From national to international Using ethnographic methods to

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 martin. webber@kcl. ac. uk 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 • 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 evidencebase for social work?

Your answers • 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

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 • 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

RCTs in mental health services

Mental health social work • 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)

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

Social interventions • 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

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

Background

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

Method • 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)

Method • 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

Method • 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

Method • 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

Findings Reducing power differentials works “They’re trying new things as well so you’re on an even field” (service user)

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

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

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,

Partnership Worker Developing skills, relationships and resources with this individual and for the future Equality Shared processes Social Network Knowledge Development Individual Developing ideas, goals, and confidence Potential and working barriers 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) 1999: 10 -year plan for UK mental health services published (National Service Framework for Mental Health) and advocates introduction of ACT in UK ACT teams in the UK begin to be decommissioned Reviews of UK evidence suggest usual care is as good as ACT (e. g. Burns 2010)

International evidence • 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,

Malawi • 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

India • 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 – More clients + more programmes = more income

Limitations • 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

Next steps (2012 -14) • 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

Thank you Please do not hesitate to contact me for further information: martin. webber@kcl. ac. uk 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)