"The state they're in": unpicking fantasy paradigms of health improvement interventions as tools for addressing health inequalities

Globally, it is recognised that the fundamental causes of iniquitous health outcomes lie within unequal distributions of wealth and power. Internationally, however, policies and interventions persist in individualising the inequalities problem and targeting individual behaviours as the main solution. This approach has been argued to represent ‘Fantasy Paradigms’. This paper explores one example of such ‘Fantasy’ intervention from the perspective of health practitioners. Further, it explores opportunities for deepening practitioner understandings of the socio-political determination of health. Data were collected through in-depth interviews with 47 professionals involved in delivering a social prescribing programme in poor areas of Glasgow, Scotland. Data were analysed thematically across and within transcripts. Narratives highlighted different explanatory types concerning how the intervention could tackle health inequalities including: firm commitment to individualised approaches; hopeful pessimism; the social-determinants-of-health as an unpoliticised and nondeterministic backdrop to poor health; and finally, incomplete understanding of the social gradient as a population concept. Disrupted narratives of the social determination of health were also evident. This paper contributes new insights to existing debates on health inequalities discourse. These are conceptually important and identify opportunities for sharpening practitioner understanding of the social determinants of health which could in turn contribute to better, non-stigmatising primary care. It argues that re-engaging communities of practice with what is meant by determination of health is necessary and that there is a need to de-couple the policy aim of reducing health inequalities from the delivery of structurally competent and equality-focused public services

Understanding forced marriage in Scotland

Executive summary In September 2015, the Scottish Government commissioned a 10 month study to better understand forced marriage in Scotland. This is the first forced marriage study that focuses exclusively on Scotland. The study had three research questions: What is the level and profile of service use relating to forced marriage in Scotland? How are services responding to forced marriage in Scotland? What is the impact of the interventions for forced marriage in Scotland? Methods The study focussed on six areas: Aberdeen, Dundee, East Renfrewshire, Edinburgh, Glasgow and Highland. An analysis of forced marriage policy in each of the six case study areas was undertaken, together with interviews with Protection Leads. One-to-one semi-structured interviews were carried out with a range of professionals including police officers, social workers, legal professionals and staff from Women's Aid organisations and other third sector organisations. Eight in-depth interviews were also conducted with survivors[1] of forced marriage. Additionally, a survey was distributed to 293 organisations - schools and women's organisations in the six study areas, and Women's Aid, minority ethnic and other support organisations throughout Scotland. Key findings and recommendations Level and profile of service use Between 2011 and 2014, there were 191 cases[2] of forced marriage reported by survey respondents, with a fairly even spread across the years. Cases tended to involve young, female South Asian victims being threatened or coerced into marriage largely by their parents and extended families. Age and ethnicity were unknown for around a quarter and a fifth of cases respectively, indicating that better recording of cases is necessary. Of the cases where age was known, the majority of victims were aged 18-25, with under 18s representing around a quarter of cases and under 16s around 1 in 10 of cases. Victims were mainly from Pakistani backgrounds (more than half of cases where ethnicity was known), followed by 'other ethnicity', Indian and Black African. Just over a half of referrals came to the attention of services through referral from other organisations, with under a third self-referrals and the remainder referred by friends or family. The interviews with the eight survivors of forced marriage echo the survey findings. The age range of when the forced marriage occurred was from 14-25. For five of the eight survivors the forced marriage was contracted with one survivor being forced into marriage twice. For two of the eight women, the experience of forced marriage was recent or ongoing (within the last two years). All the survivors interviewed were South Asian. All the women received help only when they came to Scotland - whether from abroad or another of the UK nations. Responding to forced marriage in Scotland Of the professionals interviewed, the majority had little direct experience of dealing with forced marriage but showed a sound understanding of forced marriage. However, those with direct experience of supporting victims of forced marriage had a deeper and more insightful understanding of forced marriage as a process rather than an 'event'. This was reflected at a policy level where there were differing levels of ownership and maturity of forced marriage policy, and where learning from forced marriage cases was identified as a means of improving responsiveness. Most professionals were aware that forced marriage took place in a range of communities, but it was seen as largely affecting South Asian communities in Scotland. This perception was confirmed by the survey findings, which found that the majority of cases where ethnicity was recorded related to South Asian communities. In both the policy analysis element of the study and in interviews with professionals, participants drew heavily from the Scottish Government's multi-agency guidance on forced marriage. A wide range of interventions are currently offered to support victims of forced marriage, most commonly one-to-one support, central to which is risk assessment and safety planning. Person-centred approaches were often used, and the need for therapeutic and practical support was also highlighted. Two third sector agencies interviewed offered mediation (and they were of the opinion that this was an effective intervention), despite the fact that Scottish multi-agency guidance stipulates that mediation should not be attempted in forced marriage cases. In terms of the outcome of support offered, nearly half of survey respondents reported that support offered was effective, but a further third were unsure whether the support offered was effective. Reported barriers to responding to forced marriage included 'race anxiety'; a need for more robust local authority procedures for supporting adult victims of forced marriage who have capacity (i.e. who do not meet the criteria to trigger access to adult protection); a need for further regular training for professionals; and a need for increased community education/public awareness on forced marriage. Multi-agency working was discussed both as very positive but also as a barrier - due to competing priorities and processes, with some agencies having more power than others to intervene and not always utilising the expertise available via specialists. A lack of training and learning opportunities on forced marriage was also identified as a barrier to responding effectively to forced marriage, despite forced marriage training being widely available. The survey results, policy analysis in some areas and interviews with some professionals suggest that a number of agencies and areas do not consider forced marriage a relevant issue for their organisation. This indicates that even with the provision of increased training on forced marriage, it might be challenging to recruit professionals to attend. Community education was thought to be a way to raise awareness within communities to increase reporting, but this intervention can also serve as a preventive measure. Targeted interventions for different sections of communities e.g. young people and elders would need to be developed. Although there was wide publicity about the forced marriage legislation, a lack of public awareness of forced marriage was also cited as a major barrier to increasing reporting and providing support for victims. This links with survivors' accounts that they sought help from family and friends and feared contacting agencies due to perceived confidentiality issues, family pressure, uncertainty about the appropriateness of response, and uncertainty about whether what had or was happening to them warranted agency involvement. There are examples of good practice at both a policy and practice level, including meaningful connections between child and adult protection leads and violence against women leads in some areas, proactive learning, person-centred support and in-depth expertise on forced marriage. Survivors reported that they had received excellent support from third sector organisations, but their accounts of other agencies were more mixed. Impact of interventions There was widespread support for civil remedies for dealing with Forced Marriage, from professionals interviewed and survivors of forced marriage. A number of issues were identified with regard to the implementation of civil remedies, relating to: a lack of consensus about what constitutes 'sufficient' evidence to justify granting a Forced Marriage Protection Order the onus of responsibility being placed on the victim, particularly where the victim is an adult who does not meet the criteria for accessing adult protection confidentiality of the victim not always being maintained In relation to criminalisation, most professionals interviewed thought it sent a strong message to the public that forced marriage was unacceptable in Scotland. However, a number of professionals (including some who supported criminalisation) also raised concerns about the potential for forced marriage to 'go underground', as victims would not wish to criminalise their families. It is too early to say whether this concern is justified. All survivors welcomed legal protection, but most were not supportive of criminalisation. However, one survivor who had pursued an FMPO stated that criminal procedures should be used, but only as a last resort. The impact of forced marriage on survivors of forced marriage included suicidal ideation, self-harm, eating disorders and other mental health problems. Survivors were frequently denied educational opportunities, impacting on their future careers and earning capacity. On a more positive note, survivors' experiences of forced marriage had engendered within them more liberal attitudes to parenting than those that they had experienced from their own parents. Survivors' experiences of statutory service response, including recent responses in Scotland, although positive in places, was patchy. However, it should be noted that some of the women were reflecting on historic cases stretching back a couple of decades and, at times, referring to experiences that happened outside Scotland. Most of the women had had some contact with third sector specialist women's support organisations, and all reported this as an extremely positive experience, although it should be noted that most survivors were recruited through their engagement with the women's sector. For some of the women, this was the first time they had told their story; for all of them it was the first time they had received support. Recommendations 1. Develop an innovative programme of further public/community awareness-raising activity, to prevent forced marriage and to encourage increased reporting 2. Develop further regular training on forced marriage for a range of professionals (including teachers, social workers, police officers, legal professionals and mental health practitioners), and ensure appropriate staff attend and the learning is cascaded and applied 3. Support the continued development of specialist women's sector organisations 4. Support the development of forced marriage policy in local authority areas, in order to increase ownership and consistency of approach at a local policy level throughout Scotland 5. Ensure that therapeutic and practical support is available to victims of forced marriage 6. Evaluate forced marriage interventions to develop better understandings of what types of forced marriage interventions work for whom 7. Address the issues the research identified in relation to implementing forced marriage legislation 8. Strengthen the statutory guidance of the Forced Marriage etc. (Protection and Jurisdiction) (Scotland) Act (2011) to make explicit local authorities' obligations to act in all cases of Forced Marriage 9. Improve record keeping of cases of forced marriage, as information about cases is key to developing learning and for future policy developmen

Implementing social prescribing in primary care in areas of high socioeconomic deprivation:process evaluation of the ‘Deep End’ community links worker programme

Background: Social prescribing involving primary care-based ‘link workers’ is a key UK health policy which aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to desired impact and outcomes. Aim: Our objective was to explore the implementation process of such an approach in practice. Design and Setting: Qualitative process evaluation of the ‘Deep End’ Links Worker Programme (LWP) over a two-year period, in seven general practices in deprived areas of Glasgow. Methods: We used thematic analysis to identify the extent of LWP integration in each practice and key factors associated with implementation. Analysis was informed by Normalisation Process Theory. Results: Only three of the seven practices fully integrated the LWP into routine practice within two years, based on NPT constructs of coherence, cognitive participation, and collective action. Compared to ‘Partially Integrated Practices’, ‘Fully Integrated Practices’ had better shared understanding of the programme among staff, higher staff engagement with LWP, and were implementing all aspects of LWP at patient, practice and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations. Conclusions: Even in a well-resourced government funded programme, the majority of practices involved had not fully integrated the LWP within the first two years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a ‘quick fix’ for mitigating health inequalities in deprived areas

Glycogen Content Regulates Peroxisome Proliferator Activated Receptor-∂ (PPAR-∂) Activity in Rat Skeletal Muscle

Performing exercise in a glycogen depleted state increases skeletal muscle lipid utilization and the transcription of genes regulating mitochondrial β-oxidation. Potential candidates for glycogen-mediated metabolic adaptation are the peroxisome proliferator activated receptor (PPAR) coactivator-1α (PGC-1α) and the transcription factor/nuclear receptor PPAR-∂. It was therefore the aim of the present study to examine whether acute exercise with or without glycogen manipulation affects PGC-1α and PPAR-∂ function in rodent skeletal muscle. Twenty female Wistar rats were randomly assigned to 5 experimental groups (n = 4): control [CON]; normal glycogen control [NG-C]; normal glycogen exercise [NG-E]; low glycogen control [LG-C]; and low glycogen exercise [LG-E]). Gastrocnemius (GTN) muscles were collected immediately following exercise and analyzed for glycogen content, PPAR-∂ activity via chromatin immunoprecipitation (ChIP) assays, AMPK α1/α2 kinase activity, and the localization of AMPK and PGC-1α. Exercise reduced muscle glycogen by 47 and 75% relative to CON in the NG-E and LG-E groups, respectively. Exercise that started with low glycogen (LG-E) finished with higher AMPK-α2 activity (147%, p<0.05), nuclear AMPK-α2 and PGC-1α, but no difference in AMPK-α1 activity compared to CON. In addition, PPAR-∂ binding to the CPT1 promoter was significantly increased only in the LG-E group. Finally, cell reporter studies in contracting C2C12 myotubes indicated that PPAR-∂ activity following contraction is sensitive to glucose availability, providing mechanistic insight into the association between PPAR-∂ and glycogen content/substrate availability. The present study is the first to examine PPAR-∂ activity in skeletal muscle in response to an acute bout of endurance exercise. Our data would suggest that a factor associated with muscle contraction and/or glycogen depletion activates PPAR-∂ and initiates AMPK translocation in skeletal muscle in response to exercise

Molecular brakes regulating mTORC1 activation in skeletal muscle following synergist ablation

The goal of the current work was to profile positive (mTORC1 activation, autocrine/paracrine growth factors) and negative [AMPK, unfolded protein response (UPR)] pathways that might regulate overload-induced mTORC1 (mTOR complex 1) activation with the hypothesis that a number of negative regulators of mTORC1 will be engaged during a supraphysiological model of hypertrophy. To achieve this, mTORC1- IRS-1/2 signaling, BiP/CHOP/IRE1, and AMPK activation were determined in rat plantaris muscle following synergist ablation (SA). SA resulted in significant increases in muscle mass of 4% per day throughout the 21 days of the experiment. The expression of the insulin-like growth factors (IGF) were high throughout the 21st day of overload. However, IGF signaling was limited, since IRS-1 and -2 were undetectable in the overloaded muscle from day 3 to day 9. The decreases in IRS-1/2 protein were paralleled by increases in GRB10 Ser501/503 and S6K1 Thr389 phosphorylation, two mTORC1 targets that can destabilize IRS proteins. PKB Ser473 phosphorylation was higher from 3&ndash; 6 days, and this was associated with increased TSC2 Thr939 phosphorylation. The phosphorylation of TSC2 Thr1345 (an AMPK site) was also elevated, whereas phosphorylation at the other PKB site, Thr1462, was unchanged at 6 days. In agreement with the phosphorylation of Thr1345, SA led to activation of AMPK1 during the initial growth phase, lasting the first 9 days before returning to baseline by day 12. The UPR markers CHOP and BiP were elevated over the first 12 days following ablation, whereas IRE1 levels decreased. These data suggest that during supraphysiological muscle loading at least three potential molecular brakes engage to downregulate mTORC1. m

Young people's perspectives on addressing UK health inequalities : utopian visions and preferences for action

Introduction: It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing. Methods: Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist–facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy. Findings: Proposals ranged from radical, whole‐systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual‐level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate. Conclusion: Young people contributed wide‐ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for ‘upstream’ systemic change to achieve reductions in social inequalities and the health differences that flow from these. Public Contribution: An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers

Delivering a primary care-based social prescribing initiative: a qualitative study of the benefits and challenges

Background: ‘Social prescribing’ is a collaborative approach to improve inter-sectoral working between primary healthcare and community organisations. The Links Worker Programme (LWP) is a social prescribing initiative in areas of high deprivation in Glasgow, Scotland aiming to mitigate the negative impacts of the social determinants of health. Aim: To uncover issues relevant to implementing a social prescribing programme to improve inter-sectoral working to achieve public health goals. Design and Setting: Qualitative interview study with 30 community organisation representatives in LWP areas, and six Community Links Practitioners (CLPs) in LWP practices. Methods: Audio recordings of interviews were transcribed verbatim and analysed thematically. Results: Participants identified benefits of collaborative working, particularly the CLPs’ ability to act as patients’ case manager, and their position within GP practices which operated as a bridge between organisations. However, benefits were seen to flow from new relationships between individuals within community organisations and CLPs, rather than more generally with the practice as a whole. Challenges to the LWP were related to capacity and funding for community organisations in the context of austerity. Capacity of CLPs was also an issue given their role involved time-consuming, intensive case management. Conclusions: While the LWP appears to be a fruitful approach to collaborative case management, integration initiatives such as social prescribing cannot be seen as ‘magic bullets’. In the context of economic austerity such approaches may not achieve their potential unless funding is available for community organisations to continue to provide services and make and maintain their links with primary care

What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme

&lt;b&gt;Background&lt;/b&gt; Preventive approaches to health are disproportionately accessed by the more affluent and recent health improvement policy advocates the use of targeted preventive primary care to reduce risk factors in poorer individuals and communities. Outreach has become part of the health service response. Outreach has a long history of engaging those who do not otherwise access services. It has, however, been described as eclectic in its purpose, clientele and mode of practice; its effectiveness is unproven. Using a primary prevention programme in the UK as a case, this paper addresses two research questions: what are the perceived problems of non-engagement that outreach aims to address; and, what specific mechanisms of outreach are hypothesised to tackle these.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt; Drawing on a wider programme evaluation, the study undertook qualitative interviews with strategically selected health-care professionals. The analysis was thematically guided by the concept of 'candidacy' which theorises the dynamic process through which services and individuals negotiate appropriate service use.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt; The study identified seven types of engagement 'problem' and corresponding solutions. These 'problems' lie on a continuum of complexity in terms of the challenges they present to primary care. Reasons for non-engagement are congruent with the concept of 'candidacy' but point to ways in which it can be expanded.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt; The paper draws conclusions about the role of outreach in contributing to the implementation of inequalities focused primary prevention and identifies further research needed in the theoretical development of both outreach as an approach and candidacy as a conceptual framework

Changes in body weight and food choice in those attempting smoking cessation: a cluster randomised controlled trial

&lt;p&gt;&lt;b&gt;Background:&lt;/b&gt; Fear of weight gain is a barrier to smoking cessation and significant cause of relapse for many people. The provision of nutritional advice as part of a smoking cessation programme may assist some in smoking cessation and perhaps limit weight gain. The aim of this study was to determine the effect of a structured programme of dietary advice on weight change and food choice, in adults attempting smoking cessation.&lt;/p&gt; &lt;p&gt;&lt;b&gt;Methods:&lt;/b&gt; Cluster randomised controlled design. Classes randomised to intervention commenced a 24-week intervention, focussed on improving food choice and minimising weight gain. Classes randomised to control received "usual care".&lt;/p&gt; &lt;p&gt;&lt;b&gt;Results:&lt;/b&gt; Twenty-seven classes in Greater Glasgow were randomised between January and August 2008. Analysis, including those who continued to smoke, showed that actual weight gain and percentage weight gain was similar in both groups. Examination of data for those successful at giving up smoking showed greater mean weight gain in intervention subjects (3.9 (SD 3.1) vs. 2.7 (SD 3.7) kg). Between group differences were not significant (p=0.23, 95% CI -0.9 to 3.5). In comparison to baseline improved consumption of fruit and vegetables and breakfast cereal were reported in the intervention group. A higher percentage of control participants continued smoking (74% vs. 66%).&lt;/p&gt; &lt;p&gt;&lt;b&gt;Conclusions:&lt;/b&gt; The intervention was not successful at minimising weight gain in comparison to control but was successful in facilitating some sustained improvements in the dietary habits of intervention participants. Improved quit rates in the intervention group suggest that continued contact with advisors may have reduced anxieties regarding weight gain and encouraged cessation despite weight gain. Research should continue in this area as evidence suggests that the negative effects of obesity could outweigh the health benefits achieved through reductions in smoking prevalence.&lt;/p&gt