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Identify a patient, stating the reason for admission/appointment. It must be on diabetes. Describe a specific problem that has been highlighted through the assessment process. Explore factors that may have led to their hospital admission/appointment. This could include physical psychological and social aspects.

Case details

In this essay we shall discuss the case of Mrs Singh. She is an elderly lady of 76 yrs. old. Who lives in warden assisted accommodation. She has done so for the last ten years since her husband died. She has had Type II diabetes mellitus for the last 17 years, and copes reasonably well considering her age and her comparative infirmity. She has been able to go out and get her shopping from the nearby shops and is otherwise self-caring, clean and tidy.

According to the referral letter from her General Practitioner, who arranged this admission to hospital, a number of people had recently commented that she looked ill and was not caring for herself as well as she used to do. Her family live a considerable distance away from her and, although they see her about once or twice a month, they do not stay for long as they have a business to run.

When she was admitted she was found to be lucid and coherent but her family told us that she had had a number of episodes of confusion recently. She was occasionally very sleepy and had left the gas burning on one occasion. She had a large infected ulcer on her left shin, which had clearly been there for a matter of weeks, but because of her habit of wearing long skirts, no one had noticed it. She had a degree of ankleoedema, but her physical examination was otherwise unremarkable, apart from the fact that she had a BMI in excess of 29. She is a moderate smoker.

Discussion

Mrs Singh as an individual is clearly unique, but sadly, she also represents a great many elderly diabetic patients who live in similar conditions. The thrust of this particular discussion will be the aetiology and management of her condition with particular relevance to her leg ulcer.

Diabetes Mellitus, an overview

Diabetes is a comparatively common disease process in the UK. In children it is the commonest major illness (after childhood infections). There are approximately 1.5 million diabetic patients in the UK at present and the number is relentlessly increasing. (Devendra et al 2004).

The 1.5 million are not equally spread across all segments of the population. People from the Asian and Afro-Caribbean ethnic backgrounds have a markedly increased risk of developing Diabetes Mellitus (UKPDSG 1998) with one in four of all Afro-Caribbean women over the age of 55 being diabetic. (Nathan 1998).

Increasing age and BMI also are both independent risk factors for Diabetes Mellitus (James 1997). Of this number, it is expected that about 10% will develop some form of lower limb ulceration while they are diabetic. (Amos et al 1997). To some extent, it is statistically more likely that those patients who have poor control of their diabetic state will develop ulceration (and other complications) than those patients who have good control.

The other factor that is relevant in the aetiology of leg ulceration is the length of time a person is diabetic. Chronicity of the disease process is an independent variable for leg ulceration. (Simon P et al 2004).

A number of authorities have estimated the burden of cost of Diabetes Mellitus to the NHS. A recent study by Newrick (et al 2000) considered that 9% of the total NHS budget was spent on diabetes and diabetic related issues. By far the biggest single portion of that amount (over half) was on the treatment of complications and the commonest clinically relevant complication is that of venous ulceration (Ellison et al2002)

We can start by considering the pathophysiology of Diabetes Mellitus

Pathophysiology

This is a huge subject in its own right and we shall therefore present a brief overview as far as it is relevant to Mrs Singh. In broad terms Diabetes Mellitus is a condition where the body loses the ability to metabolise carbohydrates in general and glucose in particular.

Glucose is absorbed from the gut, transported to the liver where is can be stored as glycogen, and then transported through the bloodstream to the cells in the periphery of the body, where it is one of the main metabolic substrates. It is absorbed from the blood into the cells by a specific molecular carrier system and this is totally insulin dependent.

If there is a failure of insulin production, then the circulating level of insulin falls and the glucose is not transported into the cells. This leads, initially to hyperglycaemia and finally to ketosis and metabolic failure. This is the situation of Type I diabetes mellitus.

The alternative is Type II diabetes mellitus where the cells lose the ability to respond to the circulating insulin levels. This also results in hyperglycaemia and eventual metabolic failure but is characterised by high levels of circulating insulin. In general terms, Type I diabetes mellitus is a comparatively acute illness whereas Type 1 diabetes mellitus tends to be far more chronic, sometimes taking many months or even years to become clinically apparent. (after Donnelly et al 2000)/

The complications of Diabetes Mellitus are many. The largest group are the micro- and macro vascular group of the cardiovascular complications.

(Stratton I et al 2000). The macro vascular group are usually related to the process of atherosclerosis and present with either degrees of myocardial is chaemia or as peripheral impairment such as intermittent claudication or ulceration. In general terms the incidence of this type of complication is directly associated with the average levels of HbA1 (which is a long term indicator of diabetic control) (HSG 1997).

Nursing interventions

The major nursing intervention to discuss here is the management of the leg ulcer. In any medical intervention its important to establish a sound evidence base (Sackett, 1996). We shall therefore quote the literature relevant to each point.

The first, and arguably most important consideration is whether the ulcer is primarily venous, arterial or (more rarely) neuropathic in origin. This is comparatively easily determined by an assessment of the ankle/brachial pressure ratio. This is measured by means of a Doppler measure and the ratio is easily calculated. If it is less than the critical level of 0.8 it is likely that an significant arterial element is present.(Partsch H. 2003).

Mrs Singh was treated with a 4 layer bandage. Her ratio was significantly above the 0.8 threshold and the main aetiology of her ulcer was therefore judged to be venous.

The composition and construction of a 4-layer bandage is very specific but it can be individually modified to suit the demands of the individual patient. The first layer is a cotton wool based bandage with the primary purpose of absorbing the copious amounts of exudates that are common with this type of ulcer. It also has the secondary purpose of spreading the pressure evenly across the underlying tissues the second layer is a crepe bandage which has the prime function of holding the lower layer in place. The third layer is a compressive layer, usually an elastic type of bandage is then applied and this is covered by a final binding layer. (Nelsonet al. 2004).

The rationale behind the bandage is that in the typical diabetic venous ulcer there is an increased pressure at the venous end of the capillary bed which translates into stagnation in the capillary blood flow which renders the tissues less viable because of poor oxygenation. By exerting physical pressure of about 40 mm Hg on the tissues, this increase of venous pressure is negated and the circulation improved.(Thomas S. 2003).

Clearly it follows that in an arterial ulcer, as there is a reduction in the arterial pressure at the arterial end of the capillary bed, any increase in physical pressure could further reduce the blood flow across the capillary bed, which is why it is vital to differentiate between the two types before applying the bandage.(Marston W et al. 2003).

The second main nursing intervention, and possibly more beneficial in the longer term, would be the Health Promotion aspects of the nursing relationship. Mrs Singh is overweight. Her BMI is about 29 which means that her weight is not only contributing to the reduction in venous return, and thereby contributing to both the aetiology and the persistence of her ulcer, but the obesity is also a major factor in the aetiology of her Type II diabetes mellitus. If Mrs Singh can be persuaded to reduce her weight, her need for hypoglycaemic medication may well lessen. It is possible that it may reduce to the point that she could manage her condition on diet alone. (Terry T-K et al 2003).

Smoking is not only an independent risk factor for Type II diabetes mellitus, but it is also a risk factor for cardiovascular disease. A major health promotion measure would therefore be to help Mrs Singh to give up smoking. This is not a short term measure, so is not particularly suited for hospital intervention, although the nursing staff spent a considerable amount of time with Mrs Singh to explain the problems associated with smoking. (Marks-Moran & Rose 1996).

On discharge she was referred to, and seen by, the smoking cessation nurse at the local primary healthcare team. The whole concept of patient empowerment and education is most important in this field. If a patient understands why they are being asked to do something, they are much more likely to comply with the request from the healthcare professional (Marinker M.1997).

The weight reduction needs to be carefully managed if it is to be successful. She was referred to the dietician who prescribed a low fat, carbohydrate regulated, 1,200 cal. per day diet. Because this is clearly going to be a long term intervention, arrangements were made for Mrs Singh to be followed up in the community dietetic clinic.

Mrs Singh was in hospital for seven days when the multidisciplinary discharge team were able to arrange her discharge. This involved the assistance of an occupational therapist to assist with minor home modifications and the community nurses who continued the treatment with the 4 layer bandage.

(Harrison, I. D et al 2005) The diabetic specialist nurse was also involved. As Mrs Singh’s weight slowly reduced she was able to reduce and finally come off her hypoglycaemic medication.

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In the Australian tertiary health care system, ‘best practice’ in the care of a terminally-ill neonate and the neonate’s family centres on the provision of ‘holistic care’. Neonates and their families are considered an interdependent system; therefore, holistic care involves the complete physical and psychological care of both the neonate and the family. However, quality holistic care can be challenging for nurses to achieve, particularly in a complex palliative model of care. This paper discusses the best practice holistic care of a terminally ill neonate and the neonate’s family in the context of the Australian tertiary health care system.

The term ‘palliative care’ refers to the withholding and / or withdrawal of life sustaining treatment in patients with terminal illness, to prevent or relieve suffering and allow death to occur (World Health Organisation, 2015). In all patients, and children in particular, the World Health Organisation (2015: n.p.) highlights that palliative care must be a holistic process, one which provides “active total care of the child’s body, mind and spirit, and [which] also involves giving support to the family”. Palliative care is concerned with providing a terminally ill neonate with the best conditions in which to live and with facilitating a comfortable death (Ahern, 2013; Bergstraesser, 2013). As parents are fundamental in the decision-making processes around neonatal palliation and as it is they who will be the most significantly affected by these decisions (Branchett & Stretton, 2012; Larcher, 2013), neonatal palliative care places a particular focus on caring for parents. There is consensus in the academic literature for palliation as the best model of care for neonates who are terminally ill; indeed, both the Australian College of Neonatal Nurses (2010) and the Royal Australian College of General Practitioners (2014) highlight palliative care as a best-practice option for terminally ill neonates in the Australian context.

It is accepted that the parents of a terminally-ill neonate in palliative care require significant emotional support from neonatal nurses and other members of the health care team. Parents of palliated neonates often experience a complex emotional reaction to their situation, typically one of grief, shock and confusion (Badenhorst & Hughes, 2007; Gardner & Dickey, 2011). They may also experience feelings of profound loss, related not only to the impending loss of their child but also to a loss of their expectations, aspirations, role as parents and family dynamic, etc. (Gardner & Dickey, 2011). Additionally, it is not uncommon for parents to feel indecisiveness, shame or guilt about the decision to palliate their neonate (Reid et al., 2011), particularly when the outcome of the neonate’s condition is uncertain. There is evidence from one early Australian study to suggest that women who experience neonatal loss have significantly higher rates of psychological distress and a greater risk of clinical depression than other mothers (Boyle et al., 1996). Thus, it is essential for neonatal nurses to validate the complex emotions the parents of a palliated neonate experience as being part of a normal and healthy psychological process (Badenhorst & Hughes, 2007). The provision of a clinical environment where parents’ complex emotions can be expressed and explored is also important.

Best-practice models of neonatal palliative care recommend that parents take a lead role in the care of their infant, both in terms of decision-making and practical care (PSANZ, 2009; Australian College of Neonatal Nurses, 2010). Whilst some parents may resist providing care for and thus becoming attached to a palliated neonate, fearing that this will increase the degree and duration of their grief following the child’s death, there is evidence to suggest this is not the case for many parents (Gardner & Dickey, 2011). There is also evidence which indicates that many parents regret not spending more time with their deceased neonate, both prior to and following death (Williams et al., 2008). Thus, the literature recommends that parents should be treated by neonatal nurses as ‘welcome partners’ in the care of their baby (Griffin, 2013). Parents should also be encouraged and supported to be involved in the care of their baby to the extent that they feel comfortable doing so (PSANZ, 2009).

So that parents may be meaningfully and safely involved in the care of their palliated baby, it is important that neonatal nurses provide them with the information they require to make informed decisions – and this may begin in the palliation planning phase. Developing a flexible, transparent and family-centred palliation plan is essential, and so that their preferences are met, parents should take a key role in this process (Williamson et al., 2009). The palliation plan must focus on enabling ‘open caregiving policies’, highlight parents’ wishes for their neonate and be legally documented (Breeze et al., 2007; Wiliamson et al., 2009; Gardner & Dickey, 2011). Whilst most parents wish to be involved in decisions and planning around end-of-life care for their neonate, they may find this responsibility overwhelming (Williams et al., 2008). Parents will be exposed to a range of options and opinions which they must synthesise in order to make the best decisions for their family; however, it is important for neonatal nurses to realise that highly emotive situations can often cause significant deficits in parents’ ability to comprehend and process such information (Williams et al., 2008). Evidence suggests that repetition printed literature is important in the provision of information to parents in situations involving neonatal death (PSANZ, 2009). The timing and delivery of the information provided by neonatal nurses should also be carefully planned to ensure maximal uptake (PSANZ, 2009).

Australian guidelines recommend that when supporting the parents of a palliated neonate, neonatal nurses focus on the normalcy of parenthood wherever possible (PSANZ, 2009). Neonatal nurses should assist parents to engage in normal parenting opportunities – including holding, changing and bathing their baby, and routine interactions such as reading cues and providing comfort – if they feel able to do so (PSANZ, 2009). For babies with longer palliative periods and where the baby’s condition permits, feeding – including breastfeeding or the feeding of expressed breast milk – is also an important consideration. Normal rituals associated with infancy, such as naming ceremonies and baptism, should also be followed if the family consider these to be important (PSANZ, 2009; Weidner et al., 2011).

A palliated neonate’s relationship with extended family may also be an important consideration for many families. Though visiting in intensive care nurseries is often restricted to parents, photographs and videos of the baby may be shared with extended family members and these relatives may be encouraged to send toys, clothing and nursery decorations, etc. for the baby in return (PSANZ, 2009). Research suggests that the support of family is a significant factor in the recovery of parents from the death of a neonate; indeed, the grief of parents may be enhanced when there is a lack of familial engagement with a palliated neonate (Gardner & Dickey, 2011). Grief of the family itself is also essential to consider; for example, there is evidence to suggest that better outcomes are achieved when grandparents and siblings are engaged with parents in the process of bereaving a deceased neonate (Roose & Blanford, 2011).

The literature suggests that the creation of tangible memories is fundamentally important to the parents of a palliated neonate, and this is included as a recommendation in Australian perinatal mortality guidelines (Capitulo, 2005; PSANZ, 2009). Memories collected may include photographs and videos, prints or casts of the hands and feet, locks of hair, identification bracelets or cards, toys and gifts, nursery decorations, and blankets, hats or clothing, etc. (De Lisle-Porter & Podruchny, 2009; PSANZ, 2009). It is important to note that many parents, and particularly those in denial of their baby’s palliative state, may resist collecting such memories; in this case, it is recommended that hospitals do so and hold these with the baby’s clinical documentation until such time as the family is ready to receive them (PSANZ, 2009).

So that parents may maximise the quality time they spend with their neonate, it is important for neonatal nurses consider the wider social factors which may affect them and their families (Ahern, 2013). Issues related to finances, employment commitments, accommodation, transport and the care of other children should be referred to a hospital social worker. Where required, postnatal medical attention in a clinical area where the mother will not be in close proximity to other healthy neonates, in addition to the suppression of lactation, are important (Badenhorst & Hughes, 2007). The environment in which the palliative care takes place must also be considered; Australian guidelines suggest that this environment should be private, comfortable, peaceful and supportive (Kain, 2006; PSANZ, 2009).

Once the decision has been made to palliate a neonate, all treatment which is not essential to the baby’s comfort must be withheld and withdrawn. This includes removing all inessential intravenous lines, invasive ventilation, monitors and pharmaceutical treatment. As the neonate begins to decline physiologically and the activity of the gastrointestinal system reduces, nasogastric feeding and hydration should also be ceased (Porta & Frader, 2007). Administering an appropriate dose of narcotic analgesia to relieve discomfort and sedate the respiratory drive may be useful (Williams et al., 2008; Carter & Jones, 2013); however, parents should be assured that this does not constitute euthanasia, which is illegal in Australia. At this stage, the end-of-life rituals should be conducted according to parental preference (Ahern, 2013). As the neonate progressively declines, it is essential that neonatal nurses prepare parents with information about how the baby’s death will likely occur. This includes the possibility of the neonate rapidly decompensating and displaying distressing signs such as hypoxic agitation, gasping, intercostal recession, pallour and temperature loss (Brosig et al., 2007; Williams et al., 2008; Carter & Jones, 2013). Information provided should also include the fact that timing to death cannot be predicted (Williams et al., 2008). Parents should be given a choice as to whether they remain with the neonate during death.

Following death, parents should be provided with the opportunity to hold, change or bathe their baby if they wish to do so (PSANZ, 2009). Whilst many parents are reluctant to or even fear engaging with their deceased baby, there is evidence to suggest that no parent regrets this experience and that many find it valuable (Capitulo, 2005). The policies of most maternity services in Australia allow parents to view their neonate as many times they wish, and some may also provide parents with the option of taking the baby home for a short period (PSANZ, 2009). Once the parents are ready, neonatal nurses should assist them to complete death registration and autopsy documents, as appropriate. Nurses should also support parents to organise a funeral through a company of their choice; in Australia, a funeral is legally required for all neonates born at or over 20 weeks gestation. A funeral is particularly important for many parents in terms of achieving closure (Williams et al., 2008).

Most literature recommends that the parents who have experienced a neonatal death receive ‘early supported discharge’ from hospital (Gardner & Dickey, 2011). Referral to support services in the parents’ own community – including general practitioners, counsellors and peer support groups, etc. – are essential considerations. Follow-up is also important; for example, if an autopsy was performed, neonatal nurses should communicate these results to parents in a timely manner (PSANZ, 2009; Reid et al., 2011). Additionally, many parents find personal follow-up, including telephone calls and cards, from the neonatal nurses who cared for their baby to be meaningful (Weidner et al., 2011), reinforcing that their child was important and will be remembered.

In the Australian tertiary health care system, ‘best practice’ in the care of a terminally-ill neonate and the neonate’s family centres on the provision of ‘holistic care’. As they are an interdependent system, holistic care involves the complete physical and psychological care of both the neonate and the family. This paper has discussed the best practice holistic care of a terminally ill neonate and the neonate’s family in the context of the Australian tertiary health care system. It has demonstrated that whilst holistic care may be challenging to achieve, it is essential in delivering the best positive outcomes in a complex situation such as neonatal palliation.

References

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Australian College of Neonatal Nurses 2010, Palliative Care in the Neonatal Nursery: Guidelines for Neonatal Nurses in Australia, viewed 04 October 2015, https://acnn.sslsvc.com/acnn-resources/clinical-guidelines/G3-Palliative-care-in-the-neonatal-nursery.pdf

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Griffin, T., (2013), ‘A family-centred ‘visitation’ policy in the neonatal intensive care unit that welcomes parents as partners’, The Journal of Perinatal & Neonatal Nursing, vol. 27, no. 2, pp. 160-165.

Kain, VJ., (2006), ‘Palliative care delivery in the NICY: What barriers to neonatal nurses face?’, Neonatal Network, vol. 25, no. 6, pp. 387-392.

Larcher, V., (2013), ‘Ethical considerations in neonatal end-of-life care’, Seminars in Fetal & Neonatal Medicine, vol. 18, no. 2, pp. 105-110.

Perinatal Society of Australia and New Zealand (PSANZ) 2009, Clinical Practice Guideline for Perinatal Mortality, viewed 04 October 2015, http://www.stillbirthalliance.org.au/doc/Section_1_Version_2.2_April_2009.pdf

Porta, N., & Frader, J., (2007), ‘Withholding hydration and nutrition in newborns’, Theoretical Medicine & Bioethics, vol. 28, no. 5, pp. 443-451.

Reid, S., Bredemeyer, S., van den Berg, C., Cresp, T., Martin, T., Miara, N., Coombs, S., Heaton, M., Pussell, K., & Wooderson, S., (2011), ‘Palliative care in the neonatal nursery’, Neonatal, Paediatric & Child Health Nursing, vol. 14, no. 2, pp. 2-8.

Roose, RE., & Blanford, CR., (2011), ‘Perinatal grief and support spans the generations: Parents’ and grandparents’ evaluations of an intergenerational perinatal bereavement program’, Journal of Perinatal & Neonatal Nursing, vol. 25, no. 1, pp. 77-85.

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Weidner, NJ., Cameron, M., Rebecca, C., McBride, J., Mathias, EJ., & Byczkowski, TL., (2011), ‘End-of-life care for the dying child: What matters most to parents’, Journal of Palliative Care, vol. 27, no. 4, pp. 279-286.

Williams, C., Munson, D., Zupancic, J., & Kirpalani, H., (2008), ‘Supporting bereaved parents: Practical steps in providing compassionate perinatal and neonatal end-of-life care’, Seminars in Fetal and Neonatal Medicine, vol. 13, no. 5, pp. 335-340.

Williamson, A., Devereux, C., & Shirtliffe, J., (2009), ‘Development of a care pathway for babies being discharged from a level 3 neonatal intensive care unit to a community setting for end-of-life care’, Journal of Neonatal Nursing, vol. 15, no. 5, pp. 164-168.

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Aboriginal and Torres Strait Islander people, referred to as ‘Indigenous Australians’, experience significantly poorer health outcomes than non-Indigenous Australians. This is particularly true for Indigenous women. The difference in life expectancy between Indigenous and non-Indigenous women is some 9.5 years, and Indigenous mothers are three times as likely as non-Indigenous mothers to die during childbirth (AIHW, 2014a; AIHW, 2014b). There are many complex, interrelated social factors which impact the health of Indigenous people. This paper provides a critical analysis of the social determinants of health for Indigenous mothers in particular.

Education is one of the most fundamental social determinants of health, and this is particularly true for Indigenous Australians. Education enables Indigenous women to access and interpret health-related information to prevent ill health, and it also improves their capacity to engage effectively with the health care system when necessary (Jones et al., 2014). In Indigenous women, higher levels of education are directly linked with positive health outcomes; for example, an Indigenous woman is less likely to smoke if she completes secondary schooling (Australian Government Department of Health & Ageing, 2012; Biddle & Cameron, 2012). However, Indigenous women have poor rates of formal education attainment; just 29% of Indigenous people complete Year 12 compared with a national average of 73% (ABS, 2012). Indigenous women with a lower standard of education are more likely to bear a child in their adolescent years, a particular problem for Indigenous women generally, and are also more likely to have a child with a low birthweight (Comino et al., 2009; Osborne et al., 2013). Additionally, Indigenous mothers with lower standards of education are more likely to children with poor educational outcomes; this highlights the significant problems associated with the intergenerational transfer of health and social risk in Indigenous communities (Benzies et al., 2011).

Education is related directly to an Indigenous woman’s level of economic participation – specifically, her ability to gain employment and earn an adequate income, both of which are key predictors of health (Osborne et al., 2013). Research suggests that an Indigenous person’s chance of gaining employment increases by 40% if they complete Year 10 and by 53% if they complete Year 12 (New South Wales Government Department of Education & Training, 2004). However, as with low education, low employment is a significant problem for Indigenous women; indeed, rates of unemployment for Indigenous women are above 16%, compared with a national average of just 4% (ABS, 2013). Economic disadvantage resulting from unemployment is a significant predictor of poor health. Booth and Carrol (2008) suggest that economic variables can explain up to 50% of the disparity in health between Indigenous and non-Indigenous Australians. Additionally, and demonstrating the cyclical nature of socioeconomic disadvantage and poor health in Indigenous communities, research also suggests that poor health may explain 60% of the disparity in employment participation between Indigenous and non-Indigenous women (Kalb et al., 2011).

Unemployment and socioeconomic disadvantage may affect the health of Indigenous women in a range of ways. Primarily, limited disposable income – in combination with a lack of food storage and cooking facilities within households and, particularly within remote communities, lack of access to fresh food itself – means indigenous women have reduced access to nutritionally-appropriate foods and lower food security (Osborne et al., 2013; Browne et al., 2014). Indeed, the diets of Indigenous people in many regions are characterised by a high intake of saturated fats, refined carbohydrates and salt, and little to no intake of fresh fibre-rich foods (ABS, 2006). In Indigenous women, as in all women, nutrition is fundamental to health in the ante-, intra- and post-partum periods (Browne et al., 2014). Poor dietary intake leads to high rates of gestational diabetes mellitus among Indigenous mothers – 5.1%, compared with a national average of 4.5% (2000-2009 estimate) (Chamberlain et al., 2014). Poor nutritional status also underpins the burden of chronic disease evident in Indigenous women and particularly chronic diseases related to obesity, which are a significant problem in Indigenous communities (Liaw et al., 2011). Around 60% of Indigenous women aged 25-55 years have a body mass index which indicates they are ‘obese’ (ABS, 2006). Because of the risks posed by chronic disease, Indigenous mothers are significantly more likely than non-Indigenous mothers to require antenatal hospital admission (Badgery-Parker et al., 2012). Additionally, maternal chronic disease means that around 11% of indigenous neonates have a low birthweight (ABS, 2014). This is an important marker for increased risk of chronic disease, again demonstrating the cyclical nature of socioeconomic disadvantage and poor health outcomes in Indigenous communities.

Socioeconomic disadvantage has a variety of other impacts on Indigenous mothers. For example, lack of employment and poverty mean that many Indigenous women have reduced access to appropriate housing. Up to 28% of Indigenous people live in housing which is severely overcrowded and where basic facilities – including showers, toilets and stoves – are not available or do not work (Osborne et al., 2013). Compounding the issue of poor housing is the fact that Indigenous Australians, and particularly those living in regional and remote communities, have disproportionate access to essential health infrastructure such as safe drinking water, rubbish collection services, sewerage systems and a reliable supply of power (Australian Human Rights Commission, 2007; Osborne et al., 2013). Indeed, lower standards of housing health infrastructure in Australian communities contribute directly to the high rates of parasitic and bacterial infection and increased rates of physical injury – for example, from house fires – among Indigenous women (Bailie & Wayte, 2006).

Inappropriate, overcrowded housing has had other impacts on Indigenous mothers. Specifically, it has led to breakdowns in traditional, complex social structures, norms and spiritual practices in Indigenous communities (Osborne et al., 2013). This has resulted in increases in the rates violence, including domestic violence, perpetrated against Indigenous women; indeed, Indigenous women are 40 times more likely than non-Indigenous women to experience violence, and are 35 times more likely to experience intra-familial violence which results in hospitalisation (Osborne et al., 2013). Indigenous people are also significantly more likely than non-Indigenous people to experience sexual assault (Phillips & Park, 2006; ABS, 2009). The Australian Human Rights Commission (2007) notes that a combination of unemployment, the receipt of welfare payments and a lower standard of education also predispose Indigenous women to an increased risk of poor health outcomes due to violence.

In Indigenous women in particular, social capital – including a connection with community, country and culture, is positively correlated with wellbeing (Brough et al., 2004; Biddle, 2012; Osborne et al., 2013). The relationship between social capital and mental wellbeing, particularly in Indigenous people, is well-established, however the correlation between social capital and physical wellbeing is now also acknowledged. For example, a number of Australian studies have demonstrated that Indigenous people who are connected to their community, country and culture are less likely to be diagnosed with a range of chronic health conditions including obesity, diabetes mellitus, hypertension and renal disease (Burgess et al., 2009; Campbell et al., 2011). Where there are declines in social capital, therefore, the mental and physical health of Indigenous women also decline.

Shepherd et al. (2012) report on the growing body of knowledge which suggests that Indigenous peoples’ social environment may significantly affect their mental health. Rates of mental illness among Indigenous women are high; indeed, Indigenous women are 2.6 times as likely as non-Indigenous women to report experiencing psychological distress and are also more likely to engage in self-harm and / or suicide (Australian Human Rights Commission, 2007; Burns et al. 2015, np). Mental illness is also strongly correlated with poverty; for example, Australian research suggests that people in poverty lack a sense of control over their lives and so experience higher levels of psychological stress (Australian Human Rights Commission, 2007). In addition to poor mental health, psychological stress can also lead to poor physical health outcomes – specifically, via negative effects on the immune and cardiovascular systems and metabolic function (Australian Human Rights Commission, 2007; Shepherd et al., 2012). Mental illness is not only underpinned by social health determinants, it is also problematic in terms of modifying the social factors which underpin poor health outcomes in Indigenous communities. For example, Marmot (2011) suggests that, in Indigenous communities, marginalisation results in disempowerment which in turn leads many Indigenous women to perceive little value in efforts to make health-related changes.

Social dysfunction and high rates of mental illness in Indigenous communities is driven by – and, indeed, drives – the high rate of substance abuse in these communities (Osborne et al., 2013). Indigenous women are twice as likely as non-Indigenous women to smoke on a daily basis, and three times as likely to smoke during pregnancy (Osborne et al., 2013; Passey et al., 2013). Approximately 50% of Indigenous people report consuming alcohol at least once per week, 28% report current regular use of illicit substances including cannabis and other drugs, and 15% engage in ‘risky’ behaviours related to substance use (ABS, 2006). Substance abuse is an important social determinant of health; the correlation between substance use and poor outcomes in terms of both physical and mental health in adults is well-established. Whilst the prevalence of Indigenous mothers who use alcohol and illicit substances is unknown, rates of fetal alcohol spectrum disorder and neonatal abstinence syndrome are high among Indigenous neonates (AIHW, 2015). Additionally, Indigenous mothers who abuse substances are at greater risk of losing custody of their children; because of the relationship between social capital and health in Indigenous communities, this can itself be perceived as a poor health outcome (Australian Human Rights Commission, 2007; Osborne et al., 2013).

As noted by the Australian Government Department of Health and Ageing (2013), poverty limits the access of many Indigenous people to health care services. This is particularly true in regional and remote communities – and approximately 46% of Indigenous women live in an area classified as ‘regional’ or ‘remote’ (ABS, 2010). Though many regional and remote Indigenous communities are supported by ‘fly-in fly-out’ health services, research suggests that fragmented services and discontinuity of care can contribute to poor health outcomes for Indigenous women (Bar-Zeev et al., 2012). Many communities have no health services at all, and to receive medical attention Indigenous women are often required to travel long distances to regional centres. Although the federal government subsidises the transport and accommodation expenses associated with such trips, general living costs borne by Indigenous women are often significant (Kildea et al., 2010). Additionally, the costs for those accompanying a woman are often not subsidised, so women may be required to travel without support (Kildea et al., 2010). These issues affect Indigenous mothers disproportionately; for example, in comparison to non-Indigenous women, Indigenous women tend to access antenatal care both less frequently and later in their pregnancy, and this is underpinned by lack of access to care (Osborne et al., 2013).

Further complicating these issues is the fact that the ‘risk-prevention’ paradigm evident in many medicalised health services is incompatible with the holistic perception of health held by many Indigenous women (Ireland et al., 2011). Additionally, historic protectionist and paternalist attitudes directed towards Indigenous people continue to pervade many medicalised health services in Australia. Durey and Thompson (2012) suggest that racism, both covert and overt, towards Indigenous women in Australian health services remains a significant problem; indeed, the Australian Human Rights Commission (2007) notes that systematic discrimination is a key factor underpinning the lack of opportunity for Indigenous Australians achieve a health status equitable to that of non-Indigenous Australians. These issues associated with ‘culturally-safe’ service provision often culminate in Indigenous mothers disengaging from medicalised health services. This is a significant problem considering a lack of antenatal and intrapartum care in particular, and health care in general, is fundamental to the high maternal morbidity and mortality rates in Indigenous communities (AIHW, 2014a).

This paper has provided a critical analysis of the many social determinants of health for Australia’s Aboriginal and Torres Strait Islander peoples – and, particularly, Indigenous mothers. It has demonstrated that social factors underpin the health of Indigenous mothers in both the physical and mental domains. It has also provided evidence for the complex relationship between health and social determinants in Indigenous mothers.

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Palliative care can vary significantly in its effectiveness according to condition, location, and type of patient (WHO, 2011; Gomes et al., 2013). This has long been recognised as an issue: Higginson et al. (2003) suggested that it has been difficult to prove the effectiveness of palliative care given the broad range of providers and the diverse nature of the clients. The World Health Organisation (WHO, 2011) has argued that palliative care has generally been unduly focused on the needs of cancer patients and is unsuited for the increase in older patients with diverse needs that are more common in many parts of the world. Part of this variation is the differences between the type of care required for various conditions and the fact that sometimes specialised care for a variety of conditions is required (Preston et al. 2014). There are also challenges posed to meeting patients’ wishes for palliative care through patient-centred care, and Gomes et al. (2013) suggest that the desire of most patients to die at home can stretch resources or result in palliative care provision not reaching the wishes of their clients. Likewise, the extent to which palliative care can be effectively provided through interaction with other care providers, and the role of family or informal carers is often unclear (Hanson et al., 2012). This has led to a range of views on the effective provision of palliative care. In this essay, first the challenges posed by an aging population and the challenge of providing specialist care to specific population groups will be considered. Second, the challenge of providing home-based palliative care will be discussed. Third, the challenges of developing effective communication between caregivers and the family will be evaluated. Fourth, ways in which informal caregivers may be involved in palliative care will be discussed. Finally, the arguments for earlier intervention in some cases will be evaluated.

The World Health Organisation argues that an important factor impacting upon the effectiveness of palliative care is the aging population in most countries that is coupled with a lack of attention to their complex needs (WHO, 2011). Older people more commonly experience multiple health problems, resulting in the need for such complex health needs to be more effectively supported (WHO, 2011). The model for palliative care traditionally focuses upon support for single diseases such as cancer, whereas people aged over 85 years are more likely to die from cardiovascular disease. There are also multiple debilitating diseases, such as dementia, osteoporosis and arthritis, and may require palliative care at any point in their illness trajectory (Gardiner et al., 2011). WHO (2011) indicate that palliative care does not usually form a part of traditional disease management, and with a combination of diseases the point at which palliative care is needed may become increasingly difficult to determine. The need for integration between different agencies is also cited as an important factor affecting older people (WHO, 2011). As such, palliative care for older adults must take into account the increasing variety of conditions that may develop, which is something that is not yet common amongst many care providers.

Solutions to these issues proposed by WHO (2011) include the need for palliative and primary care providers to receive more effective training in the needs of older people, and to gain a clearer understanding of the syndromes that affect this population group. This also includes a more effective understanding of the pharmacokinetics of opiates for pain management, and issues that are caused by comorbidity (Gardiner et al., 2011). Palliative physicians also need to improve their understanding of long-term care, including the administrative and clinical issues that are associated with older people dying in care homes. Likewise, inter-agency collaboration in palliative care is required to ensure that diverse needs are met through carers with different specialisms (Neilson et al., 2013). This means that palliative care needs to adopt a more personalised approach that takes into account the specific needs of clients, making collaborative approaches more common (Vitillo & Puchalski, 2014). As such, partnership working is likely to play an increasingly prominent role in palliative care provision in the future.

Similar concerns involving the specialised care for specific groups is identified by Vollenbroich et al. (2012), who investigate the potential for providing home care for children. These results suggested that where a specialised paediatric care team was used, there were high improvements in the children’s symptoms and quality of life. Additional benefits were seen as the reduction of the administrative barriers and improvement in aspects of communication between the care teams and the family. This supports arguments made by WHO (2011) which suggests greater specialisation is required to take into account the different diversities of patients who need palliative care. However, one aspect that is not identified by Vollenbroich et al. (2012) is the challenge posed by whether the condition should be considered as of greatest importance or whether the demographic considerations are needed (Gardiner et al., 2011). This suggests that perceptions of the age at death can significantly affect the patients’ needs in palliative care, and further research may be required to investigate the extent to which such suppositions are borne out in practice.

The place in which palliative care is provided is also a significant factor when considering how far the care meets the wishes of the patients. The extent to which people can opt for their place of death is an important factor affecting the effectiveness of palliative care. In the European Union, most people do not die at home (WHO, 2011). However, this is the preferred place of death for most people. In England, 58% of deaths occur in NHS hospitals, 18% at home, 4% in hospices, and 3% in other places. There is clearly an interest amongst many patients for dying at home. Jordhoy et al. (2010) report on an intervention programme staged by the University Hospital of Trondheim, Norway, which was intended to enable patients to spend more time at home and for them to die there should they prefer. This demonstrates that in order to achieve this end, close cooperation was necessary with the community health-care providers, and a multidisciplinary consultant team was needed to coordinate the care provision. This research demonstrated that intervention patients spent a smaller proportion of the last month of life in nursing homes than was possible for the control sample (Jordhoy et al. 2010). This illustrated that to increase the proportion of patients who were able to die at home, a significant investment of resources would be needed. This manifested itself in the need for greater levels of training in palliative care for community care staff, thus increasing the costs associated with the provision of care (Jordhoy et al. 2010).

Similar considerations were made by Gomes et al. (2013), who argue that providing palliative care at home increases the chances of dying at home, while reducing symptom burden that people experience as a part of an advanced illness. This also reduces the intensity of grief for family members if the patient dies (Gomes et al., 2013). However, Gomes et al. (2013) suggest that it is possible to provide home palliative care without significantly raising costs, but this is challenged by reports such as WHO (2011) who argue that for many patients, the complexity of the conditions experienced undermine the potential for home care to be effectively provided. Smith et al. (2014) suggest, however, that the context of increasing costs of healthcare means that the potential for palliative care to be provided in the home environment should be more closely investigated. In particular, this outlines that the quality of care can be significantly improved for home-based care, and in some cases the costs may be reduced by the fact that they may be spread between existing caregivers.

Communication between the patients and family members is often cited as an important factor leading to improved palliative care. Hannon et al. (2012) suggest that in contexts where family members are taken into account and given a role, family meetings can account for a significant improvement to the weekly workload for staff members. The study suggested that such meetings improved the particular areas of concern and worry for family members (Hannon et al., 2012). This demonstrates that such meetings can play an important role improving the experience of palliative care and indicate that one of the important roles of caregivers lies in the support that is given to the families of the patients as well as to the patients themselves (Hannon et al., 2014). However, although such meetings are considered appropriate and effective they may be undermined by the time constraints, the availability of appropriate staff, and the limitations of resources (Hannon et al., 2014). This may lead to less emphasis being placed on such aspects of palliative care, particularly where the benefit is not directed wholly towards the patient. Nevertheless, against this criticism is the extent to which such issues may result in the needs of the patient being better identified by consultation with family members (Gomes et al., 2013). It can be argued that this would represent an area of particular benefit to the provision of palliative care.

Harding et al. (2011) point out that informal caregivers are of significance in providing effective palliative care. Given the diversity of the care provided by this group, there is a need for a range of intervention strategies to provide appropriate support, depending on the needs of the patient. However, Harding et al. (2011) suggest that the range of models that are available to meet caregivers’ needs. Likewise, Harding et al. (2012) emphasise the significant costs to informal caregivers in terms of the emotional, physical and financial demands that informal caregiving places upon them. The conclusions of these studies indicate that support should be provided specifically to the caregiver and tailored closely to their needs, and the drawback of many existing approaches was the fact that interventions were not tailored to the caregivers’ needs. This is an important aspect for improving palliative care, as many patients prefer the services of informal caregiving, and this can also reduce the burden on professional healthcare if appropriate (Aslakson et al., 2014). The potential for providing support that is tailored to the needs of the informal caregivers would seem an important and effective means by which the quality of palliative care can be improved (Brandstatter et al., 2014).

Zimmerman et al. (2014) identify that there are limitations to the provision of palliative care in home settings that depend upon the condition of the patient. In their study, patients with advanced cancer tend to have a much lower quality of life that worsens as their condition progresses. This suggests that for some patients, palliative care should be provided at an earlier stage than is usually the case. However, such developments would depend upon the prognosis, and in such cases it is important to avoid premature judgment. Yoong et al. (2013) also suggest that early palliative care can prove beneficial in situations where patients have advanced lung cancer. This suggests that the benefits allow the palliative care teams to focus on fostering relationships with patients and their families, and improving illness understanding amongst patients and caregivers. The potential for adopting a comprehensive approach in this case provided psychosocial benefits, such as improving the coping mechanisms for patients alongside the management of medical treatment (Bajwah et al., 2012). The research thus indicates that the involvement of palliative care teams at an earlier stage in the treatment may be appropriate for some conditions and may provide significant benefits to the quality and effectiveness of care.

In conclusion, many of the arguments discussed suggest that there is an important case to be made for a greater diversity in approaches to palliative care. The need to take into account the diversity in the psychosocial needs of different population groups illustrate the importance of a more personalised approach to palliative care. Likewise, the challenge in meeting patients’ wishes to die at home requires significant attention as this can clearly provide significant benefits to patients. The research also indicates that greater engagement with family members can help support patients and prove of wider benefit to the carers. This also indicates that the involvement of informal caregivers is also a significant area of development, given the wide-ranging role they can play in the provision of palliative care. The introduction of palliative care at an earlier stage may allow benefits to the care process, particularly where the patient is cared for at home, as it helps foster an effective working relationship between different parties. Thus far, the key deficiencies of palliative care are largely that it appears to be focused on particular conditions and specific locations; the challenge is to broaden the type of patient that can be cared for, provide greater support to informal carers and family members, and be more responsive to the wishes of the patient.

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Neilson, S. J., Kai, J., McArthur, C., & Greenfield, S. (2013). Using social worlds theory to explore influences on community nurses’ experiences of providing out of hours paediatric palliative care. Journal of Research in Nursing, 18(5), 443-456.

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Deathography Reflective Essay

In life nothing is more inevitable than death, it simply cannot be avoided. Despite advances in medical sciences and increased longevity in the Western world, human life remains fragile as death can occur at any age in a myriad of circumstances. Grief follows the death of a loved one, is often cited as being a ‘universal’ response to loss (Davidson, 1988) and can be defined as ‘intense sorrow’ (Oxford English Dictionary, 2013). Each bereaved person will experience and respond to grief in a unique way, underpinned by social, cultural and religious factors, further influenced by the individual’s personality and coping mechanisms. Grief reactions are widely acknowledged to vary in length and severity and to have physical, emotional, cognitive, behavioural and spiritual components (Rosenblatt, 1993: Archer, 1999: Parkes, 2001).

On the 18th September 1989 I gave birth to a beautiful, healthy baby girl weighing 8lbs and 11 ounces. As a parent I had such high hopes and expectations for the future but on 23rd February 2002, aged 12 years, her life was drastically cut short following a tragic accident. She was excited as she set off for her first ever sleep over at her best friend’s house, I was anxious as this was the first time she had been away from home without me.

On that cold, damp Saturday afternoon they had decided to go out for a bike ride (my daughter had borrowed an old bike belonging to her friend’s brother).Whilst out riding the chain came off, as she fell to the ground the bike landed on top of her abdomen causing her liver to rupture. My daughter died within minutes from a massive internal haemorrhage, in severe pain and all alone at the road side as her friend had gone to get help. Oblivious to what had happened; I received a telephone call from her friend’s mother stating that Gemma had been in an accident and to meet her at the Birmingham Children’s Hospital. Assuming that she had experienced relatively minor injuries (I was told not to worry), I was ill prepared for the scene that unfolded before me as I entered the Multiple Injuries Unit in Accident and Emergency. Gemma lay motionless on a trolley, her body covered with a white sheet. The room was full of nurses and doctors who had attempted to resuscitate her, all of whom appeared shaken and emotional but no one was able to provide an explanation or answer my questions as there were no signs of injury or trauma to her body. It was only after the post mortem that the cause of her death was identified. I left the hospital that evening with a carrier bag containing her personal possessions and a leaflet explaining ‘what to do when a child dies in hospital’, barely able to comprehend what had just happened or the magnitude of my loss.

The loss of a child is the most devastating loss of all. It defies the natural order of events as parents do not expect to mourn their children, causing heartbreak and trauma like no other. Parental grief is different from other losses in both intensity and length. Sudden death robs the bereaved of preparatory grief, is more common in young people and often occurs in clinical environments.

There is a well-established theory base relating to issues of loss. Early theories include Freud’s (1917) grief work perspective and Bowlby’s (1969) early attachment model. Freud’s work led to grief being conceptualised as both a pathological condition requiring psychological intervention and a linear process. The individual must ‘work through’ it in order to detach the memories and thoughts associated with the deceased love one. Both Bowlby (1980) and Parkes and Brown (1972) suggest that grief follows a predictable pattern. A well-known five stage grief model developed by Kubler-Ross (1969) depicts grief as passing through phases of shock and denial, anger, depression, bargaining and eventual resolution and acceptance. Terms such as ‘normal’ and ‘complicated’ grief (Engel, 1961) were developed as a way of distinguishing grief that had not resolved within a given time frame.

Recent years have seen the development of a number of new theories and approaches to loss and grief. Stroebe and Schut (1999) explain grief reactions in terms of two concurrent processes or ‘orientations’ (also known as the dual process model). Loss orientation is described as a traditional grief reaction, characterised by despair, sadness and anger, whilst restoration orientation is characterised by attempting to rebuild one’s life and move on. Klass et al (1996) emphasises the importance not of letting go but of holding on even after the loss has occurred to maintain continuing bonds. Worden (1991) described four overlapping stages and tasks which the bereaved work through in order to relocate the deceased by redefining the relationship in the new context of the loss to invest in the future.

People who are suddenly bereaved often require more support and counselling than those who have the time to prepare for the death of a loved one. Without such support, unresolved grief reactions may occur along with a life time risk for psychiatric diagnosis (Keyes et al, 2014).Unexpected death is associated with Post Traumatic Stress Disorder (PTSD), panic disorder and depression regardless of when the death occurred in the life of the bereaved person. The incidence of generalised anxiety disorder, social phobia, mania and alcohol abuse is greater if the death occurred after the age of 40 in the bereaved person’s life. Thus, whilst extreme sadness and despair are normal reactions to loss which usually dissipate over time, some grief reactions are so severe they give rise to psychiatric disorders requiring medical intervention (Worden, 2003).

On that fateful day in 2002, my whole life’s purpose changed and everything that I had lived for now ceased to be. Neimeyer (2000) maintained that major losses challenge a person’s sense of identity. In the immediate days and months that followed I strongly identified with the initial stages outlined by Kubler – Ross of shock and denial. As a mental health professional I was familiar with the model and knew the predicted pattern that my grief would likely follow. I would ask myself over and over again, how could my only child be dead? How can someone die falling off a bicycle?

Catapulted into the depths of despair, no longer a mother, all my hopes and plans for the future had become futile and irrelevant. A major task of grief requires refocusing one’s life story to rebuild and maintain a semblance of continuity between what has gone before and what lies ahead (Neimeyer, 2006). The foundations of my belief system had been called into question; why Lord did you have to take my daughter who had so much to live for when there is so much human suffering in the world. I was consumed with anger whilst having to support my husband, parents and other family members alongside coping with returning to work. My colleagues would avoid me in the corridor, not knowing how to approach me or what to say.

Barely able to function, I felt lost, alone, hopeless and worthless. Overwhelmed by guilt, I felt that I should be blamed for failing to protect my daughter as I had not fulfilled my duty as a mother. The months turned to years, my frustration grew as I waited for the time that I would achieve resolution and acceptance. I lost motivation and became anxious, living in fear that I would lose another family member in such sudden and dreadful circumstances. I experienced flashbacks and actively avoided seeing friends and family as their children reached major milestones such as learning to drive or graduation. Loss orientation and concurring loss restoration would have been incomprehensible for me at this time. Instead, I chose to keep her memory alive by raising money for the Birmingham Children’s Hospital, publishing a diary of a bereaved mother, sponsoring an award in her name at the school she had previously attended, making frequent visits to her grave and commissioning a large portrait of her to hang in the lounge (continuing bonds).

Five years on, I was still unable to contemplate resolution and the trajectory of my grief wasn’t following a staged or linear process but zig zagged erratically back and forth between stages. This was unsettling and uncomfortable and went against everything that I had been taught as a mental health professional. Not only had the prescriptive linear and staged models been unhelpful (Sheehy, 2013) but had led professionals to conclude that I experienced a complicated grief reaction as resolution didn’t come within a given time frame. I gave up engaging with health care professions as I felt the template they were adhering to didn’t fit my unique situation. I still felt the physical pain of losing her as I acknowledged that my loss had pervaded every area of my life and completely changed my personality. Finally, I knew that it was up to me to find meaning in my life in order to have a future. That meaning came six years later when I became the mother of a baby boy in 2008.

The experience of losing Gemma was devastating and remains immensely painful but I now accept that the pain is an intrinsic part of me. I have simply learnt to live with it. The loss and trauma I have experienced has defined the person I am today, however, it must be stated that it has also positively influenced my attitudes and beliefs about life in many ways. Over the thirteen years, I have gained inner strength and I now appreciate just how precious life is. I take nothing for granted, knowing only too well how quickly a life can be taken away. I don’t plan for next year or too far into the future but I prefer to live in the moment and try to find something positive in each day. I am more tolerant and forgiving of others, whilst making a conscious effort to regularly remind relatives and friends how important they are to me and how much they are loved. If something is wrong in my life, I now have the courage to change it. I am not afraid of my own mortality, my faith has now been fully restored and I believe that one day I will be with her again when it is my turn to cross to the other side. Furthermore, the way in which I interact with bereaved people as a mental health professional has changed, shaped by my own experiences and the need to understand each individual in the context of their reality.

The hardest thing to do was to forgive myself and to realise that I am not to blame for her death. I have survived life’s cruellest blow and although life will never be the same, I am now able to experience happiness again. Gemma will always have a presence in my life as she is spoken about lovingly and frequently as a household name, her portrait remains over the fire place as a reminder of her wonderful contribution to my life.

In conclusion, whilst models and theories offer helpful frameworks and insights into the grieving process an individual’s unique response cannot be overstated. Many factors influence how an individual grieves, the dominance of linear or staged processes are too prescriptive. In supporting the bereaved, the task of the health care professional is not to favour or propose one model over another but to challenge assumptions and listen to the bereaved in order to facilitate an accurate reconstruction of the individual’s inner self and outer world. Thus, adopting broad concepts facilitates a more holistic understanding of the needs of the individual. Failure to do so will result in a continued theory/practice gap and those bereaved individuals who do not come through may remain prone to a range of long lasting psychiatric disorders. Further research is required into bereavement related contextual factors and the development of effective interventions in helping the bereaved to cope and such an approach is relevant in a wide variety of situations.

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Neimeyer, R.A. (2006) Widowhood as a Quest for Meaning. A Narrative Perspective on Resilience. In Carr, D., Nesse, R.M., and Wortman, C.B., (eds.), Spousal Bereavement in Later Life (pp 227-252).New York: Springer.

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Sheehy, L (2013) Understanding Factors that Influence the Grieving Process. End of Life Journal.3 (1)

Stroebe, M. and Schut, H (1999) The Dual Process Model of Coping with Bereavement: Rationale and Description. Death Studies, 23 (3)

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Can breastfeeding in the first six months prevent childhood obesity?

‘Obesity’ is defined as a body mass index (BMI) of ?25kg/m2 (World Health Organisation 2015). In the past decade, throughout much of the world, the rates of obesity in children in particular have increased to epidemic proportions (Lefebvre & John 2012, p. 386). The World Health Organisation (2015) estimates that 42 million children under the age of 5 years are overweight or obese worldwide and in Britain, overweight and obesity affects nearly one-third of children aged 2 to 15 years (Health and Social Care Information Centre 2009). Since obesity in childhood is strongly correlated with serious disease and increased risk of mortality throughout life (Yan et al. 2014, p. 3), and because of the significant direct costs of obesity on health services and societies globally (Department of Health 2011), strategies to prevent childhood obesity are of paramount importance. Research has suggested that breastfeeding for the first six months may be protective against and, therefore, prevent obesity in childhood (Lefebvre & John 2012, p. 386). Through a critical evaluation of this research, this paper will answer the question of whether breastfeeding in the first six months can prevent childhood obesity.

The beneficial effects of breastfeeding for children are well-established in the literature. High-quality studies have demonstrated that children who are breastfed have a reduced risk of ear infections (Duncan et al. 1993, p. 867), respiratory infections (Bachrach, Schwarz & Bachrach 2003, p. 237), necrotizing enterocolitis (Lucas & Cole 1990, p. 1519), gastroenteritis (Chien 2001, p. 69), diabetes (Owen et al. 2006, p. 1043), atopic dermatitis (Gdalevich et al 2001, p. 520) and sudden infant death syndrome (SIDS) (Vennemann et al. 2005, p. 655). Breast milk is not only rich in protective antibodies and beneficial bacteria, it is nutritionally-balanced and adapts to meet an infant’s changing needs (National Health Service 2015). Research has therefore suggested that another significant benefit of breastfeeding may be that is acts as a protective factor against obesity in childhood.

Kramer was the first to report that breastfeeding may result in a “significantly reduced” risk of obesity in children (1981, p. 4). In the next two decades, a number of similar studies also suggested an association between breastfeeding and a reduction in the risk of childhood obesity. In the mid-2000s this research was collated into three seminal meta-analyses which concluded that, overall, breastfeeding for the first six months did reduce the risk of childhood obesity. For example, Arenz et al. (2004, p. 1247) found that obesity had a “small but consistent” protective effect against obesity in children. This was supported by Owen et al. (2005, p. 1367), who demonstrated a small positive correlation between breastfeeding and a reduction in the risk of childhood obesity. Harder et al. (2005, p. 397) also found that the duration of breastfeeding was inversely associated with the risk of childhood obesity. These meta-analyses suggested an overall 15% to 30% reduction in odds of overweight from breastfeeding. However, they were widely criticised for major methodological problems, including a failure to deal appropriately or consistently with confounding variables such as parental BMI. As a result, the evidence they presented on the relationship between breastfeeding and reduced childhood obesity risk was not widely accepted.

However, the potential for a correlation between breastfeeding and a reduction in the risk of childhood obesity continued to be discussed and researched. In the past decade, a small number of high-quality studies have investigated this potential relationship. Evidence from this research is largely conflicting, with results varying depending on the study design used. For example, two large randomised-controlled trials found breastfeeding had no impact on the prevalence of obesity in children aged 6 or 11 years (Kramer et al., 2007, p. 1717; Martin et al., 2013, p. 1005). Similarly, several studies in siblings found no differences in the BMI of breastfed versus non-breastfed children (Evenhouse & Reilly 2005, p. 1781; Gillman et al. 2006, p. 112; Colen & Ramsey 2014, p. 55). Likewise, two high-quality American studies reported either no (Jiang & Foster 2013, p. 628) or small and inconsistent (Jenkins & Foster 2014, p. S128) effects of breastfeeding on childhood BMI. Conversely, multiple studies have reported a positive relationship between breastfeeding and a reduction in the risk of childhood obesity. For example, a large UK study concluded that breastfeeding reduced the overall risk of childhood obesity to a degree considered statistically-significant. These findings are supported in high-quality studies from Germany (Grube e tal. 2015, p. 1), Brazil (Assuncao et al. 2015, p. 1) and Japan (Jwa et al. 2015, p. 1527). Furthermore, these studies demonstrate that the length of time a child is breastfeed is proportional to the degree of their reduction in obesity risk, and that the inverse association between breastfeeding and overweight appears to be sustained over time.

Part of the problem underpinning these marked differences in study results can be explained by the quality of the studies themselves. Randomised-controlled trials – the gold standard of research trials – investigating the effects of breastfeeding are rare, because the well-established benefits of breastfeeding means allocating children into ‘breastfeeding’ and ‘non-breastfeeding’ cohorts would raise justifiable ethical concerns (Grube et al. 2015, p. 2). In studies where groups are not randomised, a spurious relationship between breastfeeding and reduced risk of obesity may result as a result of confounding if, for example, mothers who breastfeed also adopt a healthier lifestyle involving a nutritious diet and adequate physical activity for themselves and their children (Centers for Disease Control 2007, p. 3).

Reasons for these marked differences in study results can also be explained by the diverse sociocultural context in which both breastfeeding and obesity are grounded. Essentially, sociocultural factors have a significant impact on both breastfeeding and obesity which confounds the relationship between these two variables. For example, a cohort study examining the correlation between breastfeeding and childhood obesity in groups of English and Brazilian children found that breastfeeding was associated with reduced risk of childhood obesity in the English cohort but not in the Brazilian cohort (Brion et al., 2011, p. 670). This study suggests that sociocultural factors have a significant impact on the relationship between breastfeeding and childhood obesity in cohorts with different sociocultural characteristics. Another similar cohort study confirmed that breastfeeding in particular is a ‘socially-patterned’ phenomena, and that as a result the relationship between breastfeeding and childhood obesity may differ between cohorts in low- to middle-income and high-income countries (Fall et al., 2007, p. 47). Furthermore, a high-quality meta-analysis found that evidence for the relationship between breastfeeding and childhood obesity is primarily derived from studies conducted in high-income countries where the correlation between breastfeeding and socioeconomic status is a significant source of confounding in this relationship (Horta & Victora 2013). It is apparent, therefore, that the question of whether breastfeeding in the first six months can prevent childhood obesity is largely dependent on sociocultural factors.

The sociocultural-dependent nature of the relationship between breastfeeding and childhood obesity is also revealed in studies which have adjusted statistically for other covariates, such as sociodemographic factors and variables concerning birth, pregnancy and parental atopy, etc. For example, in one adjusted study on a German cohort, Grube et al. (2015, p. 1) conclude that breastfeeding might help to prevent childhood obesity. However, in another adjusted study on a Chinese cohort Jing et al. (2015, p. 55) found no statistically significant effect of breastfeeding on reducing the risk of childhood obesity. Because these studies both adjust for a range of sociodemographic and other covariates, sociocultural differences are an important explanation for the differences observed in results.

It is exceedingly difficult, perhaps impossible, to control for the diversity of sociocultural variables evident in different populations. The best that can be done is to control for as many other variables, such as sociodemographic factors, as possible. When this is done, the evidence overwhelmingly suggests that breastfeeding in the first six months can reduce the risk of childhood obesity. For example, a meta-analysis by Horta and Victora (2013) concluded that, if only studies which control for confounding are considered, breastfeeding leads to a reduction in childhood obesity of around 10%. This is supported by another large meta-analysis by Yan (2014) which, after examining only studies controlling for confounding, concluded that the risk of childhood obesity was lower in breastfed children by 22%.

It is worth noting that no Cochrane Systematic Review – the gold standard of meta-analysis – has been completed on the relationship between breastfeeding and childhood obesity. However, a Cochrane Systematic Review on evidence for the optimal duration of breastfeeding did conclude that breastfeeding did not confer any protection against obesity in children to the age of 6 years (Kramer & Kakuma 2012, p. 5) – a surprising finding, given the conclusions drawn in the previous paragraphs. However, this Cochrane Systematic review looked at obesity in terms of weight gain rather than BMI, the standard measure for obesity. It also did not exclude studies which failed to adjust for confounding. Thus, it is not accurate to compare its results with those of the meta-analyses discussed previously.

It is now generally accepted that breastfeeding in the first six months can reduce the risk of childhood obesity. However, complicating this conclusion is the complexity surrounding differences in the concepts of childhood obesity prevention versus risk reduction. The literature widely accepts that breastfeeding reduces the risk of childhood obesity; however, no studies claim that breastfeeding prevents obesity. Thus, in direct answer to the research question it must be concluded that breastfeeding in the first six months does not prevent childhood obesity. However, breastfeeding does reduce the risk of childhood obesity. Moreover, the length of time a child is breastfeed is proportional to the degree of their reduction in obesity risk and the inverse association between breastfeeding and overweight appears to be sustained as the child grows (Centers for Disease Control 2007, p. 4).

A variety of research is now being undertaken to further explain the relationship between breastfeeding and a reduction in the risk of childhood obesity. It has been suggested that, due to more normalised concentrations of the hormone leptin, breastfed children may have a more well-developed recognition of satiety and an improved ability to self-regulate their energy intake in both early and later childhood (Gillman 2011, p. 681). Hormones in human breast milk may influence this learned self-regulation of energy intake (Savino et al. 2009, p. 397). Additionally, breast fed children have a lower plasma insulin concentration and a shorter insulin response resulting in more regulated body fat deposition (Dietz 2001, p. 2506). Furthermore, the higher protein intake of formula-fed infants may stimulate the secretion of insulin and result in the dysregulation of body fat deposition (Dietz 2001, p. 2506).

The conclusion that breastfeeding reduces the risk of childhood obesity is widely accepted by global peak bodies on child health. These peak bodies include the World Health Organisation’s (2015) UNICEF, whose Baby Friendly Initiative is widely endorsed by maternity hospital and health service in the UK. The relationship between breastfeeding and a reduction in the risk of childhood obesity is also reflected in the policy statements and guidelines of most major paediatric bodies worldwide, including the Royal College of Paediatrics and Child Health (2011) and the American Academy of Pediatrics (2012).

Obesity in childhood is a significant problem globally. This paper has concluded that whilst breastfeeding in the first six months does not prevent childhood obesity, there is evidence to suggest that breastfeeding does reduce the risk of childhood obesity. Moreover, the length of time a child is breastfeed is proportional to the degree of their reduction in obesity risk and the inverse association between breastfeeding and overweight appears to be sustained over time. However, it must be remembered that both breastfeeding and obesity are grounded in a range of sociocultural determinants which may confound this relationship. However, since obesity in childhood is strongly correlated with serious disease and increased risk of mortality throughout life, and because of the significant direct costs of obesity health services and societies globally, a relationship between breastfeeding and a reduction in the risk of childhood obesity is a significant finding.

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Introduction

A group of young men who had been in music for some while by the name” The rolling Stones” placed a claim that they were the greatest Rock & Roll band in the whole world in the later part of 1960s. Most people disputed the claim and little did they know the group had actually raised to a world class musicians. Since then, the Rolling Stones’ music which is mainly based on Rhythms and Blues has continued to sound vital pieces through the decades.

During the period of British invasion in 1964, the members of this group were called the bad boys instead of the world’s best band. What was viewed initially as a gimmick later led to a world image that many people especially their critics could not believe. One of their comrades Brian Jones met his death in 1969 which is up to date a mystery. This tragic year also saw violent murder during their set towards the end of the year at Altamont (Regina, 1980).

This band pioneered the famous ridiculing tone of British rock’s detachment and they did this through the music they composed. They wrote songs about offhand brutality, implied sex as a source of power among other compositions that were according to British community then, a taboo.

This group did not act as per the norms of its community. Mike Jagger in his music and social controversies as a musician in this band was perceived to be evil and was as a result branded the name ‘Lucifer’. He released ‘sympathy for the devil’ which, to many, was like an admission that what he and his group were doing was devilish.

The Rolling Stones Band

Dartford Maypole County Primary School is legendry to Jagger and Richards for this was their first meeting place. Afterwards in1960 the duo discovered one familiar thing concerning themselves which was love for R&B. They managed to develop a reciprocal friendship with Dick Taylor, who was a guitarist and was pursuing economic studies in a London school. Jagger and Richards teamed up with Taylor and this also saw Richards becoming a second guitarist when they formed the Little Boy Blue and the Blue Boys band.

This formation was disastrous for Richards as he was debarred from Dartford Technical College for absenteeism. Interestingly, Brian Jones started playing bebop alto sax and clarinet while in Cheltenham. One of the most awful things, at the age of sixteen Brian Jones had to flee briefly to Scandinavia for he had been a father to two illegitimate kids. Immediately after Jones returned back to Cheltenham, they teamed up with Ramrods prior to proceeding to London. Once he settled in London he joined Alexis Korner in his band which played blues.

This did not stop him from organizing his own band of which he incorporated Ian Stewart who was a renowned pianist in London (Sandford & Richards, 2004). Just as his colleague Elmo Lewis, Jones started to work at Ealing Blues Club and later joined other groups in singing blues. With this new group, he met and played with drummer Charlie Watts. While at one side Richards and Jagger started jamming with playing Blues music, these two together with Jones started going in to private music practice while Jagger became the most famous and featured singer of the time with blues, Inc. while in the city of London, the three friends and blues musicians Jones, Jagger and Richards rented a tiny apartment.

Together with Tony Chapman who was a drummer, they cut a demo tape which to their disappointment did not meet the standards of EMI and was therefore rejected. Taylor left his colleagues to join the royal college of arts after which he started ‘Pretty Things’. The genesis of the name The Rolling Stones can be traced to this period when Taylor left. It is after his leaving when they did the song ‘Muddy Waters’.

It is this particular song that earned them the name of their band which they were to use to rise to fame and be universally recognized as the best Rock music in the whole world. Life was a little bit a challenge to the group but when one of their colleagues Ian Stewart got a job with a chemical company in London, the rest of the group could not starve to death because there was something to eat, at least (Regina, 1980).

July 1962, the band; ‘The Rolling Stones was made up of its veterans Jagger, Jones, Richards together with bass voice singer Taylor Dick and drummer Mick Avory. The latter was to join the Kinks group later. This band staged their first work at the Marquee on the 12 th of July, 1962 (Sandford &Richards, 2004). Two guys from the Clifton’s band namely Chapman and Bill Wyman soon replaced Avory and Taylor respectively after their departure from the Rolling Stones band.

According to Jagger, Jones and Richards, Chapman did not fit well in his new position. To avoid a mistake in appointing a person to replace Mr. Chapman, they decided to take their time, actually several months, to recruit Charlie Watts. They took much caution in executing this exercise because they simply wanted the best person to take that role satisfactorily. Charlie Watts previously worked in Blues.

He was an employee to an advertising agency. At one time, the Blues’ schedule would get too busy and it made his job difficult, he had decided to leave the group and concentrate on his advertising job. Recruiting Mr. Watts who was an advertiser is felt to have been a strategic approach for the members of the Rolling Stones band. First, Mr. Watts was a famous man in the city and he could appear in company advertisements for brands.

Such a famous person being associated with the band and actively participating in the Rolling Stones made the group feel proud. Most of their fans would come to see the man they saw in television adverts perform live. This contributed positively in getting more fans and more cash in that case (Sandford & Richards, 2004).

In January 1963, Mr. Watts officially joined, thus completing the band. Their fortune began when Mr. Gomelsky Giorgio, who was a local businessman, signed a deal with the Rolling Stones where they were to perform at his Crawdaddy club for eight months. This residency was most successful for the band. The owner of this club remained the manager of the Stones, although unofficially, they were signed as clients to Andrew Loog Oldham who obtained finances from Eric Easton.

Their sponsorship by Oldham was meant to raise their status so that they may out-compete the Beatles who were then the sensation of Britain. This kind of promotion was an easy way out for Mr. Stewart, who despite being mild-mannered was the band’s popular pianist both on tour and road within the residence (Sandford& Richards, 2004).

The Rolling Stones released their first track single in June 1963, known as ‘Come on’ by Chuck Berry. When the Stones first played on the British TVs ‘Thank Your Lucky Stars’ Program, the producer of that program reportedly advised the groups sponsor and manager to get rid of Stewart because he was ‘vile-looking singer with the tire thread lips’ (Mick et al. 2003).

Despite this criticism, that single reached number twenty one on the British best music chart. The same year, the Rolling Stones for the first time participated in the London based National Jazz and Blues Festival which was held annually.

In September 1963, the Rolling Stones band was short listed among other bands that were to participate in a package of tour entertaining their fans while promoting the business of their sponsors. Included in the tour were other bands such as Everly brothers, Little Richard and Bo Diddley. In December 1962, the Rolling Stones band released their second single track known as ‘I wanna be your man’ which was entirely written by John Lennon and Paul McCartney. This track brought much fame to the band and it featured in the top 15 hits in Britain.

In January 1964, The Rolling Stones band for the first time headlined a tour in Britain with the Ronettes. They jointly released a version of ‘Not fade away’ which had earlier been done by Buddy Holly. This track rose up the chart and unbelievably was rated third. The track did not only bring fame to the Rolling Stones in Britain but also crosses borders as far as the US where it was rated No. 48 in the US singles charts.

Meanwhile, the band had actually attained the dreams of their sponsors and manager because it was a real sensation in Britain. At times, the press would report things like members of the band had been spotted urinating in public which was a show of ill manners but at same time a proof of sensation in the city (Obrecht 1980).

In April 1964, Rolling Stones band released their first album in United Kingdom which was followed by an American tour barely two months later in June 1964. They covered the song ‘it’s all over now’ which had earlier been as collaboration between Valentinos and Bobby Womack. This song had been rated the British number 1 and had been one of their own (Stephen 2006).

In their tour to America in June 1964, they stopped at the city of Chicago based Chess Records, to record ‘five by five’ EP. Their recording was a success although there was a challenge when riots broke out when the band members attempted to address the press. Meanwhile, the band’s version of the blues standard track ‘little red rooster’ which had been rated number 1 on Britain’s chart was banned in the US market and media for claims that it had “objectionable” lyrics (Sandford & Richards, 2004).

At this time, both Jagger and Richards had already started the composition of their own tunes initially using ‘Nanker Phelge’ for compositions which they made jointly. In August 1964, one of Jagger and Richards piece “Tell me (you are coming back home) was one of the joint composition tracks which was accepted in the US and rated in the top forty (Regina 1980).

In November 1964, another composition by Jagger and Richards which was original, “Time is on my side” was rated number 6 on the top hit chart in US. Since then, very few of the songs that were performed by the Rolling Stones band were a joint-composition of Richards and Jagger (Nico 2008).

The year 1965 was a good year for the group because they recorded success. Their hit “The late time” became number one on the UK charts while it appeared in the top ten hits in the US in that spring. The stones next single release was “I can’t get no satisfaction” which consecutively remained number 1 for four weeks in the summer of 1965 and it is perceived to have been the most famous song.

The talented and creative duo (Jagger & Richards) continued to write songs but with time, their composition became more sophisticated. Their work was worth their effort because each of their composition appeared in the top hit charts either in the UK or the US. Some of their most famous tracks include ‘get off my cloud’ which was No. 1 in 1965, ‘as tears go by’ rated position 6 in 1965, ’19^th nervous breakdown rated second in 1966, ‘mother’s little helper’ rated 8 in 1966 and ‘have you seen your mother, baby, standing in shadow?” which was rated ninth in 1966.

The Rolling Stones released their primary LP 1966 and it was a set of purely original material (Sandford & Richards, 2004). Although it was expected to bring much impact in the music industry and market, the impact was significantly minimized because the Beatles released their ‘Revolver’ while Dylan Bob released his ‘Blonde on Blonde’ almost at the same time. This resulted in steep competition in the market because despite these three simultaneous releases by industry foes, the Middle Eastern had produced ‘paint it black’ in 1966 and the ballad “ruby Tuesday” which had remained the number 1 hits in the US (Obrecht 1980). They were simply unbeatable.

In January 1967, there was a stir up of another sensation in Ed Sullivan show when the stones performed their ‘let’s spend the night together’ which was side B of Ruby Tuesday. In this show, Jagger instead of singing the words in the title line mumbled because there was a threat of censorship after some people made claims that the first line of the track had been censored. Many people anticipated that Jagger sung the phrase ‘let’s spend some time together with clarity and audibly (Mick et al. 2003).

In February 1967, Jagger and Richards faced a major challenge when the two were arrested while in Britain in connection to crime of possessing drugs (Stephen 2006).May 1967, another challenge faced the Rolling Stones band with the arrest of Brian Jones. Luckily, the heavy jail sentences which had been made upon the three artistes were eventually put in to suspension following an appeal by their lawyer.

As a result of this drawback, the Rolling Stone band members decided to refrain from making public appearances whether performing or in private business but this were a temporary measure and a strategy to recollect and reflect on their plight. Jagger with his love, singer Marianne Faithfull, flew to India in the company of Beatles to meet star Maharishi Yogi. Following this episode, the Rolling Stones did not release another single until much later in the fall when they released the hit ‘Dandelion’ which was ranked number 14 while its side B ‘we love you’ was rated 50. In this last hit, both J. Lennon and P. McCartney sang back-up voices and the aim of this hit was to thank all fans of the Rolling Stones

(Sandford & Richards, 2004).

December 1967, the Stones released their ‘Satanic Majesties Request’ which was their psychedelic response to ‘Sgt. Pepper’ by the Beatles which was perceived to be an ambitious mess (Regina 1980). It took some time for ‘she is a rainbow’ which was a lone single track in their album featured in the top 25 chart. By the time it entered the chart, management of the group had been put under the responsibility of Allen Klein (Obrecht 1980).

In May 1968, a hit track named ‘Jumping Jack Flash’ was released and it was placed position 3 in the charts. In this month, basic rock and roll returned. Again, the electric ‘Beggars Banquet’ was in market after a 5- month delay which resulted from some sleeve photos which were in the controversial package. Critics of the band claimed that this album had been the best piece of work the Stones had ever made (Mick et al. 2003).

On June 9^th 1969, the greatest setback to the band struck. One of the most reliable and adventurous members by the name Brian Jones left the band. Jones had lent to the band a marimba, sitar and dulcimer. He had also been to Morocco where he recorded nomadic musicians who belonged to the Joujouka community. The explanation he gave for his quitting was that he did not see eye-to eye with other band members over the discs they were jointly cutting any more. Jones had made public his intentions to start his own band. The group reacted to this withdrawal swiftly and within a week, his position was taken up by Mick Taylor who was a former guitarist in the John Mayall band (Obrecht 1980).

On July 3^rd 1969, Brian Jones was found dead in his own swimming pool. Reports cited it as “death by misadventure”. It was revealed that Jones had been beset by drug problems and it had clearly come to him that the Rolling Stones band was owned by Jagger and Richards who made him barely participate in the various sessions of Beggars Banquet. A Few days after death of Jones, the Stones performed in open at Hyde Park (Mick et al. 2003).

A day after burial of Brian Jones, on July 11^th 1969, the Stones released ‘Honkey Tonk Women’, and another classic. At this time, every one of their album was in high demand including “Let it Bleed” (Regina 1980).

Immediately after Jagger’s return from Australia where he was a celebrity in the film Ned Kelly, he started the band’s massive tour to America in 1969, after 3 years of not be able to visit the US (Mick et al. 2003). Their performance at Altamont Speedway, California turned tragic and portrayed the satanic image they had adopted earlier when the Hell’s Angels motorcycle gang who had been hired by Stones to provide security stabbed a boy to death. This incident led to Stones dropping their stage shows for the following 6 years. The fall of 1970, after a long break from stage, they released a live album named ‘Get Yer Ya-Yas out. Later that year, the band founded the Rolling Stones Records (Obrecht 1980).

References

Mick, J. Richards, K. & Wood, C. (2003). Rolling Stones: Chronicle Books. ISBN 0-8118-4060

Nico, Z. (2008). The Complete Works of the Rolling Stones.New York: Sage Publication.

Obrecht, Jas. (1980). Mick Taylor: Ex-Rolling Stones on His Own, Guitar World,p.20.

Regina, R. (1980). Criminal Cases: Canada Law Book. p. 518.

Sandford, C. and Richards K. (2004). Satisfaction.New York: Caroll & Graf.

Stephen, T. (2006). Some Girls AMG: All music. London: Longman Publishers.

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Describe the development of the keyboard concerto from c.1710-1790, and assess why the form became so popular with both composers and public.

This essay explores the development of the keyboard concerto during the 18^th century considering its precursors, social and economic context and the advent of the piano. By exploring the work of key composers during the 18^th century, it will be shown how musical and social shifts created an environment in which enduring, popular and technically adventurous piano concertos could emerge.

Early Concertos

Concertos are typically defined asinstrumental works where a smaller group (in a concerto grosso) or soloist (ina solo concerto) contrasts against the sonority of a larger grouping. This technique was used in orchestration during the 17^th century in works such as canzonas (Grout 1988: 473), with the concerto form emerging towards theend of the 17^th century. Possibly the most influential composers ofearly concertos were Corelli, Torelli and Vivaldi. Wellesz and Sternfield(1973: 435) trace the emergence of the early concerto form through these three composers.

Corelli’s twelve Opus 6 concertigrossi were written at the end of the 17^th century using a structure consisting of a somewhat random alternation of slow and fast movements. Movements were ritornello-based (a ritornello is like a refrain), with alternating tutti and concertino passages showing limited decoration or exploration of thematic material.

Torelli, composing at the turn ofthe century, wrote concerti grossi and solo concerti. He established the three movement (fast-slow-fast) structure that was widely adopted. Torelli also explored the use of contrasting thematic elements within concertos and increased the complexity of solo lines.

Vivaldi, writing in the early 18^thcentury, refined the form, with more exploration of thematic contrasts, although Kolneder (1986b: 307-8) argues that Vivaldi’s material is perhaps better described as motifs than themes.

Although these three composers werekey to the emergence of the concerto form, their instrumentation focused on strings. Vivaldi wrote some flute and bassoon concerti, and orchestras would typically include a continuo keyboard part, but the first composers to use solo keyboard in concertos were Bach, Handel and Babel.

The First Keyboard Concertos

There is debate over which piece ofmusic qualifies as the first keyboard concerto. Handel wrote the first organ concertos, with a set of six published in 1738, but used a concerto-likestructure very much earlier, in his cantata ‘Il trionfo del tempo e deldisinganno’ of 1707, contrasting the organ with the orchestra in a ritornello structure.

Bach’s Brandenburg Concerto no. 5,composed around 1720, is widely held to be the first harpsichord concerto, and develops the concept of the virtuoso soloist, featuring an extensive solo harpsichord cadenza towards the end of the first movement.

However, recent research suggests that, even earlier than this, William Babel was writing concerted movements for harpsichord. The dates of composition are uncertain, but appear to be at leastas early as 1718, and possibly 5 or 6 years prior to that (Holman 2003).

Handel’s work, in addition to developing the keyboard concerto, provides interesting insights into the nature of performance and developments in amateur music-making at the time. Handel hadmoved to London, where he spent most of his adult life, in 1712, establishing himself as something of a celebrity. Initially finding success with Italian-style opera, the wane in the popularity of the form caused him to switch to oratorios. The virtuoso castrati, who had played a major role inopera, were not appropriate for oratorios, where virtuoso performance was considered not to be in the spirit of the work. By composing organ concerti tobe performed alongside the oratorios, Handel preserved an element of virtuoso performance popular with audiences, and as one of the leading organists of his day, he was able to showcase his skills through these works..

As the English organ had no pedals, music written for it transferred easily to the harpsichord, and Handel’s publisher could promote his second set of organ concerti as ‘for harpsichord or organ’, broadening its appeal (Rochester 1997).

Mid-Century Developments

The popularity of the Baroque concerto may have hindered the development of the concerto form. Wellesz and Sternfield argue that even such original composers as Sammartini and C.P.E.Bach could not rid their minds of Baroque preconceptions. (1973: 434)

C P E Bach regularly used the Baroque structure, with a number of tuttis punctuating solo passages in the ritornello style, but was innovative in other respects: his device of running one movement into another is more often associated with 19^th century music.

Wellesz and Sternfield establish three main elements where there is a clear differentiation in style between Classical and Baroque concerto forms: tonality, form and co-ordination of musical elements (1973: 435-6).

Classical concerto style develops the concept of opposing tonalities, placing tonic and dominant against each other,while the Baroque style, though often using modulation, maintains more stability.

In the Baroque concerto, exposition and development are often combined, while in the Classical era there is clearer demarcation, pointing towards sonata rather than ritornello form.

The Baroque form entwines contrapuntal elements over a more independent bassline, while the Classical form prefers all elements – including harmony, melody, orchestration and rhythm- to be held together within the same overall plan.

Also key to the development of the keyboard concerto was the emergence of the piano. The prototype instrument was developed by Bartolomeo Cristofori in the final years of the 17^thcentury and called the gravicembalo con piano e forte, meaning harpsichord withsoft and loud, although the dulcimer, where strings are hit by hammers, was more of an inspiration than the plucked harpsichord. This gave scope to developa keyboard instrument with greater dynamic versatility. However, composers were initially sceptical. In 1736, Gottfried Silbermann invited J S Bach to try one of his instruments. Bach was critical, but Silbermann worked to improve hispiano, and Bach subsequently acted as an intermediary in its sales.

The new instrument also found success in Britain. During the 18^th century, Britain, and especially London, was cosmopolitan: Handel had had great success, and records show that many musicians from the continent made Britain home. Britain offered an environment of relative political stability compared with many areas of Europe. There was a keen appreciation of music among the upper classes, and a growing middle classwith money to spend on leisure pursuits – including music.

However, in 1740 there was only onepiano in the country. In 1756, the Seven Years War resulted in an exodus from Saxony to Britain, and their numbers included a group of harpsichord makers,one of whom, Zumpe, began to make pianos and invented the square piano. It had advantages over the harpsichord and other types of piano which were a similar shape to the harpsichord. It was quicker and cheaper to manufacture, and remained popular until the middle of the next century.

Johann Christian Bach, son of J Sand younger brother of C P E, arrived in London in 1762. He developed a range of commercial interests, and became Zumpe’s London agent, providing an incentive to write material to show the instrument to its best advantage. He had other business interests too: on arrival in London in 1762, he shared lodgings with Carl Abel, also a German composer. They developed a partnership running subscription concerts, which proved hugely popular until after J CBach’s death in 1782, and had a stake in the Hanover Square Rooms, which they used as a venue for their concerts.

Johann Christian had been a pupil of his older brother Carl Philip Emmanuel, but it was the younger brother who was the more influential on the development of the concerto form, particularly with regard to exposition themes. He often used a triadic primary theme and more cantabile secondary theme, suggesting elements of sonata form, although ritornello style is still evident.

J C Bach wrote around 40 keyboard concertos between 1763 and 1777 (Grout 1987: 560). Midway, dating from 1770,are the Opus 7 concertos: ‘Sei concerti per il cembalo o piano e forte’ (six concertos for harpsichord or piano). The title itself is significant.Harpsichord manufacture was still on the increase in the 1770s, but the instrument was soon to be overtaken in popularity by the square piano, and Bachwas the first to use the instrument for public performance (Grout 1987: 562).Grout suggests that the E flat major concerto, no. 5 of the set, hassignificant structural similarities to Mozart’s K488 (Piano Concerto No. 23 inA major), with a similar combination of Baroque ritornello structure and sonataform, contrasting keys and thematic material.

While Johann Christian’s work goes some way to realising the Classical concerto form, it was Mozart who pushed theform forward to create a precedent for concerto composition in subsequent centuries:

Mozart’s concertos are incomparable. Not even the symphonies reveal such wealth of invention, such breadth and vigor of conception, such insight and resource in the working out of musical ideas.

Grout 1987: 614

Mozart’s Piano Concertos

Mozart’s move to Vienna from Salzburg in 1781 heralds musical developments and reflects social changes. On 9May 1781, he wrote to his father I am no longer so unfortunate as to be in Salzburg service (Mersmann 1938: 161): he had been frustrated by the limited opportunities of his employment at court. The joy of leaving Salzburg for Vienna seems to have been musically inspiring, and the next few years were prolific, not least in the composition of piano concertos: Mozart wrote 12 between 1784 and 1786.

The influence of J C Bach on Mozartwas significant. The two had met in London in 1764, when Mozart was still aboy. In 1772, Mozart created his first three piano concertos by rearranging three of J C Bach’s sonatas. Beyond the concerto structure, the detail of Mozart’s music suggests Bach’s influence. His subtle ornamentation and cleveruse of suspensions and ambiguities of tonality also characterises J C Bach’s work.

Mozart’s use of keys is particularly innovative: in the first movement of the A major Piano Concerto K488, the development section incorporates a passage of dialogue between thewinds and a larger grouping of piano and strings, modulating through E minor at bar 156, C major at bar 160, A minor at bar 164 and then through F major at bar 166 to D minor at bar 168. The more obvious, related tonalities for a work in Amajor would be D and E major, the subdominant and dominant keys, and F# minor, the relative minor key. This type of harmonic device gives a strong sense of departure from the safety and stability of the home key, making its eventual return in the recapitulation stronger and more satisfying.

This passage also shows examples of Mozart’s innovative orchestration: the small group-large group contrast of earlier concertos becomes a three-way interchange, with piano, winds and strings forming three groups which are united and contrasted in a range of combinations.

Conclusion

Mozart’s innovations took the keyboard concerto to a new level, and give some indication of why the form became so popular with composers and the public.

For the composer, working patterns were changing, away from the often creatively restrictive nature of patronageto an environment of more freedom, with composers having more control of performances as events – J C Bach is a particularly good example of this. With many composers also being gifted performers, who could attract audiences by way of their virtuosity, the concerto offered scope to write exciting, challenging passages within the context of a major work, giving their performances real impact.

Yet the economic reality was thatincome depended on the success of concerts and the ability to please a fickle audience.Mozart was clearly aware of the need to please a range of Viennese listeners,writing of his 3 concertos written for the 1782-3 season:

There are passages here and there from which connoisseurs alone can derive satisfaction, but they are written so that thenon-connoisseurs cannot fail to be pleased even if they don’t know why.(Quoted by Steinberg 1998: 279)

Taking the above into account, itis surely not insignificant that Mozart’s piano concertos are, 200 years after their composition, enjoyed by a huge audience and also highly regarded by musicologists.

The development of the keyboard concerto in the 18^th century demonstrates how changes in the social landscape and innovations in instrument technology planted the seeds of avibrant music industry. This helped set up the piano concerto to become an indispensable ingredient in the concert hall and a contributing factor in the phenomenon of the virtuoso in the 19^th century and beyond.

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The issue of politics and the regulation of media is not a new debate. Discussions around communications have a long history and governance and policy around telecommunications is a well-established topic at both national and international levels (Fylverboom, 2011). Even before national governments realised that international mechanisms were required to manage global issues such as trade of the environment, many realised that the benefits of international telecommunications would only be apparent if there were shared rules of the game in terms of governing how national networks would connect with each other (Fylverboom, 2011).

This study looks at the role of two key intergovernmental organisations and their role in regulating the global media. The United Nations (UN) and World Trade Organisation (WTO) both exert considerable influence on the world stage and it can be argued that both are influential in the regulation of media around the globe.

The United Nations was established in 1945 to bring together nations of the world to promote peace and security (United Nations 2015) it is involved in missions around the world ranging from peacekeeping and sustainable development to fighting terrorism and addressing climate change.

In relation to global media, UNESCO is an arm of the UN with a focus on education, cultural understanding and promoting freedom of expression and democracy. It states that it has a specific mandate to “foster freedom of expression and to promote the free flow of ideas by word and image”, The UNESCO webpage states that the organisation “works to foster free, independent and pluralistic media in print, broadcast and online. Media development in this mode enhances freedom of expression, and it contributes to peace, sustainability, poverty eradication and human rights.” (UNESCO, 2015).

Interestingly, UNESCO itself has entered the debate around media regulation, although more with a view on the contract between media self-regulation and state regulation than addressing the issue of media regulation by NGOs. A UNESCO report by Pudephatt (2011) provides a useful declaration of a media environment that supports freedom expression stating: “it will be a diverse media environment, part public, part private and part community; a plurality of different media outlets; and a system that is broadly self-regulating with the exception of broadcast media (where spectrum has been limited and a regulatory body allocates bandwidth)” (Pudephatt, 2011, p10).

Pudephatt debates a central question around media regulation, which is whether it threatens or supports democracy. Some argue that minimal state interference in the media is necessary for a media environment that supports democracy, whilst other will argue that state intervention is required to promote a pluralist and diverse media (Pudephatt, 2011). A good example to support this argument would be a democratic state in which a small number of wealthy individuals bought up most of the media outlets and used this near monopoly to promote one political or economic view with the result that democratic debate became stifled. Pudephatt (2011) makes the point that in the past many states have looked to prevent a company from occupying a dominant market share of the media in order to ensure freedom of expression.

It can certainly be argued that many arms of the UN do oppose most forms of media regulation. Human rights instruments such as the UN Charter, the Universal Declaration of Human Rights and the International Covenant on Civil and Political Rights for example can all be seen as tools to support rather than suppress freedom of expression.

O’Siochru et al (2002) suggest that there have been three broad phases in the development of global media regulation. The initial phase, pre-UN was driven by the economic and industrial revolution and accommodated the societal concerns of the time. A second phase came with the emergence of the UN and closer international relations. The increased presence of developing nations within the UN and its bodies, and calls for societal and human rights saw freedom of expression on the UN agenda, and through bodies such as UNESCO it encouraged greater freedom of expression in both national and international media (O Siochru et al.,2002). The third phase is represented by a weakening of the UN role in global media governance and one in which big business with a focus on the commercial rewards of global media looks to undercut national regulation and looks to free trade proponents such at the WTO to support this.

The WTO was established with a narrower agenda. It is an international body established to promote free trade through the abolition of tariffs and other trade barriers. It is closely linked with the ideas of globalisation and faces criticisms that it is too powerful, indifferent to worker’s rights, biased towards the rich and that it lacks democratic accountability (BBC, 2012). These criticisms can arguably be extended towards the WTO and global media, particularly when consideration is given to the expansion of powerful media conglomerates which benefit from the trade liberalisation ethos of the WTO.

The WTO has a great deal of power in relation to global economic matters and its influence on global media has also grown as media organisations become bigger business and increasingly commercialised (Leicester University, 2015). One of the key concerns for the WTO is promoting free trade and the addressing the pre-existing barriers that national sovereignty can out in place of media expansion globally.

Hackett and Zhao (2005) argue that the WTO has become an organisation which “straddles key areas of communication and is set to extend its mandate further” (p212). The WTO appears to be as supportive of the liberalisation of media and telecommunications as it is for the liberalisation of other areas of trade. With its rulings on formal trade complaints enforceable in international law, it is increasingly being seen by the largest media organisations as an ally as they look to expand into new market (Mansell and Raboy, 2011). The difficulties that companies such as Google have establishing a presence in states where there is more rigid censorship serve as one example of this.

Global broadcasting has been happening for decades yet whilst organisations such as the WTO have long had success in securing international agreements which liberalised trade, cultural industries have often been afforded greater protection by governments and certain restrictions have been placed on the importance of cultural industry products and media services (Mansell and Raboy, 2011).

One consequence of globalisation of the media however has been an increased commercialisation of the industry (Mansell and Raboy, 2011). Essentially, global media is now big business and there are huge profits to potentially be made if the largest media corporations can overcome national media regulation and expand into new territories. As Mansell and Raboy (2011) state “global markets in broadcasting are commercial, even when they involve trade among national broadcasters” (p55). In many individual nations, national broadcasters have seen their market share decline.

The WTO’s influence can be seen in the growing dominance of a small number of market leaders in the media industry and much of the context to this can be found in the US media. In 1984 around 50 corporations controlled the vast majority of news media in the US; this in itself seemed a small number but by 2004 similar criteria being applied found that this number had reduce to five huge organisations controlling over 90 per cent of mass media in the US (Mansell and Raboy, 2011). These organisation are looking to expand their influence globally and the liberalisation of trade under the WTO is enabling this to happen.

The dominance of a small number of corporations, the majority of which share a similar world view, brings us back to the question as to whether regulation of the media is a good or bad thing in terms of promoting democracy and freedom of expression. As these huge corporations use their market power as leverage to reduce traditional national interest public broadcasting, there are questions as to whether broadcasting in the public interest is still happening. Mansell and Raboy (2011) suggest that there is no global forum with sufficient influence to tackle these questions; in essence the liberalising power of the WTO is overcoming national attempts to regulate media and also the efforts of organisations such as UNESCO to promote a diverse global media.

One of the key media developments for both the UN and the WTO to address has been the growth of the Internet over the last two decades. Whereas global media had always been subject to some form of governance, the Internet has been portrayed as outside of the reach of regulation due to its global and decentralised nature (Fylverboom, 2005). Its ever-expanding nature and its versatile technical platform have left it for some time outside of global media governance but there is some evidence that this is beginning to change and the UN and the WTO have both had at least some involvement in this.

In 2003 a UN World Summit on the Information Society (WSIS) debated issues around global governance of the Internet. It looked at the status quo at the time where national governments were largely regulating the Internet within their own boundaries, and discussed whether some form of global governance was possible (Mansell and Raboy, 2011). It was clear at this point that both democratic and authoritarian governments were taking steps to deny access to their citizens for content that was seen as illegal or objectionable. The WSIS was ultimately unable to make much progress on this issue, finding that the conditions for access to the Internet would continue to be determined by the national government policies that were established and the effectiveness of their implementation (Mansell and Raboy, 2011). This suggests that the UN at least is limited in its capability to regulate some part of digital media on a global scale. Whilst the Internet is a global tool to be used, national governments so far are able to maintain a certain level of control as to the level of access that citizens have.

Unsurprisingly the WTO has looked to extend its influence into the complex area of Internet regulation. One of the difficulties it faces it that the complexity of Internet regulation makes it an issue much larger than something that simply comes under the remit of free trade or trade liberalisation. The whole area of content regulation has to be addressed; the attitude of China for example towards Internet content from the democratic West for example is not something that can easily be resolved (Kong, 2002). There remains a possibility that the WTO may be asked to step into legal battles around freedom of trade related to provision of Internet services. There has been discussion recently that companies such as Google might look to sue governments such as the Chinese’s for discrimination because of its harsh web filtering conditions (World Trade Law, 2015). If this were to happen, the WTO’s role in Internet governance would expand rapidly

Issues around Internet content make ideas of global regulation difficult; different cultures have different views on acceptable content. For the WTO, there are other issues around the Internet which it can more easily address. It may be able to coordinate regulation and standard-setting in areas such as data protection and enabling access to financial services (IP Watch, 2015).

A summary of the current position would be that the UN’s influence over global media regulation diminishes as the globalised nature of the Internet develops further, and as powerful media conglomerates exert influence to facilitate their own plans for future dominance. The WTO with its commitment to free trade has enabled some of these huge corporations to grow; the challenge it faces in future will be to resolve the ongoing issues between these media giants and the national governments which wish to maintain a level of control on the media access open to their citizens. The likelihood given its nature is that the WTO will support the media organisations; the question is whether individual governments will adhere to its decisions.

Bibliography

BBC (2012) World Trade Organisation [Online] Available: http://news.bbc.co.uk/1/hi/world/europe/country_profiles/2429503.stm

Fylverboom, M. (2011) The Power of Networks: Organizing the Global Politics of the Internet. London: Elgar

Hackett, R. and Zhao, Y. (2005) Democratizing Global Media. Oxford: Rowman and Littlefield

IP Watch (2015) Panels: WTO Could Play Crucial Role In Challenges Facing Global Digital Trade. [Online] Available: http://www.ip-watch.org/2015/10/08/panels-wto-could-play-crucial-role-in-challenges-facing-global-digital-trade/

Kong, Q. (2002) China and the World Trade Organization: A Legal Perspective. New Jersey: New Scientific

Mansell, R. and Raboy, M. (2011) The Handbook of Global Media and Communication Policy. Colchester: John Wiley and Sons

O Siochru, S., Girard, B. and Mahan, A. (2002) Global Media Governance: A Beginner’s Guide. Oxford: Rowman and Littlefield

Pudephatt, A. (2011) The Importance of Self-Regulation of the Media in Upholding FReedom of Expression

UNESCO (2015) Fostering Freedom of Expression [Online] Available: http://en.unesco.org/themes/fostering-freedom-expression

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World Trade Law (2015) Google, China and the WTO. [Online] Available: http://worldtradelaw.typepad.com/ielpblog/2010/01/google-china-and-the-wto.html

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Does Popular Journalism Reach Out or Dumb Down?

The news media has a responsibility to be objective, a responsibility it is often criticised for overlooking. Likewise the mass the media, with its huge audience, has an opportunity to educate – this is not to say that commercial television should fill its schedules with GCSE Bitesize revision programmes, but that there is much to learn through great writing, great acting and great comedy, that these are popular art-forms. Most mass media products do not seize this opportunity. Instead, a trend of pandering to the (perceived) base pleasures of certain mass markets is, more often than not, apparent, a trend that can be seen to reinforce stereotypes – an idea I will explore in this essay.

The real question then is: does the media reach out by dumbing down, or does it pander and condescend to its audience? In answering this question I intend to examine the ascendance of reality television since the late 1990s and question why such programmes came to prominence, and to analyse the differing approaches of various news products in their selection and presentation of the news and how this can relate to the notion of dumbing down.

The often criticised emergence of reality television came about in the late 1990s as a way of cutting down production costs whilst increasing output. With its stylistic roots in the documentary format but based on the concept of reality TV, the docu-soap came to prominence, and notoriety, with the unexpected successes of shows such as Driving School, Airport and Fairground, which followed members of the public as they went about their jobs and their everyday lives. The ‘stars’ of the shows often went on to enjoy minor, short-lived celebrity status, releasing pop records and guesting on other shows.

The unexpected success of the programmes opened the door to mass production, and a spate of copycat shows flooded both terrestrial and subscription channels – Sky One was notable for its successful Ibiza Uncovered series, following holiday-makers in the hugely popular club-based Ibiza night-life, which spawned countless Uncovered sequels. This was a dream come true for broadcasters, who had stumbled upon the scheduler’s Holy Grail – a format that was cheap, popular, and quick to produce. The use of ‘real people’ cut out the roles – and the fees – of writer and actor, as well as the valuable production time taken up by the writing and rehearsing process. They also cut equipment costs by the use of natural lighting and documentary style single camera format. Therefore high volumes of programmes could be churned out for little money, in little time.

The criticism which arose against the docu-soap phenomenon centred upon the flimsy content of the shows, the canonisation of trivial incidents, the lack of narrative, and the lack of any documentary-style insight into the lives of the protagonists. Many of the shows tended to make unwitting fools of its stars. Others would take the most trivial elements of its stars’ jobs – say, a routine check of an aeroplane toilet by a member of flight staff – and make it a central narrative of the show.

However what was perhaps particularly galling was that all of the terrestrial channels would pounce so fervently upon the fad. Of course any broadcaster has a lower end of entertainment, cheaper shows with lower production values than its flagship products, made quickly and cheaply to bulk out the schedule – but the docu-soap managed to find itself straddled across the channels in prime-time slots, as well as bulking out daytime schedules. For the BBC in particular, who have such a proud history of incendiary documentary film-making and social realism – this is the channel that screened Cathy Come Home (Ken Loach, 1966) – this seemed to reflect far too great a willing to sacrifice standards of content.

But in their presentation of real people in their real lives, were the docu-soaps ‘reaching out’ to the viewing public? It could be argued that the shows reflected their audience, that they made stars out of the viewing public, turned everyday events into prime-time viewing, took genuine events from genuine lives and put on screen, and thus reflected the social realities of its audiences to a greater degree than ever before.

However the stars of these shows were not comic characters penned for a cheap sitcom, they were human beings, with pasts, and families, tragedies, hopes, futures – but that’s not how they were presented. To the viewer, they were clowns and stooges, caricatures. The tools of the programmes may have been founded in reality, but the sum of the parts was as stripped down and simplistic as journalism can get. The plot of an episode of Airport: a member of staff going about his job. The point: mild amusement at his expense. And with the elimination of the creative process, the value of cheap, mild amusement at the expense of an unwitting stooge is hard to quantify. In truth, the shows had little more than stylistics in common with documentary.

And yet their effect is great. Whilst the docu-soap fad may have petered out, their influence can still be seen in the more recent popularity of reality antique and property make-over shows, and through its canonisation of members of the public, can even be seen to have paved the way for shows such as Big Brother and The X Factor, the new royalty of reality television.

This is a reality of the digital revolution. Products such as Freeview, Sky and ITV digital compete partly on the promise of more channels with greater choice than their rivals. More channels means more shows must be put in production, and unless the company wishes to go bankrupt, that means lower production values, less experienced talent both on and off screen, and more copycat shows – antique shows, reality shows, re-runs, and repeat showings. This leads to less experienced people making cheaper shows, and spreading them over a wider array of channels.

So we can see that the dumbing down of commercial television in the wake of the digital revolution is rooted not in the value system of the entertainment industry but in the economic reality of it. Writing talent, acting talent, directing talent, production values – all these elements cost both money and time, and when cheaply and quickly produced products are just as popular, the talent becomes expendable.

So what about the broadcast news, has it also undergone a process of dumbing down? Firstly, it is important to remember the role of humanity in news reportage. For example, what constitutes a news ‘event’? Is a motorway pile-up the event of the crash or the aftermath of it? Is the ‘event’ of a political speech the content of the speech or the reaction to it? Journalism relies on journalists, who rely on their own skills of interpretation, and it is generally accepted that every potential news story is judged on a certain set of ‘news values’. One of the most recognised interpretations of these values was made by Johan Galtung and Marie Holmboe Ruge in 1965. They identified eleven distinct values:

This process is merely a reality of news reportage: not every event that happens in the world can be covered, and so events must be judged on their ‘importance’. However problems can arise when this intangible ‘importance’ becomes linked not to theoretical values, but to the perceived values of a generalised target audience. In a News night investigation into the process of selecting stories for news coverage (screened in October 1999, BBC 2), a journalist from the News Of The World told the film crew that a story about white youths dying from drugs sold to them by a black man was more likely to be reported by their newspaper than a story about black youths dying from drugs sold to them by a white man.

This is based on the assumption by the newspaper that their audience is not interested in the problems of drug culture affecting the black community, whereas the representation of non-whites selling drugs to white youths reinforces racial stereotypes, and as such are more appealing, less challenging, and provide a greater sales guarantee. This is not just dumbing down, it is systemised media bias; it is a news service that bases its reportage on reinforcing stereotypical values of a massively generalised target audience in order to maintain circulation, and hence, profit. Even if the News Of The World have judged their audience correctly, it speaks of a worrying cycle of ignorance – if their audience members characterise non-whites as detrimental to whites, and their news reinforces this, how can they be expected to change their views?

So we can see that journalistic practice runs into serious problems when it considers its target audience in its methods of reportage. This is a particular problem for commercial television stations, who garner almost all their profits from advertising sales – sales which rely on the selling of a target market, one which is shared by the channel and its potential advertisers. What then happens if a certain news story does not appeal to a news product’s target market – is it tailored to be more attractive? Is it left out altogether? If the news product does not suit its target market, ratings drop, and advertisers pull out. ITV is a channel which survives on accessibility, so if its news is not accessible, does not reflect the tone and style of the rest of its programming, it risks losing viewers.

Let us examine the coverage of the first annual May Day protests in London. In May 2000 Trafalgar Square was occupied by members of the anti-globalisation protest group Reclaim the Streets, in protest against the practices of multinational corporations and the climate of brand power. As the demonstrations went on, a small minority of vandals along for the ride embarked on a low-scale wave of petty violence, which was denounced by RTS as contrary to their values.

RTS are a young political group, tapping into the youth culture trends of anti-capitalism and the deification of counterculture. Looking at the scenes of the protestors, they were young men and women, almost to a head in the 18-25 age group. The only terrestrial news channel to give any air-time to a member of Reclaim The Streets, or to even mention their name, was Channel 4 – the channel whose programming is aimed at the youth market to a greater degree than the others – in fact a channel who is contradictorily required to be ‘alternative’. The BBC news focused on the graffiti tagging of the Cenotaph, and ITV news focused on the small-scale vandalism and violence incited by a small minority of “protestors” who had crashed the party. Both news products characterised the protestors as ‘anarchists’ and ‘rioters’ (true of just a tiny minority). In this case, it is not hard to see how each news product’s target audience affected the reporting of the event. On the other hand, ‘Select’, an alternative music magazine, ran a 12 page special on the inspiration behind the protests, the base of the issues at the heart of Reclaim the Streets, and interviewed popular protagonists of the anti-capitalist sub-culture – comedian Mark Thomas and theorist Naomi Klein.

This does not necessarily suggest a greater moral credibility on the part of ‘Select’, but simply that they were in a position to make such a report. The style and tone fitted in perfectly with their target market, and the piece also ran interviews with various alternative musicians, such as Zack De La Rocha of politically outspoken anti-capitalist funk-rock group Rage Against The Machine. So whilst all of the terrestrial television news programmes can be seen to be dumbing down the event, it would be more accurate to say that they were catering their product to the perceived expectations of their target market, and ‘Select’ did exactly the same. It is hard to see the BBC devoting 10 minutes of a 30 minutes broadcast to a history of anti-capitalist theory and demonstration, but on the other hand this is a channel that recently gave prime-time half-hour debates to the leaders of the three major political parties in the run-up to the general election. ‘Select’ gave comprehensive coverage to the history of RTS and the theory behind the demonstration, but they may not have given so many column inches to, for instance, a pro-hunting group. Their coverage may have been more in depth and comprehensive on the May Day protests, but in the same way as the BBC and Channel 4, they covered what would sell.

So then we can see that ‘dumbing down’, within news reporting at least, perhaps has less to do with appealing to the lowest common denominator and more to do with appealing to a target audience. This can be seen to be a rather exclusive approach – appealing to a particular, and generalised, target audience excludes audience members who do not ascribe to the values of the target audience, and in this way we can see how popular news reinforces social stereotypes. It is, for instance, a rather galling assumption that a viewer of the BBC news is less interested in the motivations behind a political demonstration from a peaceful political group (who denounced the small-scale vandalism of a small minority as being contrary to their protest – at least they did when given air-time), than a stereotyped representation of anarchic youths run amok.