Susan Morton: playing the long game in research

Professor Susan Morton would have you think she’s an unlikely academic.

An epidemiologist and specialist in public health medicine in the Faculty of Medical and Health Sciences at the University of Auckland, her in-depth work as the principal investigator for the Growing Up in New Zealand study proves otherwise.

The study, now in its 15th year, will publicly release its latest findings in the coming months – on its cohort of about 6,800 children. This release focuses on the children aged eight and its exact timing will depend on a number of factors, not the least of which is the impact of the lockdown, or post-lockdown, world. Additional research has been undertaken specifically related to the Covid-19 lockdown.

With information on education, health and poverty, the goal is to provide evidence and stories that can inform good public policy.

This year, our approach was to tie it to the Government’s Child and Youth Well-being Strategy,” says Susan. “That aligns beautifully with the framework we put in place 15 years ago. We are interested in the holistic well-being of these children and their development.”

Growing Up in New Zealand was launched in 2008 after a three-year development phase. In 2009-10 the families were recruited and the children in the study were born over 15 months. The study has some similarities with the well-known Dunedin longitudinal study but also some important points of difference. Growing Up in New Zealand began before the children were born and there was intense follow-up in the first 1,000 days. Most importantly, it represents the ethnic diversity of children in New Zealand today rather than the mostly New Zealand European children who were born in Dunedin in the early 1970s.

“We brought families on board with the parents’ knowledge that we wanted to engage with these children until they were 21,” says Susan.

The children are now approaching 11, so innovative techniques are needed to keep them engaged with the two-hour interview process that takes place every three years or so.

“This generation is differently connected than any generation before,” she says. “They’re digital natives and their way of engaging with society and their peers is vastly different from what it was even five years ago.

“Alongside collecting, processing and using this information to inform policy, we are constantly thinking about methodological innovations for conducting the research. How do we engage with the children in a way that makes them feel valued and provides ways for them to contribute their unique voice to something important?”

Currently, iPads are among the tools, but the technology must keep evolving. The disruptions caused by Covid-19 made that even more important.

“We’re looking to bring forward the development of online/digital data collection as our primary method rather than as a complementary one,” says Susan, of the impact of Covid-19.

“It needs to have an inbuilt contingency depending on whether we’re in lockdown situations or having to stay at home for health. So that will be how we operate for the main cohort we’re planning to engage with in 2021 when they are 11 years old.”

In the first 1,000 days of these children’s lives, the interaction between researchers and families was every few months, to gain insights into how the early years of life affect children as they grow older.

“Those first 1,000 days shape the developmental trajectories for the rest of their lives, so we really wanted to have as much information as we could about the rapidity of growth and change and development … information that hadn’t been available from earlier studies.”

Susan is passionate about public health, but her path to becoming the lead investigator on such a major study was a circuitous and somewhat surprising one.

“I never wanted to be an academic. I really wanted to be a maths teacher, and then a paediatrician. Suddenly I find myself with a huge responsibility and yet huge privilege to be running this amazing study.”

After achieving a first-class honours degree in maths, Susan was teaching the subject in Lower Hutt, Wellington. As a mother to two daughters, she also sat in on Health Board meetings to lobby for better care for new mothers. She then set her thoughts towards a new career and moved north with the family to study medicine at the University of Auckland.

After completing her studies (with a gap year for the birth of her third baby), Susan embarked on paediatrics as a speciality. She was working in the hospital and juggling parenthood before opting to undertake a PhD. With the assistance of a Commonwealth Scholarship, she headed to the London School of Hygiene and Tropical Medicine in 1998 with husband Grant and three young children in tow. Her thinking was that a PhD would allow her to spend more time with her family and that she would return to paediatric training thereafter.

When she got to the UK, circumstances meant she didn’t end up working on the PhD project she’d intended.

“But I was lucky to be introduced to David Leon, a young epidemiologist interested in population health. He had been trying to extract a dataset from a researcher called Raymond Illsley who had undertaken a study of Aberdeen children born in the 1950s. The data had largely sat dormant since the 1960s.”

It included information about more than 15,000 children, their parents and family backgrounds as well as their educational and health records. Susan revitalised the dataset and linked the information with millions of reproductive records of the Scottish women who were born in the 1950s, to recreate their reproductive histories from 1967 to 2001, thereby generating information about development across three generations.

“Raymond was 90-plus and was steadfastly wanting to choose who used his data. We went to visit him in the middle of the English countryside, and I was this eager junior researcher from Taranaki, New Zealand, looking for a PhD topic. For whatever reason – maybe the timing was right, maybe he saw something in what we were proposing to do – he basically said, go for it.

“Maybe he also recognised his own advanced years and didn’t want all this data to languish in his garage. He’d had amazing vision in the 1960s to collect all this information and document it so beautifully.”

The result for Susan was a PhD and several manuscripts that demonstrated that a mother’s childhood social environment (provided by the child’s grandparents) and her own early growth and development were important predictors of her own offspring’s size at birth. From the experience of working on the Aberdeen study, and becoming aware of the impact of the social environment on health, Susan knew her clinical career was headed towards population health.

“That I ended up working on such a study was serendipitous. I fell in love with longitudinal studies, being able to follow ordinary people’s lives over time to bring their collected stories together to create something extraordinary. It was the opportunity to provide evidence that could inform policy and make a difference by actually understanding what lived realities were about, rather than just looking at routine statistics or big data.”

There was no looking back. In recent years Susan’s work has seen her honoured with a New Zealand Order of Merit and made a professor at the University of Auckland. In delivering her inaugural professorial lecture in 2019, Susan paid tribute to a number of people who’d had a huge impact on her academic success. They included Professor Emeritus Robert Beaglehole, Sir Peter Gluckman and Dame Professor Jane Harding of the Liggins Institute.

“I’d come into my first year of medical school as a mum, having had five years away from the classroom. I’m good at thinking if I get something a little bit wrong then I’ll fail completely.

“However, things went well for me, albeit with much juggling of family and study. At the end of my first year, I was seeking employment to fund my ongoing studies, but needed to have a position that also allowed me to be a mum.

“I applied for a summer scholarship, which was picked up by Dame Jane Harding and I was fortunate to work alongside her in neonatal paediatrics. That was the beginning of my academic journey.”

Susan returned to New Zealand from the UK in 2003, at a time when the Government was looking to initiate a longitudinal study to provide evidence to inform the work of up to 16 government agencies.

She led a team based at the University who successfully bid for the development phase of the study in late 2004. After a period of study design and peer review, Growing Up in New Zealand was launched in April 2008 and is New Zealand’s largest longitudinal study. The Government’s Well-being Budget in 2019 recognised its contribution by providing a further $17 million in funding to continue following the cohort into their adolescent years.

Susan was also awarded an MBIE Endeavour Grant in 2019, providing $6 million over five years to develop innovative methods to engage with the participants and more rapid techniques to translate longitudinal information into timely policy-relevant evidence.

The study also has parental consent to link to the child’s national health and education data. “Around 95-98 percent of participants agreed to that from the beginning. That gives a much richer source of what’s going on, with cross-checks and validation.”

Susan says parents, caregivers and children are still fully engaged.

“Getting the families on board was not an overnight process. We took two years to consult widely with families, communities and, particularly, with Māori and Pacific [peoples]. This was always a study that was going to partner with government in terms of providing evidence, but some communities have a distrust of government.

“So we had to do a lot of work as university researchers to talk to these communities about what the study was, and how their voices could make a difference.

“They believe their voices are not being heard at the policy table, and they want them to be. We explained how we would provide guardianship of the data and protect their privacy as we went through this long process. That said, it’s a constant challenge and we have to keep going back to communities. But what we have built over the past ten years is the trust of the University’s research team.

“We’re very aware this resource is a treasure and we take our guardianship role with its data extremely seriously.”

As well as valuing the data, the team has promised to act on it, while keeping all identifying information confidential.

“We are giving voice to that information as promised. It’s our responsibility to take that collection of voices to the policy table on behalf of these people who are least often heard. What is critically important to the ongoing trust relationship is remembering why they wanted to do this.”

There’s almost a socially philanthropic aspect to what the families are doing.

“They generally don’t want to be paid,” says Susan. “They just want to be heard. They want to be part of something that potentially can make a difference.”

The researchers also welcome collaborations with groups who can use the longitudinal information to improve community and population well-being.

“One of the things I’m most proud about would be the experience of working with The Southern Initiative (TSI) Tāmaki Herehere ki te Tonga in South Auckland. They’re very engaged with their families in terms of how to better support their well-being. We worked with them to look into resilience in those communities. Around 1,500 of our families live in that area and 80 percent of them experience poverty, by any measure that you chose to apply.

“But not all children who experience poverty have poor outcomes. Within this group there are children who are thriving, so we investigate what supports they have that enable that to happen in the face of adversity.”

Susan says the work of TSI, led by Auckland Council, is an example of how the Growing Up information can be used to understand “what works”. This has relevance for many national strategies. Another benefit of studying the families over such a long period is that they can track movement in and out of certain states over time.

For example, they can compare the impact of persistent poverty to poverty that may be transitional. The longitudinal information can also provide a fuller picture of what poverty is for families with young children, as well as ways it might be alleviated.

“Ascribing poverty based solely on income doesn’t reflect the complexity of what poverty means for families, especially in the period around the birth of a child, when income may fluctuate dramatically.

“At that time, a low income may actually be a marker of wealth, with parents able to take unpaid leave to care for their children, rather than a marker of need. That said, the time around the birth of a child is generally when most families struggle financially.”

The study looks at why people do things – their choices in everything such as taking time off work, residential mobility, movement in and out of the workforce and relationships, and changing early childhood centres and schools.

“Having this connection with the people in the study allows us to look at the finer grains of life in a much more in-depth way than we can from a Census.”

Current investigations will also reveal how resilience may come to the fore during and after the Covid-19 lockdown. “We are committed to these families and our ability to deliver policy and scientifically relevant information in the long term, so we’re looking at creative ways to engage with them during this unusual time.

“It’s a unique opportunity to understand the impact of this crisis on the children and their families, and track that on their well-being and resilience.”

- Denise Montgomery