Briefing Paper 3: The social determinants of health inequalities: implications for research and practice

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“I Hear the Music and My Spirits Lift!” Pleasure and Ballroom Dancing for Community-Dwelling Older Adults.

Physical activity for older adults is recommended to encourage the maintenance of functional autonomy and improve mental health. Ballroom dancing involves aerobic, strength and balance work and is an inherently social activity. This 12-month qualitative study considered the influence of ballroom dancing on health and well-being in community-dwelling older adults. It explores an under-reported aspect of physical activity, which may incentivise older people to participate, that is, pleasure. Qualitative data were managed and analysed using the Framework Analysis approach. Semi-structured interviews were conducted with 26 older-adult ballroom dancers. Five typologies of pleasure were identified. In addition to ‘sensual pleasure’, ‘pleasure of habitual action’ and ‘pleasure of immersion’, as suggested by Phoenix and Orr (2014), the ‘pleasure of practice’ and ‘pleasure of community’ were also identified. Ballroom dancing produces a strong sense of embodied pleasure for older adults and should be promoted by health and exercise professionals for community-dwelling older adults

“I hear the music and my spirits lift!” Pleasure and ballroom dancing for community-dwelling older adults.

© Human Kinetics, Inc.Physical activity for older adults is recommended to encourage the maintenance of functional autonomy and improve mental health. Ballroom dancing involves aerobic, strength and balance work and is an inherently social activity. This 12-month qualitative study considered the influence of ballroom dancing on health and well-being in community-dwelling older adults. It explores an under-reported aspect of physical activity, which may incentivise older people to participate, that is, pleasure. Qualitative data were managed and analysed using the Framework Analysis approach. Semi-structured interviews were conducted with 26 older-adult ballroom dancers. Five typologies of pleasure were identified. In addition to ‘sensual pleasure’, ‘pleasure of habitual action’ and ‘pleasure of immersion’, as suggested by Phoenix and Orr (2014), the ‘pleasure of practice’ and ‘pleasure of community’ were also identified. Ballroom dancing produces a strong sense of embodied pleasure for older adults and should be promoted by health and exercise professionals for community-dwelling older adults

Exploring the Impact of Patient and Public Involvement in a Cancer Research Setting

An enduring theme in the literature exploring patient and public involvement (PPI) in research has been the focus on evaluating impact, defined usually in terms of participants’ practical contribution to enhancing research processes. By contrast, there has been less emphasis on the perspectives and experiences of those involved in PPI. Drawing on qualitative data with people involved in the National Cancer Research Network in the United Kingdom, we report on what motivated participants to get involved and their experiences of involvement in this setting. We highlight how those involved in PPI often espoused the notion of the “good citizen,” with PPI in research being a natural extension of their wider civic interests. However, our findings also highlight how PPI was an important resource, utilized by participants to make sense of living with chronic illness. We suggest that PPI in research also offers spaces for the reconfiguration of self and identity

Factors influencing the utilization of health facilities for childbirth in a disadvantaged community of Lalitpur, Nepal

Background: In Nepal, half of deliveries take place at home (HMIS 2014), while institutional birth assisted by skilled birth attendants (SBAs) are still infrequent. Objectives: This study explores factors influencing the utilization of health facilities for childbirth in a disadvantaged community of rural Nepal. Method: A qualitative study with two focus groups: mothers-in-law and husbands, and female community health volunteers. 28 semi-structured in-depth interviews were conducted with selected participants 20 mothers and 8 grass-root and policy level stakeholders. Data were analysed by three delays model of conceptual framework. Results: The main reasons for giving birth at home included cultural tradition, lack of awareness about danger signs during pregnancy and childbirth, about importance of skilled birth attendants and lack of knowledge about availability of free 24-hours delivery sites/birthing centers, inability to afford two way transportation costs despite transport incentives provided by government for institutional delivery, fear of episiotomy/surgery/physical abuse and health service provider’s attitude for home delivery. Health facilities were mostly used by women who experienced complications during childbirth Policy Implications: Significant gaps from policy to grass root levels were identified which -suggests that dissemination of information about free delivery must be more effective. The health workers should convincingly inform families about benefits of institutional delivery, especially in marginalized/disadvantaged communities

Negotiating identities of ‘responsible drinking’: Exploring accounts of alcohol consumption of working mothers in their early parenting period

Mothers’ alcohol consumption has often been portrayed as problematic: firstly, because of the effects of alcohol on the foetus, and secondly, because of the association between motherhood and morality. Refracted through the disciplinary lens of public health, mothers’ alcohol consumption has been the target of numerous messages and discourses designed to monitor and regulate women's bodies and reproductive health. This study explores how mothers negotiated this dilemmatic terrain, drawing on accounts of drinking practices of women in paid work in the early parenting period living in Northern England in 2017–2018. Almost all of the participants reported alcohol abstention during pregnancy and the postpartum period and referred to low-risk drinking practices. A feature of their accounts was appearing knowledgeable and familiar with public health messages, with participants often deploying ‘othering’, and linguistic expressions seen in public health advice. Here, we conceptualise these as Assumed Shared Alcohol Narratives (ASANs). ASANs, we argue, allowed participants to present themselves as morally legitimate parents and drinkers, with a strong awareness of risk discourses which protected the self from potential attacks of irresponsible behaviour. As such, these narratives can be viewed as neoliberal narratives, contributing to the shaping of highly responsible and self-regulating subjectivities

Who are the obese? A cluster analysis exploring subgroups of the obese

Background Body mass index (BMI) can be used to group individuals in terms of their height and weight as obese. However, such a distinction fails to account for the variation within this group across other factors such as health, demographic and behavioural characteristics. The study aims to examine the existence of subgroups of obese individuals. Methods Data were taken from the Yorkshire Health Study (2010–12) including information on demographic, health and behavioural characteristics. Individuals with a BMI of ≥30 were included. A two-step cluster analysis was used to define groups of individuals who shared common characteristics. Results The cluster analysis found six distinct groups of individuals whose BMI was ≥30. These subgroups were heavy drinking males, young healthy females; the affluent and healthy elderly; the physically sick but happy elderly; the unhappy and anxious middle aged and a cluster with the poorest health. Conclusions It is important to account for the important heterogeneity within individuals who are obese. Interventions introduced by clinicians and policymakers should not target obese individuals as a whole but tailor strategies depending upon the subgroups that individuals belong to

Is childhood obesity a child protection concern?

Background The question as to whether childhood obesity should be considered a child protection issue has divided commentators, with many questioning whether a child should be removed from parents who do not seek to reduce their child's weight, where significant obesity is identified. This divide is reflected in the social work profession where there is resistance to a role focused on bodily surveillance, whilst also acknowledging the need to investigate neglect where evidence exists of a clear parental failure to manage a child’s diet, health and fitness. Similar divisions exist in the medical profession and debates are taking place in Australia and the US but with little research to inform policy and practice. In the UK, practice varies with a consideration of obesity being incorporated in some multi-agency child protection procedures but with no mention in others and little research to explain variations. In the absence of evidence the most influential guidance remains a paper by Viner et al (2010), which concludes: • Childhood obesity alone is not a child protection issue • Failure to reduce overweight alone is not a child protection concern • Consistent failure to change lifestyle and engage with outside support indicates neglect, particularly in younger children • Obesity may be part of wider concerns about neglect or emotional abuse • Assessment should include systemic (family and environmental) factors It is this framework which is both widely quoted and incorporated into the child protection procedures of some local authorities but there appears to be no research which has tested its usefulness or applicability in practice. This research project was funded by NIHR CLAHRC YH and was conducted by staff from The Department of Social Work, Social Care and Community Studies and Centre for Health and Social Care Research at Sheffield Hallam University, Doncaster MBC, Rotherham MBC and School of Human and Health Sciences Huddersfield University. Ethical approval was provided by Sheffield Hallam University and research governance from Doncaster MBC. A project advisory group was set up from health and social care professionals which met virtually at the outset of the project, to guide the direction of the research, interviewing content and protocol, and to inform sampling. Aims and Objectives The research aimed to understand whether childhood obesity is a child protection concern and had three objectives: • To explore the current and past practice of staff working within child protection and obesity services regarding child protection and obesity • To explore staff perceptions of childhood obesity as a child protection issue using interview and focus group methods • To explore the use of the Viner et al (2010) framework for action to understand child protection concerns for children who are obese. Design and Methods The research project conducted semi-structured interviews (N23) and facilitated focus groups (N3, N24) involving key stake holders from social care, health and education services. The professional roles of participants ranged from professionals involved in early help and family support, through to investigation and middle and senior management. Doncaster Council (DC) supported the recruitment of participants, through dissemination of information leaflets, email contact and the provision of interview facilities. All of the interviews and focus groups were undertaken in Doncaster in South Yorkshire, however the research was by no means an evaluation of current or past practice within the authority and participants were able to reflect on their experiences across geographic areas and professional roles and responsibilities. Framework Analysis methods were used to generate categories, codes and themes that capture the experiences, views and perceptions of the participants. The research team took a collective approach to the analytical process in order to develop the thematic framework. Findings The framework comprised of seven key themes: Obesity: The short and long term impacts that obesity may have on a young person's physical and psychosocial health were acknowledged. Social factors relating to culture and poverty were also seen as contributing factors. Parental attitudes and perceptions were seen as playing a key role in recognising and responding to childhood obesity. The clinical nature of assessing and identifying obesity is complicated for non-health professionals. Thresholds: For child protection services to undertake work, requests need to meet a severity threshold for interventions to occur. Thresholds were nuanced and complex and could act as inhibitors to providing services. The threshold operated not only as a line that had to be crossed in order for a referral to be accepted by social services but also in respect of individual practitioner thresholds regarding personal views and values regarding obesity, different agency thresholds, referrals for different services within an agency and also between agencies. Child Protection: Respondents were divided as to whether child obesity was a child protection concern. For some the impact of obesity on long and short term outcomes for children made obesity unequivocally a child protection concern, yet for others excess weight itself was not sufficient. Where there was more common ground was in respect of the links between obesity and parental neglect. This could be in the form of associated factors such as failure to attend school or mental health issues but also for many respondents a failure on the part of families to engage with support plans and services offered. Those services were seen as a continuum of intervention levels from universal to statutory with child protection and legal interventions part of that continuum rather than a separate entity. A child protection approach could act as a catalyst for families to take up support as well as a gateway to more financially expensive and intensive support offers. Viner Framework: The Viner framework was developed as a means of understanding and working with child obesity as a child protection issue. Almost all participants had no awareness of the Viner framework. Overall the framework was welcomed as a useful tool, with the caveat that over reliance on a framework can lead to over simple assessment. The framework was not seen as overcoming problems inherent in measuring and identifying obesity, and not identifying the association of obesity with sexual abuse. Good Practice: Good practice was seen as beginning with a holistic understanding of obesity and its impact followed by a multi-agency approach including health, school and social care. Direct work with the whole family is given prominence in achieving change, both within and without a child protection context. Family involvement in the development and implementation of that work in a way that empowers but does not stigmatise was identified as a goal. Parental education was seen as important as part of a preventative approach and in sustaining change. Challenges for Practice: Challenges to practice included structural issues such as a lack of funding for preventative services and a scarcity of targeted services for disadvantaged groups. Psycho-social barriers to families accepting support were identified such as poverty impacting upon individual behaviour. Multi–agency working was a source of frustration with a lack of clarity regarding roles and responsibilities. Direct work with families was central but could be contentious. Challenges included the potential reinforcement of unhealthy eating patterns and the need to balance risk management with building trust and relationships in order to bring about change. Suggestions for Future: Suggestions included training on obesity and service availability, and providing a framework and procedures to guide practice. Evidence on short and long-term outcome measurements was identified as a deficit. More research and dissemination of findings on outcomes and what works regarding interventions is required. Conclusions This research has offered a unique insight into current multi-agency practice in respect of child obesity and child protection. Whether obesity alone can be a child protection concern is contested. Families who fail to recognise that child obesity is harmful to children and the failure of families to engage in support services was thought to potentially constitute neglect. When making judgements about child obesity and levels of harm, personal views about obesity and value judgements regarding parenting and children were as important, if not more so, than factual knowledge. These views come to the fore explicitly in threshold judgements and subsequent referral behaviour regarding identifying and acting on potential and actual significant harm. The services offered to and accepted by service users in respect of child obesity are both influenced by and a consequence of those threshold judgements. Training regarding the identification, assessment and implications of child obesity was required. Given an acknowledgement of a multidisciplinary approach to child obesity assessment and service delivery being most effective, multidisciplinary training could also be most useful. Many would welcome a framework and procedures to guide, but not dictate, practice where child obesity may constitute significant harm and become a child protection concern. Direct obesity focussed work with children and families is seen as key to bringing about change whether through universal services, family support or child protection statutory interventions. More research is required on the short and long-term effectiveness, outcomes and financial viability of those interventions to guide strategic and front line service delivery

Non-epileptic attack disorder: the importance of diagnosis and treatment

A 50-year-old woman was taken to hospital by emergency ambulance during her first seizure. She was admitted to hospital, treated with intravenous diazepam, diagnosed with epilepsy and started on antiepileptic drug (AED) therapy. This was ineffective so she was referred to a tertiary centre where she underwent video EEG and was diagnosed with non-epileptic attack disorder. Her experience of the diagnosis was positive; it allowed her to understand what was happening to her and to understand the link between her seizures, adverse childhood experiences and the death of her mother. She stopped taking AEDs and she was referred to a psychologist which led to a significant improvement in her functioning and quality of life. We present this case as a good example of the benefits of accurate diagnosis, clear explanation and access to specialist car