Category: Uncategorized

Dr Clare England, Senior Research Associate and Specialist Diabetes Dietitian, in the Centre for Exercise, Nutrition and Health Sciences and the NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle, discusses the challenges of providing individualised dietary advice for people with Type 2 diabetes and introduces a new, validated assessment tool, that may offer a solution.

Diabetes UK estimates that over 3 million people in the UK are living with Type 2 diabetes, and a further 5 million are at high risk. Complications (for example, increased cardiovascular disease, kidney failure, blindness, foot ulcers and amputations) caused by poorly controlled Type 2 diabetes, costs the NHS an estimated at £7.0 billion.

There is an increasing choice of medication available for Type 2 diabetes which can help to reduce blood glucose, cholesterol and blood pressure, but a healthy diet, regular physical activity and good weight management underpin successful control.

There is strong evidence that regular dietary advice, provided by dietitians improves blood glucose control by improving diet. The National Institute for Health and Care Excellence (NICE) recommends that all people with Type 2 diabetes should receive individualised, on-going dietary advice from a health professional with expertise in nutrition, but many people aren’t getting this. Unfortunately, there are not enough specialist diabetes dietitians employed to provide this level of service, and there is considerable variation in provision. For example, the community dietetic service for people living in the north, inner city and east of Bristol is run by a different provider, on a different model, from that provided for people in South and West Bristol.

In the current environment the majority of people with Type 2 diabetes get their routine dietary advice from their GPs, practice nurses or community pharmacists. Some of these health professionals do an excellent job in providing good quality dietary advice but many say that feel they do not have the expertise to assess diets and give individualised advice. I have often heard people with Type 2 diabetes saying that the dietary advice they receive from their general practice is generic, and they struggle to see how to apply the advice they are given to make specific, beneficial changes to their own dietary habits.

With this in mind, clinicians and academics at the Centre for Exercise, Nutrition and Health Sciences and School of Clinical Sciences felt there was a need for a brief dietary assessment tool that helps people assess their diets, and enables them to set dietary goals based on this assessment.

Over the last three years we have worked with dietitians, nurses, GPs and people with Type 2 diabetes to develop a brief dietary questionnaire to rapidly assess the dietary habits thought to be of most importance for people with Type 2 diabetes. The resulting questionnaire, the UK Diabetes and Diet Questionnaire (UKDDQ), asks about consumption of higher energy foods and drinks, fruit, vegetables, oily fish, common higher fibre cereal foods and meal patterns. It takes roughly 10 minutes to complete and can be self-scored. We have just published the validation paper, which showed it to be reliable and compares as well with food diaries as other short dietary questionnaires. The UKDDQ is publically available for download and is equally applicable to people with a diagnosis of Type 2 diabetes, those at risk of Type 2 diabetes and the general population interested in healthy eating. Since the initial development, we have also worked with other researchers from the School of Sport, Exercise and Rehabilitation Science at the University of Birmingham, to check that the questionnaire is relevant to South Asian people (and made a few small changes to wording) and the UKDDQ was adopted by Birmingham South and Central Clinical Commissioning Group as the tool used for dietary assessment in the initial phase of the NHS Diabetes Prevention Programme.

We believe that using the UKDDQ in clinical practice would promote dietary change in people with, or at high risk of, Type 2 diabetes more effectively than the existing generic advice that people are currently hearing. We are planning further work to demonstrate this and would welcome interest from health professionals or people with Type 2 diabetes who would like to be involved in the project.

UKDDQ Project contact details:
Dr Clare England, clare.england@bristol.ac.uk
Centre for Exercise, Nutrition and Health Sciences / Bristol Nutrition BRU

Dr Emma Williamson, Senior Research Fellow in The Centre for Gender and Violence Research, School for Policy Studies, discusses how the current storyline in The Archers raises the question of what justice means when it comes to abuse?

Social media has once again been a-twitter with discussion about The Archers.

I wrote back in April about the domestic violence and coercive control storyline and how the producers had managed to shine a light on the often hidden aspects of abuse. As the story moves this week into the Courts, the media is once again gripped by the drama, with people posting their pictures of solidari-tea with the central character, Helen. The Mail Online even ran a story with Barristers discussing the fictional case .

As with the issue of coercive control more generally, the programme makers are tackling an important aspect of the experience of abuse, namely what is justice when it comes to abuse? This links directly to our current ESRC funded research which is looking at Justice, Inequalities, and Gender Based Violence. This research includes looking at police case files to examine the trajectory of different cases in relation to inequalities and different types of abuse. In addition, we are currently recruiting victims/survivors to speak to us about their experiences of different types of gendered abuse and justice. This includes adult men and women who may have experienced forced marriage, sexual violence, sexual abuse, ‘honor-based’ crimes, and domestic violence and abuse. This project looks beyond the narrow focus of justice in terms of the police and courts, although this is not excluded, and includes people who, for a range of reasons, haven’t reported to the police or have used alternative forms of justice.

This project, like the current Archers storyline, is intended to illustrate what justice and injustice look like, and how formal and informal responses to abuse can highlight the wider responsibilities of society to address the issue and take a stand.

Whatever the outcome in The Archers, the everyday reality for many victims/survivors is that the very idea of ‘justice’ is more complex than a court outcome. Domestic abuse doesn’t just impact on the victims/survivors, but the perpetrators themselves (research shows they have higher rates of depression and anxiety), friends and family members, as well as wider communities. This is all too real for those who have themselves or know someone who has experienced abuse.

The Archers storyline sheds a light on the wider impacts of abuse as the manipulation of the perpetrator affects a whole raft of relationships within families and communities. Irrespective of whether Helen gets ‘formal’ justice in the coming weeks, the damage to those relationships will continue for many years to come. Some would question therefore whether we can ever get ‘justice’ when so many harms go unanswered.

We look forward to following the fictional court case as well as the on-going struggles which the main characters and the Ambridge community as a whole face as they come to terms with the impact of abuse. We once again commend the writers for staying true to the victim’s story and not turning away.

Anyone interested in taking part in our justice research can register an interest, or contact us to discuss in more detail, at:

Website: http://tinyurl.com/hj5oda5
Email: sps-justiceproject@bristol.ac.uk
Telephone: 07807 799967.

Dr Sue Porter, Research Fellow at the Norah Fry  Centre for Disability Studies, School for Policy Studies, reflects on the horrific mass attack on Disabled people in Japan on the 26th July and what a Disability Studies lens can bring to our understanding of such hate crimes.

Those attacked in Sagamihara were living in a 150 bed unit for people with learning disabilities, and as such we must assume that the majority of residents were removed from their families and geographical communities. We know that a key factor that encourages hate crime is the “othering” of disabled people, which is reinforced by this sort of segregation. In the UK the Disability rights movement was born out of a desire to resist this sort of institutionalization of disabled people and campaigned to provide the means for disabled people to live within our chosen communities, whether independently or interdependently.

Since the 1980s this has been at the heart of UK government policy, informing personalisation‐related legislation and more recently the Care Act. Even at a time when many question whether austerity‐related cuts in funding to local authorities and changes in welfare benefits are undermining the practicality of independent living for growing numbers of disabled people in the UK, the importance of independent living is acknowledged as key to disabled people being active members of society. However, amongst people with learning disabilities and a label of challenging behaviour or mental health need, there are still over 2.5k living in institutional settings ‐ Assessment and Treatment Units ‐ at a distance from their home communities, for extended periods and without discharge plans. There is little provision in the community for these individuals and a growing number of mini‐institutions (18 or 20 bed) are either in operation or currently being built. So the ‘othering’ and segregation of this particular group of disabled people goes on in spite of the rhetoric, the policy and the promises made after the Winterbourne View abuse scandal.

At the same time cultural references such as the recent Hollywood film ‘Me Before You‘ continue to promote the message that it is better to be dead than disabled. For some it seems hard to imagine that a life lived with impairment or chronic illness is a life worth living. On 11 September 2015, MPs voted overwhelmingly against legalising assisted suicide, but some media coverage would have you believe that the large numbers of the UK population believe it’s a humane choice to legalise assisted suicide for terminally ill or disabled people. Opposition to assisted suicide is not confined to the medical profession and religious groups. Many disabled people, including the very people whom would be most affected by any change in legislation oppose the idea – it’s worth noting that no organization of or for disabled people has campaigned for assisted suicide (including those representing people with Multiple Sclerosis and Motor Neurone disease most often cited as likely to ‘benefit’ from such changes), and that disabled‐led groups like Not Dead Yet UK* continue to raise the issue, most recently protesting at the London premier of ‘Me before
You’.

At the time of writing the state of mind of the perpetrator of the attack in Sagamihara is unclear, what is apparent however is the culpability of the media in perpetrating and endorsing negative narratives of disability, potentially feeding the thinking and actions of some individuals.

The Sagamihara attack was a hate crime undertaken by an individual who denied the value of the lives he took, the 26‐year‐old former employee of the facility was quoted as saying. “It is better that disabled people disappear”. Hate crimes are defined as any crimes that are targeted at a person because of hostility or prejudice towards that person’s: disability, race or ethnicity, religion or belief, sexual orientation or transgender identity (UK Equality and Human Rights Commission). The UK Equality and Human Rights Commission report that there has been significant progress in the reporting and recording of disability hate crime since it was first included in national policy in 2008 . Police records show an increase from 800 in the first year to 2,508 in 2015/16. The number of prosecutions for hate crimes against Disabled people in the UK last year was up by 41.3% compared to 2014/15. In 2015‐16 there were 941 prosecutions for disability hate crimes. (Action Against Hate, The UK Government’s plan for tackling hate crime. July 2016). Disability hate crime represented 5% of police recorded hate crimes in 2014/15, but this is in contrast to the Crime Survey for England and Wales where disability hate crimes represented one‐third of hate crimes. The under‐reporting of disability hate crime demonstrates the importance of more victims
feeling able to come forward, and the prevailing attitudes and cultural references surrounding us in society risk some Disabled people internalising the negative perceptions of the value of their lives.

Regardless of its form and intention, prejudice always has the potential to cause harm because it reduces the value, status or importance attached to people from ‘the other group’. The ‘othering’ of Disabled people, and the belief that disabled lives are not of value raise fundamental questions about social justice in our society. We need to come together to fight for a global society where diversity is valued and where we can all live free from abuse, fear and oppression. And as the understanding of hate crime increases, it becomes even more important that officials across government engage with those working in the research community and with organisations of Disabled people to build the evidence base for policy interventions.

*Not Dead Yet UK is a network of disabled people in the UK who have joined a growing international alliance of disabled people, who oppose the legalised killing of disabled people. All those involved are disabled people including people with physical and sensory impairments, learning difficulties, and mental health conditions.

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

1) Whether harm has occurred to the child;

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

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

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

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

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

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

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

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

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

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

 

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