Why funding for public health research needs a more strategic approach

[Opening music…]

Gretchen Miller: Hello there and welcome, this is Prevention Works from The Australian Prevention Partnership Centre. I’m Gretchen Miller. Nearly half of all Australians, that’s 11.6 million people, have one or more chronic health conditions, many of which will change their lives, and not for the better. But those working in the space know preventive health research can save quantities and qualities of lives, as well as future health expenditure. The major health and medical research funding bodies, the NHMRC and MRFF, often require a track record of research that demonstrates clinical outcomes like new treatments or drugs, but how do you prove that prevention does work when there’s no one pill you can produce and no single action that might bring about the policy change that influences population health? Our guests will argue the nuances of that point shortly, but the paucity of prevention funding is really starting to bite in this space, and it’s becoming hard for the next generation of researchers to get funding and find job security, to see a future for themselves. The Collaboration for Enhanced Research Impact, or CERI, connects 11 Centres of Research Excellence through The Australian Prevention Partnership Centre. To work out a way through these issues, CERI has consulted with senior investigators, policy makers and early- and mid-career researchers, and we’re calling for a structural review and reform of the research funding system, and now is the time to do it, feeding into the current government consultation on improving alignment and collaboration between the MRFF and NHMRC. To discuss the solutions to these challenges, two guests, Professor Helena Teede AO, who is the Director of Monash Centre for Health Research and Implementation. She is an endocrinologist at Monash Health and Executive Director of Monash Partners Academic Health Sciences Centre. Helena is the inaugural chair and member of the Australian Health Research Alliance and sits on multiple international committees and national NHMRC committees. With Helena, an upcoming star researcher who has found it too hard to achieve job security as a researcher, Dr Tara Boelsen-Robinson. Tara’s research has been in food retail and she’s just completed four years as a postdoctoral research fellow at Deakin University. Her work has directly informed obesity advocacy campaigns, but she left to work in health promotion, implementing and evaluating chronic disease prevention initiatives in the community. So let’s get talking. Now, I know neither of you take an ‘it’s not fair, just give us more’ approach, you’re all about the practicalities of what needs to happen to ease expenditure down the track and improve Australian living conditions. So before we unpack the details, Helena, can you give us an outline of what Australia, at a population level, needs from health research funding?

Helena Teede: Yeah, Australians have a chronic disease crisis on our hands. We are one of the top leading nations in terms of excess adiposity and poor lifestyle, in terms of processed food intake and physical inactivity, and that is leading to the fact that 70 per cent of us carry weight above the healthy weight range. We have escalating rates of diabetes, we have increased hypertension and cardiovascular risk factors, we have significant increases in cancer which are, again, lifestyle and obesity related, and indeed we have a plethora of diseases and conditions that are entirely preventable. Despite the fact that we have that burden of disease which affects now the majority of the population, 70 per cent plus, we have been doing very little in terms of policy and implementation, and indeed research, around how we’re going to change and improve that, and given that research and healthcare is funded by the Australian taxpayer and the Australian community, and ultimately should be delivering benefit for that community, it is critically important that the research that we undertake informs evidence-based approaches to policies and strategies that actually improve the health of the Australian community. So at the moment we have come from very much a model of excellence; so I’m an academic, I’m supposed to be an expert in my field, I come up with the ideas, write the applications, and based on my track record the government funding comes to me because I’m excellent in my field and, essentially, I think I know what sort of research needs to be done. But what has been missing up until now is this whole focus on what is most important to the country, what is most important to Australians, in other words, what is strategic research over and above the blue-sky, expert-driven research agenda, which is still important but needs to be balanced, and indeed, if you look at the OECD reports and the reports on the higher university sector and education reform, you can see that we actually invest disproportionately in a lot of that blue-sky discovery research, and disproportionately in some of the applied research through to actually making an impact from that investment, especially in implementation and public health research. So really, what’s happening at the moment is we’re not being strategic about the use of our funds based on the fact that the community funds us, and these are the biggest problems facing the community, and that really needs to change.

Gretchen: Okay, so what you’re saying here is 70 per cent of Australians are affected by preventable disease, so the emphasis on the blue sky, where does that come from, how has that sprung up, because I don’t know that it was always the case?

Helena: Actually, I think it is historical, Gretchen. If you look at it, almost all research policies around the world have a unilateral arrow which says we start at the bench top with brilliant scientists who develop something and then 97 per cent of those drop off before they actually become a drug or a product that’s used in practice, but there are all of these valleys of death along the way where innovations and research drops off in that sort of journey into healthcare, and even when we’ve got a fantastic new drug that is really efficacious, that published in the New England Journal of Medicine, it still takes 17 years to get it into practice. That’s just not the right way to drive change, and there’s very good evidence about how you drive change, and the concept of now coming up with much more of an iterative or circular model for research, one of the problems we’re trying to solve, how are the best approaches to solve them, which may include developing a new drug, for example, we’ve had new drugs recently to manage obesity, we’ve had surgery techniques, but often we know that a lot of this has got to be public health and policy, and that part of the story has been missing in terms of its funding.

Gretchen: The fact is, is that we really don’t want to be getting to the state where we’re having injections to stop us eating or having surgery to reduce the weight that we’ve already piled on. We actually want to get there before and that’s what prevention is all about.

Helena: So I think the really critical thing people miss here is this is not a personal behavioural choice. We live in this state where for some reason we think that obesity is a lack of discipline, it’s all about the individual, we don’t want to regulate because it’ll be a nanny state, 70 per cent of Australians do not choose to be over a healthy weight, 70 per cent of Australians are no different in many ways people, as they were decades ago when we had really low prevalence of these challenges. So this is about an environmental, societal policy and systems change that just basically faces all of us, and to think that it’s anything but an environmental policy system solution, and to think it’s up to the individual for lifestyle intervention, which we know for the vast majority as an individual level is not effective, and to think that the multibillion-dollar industry of individual treatments with significant side effects, as well as surgery with significant cost and side effects is the solution, is because we’re looking at the problem the wrong way. We all want help, the reality is if you ask mothers of young children they find it incredibly difficult to feed their children a healthy diet, and most of them have no idea that most of the children’s food is full of sugar. Most people support a sugar tax, and yet these really simple, prioritised, consistent evidence-based public health strategies are not getting into practice because we’re still focused on this being an individual problem and a solution at an individual level. It’s a failure of policy and systems change.

Gretchen: It’s a great place to bring Tara in because Tara’s area of research is a healthy food retail. We’re discussing a problem for the Australian community which needs to benefit from solid, sustained research in this space, but also the problem for early-career researchers like Tara, who are actually walking away from this arena. Tara, what drew you to preventive research in the first place?

Tara Boelsen-Robinson: Thanks for having me on your podcast, Gretchen. There are so many things that I love about prevention research. I think the really core factor or the driving factor was the potential to make a difference in the lives of communities and individuals in Australia, I think that’s why a lot of people go into public health research, the ability to make an impact, to empower people, to make choices that improve their health and wellbeing, that was a really big factor for me, and once I got into research I found myself surrounded by really passionate and clever people, and we got to solve these really wicked problems together, and it felt like we were making a difference, and even though I’m, as you say, walking away from research, it’s been a really wonderful journey for me.

Gretchen: Yeah, it’s been a number of years already, what, ten years in the field?

Tara: That’s right.

Gretchen: Okay, and so what happened to see you move from new research into an application role in the practitioner space?

Tara: So the thing that I found challenging, and that I know a lot of my colleagues have found challenging over the years, is the lack of secure and long-term employment in research. It’s so highly competitive, and the way that the system is set up for grants and fellowships there’s a lot of work you have to do in applying for these grants and fellowships, a lot of energy, a lot of time is put into them, and then the success rates are so low that it’s a really big opportunity cost to apply for these fellowships and grants when the success and the outcomes are so low. And so it really feels like you’re spinning your wheels a lot of the time applying for grants that you’re not going to get, but you have to apply for them because otherwise you won’t have a job next year. And I think most of the work in research is contract work, so six months, one year, two years, and so even thinking about things like having a family and wondering if you will have parental leave when you do decide, and that moment happens, are some of the things that made me leave research, unfortunately.

Gretchen: I wonder if you could describe what your new role involves and what excites you about it, having moved out of research, for now.

Tara: Yeah, so the work that I do is working closely with local stakeholders and communities to design, implement, and evaluate chronic disease prevention initiatives within local communities, so focusing on things like healthier eating, vaping, other issues that are important to these communities, and really supporting and enabling and empowering them to live the healthiest lives they can. And the work I do really takes research and translates it and looks at it on the ground, at the coalface, how does this work with our communities, how can we support stakeholders to implement these solutions on the ground? It’s a little bit closer to that impact that I’m talking about and yeah, it’s really meaningful work, but as I said before, it couldn’t be done without the research going behind it and informing evidence-based, public health actions.

Gretchen: Can you reflect a little on what it’s been like for your cohort of researchers coming up?

Tara: My experience is certainly not unique, even those that might seem from the outside are super successful and are getting grants all the time, the reality is that it’s really stressful, the constant insecurity and scarcity of funding takes a mental-health toll on researchers, particularly early-career researchers. You spend three to four years completing your PhD, which you persist on minimum wage for, and other bits and bobs you can do, and then you come out in a hyper-competitive workforce where even though you’re highly trained, you’re highly skilled, it can often feel like you’re undervalued by the system itself, in that there’s not enough funding and not enough jobs. Competition is really important in order to create the best that we can do, so I don’t think 100 per cent of research grants should be funded at all, some competition is really critical to ensuring that we’re only funding the best and brightest, but when you’re talking about 3 per cent success rates, even 15 per cent success rates, it’s really depressing, to be honest. For me, it came to a point where I felt like I was using so much of my time applying for funding, when really, I was in research to do good work and to make a difference and to support change in the community, and to spend so much of your time writing grants that ultimately will be unsuccessful felt like it was really undermining the purpose, the real reason that I joined.

Gretchen: Helena, listening to Tara, how different was it when you were early-career, and how do you reflect on what she has to say about her experience and why she’s walking away? And we know that Tara is very well regarded, has done some significant work. She’s a loss.

Helena: So I think there are two reflections, and it’s an unfortunate loss to the field, and given that this is an area that we really need skilled people, and it’s also an area which requires a lot of soft skills, this type of research, it requires relationship building, it requires stakeholder engagement, this is not someone who can sit in a lab with the world’s best technology and collaborate with New York and Belgium, this is a person that has to be immersed in the community with people who are not familiar with research, and people who need to build critical partnerships. So loss of those sorts of experience and skills, which we don’t have a lot of, is sad. The other reflection is it’s really unfortunate from Tara’s experience about the fact that this really relates back to gender inequity, and I have a very large research program at the moment funded by two NHMRC partnership grants about the fact that the system doesn’t support that, and I have to say, Gretchen, it never has, so it’s not any worse now than it was back then. I have to say that parental leave is not parental leave in Australia, it’s maternity leave. It should be parental leave, but it’s not. There is no impact at all of having a family on a male career trajectory and there is a very profound impact for women in terms of the hours worked and their career trajectory, and the argument that women want to stay at home and want to do this is fine, but it’s actually not accurate. What we find is that women want a better balance, they would like their partner to be able to do some of this, they would like to do some of this, but they do want to work more than they are able to, because we have the most expensive childcare system in the world, which has really big problems with access, and we have a system where it’s unaffordable to have help at home. So in fact Australian women are doing it much tougher than most women around the world who either have access to government childcare, or who can afford help in the home, and we don’t have equitable and fair parenting leave, and there’s just not enough consideration of those factors at the moment. So I’m sad, but I understand the decisions Tara has made and clearly, those issues are going to have to be resolved, and we’re working hard to do that.

Gretchen: Okay, so yeah, it’s a wicked problem, basically, but even beyond the issue for women is that there’s an issue overall for researchers in this field. I wonder what transitions have happened in the field in recent decades to bring about the situation that you’re all facing now? And perhaps what we could talk to is the increasing power and sophistication of the lobby group, and how preventive health doesn’t really have such a lobby group.

Helena: So it’s fair to say that especially, perhaps, under recent governments, the impact of lobbying and engagement with government was more profound than perhaps it has been in the past, and we have really well-organised groups such as AAMRI [Association of Australian Medical Research Institutes] for the medical research institutes, we have ACTA, the Australian Clinical Trials Alliance, for clinical trials, we do have a fairly significant, one would argue not enough, but significant proportion of the pie for research funding in Australia that goes to clinical trials, we don’t have almost any workforce, and very little advocacy, for implementation research, and public health is very similar. So there isn’t a sort of national consensus body that is engaging with government, that is promoting a fair and equitable distribution of funding around what the population needs, and around the fact that the Australian funder should be the beneficiary of research and have impact from that research, and these are our biggest problems. So I do think that there was a change around the impact of lobbying, and I do think that pendulum is starting to swing back. I think there were also some benefits to lobbying, so people were getting their collective voice, and I fully understand why other groups do that, but one of the problems is when your workforce is desecrated or not yet developed, like in implementation science and public health, that really limits the voice that you could have at the table, and I have to say, I think I personally would much rather live in an Australia where there was a strategic approach to what needed to be funded, rather than an advocacy approach, but it is what it is, and we need a much clearer voice and a much stronger leadership perspective at the table, and advocacy from groups like the Australian Academy of Health and Medical Sciences, and other groups, around the importance of these sorts of approaches.

Gretchen: And it’s politically expensive to go up against the food lobby, isn’t it, they’re far better funded and far more sophisticated. Maybe, Tara, you could speak to that and then Helena.

Tara: Yeah, the food industry spend a lot of money on lobbying and they also spend a lot of money marketing foods and products to us, we’re exposed to food marketing all the time, our food environments are really saturated with unhealthy food products, and so it’s no wonder that little kids are asking for McDonald’s because that’s all they see everywhere they look, and so there’s a lot of work in research being done to capture and understand the impact of lobbying and marketing on what people eat and what they consume, but really, in public health we don’t have billions of dollars a year to spend on all of these things and there needs to be a limitation on the kind of access that the food industry have to politicians and also on the access that they have to children to influence them to eat unhealthy foods and drinks.

Gretchen: Is it a matter, then, of forming your own lobby group, your own promotion group to counter those voices?

Tara: We do have a lot of that work happening. Cancer Council Victoria is doing a lot of great work around that, and so are other advocacy groups, but you’re really talking about numbers here, the more money you have to throw at advertising. We don’t have that kind of money, and so we need to look further up the chain to see what’s influencing that in the first place, and how we can protect children and our populations from the harmful impact of commercial industries that are really just looking to make a buck off us.

Gretchen: Helena.

Helena: This is David and Goliath, and boy has Goliath learned from the smoking successes of the past. It was said recently that 85 per cent of a politicians’ time is spent with food, tobacco, alcohol, gambling, and mining, and that only gives them 15 per cent of the time left for everything else, but the reality is that we are not serving our population well, and hopefully the national consultation at the moment on diabetes, and to some extent obesity, might bring some of that to the fore. I’ve been involved in numerous submissions to that. But the problem is when your workforce is very thin who has the funded time to put the submissions in, who has the opportunity to do this? For example, AAMRI has funding, ACTA has funding, they are funded as networks, and I think we need to look for what sort of similar platform we could come up with in public health, and there are opportunities for that to actually have a funded advocacy voice. The sector has done really well, Gretchen, in terms of coming up with a consolidated, simple, single set of messages, there’s Ten Top Tips, there’s Tipping the Scales, and everyone signed up to that, so there’s no more divide and conquer, we all agree that we need to limit junk food advertising for children, who could possibly argue to keep that, and that’s consistent with population views. We need to implement a sugar tax, there are countless examples and evidence based around that, and indeed, what it does is it drives industry change in standards as much as it actually drives change in consumer behaviour. So there are really good evidence-based, consistent approaches to this, but we need research and evidence to not only generate the evidence to put these things forward, but actually to implement them, so that implementation, evaluation, optimisation, and iterative improvement in these sorts of initiatives is critical and needs to sit alongside, and it can’t be left to KPMG, Deloitte, and others of the Big Four, who have a commercial vested interest, to do a lot of work on making recommendations and on evaluation. We know that model is fundamentally flawed, and that’s what’s going to happen if we lose or desecrate this workforce.

Gretchen: I think now would be a good time to ask what an advocacy group would look like.

Helena: So I think it’s important to think about what the purpose would be. Australia could have an advocacy group for public health researchers, but I think the most important thing would be to have an advocacy group for public health in Australia comprised of critical academic and public health leaders who were respected from all the key stakeholders, and then actually one of the objectives was to make sure we had the workforce that could deliver the public health changes that Australia needs. So it had that objective, but in fact the critical factor was to make sure that the population engaged around this argument, because we know that politicians respond to public voice, and the public voice on this is actually there, we know that this is what the public wants, but we haven’t got that opportunity to bring that collective message to government and make sure that it’s actually what progresses here.

Gretchen: You mentioned to me when we were discussing this earlier that the money used to come from different buckets, but then it got folded into the NHMRC. So what would you be asking for in that regard.

Helena: Yeah, look, it needs to be coordinated. So at the moment, the state and federal governments have variable funding for prevention initiatives, usually not necessarily research, not necessarily evaluated, not necessarily evidence-based, often based on treasury bids, and it can be quite disparate, the approach we take in each state and territory is quite different, sometimes ineffective, and we don’t learn from each other. The classic examples would be some of the lifestyle programs like the Get Healthy program and the Life! program, and they’re all disparate across the country. Actually getting some coordination about what the states and territories are doing in public health is important, and then in terms of national groups, getting the MRFF, or the Medical Research Future Fund, and the NHMRC aligned, but likewise with Federal Government would be important, because it used to come from different sources, as you said, that it was folded into NHMRC, where we know that the four pillars of research, discovery, clinical health services, and public health are not anywhere near equitable. And whilst one might argue the objective is not equity, I would argue the objective should be what is the biggest problem for the country, what are the strategic priorities, and where do we have impact, in which case we’d flip the current paradigm, one would argue, but the point also is you’ve got things like the Medical Research Future Fund, which does fund strategic research, which is terrific, and all of the impact metrics are clinical, so it’s the individual, clinical outcomes that are the success metrics, there’s nothing in there about improving the health system, and there’s nothing in there about improving public health. So even broadening the success metrics of one of our biggest funders of research would be really important, and offering opportunities to coordinate. And there’s currently a review of NHMRC and MRFF, it will be critical that review does not, I think, relapse back to a non-strategic approach to an excellence approach to research, because it hasn’t delivered as much impact as perhaps it should. So actually making sure there’s still a balance of strategic and blue sky or investigator-driven research is great, but in that strategic research we need to get the recognition of the biggest problems we have, and the public health investment, and the health system implementation investment that the country really needs.

Gretchen: I mean to illustrate that, Tara, why is it trickier in the prevention space to prove a track record where you don’t have those clinical metrics that the MRFF is focusing on?

Tara: Yeah, sure. So I think an example is Helena talked about weight, 70 per cent of Australians have a weight that’s over a healthy range, and if you’re talking about a trial, even if it’s a public health trial or an intervention, seeing weight changes when you’re doing things like changing the food environment, these take a really long time to have an impact. So even if you’re changing what people are eating on a daily basis, they’re eating more fruit and vegetables, that might not necessarily relate to a change in weight over six months or a year or even two years, and so it’s really hard to prove within those specific schemes that your work is having a meaningful impact, even though we know, as per the example I gave, that eating healthier can improve mood and has many other impacts beyond that of a clinical change in weight. I think the other challenge as well is that a lot of these schemes are you’re measured on your research impact, so your impact in publications and in grants, and some of the work that we do, which is very much working closely with community, those pieces of research are more difficult to publish sometimes, and you can’t get it in such high-impact journals, like the New England Journal of Medicine, even though I might want to be published in there, and so these aren’t viewed as favourably as research that produces really clinical outcomes and can be published in high impact journals. And so these schemes aren’t measuring the kind of impacts that we are delivering to the community.

Gretchen: And in the introduction, I suggest that it is harder to prove tangible outcomes.

Helena: Yeah, look, I don’t know that it’s necessarily… I think the challenge with public health is it takes longer, it is larger scale, it takes longer to prove an impact, and maybe it doesn’t take longer than a massive, large-scale clinical trial which is a multi, multi-million-dollar enterprise. You look at the ESPRIT trial, which was almost a public health trial, I don’t know how many millions was invested in that, but I think the reality is that for public health it usually needs to be pretty large scale, and it needs to be longer term, and those sorts of enterprises are just often more difficult to get funded, especially with the current funding models that we have. We haven’t seen a single round of public health calls from the Medical Research Future Fund, even though, arguably, our health system is under more stress than it’s ever been, and we haven’t seen a single funding round around, actually, how do we change the health system. So I think that at the moment the strategic approach to research is better than it used to be, we have got a clear strategic approach, but it hasn’t evolved enough to actually address the bigger strategic problems, and I would very much hope that will happen over time.

Gretchen: The point that I make in the introduction is that in this research you don’t produce a pill or an injection that will give an immediate indication of a tangible outcome, but there have been really successful, tangible outcomes, like seat belts and tobacco, how did the research into those arenas get funded?

Helena: It was incremental. If you look at smoking, it wasn’t that there was one big miracle cure, in fact it was incremental over time, but it was persistent, and it was brave leadership, politicians like Nicola Roxon, who really took an absolute beating, personally and career wise, in terms of getting plain-paper packaging, but she did it, and the research and evaluation has borne through, and it’s now in many countries around the world, and Australia led that, but the lessons there really taught our food lobby well.

Gretchen: So they came back punching, right?

Helena: Oh yeah, in fact, if you speak to people like Jane Martin, who’s been a leader in this sort of public health advocacy field, she says they now know every trick in the book. But I think there’s a point there that’s really critical, which is public health doesn’t make money, it’s not going to come up with a gizmo or an app or a pill or a new surgical device, it’s not going to make commercial money, but my challenge around that is this is Australian taxpayers’ money that’s being invested, it should be invested in what is the biggest problem for the Australian community, and it should have outcomes that matter to the Australian community, which are not about the sexiest new app or pill that might actually cost us an absolute fortune in terms of implementing it in health care. That’s not to say that the new drugs that cure cancer, and there are pretty amazing advances, shouldn’t happen, they should, but it’s just the fact that there’s an imbalance, and that we need to recognise the difference between strategic research and research that’s out there to generate funding, because ultimately, that funding comes from the community anyway, and so it’s just really flipping that paradigm to how do we be much more strategic and how do we get the voice of the populace up into parliamentary context, to make sure that we make appropriate changes.

Gretchen: I’ve got a couple of questions that come out of this while we’re in this area. Who assesses public health grant applications, are they specialists in the area, do they talk the language, Helena?

Helena: It depends, so it depends which scheme, and we have a pretty small research community, especially in public health, Gretchen. So, for example, personally, we all complain about getting funded and not getting funded, and I must say these days our team is very fortunate and we are well funded because we do very strategic research, my team in the Monash Centre for Health Research and Implementation, but more broadly in the university, and part of that is because we spend a year, sometimes two, developing up the problem and the strategy and taking a really strategic approach before we put in a grant. But I digress, I think the real issue is that when, sometimes you put a grant in which is really quite strategic, it’s got quite robust methodology, it’s reviewed by people who don’t have the skills or don’t understand this type of research, it may actually be ranked quite low, and there have been times, honestly, Gretchen, I have turned exactly around the same grant with a couple of sentences at the most, and gone from category 4 to a category 6 and been funded. So there is a lot of coin flipping involved in here, and unfortunately, that usually comes down to the expertise, but also bias and attitudes amongst the reviewers about whether or not this is research, and is this robust methodology, and qualitative research, for it is hard to get funded. Epidemiology is not a randomised controlled trial, cohort studies are very hard, NHMRC doesn’t see it as their role to fund a cohort study. So you have this sort of challenge where the less skilled your workforce gets, because people like Tara leave it, the less expertise you have on these panels that actually appreciate what is good-quality, public health research. And interestingly, if I can make the reflection, that having got a few Centres of Research Excellence now, which are really great for public health, but I’ve sat in front of panels, when they used to interview, who were the clinical research panels, the health services research panels, the public health panels, and the difference in calibre and skill across those three panels is outstanding, the clinical researchers are world leaders, phenomenal track records, really robust methodology and process, and then often you find when you’re sitting in front of reviewers on the other panels, the expertise in the panel is really very different to the expertise on the applying team. So we don’t have capacity, and that becomes a self-perpetuating problem in that the majority of the researchers then who are evaluating grants are actually from a discovery-research or a clinical-research background and don’t necessarily have the skills to evaluate the projects, and that just becomes a self-perpetuating problem.

Gretchen: Tara, you’ve written a number of applications, as of course has Helena, but to come back to you, how could the process have been improved, given that the metrics are things like new health treatments, drugs, interventions, devices, and diagnostics, what kind of measurements, what kind of measurement metrics could bodies use to assess preventive health projects?

Tara: So I think that you can measure lots of different things for impact. I think Helena has kind of spoken about implementation a lot and how that’s undervalued, and so there are a lot of implementation outcomes that you can measure and use, and I think that some of the grant funders are starting to understand and recognise the value of what impact looks like in prevention, but it’s still not equivalent to papers.

Gretchen: So what metrics could you expect? Say someone from the MRFF is listening right now, what would you ask them to add to their metrics for assessment?

Helena: I think that the thing with public health initiatives is because it’s wicked as an actual problem, and it’s very much that relationship and building with stakeholders, the outcomes or the metrics that a successful grant is going to be judged by actually should be determined by the stakeholders that develop the project. If it’s about improving health for pregnant women, then the clinicians and those pregnant women and funders need to come together and establish what the metrics should be for success, which actually become embedded in the project. So to me, if you’ve gone through the process of establishing those metrics in a particular project, and then you’ve given a robust methodology of how you’re going to get there, that’s a much more compelling approach, but that’s a principled approach. In terms of the metrics of things like publications, grants, leadership roles, look, they’re challenging, we all know that one of the problems is that, for example, by gender but also by career stage, people who don’t self-advocate, people who don’t take credit for everything, often are not as well judged; people who tend to speak about team, we, together, as opposed to me, I, so self-promotion and almost overstating your leadership role is associated with better success, and that’s currently, unfortunately, the case, which is why I think it has significantly contributed to why women remain at lower success rates, and now that we’ve got equivalent aspirational targets for funding, that will make a transformational difference. But I think, in all fairness, there probably is some nuances around public health metrics, and there will be the same for implementation, those metrics should include things like stakeholder engagement, codesign of outcomes, now that’s not relevant at all in discovery research, but it’s critically important in public health research, and if you’ve done that, that should be something that actually becomes a metric to be recognised. Government and policy engagement, completely irrelevant metric for discovery research, but actually fundamental for public health research. So some of this is process metrics, rather than whether I’ve got a New England Journal publication, and I think that’s the same with implementation. I think you should have to spend a bit more time demonstrating feasibility, because we know until fairly recently, 50 per cent of funded NHMRC trials didn’t publish one paper, even a protocol, and so that’s really they’re a victim of mainly feasibility challenges and being underfunded often for individual trials, but other countries do that differently, they provide seed grants, you have to do feasibility research. There could be a similar model for public health where you need to be funded to do your stakeholder engagement, develop the metrics, and do those front-end processes, which often are really hard to do at the moment, and actually then would allow you to include some of those process metrics in the evaluation.

Gretchen: Thank you, that’s a really valuable response, Helena. There’s room for improvement with research as well, you’ve been critical of some of the proposals for solutions offered by public health researchers, things that might never be cost effective. Can you speak to your fellow researchers on this and encourage them to approach things a little differently?

Helena: Academics have a responsibility here, too, and that includes undertaking research that first of all resolves the problem, so it is part of a solution to a problem, it’s not part of an academic exercise, and that means we have a responsibility to understand the problem from everyone’s perspective, not just our own, and then to come up with solutions that actually would meet those stakeholders’ objectives. I mean the trials that have involved 16 sessions with a dietitian or replacing diet, there is no way they will ever be rolled out, but thinking about implementability, and there’s a paper, hopefully, that will be coming out in the MJA soon, and it’s actually also on the ACTA website, around the fact that we have a responsibility to think about the implementability of what we are designing and delivering, so that it’s not just an intervention that we think is good, but actually is an intervention that will have a health economics component, that will meet budget impact analysis, that will actually be feasible and implementable, and the other thing is when we do the fundamental research and the efficacy research we then need to have a responsibility to do the research to implement that. If someone is going to fund us to do research, surely in our field we have to then take that through to implementation and public health benefit, and indeed that’s a priority in the NHMRC, strategic priorities around research translation is encouraging partners, a partnership with researchers and end-users, encouraging capacity building and research translation, and maximising use of research evidence for public benefit, and I would suggest the public health is beautifully aligned to do all of those, but the academics take some responsibility to make sure that’s happening as well.

Gretchen: Tara, in terms of room for improvement with research as well, now that you have moved over to the implementation side of things, and I know it’s a very new situation for you, but what do you think about that relationship between the research and the implementation, and the communication between those two things, and how researchers might actually need to really think about that next step?

Tara: I can see from the implementation side just how critical the research is, the work that we do in implementing chronic disease prevention initiatives is evidence-based, and that evidence comes from research, so we wouldn’t be able to do our jobs without researchers. Along the same vein, being able to feedback to researchers about what evidence we need is really critical, so that the work they do is practice informed, so that kind of two-way communication, feeding research into implementation and into practice, and then also feeding practice into research is a really important kind of translation process, and I’d encourage all researchers who are working in the public health space to have constant communication and interaction with the people that they’re hoping are going to implement their research, because it makes your research better

Grethen: And I imagine that if you have those relationships then you can use them to inform your grant applications and argue, perhaps, for a metric which does reflect that engagement.

Tara: Yes, that’s correct, and there are some existing partnership grants that support those partnerships. The challenge, again, with research is that it can take up to a year to find out the results of your application, and in that space, sometimes practice has moved on, implementation has moved on, so there’s also these kind of different rates of movement that research and practice are running along, and they’re not always aligned, and so you have to have those deep relationships between research and practice in order to be able to jump on opportunities as they come up.

Gretchen: So what is the role of senior researchers and senior academics in supporting early-career researchers like yourself in winning some part of that pie that is so small?

Tara: There’s a lot of amazing senior academics and mentors out there, and I’ve certainly been lucky enough to have some of them, and Helena speaking about these issues in public, out loud, is amazing, and I would encourage, I would strongly encourage other academics and researchers who have more secure positions, who are in positions of power and privilege to speak up on behalf of your PhD students, on behalf of your postdocs, on behalf of your teams who are doing a lot of work that’s helping build your career, please speak up and be a part of the solution with us.

Gretchen: Dr Tara Boelsen-Robinson there, with her, Professor Helena Teede AO. Thanks so much to you both for a robust conversation. This is, of course, Prevention Works from The Australian Prevention Partnership Centre. Listeners, don’t forget to rate us on Apple Podcasts as it really helps get ears across these important issues. You’ll find more information on our discussion today, including our own submission to the government consultation into the MRFF and NHMRC. I’m Gretchen Miller, I’ll catch you next time.