Impact case study database

1. Impact on healthcare practitioners

Harnessing her research on verbal and non-verbal illness narratives ( 1- 6), Bartel led the creation of an animated clinical training tool, ‘Consider EDs in Men’, that ‘ gives insight into the mindset of the patient’ with an ED, and presents an arts-based ‘ multi-media approach [that] helps reinforce the issues’ [ I:2]. This patient-centred resource earned accreditation by the Royal College of GPs (RCGP) in 2020, which, in turn, recommends it to its 50,000+ members. RCGP directors emphasize the tool’s ability ‘ to improve the quality of GP practice and patient experience’ [ I:2], and praise it as ‘ fantastic— so powerful and so different to the usual message given to GPs’ [ E:21-22]. The tool has also achieved official endorsement from the Royal Colleges of Nursing (RCN, 450,000 members) and Psychiatrists (RCPsych, 19,000 members), with the Chair of RCPsych Scotland recommending the resource as ‘ incredibly useful’ [ I:4]. Although Covid-19 has dominated healthcare since March 2020, within seven months of its launch (May 2020) the tool has facilitated dramatically increased awareness and knowledge among GPs, nurses, mental health professionals, and healthcare students. Among the 140 direct respondents in the UK, Bartel’s training generated significant increases in practitioners feeling more confident (after training) to: 1. spot the signs of EDs in men (19% 85%); 2. begin a conversation with a male patient about his eating (32% 87%); and 3. know when to refer a patient to a specialist EDs service (18% 77%) [ E:1]. According to a RCGP Clinical Champion, commissioned by UoN to analyse the data and 15 expert-testimonials [ A], the training-results present ‘an extraordinary gain in confidence among professionals who are commonly ‘“not seeing” [i.e. not identifying] patients with these issues because they are unaware of how they might present’ [ **A:**4]. The results indicate significant shifts in practice to improve the primary care of males with EDs, and these promise to ‘ trigger behaviour change’ in GPs, according to an RCGP official [ I:2]). In health practitioners’ own words: the tool has ‘change[d] my daily practice making me more aware, confident and sensitive’ [ E:5], or ‘influenced me to become more observant and vigilant’ [ E:12]. The RCGP Clinical Champion’s evaluation summarizes the impact of the animated training tool as: ‘1. Training gaps addressed; 2. Symptom knowledge improved, 3. Raising awareness, 4. Building confidence in consultation skills; 5. Better adherence to guidelines, 6. Creating hope; 7. Assumptions and bias successfully challenged, 8. Providing more holistic care, 9. Helpful myth busting, 10. Leaving a lasting impression’ [ A:3-6].

With 86% of the 140 respondents reporting initially no knowledge of any other specialist resource on EDs in men [ **E:**1], Bartel’s tool, underpinned by her research into men’s illness narratives ( 1, 2, 6), fills ‘a shocking and important gap in the post-graduate psychology/psychiatry education agenda’ [ A:6], and will improve patient care, according to an RCGP official [ I:1]. Testament to this, the animated training tool (accessible through subtitles in seven languages) has also been taken up by: 1. the charity Mental Health First Aid England to train their 2,300 instructors [ C:4]; 2. the two largest UK ED charities, Beat and First Steps ED, for training of staff and professionals [ B; E:23]; 3. government-funded health organisations abroad to be adapted in 2021 for use in Germany [ G] and Australia [ E:24-25]; 4. UoN’s School of Health Sciences for two BSc nursing courses (380 students; 2020/21)—this School has also recommended it to the Council of Deans in Health Sciences at 85 UK HEIs (reach 110,000 students) [ F:2].

Underpinned by Bartel’s research ( 1- 6), the animation presents a ‘ range of voices’ [ I:2]. It builds on her previous 2018 AHRC-funded multimedia project ‘Poems for Doctors’ on EDs in men ( 2), which has informed current and future healthcare professionals at six national and international events (combined audience: ca. 700) [ E:27-47]. Clinical participants in Bartel’s ED masterclass (2019) reported: ‘This made me stop & think & re-evaluate my practice as a dietician, to consider eating disorders when I am assessing patients’; heightened awareness of an ‘unconscious gender bias regarding eating disorders’; ‘Reminding practitioners of the human experience of disease helps garner true empathy & therefore better holistic care’ [ E:46]. One GP reported that her resulting heightened awareness made a tangible difference: ‘Within a week, I had identified one man […] who had an underlying ED’ [ E:21]. In the words of a world-leading clinical psychiatrist in EDs, Bartel’s ‘Poems for Doctors’ are helping ‘ to root work on male EDs in a wider movement in health research to engage with experts by experience’ [ H] .

As one nurse summed up the particular impact of Bartel’s combination of narrative, art and clinical information: ‘I am unlikely to forget these voices of men in my future practice’ [ E:6].

2. Changing policy at organisational level: ED charity First Steps ED (FSED)

Since 2018 Bartel’s role as Research Advisor has changed FSED’s policy and practice, helping it to become the second largest ED UK charity in the UK [ B]. Its CEO reported seven points of policy change and expansion as a ‘direct result of our collaboration and knowledge exchange with her [Bartel]’ leading to ‘a step change in how male EDs are considered and treated by a range of stakeholders’ [ B]. Bartel’s international research collaborations and expertise in training has helped FSED become a ‘leading national charity in its specific focus on […] EDs in males’, inspiring a ‘new and dedicated service model exclusively available for boys and men’ [ B]. This increased (self) referrals to FSED by men (aged 18–32) by 12%, and by 8–15 year-old males by 35% in 2019/20. FSED’s annual income also doubled from £487,830 in 2018/19 to £1,008,666 in 2019/20 due to Bartel’s recommendations for innovating service models and research funding [ B]. This money co-finances two FT staff members, including a unique Boys and Men Lead for Patient and Public Involvement and Engagement (PPIE) helping FSED to ‘target its training and activities for males in ways we weren’t able to before’ [ B]. For their joint work in promoting public understanding for EDs in males, Bartel and FSED have been shortlisted for the national 2020 Men & Boys Award for ‘outstanding achievement in providing care, compassion and social change for men and boys’ (UK charity Men & Boys Coalition), and for UoN’s 2020 ‘Best Public Engagement Award’.

3. Impact on young people and those who work with and for them

The 14 teachers from seven regional schools, and the 13 staff from six UK HEIs attending a day’s training run by charity Mental Health First Aid England with Bartel (2017; 2018), had significant pastoral and line management responsibilities, making their rise in confidence levels (after training) to support students with mental health issues/EDs of strategic value: from 5.97 to 8.23 on a scale of 0–10 (2017) [ C:16]. Bartel’s contribution on ED-narratives gave participants greater knowledge of EDs in men: it ‘improve[d] my knowledge of the range of people who are affected by eating disorders. […] I had a gendered perception of the disorders’ [ C:41], and ‘I genuinely feel more confident to approach young people […] about mental health’ [ C:18]. Participants reported plans for changes in schools as a result of the training, e.g. mental health action initiatives, fundraising for books, lunchtime drop-ins, and reshaping PSE (Personal and Social Education) programmes: ‘The training influence[d] the way we, as a school, teach about mental health and eating disorders and the resources enabled me to put together a [PSE] scheme of work’ [ C:100].

As Board Member (since 2019) of Nottingham’s White Hills Park Trust (four local academies), Bartel uses narratives to influence practices to aid education about gendered body image issues and mental health. In February 2020 she started ‘Shelf Help for EDs’, a reading programme on EDs, in one school, with plans to roll it out regionally to schools and public libraries (Covid-delayed) [ C:103-104]. As Local Advisor to the youth-led NHS-commissioned project ‘Mental Health 2000’, Bartel engaged 31 young people (aged 14–25) in her narrative research in mental health, helping them to communicate to their peers problems that are often stigmatised, including EDs in males. These insights found their way into a youth-led poster campaign, advised by Bartel ( 1, 6) (presented online instead of ‘live’ across Nottinghamshire due to Covid; Sept. 2020). Its slogans communicated the young people’s findings about mental health and ED stereotypes: ‘ *Why should I man up?*’; and ‘ *What is normal anyway?*’ [ C:89].

As representative for EDs in Student Services, Bartel has helped the UK charity Student Minds to shape its ED Audit Expert Panel’s response to Covid-19 and what this pandemic means for HE students with EDs, including male students and those identifying as male [ **C:**91-92]. Using social media Bartel has reached a broad audience (March–Dec. 2020): 4,411 views on Youtube; 250 likes on Twitter, YouTube and UoN homepage [ E:62-69].

Focusing on educating pupils, Bartel’s two one-day events about art, literature and ‘Good Mental Health’, with a total of 112 (72+40) pupils from seven East Midlands secondary schools (Jan. 2017; April 2019), resulted in 92% of 72 students reporting greater awareness (2017) and 83% of 40 better knowledge (2019) regarding EDs in boys and men; one teacher was particularly impressed to see the boys ‘ open up’ [ **C:**98]. Five arts-centred public events introduced Bartel’s work to diverse public audiences, including pupils and students: one reading for 40 pupils of Sam Pollen’s 2019 teenage novel The Year I Didn’t Eat about a boy’s ED (2019); one exhibition for approx. 200 (‘Wonder’ at UoN, 2018); ‘Drop-in Cafés’ commissioned twice for the national ‘Being Human Festival’ (Nov. 2018; Nov. 2020) for ca. 80; and one stand-up comedy gig by a comedian recovered from an ED (Jan. 2018). 85% attendees of this gig (29) agreed that it helped them ‘to think about male EDs in a new way’, and one wrote: ‘You have given me the confidence to speak up about my own problems with food— as a man! Thank you!’ [ C:11].

4. Impact among creative organisations and practitioners

In 2018 Bartel collaborated with the film company Simply Thrilled (ST) to produce five videos from the 13 ‘Poems for Doctors’ (see above) with a diverse group, including men with experience of EDs. Inspired by the poems’ capacity to challenge audiences’ preconceptions and (visual) stereotypes ( 2), ST’s CEO states that they learned to be ‘particularly conscious about our use of perspective, camera angles, frames and cuts and […] we were especially careful about delivering intimate close-up shots whilst still retaining the personal integrity of the individual’ [ D:12]. ST’s creative take on the theme of ‘control’ was especially pertinent and informed by Bartel’s research ( 1, 2) [ D:12]. Working with Bartel on EDs has given ST ‘new impulses to rethink and refine practices that we have since applied in other productions’, e.g. for DARE, a drugs awareness charity for young people [ D:12]. A male author and performer with experience of EDs evaluated the impact of Bartel’s research ( 1,2) on creative practice generally, and on ST: ‘these […] creative decisions have a huge effect on the overall product as it makes participants more comfortable, considered and protected, meaning that they are more likely to share honest portrayals of their struggles which will help others’ [ D:2]. Furthermore, Bartel’s research into arts-based communications of EDs ( 1- 6) informed her collaboration with the animation studio WovenInk on the training film for NHS healthcare ‘Consider EDs in Men’ [Aug. 2019–March 2020, D:13], nominated for the 2021 WHO ‘Health for All’ film award. This has shaped WovenInk’s profile to establish themselves as the company for arts-based educational campaigns on EDs leading, for instance, to a 2020 film-project by the ED charity FREED: ‘Social Media, Food and Me’. Since 2016 Bartel has also changed the practices of four other creative practitioners. A well-known German author has, through Bartel’s research ( 4, 5), gained ‘ a new awareness for the real impact of [a] particular story’ she wrote about EDs in a family context (‘Salzwasser’; Saltwater; 2010). At public readings she now introduces and reads this story with a heightened sensitivity to the range of possible audience responses [ D:15-16]. Bartel’s research ( 1, 2) has also since influenced this author’s choice of topics for her further creative work [ D:16]. Bartel also enabled a UK stand-up comedian to trial a comedy gig on his own experience of EDs in Nottingham (Jan. 2018). This led to him performing the material at the Edinburgh Fringe Festival in 2019 [ D:17] and to designing an NHS-funded programme of workshops on stand-up comedy, mental health and EDs [ D:17]. Bartel’s scholarship ( 1, 2, 6), has also ‘ changed and enriched’ [ J] the work of an acclaimed Austrian documentary photographer. Bartel’s research is now included in this artist’s patient-centred photobook and international touring exhibition A Story to Tell: Regarding Male EDs ( 6) adding ‘ new theoretical perspectives to our work making it even more effective as an intervention’ [ J].

Finally, one poet (a participant in ‘Poems for Doctors’) whose poem Bartel recorded with a young rap artist, sums up the overall thrust of Bartel’s research and its benefits for others: ‘finding voices to articulate such a difficult and under-explored area will change things’ [ D:22].