Laura Tinner’s research while affiliated with University of Bristol and other places

Background Over 2 million children from low-income families are eligible for free school meals in England. The school holiday periods pose an increased risk of hunger for those children. To respond to this issue, the government introduced the Holiday Activities and Food (HAF) programme with the aim of providing free healthy food and enriching activities during the holiday periods. Existing research has focused on the direct impact of HAF on the diet and activity of children attending the programme. This study aimed to explore the wider benefits of the programme, as perceived by key stakeholders. Methods Focus groups and interviews were used. We purposively sampled participants across the Southwest, Midlands and Northeast England. Interviews were conducted with HAF providers (n=12), HAF leads (n=11), political leads (n=5), parents (n=10) and children with additional needs aged 4-11 (n=2). Primary school children aged 4-11 (n=15) took part in focus groups. A semi-structured topic guide and the 7-stage Framework analysis method was used. Results A range of positive impacts of the HAF programme, as perceived by key stakeholders, were identified, which we present thematically in relation to children, families and communities. (1) A valuable opportunity for children to receive and consume healthy food, engage in a range of enrichment activities including physical activity, make social connections with peers in a safe environment, participate in new experiences which they normally would not have and engage with a supportive network. (2) A support to families through signposting to additional support, respite and childcare, and spending valuable time together. (3) Wider benefits to communities including upskilling voluntary sector staff, supporting the local economy, and establishing community collaborations. Conclusion Our findings highlight the important and positive impacts that the HAF programme has for children receiving free school meals, their families and the wider community. It is clear there are potential benefits that extend beyond the programme’s aims. We suggest that a comprehensive ripple effects mapping evaluation to capture the widespread impact of the HAF programme would provide further valuable information to inform its development.

Background Despite increased focus on adolescence, young people’s voices are often undervalued and underrepresented in inequalities research. Through exploring young people’s perceptions of health and inequality, we may begin to understand how public health interventions can be more effective and equitable. Engaging with young people through art enables self-expression on these complex and sensitive topics. This qualitative and co-produced project aimed to engage with young people in community settings to identify their priorities in relation their health, inequality and their aspirations. Methods Creative focus groups, co-produced with a local young artist, were conducted at three community centres to participants aged 11-18 (n=30) in disadvantaged areas of Bristol, outlined by the Index of Multiple Deprivation. Participants engaged in art and were guided through discussion by a semi-structured topic guide. A thematic approach to analysis was adopted to highlight key policy priorities for young people to be presented at a local authority meeting. Results We produced a list of priorities for local change, which came under four themes: (1) adolescents felt they were ‘forgotten’ as an age group, which they exemplified through lack of age-appropriate activities and public spaces, (2) mental health was a major issue that was felt to be less stigmatised for their age group, but stigma and misinformation remained among the adults from whom they seek support (3) structural inequalities including differential Wi-Fi access across the city, gentrification visible in architecture, experiences of crime, discrimination and feeling unsafe were key issues for many young people, (4) finally, all participants were concerned about their future and wanted better support to make education and employment decisions. Co-producing this work enriched the project, partially alleviated power imbalances and created work opportunities for the artist. Youth workers felt that the arts project opened up lines of communication with young people around topics such as mental health, that they would continue to explore as a result of this project. Conclusion Art is a promising way of engaging with young people in community settings and elevating marginalised voices.Young people are acutely aware of problems related to health and inequality within the community and are motivated to inform local policy. Young people’s perceptions and experiences signal the need for city-wide structural and age-specific policies for adolescents, particularly in disadvantaged areas, to support them in living a healthy life.

Background School holidays can be a period of isolation and risk for children from low-income families. Limited opportunities for enrichment activities, and food insecurity, mean that children’s health and well-being can suffer and their learning stagnate or decline. The Holiday Activities & Food (HAF) programme is a government-funded (£200 m/y) initiative which provides healthy meals and activities to free school meal (FSM)-eligible children during the holidays. Existing evaluations of the programme have identified varied provision across England,with some challenges around engagement and attendance. In this study we aimed to explore key challenges of and recommendations for the programme, as experienced by a range of key stakeholders. Methods Using purposive sampling we recruited participants from across the Southwest, Midlands and Northeast of England. Interviews were conducted with political leads (n=5), HAF leads (n=11), HAF providers (n=12), parents (n=10), and children with additional needs (10-12y; n=2). Primary school children (7-11y; n=15) took part in focus groups. Data were analysed using the 7-stage Framework Method. Three key themes were identified (1) Reaching vulnerable children: attendance, particularly ‘no-shows’, is the main challenge faced by HAF teams. Low attendance has knock-on effects on funding and quality of provision. A community-centered approach, and flexibility around the eligibility criteria and HAF guidelines may facilitate higher attendance. As well as reaching more vulnerable families in need, a universal programme offering provision to all children would improve attendance of FSM-eligible children through reducing stigma, enabling children to attend with friends, and embedding providers within the whole community; (2) Cross-community partnerships: a high-quality, sustainable HAF programme is underpinned by a partnership-based model and commissioning for capacity building of HAF teams and communities; (3) School engagement: collaborating with schools is key, as they know the families, can signpost to the programme, and have the facilities and skilled staff to deliver successful and cost-effective HAF clubs. However, current engagement with schools is low. Conclusion To ensure the HAF programme is reaching vulnerable children and remains sustainable, we recommend that the Department for Education amends the national HAF guidelines to: consider a universal offer; increase support for flexibility and cross-community partnerships; and facilitate stronger school advocacy and involvement.

Background Despite increased focus on adolescence, young people’s voices are often undervalued and underrepresented in health inequalities research and policy. Through exploring young people’s priorities for their health and their community, we may begin to understand how public health interventions and policies can be more effective and equitable. Engaging with youth using art enables empowerment and self-expression on these complex topics. Methods Creative workshops, co-produced with a young artist, were delivered at three youth centres to participants aged 11–18 years ( n = 30) in disadvantaged areas of Bristol, UK. Participants engaged in art and were guided by a semi-structured topic guide through focus group discussion. Thematic analysis, supported by the young artist, was used to distil key policy priorities for young people to be delivered to the local authority. Results The young people identified a list of key priorities. These were: (1) mental health, (2) feeling ‘forgotten’ as an age group and having safe city spaces to socialise, (3) the need for greater support for their education and career aspirations. I provide a brief summary of these priorities, but the focus of this article is on the critical reflections on this innovative way of engaging with young people about local policy. I provide key learning points for researchers looking to do creative public health work in community settings and involve marginalised young people. Conclusions Art is a promising way of engaging with young people in community settings and elevating marginalised voices. Co-producing with a local young artist enriched the project and partially alleviated power imbalances. This approach has potential for involving different groups within local policymaking and priority setting around health inequalities.

Background In 2021, Scotland became the first UK country to launch a Women’s Health Plan. This policy signals increasing commitment to broader ambitions surrounding gender equality in health. Research shows a connection between discrimination and health, representing a contributor to health inequalities. There remains sparse evidence on how certain groups experience discrimination that could be useful for policymaking. This research set out to address this evidence gap through exploring how discrimination shapes young women’s experiences of mental health and inequalities in Scotland. Methods We interviewed women aged 16-25 years (n=28), living in Scotland, UK, adopting an intersectional approach to recruitment and data analysis. We used a semi-structured topic guide to facilitate open discussion about discrimination and health. Transcripts were analysed by two researchers using Thematic Analysis and NVivo software. Findings We identified three themes that illuminate intersectional discrimination and the impact on mental health. The first outlines how experiences of discrimination in school, work and public spaces (and the anticipation of such) creates stress leading to mental health problems, particularly for participants from ethnic minority groups. The second highlights the lack of support for mental health, both at structural and interpersonal levels, which was viewed by young women as a form of intersectional discrimination, largely because of their gender and age. Finally, we developed a mid-level theory termed the ‘chain of dismissal’ that displays that for both physical or mental health symptoms, young women’s concerns are immediately “written off” as anxiety-related and in turn a natural attribute of young women. These themes show that discrimination has the potential to amplify mental health problems for young women and is a likely contributor to health inequalities. Conclusions Structural disadvantages such as racism intersect with gender and age to compound the experience of discrimination for marginalised young women. To improve mental health and reduce health inequalities for young women, multi-level approaches are needed, with strong consideration of how the structural and cultural landscape as well as assumptions made by healthcare professionals have critical implications for young women’s health.

Background Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts. Methods This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory. Findings We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired. Conclusions For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts. Systematic review registration PROSPERO CRD42020205342

Background Food portion size guidance resources aimed at parents of young children in the UK are freely available from a number of credible sources. However, little is known about whether parents are aware of, and use, any of these resources to guide their food portioning practices. Objectives We aimed to explore the food portion size practices used by first-time parents living in the UK when feeding their one- to two-year-old child, and their awareness of and views on six food portion size guidance resources. Methods Participants were recruited via parent Facebook groups and online parent forums. Online 1–1 semi-structured interviews were conducted, during which parents were shown images of six food portion size guidance resources to facilitate discussion. Data was analysed in NVivo 11 using a Reflexive Thematic Analysis approach. Results Of the 27 participants, most were women ( n = 25), white ( n = 18), and educated to first degree level or higher ( n = 24). First-time parents mostly relied on their own judgement and “instinct” to portion foods, based on their learned experience of how much their child ate on a day-to-day basis. This experience was used alongside physical indicators of food portion size, such as the size of children’s dishware and food packaging. Most participants were unaware of any of the six food portion size guidance resources we showed them; only four had read any of the resources. Parents suggested they had previously sought advice about weaning from a range of sources (e.g. online, friends, community groups) but would be unlikely to seek out specific food portion size guidance. Parents suggested recommendations on food portion size should acknowledge and highlight parents’ perception that “every child is different” . Conclusions Existing food portion size guidance resources for parents of young children in the UK are ineffective as they have poor reach and impact. We suggest parents should be involved in developing novel strategies to promote age-appropriate consumption and healthy weight gain in young children.

Background Discrimination can affect health outcomes and increase health inequalities. There is also growing evidence to suggest that discrimination disproportionately affects women’s health, but qualitative and UK-specific research is sparse. Adolescence and young adulthood are critical periods for laying the foundations for improving health outcomes, with girls and young women experiencing specific inequalities. This qualitative research focuses on how young women in Scotland experience discrimination and the extent to which that impacts on their mental and physical health. It was developed to support evidence needs of the Scottish Government’s Women’s Health Plan. Methods Four online focus groups scoped out population groups. We then used semi-structured interviews with women aged 16–25 in Scotland, using a semi-structured topic guide. Transcripts were thematically analysed using NVivo. We practiced reflexivity using research diaries and reflecting on our positions as researchers. Results To date, we have generated four themes from our sample of young women (n=26). (1) Mental health is key to young women’s understanding of ‘health’. Many experienced sexism while seeking mental health support through school or health services, including their symptoms being invalidated (and dismissed) as wholly down to menstruation. (2) Several young women described their experiences of discrimination related to contraception. They experienced a lack of information about side effects, alternative options to hormonal technologies and felt the sole responsibility for contraception is placed on women. Participants faced resistance from practitioners when wanting to change contraception when experiencing poor mental health and other symptoms. They saw this as related to broader societal sexism and ageism. (3) Participants recognised that the intersection of age and gender led to a particular experience of gendered ageism. This intersection led to harmful stereotypes such as the ‘hormonal, overdramatic teenage girl’, resulting in disrespectful healthcare, and long waits for referrals and diagnosis. (4) Structural racism and ableism within and outside of the health system were highlighted as impacting some participants’ healthcare access, treatment and mental health. This research illuminates the embedded and interconnected experiences of sexism, ageism, ableism, racism and other forms of discrimination within the health system and wider society and the complex ways in which these impact on young women’s health. Conclusion Discriminatory experiences are often intersectional, but regularly relate to sexism, manifesting in specific ways for adolescents and young adults. Policies to reduce systemic and intersectional discrimination have the potential to improve young women’s health outcomes and reduce health inequalities.

Background: Intersectionality theory posits that considering a single axis of inequality is limited and that considering (dis)advantage on multiple axes simultaneously is needed. The extent to which intersectionality has been used within interventional health research has not been systematically examined. This scoping review aimed to map out the use of intersectionality. It explores the use of intersectionality when designing and implementing public health interventions, or when analysing the impact of these interventions. Methods: We undertook systematic searches of Medline and Scopus from inception through June 2021, with key search terms including "intersectionality", "interventions" and "public health". References were screened and those using intersectionality and primary data from high-income countries were included and relevant data synthesised. Results: After screening 2108 studies, we included 12 studies. Six studies were qualitative and focused on alcohol and substance abuse (two studies), mental health (two studies), general health promotion (one study) and housing interventions (one study). The three quantitative studies examined mental health (two studies) and smoking cessation (one study), while the three mixed-method studies examined mental health (two studies) and sexual exploitation (one study). Intersectionality was used primarily to analyse intervention effects (eight studies), but also for intervention design (three studies), and one study used it for both design and analysis. Ethnicity and gender were the most commonly included axes of inequality (11 studies), followed by socio-economic position (10 studies). Four studies included consideration of LGBTQ+ and only one considered physical disability. Intersectional frameworks were used by studies to formulate specific questions and assess differences in outcomes by intersectional markers of identity. Analytical studies also recommended intersectionality approaches to improve future treatments and to structure interventions to focus on power and structural dynamics. Conclusions: Intersectionality theory is not yet commonly used in interventional health research, in either design or analysis. Conditions such as mental health have more studies using intersectionality, while studies considering LGBTQ+ and physical disability as axes of inequality are particularly sparse. The lack of studies in our review suggests that theoretical and methodological advancements need to be made in order to increase engagement with intersectionality in interventional health.