far, got a good mark, and toddled off back to his real job promising to send us a draft of a paper sometime. Often those manuscripts never materialise. But lo! This one did. I wasn’t absolutely convinced that the BMJ really would love it, but we’d said they would and it seemed a shame not to try. They say ‘no’ pretty quickly.

I was mildly offended when the BMJ’s response to our rather serious and important piece of work was that it was “quirky” enough for their Christmas edition. Sure it was fun and sure I wasn’t quite convinced that it was good enough piece of work to be considered normal BMJ material. But there is a serious point here: lots of public health advice suggests that people should cook from scratch and implies this is better for you than eating ready meals. If you don’t know how to cook from scratch, then it isn’t a wild assumption to suggest that you might learn from the most prominent cooks around – celebrity TV chefs. A nutritional comparison of the two doesn’t seem outrageous.

Presumably you know what our findings were? We found that, on a number of nutritional metrics, ready meals did better than celebrity chef meals, but neither of them did very well. The ready meals were less unhealthy than the celeb chef meals, but it would probably not be right to say the ready meals were healthier than the celeb chef meals.

I knew what was going to happen. I didn’t have any idea how to stop it happening. Perhaps there was none.

The BMJ went to town promoting our paper. The media loved it. We got on the Today programme headlines, the paper was covered by loads of newspapers and not just in the UK, all three of us spent most of publication day doing interviews with just about everyone and their dog. But however much we tried, it was very difficult to get the message across that neither group of meals were particularly good for you – we were definitely not saying that ready meals are the way to go. But that’s the message that everyone seemed to hear.

Ho hum. What can you do? The media circus would move on. No-one would remember. And presumably any colleagues who would, might take the time to read the paper (or at least the abstract), and not just go on what was in the newspapers?

I can understand why people went for the “ready meals healthier than celeb chefs” headline and why that then prompted all the various responses it did. But I was most bothered by Monty Don’s response. And not just because I’ve always thought he seemed like a nice, and thoughtful, guy.

Do lots of people think scientists should only do, and publish, studies that come up with the ‘right’ results? That we should make sure the measures we use are designed to come up with those ‘right’ results? What about Ben Goldacre and the All Trials campaign for open data and publication of all trial results – not just positive ones? How does that match with this attitude? Or maybe I’m assuming that Monty is more representative of ‘the public’ than he really is.

My Big Fat-and-Caffeinated New Year’s Resolution

Posted by Heather Yoeli

I need a coffee. I can’t write without coffee. Happy New Year. May 2013 be a year of love and blessings and decaffeination for you and all those whom you love. And please excuse the very inept deployment of the subjunctive in the previous sentence. I need a coffee, you see...

I’m sure I’m not the only one within Fuse to have made a New Year’s Resolution. I imagine that I’m not the only one within Fuse to have made a health-related behaviour-changing type New Year’s Resolution either. I am (deep breath) going to make fewer – alrightalright NO - trips to the friendly new espresso machine located at the local garage and I am (even deeper breath) going to put the money saved towards one of those cringworthily excruciating-sounding Mummy-and-Tot Dance Classes, through which I will instil in my progeny an enthusiasm (grit teeth) for exercise. And I’m wondering what New Year’s Resolutions others might have, and how forthcoming they might be in sharing them with a blog…

My vice. This is a caffeine molecule, apparently. Chemistry was never my strongest suit, so I’ll take its word for it.

Within most areas of health, healthcare and health sciences, there exists an ethos which says that professionals and researchers should distance themselves from their area of practice or study. If, for example, you’re a doctor or a PhD student with diabetes or bipolar disorder, it’s nobody else’s business at all and they can piss off if they ask you anything about it. You don’t go there because to do so would be unprofessional or self-indulgent or irrelevant or burdensome to others, in essence a transgression of Western society’s Cartesian boundary of subject/object, body/mind, Self/Other. In other words, our personal lives need neither to be affected by nor to affect anything we do to pay the bills. It’s all a stress-management technique or a coping mechanism or a survival strategy, and one with which few would disagree.

Within public health, however, ethical challenges emerge from attempts to uphold such distinctions. Even those of us who subscribe to the most deterministic and we’re-all-merely-victims-of-our-social-environment woolly leftie-isms would concede that we all exercise some level of choice regarding our health behaviour: we decide, for example, how much (if any) chardonnay we drink, how frequently (if ever) we disinfect our chopping boards and whether (if female) we turn up for smear test appointments. Merely by virtue of possessing some level of personal autonomy and merely by living in a country offering virtually universal health services, we are all patients (or service users, clients or consumers) of public health. And some of the choices we make with regard to our health will be visible or apparent to those with whom we’re working.

Within qualitative service evaluation literature produced on public health interventions in the Cowgate community, smoking is a case in point. Davies (1998) does not mince her words:

… some families spend a third of their income on cigarettes. The smoking message is one that the midwives repeat over and over again, and everyone, including social workers, seems to ignore it... 

Stacy (1988) puts it a little more discreetly:

Staff should decide whether to make reduction in smoking one of the objectives in their health promotion work.

In other words, if we can’t give up smoking why should they want to?

And if I’m wasting £2.30 a day on un-recycled paper cups of over-caffeinated beverages funding a monolithic rainforest-destroying global multinational, how can I think with any integrity about questions of ethics and sustainability with public health? I’m really [expletive redacted after long tea-fuelled discussion with editor] going to have to do this. Aren’t it?

So, before I put the kettle on for camomile tea in a vain attempt to assuage the shakings and cravings of my coffee withdrawal, would anyone else like to share what they’re resolving to do to address their own un-public health-worthy little vices? What’s your New Year’s Resolution, and why?

The pensiveness of the long distance runner*

Posted by Jean Adams

Have you been following #episongs? It’s like a game. But for epidemiologists. On Twitter. You’ll appreciate this lends it a certain in-crowd, geekiness:

     Bayesian Rhapsody (from @martinwhite33)

     One way or ANOVA (from @soozaphone)

     Geoffrey Rose the boat ashore (from @gingerly_onward)

     You say use StAYta, I say use StAHta (yours truly)

I have been using my running time this week to dream up contributions.

The loneliness of the long distance runner, Dir. Tony Richardson

I run most days. I down tools sometime between 5 and 6pm, gather up my stuff, head down to the toilets in the lobby of our building, where a secret door takes you through to a tiny changing room, and change from smart young professional into Supergirl. Well, more often it is from slightly scruffy climbing hut chic (as my dad once graciously labelled it) into rather smelly day-glo shirt and running tights.

Often I can’t quite be bothered. But I have found that this thought can be turned off long enough to get changed and out the door and by the time it comes back there’s no choice left.

I run because I like to be fit enough to keep up with my climbing hut buddies, because it gives me licence to eat a certain amount of cake, because it gets me outside for at least 45 minutes, and because it allows my brain to think in a different way from normal. I think it keeps me healthy. But it might not.

When I'm running, my thoughts take on a different quality. I don’t have to stop them because I need to focus on getting an abstract down to 250 words, wording an email just right, or so I can work out what exactly the person speaking is trying to say. I can just let them happen. But it’s not like there is a jumble of thoughts. Often it’s just one thing. Going back and forth. Round and round. Upside down.

I have some of my best ideas when I'm running. Ideas for research projects. Ideas for how to solve the problem I've been sweating over all day. Ideas for how to teach the cohort study session without killing everyone in the room with boredom. Ideas for #episongs.

Sometimes I think that the quality of my thoughts is so good when I'm running that running time should be reclassified as working time. Other times, my thoughts are not about work at all and I would feel resentful of having to think about something in particular when I'm running.

I presume the two things are not unlinked: my thoughts happening differently, and the good ideas coming. I presume there’s a technical term for the thoughts thing too. Once when my brother was particularly frustrated about something or other, I suggested he take up running. He said he was going to go on a meditation retreat instead. I suspect they might amount to nearly the same thing.

I'm a bit of a running evangelist  But I try not to be a running bore. Pounding the same loop, or variations of it, day after day is not that interesting of itself. Beyond the occasional wildlife spot, hardly anything interesting happens when I run, apart from in my head. There is not much about running itself to talk about. And, to be honest, I can get the same thought effect from swimming, walking and various other repetitive physical pursuits.

What I really want to get out of running right now is a running related #episong


*with apologies to Alan Sillitoe

From middle-class to world-class

Posted by Peter Tennant

I enjoy watching tennis, use words like 'loo' and 'supper', and open my Christmas presents after lunch. In the UK, this makes me firmly middle-class. But much as I might protest (usually by wittering about my 'deprived' schooling), I know it's the truth. Why else would I feel so at home in academic research, a profession dominated by the middle classes?

Strawberries and cream at Wimbledon

On the plus side, this makes for some delicious bring-and-share lunches, what with all the Marks & Spencer nibbles, and home-made cakes (made, of course, with organic locally-sourced ingredients). But much as I enjoy free-range cupcakes, is it good for research, especially in a subject called 'public' health?

Former British Prime Minister Tony Blair might have once declared that 'we're all middle class now', but the gap between the UK's rich and poor is arguably wider than any time since the Second World War. And where there are income differences, there are also differences in health status and health-behaviour. Which has left me wondering, are a largely middle-class community best placed to understand and empathise with the UK's most deprived, so often the 'public' we are trying to target in 'public health'?

Don't get me wrong - I'm not saying that great work isn't being done by great people. And I'm not saying any researcher is actively biased. Anyone who's ever met a Scientist will agree; we are generally quite objective. After years of being drilled to act like a robot, some of us have even converted to running on petrol and oil, rather than continuing to rely on the inefficiency of food and water.* But even the most robotic researcher will find it harder to accept something, or even think to ask about something, that doesn't fit with their own experiences or world-view.

ERROR! ERROR! DOES NOT COMPUTE

Could this narrow demographic also (partly) explain why researchers find certain groups so hard to recruit? Or, to put it more bluntly, are UK public health researchers sometimes talking a different language? As an unhealthy person working in an Institute with the word ‘health’ in its name, I know how patronising it can feel:

“Post-exercise endorphins you say? I’m afraid all I get is wheezing, cramp, and a sensation of impending death”

I doubt it’s a coincidence that successful commercial organisations like Weight Watchers employ members of the local community, who have previously lost weight and maintained a healthy weight thereafter, to run their meetings. In other words, people who speak the same language. Could you imagine the same meetings being run by an average public health researcher?

1) LOADING WEIGHT LOSS PROGRAMME LESSON 001
2) INSTRUCT AUDIENCE TO “DO 30 MINUTES OF MVPA**”.
3) LESSON END

OK. Slight over-exaggeration. In fact, the best public-health interventions draw on detailed qualitative research (i.e. where brave researchers have ventured outside the ivory tower to speak to real members of the public) to ensure it addresses the needs and barriers of the target population. But I still think a bit more demographic diversity wouldn’t do the profession any harm.

*This sentence may contain factual errors
**MVPA, by the way, is public health research speak for 'Moderate or Vigorous Physical Activity'

What happens when you put fresh fruit & veg in local corner shops?

Posted by Jean Adams

This post is about a research paper that is published on-line today. Writing about research findings is a new venture for the Fuse Blog. Let us know if you want to see more results write-ups like this by leaving a comment below, or tweeting me @jeanmadams

In 2008, the Department of Health in England decided that one way to get people to eat more fruit and veg was to make it more readily available in local, corner shops.

The rationale was fairly simple – corner shops are less likely to sell fruit and veg; people who live in poorer neighbourhoods are less likely to have cars; thus they probably shop more at local corner shops and so probably have less opportunities for buying fruit and veg than people who have a car and use it to shop at a big supermarket.

Simple, but perhaps flawed. But let’s not talk about that for now. 

The corner store initiative was part of the all-singing-all-dancing Change4Life campaign. In our region, the North East, 17 stores were selected for an intensive intervention that involved part funding for a brand new chiller cabinet, a partial store re-fit to allow fruit and veg to be displayed more prominently, a funky little fruit and veg stand on wheels, and lots of Change4Life branded ‘merch’ – posters, stickers, shelf strips, you name it. A further 70 stores got just the stand and the merch. All stores were given various written materials to help them make more of fruit and veg.

Launch of a new Change4Life store in Portsmouth

There was a lot of publicity around the intervention and lots of shops got in their local papers. Which was great. But the point was to encourage people to eat more fruit and veg. Did it?

We spent a lot of time and effort trying to get funding to do a full-on outcome evaluation of this intervention. Sadly, although we did initially get awarded funding, it was withdrawn at the last moment (a story for a different post). Instead we did a small, process evaluation. Around two years after initial implementation, we looked at whether the stores were still using the intervention materials. We also asked 10 people who had been involved in the intervention in different capacities how it had gone.

What we found was that less than half of the stores were still using the campaign materials – apart from the funded chillers, which were all still in place. Shopkeepers told us that the merch just didn’t last very long and they didn’t know how to get replacements. They also thought that the campaign had been intended as a short-term initiative and were a bit surprised that we were still interested two years on.

Lots of shopkeepers and managers complained about a lack of communication with the intervention team. They didn’t have a clear idea what the intervention was aiming to do, or how to keep it going after the initial fanfare of its launch. DH was aware of this, and they tried to maintain the momentum by linking shops to local health workers and primary schools in the hope that schools and other community organisations might choose to buy their fruit and veg from Change4Life stores. Unfortunately, this never really worked and there were some tensions between the ultimate commercial aims of shops and health promotion aims of health workers.

As we weren’t able to collect any information on the impact of the intervention on consumption of fruit and veg amongst local people, we can’t ever say for sure whether or not the campaign was effective. But our results do suggest that it was unlikely to have had any sustained impact.

Sadly, lots of enthusiasm and funding seems to have got bogged down by poor communication and a focus on style over substance. The lessons are wide reaching, but perhaps not new.

You can read the full results here.

10,000 steps? Easy-peasy-lemon-squeezy!

Posted by Jean Adams

I admit it. I am a health fascist.

Well, now I’ve read the Wikipedia entry on healthism, I think I am only a part-time health fascist. I’m strongly in favour of living a healthy lifestyle and of the government going out of its way to make this easier for everyone to achieve. I don’t necessarily think that “the problem of health and disease [is situated] at the level of the individual." In fact, I read a great article this week taking an evolutionary approach to socio-economic inequalities in health behaviours. The phrase that most sticks in my mind is: “if you want to change an organism’s behaviour, you need to change its environment”.

But, anyway. I’m all for the healthy lifestyle. As a public health insider, I try to set a good example without the need for environmental or motivational interventions. I don't buy any of that "these targets are unobtainable" stuff. I eat my five-a-day. I do my 5x30 minutes of physical activity per week. I don’t smoke. I don’t drink. I don’t have multiple partners (well, not in bed). OK, I admit it, I do drive marginally (a lot) faster than the speed limit on occasion (every day).

Surely I do enough running to make the grade? (photo: Martin White)

If totally motivated, no kids, decent salary, partner who definitely does almost 50% of the housework, me can’t meet the guidance, who can? 

So, it was with rather gay abandon that I took on a step-challenge competition with some colleagues. The idea is that we should be taking 10,000 steps per day. This is, apparently, equivalent to walking about 5 miles. At a brisk pace of 20 minutes per mile, that would be an hour and 40 minutes per day. So, quite a lot more than your 30 minutes, five times a week. Unfortunately, I didn’t stop to work all of this out until after agreeing to the challenge. 

The bottom line is that I thought it would be easy-peasy. My colleague reports he manages his 10,000 steps easily. Obviously super-healthy me is going to totally Whup. His. Ass. 

As health researchers, we know all about the problems of measurement error and the importance of comparing like with like. The competition will, therefore, involve standard issue pedometers – a step counting gadget that my colleague has taken the trouble to validate against more expensive gadgets. 

Yesterday was my first day on the pedometer. I had a fairly normal day that included a short bike commute and a six mile run. I only managed 9089 steps. 

Now come on! That’s not fair. How can a six mile run not be enough? This gadget is obviously useless. Everyone knows that a running step is longer than a walking step. And think of all the extra energy involved in running versus walking. My steps are clearly worth a lot more than other people’s steps. 

So you can take your 10,000 step challenge back. Your targets are totally unrealistic and unobtainable. I’m not playing anymore.