Playing in the sand: the joys of peer pressure

Posted by Peter van der Graaf

Have you ever wondered what would happen if you put 28 stressed-out early career researchers in a country hotel and gave them the option to either enjoy the available swimming pool, spa, snooker room, and pub with sun soaked terraces, or to write a full research proposal of up to 5,000 words with five unknown people in less than four hours and submit their work for scrutiny to a hard-nosed review panel of senior academics and professionals? Remarkably, when Fuse tried this out last week in the Sandpit event at Linden Hall, the result was five serious proposals, steeped in blood, sweat and tears, that somehow managed to persuade the review board to part with £2,500 of prize money.

The distractions were plentiful: giant Jenga, Connect4, indoor cricket, extensive breakfast and lunch buffets, (attempts at) nouveau cuisine diners, tough pub quizzes presided over by quiz-wizard communications officer Mark, log fires with arm chairs, and more coffee, tea and cakes than was healthy to consume, while hero professors bared all (at least their life stories) under large glass chandeliers. In spite of all these temptations, the researchers locked themselves up in their rooms, questioned the wisdom of their mentors, cross-examined policy and practice experts on their chosen subjects, argued and quarrelled at length with each other, and somehow managed to produce something that could pass for a research proposal.

Nerd peer pressure

The secret, you might wonder, is a classic tale of peer pressure, which early careers researchers are especially prone to. What the event allowed them to do was to learn this lesson (and many others in the course of it) and, even better, to enjoy it: a relaxing swim or pint in the pub is much more enjoyable after a chaotic session with five strong minded colleagues who are trying to reach a decision on what topic to choose for their proposal (only to find out later that they were allocated their third choice). A quiz or game of Jenga seems all the more exciting after struggling for three hours to put anything on paper, only to realise you have an hour left to write the remaining 5,000 words.

Therefore, a big thank you is in order for the organisers of the event, particularly to Avril, who had to miss out on many of the temptations due to a sudden bout of flu, and to quizmaster Mark, who clearly has too much free time on his hand to come up with the questions he did.

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

Making the connection

Guest post by Kathryn Oliver

About 2 years ago, I had one of those ‘Eureka’ moments that totally changed my life. Genuinely. It was right up there with finding out about Oyster cards, or washing machines, or something.

At the time, I was a PhD student in my first year, working on a fairly standard project about developing health indicators. As a project, it was fine – about the use of evidence by policy makers, one of my main interests, and I was getting lots of experience in survey design. But for years, I’d been kicking round ideas in my head about the importance of personal relations. Didn’t they really explain nearly all human behaviour? Weren’t peer effects important for the spread of obesity or smoking? Wasn’t social capital important for mental health?

I’d been living on my own in London for a year or two and had found myself pondering the role of human relationships more and more. Of course, I had friends and relations, but I also liked being known by the man in the newsagents and the end of the road, and saying 'hi' to the neighbours. Did they count, I wondered? Would these relationships be enough to protect me from isolation, or going ballistic on the tube?

Imagine my delight when, attending a Social Network Analysis seminar day, run by the Mitchell Centre at the University of Manchester, I discovered an entire body of research – methods, philosophy, approaches – which looked at connections between individuals using formal statistical methods. Finding out that other people had had similar ideas to me, and had developed dedicated research methods to investigating these ideas was probably one of the best research moments I’ve ever had.

Unlike traditional statistics, network analysis does not treat individuals (whether bridges, policy makers, or swingers) as independent. Instead, any ties between actors are identified, described quantitatively and/or qualitatively and mapped. The statistics used are based on graph theory, but you don’t have to understand it to admire the elegance and usefulness of network analysis. Depending on the relationship collected, people’s attitudes, behaviours, health outcomes and more can be predicted.

For me, this is really the missing element from a lot of public health research. It can be used to identify good targets for research, or opinion leaders in secondary schools, so more targeted messages can be produced and sent out. It allows us to understand, describe, and analyse the social context within which individuals live. And, of course, make beautiful pictures. 

Example of Social Network Analysis diagram.

People have used network analysis to study all kinds of things – it’s very popular in the business world to identify ‘future leaders’ or ‘people who make things happen within my business’. Researchers have compared US senators voting patterns to cows who lick one another.

My PhD changed quite a lot after this seminar. I ended up using a combination of social network analysis and ethnography to study where public health policy makers found evidence, who the main sources of evidence were and how evidence was incorporated in the policy process. For years, academics in my field have been talking about the importance of interpersonal knowledge translation and how policy makers prefer to get their info from real people. Now I’ve been able to add my own tiny part of the story, come up with new research ideas on the basis of my findings, and learn a niche method (always useful).

My boyfriend still calls them snog webs though.

On evidence

Posted by Simon Howard

In my first week at medical school, one of the professors warned that most of what we were to be taught was factually wrong. It was an arresting statement, but it may have been true: Studies have shown that textbooks and experts frequently lag behind evidence, sometimes recommending “treatments” that are actually known to be harmful.

Do Primary Care Trusts do the same? PCTs, like the one I work in, currently commission the majority of NHS services provided to patients in their catchment areas (though not for much longer). Sometimes, academics get frustrated with PCTs for seemingly doing things that either have little evidence, or appear to contradict it altogether. Given that evidence is the bedrock of public health, and given the potential for decisions to affect whole populations, this might seem worrying.

In defence of PCTs, a lot of evidence based work does happen. Most major pieces of work include a review of academic literature at an early stage, and follow the findings. The annual Joint Strategic Needs Assessment and regular detailed Health Needs Assessments also take into account published literature and local and national data in a fairly systematic way.

But there are lots of barriers to following the evidence. Books and books could be written on this topic, from the applicability of evidence in the real-world to deciding if research is really relevant to a particular population. But I’m no expert, and I’m not going to try and describe anything technical, complicated, or even remotely clever. These are just a few examples of practical barriers to following the letter of the academic evidence in public health.

One huge barrier is – as with most things in life – money. In a world of ever-tightening budgets, an academic’s seemingly reasonable intervention can be unaffordable. As an extreme example, research by the FAA and CAA suggests that three or four lives would be saved in an average aircraft fire if all passengers were provided with smoke hoods. However, the vanishing rarity of in-flight fires, the enormous cost of supplying and maintaining smoke hoods, and the cost of the fuel required to propel them around the world, all make this proposal financially unjustifiable.

Not all examples are quite so clear-cut. Sometimes, instead of choosing not to do something, PCTs try to cherry-pick the best bits of interventions in a way that is almost certainly infuriating to the academics who pioneered them, and possibly less effective in practice. But, sometimes, doing something is better than doing nothing.

Often, there can be a big lag between publication of evidence and its implementation. One reason is the complex contractual nature of commissioning: it’s often difficult to make small changes to services that have already been commissioned. The constant pressure to reduce costs incentivises longer contracts which spread the financial risk, but which also increase the evidence-practice lag. I’m sure it’s deeply frustrating to be an academic shouting “there’s a better way to do this” while services continue unchanged.

There’s also a political element to public health. Decisions to cut services that are no longer supported by evidence are particularly tricky. In England and Northern Ireland, the evidence that cervical screening in women under the age of 25 causes more harm than good has led to a withdrawal of the service in this age group. The clear evidence, combined with clear recommendations from the World Health Organisation and National Screening Committee hasn’t stopped this becoming a topic for political debate and petition, and hasn’t (yet) changed policy in Wales or Scotland. It seems likely that this political element will play a bigger part in decision making as public health moves to the overtly politicised world of local authorities.

To me personally, the most frustrating barrier to following the evidence is an inability to access it. It continues to baffle me that the NHS doesn’t have anything like the level of straightforward desktop access to literature that university colleagues have. In the 21st century, it seems crazy that I sometimes have to ask the BMA to take a paper journal off a physical shelf, scan it in, and email it to me as the only practical cost-effective way to access a paper that’s of general interest, rather than something specific to any individual project.

I think a latent awareness of what’s going on in academia is important in public health. It might not matter so much when someone’s doing a big literature review prior to introducing a new service, but it can help with horizon-scanning, and with those little every day decisions that aren’t worthy of a trawl though the literature, and with planning for the future. This is something we can all play a part in: public health professionals probably need to broaden their awareness of the academic things going on around them, and academics probably need to shout louder about the latest developments in their fields. As an associate member, I’m probably biased, but I think FUSE is great at helping both groups.

Seeing is believing: exploring qualitative methods beyond text and talk

Posted by Shelina Visram (with Ann Crossland)

In the run up to the recent UKCRC Public Health Research Centres of Excellence meeting, I received an email asking for volunteers to help organise and deliver workshops. One of the suggested topics – ‘The use of novel qualitative methods in evaluation research’ – immediately caught my eye. I’ve been involved in a number of evaluations and most have relied on qualitative methods. So I put myself forward and was glad to hear Professor Ann Crosland had volunteered too. We decided Ann should do the bits on using commonplace methods in novel ways and I’d do the bits on visual methods. Then we went our separate ways to work on the content.

That’s when I stopped and thought: how much do I really know about visual methods? Yes, I’ve used them in a number of projects but I’m certainly no expert. I wondered who would attend this workshop. Would they be expecting to explore the philosophy of creative methods? Should I be using words like epistemology and ontology? Or could I get away with showing cute pictures drawn by small children? I decided the most sensible approach would be to hedge my bets and do a bit of both (without getting bogged down by philosophy).

Picture drawn by a 7-year-old when asked “What things affect your health?” during the evaluation of a weight management programme 

Here comes the science… Qualitative research relies heavily on the things people write or say. If you’re a positivist, you might ask how we know whether this information is ‘true’, i.e. does it accurately reflect the ‘real world’? We interpretivists tend not to worry about those things and instead accept the existence of multiple realities and therefore multiple versions of the ‘truth’. However, we still assume that what people write or say is a reliable account of their truth. Yet we know that people have different capacities and motives for sharing information. During interviews or focus groups, participants are telling particular stories in a particular social context. To what extent can we use these stories to draw interpretations about their lives outside of that context?*

This is part of the rationale for using visual methods. We acknowledge that the information people provide verbally or in writing is only ever partial and cannot be taken at face value. Visual methods give us an alternative means to examine their beliefs, attitudes, experiences and ideas about themselves. These methods are particularly useful in exploring the routine of daily life that tends to go unnoticed. For example, how many of us could describe our journey to work in any great detail? Yet if we were asked to draw, map, photograph or film our travels, we would undoubtedly provide a far richer picture of the same journey. Other examples of creative methods include spider diagrams, clay modelling, body mapping, and something called Lego Serious Play which I am desperate to try (but maybe with Fuzzy Felts – remember them?).

Advantages of using visual methods include the fact that they are interactive, encourage free expression, and often generate unexpected findings. They are also inclusive, in that they don’t require participants to be especially articulate in speaking or writing in English. I’ve used drawing in a project involving children from 4-years-old and this helped to give them a ‘voice’ in evaluating a service. Challenges include the potential to generate vast amounts of data that can be difficult to interpret, although visual methods are generally used alongside interviews and focus groups. This helps to engage participants in the process of interpretation. There are also ethical issues to consider; for example, consent is required if others appear in photos or videos.

It can take a lot of time, energy and resources to use creative methods in any research or evaluation activity. But I would argue that they represent one way of overcoming some of the criticisms about the validity and anecdotal nature of qualitative research. And they’re fun too.


*For an in-depth discussion of this argument, read this book.

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'