“It’s not about telling people to eat better, stop smoking or get on the treadmill”
Mandy Cheetham, Sarah Gorman, Emma Gibson and Alice Wiseman
In the following chapter, we describe an example of a collaborative embedded research (ER) project, to develop a community-led, place-based approach to address childhood obesity. We draw on the perspectives of staff from the voluntary and community sector, local government and academia who were involved in the project.
Background and context
Gateshead Council have a track record of testing new approaches to public health challenges. The Director of Public Health could see the benefits of having an embedded researcher working on a childhood obesity project in an area facing significant health inequalities. In Gateshead at the time National Child Measurement Programme data (Gateshead Council JSNA 2018) showed that 23.2% of Year 6 children were classified as obese and 36% had excess weight (overweight and obese). Alice Wiseman (Gateshead Director of Public Health) commented:
We are well aware that the burden of obesity is falling hardest on those children from low-income backgrounds. Obesity rates are highest for children from the most deprived areas and rates are rising. Children aged 5 from the poorest income groups are twice as likely to be obese compared to their most well-off counterparts and by age 11 they are three times as likely to be obese. Previous interventions have had limited success in reducing rates of obesity.
The Foresight report (Government Office for Science 2007) suggests that tackling obesity is complex, and the scale of the challenge requires action at an individual, community and societal level (Government Office for Science 2007). A ’place-based', community centred approach (South 2017) is a different way to develop local solutions that draw on all the resources in an area. This approach has the potential for people to take control of their health and wellbeing and allow them to influence the factors that underpin good health. Co-produced in partnership with local communities, the approach
It's not about telling people to eat better 67 encompasses Gateshead’s commitment to integrating evidence in to practice. As Alice acknowledged: “We knew we could not solve a complex problem with a linear solution”.
The partnership involved Gateshead Council, Pattinson House, a community development organisation, and a researcher from Fuse, the Centre for Translational Research in Public Health (www.fuse.ac.uk).
Pattinson House was launched in 2015 by the charity Edberts House (http://www.edbertshouse.org/), and funded by the People’s Health Trust. The project works to build a happier, healthier, friendlier community, and aims to reduce health inequalities by addressing the wider determinants of health. After a 12-month period of engagement, a community hub was created in the heart of an estate in Gateshead, facilitated by experienced community development staff and managed by a steering group of local residents.
Through the hub, community members are encouraged to build supportive relationships with one another, working together to identify key issues in their area and manage a budget to create activities and make their area an even better place to live. Within this context of well-established community development and relationships of trust, it was possible to host a thematically specific piece of research: the focus on obesity became a vehicle to test the underlying proposition that a community-led approach to a specific problem could lead to some innovative and sustainable change.
An embedded researcher based with the public health team, was invited to help understand what community-led interventions might be effective in tackling childhood obesity. ER involves a particular form of evidence coproduction and use, which takes account of local context and stakeholder interests (Holmes et al. 2017; Rycroft-Malone 2014).
Embedded researchers have been defined as “either University based or employed, with the purpose of identifying and implementing a collaborative, jointly owned research agenda in a host organisation in a mutually beneficial relationship” (McGinity and Salakangas 2014: 3). Gateshead is an early adopter of the approach, which has been gaining interest in the UK as a way to create evidence-informed impact in service improvement (Marshall et al. 2016; Vindrola-Padros et al. 2017) and public health (Cheetham et al. 2017).
Meaningful engagement of communities in areas of socio-economic disadvantage is particularly important given recognition that they are often left out of research on obesity (Blacksher and Lovasi 2012). First-hand perspectives on health inequalities do not always inform public health research, policy or practice.
We hoped this study would offer local community members opportunities to identify and explore the issues they prioritised, whilst designing and participating in a range of activities. The process of co-producing and joint planning can be, in itself, health enhancing (Whitehead et al. 2016). The importance of creating the conditions for people to take control of their lives and places was highlighted by Marmot (2010):
Autonomy, how much control you have over your life - and the opportunities for full social engagement and participation are crucial for health, wellbeing and longevity.
(Marmot 2010: 2)
The ER approach was not without its critics, however. All three partner organisations were challenged about the value, methodology and potential risks of an ER project of this kind. Questions were raised about the wisdom of allowing a researcher open access to a community organisation without knowing what they might uncover. Others questioned the iterative nature of the research process, how outcomes would be measured, whether the researcher would become emotionally involved and lose the objectivity valued in some traditional academic quarters. There were also doubts about whether the research would be publishable in academic journals. There did not seem to be a lot of encouragement as we embarked on our Fit for the Future journey. Everyone seemed to be focussed on risk and what might go wrong, as Sarah Gorman, Chief Executive of Edberts House observed:
I had only ever thought of the embedded research as a fantastic opportunity. An external pair of eyes on our work to help us articulate the value of what we are doing, plus the chance to identify our weaknesses and to try and develop. The presence of the researcher did not feel like an imposition or a ‘spy in the camp’ as people were suggesting!
ER was a relatively new way of working for Gateshead Council and some people had understandable concerns about reputational risk. It took persuasion by the Director of Public Health that this was the right approach to take. Other Councils have subsequently commented on how ‘brave’ and ‘bold’ the Council were in terms of managing the ‘unknowns.’
Organisations that open themselves to the levels of scrutiny involved in this kind of insider research, take enormous risks. ER can reveal attitudes and behaviours that may not sit comfortably. Senior leaders in the organisations involved need to be willing to open themselves up to scrutiny, risk exposing vulnerabilities, both with staff, community members, and wider stakeholders, with whom information may be shared. The process can be threatening, and potentially cause long term damage to relationships, so must be handled with
It’s not about telling people to eat better 69 both sensitivity and bravery, whilst not shying away from potentially uncomfortable truths, as Sarah comments:
The embedded researcher doesn't just see you on your good days. You can’t put on a show! If they are with you for a whole year, they will really see you: your relationships, the way you do things, your values, so the research has real authenticity.
Shared values and non-judgemental attitudes and, most fundamentally, trust, were essential to make the project work:
I knew that Alice and Mandy were both on a genuine journey of discovery -as were we. Our work is a complex adaptive process, and the research was absorbed into that, changing and enhancing our culture, allowing us to learn together. There was no fear of recrimination or blame if the project didn't live up to expectations - it was based on mutual trust and respect.
(Sarah Gorman, Edberts House)