Areas Of High Social Deprivation Research Articles

Reflecting on parental insights into healthy lifestyles: a qualitative study

BackgroundChildren living in the most deprived regions are more than twice as likely as their affluent peers to be obese. One way we can explain the social gradient of health (determined by relative position on the scale of social disadvantage or advantage) is by identifying the barriers and drivers to health that different groups of people experience. This study explored the understanding and perceptions of (and barriers and drivers to) a healthy lifestyle to investigate how commissioned services can better support residents to enable behaviour change in an area of high social deprivation. This community engagement activity was also conducted to inform commissioning decisions in children's public health services. MethodsWe used a qualitative study design with a semi-structured interview schedule. Four focus groups (5–8 participants, n=26) were conducted in an area of high deprivation in northwest England. Parents or carers were invited to attend anonymously by the Public Health Community Engagement Officer (in June 2022). The inclusion criteria were previous attendance on a weight management programme. Data were analysed using thematic analysis. Engagement activities do not require ethics approval. All participants provided written informed consent to take part. No further information was collected about personal characteristics. FindingsThe study participants demonstrated an awareness and understanding of factors affecting child and family health and health behaviours: healthy eating, exercise, mental health and emotional wellbeing, family values and attitudes towards a healthy lifestyle, cooking and budgeting, wider social connections, access to open spaces, availability of local activities, costs (including hidden costs), and structural barriers. InterpretationUsing the finding that participants recognise barriers and drivers to behaviour change beyond knowledge and skills, we reflect on why there was no take up for a commissioned intervention that aimed to address childhood obesity in the Lancashire area. These reflections inform arguments for an alternative model of service commission that relies less on established randomised trial evidence base and more on participatory codesign and a place-based approach (working with populations' existing knowledge and skills) and is particularly sensitive to people's own perception of the specific drivers and barriers they experience to behaviour change. Limitations include sampling from an area with low diversity and selection of participants who have previously agreed to uptake a weight management intervention. FundingNone.

Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study

ObjectiveTo develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in...

Trends and Reported Complications in Ankle Arthroplasty and Ankle Arthrodesis in the State of New York, 2009-2018

Background:Ankle arthroplasty has emerged as a viable alternative to ankle arthrodesis due in large part to recent advancements in both surgical technique and implant design. This study seeks to document trends of arthroplasty and arthrodesis for ankle osteoarthritis in New York State from 2009-2018 in order to determine if patient demographics play a role in procedure selection and to ascertain the utilization of each procedure and rates of complications.Methods:Patients 40 years and older from 2009-2018 were identified using International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10), Clinical Modification (CM) diagnosis and procedure codes for ankle osteoarthritis, ankle arthrodesis, and ankle arthroplasty in the New York statewide planning and research cooperative system database. A trend analysis for both inpatient and outpatient procedures was performed to evaluate the changing trends in utilization of ankle arthrodesis and ankle arthroplasty over time. A multivariable logistic regression was used to assess the odds of receiving ankle arthrodesis relative to ankle arthroplasty. Complications were compared between inpatient ankle arthrodesis and arthroplasty using multivariable Cox proportional hazards regression.Results:A total of 3735 cases were included. Ankle arthrodesis increased by 25%, whereas arthroplasty increased by 757%. African American race, federal insurance, workers compensation, presence of comorbidities, and higher social deprivation were associated with increased odds of having an ankle arthrodesis vs an ankle arthroplasty. Compared with ankle arthroplasty, ankle arthrodesis was associated with increased rates of readmission, surgical site infection, acute renal failure, cellulitis, urinary tract infection, and deep vein thrombosis.Conclusion:Ankle arthroplasty volume has grown substantially without a decrease in ankle arthrodesis volume, suggesting that ankle arthroplasty may be selectively used for a different population of patients than ankle arthrodesis patients. Despite the increased growth of ankle arthroplasty, certain patient demographics including patients from minority populations, federal insurance, and from areas of high social deprivation have higher odds of receiving arthrodesis.Level of Evidence:Level III, retrospective cohort.

PREDICTING THE RISK OF FALLS IN PATIENTS WITH AN INDICATION FOR ANTIHYPERTENSIVE TREATMENT: DEVELOPMENT AND VALIDATION OF THE STRATIFY-FALLS PREDICTION MODEL

Objective: Falls are one of the most common side effects associated with antihypertensive medication. In patients at high risk of falls, the additional risk of harm from medication may outweigh the potential benefits in terms of cardiovascular risk reduction. However, it is currently unclear which patients are at high risk of falls. This study aimed to develop and validate a clinical prediction model for risk of hospitalisation or death from falls in adults eligible for antihypertensive treatment. Design and method: Eligible patients were aged 40 and above, with at least one blood pressure measurement between 130–179 mm Hg. The outcome was a fall resulting in hospitalisation or death within 10 years of entering the study. Model development was conducted in data from CPRD GOLD using a Fine-Gray approach, accounting for the competing risk of death from other causes, with subsequent recalibration at specific time-points using pseudo-values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves, the Observed/Expected (O/E) ratio, C-statistic, and D-statistic, each pooled across GP practices. Results: Analysis included 1,773,224 patients (62,691 events) for model development, and 3,805,322 (206,956 events) for external validation. Conditional on other variables, increasing age, being female, of white ethnicity, being a heavy drinker and living in an area of high social deprivation were associated with an increased risk of falls. Upon external validation, the re-calibrated model showed good discrimination, with pooled C-statistics of 0.843 (95%CI: 0.841 to 0.844) and 0.833 (95%CI: 0.831 to 0.835) at 5 and 10 years respectively. Original model calibration was poor on visual inspection and whilst this improved with re-calibration, under-prediction of risk remained (Observed/Expected ratio 1.839 at 10 years, 95%CI: 1.811 to 1.865) (Figure 1) Conclusions: STRATIFY-Falls uses commonly recorded clinical characteristics and shows good discrimination on external validation, accurately distinguishing between patients at high and low risk of falls in the next 5–10 years. This model may be used in routine clinical practice to help identify those at high risk of falls, for whom the benefits of antihypertensive medication may be outweighed by the harms.

The Impact of Social Determinants of Health on 30 and 90-Day Readmission Rates After Spine Surgery.

Since its 2012 inception, the U.S. Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program (HRRP) has espoused cost-effective health-care delivery by financially penalizing hospitals with excessive 30-day readmission rates. In this study, we hypothesized that socioeconomic factors impact readmission rates of patients undergoing spine surgery. In this study, 2,830 patients who underwent a spine surgical procedure between 2012 and 2018 were identified retrospectively from our institutional database, with readmission (postoperative day [POD] 0 to 30 and POD 31 to 90) as the outcome of interest. Patients were linked to U.S. Census Tracts and ZIP codes using the Geographic Information Systems (ArcGIS) mapping program. Social determinants of health (SDOH) were obtained from publicly available databases. Patient income was estimated at the Public Use Microdata Area level based on U.S. Census Bureau American Community Survey data. Univariate and multivariable stepwise regression analyses were conducted. Significance was defined as p < 0.05, with Bonferroni corrections as appropriate. Race had a significant effect on readmission only among patients whose estimated incomes were <$31,650 (χ2 = 13.4, p < 0.001). Based on a multivariable stepwise regression, patients with estimated incomes of <$31,000 experienced greater odds of readmission by POD 30 compared with patients with incomes of >$62,000; the odds ratio (OR) was 11.06 (95% confidence interval [CI], 6.35 to 15.57). There were higher odds of 30-day readmission for patients living in neighborhoods with higher diabetes prevalence (OR, 3.02 [95% CI, 1.60 to 5.49]) and patients living in neighborhoods with limited access to primary care providers (OR, 1.39 [95% CI, 1.10 to 1.70]). Lastly, each decile increase in the Area Deprivation Index of a patient's Census Tract was associated with higher odds of 30-day readmission (OR, 1.40 [95% CI, 1.30 to 1.51]). Socioeconomically disadvantaged patients and patients from areas of high social deprivation have a higher risk of readmission following a spine surgical procedure. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England.

Background: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes. Methods: We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group). Results: We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0). The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600). The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512). Conclusion: Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.

Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England.

Background: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes. Methods: We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group). Results: We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0). The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600). The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512). Conclusion: Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.

Condiciones de vida en áreas de alto rezago social y factores sociodemográficos de la pobreza multidimensional en Baja California

The information of this paper comes from a census that we apply in areas of high social deprivation in the municipalities of Mexicali, Tecate, Tijuana and Playas de Rosarito, obtaining data on living conditions of 39,418 residents. The paper describes the results of the census in relation to the characteristics of dwellings and household members, and classifies the population according to the categories of multidimensional poverty. Later, an ordinal logit model was used to estimate the relationship between socio-demographic conditions and poverty, and to define the profile most likely to suffer from poverty. The results indicate that the most prone profile is to be a young unemployed woman, of indigenous culture, with disabilities, born in the southwest of the country, who has not lived in the United States, and resident in a large household, with few family members employed and female head of household with low level of education, in Playas de Rosarito.

Using a Community-Engaged Research (CEnR) approach to develop and pilot a photo grid method to gain insights into early child health and development in a socio-economic disadvantaged community

Plain English summaryThis paper reports on the use of a Community-Engaged Research (CEnR) approach to develop a new research tool to involve members of the community in thinking about priorities for early child health and development in a deprived area of the UK. The CEnR approach involves researchers, professionals and members of the public working together during all stages of research and development.Researchers used a phased approach to the development of a Photo Grid tool including reviewing tools which could be used for community engagement, and testing the new tool based on feedback from workshops with local early years professionals and parents of young children.The Photo Grid tool is a flat square grid on which photo cards can be placed. Participants were asked to pace at the top of the grid the photos they considered most important for early child health and development, working down to the less important ones at the bottom. The findings showed that the resulting Photo Grid tool was a useful and successful method of engaging with the local community. The evidence for this is the high numbers of participants who completed a pilot study and who provided feedback on the method. By involving community members throughout the research process, it was possible to develop a method that would be acceptable to the local population, thus decreasing the likelihood of a lack of engagement. The success of the tool is therefore particularly encouraging as it engages “seldom heard voices,” such as those with low literacy.BackgroundThe aim of this research was to consult with professionals and parents to develop a new research toolkit (Photo Grid), to understand community assets and priorities in relation to early child health and development in Blackpool, a socio-economic disadvantaged community. A Community–Engaged Research (CEnR) approach was used to consult with community members. This paper describes the process of using a CEnR approach in developing a Photo Grid toolkit.MethodsA phased CEnR approach was used to design, test and pilot a Photo Grid tool. Members of the Blackpool community; parents with children aged 0–4 years, health professionals, members of the early year’s workforce, and community development workers were involved in the development of the research tool at various stages. They were recruited opportunistically via a venue-based time-space sampling method. In total, 213 parents and 18 professionals engaged in the research process.ResultsUsing a CEnR approach allowed effective engagement with the local community and professionals, evidence by high levels of engagement throughout the development process. This approach improved the acceptability and usability of the resulting Photo Grid toolkit. Community members found the method accessible, engaging, useful, and thought provoking.ConclusionsThe Photo Grid toolkit was seen by community members as accessible, engaging, useful and thought provoking in an area of high social deprivation, complex problems, and low literacy. The Photo Grid is an adaptable tool which can be used in other areas of socio-economic disadvantage to engage with the community to understand a wide variety of complex topics.

Survival Disparity Following Abdominal Aortic Aneurysm Repair Highlights Inequality in Ethnic and Socio-economic Status

Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihood of increased mortality. The aim of this study was to investigate how SES and ethnicity impacted patient survival after abdominal aortic aneurysm (AAA) repair. Consecutive patients undergoing open and endovascular AAA repair during a 14.5 year period were identified. Ethnicity was defined as recorded on health records and SES (a score of 10, where 1 is least deprived and 10 being most deprived) and was linked to census data. Operative outcomes were reported at 30 days and a medium-term survival analysis used the Cox model to report adjusted hazard ratios (HR). A total of 6239 patients with a median age of 75 years and 78.7% males were included. The majority (5,654) were identified as New Zealand (NZ) Europeans, with 421 identified as NZ Maori, 97 identified as belonging to a Pacific ethnic group, and 67 identified as an Asian ethnic group. The median survival follow-up period was 5 years and after adjusting for confounders, those who identified as NZ Maori had the lowest survival compared with all other ethnic groups with a HR of 1.46 (95% CI 1.23-1.72). Living in areas of high social deprivation ≥ 7 was an independent predictor of short and medium-term overall mortality when compared with living in deprivation deciles 1 or 2. Low SES was identified as a marker of risk for all ethnic groups in relation to both reduced short and medium-term survival. However, regardless of SES, NZ Maori had worse overall medium-term survival following AAA repair than the other ethnic groups. Therefore it appears that both SES and being Maori were markers of increased exposure to risk that negatively impact upon survival after AAA repair. There is a need to ensure systemic processes support initiatives that reduce this inequality.

CHOICE: Choosing Health Options In Chronic Care Emergencies

BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Tackling obesity in areas of high social deprivation: clinical effectiveness and cost-effectiveness of a task-based weight management group programme - a randomised controlled trial and economic evaluation.

An increasing number of people require help to manage their weight. The NHS recommends weight loss advice by general practitioners and/or a referral to a practice nurse. Although this is helpful for some, more effective approaches that can be disseminated economically on a large scale are needed. To assess whether or not a task-based weight management programme [Weight Action Programme (WAP)] has better long-term effects than a 'best practice' intervention provided in primary care by practice nurses. Randomised controlled trial with cost-effectiveness analysis. General practices in east London, UK. Three hundred and thirty adults with a body mass index (BMI) of ≥ 30 kg/m2 or a BMI of ≥ 28 kg/m2 plus comorbidities were recruited from local general practices and via media publicity. Those who had a BMI of > 45 kg/m2, had lost > 5% of their body weight in the previous 6 months, were currently pregnant or taking psychiatric medications were excluded. Participants were randomised (2 : 1) to the WAP or nurse arms. The WAP intervention was delivered in eight weekly group sessions that combined dietary and physical activity, advice and self-monitoring in a group-oriented intervention. The initial course was followed by 10 monthly group maintenance sessions open to all participants in this study arm. The practice nurse intervention (best usual care) consisted of four one-to-one sessions delivered over 8 weeks, and included standard advice on diet and physical activity based on NHS 'Change4Life' materials and motivational support. The primary outcome measure was weight change at 12 months. Secondary outcome measures included change in BMI, waist circumference and blood pressure, and proportion of participants losing at least 5% and 10% of baseline body weight. Staff collecting measurements at the 6- and 12-month follow-ups were blinded to treatment allocation. The primary outcome measure was analysed according to the intention-to-treat principle, and included all participants with at least one recorded outcome at either 1, 2, 6 or 12 months. The analysis employed a mixed-effects linear regression model, adjusted for baseline weight, age, sex, ethnicity, smoking status and general practice. The European Quality of Life-5 Dimensions-5 Levels questionnaire was completed and used to estimate quality-adjusted life-years (QALYs) within the cost-effectiveness analysis. There were 330 participants (WAP arm, n = 221; nurse arm, n = 109; 72% women). A total of 291 (88%) participants (WAP arm, n = 194; nurse arm, n = 97) were included in the main analysis for the primary outcome. Weight loss at 12 months was greater in the WAP arm than in the nurse intervention arm [-4.2 kg vs. -2.3 kg; difference -1.9 kg, 95% confidence interval (CI) -3.7 to -0.1 kg; p = 0.04]. Participants in the WAP arm were more likely than participants in the nurse arm to have lost at least 5% of their baseline body weight at 12 months (41% vs. 27%; odds ratio 14.61, 95% CI 2.32 to 91.96; p = 0.004). The incremental cost-effectiveness ratio for WAP over and above the nurse arm is £7742 per QALY. A WAP delivered in general practice better promotes weight loss over 12 months than a best usual practice nurse-led weight loss programme. The trial recruited mostly women. Research is needed into factors that would make weight loss programmes more attractive to men. Current Controlled Trials ISRCTN45820471. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 79. See the NIHR Journals Library website for further project information.

Getting real in the community: Evaluating the “making a difference” interdisciplinary social engagement project

This article was migrated. The article was marked as recommended. PurposeIt is increasingly recognised that medical schools have a duty to the communities they serve, and that there are many benefits to be gained from student social engagement within those communities. There is also ongoing interest in the value of inter-professional working. Social engagement takes many forms, and benefits to student learning are likely to be multi-faceted. We conducted a detailed qualitative analysis of a "Making a Difference" community project; to investigate pedagogic benefits, to identify how students could indeed 'make a difference' with a population with complex health needs, and to explore the value added by inter-professional working. In framing the character of social engagement, we classified activities into community-orientated, community-based and community engaged education and considered our findings within these contexts.MethodsThe project provided interdisciplinary experiences for student volunteers from medicine and nine other healthcare disciplines (ten professions in total), in attachments to three community-based providers. In addition, students collaboratively organised and delivered a one-day health promotion event for the entire community at a health facility in an area of high social deprivation. Extensive qualitative data were collected from student diaries, interviews and focus groups with students and provider organisation staff. The findings were analysed thematically using NVivo, and as a first level of analysis were mapped onto a modified Kirkpatrick framework of evaluation.ResultsStudents gained new insights, knowledge and skills; these arising from both the community experience and from working with different disciplines. Analysis identified pedagogic benefit at all 4 Kirkpatrick levels. Students were able to contribute in diverse and sometimes unexpected ways. Our data suggest that many other benefits such as development of deeper relationships, opportunities for communication of feelings, breaking down of class and professional barriers resulted from the experience.ConclusionsThe two activity components of the project (attachments and health promotion event) provided distinct but complementary experiences. It is clear from the data that students enjoyed the often new experience of working with peers from other disciplines. They also enjoyed, but were greatly challenged by, working with service users with multiple and complex needs, such as when they were placed with providers working with homeless persons for example. There was strong evidence of new learning, with clear examples of change of practice resulting from these experiences. We considered that the project provided mostly community-based, but also some community-engaged, experiences. Philosophically, sending healthcare students into communities represents a radical change of practice for medical and nursing schools, and our second level of analysis has included theoretical attention to this idea. Further work is ongoing.

‘You want the best for your kids’: improving educational outcomes for children living in poverty through parental engagement

Background: Existing evidence suggests a relationship between family social contexts, family relationships and interactions, children’s social and cognitive development and educational outcomes. Interventions that assist families in relation to parenting and supporting children’s development can have positive effects on both parents’ skills and the educational progress of their children.Purpose: This article reports on a study conducted in an area with high levels of social and economic deprivation in Scotland, which aimed to investigate the nature and effectiveness of the services in place to support poor families. The project focused on capturing the experiences of parents and what they perceived as effective support from the nursery and school staff in terms of getting them more involved in their children’s learning.Sample: There was a particular focus on the four-to-seven-year age group, thus covering the crucial transition from pre-school (or non-school) provision to primary school. A sample of three Early Education & Childcare Centres (EECCs) and three schools were selected. The schools and EECCs were all from areas of high social deprivation and had a high proportion of children on free school meals.Design and methods: The study was qualitative in design and included in-depth semi-structured interviews with 19 service managers and practitioners, six focus groups with parents and six activity groups with children. Data were analysed using both pre-determined and emerging codes.Results: While all parents recognised the value of education for their children’s social mobility and opportunities and were keen to engage in activities, they remained aware of the limited resources they could draw upon, mainly in terms of their restricted academic competencies, specialist knowledge and qualifications. The desire to help their children overcome their families’ economic circumstances was also hampered by the absence of strong social and kinship networks that they could draw upon.Conclusions: We draw on concepts of social and cultural capital to examine parents’ positioning in relation to their children’s education. The conclusion highlights parents’ strategic orientation to school/nurseries, often seen as a resource of cultural capital, and calls for a more positive discourse of parental engagement in relation to disadvantaged groups.

Peep into Policy, Politics, Parliament

Equity and prevention of blindness with a disintegrated eye health serviceIn 1951, three years after the birth of the NHS, Nye Bevan resigned from the Labour Cabinet because Gaitskell's Government introduced prescription charges for dental care and spectacles. A decision not to provide false teeth and spectacles in order to save £13 million pounds was probably the reason why eyes and teeth are now extraordinarily and inappropriately lumped together in The Department of Health administrative structures, and continue to be half in and half out of the NHS.With the delegation of the primary eye care function to ophthalmic opticians (more recently termed optometrists) never formally taking place-beyond the expectation that they provide a prescription for the optical correction of refractive errors and refer anyone with an abnormality - the eye health service has become inefficient and disintegrated. Poor communication between optometry (primary care) and ophthalmology (secondary and tertiary care) is evident, with letters and operation notes from the eye clinic being sent to the GP but often not copied to the referring optometrist. Consequently there is no continuity for a management plan of patients who are discharged from the Hospital Eye Service (HES), which ultimately leads to unnecessary re-referrals and also potentially mismanagement.The location of many optometric practices also prevents access. The geographical distribution of optometric practices, results in a bias of services away from those in more socially deprived areas who have poorer access to health care in general.1 Moreover it is well understood that the prevalence of blindness is significantly higher in areas of high social deprivation.2 The perception of many that a visit to the optometrist will result in heavy expenditure also creates a further barrier to attendance. The opportunistic surveillance by optometrists for the major eye diseases such as glaucoma, cataract and diabetic eye disease is still how the majority of referrals to the HES originate.With a rapidly ageing population, further demand is placed on optometrists with the need for new treatments and higher standards for established interventions; all of which is creating unsustainable requirements for service delivery from the HES. This is exemplified in glaucoma.4 Glaucoma is the most common reason for referral to ophthalmology departments in the UK and 10% of UK blindness certifications identify glaucoma as the primary cause of sight loss.5 Lifetime ophthalmology followups are required if glaucoma is diagnosed and if appointments are sustained many of these patients will remain stable for years. It is increasingly argued that such patients could safely be reviewed by suitably accredited optometrists thereby freeing up clinic time to concentrate on the patients with advanced glaucoma. The argument is strengthened by the fact that in 2009, National Patient Safety Agency figures revealed that 44 patients lost part of their sight as a result of delayed followup appointments and a further 13 were rendered blind.6Currently 40% of referrals to ophthalmology for glaucoma are inappropriate and patients are often discharged at the first visit. …

Give me ‘strength to change’: insights into a social marketing campaign in the North of England

In this paper, we report on how formative research was utilised to design a social marketing campaign commissioned by a Primary Care Trust within an area of high social deprivation in the North of England. Men represent the majority of perpetrators of domestic violence and there is increasing interest in developing services for this group with the aim of changing abusive behaviour. However, men are known to be less likely to engage in help-seeking behaviours, and this reticence has been attributed to the social construction of masculinity. A further barrier for men seeking help in relation to domestic violence is the cultural construction of domestic violence. Formative research was undertaken to explore the perceptions and attitudes of a community population of males (n584). Focus groups explored barriers and drivers to help-seeking and identified effective communication messages. These findings were translated into the 'Strength to Change' campaign that minimised stigmatisation and blame while emphasising help-seeking as a 'strength' rather than a perceived weakness. Social marketing techniques facilitated an in-depth appreciation of local barriers to help-seeking and generated context-specific messages to encourage take-up of a new service for male perpetrators.

The role of education, training and skills development in social inclusion

Purpose – The objective of this paper is to examine the initiation of the University of the Heads of the Valley Initiative (UHOVI) project and evaluate the development of its focus, materials and structure. Design/methodology/approach – The methodology employs interviews with a purposive sample of local employer stakeholders. The rationale for this approach is that it allows identification of the key requirements that UHOVI will need to fulfil if it is to be successful in this endeavour, within a reasonable timeframe. The in‐depth interviews also allow increased clarity in terms of the conclusions that can be drawn, particularly in terms of the recommendations for the next stages of UHOVI project. Findings – UHOVI's aim is to encourage social inclusion, through vocational education and training programmes explicitly suited to non‐traditional learners in an area of high social deprivation. UHOVI is a strategic partnership backed by the Welsh Assembly Government and the European Social Fund, between the University of Glamorgan and University of Wales, Newport. The purpose of the project is to alleviate the long‐term problems inherent within the Valleys area of Wales, which include low levels of professional and managerial jobs, limited qualifications and educational progression and high levels of economic inactivity, sickness and disability. Practical implications – This study can also act as a case study for other similar policies undertaken in similar economic geographies in the future. It also provides an important and original insight into the underpinning design of a large scale social inclusion educational project which will be of interest to policy makers, academia and enterprise support agencies. Originality/value – The paper provides an in‐depth study of the significant UHOVI project, examining the requirements for such an initiative in terms of both content and delivery of vocational education, and how this can affect the role that an education and training programme can play in meeting a social inclusion agenda.

Keeping Kids Smokefree: Rationale, Design, and Implementation of a Community, School, and Family-Based Intervention to Modify Behaviors Related to Smoking among Māori and Pacific Island Children in New Zealand

Despite a concerted, sustained and comprehensive tobacco control effort, smoking is prevalent among young people in New Zealand, particularly for Māori and Pacific Island teenagers. Many took up smoking in their pre-teen years. New Zealand research has shown that daily smoking by children aged 14-15 years is strongly influenced by parental smoking. The Keeping Kids Smokefree study is investigating whether changing parental smoking behavior and attitudes via a community-partnership approach with parents, schools, and local health providers can reduce smoking initiation by 11-12 year olds. It is a quasi-experimental trial involving four schools in an urban area of high social deprivation with large numbers of Māori and Pacific Islands families. Schools were allocated to intervention or control and the intervention was developed through a process of engagement with the schools, parents of children and local healthcare organizations. This article describes the rationale, context, methodology and methods involved in establishing the study. Building Māori and Pacific Islander research capacity was a secondary objective of the study.

Engaged outreach: using community engagement to facilitate access to higher education for people from low socio‐economic backgrounds

Despite ongoing equity initiatives, there is still a clear discrepancy in regards to access to higher education for potential students from socially disadvantaged backgrounds. This paper reports on an action research initiative that has developed a model of engaged outreach as an alternative approach to traditional university outreach. Engaged outreach uses the principles of higher education community engagement to develop stronger relationships between universities and their local communities for the purposes of increasing aspiration and access to higher education. The project was designed using a reflective, collaborative process with local Pacific Island immigrant communities living in an area of high social deprivation in southeast Queensland, Australia. Research progressed in three key stages, which together form the basis of the proposed model of engaged outreach. While it is acknowledged that the success of engaged outreach will depend on its implementation as a long‐term strategy, preliminary results from this pilot project suggest that it demonstrates real potential to address this important but seemingly entrenched issue in Australian higher education.

Time to confront Willis’s lads with a ballet class? A case study of educational orthodoxy and white working‐class boys

This is a retrospective study tracing the longer term effects on identity and aspiration of white working‐class boys from an area of high social deprivation. The boys were members of an acclaimed boys’ dance company and have been retrospectively interviewed as young men in their twenties. Documentary and film material dating from the time they were 14 year olds and the film Billy Elliot were used in the interviews. A media discourse driven by a view of boys ‘in crisis’ that is blind to social class and the difficulties faced by some girls was uncovered. This is found to pervade the entire Billy Elliot discourse, which focused on the sensation of a boy performing ballet rather than on the class background and historical context of the miners’ dispute. The paper questions the discourse of laddishness and the social identity that is attached to the term ‘lad’.