Report transcript in: Theo talks about the value of coproduction in public health

Please Report the Errrors?

sure. Thank you.

Bye.

Introductions. I I work in

three different roles in the public health sector,

Uh, one for public health education. Working for

a a global community based charity.

Uh,

secondly, I work at a much more local level. Um, for a

Somali led charity,

Um,

that's focused on reducing health inequities

and inequalities in the Bristol area,

in particular,

in the city of Bristol.

Um, and thirdly, I work for the university in the city, uh, working in,

uh, the Medical Research Council integrative epidemiology department,

where I I support with impact and engagement and supporting,

uh, different areas of co-production

from that point. Um, so I guess an example of, of of coproduction.

I think the definition is ambiguous.

Um, but that's to our advantage to some extent,

because it means that we can be created with it.

I think

key for us.

Um, when I say us working with with the the first of those charities Global charity,

I think it it's just that it's genuine co-production so that people

have a voice have input. Um,

they are not only listened to, but they are heard that is, that

they can see

the

output of what they

say is listened to and the outcome is

that actually it's integrated into the programme.

So an example of that is, um,

working on a maternal health project that's based in Cameroon.

Um, we work

directly with a local charity and very keen

to foster local ownership.

Um, so it's in the southwest of the country working maternal mortality,

and we've taken a very kind of, um, ground up approach

to the project, Um, taking advantage of the fact that we've got a global team.

We've got expertise often trained at some of the public health schools in London

and around the globe, based everywhere, from from Singapore to to Bermuda

to Peru,

um and, um, London

as well.

And bringing that team to work collectively to work locally

and why it sets a good example of co-production is because

we're working directly with the local organisation, the will

foundation,

and even at the

first phase of the project,

we focus very much on social listening or community listening.

So we devised a qualitative survey that's quite in depth. Um,

it does have a few questions that you could generate quantitative data from,

but in effect, what we're really trying to do is understand.

First, what do the mothers need to know?

In rural parts of Cameroon, where there is an ongoing conflict,

the Anglophone crisis and thus the health clinics have closed down.

So a lot of the health services have

have have have fallen to traditional birth attendants.

So first, what the mothers need then what do the closest to the mothers need,

such as the birth attendants need to know

and then working your way up through the health system?

So afterwards, what do the nurses the midwives need to know?

And then afterwards, what's the link between that and the health system?

But really,

the point why I make it is that I I suppose it's It's that local ownership working, um,

in the sense of kind of a bidirectional innovation between ourselves and

the

foundation, where we've developed the project collaboratively from the start.

But now, even when working in the field,

it's really important to us that it starts

with the community and understanding what the mother's

needs are and what they need to know, as opposed to

presuming or assuming

uh, a system, um, or an intervention,

uh, it's developed from the ground up in that sense.

Um,

yeah, thanks. The

what's

what's the impact of that in terms of the people and the organisations involved, Um,

and the difference that it makes,

the

impact that it has on the organisations.

I think it gives everybody a sense that they are

engaged and involved with those who understand the context.

Um, and in public health, it is so much to do with the context

and being appreciative maybe from a kind

of anthropological perspective being appreciative that,

uh, we have different cultures,

we have different needs and we see things differently. And we we shouldn't presume,

uh, a kind of ownership of knowledge in terms of what works.

So I think that point is that openness is really key.

I think that's what makes a difference in this project in the sense that

we're all being open in the sense that we're going in with not knowing

what will work

and developing a project based on

what the community identified

as the challenges and the barriers to change around them,

with the hope of designing a project and co producing a project with the

foundation

and later with local government networks

ensure that it has the buy in at a higher level. But really,

what's integral for us is that it has the buy in at a local level,

and then that's the difference.

It's the community empowerment,

community involvement and community engagement from the off.

And And I know you.

You talked when we were chatting earlier

about the examples of of doing co-production,

you know, in in in the UK, obviously one with a smaller community.

But, you know, the the other one in a kind of health, um, research setting.

Um, is there a difference?

Do you think between that experience and your experience of coproduction,

um,

or is it? Is it quite similar?

I think it's quite different, Um, in my own experience in, in, in,

in the university setting, it's It's It's the priorities are quite

there are, um,

the the priorities are different.

I mean, every everybody's trying to improve population health.

Um, but, um,

the methods to which

we do that are different. Um, so thus,

internally, there's different priorities. So, for instance, in the

for for the University of Bristol, I work in in, uh,

an area of epidemiology. That's that's to do with genetics.

Um, and it's driven a lot by statistical analysis,

and therefore co-production is not necessarily a natural fit for stats.

However, if we look at the challenge at a very high level, um and you say, Well,

there's huge

inequalities in terms of the diversity of genetic data available, say,

for instance,

um,

at present, 95% of global genetic data is based on those from European descent

and participants. Um, in fact, I think it's a slightly higher If you take dissent.

It's up to 97%.

So thus we Thus,

we're developing our prescription medicines or interventions based on,

um,

European genetic dispositions, um, and and that makeup.

So why it's so important that we integrate co-production is

is that we need to buy in from the community.

You need to build trust somewhere along, so that's the highest level challenge.

Um, and what we want to do is include more representative samples

and so to include kind of more representative samples,

I suppose from a university perspective, you could say

the approach within this area. This is kind of a fourfold approach.

You could say there's a knowledge argument. I e.

that you you want people with lived experience of a disease,

whether it be Parkinson's disease and you're

working around that or whether it even be

lived experience from smokers, um, or alcohol, uh, consumption. You it.

It's interesting for the researchers to hear that lived experience.

There's a moral argument that the the taxpaying public should really

be involved when it's funded from from the Medical Research Council.

Went through that

their their their work. And And I suppose, is the policy imperative where

you really want to evidence that

patient and public involvement is is actually a part of the process.

And actually that aligns with many of the

funding policy direction that things are headed in.

Uh, the the the P.

P I public and patient involvement is is central

and and I suppose there's a consequentialist argument.

There's a later point where you just need to have transparency and accountability

in the process to the wider communities. So it's not

designing health interventions for communities or to improve health.

But it's by and with them.

Um, and I suppose that's that's the

aspect which we try and cultivate.

It's it's not straightforward because it's not the way that it's been done

conventionally. But it's definitely aspired to

do that way to engage other underrepresented groups and and to really

hopefully engage more genuine co-production from the offset so that

we can design better questions that meet community needs.

If that makes sense,

Yeah, it does. I'm just wondering if you've got, um,

you know, a a specific example or something you know,

around the impact of of working with communities

in that way

in in relation to that through the university. Yeah,

So I guess Say, for instance, a recent recent recently year, um,

a younger researcher came to to to ask about how to,

um, look at vaping.

Uh, still looking at the what? What are the impacts of vaping?

Is it Does it have a negative health or or positive health impact? Well, at

the moment, the data seems to suggest that it it doesn't have

a negative health impact. That's of high concern.

At least thus far we don't know that

um,

and the researcher also wanted to kind

of understand from an empathetic perspective,

how do

smokers ex-smoker

or non-smoker think about

this? Uh, as an alternative.

And thus, how do your potential markets for vaping. Consider

the role of vaping in the community.

So you work with the community in terms of discovering

you could use kind of design thinking

methodologies like affinity mapping the process,

asking people to generate the questions and asking

them to provide the insights that will enable

the researcher to think more broadly. And I think that's the key.

Is there is it It helped the researcher from this perspective

to redesign a question,

uh, to consider that, And and I think another probably a better example is,

um, on a mental health

related project.

A lot of what is done in, in, in in this particular area of epidemiology

is under which were trying to make more participatory epidemiology.

But what was done was, um,

mental health intervention. A lot of it's focused from a genetics point. Um,

how do you deal with it? From a preventative point?

I How do you prevent, uh, challenges in mental health arising?

Um, but when asking the community,

what the researchers found is actually the community are more interested in

learning

how to deal with mental health,

and thus it shapes how researchers are thinking about

the question at quite a fundamental level

in terms of Is it responsive, or is it preventative?

Um, which, which I think is hugely important.

And it enriches the research as well through that that process of engagement and

the earlier that that happens at a participator rate to point or

whether you're involving the community all the way along the line and

having a a kind of a board where you can copro produce policy,

um, copro produce how it's communicated is is is really helpful,

uh, from the Officer.

But that's a really interesting, um,

example, isn't it?

And I don't think I'd even thought about it quite in that context,

we talk a lot about prevention,

but actually

that

that is a that's almost redefining what the what?

We think the problem is in the first place and if prevention is gonna

solve the problem, But until you actually involve people in that process,

you don't know that.

Actually, there's a lot of stuff that probably can't be prevented. But

how we how we work with people

to support them on their journey through mental ill health? Um,

it is probably, Yeah, that that's yeah,

send send me off on all sorts of things in my mind

that that whole redefining, um

is we? We missed that. Do you think?

Do you think then, in that context,

there's a lot of moments like that where people just stop and

and rethink

what it is they're trying to

solve in the first place.

Yeah, and I wouldn't say that's exclusive to that contest.

I think that's part of Co-production is, is, um,

for me, at least, I think it's It's it's it's it's

giving people the opportunity to speak.

Um,

and it's facilitating it. I think

it's it.

It's it's It's helpful sometimes to

have an intervention approach to interviewing I

probing to help people through and facilitating that process

so that they both benefit from from the results.

But I think having those sort of questions as I mentioned earlier,

having those questions listened to

once people have spoken and heard is the key part

and heard is the difficult part in a sense,

because I think

we ourselves, as human beings are always trying to hear,

Um, but we don't necessarily know

that the person on the other side of the table

has heard what we intended

to be

received. Um, and thus I think co-production is an opportunity to start to

bring people from the margins. Let's say in research

or bring policymakers who are on the margins when it comes to grassroots,

uh, collaborative work

or or bringing us from the margins when

it's working in that maternal health project.

Because we sit outside the context bringing us in

to understand what's needed

within the context that people are living in

and how they identify with it,

Um, and and sharing expertise to also generate new kind of, um,

I suppose Segways to knowledge, uh, new paths to knowledge.

Um,

as as as I think that's what Co-production allows allows us to kind of rethink,

reevaluate.

Consider what is available and what we can do.

Uh, but also how people are defining the challenges.

Because sometimes it's not always what we presume as as you started with

Yeah, yeah,

so So there is that kind of iterative nature of it.

And there is the kind of you use the word facilitation,

um, as suppose to a kind of training or or the form of development approach. So

maybe a different skill set

within that for people

um, as well.

Yeah.

How How does that How does that differ, then? From the from the third example.

Then you know, is that Is that different again?

Um,

or are there some similarities

in terms of,

for example, being so

sorry? The, um

the, uh, Somali charity working with the primary care networks. I think you said,

Yeah,

I I think I think on both sides are probably an element of something else which we

could do potentially through. Co-production is unlearning things as well.

Um, that is challenging or kind of

assumptions. The implicit assumptions about what works, what doesn't work? Um,

some of it is so difficult to quantify. I

think that's one of the most difficult things. So, for instance, um

a, um discussion circle may work within the community Well,

but trying to quantify

the impact of discussion circle is not straightforward. It could be done.

You could ask pre surveys.

You could ask post surveys, makes it almost into a clinical work workshop

before and after. But

it we we struggle to otherwise measure it. But

I think that's one of the things is is kind of, um,

learning from the communities that actually

their knowledge,

resources and skills work. Um, and they have worked and they are tried and tested.

They're kind of customary, and you could say threat and tested over generations.

And

I think that one to always have evidence to back up a

intervention can sometimes hinder

the freedom or the innovation

that is naturally occurring or naturally emerging

from

their way of doing it. Or their approach, which is gone

on a human level. Visibly high levels of impact.

Um, and you could say on a qualitative level on the feedback forms really

excellent impact.

So I think that's that's one thing. And I think

from our perspective, it's it's kind of learning. Well, how does that fit within

a method that we can measure it to the primary care network and then also considering

what do the GPS need to potentially learn and unlearn?

Um, if there is inequity at every point in the cancer pathway,

there is an inequality, or there is a delay

comparable between, uh, the Caucasian community,

the Asian community and the black community.

If they all have different treatments, but they've also all got different needs

then, then that approach needs to be nuanced.

And I think this is where co-production is kind of bringing voices

from,

um that aren't necessarily heard or aren't visible to the surface, um, or can do.

Um and that does require a certain amount of of unlearning in the

sense of of I think policy is quite prescribed and top down.

Um, and I I'm hopeful that coproduction has kind of methodology,

and an an approach is is more widely used so that

communities are more empowered to to to shape those narratives

as opposed to just being spoken to

if you're also spoken for and

the voices are spoken by them as well.

Yeah, and And that and that pull of

feeling like you have to evidence something in a way that suits the

system rather than evidence things in a way that actually really means something

to people,

um, is is hard.

Yeah, but stuck in a paradox, though

are,

we are stuck in a paradox.

I think I've had some interesting conversations with people, and and, um,

there was one chap who talked about his experience of using data, actually to

inform who he had in the who he had in the room really, really effectively.

I couldn't remember the detail of it. Now I'd have to go back and,

um and and relisten. But I do.

I do wonder sometimes whether with the with the coproduction kind

of in that bit of what we're trying to achieve,

whether we're trying

whether we're trying to create,

not that we are really

something. That evidence is how it works when, actually

is it. If co-production works, then

the impact is on the data that's already

in existence. And how do we build the relationship between the two?

Does that make any sense

at all?

So,

yeah, I mean, could I could I ask you to rephrase?

I I'm trying to think it through because it's a difficult question,

but I think it's an important one to ask.

Yeah, so So I think, for example, you know,

to use a mental health example we often talk about or, you know,

how do we How do we quantify how we're co producing with people when actually,

if we copro produce well with people,

the knock on impact is that less people go and

see their GP less people get referred into secondary care.

More people come out hospital and are better supported in

terms of the experience they have in their own community.

So are we may be trying to realise the value in the the

wrong or look for the value in the in the wrong places.

I don't know. I just kind of thinking aloud, really.

But

I think it's a conundrum.

honest, I think it's difficult to quantify.

And it's, um I think we spoke about, I think, um,

the idea of that that Max Weber came out with

a century or so ago

with regards to the fact that we're in an iron cage or the

the kind of, um, bureaucratic system,

you can only change the system within the bureaucracy.

You can't

change the system outside the bureaucracy because the

bureaucracy is all encompassing and all pervasive.

It's everywhere.

Um, and I think we're also kind of like we're stuck in a cage of words as well.

I mean, we're we're kind of

doing that and then

bringing it al also to a level.

We're kind of stuck within a cage of of how to quantify things

with the health sector.

It's difficult because in the sense you're kind of dealing with the

alternative, which is quantifiable data, which is straightforward, that is,

how many malaria nets do you distribute within a region?

Um,

what is the uptake of the use of those malaria nets?

What is the result?

I did the number of those being infected with malaria go down or did it go up?

So that's kind of a vertical health intervention.

I think, on the horizontal side where co-production is is a key element.

So that's not where you're dealing with

health interventions that could be pharmacological,

like the COVID-19 vaccine or

but rather, um to do with things like social distancing.

And And how do you quantify whether social distancing has actually impacted?

Uh, the disease spread or not?

It's really difficult unless you put it in a laboratory environment.

But the human world is not a laboratory environment,

Um, and it's not always straightforward,

and so it even becomes even more difficult when

you're dealing with things like public health education or

our

youth training programme.

It's it's really difficult to quantify it because the whole

idea is that they themselves develop their own projects.

So the output is them actually

working coherently together and developing something,

um in. And, um,

I think that's That's true of a lot of areas of public health.

It's difficult to quantify. It's difficult to quantify the

the the challenge that

living in in in densely

packed housing environments

increases the spread or transmit ability of a disease

or exposes you. It's difficult to quantify. We know these things.

It's difficult to quantify that

if you're in a

if if one out of seven families in the UK has a food,

uh, crisis, in fact, that they've got a food insecurity problem,

which is the current situation.

We know there are a lot of elements that will be impacted by that childhood obesity,

because the pricing of of high calorific food is, is is there

we know that that the obesity,

um, is is prevalent within more deprived areas.

This is going to exacerbate these challenges.

So this is This is where I think this co-production becomes a part of listening,

and I think it's a kind of lesson.

Uh,

if you like or transferable way of thinking about how we really

do need to start to to to to engage more in community,

lessening community involvement.

Um and it is difficult to to quantify that,

uh,

and it's difficult to quantify the value of that because what we see is the data on it.

We see the data on

the population.

We map,

we put a G i s map together and we we say that there's

high density housing in this area and this has got a high crime rate,

and there's so many other causes and factors to be considered.

My view is that I think these community sharing circles, discussion groups,

co-production

sometimes when it's off the record or

out of the, um

the more prescribed way of doing things

is is how we uncover more about what the system is doing and how the system interacts

itself.

What are the different points? What are the effects that it's happening?

It's negative and positive, according to the community.

Yeah, no, that's that not.

It's really interesting that there's there's definitely a value there,

but But quite what? That

quite how you evidence that

is, um,

is is is the challenge.

Um,

so, yeah, and there there is a value in it. I just I don't know how else to

to to say that whether I could evidence it or not.

I just know that that's I just know that that's true in my experience. But,

um,

that is a challenge. What? What would you say? Um,

so I did have another question in my mind, but it's kind of wandered off somewhere.

Um,

no, it's gone. I think.

I think it's a challenge partially because we're we're so dependent on, um,

having readily available data when it comes to economic impacts,

and you look at where the markets work.

Food pricing is a really good example. Here,

for instance, you have a conflict going on.

That conflict may be a cascading crisis from the environmental challenges,

which we're facing kind of as a blow,

that it affects us both on a macro and micro level.

It's affecting our food, pricing, our fuel pricing in the UK

as well as

in yeah, everywhere else in the world.

so I think I think that's where we see immediate impact.

We see the kind of ricochet effect

and when it comes to to to to to health interventions and

kind of quantify the value of provided community hubs and so forth.

It's dependent on us ourselves kind of validating that in the first instance,

saying it works or not,

it's more difficult to quantify the effect that it has downstream.

So what's what's what impact does that have on us on an individual level?

Does it build our confidence? Does it

take us on a different path? Um,

does it help us with the smoking cessation, for instance,

attending a health clinic being listened to?

Um,

that's something you could quantify,

but you can't quantify how that ripple occurs necessarily,

and it's often that it happens over time. I suppose,

uh,

we see the effects of our educational policies, our housing policies

over time

to Michael Mama, who was mentioning yesterday

that, um, it's

in his view,

all this austerity and so forth left us incredibly underprepared for the pandemic.

Which is why

England and Wales, um, were some of the worst performing countries

in the European continent

because of of of this kind of, um,

repeated

under investments in in policy,

but also that that results in the fact that

communities are less well equipped or have less access to

um aspects which which complement public health, the housing

education

and access to to to to to kind of health

champion networks or to charity organisations and play their role.

Yeah,

who play their role?

No, no, it's It's really interesting. It's It's the access.

It's It's not even the access, is it? It it for? For a lot of people it is.

But for some people,

it is, actually, how can they be actively involved in the conversation?

How are they being listened to? How are their views taken on board in that,

um, and and I And that's some of what you've described,

um, in in the examples that you've you've used, there is a value in that,

um,

but it's Yeah, the challenge is the,

um, evidencing that. And maybe it's just talking about it more

in some way,

actually. I mean, this is how social media defines a trend, right?

It generates a hashtag which, which takes,

uh, uh, the world by storm, so to speak.

And, uh

and yeah, we see the effects. Yeah, it's it's having that conversation.

It's

important point.

Yeah. No, thank you.

Is there anything else you'd like to, um add in terms of your experiences?

No, I think I think it's I think, um, more just on a general point.

I think it's just an important thing to continue engaging and discovering itself,

like, how does does it get defined?

I think it's, um

it does help to have,

hey,

language for coproduction

because I think that provides clarity

for stakeholders interested in working in it.

Think the most difficult bridge, which I've tried to

cross numerous times

in terms of coproduction that I found more difficult is, is the corporate

engaging corporate organisations in it.

There seems to be a willingness, but there is also, um,

a challenge,

the

the mutual benefit

that they wish to see. So this is me speaking slightly controversially, but

the the the the A corporate one in the charity sector often wants to see well,

what do they gain from the relationship?

And I think this is a bit backwards. I think it should be more.

What did the community gain and

education will be centred. I'm I'm not a great fan of,

um, volunteer tourism and things like this,

where where I think it's something we have to really examine

as to whether that's actually helping the community, um, flying in

people from a corporation to see what they funded

and to walk around that community.

It's it's not, is that in the community's interests, it's a big question.

We need to ask,

Um and, um,

I think possibly a lot of, of, of of how we think about

it from a charity perspective and co-production is, is that

the

money does exist and it's greatly appreciated. But at that same time,

the work doesn't happen without the charity.

Hm.

And this is the point.

This is,

and and and the communities don't become healthier or better

or more confident and more capable or gain access,

um,

without

them being validated in that process.

And I think charities are good at validating the role of communities,

possibly less good at quantifying that

something they strive to do. And I

think that

that's where that is probably the bridge where I do think there's probably huge

amount of potential is working with corporations

or consultancies to try and quantify that

you've mentioned it before. How do you measure that impact? Well,

some of the most intelligent

minds work for these large companies, and I'm sure they can help crack that. No,

but it's gonna entail co-production

it? It has to be a co-production that neglected. It can't be.

We think this will work because

it's not what they assume.

And you're dealing with drug dependency, necessarily, it's

or or cancel inequalities. It's These are complex issues

that require a listening and hearing approach that coproduction can offer.

Mhm,

hm?

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Post date

25/05/2022