From Bristol City to Mexico City: New challenges for obesity research

In this blog, Simon Sebire from the Centre for Exercise, Nutrition & Health Sciences and three PhD students reflect on new avenues of research into childhood physical activity and obesity in Low and Middle Income Countries and the opportunities and challenges this work presents.

New ideas emerge in the least likely places. As I listened to Professor Andy Gouldson present his research to the School for Policy Studies in spring 2014, I was inspired to sketch connections between some of Andy’s concepts (economic development and environmental issues) and my own (the psychology of motivating people to adopt healthy behaviours like being physically active). After the talk, I shared my scribbles with my colleague Prof. Russ Jago, only to find that he had an almost identical set.

Our thoughts had independently been transported from Bristol to Mexico and musings about the potential associations of urban development and rural-urban migration on the lifestyle behaviours of children and their families. This international perspective is not something either of us had previously pursued is but clearly had prompted some scribbling! The Mexico connection was inspired by three CONACyT-funded students, from Mexico, who at the time were studying our MSc in Nutrition, Physical Activity and Public Health and were considering PhDs.

Nearly 1 year on the three students (Ana Ortega Avila, Maria Hermosillo Gallardo and Nadia Rodriguez Ceron) are now PhD students in the School for Policy Studies Centre for Exercise, Nutrition and Health Sciences supervised by Prof. Russ Jago, Dr Angeliki Papadaki and I. They secured further funding from CONACyT to pursue their programme of research to study how various social, psychological and environmental factors might be related to physical activity and nutrition behaviours in children adolescents and their families in Mexico.

The causes of and response to increasing levels of obesity in low and middle income countries have been the focus of a recent Guardian Global Development Podcast. The podcast draws on the experiences of children, families, health practitioners and campaigners from South Africa and Mexico. In Mexico 73% of men, 69% of women and approximately 35% of adolescents are obese or overweight which is higher than in the USA. It is clear that there is much to be done to both treat those who are already overweight and prevent the development of obesity in young people. However, extrapolating our existing research and knowledge of what we think drives obesogenic behaviours in places like Bristol to the context of people’s lives in Mexico presents a number of challenges.

Ana, Maria and Nadia have a wealth of experience from previously working in Mexico as nutritionists or within the food industry, so I asked them to listen to the podcast and share their insider’s view of the challenges ahead:

Maria referred to the potentially damaging effects of families in Mexico aspiring to an American lifestyle dominated by unhealthy foods and sedentary behaviour:

The blog says that processed foods and junk food are one of the main causes of overweight and obesity increasing in Mexico, which is partially true, but I think it has to do a little bit more with what I call “junk behaviours”. For example, how mums from rural areas prefer to give their children processed foods instead of home-made meals because they heard somewhere that people from USA consumed them, and because Americans always choose right (at least that’s the belief in some parts of Mexico); junk food and processed foods are the way to go for feeding their children.

Ana suggested that this influence may be strongest in regions closest to America and highlighted the broader problems associated with researching an issue which is geographically diverse:

Mexico is among the largest countries in the world geographically and demographically (118 million people); where differences in dietary pattern exist between rural and urban areas or between north, central and south regions.I have always lived in the northwest and the influence of the U.S.A. is visible in a lot of aspects in our life compared to the centre or south of the country. Our dietary patterns are based on American food choices and less on the Mexican traditional diet.

Ana, Maria and Nadia all added that the potential mismatch between perceptions of wealth and health may be making being overweight an aspiration:

Ana: In my experience as a nutritionist there are a number of cultural misconceptions among population when it comes to healthy nutrition. For example, being a little overweight still means you are healthy and well-nourished whereas being thin means you are unhealthy or sick. People don’t see overweight as a problem, on the contrary, they see it as something normal.

Nadia suggested that such perceptions may prevent parents from identifying obesity as a potential health problem in their children:

I think the healthy body image is distorted as family, friends or in the streets, the most common thing is to see someone obese; and that is really concerning because how will they do something to improve their health if they don’t even think there’s a problem. 

Ana, Maria and Nadia reflected on the challenges of applying our physical activity and nutrition research findings which are largely based on evidence from developed countries such as the UK or USA to the context of middle income countries such as Mexico. A good example is parents’ perceptions of safety when letting their children play outside of the home. In UK research, including some in Bristol by my ENHS colleagues, we tend to focus attention on the presence of traffic or children’s risk of injury while unsupervised. In contrast, perceptions of safety in Mexico are measured nationally with questions including those related to the risk of kidnap, existence of violent gangs in the neighbourhood, armed robbery and frequency of firearms shootings. 73.3% of the participants in the 2014 National Survey on Victimization and Perception of Public Safety (ENVIPE) in Mexico reported not feeling safe in their local areas. In addition to the safety implications of conducting research in this context, it is clear that current measures of parents’ perceptions of their child’s safety to be active outside the home will not be sufficient and Nadia has plans to develop a new tool.

In addition, the political landscape challenges us to consider different ways in which our research may be best able to impact on health policy:

Ana: The political context in Mexico is complex, the government is dealing with high levels of insecurity and corruption, events that prevent the government from focusing on other matters such as the implementation of new health policies.

Maria believes that more is needed to be done to educate policy makers in addition to the public: There is a huge educational barrier, both governmental and individual, which makes difficult to take seriously the obesity and overweight problem.

Nadia: All those factors are completely different to high-income countries, and makes the context a complex matter to understand when almost all the research has developed in a completely different contexts with a wider range of opportunities to change or create policies that have a real impact in the population’s health. 

In summary, over the last year or so, I have been transported from Bristol city to Mexico City thanks to a fortuitous combination of research daydreaming and inspiring MSc (now PhD) students.  As a supervisor, my initial conversations with our new students has forced me out of my research comfort zone, an experience which has been echoed and reported by researchers in the International Physical Activity and the Environment Network in Latin America. Undoubtedly, our success in co-producing research which could have international impact will require us to work together to combine our collective knowledge to understand the context and key drivers of obesity-related behaviour change in Mexico.

Thanks to Ana Avila Ortega, Maria Hermosillo Gallardo and Nadia Rodriguez Ceron for their contributions.

  • Ana’s PhD focusses on the development of a social media intervention to reduce consumption of sugar-sweetened beverages in  Mexican older adolescents
  • Maria is studying the associations between urbanicity in Mexico and lifestyle behaviours and the influence of the rural urban transition on family health.
  • Nadia’s PhD focusses on the environmental and social correlates of physical activity in children in Mexico City.

Dr Simon Sebire is Lecturer in Physical Activity & Exercise Psychology in the Centre for Exercise, Nutrition & Health Sciences (ENHS) in the School for Policy Studies.The results of the 2014 Research Excellence Framework (REF) confirm the Centre’s international reputation for research excellence within the field of physical activity, nutrition and health. ENHS was rated 1st overall in the UK.

 

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Social housing futures

Alex MarshIn an essay published for the Chartered Institute of Housing, Alex Marsh, Professor of Public Policy and Head of the School for Policy Studies, speculates on social housing futures 

The housing problems facing the UK are multifaceted. They include the failure to build sufficient new dwellings to keep pace with population growth; significant market volatility; problems of affordability for both owners and renters; and problems of insecurity in the private rented sector.

The Coalition government has been quite strong on rhetoric and has announced a succession of new policies and initiatives. In the social housing sector these have included changes to subsidy, tenancy security, regulation, and rent levels. The Coalition has had rather less success in bringing affordable, secure accommodation within reach of a greater proportion of households. Indeed, housing circumstances have become more precarious for many.

In the run up to the General Election, the Chartered Institute of Housing has published a series of policy essays looking at various aspects of the housing challenge and the policy responses not only in housing, but also in related areas such as welfare reform.

In the most recent essay in the series I have provided a perspective on the future of social housing, focusing on housing associations in England. The essay covers four broad areas: the squeeze; looking beyond housing; narratives; and marginal voices.

None of the political parties with a chance of power are proposing a significant departure from the current policy trajectory. So, barring some major unforeseen event, we are going to see the continued squeeze of austerity. The result will be many housing associations continuing to move towards higher levels of borrowing to fund development and higher rents to service their loans. This is going to challenge housing associations in reconciling the commercial imperatives they face with their social purpose. This challenge is not new, but it will be felt more urgently. It is not easy to predict how this tension will play out. But as I state in the essay, in my view commercialisation will eventually triumph: “financialisation has an insidious, transformative power”.

The squeeze is not just affecting housing organisations. The organisations they work with – local authorities and the health service in particular – are facing similarly tough times. And the public spending cuts planned after May 2015 are going to be more painful. Gaps in services will open up. This will present housing associations with opportunities to demonstrate greater place-based leadership. We will find out quite quickly whether associations are minded to take up these opportunities.

There is much talk in the housing association sector about the increased risks associated with current policy directions. Much of this talk has focused on development and private finance. I would argue that reputational risk is a broader issue and enters the picture earlier. There are risks to housing benefit-dependent households in the face of an increasingly inadequate social security system. But there are risks associated with succumbing to the increasing pressure to house relatively better-off households at higher rents and use the revenues generated to cross-subsidize genuinely affordable social housing. Similarly, there are risks associated with efficient asset management which has the potential to transform neighbourhoods and increase social segregation.

A key part of how these risks is managed should be greater attention to narratives – are social housing organisations doing enough to explain what they are doing and the constraints within which they operate?

The political economy of housing policy is driven by the interests of older owner occupied households because they are the households that are more likely to vote. However, we can see that this political economy is changing. The rise of Generation Rent, the activities of the Radical Housing Network or the Focus E15 protesters all indicate that new voices are being heard in housing policy making. Some of those voices are making claims using concepts such as the Right to the City, which represent a profound challenge to the logic of mainstream policy approaches.

The volume and influence of such marginal voices is likely to increase in the coming years. Eventually the political system is likely to be compelled to take them more seriously and to take more decisive policy action addressing the concerns of renters and those excluded from the housing market.

The social housing system is facing profound challenges and housing organisations will need to innovate to survive and succeed. While the constraints on the system are real, it would be a mistake to treat them as binding. The future is not given. It is made. And if we are to secure the broadest possible social benefit from innovation then learning and effective practice needs to be shared as widely as possible.

You can read the full essay here.

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Informing the debate on directly elected mayors

David-SweetingDavid Sweeting

Recently George Osborne announced the creation of a ‘metro-mayor’ for Greater Manchester. In doing so he has joined a long line of heavyweight politicians who have endorsed the idea of directly elected mayors as at least part of the solution to issues in urban governance in English cities. From as far back as Michael Heseltine in the early 1990s, via Tony Blair, and through David Cameron the idea of a single figure to govern our cities has resonated strongly in Whitehall. In the press release on Manchester’s metro-mayor, Osborne is quoted as saying: ‘This will give Mancunians a powerful voice and bring practical improvements for local people, with better transport links, an Oyster-style travelcard, and more investment in skills and the city’s economy.’ The prospect of other cities introducing similar figures is clearly back on the agenda – whether on existing city boundaries or across a city-region.

One of the frustrations in the debate around directly elected mayors is the lack of empirical evidence around which to base judgements on their impact. Competing camps tend to paint over-idealised or over-pessimistic scenarios, depending on the position they wish to advocate. The pro-camp points towards the creation of a powerful central focus for urban governance. A leader of place rather than the council, this figure increases interest in civic affairs and is able to use their profile for the good of their areas, joining up diverse interests, and is firmly held to account at the ballot box every four years. The anti-camp tends to warn of the dangers of centralisation, with a directly elected mayor able to have free rein over the electoral cycle, yet with no reason to suppose that this figure is better able to work with diverse interests than traditional council leaders in their areas, often with concerns about the ‘wrong’ sort of person being elected.

In 2012 Bristol introduced a directly elected mayor, based on the city council area of Bristol. The Bristol Civic Leadership Project is analysing the introduction of the new system, drawing on empirical data from before and after its institution, both from members of the public in Bristol, and from different sectors involved in the governance of the city. We have reported our most recent analysis in our Policy Briefing, published via Policy Bristol.

Here I discuss two findings that are likely to be of interest in the debate around the introduction of mayors in other cities. The first is that there has been a dramatic increase in the proportion of citizens who agree with the statement ‘the city of Bristol has visible leadership’. It has risen from 24.1% in 2012, before the introduction of the mayoral system, to 68.6% in 2014. This is a startling rise, and provides a boost to those who argued for the introduction of a mayor in Bristol on the basis that existing city leadership lacked sufficient public profile. The second is that there are very different views on the introduction of the mayor in different sectors of governance in the city. Our survey of civic leaders in 2012, before the introduction of the mayoral system, found that, on the whole, councillors were much less positive about the introduction of a mayor than other respondents from the public, private, and third sectors in the city. This is significant because directly elected mayors are often advocated on the basis that they will facilitate positive relationships across the city beyond the council chamber. Our research suggests that this may well be the case, but there clearly would be work to be done to convince councillors of the benefits of the system.

Our project in Bristol is ongoing, and in future we will be able to report a much larger, more rounded set of results. As we have data from both before and after the introduction of the mayoral system in the city, our work is well placed to shine light on claims about profile and visibility, or relationships between sectors, as a result of changing the system of governance, as reported above. Of course, there are limits to these claims, both as a result of methods used, and as a result of the complex nature of urban governance. For example, survey research is not sophisticated enough to disentangle the impact of the change in governance system and the change in political leader. There are also limits to the transferability of these results beyond the Bristol context. In relation to ‘metro-mayors’, for example, there is the issue that the mayoral system in Bristol was introduced on existing city boundaries, whereas, for example, the Manchester proposals are across the sub-region. This inevitably adds a layer of complexity when establishing new governance structures that are both effective and democratic. We nevertheless hope that other cities considering a variant of the directly elected mayor model of decision-making will find these results very useful in thinking through the consequences of introducing mayoral governance in their cities.

David is Senior Lecturer in Urban Studies in the School for Policy Studies at the University of Bristol

The Bristol Civic Leadership Project is being carried out by researchers at the University of Bristol, and the University of the West of England, Bristol, and has benefitted from ESRC Impact Acceleration Account funding.

This piece was originally posted on the LSE British Politics and Policy blog

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Emma Williamson, Senior Research Fellow in the School for Policy Studies, discusses gendered violence

010-savile

People around the World are currently engaged in 16 days of activism against gendered violence.  Communities across different nations are challenging the inequality which some men interpret as an excuse to violate and oppress those, predominately women and children, who are more vulnerable than themselves.

This image is being used with permission from J.Fleming

This is a global phenomenon which has landed in the middle of our city of Bristol. I drove past the Premier Inn on my way to work this morning.  The same hotel where last week it was revealed that a young, vulnerable, girl of 13 had been raped and sexually abused by a group of men who had been grooming her for sexual exploitation.  That building used to house Bristol Social Services.

It is possible that I have met this young woman, or someone like her, during the course of our research on the needs of homeless women or in the recent evaluation of a nearby Child Sexual Exploitation project.

She could be Jasmine, not her real name, who we first met when she was 19.

But when I got kicked out the last time, that was the only person who I could go to … but he’s on like a paedophile thing, he’s on the sex offenders for life … and he’s just not right in the head. […] Not … he never done nothing to me … or that I know about … cos he could have done it when I was asleep … but I never felt safe there. It was just horrible. (Jasmine, age 19)

When we spoke to her again, she told us

When I think back to that I do get very paranoid thinking he might have put stuff in my drink and … cos I just would not put it past him.  And … but I try not to think of it, cos I’d never find out now. (Jasmine, age 19)

When Jasmine told us about this she did so with a resignation and matter of fact honesty.  She genuinely does not know, on that occasion, if she was sexually assaulted or not.  The rest of Jasmine’s story has an inevitability about it, for example she told us about both her current and ex- ‘boyfriend’:

One time my ex-boyfriend, he hit me before … this was like proper punches to the head … never got the police involved when I should have.  But this one’s a bit different – although he’s physical, he’s like in your head.  That’s what he’s more like – he tries brainwashing you. (Jasmine, age 19)

And about how she coped with alcohol and drugs:

I know it sounds stupid, but I was just thinking a bit religiously and thinking it’s not natural, this is not what God like wanted you to do – take drugs and drink all the time. There’s got to be more to life than that (Jasmine, age 19).

Speaking with older homeless women, the vast majority of whom had experienced domestic or sexual violence throughout their lives and used alcohol and drugs as a coping strategy, demonstrates how the abuse of vulnerable girls and women continues overtime with immeasurable personal costs.

Blossom was 52 when we spoke to her:

[…] this person I’d known from last year, […] he harassed me going along the road, he wouldn’t leave me alone … he said “I need to talk to you” … and the outcome was I was assaulted […] And you see the thing is I knew him when I had nowhere to live, and I stayed there for a night.  And people don’t realise how vulnerable you are when you have nowhere to go. […] you’re vulnerable to all sorts of people.  And believe me I’ve met people that are not nice, and they take advantage of the situation. (Blossom, age 52)

Or Daisy and Ginger who spoke to us about staying in a mixed homeless hostel:

[…] the mixed [shelter], it ain’t safe in there because being women, sometimes I’d get a lot of attention from men, you know?  […] you don’t like waking up in the night getting touched or things going that shouldn’t be going on, you know what I mean?   (Daisy, age 30)

Yeah it’s mostly men, there’s only four women there.  It can be a bit agitating, cos the men there think they can just grab you when they’re drunk and do what they like, you know, but they can’t really can they? (Ginger, age 49)

The Bristol case yet again highlights the abuse and exploitation of vulnerable girls but it also challenges us all, as a society to reconsider how we respond to victims and how we all contribute to the reality in which abusive behaviours, across the continuum from wolf whistling to rape, are experienced and understood.

Whilst the media is rightly abhorred by the rape and sexual exploitation of young vulnerable girls, it doesn’t ask about the wider dynamics of gender and power which contribute to such abuse taking place.  When exploited girls talk about perpetrators as their ‘boyfriends’ it is in a context where society teaches young women to judge their self-worth on the basis of women’s objectification in the eyes of men.  Where they are bombarded by objectifying images on a daily basis in our newspapers, on TV, and on the cover of magazines.  Where senior executives from one of our national TV stations think it is ok to represent the harassment and abuse of women as tongue in cheek comedy entertainment.

In Bristol we have a council that sanctions licenses for sexual entertainment venues – whilst simultaneously seeking to educate young people in the city about respectful relationships. What we need to realise is that the violence and abuse experienced by women and children is inextricably linked to gender and inequality.  If we fail to challenge the latter, we fail to address the root causes of abuse and let victims and survivors down.

Dr Emma Williamson

Anyone who wishes to donate to a local Bristol charity which works with vulnerable women in relation to sexual exploitation might wish to donate to:

http://one25.org.uk/

http://www.sarsas.org.uk/

 

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Nudge and the state

alexmarsh

Professor Alex Marsh, Head of the School for Policy Studies

Last week I took part in an enjoyable discussion on nudge policy as part of Thinking Futures, the annual festival of social sciences. Through a slightly mysterious process I ended up speaking in favour of nudge-type policies, while Fiona Spotswood from UWE made the case against relying on behaviour change initiatives. Fiona made a robust case. I have to say mine was a little less than compelling, in part because in reality I have quite a lot of sympathy with the critics. I find debating from a position you don’t entirely agree with more successful on some days and some topics than on others. This was not one of the better days.

Nonetheless, I find the topic of nudge, and behaviour change policy more broadly, fascinating because it raises so many issues.

Thaler and Sunstein’s Nudge was published in 2008 and has subsequently generated a vast critical response. Such a response is not uncommon. But what is rarer is that it has got everyone worked up. There is barely a discipline across the social sciences and humanities that hasn’t had something to say on the matter. Thaler is an economist and Sunstein a lawyer, but the critical response has gone beyond those fields to include philosophers, sociologists, political scientists, geographers, management, marketing, public health and public policy scholars. We have also seen cognitive and behavioural scientists offering views on the issue.

The critical response has addressed nudge from a wide variety of angles. Much of literature addresses the ethics of nudge. Is it ethical for governments to seek to exploit known systematic biases in human cognition in order to assist individuals in meeting ends they would desire, if they had stopped to think about it? A whole host of questions follow: how are those ends identified and by whom? Does this constitute manipulation? Is it acceptable or unacceptable for governments to manipulate in the ‘public interest’? Is it coercion? Is this the thin end of a wedge that leads to authoritarianism or even fascism (which is part of the critical response primarily among more libertarian-inclined lawyers/economists in the US)?

Is a failure on the part of government to nudge simply allowing other (private sector) economic actors a free hand to nudge individuals in all directions, without any countervailing action to mitigate the worst effects of private nudges? Perhaps the simplest way to make that point is to consider the nudge argument that if you place healthy food more prominently near the checkout in a cafeteria, rather than the confectionary that is usually there, then it increases the likelihood that people will eat healthily. Critics object to government manipulating choices in this way. But the prior question is why is the confectionary there in the first place? It is, of course, because the manufacturers of sweets know that we are prone to temptation and impulse purchases while standing in line. They are manipulating a systematic bias in our decision-making.

Of course, the alternative response to this problem is to seek to do something about the way private actors manipulate choice in the first place, rather than surreptitiously nudging in the opposite direction. But that would require a braver government than any we have seen in recent years.

A second strand of the argument focuses on the evidence base underpinning policy proposals. How well attested are these behavioural effects? One simple criticism of the literature is that much of the original experimental data comes from studies of the decision making practices of US undergraduates. To what extent do these conclusions generalise? Behavioural economics tends to assume that generalisation is unproblematic, but that is hardly a sound starting point for policy. Under the UK Coalition government the policy debate about behaviour change has been one area where considerable prominence has been placed on the role of evidence and on policy pilots. But it is an area in which one type of evidence – that drawn from randomised controlled trials – is seen as pretty much the start and finish of the conversation.

A third strand of argument is about the efficacy of nudge. Even if we accept that there is robust evidence of systematic biases in cognition (such as the tendency to weight current consumption more heavily than future costs when making decisions) what can be done with this information? Most importantly, is it a substitute or complement to other forms of government action? Can nudge be used instead of more paternalistic regulation, for example? This is a point that governments have been rather vague on. Nudge, when it arrived on the scene, was viewed as being able to stand in for more interventionist approaches. But this position has subsequently been modified in the face of criticism. It may be possible to improve social outcomes in modest ways using nudge techniques, but it is hopelessly underpowered for addressing some of the major challenges facing society.

Finally, there is the fact that “nudge” is rather elusive. By that I mean that it doesn’t refer to a very clearly defined set of actions. Or rather it has been applied to a wide range of actions and interventions that don’t really accord very well with the original definition of a nudge offered by Thaler and Sunstein – a definition which has, itself, been heavily criticised. The Government’s Behavioural Insights Team was colloquially referred to as the “nudge unit” but it drew much more broadly on insights from social psychology and behavioural science than simply focusing on nudges of the Thaler and Sunstein variety. There are now quite a number of other approaches to behaviour change circulating. Some of them have similarly catchy labels (think, steer, budge, shove). Some of them start from very different premises to nudge itself. Some have had an impact on policy in particular fields – with much of the running being made by the debate in public health. Some of them have yet to make much of an impact on policymaking in practice. The academic discussion is a riot of theoretical innovation, with various frameworks and heuristics being proposed. Some are engaged in the hard graft of evaluation and synthesis, with the aim of being clearer regarding what works, when and how.

An outstanding question is whether as the accounts of behaviour change become more complex and nuanced they start to lose their purchase on policy – which typically wants simple messages leading to clear prescriptions. But that is simply another case of the perennial tension between research and policy.

This post was originally published on Alex’s Archives.

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Child Sexual Exploitation: Groundhog day

Emma Williamson and Natasha Mulvihill, Centre for Gender and Violence Research

The report into the abuse and sexual exploitation of children and young people in Rotherham[i] whilst shocking, is not a surprise. The report comes in a long line of reports, inquiries, research, and reviews which are consistent in their findings. That victims have been ignored or not believed; that busy professionals have been unable (for a variety of reasons) to respond appropriately; that officials have not adequately prioritised the work of those on the front line; and that existing legislation is not being used even in cases where it could be, to tackle the sexual exploitation of children and young people.

As British actor Samantha Morton made clear in her recent interview, every incident of child sexual abuse is a life sentence for that individual, their families, and those around them.

As calls for yet another inquiry are made, maybe this is the time to take a different approach. A recent Parliamentary Select Committee Report, published in April 2014, concluded that there was no evidence to suggest that in terms of child sexual exploitation “justice cannot currently be served due to the lack of a specific offence”. The recommendation of this report was that “existing offences could be used more effectively”.  Sheila Taylor, CEO of NWG Network, in recent news interviews and her own press release, highlighted how their organisation had compiled the recommendations from 16 recent relevant reports which resulted in up to 400 recommendations. The result, she suggests is that practitioners are overwhelmed, frustrated, and struggle to implement the findings from a report before a new one comes out. Ms Taylor suggests, and we would wholeheartedly agree with her, that maybe that money would be better spent on dedicated, ring fenced, services to implement the recommendations we already have and provide the much needed victim-focused services which are clearly needed.

Too often the response to inquiries, reviews, and reports by the time they come out, however damning, are that lessons have been learnt and changes made. The scandal which we need to face is why this keeps happening if lessons have been learnt? What happens in these areas when the glare of the media spotlight disappears and victims once again become the target of perpetrators whose behaviour society allows to go unchallenged?

Our recent evaluation of a specialist service working with young people at risk of sexual exploitation[ii] is that lessons haven’t been learnt. Austerity is impacting on the ability of statutory services, the police, social services, and youth services, to deal with the cases that fall onto their desks, let alone going out and finding what are hidden and difficult cases to deal with. Too often the services for those in need, as opposed to those where there is a statutory responsibility to intervene, are restricted, where they exist, to short term interventions. It beggars belief that commissioners think that someone being groomed for sexual exploitation would be identified, supported to recognise the abuse, and disclose that abuse in the 6 week support packages currently written into so many service contracts. Those being exploited need specialist support, over a long period of time, and for there to be coordinated responses between the police and support workers. All of that costs money which is increasingly difficult for local authorities and voluntary services to find.

Given the difficulties faced by service providers with ever increasing workloads and limited specialist service providers where they can send clients, it is not surprising that victims end up falling through the net. The vulnerabilities which perpetrators target victims for, are the same that allow agencies under pressure to perceive these victims as difficult and un-credible.

Rather than waste yet more money on an inquiry, the responses to which we have heard before, maybe the government and all political parties should commit to 10 years of ring fenced funding for the establishment of a national response. This should include specialist sexual exploitation workers to support victims in every area of the country and specialist dedicated police officers in those areas to use every law at their disposal to target perpetrators so it is their behaviour under the spotlight and not that of the victim.  Where this has happened in local areas, real progress has been made.  We need the same concerted effort nationally to tackle this problem.

The authors can be contacted at nm8543@bris.ac.uk and e.williamson@bris.ac.uk 

This blog was originally posted on the PolicyBristol blog. 

[i] Jay, A. (2014) Independent Inquiry into Child Sexual Exploitation in Rotherham 1997 – 2013. Rotherham Metropolitan Borough Council.

[ii] Mulvihill, N. and Williamson, E. (2014) An Evaluation of the GDVSAP Trafficking and Grooming Project, Gloucester, UK.  Bristol: Centre for Gender and Violence Research, University of Bristol.

 

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How long is a good life?

David Abbott, Professor of Social Policy, asks some thought-provoking questions about life and death

David Abbott

How long are we ‘supposed’ to live for? ‘Three score and ten’ was a phrase I used to hear growing up (70 in new money). Our cultural ideas about life course and life span and who should die when are deeply ingrained. Parents should never bury their children, right? But what if you are born with or develop a condition which means that from a relatively young age your life span is destined to be much shorter than the norm and that without a dramatic medical breakthrough, very little will change that.

Boys (and it’s nearly always boys) diagnosed with Duchenne muscular dystrophy are one such group. Duchenne (or DMD) is an inherited neuromuscular disease and the average age of death used to be 19 but during the last few years, with significant improvements in the ways DMD is managed, life expectancy has risen to around 27 years. There is currently no cure for DMD.

The Guardian recently reported on two fathers whose sons had been diagnosed with DMD. One, now rather famously, produced a poster for the Evening Standard with a controversial strapline – ‘I wish my son had cancer.’ Why? Because in the Dad’s words: “I felt a cancer diagnosis would have more options, more of a chance, a chance to try something – a chance that those with DMD still don’t have.” In the second article, a father whose two sons had received a diagnosis of DMD decides he must cherish his ‘dying’ sons and ‘hold them close to my heart.’

As a generation of adult men with DMD emerge their status as role models is so important. Pioneers like Jon HastieCarl Tilson and Doug Robins – to name just some suggest that much is possible. Yes it happens within a different time frame. My question is: how can men with DMD can be supported to live full lives in the time that there is? How disabling might it be to live a life weighed down by the pressure associated with our ideas of what a ‘normal’ life span is? Look at the comments on the Guardian articles. Readers respond to a ‘tragedy’. You can’t lead a tragic life all your life – however long or short. Deep breath. I am not in any of these parents shoes. And I wonder for a moment what it is like to grow up as someone who is perceived to be dying all of their lives? Is it true that boys – and men – with DMD don’t have options or chances?

From our research at the School for Policy Studies, (see our freely available research report, and our academic article) we know that men with DMD don’t always get enough support to live the lives they want to. Whilst health and social care services need to up the ante it maybe that our ideas about the length of a ‘good’ or ‘normal’ life need to change as well.

David Abbott is Professor of Social Policy in the School for Policy Studies at the University of Bristol.

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Driving outcomes

David B photoDavid Berridge reflects on some older and newer research that he has undertaken on children’s residential care

Over my research career I’ve undertaken several studies of children’s residential care in England.   Like others, I sometimes wonder why I select the topics that I do, although research funding being as it is, you often have to take the opportunities as they come along.  As a young graduate my first jobs in the late 1970s were in residential settings with teenagers.  I’m not sure that we were particularly effective; we didn’t know exactly what we were trying to do and the knowledge base was much less developed than now.  At least I tried to offer professional friendship (there’s an interesting concept, similar to what continental European social pedagogues aspire to) as well as introducing young people to a wider range of interests, sports and situations.

On becoming a researcher, my first main study of children’s homes in 1985 (long out of print) entailed me undertaking fieldwork and living for a week in 20 different homes.  All this happened in the first year I was married, which didn’t make me especially popular.  Others  have followed (studies rather than marriages).  Residential care is now a small service in England compared with many other European countries but caters for a very troubled minority.  It continues to attract negative publicity, including the sexual exploitation of residents by groups of local men.  Whatever its other shortcomings, to its credit the current UK Coalition government is taking some positive steps to strengthen children’s residential services.

The latest project that I finished recently is a somewhat unusual one – Driving Outcomes:  Resilience, Learning to Drive and Young People Living in Residential Care.  It entailed a small pilot which offered driving lessons to a group of six older adolescents living in a group of residential homes in Bristol.  Raising funding took time but the project and a qualitative evaluation proceeded thanks to the generosity of the AA Charitable Trust, British Academy and University of Bristol.  Readers can find out more about the research here but it is interesting to reflect on some of the issues.  A journal article should  be available later in the year once it grinds its way through the academic peer review process.

In a nutshell, although only one of the six young men had so far passed his driving test, pupils, professionals and heads of homes  interviewed felt that the initiative had been very successful.  The person who passed said that it had changed his life.  For others, there were perceived benefits in raising self-esteem and self-confidence, as well as in encouraging close relationships with supportive adults.  These stand out in the resilience literature as important in helping young people overcome the effects of early adversity, including abuse, neglect, family breakdown and parental rejection.  Learning to drive may help combat some of the stigma associated with being in care and social exclusion, as well as an important symbolic transition to adulthood, which children in care may otherwise find difficult.  I keep explaining that you wouldn’t expect driving and cars to be a panacea (‘silver bullet’) for complex personal, social and structural problems.  However, the limited evidence, and theoretical justification, suggest that driving may be of disproportionate benefit.

Furthermore, it is often commented that it is unacceptable that the State doesn’t provide for children separated from their families and living in care in the same way as we would for our own children.  Examples include the low educational attainment and the inadequate support (‘accelerated transitions’) for care leavers.  The statement is rarely (never?) questioned.  How realistic is it?  For example, our son or daughter may ask us to look over and help with a school essay; would we do so with the same commitment and conscientiousness as a foster carer, residential worker or social worker?  This is one reason why adoption works particularly well as parents are more likely to provide the limitless support or ‘unconditional love’ that children need.  How else can the State replicate this in more temporary legal and social work circumstances?  How can it be expressed for adolescents in care?  What is a close approximation?  A useful article helps unpick some of these issues.

On reflection, starting off the driving lesson initiative was one effort in this direction.  Providing opportunities is no doubt more straightforward than guaranteeing care and emotional support. We often arrange driving lessons for our own children, so why shouldn’t we do the same as ‘corporate parents’?  In England at least, this has so far been unusual for residential settings, although foster carers may have made their own arrangements.  What other experiences might there be that could have a similar effect to strengthen resilience?  High educational attainment is probably best.  No doubt sports, caring for animals, music and drama work for some.  Another might be seeking part-time work, which is very uncommon if not unknown from my past residential studies.  Getting involved in advocacy work for children in care/Care Councils could work too.

It would be interesting to know what others think.

David is Professor of Child and Family Welfare in the School for Policy Studies at the University of Bristol.

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Supreme Court ruling defines deprivation of liberty

Leona McCalla, Teaching Fellow in SPS and mental health practitioner, discusses the implications of recent judgements on the deprivation of liberty.

On 19 March 2014 the Supreme Court finally gave its judgement in the cases of P v Cheshire West and Chester Council, P & Q v Surrey County Council (2014). These cases concern the criteria for judging when care and treatment for ‘mentally incapacitated people’ amounts to a deprivation of liberty.  P is an adult with Down’s syndrome and cerebral palsy, living in a registered care home setting; he has 24 hour care and support and requires physical intervention when he experiences agitation. P & Q (MIG and MEG) are sisters who became subject the care proceedings. MIG was placed in foster care and appeared settled there. She never attempted to leave, but would have been prevented from doing so if she tried. MEG was placed in a residential home for adolescents with learning disabilities and complex needs; she required occasional physical restraint and medication for the purpose of sedation.

The ruling found that P in the Cheshire case and P & Q were all deprived of their liberty. Lady Hale led the judgement and concluded that if a person is subject to continuous supervision and control, and they are not free to leave, then they are deprived of their liberty. This ruling has significant implications for Local Authorities who act as Supervisory Bodies in the Deprivation of Liberty Safeguards process, as it means that many people are likely to be unlawfully deprived of their liberty without safeguards in hospital settings, care homes and in supported living placements.

The Deprivation of Liberty Safeguards (DoLS) was implemented in 2009 as an amendment to the Mental Capacity Act 2005. The purpose of DoLS is to provide protection to people who lack capacity to make decisions about their care and treatment either in care home or hospital settings. The process involves independent professional assessments which are undertaken by a Mental Health Assessor, usually a Consultant Psychiatrist and a Best Interests Assessor (BIA) most likely to be a Social Worker or Mental Health Nurse. The BIA’s role is central to the process and involves assessing whether a person lacks capacity to decide on their care or treatment, deciding whether a person is deprived of their liberty, and deciding whether the DoL is in their best interests, necessary to prevent harm to them, and whether it is proportionate to the likelihood of that harm occurring. The Mental Health Assessor and BIA submit their assessments to a Local Authority Supervisory Body who ‘authorise’ the Deprivation of Liberty; in this way the DoL can be made compliant with Article 5 of the Human Rights Act 1998, the Right to Liberty.

Having worked as a Best Interests Assessor since the role’s inception, I have firsthand experience of the complexities of the work. One of the main challenges involved is deciding whether or not a person is actually being deprived of their liberty. The absence of a definition of what constitutes a deprivation of liberty in the Mental Capacity Act 2005 means that practice is guided by case law. Complexities have arisen because judges have not been entirely consistent in their interpretation of DoLS and therefore definitions of Deprivation of Liberty have evolved with each landmark judgement. Empirical studies such as that conducted in the School for Policy Studies (Carpenter, Langan, Patsios, & Jepson, 2013) have highlighted that BIAs have historically taken a range of factors (based on case law) into consideration when deciding if someone is deprived of their liberty. These include coercive staff behaviour, the resident’s level of objection to their care, the use of medication to reduce agitation, restriction of movement, and family unhappiness with the care.

The judgement handed down in the Supreme Court indicates that factors which have previously been the main considerations in deciding whether or not a person is deprived (objection, acquiescence and the purpose of the care and treatment) are not relevant. Lady Hale confirms that a simple definition should apply: If a person is subject to continuous supervision and control, and they are not free to leave, then they are deprived of their liberty.

This ruling provides clarity about what constitutes a DoL and, as a BIA, I welcome this. However, the judgement means that many more people will require a DoL authorisation.  Potentially anyone accommodated in a care home or hospital setting who is not free to leave and lacks capacity to make this decision will require assessment and authorisation. There are thousands of people living with a mental disorder, accommodated in secure care homes or on hospital wards, who previously would have not needed an assessment because they were compliant with their care and treatment, who will now need to be assessed.  Since the judgement on the 19th March I have consulted a number of BIA colleagues and we have all identified recent cases where our decision based on case law was that no deprivation was occurring, but under the ‘new definition’ a deprivation would have been judged to be occurring.

Similarly, the case of P&Q involved sisters living in foster care. The fact that P&Q were found to be deprived of their liberty sets a precedent. There could be an influx of cases for people residing in supported accommodation or from people receiving care in their own home (not covered under DoLS), if they are under continuous supervision and they are not free to leave. This has huge resource implications for public bodies and the Court of Protection and questions have been raised about how the system will cope.  

I wait with anticipation to see how Supervisory Bodies will respond. There are many questions to be answered: Will the new definition provide more safeguards for people living with mental disorder? Will reassessment of recent cases by required? How will training be provided to Managing Authorities to ensure that care staff are aware of the changes?  How will the system cope with the potential influx of referrals?

I look forward to lively debate over the coming weeks and months as we consider further how this judgment will impact on practice and whether it will provide better outcomes for the service users. If the Government act on the House of Lords Select Committees post legislative scrutiny of the Mental Capacity Act , which was published a week before the Supreme Court ruling, the Deprivation of Liberty Safeguards process will be replaced in due course . Until that time comes those of us involved in this field of practice will continue to practice in line with case law judgments, with the aim of safeguarding some of the most vulnerable people in our society. 

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The Narey Report on Social Work Education

On 13th February Sir Martin Narey published his long-awaited report on social work education. In this post Dendy Platt offers his initial response.

Sir Martin Narey’s report, published on 13th February, is typically challenging and hard-hitting, but it is also thoughtful and insightful.  Newspaper headlines have exaggerated some of his points, but behind these headlines are insights that social work academics would do well to heed.  I, for one, welcome the encouragement to continue to improve education in child development and child protection on social work degrees.  I also welcome the advice to move on from the dogma of anti-oppressive practice.  However, Sir Martin was wrong to appear (perhaps unintentionally) dismissive of the importance of ethics and values in social work.  There are fundamental and intense contradictions in our work.  Sir Martin is right that overemphasis on an empowerment approach can lead to collusion with the parent and insufficient focus on the child.  However, this is not an inevitable result, and good relationship-based practice is central to the work of social workers up and down the country, social workers who also keep the child clearly in view.  My own take on this is summed up in my editorial (with Danielle Turney) of a recent Special Issue of Child and Family Social Work.

That said, I welcome Sir Martin’s view that there should be greater clarity with regard to the curriculum.  The plethora of statements, competence requirements, and so forth, has long been a problem, and the former General Social Care Council was notably ineffective in addressing it.  The role of sorting out the mess is clearly one that should be taken on by the College of Social Work, as the report suggests.  The problem, however, is to avoid ending up with another mess.  Once all the different interest groups have made representations about what should appear in the social work curriculum, if those views are all incorporated, we risk ending up with such a huge range of topics that teaching them all to an acceptable level, and assessing the students adequately, will be completely beyond the scope of a three year degree.  Someone will have to prioritise. Continue reading

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