Tuning in to the sexual histories and lives of older adults

paul-willisDr Paul Willis, is a Senior lecturer in social work with adults, in the School for Policy Studies. His research interests include sexuality, care and ageing, and trans issues in later life.  This blog was first published on the website for Lyn Romeo, the Chief Social Worker for Adults.

Sex and sexuality are undoubtedly difficult topics to discuss with service users and carers – with older adults, even more so. To open up conversations about sexual intimacy risks causing offence, alienating older adults and compromising rapport built up with service users over time.

In some recent research on care home provision for older lesbian, gay and bisexual adults, we found that often managers and staff were reluctant to have these conversations with residents—these were no-go zones because of concerns about offending others, causing embarrassment (for staff and residents) and infringing people’s privacy.

The notion of individual wellbeing sits at the heart of the Care Act 2014. If we are truly invested in promoting the wellbeing of older adults then sexuality needs to be acknowledged as an integral part of their physical, mental and emotional wellbeing.

We often talk about person-centred approaches in adult social care, but what about sexual personhood? This means recognising the unique elements of an individual’s sexual life-story, including their sexual identity and past and current relationships. Experiences of sexual activity in early adulthood, affirming or negative, can have a lifelong impact on how individuals view themselves and relate to others in later life.

So what makes sex such a tricky subject to discuss with older adults? First, we have to look past the common myth that older people are asexual, in other words older adults are disinterested in sex and it’s no longer important to them. We know that older adults remain sexually active in later life.

The most recent wave of the National Survey of Sexual Attitudes and Lifestyles 3 in Britain included respondents up to 74 years of age for the first time and highlighted how older adults over 59 years continue to engage in sexual activity, albeit with less frequency than younger folk.

The idea of older adults engaging in sex can often evoke individual responses of disgust and repulsion—some researchers in ageing studies refer to this reaction as ‘ageist erotophobia’. These negative beliefs can make us blind to the sexual health needs of older adults, which can prevent older people from accessing sexual health services. Sexually transmitted infections and HIV do not discriminate on the basis of age. According to the National AIDS Trust in 2014, 636 people over 55 years of age were diagnosed with HIV.

Another popular myth is that all older people are straight or have lived heterosexual lives. Many older adults belong to sexual and gender minority groups and identify as lesbian, gay and bisexual (LGB).

Equally, some older adults may be same-sex attracted but do not identify as LGB. For older gay and bisexual men this means they may have had hidden relationships during a time when sex between men was a criminal act and subject to prosecution, prior to decriminalisation in 1967 in England and Wales.

For older lesbian and bisexual women their identities and relationships were not recognised in UK law and policy prior to the wave of equality laws introduced during the last 15 years. During their younger years, some older women and men may have felt compelled to receive psychiatric treatment to ‘cure’ their sexual and gender orientation while others may have experienced social exclusion from faith groups, family and local communities.

These legacies cast a long shadow and we know that older LGB adults are reluctant to access health and social care services as a consequence.

So how do we tune in to the sexual lives and histories of all older service users? This is not a topic easily broached in a first meeting. It’s a gradual and persistent process that relies on trusting relationships built over time, gently and sensitively asking open-ended questions about past and current relationships, and continually signalling to older service users that we are receptive to conversations about sexual health, relationships and identity.

It requires us to ask questions about relationships and intimacy when these issues may not be mentioned or initially appear relevant to people’s care needs. It also requires us to quietly challenge the views of others working with us such as students, colleagues or professionals from other agencies.

And for a lot of us it could mean taking time to reflect on and reconsider the ageist views and assumptions we may hang on to about sex, sexuality and ageing, often unknowingly. This is not an easy endeavour when religious beliefs and personal values about sex and sexuality can run deep.

Fundamentally, social workers have a pivotal role in advocating for the sexual wellbeing of older adults in receipt of care services in their homes, in community settings or in long-term care. Maintaining sexual health and sexual wellbeing is a human right applicable to all—the World Health Organisation reminds us that ‘the sexual rights of all persons must be respected, protected and fulfilled.’ Older people are no exception.

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How Social Workers Assess Parental Capacity to Change

 

c-change-opt

Dr Dendy Platt, Senior Lecturer in Social Work, and Head of the Children and Families Research Centre, School for Policy Studies, examines the potential for the C-Change approach.

Social workers’ assessments of parental capacity to change are becoming increasingly important when working with children in need and children who may be at risk of maltreatment.  Expectations from the courts regarding care proceedings in England have increased in the last couple of years, focusing particularly on better analysis in social work assessments, and better exploration of alternative courses of action for the child in question.  Assessing the likelihood of a parent being able to make sufficient changes in their lives to ensure the child’s safety and wellbeing is a part of this analysis.  And capacity to change is now included in the court report template from the Association of Directors of Children’s Services – requiring assessment of whether a parental capability gap can be bridged.

Fulfilling these requirements, however, presents some problems.  One view of court decision-making suggests that the key evidence the courts need to make a decision is:

1) Whether harm has occurred to the child;

2) What caused that harm, and whether it can be attributable to the parent(s);

3) What can be done about the situation – and in particularly, whether the parent(s) can change things sufficiently to ensure that the child is well cared for into the future.

A brief look at the history of child protection work shows that there has been a great deal of research into the first point.  Child maltreatment is well-understood.  Research has helped us develop and improve methods of identifying it, investigating it, utilising medical expertise to arrive at satisfactory diagnoses, and so forth.  Similarly, on the second point, a variety of assessment approaches have been developed over the years to give us ways of exploring the context of the harm, the contributory or causal factors, and to help us understand the parents’ roles.  Examples include the Framework for the Assessment of Children in Need and their Families, and the Signs of Safety approach, but there are many others.  All these developments have been backed up by theory and research.

The third element of the decision, the potential for changes that benefit the child, has received much less attention.  In terms of assessing parents, there are methods that support parents to make changes, and the impact of this can be measured using before and after measures.  Examples include the work of Paul Harnett, but few such approaches are widely used, despite their underpinning research.  In terms of theory related to behaviour change, the only theoretical approach that has had a significant impact in the context of UK social work practice is the Transtheoretical or Stages of Change model.  This model is useful in drawing the practitioner’s attention to the idea that individuals approach change in different ways, and that relapse is a regular part of most attempts to change.  However, the model itself has been widely criticised, particularly in the child welfare field.  The stages themselves have not proved detectable in significant empirical studies, and individuals’ progress from one stage to the next has not been demonstrated at all clearly.

The key point is that theory and research, to date, have not offered very much help to social work practitioners in relation to understanding and assessing capacity to change.

The C-Change approach, developed by Katie Riches and myself at the University of Bristol aims to fill this gap.  Its central principle is that there are two parts to an assessment of capacity to change.  The first involves understanding what helps and hinders change in individual parents.  The second involves creating an opportunity for change and assessing progress.  C-Change brings both of these elements together into one systematic approach.

The first part of the approach draws on behaviour change theories.  It can be seen that capacity to change is affected by a variety of factors, ranging from social and contextual circumstances to individual motivations and intentions.  These factors interact, and practitioners should avoid relying for their assessment on isolated elements – such as whether a parent has ‘owned up’ to actions that have harmed their child.  Some factors may help change, and others may hinder it.  The social work assessment should weigh up barriers and facilitators in the individual situation.

The second aspect of the C-Change approach involves creating an opportunity for change, with appropriate support and help, and assessing the success or otherwise of achieving the necessary changes.  In this, we have drawn on the work of Paul Harnett in particular, including his use of Goal Attainment Scaling.

These two parts have been combined into a single approach, under the name C-Change, and are supported by a practitioner-friendly manual.  The double meaning of “C-“ in the name refers not simply to “capacity” but also indicates our view that a “sea change” is needed in the importance of capacity to change assessment.  Whereas at present this part of the assessment can be a bit of an afterthought, our view is that it should be have a central role in the assessment process in recognition of its real importance in decision-making.

Further information, about the C-Change approach and the ideas put forward here, is available from our website: www.capacitytochange.org.uk. The practice manual can be downloaded free of charge by following the links on the site.

 

See also: Platt D. & Riches K. (2016), Assessing Parental Capacity to Change: The missing jigsaw piece in the assessment of a child’s welfare?  Children and Youth Services Review, vol 61, pp. 141–148.

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Life Chances: Co-written re-imagined welfare utopias through a fictional novel

143209Dr Debbie Watson, Reader in Childhood Studies discusses an innovative research methodology in this blog piece for the Sociological Review. This is part of their special issue on the relationship between sociology and fiction. With colleagues from the ‘Life Chances’ research team, Debbie describes how the project has been using fictional methods to co-create a fictional novel with community volunteers to better understand life on low income for children and families.

The Life Chances project is part of the ESRC funded Productive Margins project led by Professor Morag McDermot which has a number of themed co-produced projects with academics from the universities of Bristol and Cardiff working with a number of grass roots organisations and volunteers to enable new forms of engagement and to challenge regulation of people’s lives.

Read ‘Life Chances: Co-written re-imagined welfare utopias through a fictional novel

 

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Why inequality matters

Inequality discussion_watershedTessa Coombes, PhD student in the School for Policy Studies, former councillor, ex-policy director at Business West, and part-time blogger discusses why inequality matters, following the screening of a new documentary at the Bristol Festival of Ideas.

“The people will always forget” was a significant line in the documentary The Divide which I saw this weekend as part of the Bristol Festival of Ideas. In the film the line refers to the belief repeated by those to blame for the sub prime mortgage crash in the US, the bankers and financiers, who led us into the Global Financial Crisis and then expected us to bail them out. It’s an assumption that one could well believe our politicians make on a regular basis when taking some of the decisions they do – it’s ok they’ll forget about it when it comes to voting! It’s also an assumption that means we fail to learn from the mistakes of the past and that potentially stops us from addressing many of today’s issues and concerns. Which brings me to the subject of this discussion – the increasing levels of inequality in the UK and the growing divide between top and bottom.

The Divide catalogues the stories of different individuals in the UK and US just trying to get on in life. It highlights all too easily the increasing divide between those that ‘have’ and those that don’t. It illustrates the growing extent to which many of us are perhaps mistakenly driven by money and consumerism, by keeping up with our peers or striving to do better than them, and aspiring for things that are, in the end, unlikely to make us any happier. The main message of the film is based on the book “The Spirit Level” by Richard Wilkinson and Kate Pickett, first published in 2009, but becoming ever more pertinent as time goes on. One of the most important points that the book makes is that inequality affects all of us. The problems are not just confined to the poor, the effects are seen across all aspects of society. Income inequality is a social pollutant because it spreads and everyone is worse off in a more unequal society.

The film illustrated many relevant issues that we are beginning to see the impact of in the UK, but in this post I’m just going to pick up on a couple of them that I think are becoming ever more relevant, that is, the impact of zero hours contracts and the growth of gated communities.

The use of zero hours contracts has become more prevalent in the UK in recent years across a range of sectors. Whilst some in government have tried to argue that it suits both workers and employers, the human impact of these contracts is illustrated particularly well by the film. If you don’t know how many hours you will be working in any particular week how can you budget for rent, food, bills etc? Imagine the levels of stress this type of contract could impose on you from day to day. You don’t know when you will be needed or for how long, so you don’t know what time you need to go in to work, if at all. You don’t know what you will earn in a week, so how can you plan ahead? The insecurity and uncertainly this creates is huge. Imagine having to live with that, even as a single person, but what if you have children and have to plan for their lives too, how does that work? In New Zealand this form of contract has been banned altogether (by a centre-right government), perhaps we could learn something from them?

The concept of gated communities has been around for some time now, with many more at a massive scale in the US, but something that is also creeping into the UK. In the US it’s a way of creating a sanitised community, where white people can feel safe surrounded by other white people, protected by armed guards at the entrance to their ‘community’. The community in the film had its own golf course, lake, play areas and parks and was characterised by large individual houses in their own plot of land. It’s a community that to many would look and feel like ‘prison’ but which in the US is something to aspire to. In the film these places came across as very exclusive, a place to live where people felt safe, but also where people felt isolated. There was in fact little sense of community in evidence, with estate agents promoting the place as lovely and quiet and where you won’t see your neighbours. That’s not a community! In the UK these types of gated community are happening, not on the scale of the US, but they’re there to make people feel safe, so people can surround themselves with other people who have money and status. To me it would feel like a prison, where you have to sign in visitors and go through guard gates just to get home, and where the diversity that makes our communities so rich and fascinating is totally missing. Let’s hope we choose to learn less from the US and focus more on the innovative and creative approach of our European and Scandinavian neighbours.

This point on who we learn from is an interesting one, which was picked up during the discussion with Kate Pickett after the film. It seems the devolved administrations of the UK are more likely to look to Scandinavia, The Netherlands and Germany for inspiration, when it comes to tackling inequality, than the UK Parliament as a whole, where sadly, all to often we look to the US for ideas.

That is the US where health and social inequalities are worse than anywhere else and where income inequalities are at their most extreme. There are many lessons to learn from elsewhere but let’s please make sure we are looking in the right direction. For example, in Utrecht, in the Netherlands, they are looking at paying citizens a basic income and in Bhutan a Gross National Happiness Framework was introduced to replace measures based on GDP.

Inequality destroys empathy” that’s why whilst inequality does of course matter, it doesn’t matter how you achieve greater equality. There are a range of many different measures and policies from across the political spectrum that can work. The key is to do something about top and bottom levels of pay to create greater income equality because as Kate Pickett put it “every action we take individually matters and can make a difference”.

 

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Daryl Dugdale, Programme Director of MSc Social Work in the School for Policy Studies reflects on teaching and learning in the field

International Social Work Day- Promoting the dignity and worth of people; A social work educator’s PerspectiveDr Daryl Dugdale

In celebrating International Social Work Day it is important that social work students experience dignity and self worth in the delivery of social work education. I should declare at the outset a vested interest in this issue as Programme Director of an MSc Social Work course at a Russell Group University. My responsibility, alongside that of my colleagues, is to ensure we deliver a rigorous learning experience so we can optimise the chances of developing top quality social workers. This of course is no easy thing. As Jonathan Dickens has acknowledged, the complex and contradictory roles and responsibilities associated with social work means “that change is always a work in progress and never a task achieved” (p22, 2011). How do we respond to the individual challenges and complex needs of our service users in what is a constantly changing environment? There are challenges for all practitioners in responding to increased volumes of work, whilst experiencing reduced capacity, during a period of near constant agency reconfiguration, and at a time of austerity. Additionally these challenges exist when there is significant political and academic discussion surrounding the future of social work as a profession and debate around the best methods of delivering social work education.

I have a responsibility to ensure the students’ learning environment models best practice and introduces skills to support behaviour expected in their engagement with their prospective service user groups. The learning experience of the student group must promote dignity and provide examples of self-worth; failure to do so risks these qualities not transferring to their practice.

Attempts to fulfil this aim are supported by ensuring the structure and content of the programme has at its core the ‘three Rs’, the student experience must be Robust and Reflexive with opportunities to develop Resilience – these are foundational to the programme.

Robustness is ensured through immersion in the latest research and opportunities to share innovative practice. We consider our programme to be research live and practice near. The students are taught by academic staff who are all involved in undertaking research. The areas of research address the broad spectrum of social work including mental health, learning disability, children and families and gerontology. Students are able to access up to date research messages and debate cutting edge methodologies both of which help inform the development of their practice. This supports Croisdale-Appleby`s suggestion that social workers be acknowledged as social scientists. This research robustness is further enhanced by close collaboration with partner agencies. Practitioners are actively involved in the design and delivery of all elements of the programme. In addition the programme has a very active Service User Carer Forum group who ensure lived experiences and the importance of power are shared with the student group. This promotes healthy discussion and debate around the professional role, the relevance of social work values, and intersections of oppressions. It also asks fundamental questions on what constitutes ethical practice. The collaboration between academics, practitioners and service users ensures students are able to draw on a broad range of knowledge and experiences to help inform their professional judgements. It is important professional decision making doesn`t rely on instinct but has a robust evidence base at its core.

Reflexivity is the second R and fundamental to social work learning and everyday practice. The students are told on the first day of the course that on completion in two years there is an expectation that there will be a change in how they understand the world and how they understand the construction of knowledge. I acknowledge the process of learning is deskilling and by definition a painful experience. The use of reflection is a vital tool in the social workers toolkit. Pedagogy informs the variety of teaching styles on the programme and opportunities to engage in group work informed by an enquiry and action learning approach helps facilitate the reflective process. It also ensures the students take responsibility for their own learning. The act of reflection is further influenced and supported on placement by quality supervision, peer support, and additional training opportunities. I expect space for reflection to be a fundamental right for all practitioners and this opportunity should begin at the qualifying stage.

Resilience, the third R, is crucial to practitioners being able to sustain themselves in what is an increasingly challenging practice environment. It helps amongst other things to protect against experiences of vicarious trauma. The emotional component of the social workers role demands all students develop emotional elasticity. It also requires the student is able to develop strategies to help self-manage. This might include developing strategies for chairing difficult inter-professional meetings, communicating with reluctant children or adolescents, developing rapport with adults experiencing mental unwellness, or identifying best ways of de-briefing after a challenging home visit.

The three Rs exist as a golden thread fundamental to the design and delivery of the social work programme.

During this period of rapid and significant change there is I believe a real risk to the golden thread. Whilst engaged in celebrating social work in its international context, recent developments in England suggest dangers are afoot. I have anxieties that the Rs may be lost or at the very least diluted, which may impact on students’ experiences of dignity and worth.

I`m not so arrogant to assume there is only one way to deliver social work education, nor would I suggest the structure we have designed is necessarily the best example. However recent changes to how social work education is being delivered does concern me. Fundamental to this concern is the rapid rise of fast track programmes, and there are number of reasons why:

• First of all the proposed numbers involved. One third of the 4,590 social work graduates (2013-14-figures from HESA) undertook post graduate social work programmes. The proposed advance of fast track programmes both Step Up and Frontline aim to train 950 students by 2019. This figure constitutes two thirds of the current post graduate figure. This proposal will have a significant impact on those research intensive HEIs who currently run social work programmes.

• These changes appear to be ideologically driven with a lack of robust evidence to support the assumption that this method of delivering social work education adds value to that which currently exists.

• The focus on children and families work and the move towards specialism puts at risk the benefits of the generic programme. It is a generally held view of social work academics that the generic programme offers the best opportunity for social work students to appreciate the wider social context of family and human development as a whole life course.

• The fast track programmes with their significantly larger bursaries offers a financially perverse attraction to applicants. This creates a two tier application process with those traditional programmes having their bursary allocation squeezed. There is no guarantee that the fast track programmes will attract the best possible candidates with their mix of social care and life experience, all key to supporting the development of well rounded practitioners. In addition there are questions around diversity. In targeting high performing undergraduates there is the potential risk that the fast track programmes attract students of a certain age, class and ethnicity. This will impact on the makeup of the social work profession moving forward, which will further impact on the experiences of the vastly diverse service user groups.

• Squeezing the learning into a fourteen month period places significant pressures on the student. The complexity of the social worker role demands time is taken to help form effective links between social work theory and practice. There are dangers this pace of learning will result in knowledge deficit. This runs the risk of practice becoming overly bureaucratised, target driven, and risk averse. This manifestation mirrors weaknesses in current practice regimes. The result may be paternalistic practice that pathologises service users and fails to acknowledge the impact of the wider social and political context. The danger is such an approach risks creating an ethically naive profession, where principals of social justice are deemed a luxury rather than a fundamental human right.

It is important on this day that we acknowledge all those involved in learning the craft of social work as well as those delivering social work education. Social work “promotes social change, problem solving in human relationships and ensures the empowerment and liberation of people to enhance wellbeing” (IFSW 2011). This task is both complex and messy. The act of delivering social work education has many challenges, Wenger (1998) suggests that “learning is the engine of practice and practice is the history of that learning”. The suggestion is people’s learning and the environment in which it is experienced influences what they become. I suggest the principles and structures of the fast track movement offer potential dangers to social work education and the qualifying experience. There is a risk that a learning context is being created that negates the long history of research messages relating to social work education. There is a need for this debate to be amplified and the discussion should be informed by robust research to ensure the student social worker experience is maximised. There is a need to ensure the three Rs remain a fundamental part of any social work programme and aren`t replaced by the three D`s, risk of dilution, the risk to diversity and the risk from dogma.
Dickens, J. (2011) Social Work in England at a Watershed—As Always: From the Seebohm Report to the Social Work Task Force British Journal of Social Work Vol. 41 p22

IFSW. Ethics in social work, statement of principles. Available at www.ifsw.org/f38000032.html
Wenger, E. (1998) ‘Communities of Practice. Learning as a social system’, Systems Thinker, http://www.co-i-l.com/coil/knowledge-garden/cop/lss.shtml

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Growing the conversation: how to make Bristol a Child Friendly city

Close up of little boy in canvas shoes drawing with chalks on the sidewalk

Debbie Watson reports as The Bristol ‘Child Friendly City’ Network ran the first Child Friendly Symposium as part of the 2015 Thinking Futures festival.

Inspired by global UNICEF guidelines, the Child Friendly City’s Network aim is to bring together a wide range of partners to campaign strategically and deliver grass roots projects that support child friendly environments. The Child Friendly Symposium brought together around 20 children and young people, as well as 80 adults who worked for and with this demographic, from all over Bristol.

Mayor George Ferguson opened the event and emphasised the need for cities to actively consider children and young people, whether in urban planning decisions, allocation of community resources or in the respect afforded to our youngest citizens. He said: “A child-friendly city is a healthy, happy, liveable and playable city”.

The symposium then saw short presentations delivered by Bristol academics: Dr Angie Page on children’s activity levels and public health outcomes; Dr Helen Manchester on a project which explored young people’s cultural engagement in Bristol; and Dr Debbie Watson on a project which co-developed research capability and awareness with Room13 Hareclive children and artists.

But the main event saw child-led participatory activity to engage adults in the room. Together they made creative banners, highlighting what needs to change in Bristol for it to be truly child friendly. These banners were then showcased, sharing many powerful and provocative messages.

Giving young people from Room 13 Hareclive, Hartcliffe and Felix Road Adventure Playground, Easton, a contributing role in the symposium was an important statement of intent. Harnessing this potential is what Child Friendly Cities (CFC) are all about, holding true to the principle that ‘if a city is successful for children it will be successful for all people’.

“The Thinking Futures Bristol Child Friendly City Symposium was a great opportunity for us to bring together representatives from different backgrounds in the city to share an equal platform: children and young people, academics, organisations working with children and young people, arts and cultural organisations, Bristol’s mayor and Bristol City Council officers.”

We heard compelling arguments from different perspectives – research, local government and children themselves – about why it’s so important for Bristol to be more child friendly. Children and adults identified key calls for change in the city such as ‘free bus travel for children’, ‘safer streets’ and ‘believe and trust in us’, which we all endorsed. It was good to see children and young people, many of them from more disconnected parts of Bristol, sharing thoughts and ideas with academics and practitioners, and vice versa.

This event in partnership with the University of Bristol really helped to raise the profile of Bristol CFC and to consolidate and move on our agenda within the city. We’re excited by the possibility of further collaborative work with academics.” – the Child Friendly City network.

The event is part of a wider strategy to grow the conversation in Bristol, beyond immediate partners and interested parties. Already, impact can be seen across the city through press releases, media coverage, and new partnerships. Bristol and other cities have already been in touch, with potential collaborations stretching as far as Sweden. In late February these interested parties came together at a seminar hosted by Cardiff University’s Children’s social care research and development centre (CASCADE), opened by Dr Sally Holland, the children’s commissioner for Wales.
Ongoing local campaigning includes: a proposal for research impact funding to tackle one key issue with children in the city; organising a young people’s Mayoral hustings in May; and an international conference hosted in Bristol, for the city to truly lead on child friendly policy and practice.

For more information:

Towards a child-friendly city

The Child Friendly City network consists of University of Bristol academics and grassroots organisations Architecture Centre, Playing Out, and Room13 Hareclive.

Debbie Watson is Reader in Childhood Studies in the Centre for Family Policy and Child Welfare.

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Capturing the benefits of ‘playing out’

School for Policy Studies academics work with a range of local interests. Playing out is a non-for-profit Bristol based organisation that encourages street play in the UK. Naomi Fuller, from playing out, has written this blog about how their work with the School is helping them to capture the benefits of such activity. 

I stood turning the skipping rope for ages at our last playing out session. Tall ten-year-olds and sturdy toddlers queued to have a go at jumping in as I chanted “Mickey Mouse Built a House” on request. I watched them – some skipping deftly, others stopping and starting with the rope getting tangled, some squatting down to do some chalking close by while they waited and I wondered whether it was possible to unpick what was going on. Of course they were having fun, giggling and trying to hold hands and skip together, then running out of the turning rope to add chalked horns to the rainbow-coloured cow they had drawn together in the middle of the street. But is there any way to measure this activity. And is there any need?PORTRAIT-grandma-skipping-rope.jpg

A conference hosted recently by University of Bristol gave some clear answers to these questions. The event was called “Outdoors and Active: Delivering public health outcomes by increasing children’s active travel and outdoor play”. It gathered people working in local authority public health teams, education and play services to share new research showing beyond doubt that children at playing out sessions are getting more exercise and activity than they would if they were indoors during that same period. Dr Angie Page and Professor Ashley Cooper are lead researchers for the PEACH project, a long term study examining the links between the different physical environments children spend time in and how active they are in them. They and their team have already measured children’s activity levels on their school journeys – whether in cars, on foot or by bike, during the school day and in the after-school period, examining the length of time they spend outdoors and indoors and exactly how much physical exercise they do.

To carry out these studies and gather the data they need, researchers have kitted children out with GPS tracking devices which show precisely their location at every stage of their journey. Children have also worn ‘accelerometers’ which measure the intensity of their exercise and activity. Recently Angie and her research team have turned their attention to street play – visiting playing out sessions to measure the intensity and type of physical activity children are doing. As well as equipping the children with the technical kit, her team interviewed parents and children about their activity patterns and habits.

It’s the levels of ‘moderate to vigorous physical activity’ (MVPA) that are a key focus. Government guidelines are clear: children between five and eighteen need to get at least an hour’s MPVA each day to ensure they are healthy. But very few are managing this and recent figures show just 14% of boys and 8% of girls are doing so. And these levels of inactivity are increasingly worrying for children’s long-term health and wellbeing. During a playing out session MVPA is the energetic play we often see; the skipping, scooting, hopscotch and playing tag as you would expect. But it’s brisk walking and similar types of activity as well and lots of imaginative games would include periods of MVPA as I’ve observed on my own street when make believe wizards and witches take to their broomsticks after huddling over a pretend cauldron for a while. The University of Bristol data shows;

  •  Children are three to five times more active outdoors than indoors
  • Time spent outdoors with friends is linked to an increase in children’s physical activity levels
  • During playing out sessions children spent 30% of their time in moderate to vigorous physical activity (MVPA) and another 15% in light activity.
  • This compares to 5% of time indoors usually spent in MVPA

Holding-one-end-skipping-ropeAngie Page introduced some important questions in presenting these findings. First was the notion of ‘subsitutional replacement’. Put in lay terms the issue is whether the children at the playing out session would have got their physical activity in another place such as their garden or local park if they hadn’t been playing in the street that day. The clear answer was no. The responses from parents and children showed that the playing out session was usually an alternative to a less active option – watching TV or another sedentary indoor activity.

And the other intriguing question was around the idea of ‘compensation’. This is the question of whether being active during a playing out session means children flop on the sofa for longer afterwards and are ironically less active than they would have been normally (as many adults often are after a gym session!). Again the data showed that this did not happen to the children playing out and that they did not have a pattern of doing less activity after playing out to ‘compensate’ for the more vigorous play they had done.

Professor Kevin Fenton, Director of Health and Wellbeing at Public Health England closed the conference by starkly stressing the urgency of improving children’s levels of physical activity and the need to make active play the norm once more. “It’s often said that the environment is an important health service,” said Professor Fenton. And he talked about both green spaces and urban spaces like streets, needing to be seen in this way – as potentially health-giving spaces for those spending time in them. The challenge both for the audience gathered at the conference, and for policy-makers and public health commissioners, is to support the idea of street environments as a ‘health service’ and to act on the growing body of research and data which clearly shows the benefits of street play. The evidence is there – not that anyone who has watched a playing out session has ever doubted it.

A few days after the conference my street played out again and this time as I watched the pink-cheeked skippers, legs blurred as they jumped faster and faster it felt inspiring to realise that what they were doing – so naturally and with so much fun – is part of something increasingly important to researchers and policy makers. You can read more about the University of Bristol’s research findings here. If you want to know how to support street play in your street, or work for an organisation interested in finding out more do get in touch.

This piece was originally posted on the playing out blog.

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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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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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Multimorbidity guidelines falling short: National Institute for Health and Care Excellence (NICE)

Pauline Heslop, Norah Fry Research Centre

The National Institute for Health and Care Excellence (NICE) has recently been consulting on the scope of proposed guidelines on multimorbidity. Multimorbidity is, in summary, the co-occurrence of two or more chronic medical conditions in one person. Yet the proposed scope of the guidelines will not, in their current form, offer guidance on multimorbidity in people with learning disabilities. So is this a problem that needs attention? Yes.

The recent Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) and other national and international studies suggest that people with learning disabilities have a greater number of health problems than others, and a greater variety of healthcare concerns than those of the same age and gender in the general population. This would suggest that particular attention must be paid to this population in any NICE Guidelines. Indeed, recommendation 3 of the CIPOLD report was that NICE Guidelines should take into account multimorbidity in relation to people with learning disabilities.

Despite this, the draft scope specifies that clinical issues that will not be covered include:‘Identification and management of specific morbidities associated with learning disabilities’. No justification for this exclusion is given, and this sentence alone raises four issues:

1)    What does ‘associated with’ mean in practice, and what would be the threshold for a disorder to be ‘associated with’ learning disabilities?

2)    Some people with the same condition (e.g. autism, cerebral palsy) may or may not have learning disabilities. As it stands, the NICE Guidelines would include people with autism and associated multimorbidity who do not have learning disabilities, but would exclude people with autism and associated multi-morbidity who do have learning disabilities. Clearly, this would be a nonsense.

3)    No other groups with protected characteristics under the Equality Act 2010 are excluded.

4)    No other groups of people with conditions that themselves have associated comorbidities are excluded.

In addition, people with learning disabilities (and people with dementia) are excluded from the guidelines in relation to ‘the management and organisation of care’ in relation to multimorbidity. Again, no rationale for this is given and no other potentially vulnerable groups have been excluded.

Although these exclusions are of serious concern, there is a second issue that suggests discrimination against disabled people, with the proposed use of Quality-Adjusted Life Years (QALYs) as the preferred unit of effectiveness. QALY is a measure of the value of health attributes in a single index number. The basic idea underlying the QALY is that a year of life lived in perfect health is worth 1 and that a year of life lived in a state of less than this perfect health is worth less than 1. QALYs are usually incorporated with medical costs to develop a cost-effectiveness analysis of any treatment or intervention. My concern is that on the QALY scale, the quality of life of those with illness or disability is ranked below that of someone without a disability or illness, suggesting that QALY gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled, and favours those with treatable conditions and those with greater potentials for health – in terms of functioning or longevity. Indeed the European Guidelines for Cost-Effectiveness Assessments of Health Technologies, which conducted the largest experimental survey ever undertaken in Europe to test the validation of QALY assumptions, concluded that the use of QALY indicators should be abandoned for healthcare decision-making.

In all, the draft scope for guidelines on multimorbidity by NICE has a long way to go in relation to equality for people with learning disabilities. To me it appears to be arbitrary, discriminatory and contrary to the requirements of the Equality Act 2010.

As supporters of people with learning disabilities we are raising our concerns about this. What will you do?

This is an edited version of a blog sent to the new Learning Disability Association England.

This blog was originally posted on the PolicyBristol blog. 

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