Supporting perinatal mental health: from peer-support to specialist services

There is a societal expectation that pregnancy and the arrival of a new baby are happy and exciting times.  However, it may come as a surprise to learn that up to 1 in 5 women develop a mental illness during pregnancy or within the first year after having a baby (also known as the ‘perinatal period’).

Up to 1 in 10 women may develop postnatal depression, however, there are actually a number of other mental illnesses that can affect women during pregnancy or following birth.  These include:

  • Antenatal depression
  • Perinatal anxiety
  • Perinatal obsessive compulsive disorder
  • Post-traumatic stress disorder (PTSD)
  • Post-partum psychosis

These illnesses can range from mild to severe.  Left untreated, perinatal mental illnesses can have a devastating effect on mental and physical health.  In fact, suicide is the leading cause of death for mothers during the first year after pregnancy.

The wider impact on children and families

Perinatal mental illnesses can also impact upon children, partners and significant others.  Research shows links to depression in partners, higher rates of divorces, lower levels of emotional and cognitive development and higher levels of behavioural problems and psychological disorders among children.

As well as the high human cost, there are also a number of economic costs associated with failing to address perinatal mental health needs. Research commissioned by the Maternal Mental Health Alliance found that perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK.

In comparison, it would cost only an extra £280 million a year to bring the whole pathway of perinatal mental health care up to the level and standards recommended in national guidance.

Access to specialist services is a ‘postcode lottery’

The good news is that most mothers who experience mental ill health can and do make a full recovery.

At present, mild to moderate cases of mental ill health in pregnancy and following birth are treated by the GP through anti-depressants, talking therapies and/or support from a community mental health team.  For more complex or serious illnesses, GPs can make a referral to specialist perinatal mental health services for expert advice and support.  This may involve staying in a specialist psychiatric Mother and Baby Unit (MBU) – where mothers and their baby can be admitted together.

However, despite the high prevalence of, and risks associated with, perinatal mental illness, access to specialist perinatal mental health services across the UK is a postcode lottery.

Maps by the Maternal Mental Health Alliance show that women in around half of the UK have no access to specialist perinatal mental health services.  There are currently no MBUs in Wales or Northern Ireland, meaning mothers with more serious or complex mental illnesses often face either being admitted to a MBU far from home, or being admitted to a general psychiatric ward without their babies, in order to receive treatment.

For those with mild to moderate mental illness, waiting times for NHS talking treatments can be many months.  Lack of awareness means that many cases of mild to moderate mental ill health go undiagnosed and untreated.  There is an urgent need for both greater awareness of mental illness and better access to mental health services across the country.

The role of peer-support

In recognition of and response to the need for better access to mental health support for pregnant and new mothers, a number of local ‘grassroots’ peer-support projects have been established by dedicated volunteers and campaigners.

One such project is Blank Canvas.  Blank Canvas is a creative journaling workshop in Lanarkshire, aimed at women during pregnancy or in the first two years since birth, who are experiencing mental health difficulties.

The project was set up earlier this year by midwife Elaine Connell, together with some of her midwife colleagues, who shared her dedication to improving mental health support for women in the perinatal period.

Elaine was keen to start her own peer support group following her own personal and professional experiences of perinatal mental ill health, and was inspired by the success of other projects focusing on art and creativity, such as Maternal Journal.

As Elaine explains:

It is free… …to access, and each attendee is given their own art kit to keep. We have a different theme each week and have guest speakers coming to do sessions also. During the group they can explore new art materials and create reflections in their journal, whilst chatting over some tea and cake. Each session they will take home a prompt card which can inspire their journalling during the week until the group meets next.”

Blank Canvas is free to access and works on a self-referral basis, with advertising mainly through Facebook.  A local shop and community space (Swaddle in Hamilton) donated a venue space, and all other costs (including materials) have been raised by volunteers committed to the project, through fundraisers such as coffee mornings and participation in the Kiltwalk.

Elaine has conducted an evaluation of the first 10-week block and feedback from participants has been extremely positive.  Word about the project has spread and the next block of Blank Canvas – which started on the 18th September – is fully subscribed (with a waiting list).  As Elaine notes, this is fantastic for the project, but highlights the high level of demand that exists for mental health support among new mothers.

The long term plan is to run 6-week blocks frequently throughout the year, moving to separate antenatal and postnatal sessions in 2020.  Elaine also hopes to start up a creative journaling group aimed at fathers too – noting that father’s mental health is often overlooked.

One of the key things Elaine has learned from the creation of Blank Canvas is that there is a lack of support available for people who want to establish their own peer-support groups:

What has been clear when forming the group, is that there is very little support to establish peer support. There are lots of people who want to help others but who won’t because they don’t know where to begin, or how to access funding, or lack of training opportunities.”

Grassroots peer-support groups are an important source of support for mothers in the perinatal period, particularly in cases of mild to moderate mental ill health, where NHS capacity is strained.

Attending peer-support groups such as Blank Canvas may also have a preventative effect for mums who attend during pregnancy. Statistically, women who experience antenatal anxiety are more likely to develop postnatal depression, and so early intervention could help to reduce that risk.

Urgent need for better access to specialist services

While these projects have been successful, they are aimed predominantly at women experiencing mild to moderate mental ill health.

For those experiencing more complex or serious mental ill health, there remains an urgent need for better access to specialist treatment and support.  The Maternal Mental Health Alliance ‘Everyone’s Business’ campaign calls for all women throughout the UK who experience perinatal mental ill health to receive the care that they and their families need.  Specifically, it demands that:

  • perinatal mental health care should be clearly set at a national level and complied with
  • specialist perinatal mental health teams meeting national quality standards should be available for women in every area of the UK
  • training in perinatal mental health care should be delivered to all professionals involved in the care of women during pregnancy and the first year after birth

Promising signs of progress

There have been some promising signs of progress.  NHS England recently announced their plans to rollout specialist perinatal community services across the whole of England, including the opening of four new Mother and Baby Units.

And in Scotland, the Scottish Government recently announced the rollout of an initial £1 million for perinatal mental health services, as part of a wider £50 million investment in mental health services.  This initial investment will support a range of areas, including supporting the third sector to provide counselling, befriending and peer support for women and their families.  It will also help provide more consistent access to psychological assessment and treatment, by increasing staffing levels and training at Mother and Baby Units, for women with the most serious illnesses.

The Scottish Government also established a Perinatal and Infant Mental Health Programme Board earlier this year.  The PIMH Programme Board aims to help implement the commitments to improving perinatal and infant mental health set out in the 2018/19 Programme for Government and Better Mental Health in Scotland.

Clare Thomson, Everyone’s Business Co-ordinator for Scotland, says “It’s fantastic to see the evidence-based approach to developing community perinatal mental health services and look forward to hearing about the first steps – particularly in the North of Scotland“.

Perinatal mental health is Everyone’s Business

However, there is still much to do, including ensuring that this funding translates into services on the ground.  Wales and Northern Ireland are still without MBUs and there is a pressing need to raise awareness of and address mental illness among fathers.

The cost to the public sector of perinatal mental health problems is 5 times the cost of improving services.  It clearly makes sense to invest in improving this care – not only from an economic perspective, but to help improve the lives of women, their children and families across the country. And while more funding is essential to achieve this, raising awareness of the importance of perinatal mental health really is ‘everyone’s business’.


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Good enough is not enough: International Making Place Conference

International Making Place Conference, Glasgow. Image: Jason Kimmings

There is now a growing body of evidence to indicate that our physical environment – the places where we live, work and socialise – affects our health and wellbeing and contributes to creating or reducing inequalities. But even without the research, it’s plain to see how a neighbourhood with lots of facilities for pedestrians and cyclists, a choice of shops and good public transport connections could benefit health in ways that one with an excess of pubs, fast food shops and car traffic would not.

The importance of place-based approaches to improving health and reducing inequalities was the theme of an international conference held in Glasgow last week.

The venue for the conference – Glasgow’s Old Fruitmarket building – is a shining example of how a great place can be repurposed and reinvented. Originally a wholesale fruit market, the building has been reborn as a unique setting for cultural and business events, but has retained many of its original features, including a lofty vaulted roof and a cast iron balcony.

David Crichton, Chair NHS Scotland
Image: Jason Kimmings

Facing up to the challenge of place

In his introduction, David Crichton, Chair of NHS Scotland, pointed to the sobering statistics that throw the importance of place into sharp focus. He noted that while the health of Scotland’s population was generally improving, people living in 10% of the country’s poorest areas are four times more likely to die prematurely than those in more prosperous places. The city of Glasgow knows all too well about these stark health inequities. A person living in the deprived area of Calton has an average life expectancy of 54 years, while someone growing up in affluent Lenzie, just 12km away can expect to live to 82.

Glasgow Lord Provost Eva Bolander
Image: Jason Kimmings

Glasgow’s Lord Provost, Eva Bolander, acknowledged the challenges facing the city, but also noted that Glasgow is at the vanguard of place making. The city council’s Avenues Project aims to transform 17 key streets, prioritising space for cyclists and pedestrians, introducing sustainable green infrastructure and improving public transport connections. Glasgow is also investing £20m in its Community Hubs programme to bring multiple support services together in areas experiencing high levels of poverty.

Aileen Campbell, the Scottish Government’s Cabinet Secretary for Communities and Local Government, highlighted projects such as Clyde Gateway in Glasgow and the Bellsbank Initiative in East Ayrshire as successful examples of placemaking. Their success, said the minister, lies in focusing on what’s important to the people and communities of these areas, with the support of government and local authorities.

This international conference also heard from Monika Kosinska from the World Health Organisation, who noted that the problems facing Scotland are not unique. Around the world, countries and communities are experiencing the challenges associated with ageing populations and health inequalities. In this sense, she observed, all countries are developing countries.

Sir Harry Burns
Image: Jason Kimmings

A sense of coherence

The World Health Organisation’s assertion that health is a complete state of wellbeing, not merely the absence of disease, was at the heart of a powerful presentation delivered by Sir Harry Burns, Director of Global Public Health at the University of Strathclyde.

His research has underlined that poverty is not the result of bad choices. The real problem is that, without a sense of coherence and purpose, people are not in a position to make good choices.

As Sir Harry explained, a child experiencing chaotic early years (featuring parental substance abuse and/or domestic violence) is already on a path to mental health problems which can culminate in a loss of control and long periods of worklessness and poverty. But the implications can be even more serious: “The more adverse experiences you have as a child, the more likely you are to have a heart attack.”

A eureka moment for Sir Harry Burns occurred when he read a book by an American sociologist. Aaron Antonovsky spent the latter half of his career in Israel studying adults who as children had been in concentration camps. He found that the children who survived had developed what he termed a “sense of coherence” – a feeling of confidence that one has the internal resources to meet the challenges of life, and that these challenges are worth engaging with.

That sense of coherence, Sir Harry believes, lies in giving people in poverty greater control over their own resources: “People who have a sense of purpose, control and self esteem are more positive and secure about the places they live in, and a greater ability to make the right choices.”

He concluded that rather than being passive recipients of services, all of us have to be given the opportunity to become active agents in our own lives: “‘Ask people to take control of their lives, build their trust, and people can make choices that support their health. We must create places that do that’.

Woodside Health Centre
Image: Jason Kimmings

Placemaking in action

This theme of active engagement in placemaking was demonstrated during a site visit to a new health centre in Woodside, one of the most deprived parts of Glasgow. The aim of the new health centre is to reshape health services from the patient’s point of view, helping them to manage their own health and improve the care they receive. The new centre will bring together GP services, along with dental, pharmacy and physiotherapy services.

The health centre and its surroundings have been created by engaging with the local community. Using ideas from local people, the exterior of the building features designs reflecting the natural and industrial history of the area. Natural light from large windows in the roof floods the centre of the interior, giving a sense of brightness and tranquility, while wooden slats feature designs linking the centre with natural features nearby.

Claypits Local Nature Reserve. Image: Jason Kimmings

That connection with the natural environment will be reinforced with the development of a community green space close to the new health centre. The Forth and Clyde Canal is just a few minutes’ walk from the health centre, and a new foot and cycle bridge linking the centre to the local nature reserve is under construction. Other features will include new and improved pathways and new wildlife habitats. The natural space is already attracting walkers, joggers, families and cyclists, and local people report feeling they can now visit this area in greater safety than ever before.

Mark Beaumont and Glasgow Disability Alliance. Image: Jason Kimmings

The Place Standard

One of the threads running through this conference was the Place Standard, a practical tool developed in Scotland to help communities assess and redesign their own places.

For the final session of the afternoon, round-the-world cyclist Mark Beaumont introduced members of the Glasgow Disability Alliance (GDA) who shared results from their day as the Place Making Team using The Place Standard Tool. The results highlighted some of the elements of place that are important to people with disabilities – but also to others: lack of accessible toilets, poor transport links, networking events with no seating, inaccessible information, no social care support.

Final thoughts

This conference provided some important ideas on what’s wrong with our places, and some examples of places that are getting it right. And even for those that are on the right track, everyone was left with a clear message: when it comes to placemaking, good enough is not enough!

Merchant City, Glasgow
Image: Jason Kimmings

A road less travelled: celebrating Gypsy, Roma and Traveller History Month – part 2

June is Gypsy, Roma and Traveller History Month (GRTHM), which aims to raise awareness of and promote GRT history and culture.

It is widely recognised that raising awareness of different cultures is a key part of addressing prejudice and discrimination.

In this post – the second of two for GRTHM – we look at the inequalities and discrimination that GRT face across education, employment and health.  We also highlight work to address these inequalities and raise awareness of GRT communities’ rich cultural heritage.

GRT communities experience many educational and health inequalities

The recent House of Commons report, ‘Tackling inequalities faced by Gypsy, Roma and Traveller communities’, sets out a comprehensive review of the available evidence across a range of areas.

In education, Gypsy and Traveller children leave school at a much earlier age and have lower attainment levels than non-GRT children, and only a handful go on to university each year.  They also experience much higher rates of exclusions and non-attendance.

There are many reasons for this – from discrimination and bullying, to a lack of inclusion of GRT within the educational curriculum. There are also cultural issues to be addressed within the GRT community itself.

Scottish Traveller activist Davie Donaldson has spoken about the discrimination he faced in school where a teacher refused to “waste resources” by marking his homework because he was a Traveller, who she assumed was “not going to do anything with his education anyway”.  He also discusses how many Travellers within his own community felt he was betraying his roots by attending university. This clearly illustrates the multi-faceted nature of the issue of supporting GRT children in education.  The Traveller Movement addresses this and other related issues in their recently published guide to supporting GRT children in education.

Health outcomes for GRT communities are also very poor compared to other ethnic groups.  Their life expectancy is 10 to 12 years less than that of the non-Traveller population.  Maternal health outcomes are even more shocking – with one in five Gypsy Traveller mothers experiencing the loss of a child, compared to one in 100 in the non-Traveller community.

Poor health outcomes can be partially attributed to the difficulties that many experiences when accessing or registering for healthcare services due to discrimination or language and literacy barriers.  There is also a lack of trust among GRT communities which can result in a lack of engagement with public health campaigns.

Historic fear of engagement with public services

Indeed, there is a historic wariness of public services among many in the GRT community.

In the 1800s, many Travellers had a well-placed fear of the ‘burkers’ – body-snatchers looking to provide the medical schools with bodies for dissection.  Travellers felt particularly at risk because they lived on the margins of society.  There are many Traveller stories about burkers that have been passed on from generation to generation.

Similarly, a fear of social services intervention also exists, following the forced removal of children from Traveller families.  Some were taken into care, and others were deported to be servants in Canada or Australia.

Being aware of these cultural issues, along with the historic criminalisation and continued discrimination that GRT communities face, can help health and social services to understand and empathise with the GRT community when reaching out to them.

Poor employment outcomes and a lack of target support

Gypsies and Travellers were an essential part of the economy in the 19th Century and early 20th Century.  Many were skilled tinsmiths, silversmiths, basketmakers or other crafters.  They also played an important role as seasonal agricultural workers – for example, in the berry fields of Blair and farms of the north east of Scotland.  They moved from place to place, and bringing news and selling and trading their wares.  In the days before roads and motor vehicles, they were a lifeline for rural crofting communities who may have been many days travel away from the nearest settlement.

Time has rendered many traditional Traveller occupations redundant, and today employment outcomes for GRT groups are generally poor.

While more likely to be self-employed than the general population, the 2011 England and Wales Census found that Gypsies and Irish Travellers were the ethnic groups with the lowest employment rates, highest levels of economic inactivity, as well as the highest rates of unemployment.

However, unlike other minority groups, there has been no explicit government policies that support Gypsies or Travellers to enter employment or to take up apprenticeships and/or other training opportunities.  Many Gypsies and Travellers have also reported being discriminated against by employers, making it more difficult for them to find and stay in work.

A lack of robust data

There is a lack of robust data about the different GRT groups in the UK – even something as seemingly simple as how many GRT people there are.

This is because most data collection exercises – including the Census and in the NHS – do not include distinct GRT categories.  If an option exists at all, often it conflates the different GRT ethnicities into one generic tickbox, with no way to differentiate between the different ethnic minorities.  This is an issue that is being increasingly addressed and there are plans to include a Roma category in the 2021 census.

However, there are also issues with under-reporting.  Many people from GRT communities are reluctant to disclose their ethnicity, even when that option is available to them.  This stems both from a lack of trust and the fear of discrimination.

So, while the 2011 Census recorded 58,000 people as Gypsy/Traveller in England and Wales, and a further 4,000 in Scotland, it is estimated that there are actually between 100,000 to 300,000 Gypsy/Traveller people and up to 200,000 Roma people living in the UK.

Raising awareness of GRT culture

While this all may make for some pretty depressing reading, there are some promising signs of progress.

From Corlinda Lee’s Victorian ‘Gypsy Balls’ – where the curious public could pay to come and see how a Gypsy lived and dressed, to Hamish Henderson catalysing the 1950s Scottish Folk Revival with the songs and stories of Scottish Travellers – there have been attempts to promote Gypsy and Traveller culture among the settled population.

Today, organisations and individuals such as The Traveller Movement, Friends, Families and Travellers, and Scottish Traveller activist Davie Donaldson strive to promote awareness of and equality for the GRT community.

The recent Tobar an Keir festival held by the Elphinstone Institute at Aberdeen University sought to illustrate traditional Traveller’s skills such as peg-making, and there is a wonderful Traveller’s exhibition – including two traditional bow tents – at the Highland Folk Museum in Newtonmore.

There are even more events planned for GRTHM – including an exhibition of Travellers’ art and photography at the Scottish Parliament.

The hard work may be beginning to pay off – just last week, the government announced a new national strategy to tackle the inequalities faced by Gypsies, Roma and Travellers.

Using knowledge to fight prejudice

While there is without doubt an urgent need for practical measures to address the inequalities that the GRT community face – such as an increase in the number of authorised sites available – addressing the fundamental lack of awareness and knowledge of GRT culture is a key step towards eradicating prejudice towards GRT communities.

As well as raising awareness among the general public, there is also a need to for people working in public services – from health and social services to education and even politics – to have a better awareness and understanding of Traveller culture and history, and how this affects their present day needs and experiences.

Gypsy, Roma and Traveller History Month is an ideal opportunity to address the huge gap that exists in society’s collective knowledge about the GRT way of life, their history, culture and contribution to society. All of which can help to combat the prejudice and discrimination that they continue to face.


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A road less travelled: celebrating Gypsy, Roma and Traveller History Month – part 1

Traditional Scottish Traveller bow tent at the Highland Folk Museum, Newtonmore

This month is Gypsy, Roma and Traveller History Month (GRTHM).

GRTHM aims to celebrate and promote awareness of Gypsy, Roma and Traveller (GRT) history, culture and heritage, and the positive contribution that GRT groups have made and continue to make to society.  It also seeks to challenge negative stereotypes, prejudices and misconceptions associated with GRT groups.

Over the next two blog posts, we will raise awareness of the many issues faced by GRT communities in the UK today, and highlight some lesser known aspects of GRT culture and heritage.

Gypsies and Travellers are not a homogenous group

One common misconception is that Gypsies, Travellers and Roma are a homogenous group.

In fact, GRT is a term which encompasses many distinct ethnic groups with their own cultures, histories and traditions.

This includes Romany Gypsies, who today are generally of English or Welsh heritage.  Gypsies first arrived in Britain in the 16th Century. The term ‘Gypsy’ was coined due to a common misconception that Gypsies originated from Egypt. However, recent DNA studies suggest that they actually originated from the Indian subcontinent.  Some Gypsies may prefer to be known as either English Gypsies or Welsh Gypsies specifically.

Irish Travellers are Travellers with Irish roots, however, a recent DNA study suggests they have been genetically distinct from the settled Irish community for at least 1000 years. Irish Travellers have their own language – Shelta (also known as Cant).

Scottish Gypsies/Travellers are indigenous to Scotland.  Their exact origins are uncertain, but it is thought that they may be descended from the Picts, and/or the scattering of the clans following the Battle of Culloden in 1746.  Certainly, Scottish Travellers tend to share many of the same Clan surnames – including Stewart, McMillan, McPhee and McGregor.

Scottish Travellers also have their own language – the Gaelic-based Beurla Reagaird.

European Roma are descended from the same people as British Romany Gypsies, and they are Gypsies/Travellers who have moved to the UK from Central and Eastern Europe more recently.  Some have arrived as refugees and asylum seekers. While they face many of the same issues as Gypsies, Irish and Scottish Travellers, they are also subject to a number of additional challenges.

There are also other groups that are considered ‘cultural’ rather than ‘ethnic’ Travellers.  These include Occupational Travellers such as fairground and circus owners and workers and New Age Travellers – individuals who have chosen a travelling lifestyle for ideological reasons.

Distinct ethnic minorities protected by law

Whilst there are some similarities between GRT groups in terms of lifestyle, economic, family and community norms and values – and certainly in terms of the discrimination and poor outcomes that they experience – there are clear genetic differences between each of the groups.

As such, Gypsies, Irish Travellers and Scottish Travellers are each considered ethnic minorities in their own right and protected as “races” under the Equality Act 2010.  Migrant Roma are protected both by virtue of their ethnicities and their national identities.

However, despite this protection, GRT groups are still subject to high levels of discrimination.

‘The last acceptable form of racism’

Indeed, prejudice and discrimination has affected GRT groups throughout history.

In the 16th century, any person found to be a Gypsy could be subject to imprisonment, execution or banishment.  Even after anti-Gypsy laws were repealed, discrimination continued.  In the 19th and early 20th centuries, it was not uncommon for doctors to refuse to attend to Travellers.  And despite Travellers’ strong Christian beliefs, churches would often refuse to bury their bodies within their grounds.

And today, GRT people have the worst outcomes of any ethnic group across a huge range of areas, including education, health, employment and criminal justice.  They have the poorest health and the lowest life expectancy of any ethnic group in the UK, and are subject to high levels of racism and hate crime.

GRT groups still face barriers to accessing health services.  As part of a mystery shopper exercise by the Friends, Families and Travellers (FFT) charity, 50 GP practices were contacted by an individual posing as a patient wishing to register without a fixed address or proof of identity. They found that almost half would not register them, despite NHS guidance to the contrary.

And while racism towards most ethnic groups is now seen as unacceptable and less frequently expressed in public, racism towards GRT groups is still common and often overt – even among those who would otherwise consider themselves ‘liberal’ or ‘forward thinking’.  This had led it to be termed “the last acceptable form of racism”.

The 2015 Scottish Social Attitudes Survey found that over 30% of people in Scotland would be unhappy with a close relative marrying a Gypsy or Traveller, and 34% felt that Gypsies or Travellers were unsuitable as primary school teachers.

Research by Travellers Movement has found that four out of five (77%) of Gypsies, Roma and Travellers have experienced hate speech or a hate crime – ranging from regularly being subject to racist abuse in public to physical assaults.

Prejudice and discrimination against GRT groups is not limited to the public – there is also evidence of discrimination against GRT individuals by the media, police, teachers, employers and other public services.

Even politicians have openly displayed anti-GRT sentiment.  In 2017, the Conservative MP for Moray Douglas Ross, stated that he would impose “tougher enforcement against Gypsy Travellers” if he were Prime Minster for the day.

His remarks were widely criticised.  Amnesty International’s Scottish director, Naomi McAuliffe, said “When our elected leaders use this sort of blatantly partisan speech, they set a terrible example that only serves to foster further discrimination and prejudice.”.

A lack of sites has led to a ‘housing crisis’

Mr Ross’s remarks reflect another common misconception about GRT communities – that they all live in caravans, purposefully choosing to set up on unauthorised sites.

The truth is that while Gypsies and Travellers have traditionally lived a nomadic life, living in bow tents, wagons – and even caves – over 70% of Gypsies and Travellers no longer live in caravans, having chosen, or being forced for one reason or the other – disability, old age, lack of suitable sites – to move into traditional ‘bricks and mortar’ accommodation.

For those who do still live in caravans, it is widely recognised that they face a ‘housing crisis’ – an urgent shortage of authorised sites to set up on, which threatens their travelling heritage.  It is this shortage that drives much of the use of unauthorised sites.

Of those sites that do exist, quality has been raised as a key issue.  Many sites can lack even the most basic amenities, and some are sited near recycling plants or in other undesirable locations.  Poor conditions and sanitation contributes to poor levels of health, exacerbating existing health inequalities.

Further inequalities

In our next blog post, we will look in more depth at the inequalities that GRT communities face – in health, education and employment.  We also highlight work to address these inequalities and raise awareness of GRT communities’ rich cultural heritage.


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Tackling health inequalities: what does the data tell us and how can it help?

Health inequalities in Scotland are significant. Every year we hear about how Scotland has some of the biggest gaps in the health and wellbeing of the poorest and richest in society. In some cases, Scotland has the largest gaps in equality in the whole of Europe. And in many instances, they are rising. Scotland also has the lowest life expectancy of all UK countries.

A number of studies and research projects have been commissioned to try to identify the key indicators and factors that are creating and reinforcing these inequalities, and what sorts of interventions would work best to try and reduce or eradicate them altogether. It is hoped that by conducting research, and compiling data, policymakers can use this to identify groups and geographic areas where health inequalities are significant, and to intervene to reduce them, with data to help back up and evaluate the effectiveness of these interventions. In Scotland, work is being done by a number of organisations including the Scottish Government, Glasgow Centre for Population Health (GCPH) and Public Health Innovation Network Scotland (PHINS).

What indicators and factors are being measured?

Income inequality has a related impact on health inequalities, and the scale of low pay is significant. The relationship between health inequalities, poverty and household income is one which has been explored at length and is often highlighted as one of the main factors which influences health inequalities. Studies which look at income, and also at relative levels of deprivation can provide useful comparison points, with comparable datasets on employment status and income readily available at a national and local level. Data also considers trends over time, comparing pre- and post-economic crash data, as well as relative earnings and expenditure relative to inflation and the rising cost of living. Other factors include age (those under 25 and earning a lower minimum wage for example) and by gender, with more women in lower paid, lower skilled and part time or insecure work.

How usable is the research being created?

The research which examines health inequalities explores a whole range of interrelated factors, and highlights just how complex the landscape of inequalities is. Creating a clear and holistic picture of all of the factors which contribute to health inequalities is not easy. Many studies, while detailed and effective, are niche, and focus on a very limited number of factors across a limited demographic source. As a result, questions have been raised about the utility of this research and its applicability and scalability at a national level. In an attempt to tackle this, combined data sets are being produced which provide opportunities for comparison across data from a range of studies.

The “Triple I” tool from NHS Health Scotland is designed to help policy designers to create effective interventions to reduce health inequalities. A second edition of the tool is due to be released in 2018/19. Triple I aims to provide national and local decision makers with practical tools and interpreted research findings about investing in interventions to reduce health inequalities in Scotland. It does this by modelling the potential impact of different interventions and policies on overall population health and health inequalities.

 

What can be done to act on the data?

While the research being produced is high quality, and thorough in relation to findings, the real question is what can actually be done with the research, and what steps can policymakers and practitioners take to use the findings to inform their own practice.

There are, researchers suggest, significant opportunities presented by the recent research which has been done on income inequality. In particular, they cite the public sector and public sector pay as a key way to reduce the income, and therefore the inequality gap, particularly among higher earners and those who would be considered “working poor” or “just about managing”. In Scotland, significantly more people are employed in the public sector than in any other part of the UK, and there is, researchers suggest, an opportunity to better align and increase low wages to help to reduce the gap.

The adoption of new initiatives, such as the “housing first model”, which is due to be rolled out in Glasgow to help homeless people break the cycle of homelessness, are also opportunities not only to address inequalities, but to ensure that long term help and support is in place to prevent any relapse into chaotic or risky behaviour. In relation to housing first, the savings on front line services such as emergency admissions to hospital, or contact with the police after committing a crime are significant, and while more in depth research is needed to create a full cost benefit analysis model of the scheme and its effectiveness, early studies show that the impact on health and wellbeing on those who had previously been homeless is huge in terms of reducing inequalities and improving wellbeing. However further data on homelessness in Scotland shows how far we have to go, and that housing first is only one mechanism which can be used to begin this process of reducing inequalities among the most and least deprived communities in Scotland.

Alternatively, some have suggested a more radical overhaul of how we distribute welfare and wealth within the country. Research has been coming thick and fast on the subject of a “citizens basic income”, particularly following the trial which was rolled out in Finland (the findings of which have not yet been published). Research on how this could impact on inequalities is not widespread yet, as pilots have been small scale, However, it is suggested that a total overhaul of welfare, replacing it instead with a citizen’s basic income would be a more effective way to reduce inequalities across the board, including in health.

Summing up

Health inequalities are significant in Scotland. Much of the research focuses on the impact of deprivation, poverty and low income on health inequalities and how, in order to tackle health inequalities in Scotland we must also tackle some of the other significant social problems within our communities, including low income and insecure work, and the impact of homelessness or chaotic lifestyles on health.

Data can be used in a number of ways to help inform policy decisions, some more radical than others. But creating a complete understanding of inequality in Scotland is challenging. It is up to researchers and policymakers to work together to create a better understanding of the conditions and factors which contribute to inequality, and what can be done to help tackle systemic and entrenched inequalities in our communities through policy levers and evidence based policy making.

If you liked this article you may also be interested in:

Universal basic income: too good to be true?

A world of evidence … but can we trust that it is any good?

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Health Champions – “unlocking the power of communities”

Health Cubes_iStock_000022075266Large

By Heather Cameron

“On the societal level, we must understand that health is not an individual outcome, but arises from social cohesion, community ties, and mutual support.” Dr Gabor Maté

Health inequalities have long been an issue in the UK and despite continuous government commitment to tackling them, they continue to persist.

It is estimated that avoidable illness costs around £60 billion and that 1 in 4 deaths are preventable with the adoption of healthier lifestyles. Calls have therefore been made for radical changes in the approach to public health by improving health and wellbeing outside of the core public health workforce.

This is just the approach of the Community Health Champion model, developed by Altogether Better, which has demonstrated not only the positive impact on health but the social value of such an approach.

What are health champions?

Health Champions are volunteers from all walks of life who are provided with accredited training and support so they can undertake health promotion activities within their communities to reduce health inequalities and improve the health of the local population.

The Community Health Champion role began as a five year Big Lottery Funded programme (Wellbeing 1) in 2008. Over 18,000 Health Champions were recruited, trained and supported between 2008 and 2012, reaching over 105,000 people.

Through a combination of their training and own personal experiences, these volunteers empower and encourage people within their families, communities and workplaces to take up healthy activities, create groups to meet local needs and can signpost people to relevant support and services.

Challenges

While Wellbeing 1 succeeded in reaching many people in need, the programme also raised two specific challenges: in almost all cases, the work being done was invisible to the NHS; and securing ongoing funding to continue the support was difficult.

Peer support was later identified as the most appropriate way of trying to connect communities with health services.

Following this recognition and the success of the original model, further lottery funding was awarded to develop the Champion model and use it to engage champions, communities and health services (Wellbeing 2).

Co-production of health and wellbeing outcomes

The model was applied to health services specifically with the aim of addressing the apparent disconnect between the NHS and community-based services. It helps connect both patients with support in their communities and professional practices with those communities.

Many citizens have volunteered in different ways and in different settings. These include:

  • Practice Health Champions working closely with their General Practice to create new ways for patients to access non-clinical support
  • Youth Health Champions where children and young people are recruited, trained and supported to help young people more actively engage with and influence their own and their community’s health
  • Pregnancy and early years Health Champions who are interested in giving children a better start
  • Health Champions working within a specialist, hospital-based NHS service
  • Senior Health Champions who engage with older people, offering a complimentary approach to more formal programmes

Community-based health improvement initiatives such as this could help to strengthen community-professional partnerships and cross-collaboration among health, social and other services. And this in turn could lead to a reduction in health inequalities.

Positive outcomes

According to a recent evaluation of the Health Champions programme, Wellbeing 2 has resulted in a range of benefits:

  • 86% of champions and 94% of participants in the programme reported increased levels of confidence and well-being;
  • 87% of champions and 94% of participants in the programme acquired significant new knowledge related to health and well-being;
  • 98% of champions and 99% of participants in the programme reported increased involvement in social activities and social groups;
  • 95% of practice staff involved with the programme would recommend it and wish to continue.

Other benefits included reduced social isolation, increased levels of exercise/healthy eating and feeling physically better. One champion reported “this has helped me more than any medication might.”

Success stories  include the work of a cycle champion who has improved her own health and wellbeing, encouraged over 70 other people to improve theirs through taking up cycling, provided cycle training to over 50 people in 6 community groups and provided specific detailed help to 5 people.

Other successes have involved volunteers setting up football training, providing support to women with mental health issues, providing advice and support to ethnic minorities and providing advice on healthy eating.

In terms of monetary value, an  analysis of the social return on investment (SROI) of a series of Altogether Better project beneficiaries found a positive SROI of between £0.79 and £112.42 for every pound invested, highlighting the potential value of these initiatives to funders.

Final thoughts

At a time of increasing demands on health services and with the relentless squeeze on public sector resources, perhaps the move towards greater community empowerment and collaboration across sectors is the right one. After all, as I’m sure we’d all agree, prevention is better than cure.


If you liked this blog post, you might also want to read Heather’s earlier post on social prescribing

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Public health in Scotland … problems and solutions

scotpho logoBy Stacey Dingwall

On Friday 11 September 2015 I attended the annual seminar of the Public Health Information Network for Scotland (PHINS) at Glasgow Royal Concert Hall. Now in its 16th year, the event provides an opportunity to keep up to date with the latest developments in public health related issues and research at both the local and national level.

This year’s sessions were focused around two themes: health inequalities in Scotland, and active travel.

Health inequalities in Scotland: causes and interventions

The first speaker of the day was David Walsh of the Glasgow Centre for Population Health (GCPH). David outlined the findings of research he’s been involved in, looking at explanations for excess mortality in Scotland compared to the rest of the UK and Europe, and in Glasgow particularly. Currently, there are still 5,000 ‘extra’ deaths in Scotland than in England each year, i.e. excess mortality.

The session particularly focused on the findings of the 2013 study, Exploring potential reasons for Glasgow’s ‘excess’ mortality: results of a three-city survey of Glasgow, Liverpool and Manchester. These three cities are home to the highest levels of deprivation in the UK and consequently, the lowest life expectancies, with Glasgow being the worst of the three. David explained that over 40 potential causes for this were synthesised as part of the research, with the following identified as among the most plausible explanations:

  • The scale of urban change post World War 2 had a larger impact on Glasgow, in the form of slum clearances, the construction of poorer housing and large amounts of high rise flats, and limited investment in maintenance of this housing.
  • The ‘socially selective’ new towns programme created social divisions, with only the wealthier and higher-skilled able to move there.
  • Different responses at the local political level – Manchester and especially Liverpool vehemently resisted the Conservative policies of the time, however this was not the case in Glasgow.

The morning also saw a presentation from Jim McCormick from the Joseph Rowntree Foundation (JRF) on rising poverty levels in Scotland and the UK since the recession. Jim suggested that the increasing casual nature of work now seen in the UK is what is driving the rise of poverty. He highlighted the hourglass shaped economy we now have, due to the disappearance of mid-level semi-skilled jobs alongside a rise in higher- and lower-skilled jobs.

An analysis of whether a National Living Wage would bring different groups up to the JRF’s annual Minimum Income Standard by 2020 was also presented; according to their findings, the only group that will be close to it is single people without children.

Physical activity and active travel in Scotland and the UK

The first session after the break saw another presentation from GCPH – this time from Bruce Whyte on trends and challenges in active travel in Scotland (i.e. walking and cycling).

It was highlighted that travelling by car remains the most popular mode for people to travel to work, despite the fact that most of the journeys undertaken are short (i.e. less than two miles long). Bruce highlighted successful initiatives in this area in Glasgow, however, including the cycle hire scheme and the development of the Kelvingrove-Anderston cycling and walking route, on which GCPH published a report earlier this year. His presentation included comment from those who use the route on its health and safety benefits, and it was suggested that its success has led to impetus for similar projects in the city.

The following presentation came from Niamh Shortt of the Centre for Research on Environment, Society and Health (CRESH) at the University of Edinburgh. She looked at the findings from research into whether the physical environment has an impact on inequalities in physical activity and active travel. Tying in with the first theme of the day, this session noted the impact of health and income inequalities on physical activity rates and travel mode choices.

The morning was rounded off by Stuart Hay of Living Streets Scotland, a charity working to promote the benefits of walking and ensure that the country’s streets are fit to do so. Stuart praised the work of the Scottish Government in this area, highlighting the development of a separate walking strategy for the country. He concluded that we have the policy infrastructure in place, and it’s now time to ensure it is implemented.


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Read our other recent articles on public health issues:

The Idox Information Service can give you access to a wealth of further information on health inequalities and active travel, to find out more on how to become a member, contact us.

Is 20 plenty? The evidence for lower speed limits

20mph

Image from Flickr user Edinburgh Greens via Creative Commons License

By Donna Gardiner

This week (18-25 May) it’s Walk to School Week – where parents and children are encouraged to leave the car at home and experience the benefits of walking to and from school.

The campaign is particularly important given recent evidence which suggests that the number of children who walk to school is falling. The most recent Department for Transport National Travel Survey found that only 42% of children walked to school regularly in 2013, compared to 47% in 1995/97. Indeed, Britain has one of the lowest levels of children walking or cycling to school in Europe.

A recent YouGov survey of 1,000 parents of five- to 11-year olds in Great Britain found that speeding traffic was the main reason that parents no longer let their children walk to school. In particular, 39% felt that school-run traffic was dangerous. Almost two-thirds reported that they would like to see car-free zones outside both primary and secondary schools, as well as 20 mph speed limits in surrounding areas.

20 mph limits and zones

The introduction of 20 mph speed limits and zones has received widespread interest of late, with a number of large schemes, such as the one planned in Edinburgh, capturing the headlines. The Edinburgh scheme is particularly notable for its scale. It covers over 80% of the city’s roads – effectively making 20 mph the default speed for all of its urban areas. Implementation is due to start in late 2015.

At the other end of the UK, the London Borough of Hackney has this week begun the rollout of its own 20 mph scheme, through which more than 99% of the borough’s roads will become subject to 20 mph limits by October 2015.

The Edinburgh and Hackney schemes join a host of others across the UK, including those in inner London, Liverpool, York, Bath, Bristol, Manchester, Newcastle, Brighton, Oxford and Glasgow.

Support for further implementation

Numerous campaign and road safety groups have called for the greater implementation of 20 mph zones and limits across the UK, including the Royal Society for the Prevention of Accidents (RoSPA), Sustrans, the Campaign for Better Transport, CTC – the national cycling charity, 20’s Plenty for Us, The Slower Speeds Initiative and the European Transport Safety Council (ETSC).

The UK Government have also shown support for the wider implementation of 20 mph zones and limits. In 2013, they published revised guidance to make it easier for local authorities to implement 20 mph limits and zones in their areas, and earlier this year, new guidance which further supports 20 mph limits was published by Transport Scotland.

There is also clear evidence of the public’s desire for lower speed limits. A recent YouGov survey found that the majority of respondents supported the introduction of 20 mph speed limits in residential streets (65% support or strongly support) and busy shopping areas and busy streets (72%). Improved road safety and children’s safety were the key reasons for this, along with other reasons – such as making our streets more pleasant to live in, encouraging more walking and cycling, reducing noise and improving the quality of life.

The YouGov survey echoes the findings of the British Social Attitudes Survey 2013, which found 68% of people to be in favour of 20 mile per hour speed limits in residential streets.

Talking of the Hackney scheme, Cllr Feryal Demirci, Cabinet Member for Neighbourhoods and Sustainability, Hackney Council neatly summarises the anticipated benefits of 20 mph zones:

“We strongly believe this 20 mph rollout will be better for everyone. It will mean a safer, calmer and more liveable neighbourhoods for all residents, leading to more walking, cycling and playing outside, which in turn will have a positive impact on health and the community.”

Evidence of the benefits

But does the evidence support these anticipated benefits?

One of the most commonly cited benefit of lower speed limits is improved road safety, resulting from a reduction in the number and severity of collisions. There is widespread evidence that this is the case – for example, research published in the BMJ in 2009 concluded that 20 mph zones were effective measures for reducing road injuries and deaths. Specifically, their introduction was associated with a 41.9% reduction in road casualties, with the effect being greatest in younger children and for the category of killed or seriously injured casualties.

Similar findings have been reported elsewhere, for example, in a review of evidence reported to the London Road Safety Unit, in research by the DfT and by the SWOV Institute for Road Safety Research.

There is also evidence that lower speed limits may help to tackle health inequalities. This is because children and young adults are more at risk of road traffic accidents within poorer localities than in richer urban neighbourhoods. Indeed, in January 2014, Danny Dorling, Halford Mackinder Professor of Geography at the University of Oxford, went as far as to claim that implementing 20 mph speed limits was the main way in which local authorities could effectively improve the health of the local population and reduce health inequalities.

Similarly, research published in the Journal of Public Health in 2014 reported that targeting 20 mph zones in deprived areas may be beneficial. It also concluded that “20 mph zones and limits were effective means of improving public health via reduced accidents and injuries”.

Improved public health is another often cited benefit of lower speed limits. Evidence from Bristol and Edinburgh demonstrates that 20 mph zones do indeed encourage increased levels of physical activity, including walking and cycling, and there is also evidence that they improve resident quality of life, through increased opportunities for social interaction and less noise and air pollution.

The reduced levels of pollution also mean that lower speed limits can be better for the environment.

Finally, there is also some evidence that 20 mph zones may result in increased local economic activity – with improved walking environments having many potential benefits for local business. Research conducted by Living Streets in London also found that pedestrians tended to spend more than those arriving by car.

Driver concerns and attitudes

Despite the evidence in their favour, 20 mph zones are not always welcomed with open arms. There remain a number of concerns about the implementation of 20 mph zones, including fears that they may lead to increased levels of congestion, increased carbon emissions, suffer from a lack of enforcement, increase journey times, and increase emergency response times.

Most of these concerns have been countered by research evidence; however, attitudinal barriers remain. In an analysis of a YouGov survey of public attitudes towards 20 mph zones, Professor Alan Tapp of UWE Bristol, reports that a sizable minority of people (31%) claim that ‘If a 20 mph speed limit is introduced, I may not stick to it’. He also points out that 49% felt that ‘It is just too difficult to stay at 20 mph’ and almost a third of people (30%) thought that 20 mph is an example of a nanny state.

The way forward

So despite the progress that has been made, there is clearly still some way to go before 20 mph limits and zones become a fully accepted part of UK towns and cities. Implementing more 20 mph limits is only the start – it seems that there is also a need for local authorities to tackle the negative perceptions of 20 mph zones held by many drivers in order to ensure that 20 mph limits are adhered to in practice.

Sharing evidence of the positive benefits of 20 mph zones and demonstrating that many of the main concerns associated with them are ill-founded is likely to play an important part in encouraging more positive attitudes, changing driver behaviour, and in turn, make streets safer and more enjoyable for children and adults alike.


 

The Idox Information Service can give you access to further information on improving road safety. To find out more on how to become a member, contact us.

Further reading:

Addressing health inequalities: five practical approaches for local authorities (Perspectives in Public Health, 2014)

Reducing unintentional injuries on the roads among children and young people under 25 years (Public Health England, 2014)

Road safety and public health (The Royal Society for the Prevention of Accidents, 2014)

Achieving safety, sustainability and health goals in transport (Parliamentary Advisory Committee for Transport Safety (PACTS), 2014)

Unlimited aspiration for a calmer city (speed limits) (Local Transport Today, 2011)

Sign of the times (20 mph speed limits in Portsmouth) (Parking Review, 2010)

Review of 20 mph zone and limit implementation in England (Department for Transport, 2009)

Public Health Information Network for Scotland (PHINS) – 14th Seminar

Image of outside of the Glasgow Royal Concert Hall.

Image by Neil Turner under Creative Commons License, via Flickr

By Steven McGinty

On the 10th October I attended an annual event organised by the Scottish Public Health Observatory (ScotPHO) in the Royal Concert Hall in Glasgow. The event focused on health inequalities and the factors driving them. It brought together individuals from a variety of areas, including academia, public health organisations, local and central government, and the voluntary sector to review current evidence, highlight upcoming research and debate key issues with fellow professionals. Continue reading