No single food or nutrient is to blame for obesity, so what is the right balance?

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Dr Laura Johnson, Senior Lecturer in the Centre for Exercise, Nutrition and Health Sciences, discusses her new paper in which she assesses the impact of dietary patterns on obesity and how modelling may help influence change in both personal habits and public policy.

No single food or nutrient is to blame for obesity. There so many routes from diet to overeating and weight gain, and in real life foods and nutrients aren’t eaten on their own. So, it’s misleading to look at foods that way in research, it’s the overall balance of diet that matters.

I realised this a while ago when I  used detailed records of food intake from children age 5 and 7 in the ALSPAC cohort to generate an overall diet score that predicted obesity later on. I thought that eating more fat, less fibre, and having a more energy dense diet (more calories in each bite) would all feature in a diet that fuels obesity (or an ‘obesogenic’ diet). I used reduced rank regression or RRR (a pimped up version of factor analysis, see excellent explanation by Andy Field here) to find the best combination of foods to capture differences in the fat, fibre and energy density of the children’s diets. RRR generates a score based on what you eat. It’s calculated by adding up the intake (grams/day) of 42 groups of foods that are weighted for importance and a higher score means your diet is more obesogenic. I showed that children with the highest pattern score at age 7 were 4 times more likely to have too much fat by the time they were 9 years old (other researchers have since seen similar associations in adolescence and adulthood).

A pretty strong result, right? But, what use is a score made up of 42 foods? Isn’t it too complicated to ever be the basis for changing behaviour? I don’t think so, not if we use computers to deal with the complex calculations. All we need to know is what foods have been eaten (by individuals or populations) and then the obesogenic score can be computed automatically. We would then have a single score indicating whether the overall balance of your diet (or the Nation’s diet if thinking in policy terms) is more or less obesogenic. A total diet score would be better than current measures which only focus on fruits and vegetables or sugar-sweetened drinks, which let’s be honest, no one believes are going to solve the obesity epidemic on their own!

In our latest paper we asked “Do the same foods make up an obesogenic diet regardless of whether you are young or old, boy or girl, rich or poor?” (Because the ALSPAC score might only matter to children living in Bristol in the late ‘90s) “Who in the UK has a more obesogenic diet?” (Because those people need the most help to change) and “Are diets getting more obesogenic over time?” (Because that might suggest national obesity policy isn’t working).

To find some answers we used diet diaries from nearly 10,000 adults and children taking part in the UK National Diet and Nutrition Survey between 2008 and 2014. We repeated the RRR in different groups and found it was remarkably stable – the same foods came out as most important to an obesogenic diet over and over again. So, we can feel confident that the obesogenic pattern score and that way foods are weighted by importance reflects the way everyone eats in the UK today. The most and least obesogenic foods we found were (sized and in order of importance):

In terms of whose diets are most imbalanced we found massive social gradients with those in manual jobs and households earning less than £15,000/year having the most obesogenic diets, which mirrors social inequalities in obesity prevalence. Among children, diets became more obesogenic between 2011 and 2014. Among adults a more obesogenic diet went hand in hand with more time spent watching shows on TV/Laptops/Tablets, less physical activity, and eating takeaways more frequently.

All these trends are a starting point for targeting and testing interventions designed to make small changes across a range of foods to shift the balance of diet. By using our score, it could be possible to gauge how multiple changes to policy or what we eat adds up to a less obesogenic diet and with luck prevent obesity in future.

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Disability needs to be central in creating a more just and equal society

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Professor Val Williams, from the Norah Fry Centre for Disability Studies, discusses tackling disabled practices and how we all have a part to play in getting things changed.

When times get tough, disabled people always seem to go to the bottom of the pile. It’s as if the problem of ‘disability’ is always one step too far, or something which cannot be contemplated until everything else is sorted out. For instance, the debates about BREXIT have centred on trade agreements and free movement of citizens. How often do we talk about the rights of disabled people, and how they may be protected under existing EU legislation?

The UK itself has laws to protect disabled people’s rights, with the 2010 Equality Act. But constant vigilance is needed to remind public services that they have a duty to provide reasonable adjustments for disabled people. UK financial cuts are impacting most heavily on disabled people, and a recent report by the charity SCOPE highlights that, on average, for every £100 earned by a disabled person, only £67 is left after disability-related costs.

Disabled people certainly incur additional costs by virtue of their additional needs, but is disability too much of a ‘cost’ for society? We would argue that the reverse is true: economic, political or social crises create moments when disabled people must be at the forefront. This is what we have been documenting in our project ‘Getting Things Changed’ (Tackling Disabling Practices: Co-production and Change).

Disabled people have always faced problems which are created because society is structured without disability in mind.  For instance, the rail transport system assumes that all passengers can step over a gap between a train and the platform, that they can walk to their seat, and indeed that sitting in a ‘standardised’ seat is an option. At a more subtle level, we have also found countless practices in our study which exclude or marginalise disabled people. The way things routinely get done in everyday life can be problematic, and that can include the material infrastructure of a building as well as the ways in which people interact. For instance, people with dementia might rely on familiar, clear signage to find their way in and out of a building, or the facilities in it, but they also need people who will give them time to communicate, or understand how to wait for a response in a respectful way. In parts of our project, we are looking at the barriers disabled patients face in English hospitals. With regular news items about the crisis in the hospital system,  we know that change must happen.

We argue that this is the time to include disabled people, not just as recipients of care, but as change makers. Our project is co-produced with Disability Rights UK and with other groups of disabled people who are actively involved in the research. Given that disability is part of humanity, we should all be working WITH people with disabilities, to create a more just society where all are included.

Understanding a disabling society

So how can we start to understand why things get stuck? Since the 1980s and the introduction of the social model of disability, Disability Studies theory has focused considerable attention on the dichotomy between the social and medical model of disability. There have been continual debates since that time, with UK theorists arguing since the 1980s for a new understanding of disability and impairment. Oliver (2013) sums up neatly what the real issues are now:

“While all this chatter did not matter too much when the economy was booming, now it no longer booms it is proving disastrous for many disabled people whose benefits and services are being severely cut back or removed altogether”

Have disabled people’s lives become more restricted  since the 1980s, or have the concerns of disabled people themselves been overtaken by theoretical debate?  And how can we as activists and academics change that tide? In our recent article from ‘Getting Things Changed’ we argue that we need as a society to go further than debates about ‘what is disability’. The social model directed our attention towards the external barriers facing disabled people, and now we need to find better ways of analysing and understanding those barriers.  Many people use the word ‘culture’ here, to bemoan the difficulties caused by unhelpful attitudes and approaches which can be evident in congregate services such as care homes or hospital. In our study, we have turned towards the ideas of social practice theorists such as Elizabeth Shove, which have helped us to understand  how things get done, how practices get shaped – and therefore how we can get a handle on change.

An example from our wide-ranging project comes from the insights of people with dementia. Since 2009, we have had an English Government policy called ‘Living Well with Dementia’ . What matters for people with dementia is the quality of life they are leading right now, and our work with the ‘Forget-me-Not’ group from Swindon has helped us to unpick what this might mean.

Here are some words from the researchers with dementia from the Forget-me-Not group:

“Everyone will tell you the same thing. You’re diagnosed, and then it’s ‘You’ve got dementia. Go home and we’ll see you next month’. What we need is for someone, like a counsellor or someone else with dementia, to tell us at that point ‘Life isn’t over’.  You can go on for ten or fifteen years. And you’re not told, you’re just left. And I thought, tomorrow my day had come. The fear and the anxiety sets in, and then the depression sets in, doesn’t it? I think when you’re diagnosed, you should be given a book. And on the front of the book, in big letters, it should say: ‘Don’t panic’.”

In terms of social practice theory, these are people who do not want to be seen through a medical lens as individual tragedies, but are turning around the whole meaning of dementia into something where they are in control, can support each other and where they have a voice.  However, social practice theory also reminds us about the importance of material resources. For instance, in order to meet each other and to have a collective sense of peer support, people need to have spaces which are not institutionalised, which they feel they can ‘own’.  All too often, we have seen very well-intentioned group activities taking place in old, large halls, or where people are routinely sitting in configurations which make communication difficult. But we have also seen the Forget-me-Not group, in an ordinary, homely environment, where staff members interact on a basis of equality with the members who have dementia.

This is just one of many examples where we are finding that people CAN do things differently, and where the ‘culture’ can change towards inclusion and empowerment. We hope our research will provide the impetus to take some of this further.

Change will never be completed – but we will be presenting the latest research from our project and discussing some of these ideas at our launch event on 25 May. Book your place now to find out more about the many strands of the project how we can all be change-makers.

This post was written by Prof Val Williams with assistance from Prof Pauline Heslop, Beth Tarleton, Wendy Merchant, Bernd Sass and Joe Webb at the Norah Fry Centre for Centre for Disability Studies.

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More people with learning disabilities should be on TV!

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My name is Beth Richards, I have a learning disability and I am an actress. I want to educate the world about people with learning disabilities through my acting, and think that mainstream TV in the UK should be doing more to represent people like me.

I am doing some research to find out why so few people with learning disabilities are on TV and what can be done to change this. At the moment data suggests that only 1.2% of people on TV have a disability (Mental Health Foundation, 2014) and we still don’t know how many of these have a learning disability.

My research is part of a much bigger ESRC funded project called “Getting Things Changed” at the Norah Fry Centre for Disability Studies, University of Bristol. This project is looking at how the barriers people with disabilities in the UK face can be overcome by changing the way people do things.

Very little research has been done to explore why so few people with learning disabilities are on mainstream TV, or in the media in general, but organisations like Mencap and The Mental Health Foundation have campaigned for things to improve. Some actors with learning disabilities have also spoken out about the issue. For example, Sarah Gordy, an actress with Down’s syndrome who has been on shows like Downton Abbey on ITV and The Silkworm on BBC 1, said:

“It’s important that people with a learning disability are seen on our screens and on stage – simply because we exist.”
(The Huffington Post, 2017).

These campaigns are starting to make a difference as both the BBC and Channel 4 have made commitments to improve the representation of disabled people on their channels. For example, the BBC has committed to quadrupling the number of disabled people in its shows by the end of this year, whilst Channel 4 launched its 360 Diversity Charter in 2015 and made 2016 it’s Year of Disability. I think these commitments are great, but it is hard to find out what impact they have had as the channels aren’t reporting their success widely. From a viewer’s perspective, it doesn’t seem like there are more disabled people, especially people with learning disabilities on TV, than there were a few years ago.

One reason why the numbers of disabled people on TV might not have increased despite the BBC and Channel 4’s commitments, might be down to the way TV is made. Shows are written, commissioned, casted and produced by different groups of people. This means there are lots of different layers where disability can be excluded or discriminated against. Many of them out of the control of the television channels themselves.

This seems to suggest that the way TV is ‘done’ affects the number of people with learning disabilities who end up on our screens. I hope to explore this issue in my research by talking to writers, commissioners, casting agents, producers and actors both with and without learning disabilities about the industry. I am going to look at what these people say using Social Practice Theory to help understand how the way TV is ‘done’ can be changed to help get more people with learning disabilities on TV.

I know people with learning disabilities can be actors and have lots of talents. We are role models for others because we know what it’s like to grow up with a learning disability.

Hopefully my research can help change the media for the better.

If you want to be involved or have anything else you could help me with my research, please contact me at beth.richards@bristol.ac.uk or my PA Victoria Mason-Angelow victoria.mason@bristol.ac.uk. You can also find out more about my research and the wider ‘Getting Things Changed’ project on our website http://www.bristol.ac.uk/sps/gettingthingschanged/

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‘Fat but fit’ – Lessons in the language of a press release

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This week a paper from the EPIC-CVD which I co-authored was published in the European Heart Journal. Unfortunately the article was subsequently promoted in the press with the headline ‘Fat but fit’ still risk heart disease, encouraging a belief that physical activity offers no heart health benefit to those that are overweight.

This headline is misleading because most people understand ‘fit’ to mean physically activity, however the paper didn’t measure physical fitness. Instead it measured metabolic health (ie, high blood pressure, cholesterol and blood glucose) which some term ‘medical fitness’, and is often shortened to ‘fitness’. Hence the confusion.

What the paper really shows is that being overweight and having poor metabolic health both contribute to increasing risk of coronary heart disease (CHD), or a heart attack, to put it more simply. If you group people based on their weight status and metabolic health then the risk of having a heart attack increases in the following order:

 

 

 

 

 

 

To provide some context to these numbers, we know that having a heart attack is more common in older people – that risk increases with age by about 10% per year. Being overweight and healthy notionally makes you 2 ½ years older (in terms of heart disease risk) than a normal weight and healthy person. Whilst being obese and unhealthy notionally makes you 15 ½ years older!

My take home message from these figures is that having poor metabolic health is much worse than being overweight or obese on its own; however people carrying excess weight still don’t get off scot-free. So, if you can improve your metabolic health (whether you are normal weight or overweight or obese) you can substantially reduce your risk of CHD. Equally if you can reduce your weight (whether you have good or bad metabolic health) you can reduce the likelihood of a heart attack even further.

What about being fit, ‘physically active’ fit?  

If you are overweight and are physically active then this will more than likely be good for your health – we know that physical activity has beneficial effects on metabolic health. The long-standing fat-fit hypothesis states that the health benefits of being physically active can cancel out the increased risk of being overweight, so it’s possible to live just as long if you are fat as long as you are fit. Does our work say anything about that idea? Not really, not without a lot of inference and assumptions. You’d need a study of physical fitness and weight and metabolic health to get to the bottom of that one (a study like this).

What is apparent from this analysis is that grouping people based on continuous measures of health is spurious. If you look at the ‘apparently healthy’ overweight or obese group you’ll see that their blood pressure, cholesterol, blood glucose, etc are actually still higher than the supposedly equally healthy normal weight group. To me this suggests that metabolically healthy obesity doesn’t really exist, not long-term. The people in the healthy obese group just didn’t quite meet the cut-offs for being defined as ‘unhealthy’ yet, suggesting it’s only a matter of time before they cross over to the unhealthy group.

So what’s the point of putting people in boxes, we are all individuals after all, with our own unique profile of risk factors. I’d say let’s try and keep continuous risk factors continuous and aim for lowering them across the whole range using whatever methods have been shown to work in the past. Physical activity and diet can both help in different ways, to either improve metabolic health or promote weight loss, so aiming for a healthier lifestyle is as important as it ever was.

This blog was written by Dr Laura Johnson, a Lecturer in Public Health Nutrition in the Centre for Exercise, Nutrition and Health Science, School for Policy Studies.

 

 

 

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Back to school for MyHeart Beat

Dr Laura Johnson, is a Nutritional Epidemiologist and Senior Lecturer in Public Health Nutrition. Her research focuses on establishing the role of overall dietary and eating patterns in the prevention and treatment of obesity, diabetes and coronary heart disease as well as understanding the factors that influence food intake and appetite control. In this blog, she reflects on a recent visit to Malaysia to research adolescent lifestyle in conjunction with the MyHeart Beat project.

In April, this year I went back to school, some things were just the same as I remembered but others were very different, mainly because I was in school in Malaysia. I had found myself in Kuala Lumpur for work and I was visiting schools to find out exactly how big a task we had taken on for our new collaborative research project MyHeart Beat (Malaysian Health and Adolescents longitudinal Research Team Behavioural Epidemiology and Trial).

MyHeart Beat is funded by the UK Medical Research Council and Academy of Sciences Malaysia (Newton Ungku Omar Fund). The project aims to explore how changes to diet and physical activity could improve heart health in Malaysian adolescents. It’s a collaboration between researchers in the University of Bristol’s Centre for Exercise, Nutrition and Health Sciences and the University of Malaya’s Faculty of Medicine. Our aim is to find ways for Malaysian teens to be more active and eat better, which will help them in the future to avoid obesity, type 2 diabetes, and cardiovascular disease, chronic conditions that are affecting ever increasing numbers of people in Malaysia.

MyHeart Beat builds on MyHearts (Malaysian Health and Adolescents longitudinal Research Team study) an excellent project by researchers at the University of Malaya, in collaboration with researchers from Queen’s University of Belfast, who have spent the last 5 years following more than 1000 teenagers from the age of 13 to 17 years in 3 Malaysian states. MyHearts has collected detailed information on diet, activity, lifestyle and health and has shown that 15% of adolescents are overweight and a further 9% are obese. Physical inactivity is rife (64% of teens are inactive) and breakfast habits are erratic (25% of teens never or only occasionally eat breakfast). We’re planning more analyses of this rich data to find out about the patterns of behaviour related to obesity and heart health.

I’ve previously explored patterns of food intake associated with obesity and shown that it’s a combination of high-fat, low fibre and energy density that is important rather than any single aspect of diet. Key foods part of an obesogenic dietary pattern in the UK include fruits, vegetables, and high-fibre bread (not eating enough of them) and white bread, crisps, sweets, and processed meat (eating too much of them). We expect the most common foods eaten in Malaysia to be different to the UK but in principle whatever foods there that make a diet energy dense, low in fibre and high in fat are still likely to be those most important for preventing obesity. In MyHeart Beat we will apply the same method for finding patterns of behaviour (reduced rank regression, RRR). RRR is a statistical technique that, for dietary patterns, adds up intakes of all foods after giving some foods more emphasis than other (by giving pattern loadings). RRR works out how much emphasis to give different foods by trying lots of options until it settles on the one where foods are combined in such a way that the energy density, fibre and fat content of the whole diet can be predicted best. You end up with pattern loadings (numbers) for each food and the larger the loading the more important that food is for predicting the obesogenic features of diet. Using the loadings, it’s then possible to rank foods in order of importance and identify exactly what foods to change to make diets less likely to lead to obesity. With our analyses, we hope to find out not only what the most important foods are but also what activities are best for maintaining health throughout adolescence. Once we know what the high-risk behaviours are we can start working out ways to help teenagers to change.

Although, even when you know what to change you then have the task of working out how to change it. There are many different routes we can take to change behaviour; the sheer number of options can be challenging but is also what makes the project fascinating. The MyHeart Beat team has lots of experience trying to change behaviour in children in the UK, Europe and Malaysia. For changing diet we’ve attempted intensive programs led by dietitians as well as computer based courses supervised by teachers. Innovative strategies we’ve tried for increasing physical activity have included after school clubs led by teaching assistants; dance workshops and harnessing the power of social networks to spread positive physical activity messages. In Malaysia, the MyBFF@school program (My Body is Fit and Fabulous) has been designed specifically to help overweight and obese adolescents control their weight and provides a valuable platform on which to build a broader program that could help all adolescents stay healthy.

A starting point for designing an intervention is simple logistics. What is even possible to change within Malaysian schools? So that’s what brought me to Kuala Lumpur, to visit schools and see for myself how life works for adolescents at school over there. I realised that the biggest difference compared with my school in the UK was the timing. In Malaysia, school starts at 7 am and ends at 1 pm, break time is for 20 minutes between 0930-1030 (depending on which year you are in) and this is the time when the cafeteria is open for hot meals and cold drinks.

The school canteen offers lots of fried and sweet snacks like burgers, sausages, chicken and samosas, not so different to school food I remember. But more traditional meals, made of rice, noodles, eggs, fish or meat with sauce, were also for sale.

Some schools had fruit snacks suggesting it may be possible to alter the range of foods available. There were vats of ice-cold drinks like fruit squash and Milo and iced tea, all sugar-sweetened. Water wasn’t freely accessible but water bottles were sometimes brought in from home.

Touring the rest of the school, I saw that there were plenty of spaces for physical activity, a school gym, hall, basketball courts and a playing field. But the heat was high as was the humidity, I was sweating just standing still! I had no desire to be physically active in those conditions, which made me wonder what the kids thought about that.    

That leads me back to what MyHeart Beat aims to do in the next 18 months. We plan to find out what staff and students think about different options for changing diet and activities – because ultimately it’s the people whose behaviour you are trying to change that know best what will work for them. We’re also aware of some local initiatives by state nutrition divisions starting this year to make improvements to the school food supply e.g. in Perak, parents/teachers are asked to report if the canteen is selling unhealthy food. To find out more about what the adolescents, teachers and Ministry of Education officials think about what can and should change, we’re planning some interviews and focus groups to ask them directly. From this we’ll work out the options that will be most feasible for changing. Then we’ll develop an intervention (set of changes) that we hope will improve diet and physical activity and ultimately cardiovascular and metabolic health. Our approach follows the UK Medical Research Council (MRC) recommendations for designing interventions. We hope that by building on a strong evidence base and crucially talking to the local people, we’ll ensure the intervention we design will be a success.

Towards the end of 2018 we’ll be taking our intervention out to some schools to test it out. This small pilot project is the ultimate aim of all of the different parts of the project and will tell us if the plans we’ve made will work in practice. I’m looking forward to visiting Malaysia again at that stage, and getting some more fabulous hospitality from the MyHeart Beat researchers over there!

To Shooka, Shafina and Fadzrel, Terima Kasih (Thank You) for having me.

 

 

 

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Women Studies Departments in Indian Universities face threat of closure

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Dr Geentanjali Ganjoli, Senior Lecturer at the Centre for Gender and Violence Research, School for Policy Studies, discusses the future of Women’s Studies in India.

There are 163 Women’s Studies Centres (WSCs), funded under the University Grants Commission (UGC) in universities and colleges across India, most of which now face the threat of being wound up after September 2017.

Concerns over the future of the Centres were originally raised in March 2017 but were temporarily allayed when the UGC issued a public notice on 29th March stating that all existing schemes would continue for the fiscal year 2017-18. However, on 16th June, the UGC published a revised notice that ongoing schemes under the Plan Head would be funded only up to September 2017.

The women’s studies centres in India are organically allied to feminist movements in India, and are historically linked to the UN international decade for women (1975-85), and the Status of Women Report led by a group of Indian feminists in 1974, which revealed the myriad social and economic hardships and inequalities suffered by Indian women. Women’s Studies was introduced into the National Policy of Education in 1986. The late 1970s and 1980s also saw the rise of women’s movements’ campaigns against forms of violence against women, including rape, sexual harassment in public spaces and the workplace, dowry, domestic violence, representation of women in the media and female infanticide, and is also linked to wider secular movements.

These concerns have always been represented in the teaching and research interests of women’s studies departments in India. For instance, the Research Centre for Women’s Studies, SNDT University, which was the first women’s studies department set up in the country in 1974, conducts action research programmes on topics as varied as assessing the extent of sexual harassment in university campuses, research on problems faced by the girl child within the family, and teaches women’s studies at Masters and research PhD levels.

In spite of the intellectual and political insights provided by women’s studies scholars in India, the discipline itself has often been treated as marginal by universities and funding bodies. One suggestion is that the challenges to patriarchy and gender roles posed by the Women’s Studies Centres threaten the inherent misogyny within the academy, and this may the reason why this discipline is under threat now. As observers of Indian society are aware, women students have always been subjected to discriminatory policies. Examples of this include: curfews for women in hostels, women students being evicted from their hostels in the summer break and dress codes imposed on female students in different universities.

Within this context, the threat to women’s studies centres indicates the further shrinkage of secular and feminist spaces within Indian academia, and is concerning particularly within the wider context of the rise of misogyny and right-wing Hindu politics in the country, and indeed internationally.

The Centre for Gender and Violence Research has always had close working and personal connections with women’s studies departments in India, and elsewhere, and this is reflected in our new journal in its scope, editorial board and papers. The first issue of the journal has an interesting paper written by academics from the Women’s Studies Centre in Tata Institute of Social Sciences which showcases the work of women’s studies departments in India in terms of its links to activism and feminist concerns with regard to policy and practice on gender based violence.

To read more articles like this, sign up for a free trial of the Journal for Gender Based Violence.

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What can children in the care system tell us about their well-being?

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Professor Julie Selwyn is a Professor and Director of the Hadley Centre for Adoption and Foster Care Studies at the School for Policy Studies. Here, she shares the findings from the new report she co-authored, Our Lives, Our Care: Looked after children’s views on their well-being.

There were 70, 440 children in care in England as of 31 March 2016, according to the Department for Education. The majority of children enter care because of parental abuse and neglect and often enter with physical, emotional and behavioural difficulties as a result of traumatic experiences. Every year ‘outcome’ data are collected and published by the Department for Education on children’s educational achievements, offending, mental health, and number of teenage pregnancies.

Children’s experiences not heard across system

Generally, children in care do not achieve the same level of academic success as their peers and are much more likely to have problems with crime, drugs and have poor mental health. Consequently, the care system is often viewed as failing but there is no systematic collection of information on how children feel about their lives in care. Nor do we know whether children in care emphasise the same aspects of their lives as being important to their well-being, as those identified by children in the general population.

This excerpt was taken from the original post in the WhatWorksWellbeing blog. Read the post in full.

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Crisis in care homes: how can we improve standards in the context of austerity?

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Liz Lloyd, Professor of Social Gerontology in the Centre for Health and Social Care discusses the factors behind deteriorating standards in care homes.

There is a crisis in British care homes, arising not merely from bad behaviour by staff members but from the economic and political context of the social care market.

There are currently close to half a million individual places (‘beds’) used by around 4% of the population aged 65+ and 17% of people aged 85+. Statistics vary somewhat, according to what is being measured, but we can be certain that although the number of older people in the population have risen, a smaller proportion of them live in a care home, that they are older on average when they first enter the home and have more complex, long-term illness that require more skilled assistance.

Older people are also increasingly likely to pay at least a part of their care home fees. According to Laing and Buisson’s 2012-2013 Care of Elderly People UK Market Survey, some 43.4% of older residents in the independent sector paid the full costs and a further 14% received partial council support and topped up their fees. The majority therefore still rely wholly or partially on public resources but this proportion is falling.

Running parallel to these changes is the rise in private ownership of care homes and payment of fees. Over three decades, the proportion of places in local authority run care homes in the UK has dropped while the proportion in the private, for-profit, sector has risen so it now has a 75% share of all places. The voluntary, not-for-profit, sector share has been more stable but is falling slightly. The current crisis involves increasing levels of provider failure and exit from the care home market. Several big providers are deeply in debt, raising fears of a major collapse like that of Southern Cross in 2008. Owners point to rising costs as a consequence of the introduction of the national living wage and falling profits because fees paid by local councils have not risen in line with increased costs. The consequences for providers is an unsustainable business model.

The consequences for older people who need residential care are evident in delayed discharges and hospital waiting lists, a point illustrated perfectly in the case of Mrs Iris Sibley, who remained in the Bristol Royal Infirmary for six months while her family sought a care home place. For residents and their families the insecurity associated with provider failure means added anxiety and stress. Add to this the associated problem of worsening standards, which the Care Quality Commission fears will grow in the absence of major reform. Mrs Sibley’s son described how one place she was offered was so bad that he ‘wouldn’t put a sick dog in there’.

Not all older residents experience the same thing, of course. According to Norman Lamb MP, former Health Minister, the market has come to benefit older people with enough money to pay for their own care while disadvantaging those who rely on state support. Care homes where all or most residents pay their own fees are more secure than those that rely mostly on the local authority payments and are more able to absorb the additional cost of the national living wage. We might question why anyone would argue against a decent level of pay for the people who care for us when we are sick and disabled, but the dominant theme in social care for older people is that it should be as cheap as possible – hence, high numbers of migrant workers in the care home sector.
In fact, debates about care homes focus overwhelmingly on keeping costs down and agreeing who should pay. Should it be individuals (during their lifetime or after their deaths), their families or the public in general? Health and social care are frequently portrayed as unaffordable in the context of the ageing of the baby boomer generation.

I declare an interest here, being a baby boomer, but take issue with such a simplistic argument. Demographic trends have an impact on demand for care, for sure, but there is evidently a wider set of factors at play. Indeed it is arguable that demographic trends provide a useful rationale for cuts to public spending that would be made anyway. Policy-makers have placed themselves in a bind as cuts to public spending have impacted on private sector profits, proposals to recoup the cost of care from older people’s estates after death are met with outrage in the press, as are stories like that of Mrs Sibley.

Evidence on what makes a care home a good place to live and work is abundant. Higher standards of care are usually reflected in higher levels of staffing, more skilled workers and a culture of person-centred care that attends to the whole range of an individual’s needs, not merely to their basic physical requirements. A culture of ‘person-centred care’ promotes a sense of belonging and security and enables residents to maximise their capacities, enjoy new experiences and take risks. Care homes are likely to remain a part of the care system, despite their reputation, so we need to focus on standards. A sizeable number of us who will live in a care home at some stage of our lives, or have a close relative who does. But more importantly, care homes are inextricably linked with other parts of the care system so it is in our interests to think about standards in care homes as a policy issue that affects us all.

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International Day for the Elimination of Violence against Women

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Dr Emma Williamson, Senior Research Fellow in the Centre for Gender and Violence Research, comments on why recognising the subject of violence against women has never been more relevant than it is now.

25 November marks International Day for the Elimination of Violence against Women, followed by 16 days of Activism against Gender-Based Violence.

On this day, communities reflect on the damage caused by violence against women and its impact on women, children, men, and societies around the globe.

As well as acknowledging the harm that violence against women causes, 25 November is also a day to celebrate the achievements of a movement which seeks to eradicate the gendered violence which many face every day. To recognise the men and women who work to support victims and perpetrators, to challenge abusive behaviours within societies across the world, and to stand up to the causes of violence by naming misogyny and oppression in its many forms.

At the Centre for Gender and Violence Research based at the University of Bristol, we know only too well about the experience and impact of gendered abuse. Researchers are currently engaged in projects speaking to victims and perpetrators of a wide range of abuses; collecting official data from the police and other statutory bodies; working with refugee communities to address violence against women during displacement; and working with a range of non- governmental organisation (NGO) partners to ensure that research makes a difference in the world.

So, along with our partners in the UK, Europe, and internationally, we mark 25 November as a day to recognise the achievements of a social movement which still has many uphill struggles to face.

In addition to the consistently high rates of domestic and sexual violence and other forms of gender-based violence which are experienced every year, this year in particular is a poignant year. Women’s rights have been attacked in a number of countries around the world: Poland and its attempts to restrict access to safe abortions; US presidential candidates’ “locker-room banter” about grabbing women whether they want it or not; the re-trial of a footballer on the basis of the introduction of evidence about the victim’s sexual history; and the crowning of Bono as one of Glamour magazines “women of the year”.

Okay, so the last one isn’t quite an obvious offence to women and equality – he does a lot of work about poverty and its impacts on women- but in a world where over half the population is female, it would be nice if an honour for women were given to one!

These examples show the struggles which we face to challenge the oppression which underpins gendered violence and abuse. They also show us the power of solidarity in the many acts of resistance they evoke. Polish women striking and taking to the streets against the attack on their already limited rights. Michelle Obama’s eloquent speech about the everyday reality of sexism and misogyny. Government reaction to the use of sexual history in sexual assault cases. We have yet to see how sisters uncut respond to Bono but you can be assured it will be creative and fitting!

Of course we also face an additional challenge in the UK with the recent Brexit vote to leave the European Union. The Centre for Gender and Violence Research in Bristol has a long tradition of working with European partners and we regularly meet to identify the emerging challenges which threaten the elimination of violence against women.

Whilst the terms of Brexit remain unclear, we continue to appreciate the importance and power of a global network of campaigners, researchers, and activists challenging the status quo and fighting for women’s human rights.

In Spring 2017, the Centre will be launching a new Journal of Gender-Based Violence. This is the first European- based international journal focusing specifically on this type of violence and abuse. We believe that now, more than ever, we need a space where evidence, policy, and ways of tackling gender-based violence across national borders, can be shared. It will provide a critical space in which we can continue to learn from one another and recognise the connectivity between the different challenges we face.

To articulate how far we still have to go, take a moment to look at the predicament of women worldwide below. (Infographic reproduced with kind permission from United Nations Women).

infographic-violence-against-women-en-11x17-no-bleeds

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Gender, Violence and Justice: What does justice look like?

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Dr Emma Williamson shares her reflections on the recent Thinking Futures event at the University of Bristol, which debated what justice means for victims of gender based violence.

What does justice look like? This was the question asked at last week’s Thinking Futures event run by the Centre for Gender and Violence Research at the University of Bristol. The event was part of the wider Thinking Futures programme which celebrates research from the University’s Faculty of Social Science and Law, and supports the national ESRCs Festival of Social Sciences.thinking-futures-cgvr-event

We chose the topic of Gender, Violence and Justice as it coincides with current research looking at Justice, Inequalities, and Gender Based Violence being conducted in partnership with Women’s Aid, England, and Welsh Women’s Aid.

The event, held at the Church Above The Shops, was introduced by Thangam Debbonaire, MP for Bristol West. Thangam brought to the evening her experience of working with the perpetrators of abuse, whether individuals or collective within processes and systems. She reminded us of the need to challenge and change those behaviours and the ideas from which they come. Thangam also recognised the long and on-going history in Bristol of women fighting gender based violence, from the early Women’s Aid movement, to Rape Crisis, to Integrate – all of whom were represented on the evening.

Geetanjali Gangoli, from the Centre for Gender and Violence Research was first to speak, highlighting findings from a recent study conducted for Her Majesty’s Inspectorate of the Constabulary (HMIC) on so called ‘honour violence’. Geetanjali highlighted the barriers faced by Black and Minority Ethnic Women when trying to challenge abuse which might be categorised as honour based. She recognised that for some of the women in the research other relatives, including male relatives, were sometimes the ones to encourage victims/survivors to seek justice through the police and official systems. Geetanjali also discussed the difficulty of challenging abuse which might be condoned by families and communities, and the importance therefore of thinking about what justice means in wider and community based context.

Layla Ismail was next on the podium, both in her capacity as director of Refugee Women Bristol, and in her role for FORWARD, the national charity concerned, for many years, with the issue of Female Genital Mutilation (FGM) or ‘cutting’. Again, the importance of community justice was raised. – To stop this particular abuse, adult survivors of FGM should be given the space to talk about their experience and the impacts it had had, in the hope that it would be a catalyst for social change. Young women in Bristol, supported by FORWARD, have been at the forefront of work on this issue nationally, and it was a pleasure to hear about their success in changing attitudes. In terms of our initial question, what does justice look like, justice here looks like no more FGM/cutting.

As well as inspiring the audience, Layla also challenged the multiple and sometimes contradictory oppressions which women might face. In this case the abhorrence society directs to FGM whilst condoning within popular media similar plastic surgery procedures. These contradictions do not go unnoticed within those populations where FGM has been an issue.

Following Layla was Rowen Miller from SARSAS – Somerset and Avon, Rape and Sexual Assault Service. Rowen was talking about sexual violence and justice, and what it feels like, from a survivor’s perspective to walk into a court of law, to take steps to seek formal types of justice. For most it feels like walking into the lion’s den. Rowen highlighted the importance of empowering survivors following assault to make they own decisions about how they wish to proceed, and the systems they have put in place to assist with this, including acting as a go-between for survivors who might want to report anonymously and the police. As with all of the speakers, Rowen offered us hope about the growth which is possible for survivors following experiences of gender based violence, and the importance of supporting, standing alongside and behind, survivors to their sources of justice, whatever that is.

The final panel speaker of the evening was Marianne Hester. Marianne focused more on domestic violence as one part of the wider gender based violence continuum. She highlighted the failures of formal justice to offer ‘justice’ in the sense of convictions for crimes, and discussed the alternatives we might then wish to explore. If formal justice on a population level, on the whole, doesn’t work for victims/survivors then what are the alternative available to us?

Following the panel presentations, the chair opened up the discussion to the audience. Initially reluctant, understandably, the audience come forward with a wide range of ideas about what justice might look like: rough justice, social justice – social change, restorative justice – in its true and safe form, empowerment, and resistance. As well as people’s experience of working in the field of gender based violence, people also talked about their experiences of abuse and the formal justice system.

We would like to thank all of the audience members for creating a safe space and atmosphere where survivors felt able to speak, and to those speakers for sharing their experiences with us. Injustice was not being able to face the perpetrator, in court, and tell him what he did. Injustice is over five years fighting a perpetrator who twists the system to drag you, as a victim/survivor, through the courts repeatedly. Injustice is being told by a therapist that if you choose to report an incident to the police then you cannot continue to receive their help.

So, taking the injustices which unfortunately inform our ideas of what justice might look like, for this group justice was about a wider recognition of gender, and other, inequalities. It is recognising misogyny as a form of gendered hate crime, and of finding new ways to challenge it. It is challenging schools to implement relationship and respect education – despite the government not making it mandatory. It is fighting for the support services needed to allow victims/survivors to seek the help they need, and to stand alongside them in their struggles to stop it happening in the future to others. Above all justice was what victims/survivors think it should be.

In a week when the US elected a president who admitted sexually groping women without asking (many would call that sexual assault) – justice is living in a society that says that is not okay and stands together to change it.

For further information about the Centre for Gender and Violence Research: http://www.bristol.ac.uk/sps/research/centres/genderviolence/

Anyone interested in talking to the research team about experiences of abuse, as part of the Justice Project, please contact us via the project page or email: sps-justiceproject@bristol.ac.uk

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