From national to international: Using ethnographic methods to develop standardised interventions to enhance the international evidence base for social work Dr Martin Webber Lecturer in Social Work [email protected]

www.martinwebber.net

This presentation presents independent research funded by the Department of Health’s NIHR School for Social Care Research. The views expressed in this presentation are those of the authors and not necessarily those of the NIHR School for Social Care Research.

Some questions

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Why do we need evidence-based interventions in social work?

How can ethnography be used to develop social interventions?

– Connecting People Study

How can this method be applied to the development of an international evidence-base for social work?

Your answers

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Why do we need evidence-based interventions in social work?

Intervention is at the heart of social work

Definition of Social Work:

The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work. (IFSW Code of Ethics)

Poor public perception of social work

Only 1 out of 740 social workers agree that media coverage of social work is “completely fair and accurate” (The College of Social Work, 2012)

Could do better?

• Cohort study of 595 children investigated for suspected maltreatment • No change in social support, family functioning, poverty, maternal education, or child behaviour problems following intervention of child protection services • Maternal depression worsened

Others define ‘our’ evidence base

• Reduced child behaviour problems and improved parenting competencies

Others define ‘our’ evidence base

• Improved parenting skills in deprived area of inner London

But social workers can too…

• Social skills training and parenting intervention improves children’s behaviour, decreases aggression and increases social contact with peers

Social interventions

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Objections to RCTs of social interventions in the UK:

– Oversimplify causation – – Cannot test complex interventions Ignore the role of theory in understanding effectiveness – – Inappropriate where ‘blinding’ is impossible Politically unacceptable – – Too expensive Unethical because of withholding intervention from control group and experimental research is exploitative – Good alternatives to RCTs exist (Oakley et al 2003)

RCTs in mental health services

Mental health social work

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Evidence-based practice in mental health settings

– Favours randomised controlled trial evidence – – Favours psychological and pharmacological interventions Struggles with complexity or ‘messy’ practice

UK mental health services strongly influenced by EBP

– National Service Framework (now superseded, but still influential) – NICE clinical guidelines

Mental health social work

– Reduced to bureau-medicalised roles and reliance on statutory functions in absence of strong evidence base for interventions (Nathan & Webber, 2010)

Social intervention development

•Incidence and prevalence •Explanatory knowledge •Practice knowledge •Local knowledge Efficacy testing Intervention design Modelling Implementation Effectiveness testing Epidemiology (Adapted from Fraser 2003)

Social interventions

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Greater impact on policy and practice if:

– High inner quality (robust, defensible, scientific validity) – High outer quality (incorporate practice wisdom and values, currency with practitioners) (Shaw & Norton 2008)

Ethnography could improve outer quality of social interventions and prepare them for RCT evaluation to improve their inner quality

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Connecting People Study 2010-12: developing an intervention to support people to increase their access to social capital

Background

• • • • • • Economic capital: Resources that can be used to produce financial gains (Marx, 1867) Cultural capital: Information resources and socially valued assets, e.g. knowledge of the arts, music or literature (Bourdieu, 1997) Human capital: Qualifications, training and work experience (Becker 1964) Social capital: Sum of resources (actual or potential) that accrue to a person or group from access to a network of relationships or membership in a group (Bourdieu, 1997) Community capital: Combination of capitals within a defined area or community, required to help people fulfil their potential (Hancock, 2001) Erotic capital: Beauty, sex appeal, charm, liveliness, presentation (Hakim, 2010)

Background

• • • • • Wealth, power and status of network members can benefit other individuals in that network (Lin 2001) Informal social networks are influential in helping unemployed people find work (Perri 6 1997) Social capital helps reemployment (Sprengers et al 1988) and has an effect on income (Boxman et al 1991) Social capital is positively associated with current occupational status (Flap & Volker 2001) Social capital can lead to greater occupational prestige, income and political influence when mobilised (Lin & Erickson 2008)

Background

Access to social capital 20 18 16 14 12 10 8 6 4 2 0 General population People with depression (primary care) People with SMI (secondary care) Punjabi women with SMI Volunteers with SMI

Aims

• • • • To understand the ways in which workers are currently helping young people recovering from psychosis to generate and mobilise social capital To investigate how workers develop effective working relationships and secure attachments with service users, and thereby promote their social engagement To develop an applied social capital theory for mental health social care practice in the UK and beyond To develop social capital interventions that can be used by workers in their everyday practice

Method

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Combinative ethnography of social care practice

– – Semi-structured interviews, observations of practice and focus groups Exploratory, not evaluative

Setting

– NHS mental health services (mental health professionals and support time & recovery workers in early intervention in psychosis teams, social inclusion and recovery services) – Housing support (supported housing & floating support workers) – Third sector (social enterprises, voluntary organisations)

Sample

– 145 workers, service users, managers, commissioners (so far)

Method

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Ethnography phase 1

– Agencies identify workers likely to be effective at enhancing service users’ social capital – – – – – Researcher interviews workers to discuss their practice Researcher observes practice, particularly with new service users, and interviews service users and carers about their experience This process is repeated with different workers, or in different settings within the agency, to obtain full data This process will be repeated in each of the agencies and teams as an iterative approach Focus groups of service users, carers and workers to discuss emerging findings

Method

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Ethnography phase 2:

– Additional workers not interviewed in phase 1 are identified by the agencies and researchers – Researcher interviews workers to discuss and conceptualise – – – – their practice Researcher observers practice and interviews service users and carers about their experience Researcher also interviews a sample of service users from phase 1 to reflect on changes for them since then New questions emerging from phase 1, or areas of practice previously unobserved, is the focus of phase 2 Focus groups of service users, carers and workers to discuss emerging intervention model

Method

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Delphi Consultation (starting in April):

– – – – Intervention is developed in liaison with project’s advisory group (incorporating service users, carers, practitioners and researchers) Intervention is revised using a Delphi consultation method using advisory group and a wider group of stakeholders (including practitioners, managers and service users) Delphi consultation will ask for feedback on fidelity of interventions to social capital theory; adequacy, clarity and comprehensiveness of the practice guidelines; and feasibility and accessibility of interventions in practice Two rounds of ratings plus qualitative feedback will help us to refine intervention and make it fit for purpose

Findings

Reducing power differentials works

“They’re trying new things as well so you’re on an even field” (service user) “…it creates a level playing field for them because it takes the pressure off them to deliver and they can just, really, buddy up with the guys and take part in the activities” (worker)

Findings

Non-stigmatised locations bring people together

“I remember working with a young lad in Dartford who did not want to come onto the Charlton project because he didn’t want to be around people with mental health problems” (worker)

Findings

Local knowledge is essential

“But I, you know, we’ll sort of ask each other on the team, ‘Oh does anyone know of a place where so-and-so can volunteer’ or whatever” (worker)

Findings

Connections occur through shared activities

“They’ve suggested it on their…sheet and we’ve matched it up with five others who have said that they want to do that [activity]” (worker) “But I think that they sort of felt that I, I play guitar, I was a singer in a band, sort of have got a lot of sport interests, sort of like a lot of different things and I think that they felt that perhaps some of the people there are harder to engage. And because I might have more in common with them…” (worker)

Findings

Focus on an individual’s goals

“…the way they’ve helped me connect with things… like going to college, that will stay with me forever. Because I’ll get an education…” (service user)

Findings

Informal contacts provide access to resources

“Well my mate goes there and she rung me up and told me about it because she knew I needed maths and English. So I rung the key skills and got an interview and then they said that I could go through.” (service user)

Findings

Social capital is not a panacea

“Because even though I’ve got friends to hang around with, some of them are not very good friends. Some of them drink, drugs, and even though I drink the odd time, but, they do drugs and you know, it’s just sort of like, they’re wrong ones, do you know what I mean? And I want to hang around with decent people who want to get their life on track and not destroy their life”. (service user)

Worker Partnership

Equality

Individual Social Network Knowledge Development

Developing skills, relationships and resources with this individual and for the future Shared processes Potential barriers Developing ideas, goals, and confidence and working to attain and expand on these

Social Network Development Agency

Intervention guidance

International evidence

Crowther et al. (2001) British Medical Journal, 322 : 204-208

International evidence

Assertive Community Treatment (ACT)

1998: Cochrane review of ACT published Successive UK trials of found no positive effect of ACT vs. usual care (e.g. Burns et al 1999, Killaspy et al 2006) ACT teams in the UK begin to be de commissioned 1999: 10-year plan for UK mental health services published (National Service Framework for Mental Health) and advocates introduction of ACT in UK Reviews of UK evidence suggest usual care is as good as ACT (e.g. Burns 2010)

International evidence

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Ethnography can provide

– A rich understanding of local context – – An insight into practice An insight into intervention processes – – An understanding of how theory can be applied to practice An understanding of the difference between reality and rhetoric – Reasons why intervention A does not work in context Z

Used at the intervention development stage, ethnography may be able to effectively translate theory into practice into different contexts

Malawi

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9 pilot interviews (4 nurses, 5 social workers)

– Qualified for an average of 6 years – Explored practitioner’s understanding of social capital in the context of their practice

Good communication and trust is essential to building relationships Most don’t see developing inter-personal relationships as part of their role But, over half foster contacts with ‘resourceful’ people Resourcefulness:

– Ability to deal with new situations – Ability to identify needs to satisfy ones own requirements

India

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Interviews with 15 psychiatric social workers

– Qualified for an average of 17 years

Family is the predominant source of social capital Social security provided by NGOs

– – Linkages between NGOs are poor Don’t refer people to other NGOs for fear of losing clients – –

But social workers advise people about services available beyond their agency (if they can’t provide it) Resourcefulness:

– More clients + more programmes = more income Develop service around clients Material resources within the community

Limitations

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Lack of resources

– No research grant and time is prioritised elsewhere

Limited expertise in research methodology

– How do we enhance reliability of data collection?

Local risks

– Computer and voice recorder stolen by armed gang in Malawi

No more than pilot data at this stage Exploration is limited to two low & middle income countries

– Do concepts translate across Europe?

Next steps (2012-14)

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Adapt Connecting People Intervention for use with adults with a learning disability and older adults with mental health problems Develop measure of fidelity to intervention Quasi-experimental study to pilot intervention

– Involving 12 agencies and 240 people – Follow-up over 12 months to evaluate outcomes and cost effectiveness

Prepare for a randomised controlled trial Prepare grant application for international study: Collaborators sought

Thank you

Please do not hesitate to contact me for further information: [email protected]

martinwebber.net

(+44) 20 7848 5096 Acknowledgements:

NIHR School for Social Care Research David Ansari, Hannah Reidy & Meredith Newlin (Researchers) David Morris & Polly Kaiser (University of Central Lancashire) Paul McCrone & Martin Stevens (King’s College London) Peter Bates (National Development Team for Inclusion)