Health promotion in prisons: Whose health is promoted?

Prisons are providing a public service that meets fundamental needs of society. They increase the feeling of safety, punish offenders for their crimes and work on the rehabilitation and reintegration of prisoners into communities. In Scotland, nine offender outcomes have been promoted by the Scottish Government. They are:

• Sustained or improved physical and mental well-being
• The ability to access and sustain suitable accommodation
• Reduced or stabilised substance misuse
• Improved literacy skills
• Employability prospects increased
• Maintained or improved relationships with families, peers and community
• The ability to access and sustain community support, including financial advice and education
• The ability to live independently if they choose
• Improvements in the attitudes or behaviour which lead to offending and greater acceptance of responsibility in managing their own behaviour and understanding of the impact of their offending on victims and on their own families

These offender outcomes include a number of aspects relevant to the health of prisoners and the community in general.Promoting health-related offender outcomes are not only a pledge by the Scottish Government. The United Nations (United Nations, 1966) and the European Union (Council of Europe, 1993) had previously declared that it is a fundamental right of prisoners to be offered a standard of care equivalent to that available in the wider community (Møller, Stöver et al 2007).

Indeed, from a public health perspective, prisons play a considerable role in improving health and reducing health inequalities. This role is summarised in three bullet points (Møller, Stöver et al 2007):

• Good prison health is essential to good public health;
• Good public health will make good use of the opportunities presented by prisons; and
• Prisons can contribute to the health of communities by helping to improve the health of some of the most disadvantaged people in society.

The main reason for the high relevance to public health is that the vast majority of prisoners come from deprived, poor or otherwise marginalised backgrounds (Møller, Stöver et al 2007). Further problems are added by the likelihood of not having any qualifications, accommodation, or employment. They tend to have a history of drug and/or alcohol misuse and mental health problems (Ministry of Justice 2010). These problems are pervasive across all prisoners but especially exaxerbated in female prisoners. People from such backgrounds are likely to have worse health than the population norm and oral health is no exception. It turns out that after drugs/alcohol abuse, mental health issues, oral health is the third biggest health problem in prisons.

Prisons, therefore, provide a valuable opportunity to reach and enage some of the most disadvantaged groups in society and thereby addressing health inequalities and wider determinants of health on an individual and wider population level (Hayton 2007).

Click on the picture to check out the blog from which this image was taken!! Very interesting!

Providing health care in prisons, however, is riddled with difficulties. The main challenges are posed by the prisons’ primary focus on security and the mobility of prisoners. Security concerns relating to individual prisonser or the entire establishment, for example, can stop health care provision or access to health care at any time. Additionally, prisoners are often moved within establishments or released on short notice and thus also interrupting their health care provision.

For the latter reason it may be helpful to know more about relevant prisoner characteristics. The following statistics were all taken from the Ministry of Justice (2010) evidence report on offenders.

Prisoners significantly differ from the general population in various characteristics, many of which relate to their early years. These characteristics may influence the likelihood of offending and reoffending. They are:

• Offenders are more likely to come from disadvantaged backgrounds, for example to have witnessed violence in the home as children, experienced early contact with the criminal justice system, and suffered from addiction problems as children than the general population
• Offenders are more likely to have been a regular truant and to have been excluded from school compared to the general population
• Children who become prolific young offenders typically suffer from harsh or neglectful parenting and develop behaviour difficulties at an early age
• Offending can be passed down through generationsand this has also been found internationally

The average age of first offenders is 15. The likelihood of offending peaks between 14 and 16 years of age and then declines. Around 28 per cent of the juvenile prison population and 15 per cent of the adult prison population are held on remand.

Within one year of release, almost 50% of ADULT offenders are imprisoned again. This rate rises to 61% for offenders on sentences of up to one year.  The probability of reoffending one year on or later levels off considerably. Reoffending rates also vary greatly from prison to prison, depending on the mix of offenders housed by different catergories of prisons.

Reoffending rates, naturally, also differ between prisoners. Only 2% of offenders, for example, account for 25% of proven offenses committed by the entire offender population. But even the less prolific offenders have a high chance of reoffending. Indeed, three out of four prisoners will reoffend within nine years, irrespective of their initial offense. The most serious offenders generally have the lowest reoffending rates.

It seems to me that based on these statistics, it is difficult to speak about prisoners or inmates as one group. Yet, in public debates, differentiations are rarely made. In a way, this is another example of the Inverse Care Law as prisoners on shorter sentences receive few interventions but tend to be the ones with higher reoffending rates.

It is difficult to deliver rehabilitation programmes to prisoners serving sentences shorter than 12 months. Yet, it is these offenders, on remand or short-term sentences, who account for the vast majority of offenses. Almost 9 out of 10 prison sentences given to the two per cent of offenders who have been convicted of more than 75 previous offenses were for less than twelve months. Additionally, short and long-term prisoners are often moved between prisons for various reasons. These transitions also make it difficult to provide rehabilitation-focused interventions, particularly if they were to be tailored to individual prisoners’ needs, which evidence emphasises as an important component of prisoner-focused interventions. (Ministry of Justice 2010). This situation increases the need to focus on through care and prisoner resettlement upon release, which have also shown to reduce reoffending rates.

It also makes me wonder why the socio-demographic characteristics of the population is not reflected in the prison population. Why are over 80% of prisoners from lower socio-demographic backgrounds?

Working in health research, I am usually confronted with health inequalities, which are present here as well. It strikes me, though, that the over-representation of people from lower socio-demographic backgrounds in prisons is a symptom of  social injustice at work. I am not  making excuses for offenders, far from it. Yet, the social make-up of the prison population appears odd.

Also, what do these statistics mean in terms of using prisons for prevention, treatment and rehabilitation of offender’s physical, emotional, and mental health and in turn making the communities safer?

How best to access this line of thought?

Maybe Amartya Sen will manage to help me clarify my idea of justice:

References:

Council of Europe (1993). 3rd general report on the CPT’s activities covering theperiod 1 January to 31 December 1992. Strasbourg, Council of Europe (CPT/Inf(93) 12).

Hayton, P. (2007). Protecting and promoting health in prisons: a settings approach. In L. Møller, H, Stöver, R. Jürgens, A. Gatherer and H. Nikogosian (Eds). Health in prisons: A WHO guide to the essentials in prison health. Copenhagen: WHO Regional Office for Europe, pp 15-20. Retrieved from http://www.euro.who.int/en/what-we-publish/abstracts/health-in-prisons.-a-who-guide-to-the-essentials-in-prison-health

Ministry of Justice. (2010). Green Paper Evidence Report – Breaking the Cycle: Effective Punishment, Rehabilitation and Sentencing of Offenders. London: Crown. Retrieved from http://www.justice.gov.uk/consultations/docs/green-paper-evidence-a.pdf

Møller, L.; Stöver, H., Jürgens, R., Gatherer, A. and Nikogosian, H. (2007). Health in prisons: A WHO guide to the essentials in prison health. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/en/what-we-publish/abstracts/health-in-prisons.-a-who-guide-to-the-essentials-in-prison-health

United Nations (1966). International Covenant on Economic, Social and CulturalRights. Geneva: Office of the United Nations High Commissioner for Human Rights. Retrieved from http://www2.ohchr.org/english/law/cescr.htm

Oral health promotion for people in prisons or experiencing homelessness: Assessing readiness for change

Outline of a strategy to support oral behaviour change in people in prison or experiencing homelessness

Assessing readiness to change Patients’ compliance with advice on oral health care is dependent on a range of factors such as perceived susceptibility, the potential severity of the condition, the ‘costs’ to the individual of making changes etc. (Health Belief Model: Rosenstock, 1974). Bringing about lasting and effective changes in health behaviours is not about manipulating patients and getting them to do what we, the health professionals, want. Rather it is about exploring the patients’ attitudes and values in relation to their own oral health and encouraging them to identify and express their own dental health needs, as well as empowering them to make any necessary changes in their own lives (Jacob and Plamping, 1989).

Behaviour and behaviour change are complex processes. There is no simple method or strategy to predict or change behaviour. However, the more complex a process is, the more important it is to explore it from different perspectives. One role of service providers is to identify behaviours which may negatively impact oral health, assess the patient’s state of readiness to change, and provide the appropriate level of help and support from the interventions available and enable the client to make the necessary changes. In order to improve understanding and facilitation of behaviour change, it is helpful to view this process from multiple perspectives. Fortunately, service providers are able to utilize a range of evidence-based tools to guide and inform this quest. Of particular interest to health promotion is the combination of tools to combine their effects on patient or client behaviour.

Promoting oral health and facilitating healthy behaviour change in people experiencing homelessness/prisoners is such a complex process, which may well be informed by behaviour change techniques. Overall, people experiencing homelessness/prisoners tend to have worse oral health than evident in the population as a whole. Nevertheless, among this population group there are vast differences in the oral health status as well as the readiness to adopt oral health behaviours.

Developing oral health interventions based on behaviour change models supports service providers in tailoring health messages or interventions to fit individuals or groups of people sharing the same characteristics. Some behaviour change models can be used to identify areas of interventions, for example how an individual perceives the threat or severity of oral ill health. Other approaches are useful in identifying an individual’s readiness for change, including whether or not they are aware of oral health threats. A third set of behaviour change models provide guidance for increasing the likelihood of healthy behaviour changes being implemented. An example of each type of model is discussed below.

Working with client knowledge and beliefs

The Health Belief Model is a widely used approach to elucidate an individual’s thoughts and attitudes about a health issue. Using the model, a service provider explores a patient or client’s socio-demographic circumstances. Together they further explore both how susceptible this person thinks s/he is to experience oral ill health and how serious or severe the impact of oral ill health would be for them.

Personal circumstances and client perceptions help to gauge the client’s perceived level of threat from oral ill health. Information about the client’s personal circumstances combined with his or her perceived threat from oral ill health are helpful in outlining benefits and costs of adopting or maintaining oral health behaviour. A further influence on oral health behaviour stems from various cues to actions clients encounter. These cues can originate in physical symptoms like pain, oral health promotion, or from any other source. Once all this information, as well as potential cues to action, have been identified and discussed, service provider and client usually have a good idea of how likely a client will engage in oral health behaviour.

Perceived threat of oral ill health

Assessing client readiness for change

As demonstrated, the Health Belief Model is useful in identifying a client’s thoughts, beliefs, and perceptions of health issues. Sometimes, however, clients do not have sufficient knowledge about or experience with oral health matters to form beliefs and perceptions. The Precaution Adoption Process Model does not rely on a client’s level of previous engagement with oral health matters. Instead, using this model enables the service provider to focus on work with clients regardless of whether they are utterly unaware of oral health matters or whether they have stopped looking after oral cavity. The Precaution Adoption Process Model identifies seven stages ranging from ignorance of a health issue to routinely engaging in healthy behaviour.

Depending on the stage they are at, clients show different patterns of behaviour. People on different stages also experience different facilitators and barriers to behaviour change. Clients unaware of an oral health threat (Stage 1) are likely to not to have a previously formed opinion on this threat. The first step towards adopting healthy behaviour in this client group is to raise awareness of the consequences of their (lack of) oral hygiene strategies. Other clients may be have heard of the health threat and may be starting to form beliefs (Stage 2). At the time, however, they do not yet feel threatened by oral ill health. The service provider’s task is to evoke in the client a sense of personal relevance of the health threat. A further group of clients is in the process of deciding whether or not to adopt preventive oral health behaviours (Stage 3). Usually, at this stage, clients have some level of personal or vicarious experience with oral ill health. This stage is particularly important as clients decide either to act or not to act. The service provider’s key role is to facilitate the decision-making process with effective communication and the use of available resources.

Good communication is essential at this stage, as the service provider needs to distinguish between clients who have not yet made a decision and those who did. Clients who made a decision, may have considered the available information and decided not to act for whatever reason (Stage 4). They will be protective of their decision and resistant to attempts at persuasion or the provision of additional information. This group will be better served with Motivational Interviewing.

PAMP-STSA INTERVENTIONS

Clients who decided to act (Stage 5) are usually grateful for any resources, information or advice to support taking action. Any resources or information they receive will influence the nature and extent of their oral health strategies (Stage 6). At this stage, they are usually appreciative of support. Once clients have started to engage in oral health behaviours they, maybe with support of their service providers, will be keen to turn the healthy behaviour into persistent habits (Stage 7) and, ideally, develop strategies to counter potential relapses.

Supporting clients in making changes

Regardless of what stage of change readiness the client is at, the service providers is always well served by applying one of a third set of behaviour change models aimed at facilitating the implementation of healthy behaviour. Two particularly effective approaches in terms of increasing the likelihood of implementing changes and overcoming barriers are the Implementation Intentions approach and Motivational Interviewing.

Implementation Intentions

The Implementation Intentions rests on the understanding that simply setting goals or making resolutions does not necessarily mean that these are achieved. In fact, they rarely are. The Implementation Intentions model asserts that stating if/when-then plans, which link situational cues with the explicit stating of desirable goals (engaging in oral hygiene activities). This linkage facilitates the taking of healthy action by providing cues to action. For example, an oral health focuses implementation intention could be that (homeless: before I climb into my sleeping bag I will take the tooth brush, put toothpaste on and brush my teeth for two minutes) (Prison: after my shower I will take the tooth brush, put toothpaste on and brush my teeth for two minutes). The more personalized detail, within reason, that can be added to this scenario the better. Although very simple, this technique counters common barriers to act, including simply forgetting to act, not being aware of opportune times, having second thoughts at critical moments, giving in to temptations, reverting to old habits, or finding excuses due to momentary distress.

Motivational Interviewing (MI)

“A directive client-centred counselling style that is designed to assist clients in exploring and resolving ambivalence to increase motivation for change” (Noonan and Moyers, 1997)

There will be times when regardless of the information you provide of the harmful effects on dental health your client will continue with their current patterns of oral health related behaviours. A part of them may want to change while another part is quite resistant to change. They may access the health related resources offered to them but also indicate their current dental behaviours are acceptable to maintaining oral hygiene. These confusing messages can be described as ambivalence and are a natural occurrence in the change process, which should not be interpreted as a sign of unwillingness to change, denial or resistance.

MI is a process which can be undertaken alongside your client in order to help them progress from feelings of ambivalence toward action and change (Figure x). This approach is based on for general principles. They are expressing empathy, supporting self-efficacy, rolling with resistance, and developing discrepancies in where a client is and wants to be.

Expressing empathy

Being empathic means to walk in the client’s shoes or see the world through their eyes. Client’s who feel that a service provider understands their situation find it easier to open up and share their experiences. The more open and honest a client is the more information service providers have at their disposal and the more they can anticipate facilitators and barriers to healthy behaviours. Moreover, clients who feel they are understood find it easier to explore their ambivalence about change and show less inclination to defend their beliefs and actions.

Supporting self-efficacy/affirmations

Clients often have low confidence in their ability to consistently engage in healthy behaviour. MI is used to build self-confidence and sustain client motivation, for example with the use of affirmations. Recognising and emphasising client strengths, even if unrelated to oral health, is a useful way to build confidence in clients. Affirmations allow service providers to communicate to the client that change is possible and that they have already demonstrated capable behaviours. Affirmations must be sincere or they risk damaging the relationship with the client.

Rolling with resistance

If a client shows resistance to any part of the process, the service provider does not address this unwillingness but, instead, rolls with it. S/he does not challenge but accepts the nature or reason for the client’s resistance. However, the service provider continues to explore the client’s point of view and encourages them to find their own solutions or ways forward.

Developing discrepancies

Rolling with resistance, for example, is used to identify and develop discrepancies between current behaviours and behaviours that help the clients achieve their goals. Once such discrepancies are established in a way that is not discouraging but motivating, they stop being problems and become motivators.

Communication strategies in MI

MI encourages service providers to engage in five simple but not always easy communication strategies. 1) Asking open ended questions, 2) listening reflectively, 3) affirming client difficulties, 4) summarising periodically, and 5) supporting the client in eliciting self-motivational statements.

Open ended questions

Questions are open ended if they cannot easily be answered with a simple response e.g. “yes” or “no”. By adopting this questioning style, clients provide information about their current views and thoughts, which will inform further discussions. Typically, open questions start with phrases such as “Why…” “How…” or “Tell me about…”

For example:

CLOSED QUESTION

How often do you brush your teeth? Elicits a number response

OPEN QUESTION

Tell me about your tooth-brushing routine? Elicits an open narrative.

In MI, open questions are often used to review a client’s typical day; to revisit past experiences or their thoughts about the future; to list helpful and problematic aspects of current behaviour, or to discuss the stages of change (see PAPM).

Listening reflectively

A key aspect of MI is being able to listen carefully to the client. There are many different levels of reflective listening. They share the aim of indicating clear interest to the clients while allowing them to remain the ‘driver’ of the conversation. Reflective listening is particularly helpful when ‘rolling with resistance’.

Simply repeating what clients say helps to reduce resistance by acknowledging that they have been understood. Repeating client statements can be done in four ways:

• Repetition – simply repeating an element of what the client said.

• Rephrase – rewording for the purpose of clarification.

• Paraphrase –interpreting the meaning of what is said and reflecting this in one’s own words, thus extending the conversation.

• Reflection of feeling – the deepest form of reflection, a form of paraphrasing that emphasises the emotional dimension through feeling statements, metaphors etc.

Amplifying or exaggerating a client’s statement is sometimes helpful in order to illicit a response. This technique should not be over-utilised as this can make the client feel mocked or patronised thus eliciting an angry reaction.

Reflection can also be used to highlight contradictions between current and past statements made by the client.

Affirming client strengths

As indicated above, recognising and emphasising client strengths, even if unrelated to oral health, is a useful way of building confidence in clients.

Periodical summaries

Service providers should frequently summaries they key points covered over the course of a conversation. This technique can be effectively adopted for a number of reasons e.g. draw attention to the key points discussed, shift attention to another topic, provide direction, etc.

Eliciting self-motivational statements

During conversations, clients are repeatedly encouraged to acknowledge and emphasise their strengths and resources. Discussing their future is a helpful tool in eliciting self-motivational statements.

Above all, the most important aspect of motivational interviewing is to ensure that good communication is maintained with the client. Whilst interacting with clients there are some basic principles to remember:

• Allow the client to convince you of the problem behaviour and of the need for change because: “I learn what I believe when I hear myself talk”.
• Avoid the Question/Answer Trap as you won’t be able to explore the clients behaviours or motivations for change
• Avoid Confrontation/Denial Trap where your client is not yet ready to change and you may have to explore other motivators and barriers or revisit the behaviour at a later time.
• Expert Trap – where as a health professional you provide the direction or solution without first allowing your client to determine his or her own goals, direction and plans.
• Avoid labels – labels often carry a certain stigma and can therefore have a negative impact on the conversation.
• Premature Focus Trap – focus too quickly on a solution without giving your client a chance to explore the issues which matter to them.
• Assigning Blame – it is important that you are clear before commencing motivational interviewing that there is no blame to assign.

http://motivationalinterview.org/clinical/interaction.html

Combating professional isolation: Connecting professionals via social and technological networks

Image Source: Jean-Guichard.com

One of David’s tweets pointed me to this blog by  George Siemens. He discussed the use of social and technological networks in education.  Reading his analysis, I realised that the very same principles are at work when trying to connect professionals with the aim of keeping them informed of new developments and learning from each others setbacks and successes.  

Paraphrasing George it is fair to say that online networking opportunities have transformed personal and professional lives. They nothing short of revolutionsed the way we learn, communicate, and interact with others. While some sectors have embraced these new opportunities, there are still many areas and professionals who either have yet been exposed to such networks or who have not had opportunities to make use of them in their line of work.  

Mirroring education in schools and Universities, their professional development events tend to still follow the traditional expert-centred template. Seminars, workshops or conferences are structured via a speaker system in which participation in one form or another is either encouraged or not. Either way, they remain a rather closed and localised way of learning and engaging.  

While face-to-face interaction and human contact are key factors in learning and (personal as well as professional) development, every internet user has access to experts and scholars irrespective of their geographical location or difference in time zones. To quote George Siemens, professionals (like or as students),  

“are not confined to interacting with only the ideas of a researcher or theorist. Instead, a student can interact directly with researchers through Twitter, blogs, Facebook, and listservs. The largely unitary voice of the traditional teacher [or any expert, speaker, etc.] is fragmented by the limitless conversation opportunities available in networks.”  

Using such networks allows for the ultimate tailoring of each person’s personal or professional development. While they allow for a bespoke approach for each individual user, they need to be set up, maintained and guided by someone with a fairly good understanding of the respective area of interest (i.e. the teacher in the education context).  

George suggested seven roles a teacher plays in a networked learning environment. Once more, I will stick closely to his portrayal of these roles, while applying them to the context of connecting professionals.  

These are the roles he suggested:  

1. Amplifying
2. Curating
3. Wayfinding and socially-driven sensemaking
4. Aggregating
5. Filtering
6. Modelling
7. Persistent presence  

Amplifying

Getting professionals engaged in any undertaking has more changes of success if information is accessible with a minimum of effort required to retrieve and forward it. Twitter, Buzz and similar services provide a means of doing just that. Each tweet has a maximum of 140 characters (roughly three lines), forcing the creater to convey information  in a concise manner. Within seconds a piece of information can be evaluated for its relevance. Usually, the tweet is accompanied by a shortened URL, which makes more comprehensive information accessible with only one extra click.  

Amplification comes in by retrieving this information and then re-tweeting it, thus making it available to others linked to the person sending the tweet. Information can be tweeted and then re-tweeted by the host of a network or by anybody else aligned to the network.  

Curating

The term curator is derived from the Latin words curare and cura, whose meanings include attending to, taking care of, or taking responsibilty for. Once more I quote George Siemens directly to convey the relevance of this concept to teaching (as well as connecting professionals):  

“An expert (the curator) exists in the artifacts displayed, resources reviewed in class, concepts being discussed. But she’s behind the scenes providing interpretation, direction, provocation, and yes, even guiding. A curatorial teacher acknowledges the autonomy of learners, yet understands the frustration of exploring unknown territories without a map. A curator is an expert learner. Instead of dispensing knowledge, he creates spaces in which knowledge can be created, explored, and connected…The curator, in a learning context, arranges key elements of a subject in such a manner that learners will ‘bump into’ them…As [professional] learners grow their own networks of understanding, frequent encounters with conceptual artifacts shared by the teacher [network host or other members] will begin to resonate.”   

Wayfinding and socially-driven sensemaking

When learning a new skill or engaging with a  new medium or area of interest the amount of learning required often appears daunting. However, with each step the terrain ahead becomes more familiar, even though the odd dead-end or detour will be encountered. Professional networks, through their structure and member input, provide valuable sign-posting in initial familiarisation as well as the development of subsequent expertise in a given field. Networks facilitate this process by filtering information and by emphasising salient information.  

Aggregating

In the days before the emergence of tools like Google Reader or other aggregation services, interested individuals had to visit  a number of different hompages by organisations, journals, blogs, etc. to remain informed of new developments. Services like Google Reader offer and individualised one-stop platform for this purpose. Rather than visiting different websites, these websites are linked to Google Reader. As a result, one visit to the Reader contains all the new information available on the linked websites.  

A professional network has the potential to function in a very similar way. Within this network, relevant sources of information can be linked, displayed, discussed, and amplified.  

Filtering

The above roles and functions of professional networks also help to somewhat safeguard its members from the danger of being inundated by information. In the same way as they collate relevant information, members’ also contribute to determining the boundaries of interest.  

Modelling

In the same fashion as a network’s membership collectively determines the boundaries of interest, the collective but also individual members function as role models in various ways. George Siemens alludes to the idea of apprenticeship learning and the process of becoming in this respect. I think he was referring to Deleuze and his concept of apprenticeship.  

A couple of years ago, a colleague and I published a paper applying Deleuzian ideas to Action Research. Some of these application also hold true for professional networks. In the following excerpt I simply replaced any reference to Action Research with professional networks.  

“Deleuze’s notion of an ‘apprenticeship to signs’ carries within it interrelated elements of meaning.   

‘Signs’ refer to the elements of the unfolding of events, both virtual and actual, with which the participants   

engage as part of their learning in a social or technological network. Learning is essentially concerned with signs.   

Signs are the object of a temporal apprenticeship, not of an abstract knowledge.  To learn is first of all to consider  

a substance, an object, a being as if it emitted signs to be deciphered, interpreted (Deleuze, 2000, p.4, emphasis in the original).  

   

The concept of ‘apprenticeship’ in this context does not mean ‘novice’ or ‘beginner’ in the conventional sense (although it may include that).   

As Deleuze in the quote above indicates, it refers to the educative aspect of being part of a network of professionals.   

An apprenticeship to signs embraces a necessary participative engagement with the substance of the network rather than   

‘bystander’ or ‘objective observer’ status.  Thus, as regards learning, it is not “do as I say”, but rather “do with me” (Deleuze, 1994, p.23).   

This relates to the minoritorian aspect of becoming the ‘friend’ of the problems discussed in the network through direct engagement.   

‘One becomes a carpenter only by becoming sensitive to the signs of wood, a physician by becoming sensitive to the signs of disease’ (Deleuze, 2000, p.4).   

Of course, direct engagement refers not only to participate but also to the overall management of a network.”  

The apprenticeship idea, particularly the modeling involved in learning, also plays a key role in Bandura’s social learning theory or in Roger’s innovation diffusion theory. Social or technological networks provide ample learning to learn from other participants in many different ways, either as active participant or passive recipient of the information and ideas addressed.  

Persistent presence

Well run and managed networks also provide a consistent presence for participants around the clock and without holiday or weekend brakes. As such, they provide information and access to other participants at any time. This constant availability provides flexibility but also reassurance as information is available as needed.  

Finally…

Social and technological netrworks based on or guided by these characteristics should make it possible for almost all professionals to avoid professional isolation and stay up-to-date on professional matters and beyond. The challenge is to construct networks, which are attractive, useful, manageable and sustainable.
  

  

 

Tackling health inequality and mental wellbeing in the community: Reflection on a project evaluation

The first impression I had when starting an evaluation of a project tackling health inequalities and mental wellbeing in a defined community was that the key terms are vague and – at least on first impression- not well defined. Hence, first challenge for the evaluation.

The project builds on changes to existing service delivery within the area, particularly on improved partnership working. Here is the second (and related) challenge, what does partnership working mean?

A look through the baseline data and relevant community surveys showed another interesting picture. 80% of the project area was classified as very deprived in Council and Government reports. However, survey findings indicate high satisfaction with most features of the area. The main problems appear to be drug use and prostitution but these were mentioned as problems by less than a third of the surveyed people. Also, some wellbeing scores (using WemWbs) were higher in this area than in one of the regions most affluent areas. Serendipitously, just this week a paper was published looking income and happiness in a global survey.

The authors write that  the level of income was a predictor of life evaluation but not so much of positive and negative feelings. These feelings were strongly related to the fulfillment of psychological needs, including learning, autonomy, using one’s skills, respect, and the ability to count on others in an emergency. They conclude that a person’s economic status and psycho-social evaluation predict different types of well-being. Interesting.

Partnership working in health care – Ontological and epistemological perspectives

Partnership working: What is it and how do we know it when we see it?

The following is a summary and reflection on Janette Pow’s PhD Thesis entitled “Assessing partnership working: Evidence from the National Sexual Health Demonstration Project“.  I had the honour of being one of her supervisors and I am now able to reap the harvest from her excellent work. All the substantial information provided is taken out of her thesis, which is an excellent read!! My only contributions are the odd comments and bridges.

Reference: Pow, J. (2010). Assessing partnership working: Evidence from the National Sexual Health Demonstration Project. Unpublished thesis: Napier University.

Partnership working has been a buzz word within health care and beyond for quite a while. Yet, defining partnership working is a “terminological quagmire” (Lloyd, et al 2001). Terms such as collaboration, cooperation, coordination, coalition, network, alliance and partnership are often used interchangeably within the same literature (Huxham 1996, Percy-Smith 2005 and Sloper 2004).  Indeed, the Audit Commission (2004) argued that “the term partnership is increasingly losing credibility, as it has become a catch all for a wide range of concepts, and a panacea for a multitude of ills”.

Thankfully, various systems to identify and evaluate partnership working have been developed. Overall, partnership working is likely also to involve a combination of social, political, environmental and health care factors (Baron-Epel et al 2003).  Various ways to characterise partnerships in more detail have also been suggested. For example, the Audit Commission (1998) differentiates between formal and informal partnerships, whereas Lasker et al (2003) distinguish between strategic and operational partnerships.

Wildridge (2004)  is one of many authors who provided  assistance in navigating this quagmire by identifying several commonalities between the different conceptualisations of partnerships.

Commonalities between the different conceptualisations of partnerships (Wildridge, 2004)

Between organizations, groups, agencies, individuals, disciplines	Common aim or aims, vision, goals, mission or interests	Joint rights, resources and responsibilities
New structure(s) and processes	Autonomous, independent	Improve and enhance access to services for users and carer’s
Equality	Trust

Ling (2002), on the other hand, provided an  illuminating perspective on variations in partnership characteristica.

Varying characteristics in partnership working (Ling, 2002)

Partnership Members	Links between partners	Scale and Boundaries	Organizational context of partnership
Individuals	High or low trust	National/local/global	‘Fit’ with existing institutional architecture
Parts of organizations	Equal or hierarchical	Numbers of partners	Maturity of relationships
Whole organizations	Focused or broad sweep	Boundaries (where they are drawn)	Legitimate or illegitimate
Public	Co-evolution, coupling and convergence	Boundaries (tight or loose)	Resource dependency
Private	Formal/Informal/ Contractual	Boundaries (own or mandate)	Impact/steerage capacity
Voluntary

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Taking Moodle into Prison Dentistry

It’s official, I’ll start a new job in August looking into oral health promotion in Scottish prisons. Here are my first thoughts ab0ut how to approach that.

Dentists working in prisons tend to work in professional isolation. They are usually the only dentist in a prison and work without the support of dental hygienists or therapists. In addition to dental and oral health challenges they are also working in an environment, which is, at times, challenging their interpersonal and stress management skills.

Dentistry in prison is also rarely a funding priority, which results in under-staffing, long waiting times, logistic difficulties in moving prisoners from their cells to the prison surgery, difficulties sourcing necessary equipment and materials in a timely fashion, etc.

While the funding shortage is not likely to change, there are some apparently cost-neutral strategies to at least address professional isolation, professional development as well as sharing of good practice and challenges.

Moodle is an open source, virtual learning environment, which is free to use. It has been traditionally adopted in schools or Universities but is now used by almost 50,000 organisations across the globe. This widespread uptake is a testimony of its flexibility, free service, interactivity and a host of other features, which are either part and parcel of the package or can easily be linked to wherever they are in the web. As a result, it lends itself well as a platform to support collaboration and networking among groups like prison dentists as well as between dentists and other professions (health and otherwise).

I’ll be keeping a close eye on David’s blog to inform my thinking and approach on this matter.

Let’s assume that offering a Moodle platform to prison dentists is a good idea.  First of all, prison dentists would have to be part of this right from the start. They would need to inform the content of the Moodle platform, the tools utilised, the appearance, and the level of interactivity.

What arguments are there to convince them of the benefits of participating in such an endeavour? How could these arguments be presented so that they convince dentists and potential funders?

Let’s use David’s ideas for the first time and explore the concept of distributive or distributed leadership. Distributed leadership was described “as a shared process of enhancing the collective and individual capacity of people to accomplish their work roles effectively” (Yukl, 1999, p. 292). Exploring the idea of distributed leadership makes intuitive sense from a number of perspectives.

• Prison dentists are highly qualified professionals used to working in isolation. Each one is an expert in their field, potentially providing gold standard care, which could inform service delivery in general. Often they also work in private practice where they have leadership roles in their business.
• There is usually one dentist per prison. Each prison will provide an idiosyncratic context for the dentist’s work. Consequently, each prison dentist needs to consider his environment but may be able to benefit from other perspectives in the aim of improving practice generally as well as in each prison context.
• Health care provision in prisons falls under the responsibility of various leaders, including health professionals, prison authorities, and governance institutions. A distributed leadership perspective would allow for the various roles and remits to be integrated.
• The skills required to provide gold standard oral health care within the constraints and unique challenges of the prison system are likely to exceed the skills set of any one person.

On the other hand, it may be a stretch to call individual dentists’ practice shared leadership. Maybe, this should rather be viewed as a network or a potential partnership. Let’s have a look at partnership working within the health context. Following this, I’ll delve into Social Network Analysis.

References:

Yukl, G. (1999). An evaluation of conceptual weaknesses in transformational and charismatic leadership theories. Leadership Quarterly, 10(2), p. 285-305.

Biophilia – A synopsis of the concept as presented in Erich Fromm’s ‘The Heart of Man’

I found a first edition of this book online for a good price and bought it. That was a couple of years ago. I finally managed to read it and it was an interesting journey back in time, both in zeitgeist (written and published during and shortly after the Pig’s Bay crisis and the threat of nuclear war) and psychodynamic theory.

Fromm is searching for the essence of mankind, the characteristic that defines humans. His take on this is that the basic position of man is to stand apart from nature due to his ability to be aware of himself and his consequential ability to be reflexive. These abilities separate man from nature and make him stand alone. Fromm refers to this separation as “a contradiction inherent in human existence” (Fromm, 1964, p. 116). This contradiction is evident in two ways.

1) Albeit being an animal, man’s survival instincts are incomplete or not sufficient to survive anymore (they have become blunt). Man relies on speech and tools to survive and that makes him special among all other living beings (although this might not be quite true anymore today, as we discovered some animals using tools and know more about their communication strategies).

2) We are aware of ourselves and of the fact that we are mortal. In this sense, we transcend nature because we are aware of life itself (the animal is not, which makes it a part of nature).

His quest about how we deal with this contradiction in our existence leads him to the question of whether our action are based on free will or whether they are determined by nature and/or nurture. He brings this conflict and contradiction to the point as follows:

“Man is confronted with the frightening conflict of being a prisoner of nature, yet being free in his thoughts; being part of nature, and yet to be as it were a freak of nature; being neither here nor there. Human self-awareness has made man a stranger in the world, separate, lonely, and frightened” (Fromm, 1964, p. 117).

As a result, we strive towards overcoming our sense of separateness and to become one again with nature. Our attempts at achieving a sense of belonging, we either regress or progress. Regression leads us back to nature (i.e. Rousseau, becoming childlike or childish, the womb), to animal life (rule of strength, violence, etc.) and to our ancestors (religions, laws, etc.). Progression means to develop to become fully human and to regain the lost harmony with nature and to lose the terror of separateness.

Fromm explores humans’ ‘Genius for Good and Evil’ and our regressive and progressive paths by investigating the dimensions of narcissism (benign-malignant), necrophilia-biophilia and incestuous ties (absent – incestuous symbiosis). In their malignant or destructive expressions, he calls these three concepts the syndrome of decay. This syndrome encompasses all tendencies directed against life and finds its expression in necrophilia, narcissism, and incest. I have always been particularly interested in his concept of biophilia. Hence, I summarised the key aspects of biophilia, as well as its opposite necrophila, below.

Necrophilia or the love of the dead shows itself in sexual perversion or the ‘morbid desire to be in the presence of a dead body’ (Fromm, 1964, p. 39). However, it is more than that. A person with necrophilous tendencies is drawn to everything that is dead or not alive, including corpses, decay, feces, dirt. They prefer to talk about sickness, funerals, death, destruction, the past; they are ‘cold, distant, devotees of law and order’ (p. 40) and like the use of force. Necrophiles like everything that does not grow but which is mechanical. ‘The necrophilous person is driven by the desire to transform the organic into the inorganic, to approach life mechanially, as if all living persons were things. All living processes, feelings, and thoughts are transformed into things’ (p.41). He continues to provide example in a similar vein but I think the picture he draws is emerging.

The opposite to necrophilia is biophilia, the love of life, the attraction to everything that lives and grows. Preserving life and preventing death is one form of biophilia. Biophilous tendencies can be much more varied and tend to integrate and unite, to fuse with different and opposite entities (this starts on a molecular level but also includes sexual union). This productive orientation expresses itself in curiosity, preference of the new over the old and a functional rather than mechanical approach to life. For biophilia to emerge or be sustained, certain societal conditions need to be in place. Chief among them are the absence of injustice and the presence of freedom to create and innovate.

Interestingly, Fromm also had something to say about knowledge management: ‘Briefly then, intellectualization, quantification, abstractification, bureaucratization, and reification – the very characteristics of modern industrial society, when applied to people rather than to things, are not the principles of life but those of mechanics. People living in such systems become indifferent to life and even attracted to death‘ (Fromm, 1964, p. 59).

The concept of biophilia encompasses people searching for self-awareness, aspirations, and growth. Given the current emphasis on mindfulness in psychological therapies and beyond, it was interesting to rediscover that in the 60s, when this book was published, From was already repeatedly referring to Buddhism and the eightfold path leading to awareness to the good in man by discovering him/herself. Moreover, Fromm’s approach fits with the psychological, health, and economic theories for which I have the greatest affinity: Frankl’s Logotherapy and Existential Analysis, Antonovsky’s Salutogenesis and Amartya Sen’s Capability Approach.

Cognition Accelerated by Just 4 x 20 Minutes Meditation

I came across this blog and it was another piece of evidence about the benefits of mindfulness mediation.

Cognition Accelerated by Just 4 x 20 Minutes Meditation.

A selection of psychological theories on motivation

Below is a quick overview of the main motivation theories used in psychology, education, economics, and public health. I took most of the information of the net and tried to link you back to informative, yet brief, sites.

Content theories of motivation

Content theories explore the forces or building blocks driving people’s actions.

The main content theories of motivation are:

–     Maslow’s Hierarchy of Needs

–     ERG

–     Herzberg’s Two Factor theory

Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs model has definitely become part of common knowledge. A short but educational summary of the main tenets of this theory can be found at http://www.abraham-maslow.com/m_motivation/Hierarchy_of_Needs.asp

ERG Theory

Clayten Alderfer modified Maslow’s Hierarchy of Need by summarizing the levels of need into three basic categories: existence needs, relatedness needs, growth needs (ERG). More about ERG and the differences to Maslow’s model can be found in a short and concise overview at http://www.netmba.com/mgmt/ob/motivation/erg/ .

Herzberg’s Two-factor Theory

Herzberg’s theory takes a different perspective on what motivates (satisfies) or de-motivates (dissatisfies) us. In a nutshell, Herzberg’s theory did not define satisfaction and dissatisfaction as being at opposite ends of the same continuum. The opposite of satisfaction is not dissatisfaction, but no satisfaction. The opposite of dissatisfaction is not satisfaction, but no dissatisfaction.

The following figures provide schematic overviews of the traditional view of viewing satisfaction and dissatisfaction on two ends of the same scale. Herzberg, as discussed above, saw different factors leading to satisfaction and dissatisfaction.

For more information, including critical views of the theory’s validity, see one of the links below:

http://psychology.wikia.com/wiki/Herzberg%E2%80%99s_Two_Factor_Theory_of_motivation

http://www.netmba.com/mgmt/ob/motivation/herzberg/

Here is a link to Herzberg’s book in which he outlines his two-factor theory: Motivation to Work

Process theories of motivation

Process theories explore the cognitive processes determining people’s actions.

The major process theories are

–     Equity theory

–     Expectancy theory

–     Goal-setting theory

Equity theory

According to equity theory the perception of unfairness in a social or organisational setting leads to tension, which in turn motivates the individual to act to resolve that unfairness.
For more information, see http://www.businessballs.com/adamsequitytheory.htm

Expectancy theory

F = ∑(V x I x E)

Expectancy theory argues that the strengths or ‘force’ of an individual’s motivation for behaviour change is expressed as the product of the valence of the outcome from that behaviour, the expectancy that effort will lead to good performance, and the instrumentality of good performance in leading to valued outcomes.

For more information, see http://www.arrod.co.uk/archive/concept_vroom.php

Goal-setting theory

Goal setting is both a process theory of motivation and a motivational technique, based on the argument that work performance can be explained with reference to characteristics of the objectives being pursued, such as goal difficulty, goal specificity and knowledge of results.

For more information, see http://www.mindtools.com/pages/article/newHTE_87.htm