Experiences in the delivery of preconception and pregnancy care for LGBTIQA+ people: A systematic review and thematic synthesis of patient and healthcare provider perspectives

BACKGROUND

The widespread availability of reproductive technology and family planning services has led to an increase in the number of available pathways to parenthood for LGBTIQA+ people. However, emerging research indicates that significant healthcare inequities have been documented among LGBTIQA+ people and attributed to the pervasiveness of structural and systemic discrimination that extends to preconception and pregnancy care.

AIM

The aim of this systematic review was to synthesise qualitative research that has explored the experiences of LGBTIQA+ people in navigating preconception and pregnancy care services to inform healthcare quality improvement.

METHOD

Six databases were searched for relevant research published between 2012 and 2023. The findings of all included studies underwent a secondary thematic synthesis, and methodological quality was assessed using the Joanna Briggs Institute Checklist for Qualitative Research.

FINDINGS

A total of 37 studies were eligible for inclusion. Four major themes were constructed through thematic synthesis: (1) unavailability of information, services, and support; (2) clinical competencies of healthcare staff; (3) hetero- and cis-sexist care experiences; and (4) discrimination and traumatisation.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings of this review indicate that LGBTIQA+ people experience significant challenges during the journey towards parenthood, marked predominantly by the pervasiveness of inequity, and defined by discriminatory healthcare processes. This review has led to several recommendations for future healthcare quality improvement through an investment in policies, procedures, and interactions that are sensitive to the needs of LGBTIQA+ people. Importantly, future research must be co-designed and led by LGBTIQA+ community input.

Social Support in Older Transgender and Gender Diverse Communities in the United Kingdom and Australia: A Comparative Study During COVID-19

While the impact of the COVID-19 pandemic on older people has been recognized, there is limited understanding of its impact on older trans and gender diverse people who often have different experiences of care and support than the general population. This article examines older trans and gender diverse people's experience of social support during the COVID-19 pandemic, based on a comparative mixed method survey administered in Australia and the United Kingdom. Using a non-probability sample of 84 participants who were connected to social media and service organizations in the United Kingdom and Australia, we found some commonalities and differences between experiences in these countries. Some participants were isolated, including almost 1 in 5 participants who said that they did not have someone they could call upon in an emergency. However, participants had rich networks of friends, partners, and family members. Religious organizations and the community also played an important role. Friends were reported as the main emergency contacts and as the main people to whom support is provided. This research supports previous findings that friends of trans and gender diverse people play an important role in well-being.

Talking really does matter: Lay perspectives from older people on talking about suicide in later life

Background

The cumulative body of research on suicidality in later life describes its unique and complex features in older people when compared with that in other population groups. Yet significant gaps exist in how research informs the further development of suitable interventions. The perspectives of older people are also limited in research findings.

Aims

Therefore, this exploratory study aimed to (1) identify potential barriers and enablers in discussing suicidal thoughts and their expression in later life from the perspectives of lay older people and (2) explore where opportunities might occur in approach, place, relationships, and language with older people to discuss suicidal thoughts and their expression.

Method

We conducted in-depth qualitative individual interviews with 15 people aged 70-89 years. This method helped explore older peoples' own lay perspectives on suicidal thoughts in later life and how these are expressed, and their understanding of where and how people might seek support.

Results

A total of three themes were generated from the dataset: (1) intergenerational and socio-cultural differences in suicide expression, (2) the normalization of suicidal thoughts in later life, and (3) the importance and difficulties of everyday discussion and opportunities to express suicidal thoughts.

Conclusion

Suicidal thoughts and their expression appear commonly and are normalized in later life yet remain taboo and hidden. The participants revealed how such thoughts and behaviors are typically expressed through colloquial or "off-hand" remarks and comments and the importance of authentic listening. The findings highlight the importance of more informal discussions around these topics and how care professionals, practitioners, and providers might frame opportunities for dialogue with people who may want to access support. Further engagement with community-informed participatory research methods in which older people provide their own perspectives and experiences is important in addressing these gaps. There is a need for co-designing in developing screening, assessment, and signposting outside of clinical settings that can be used in everyday caring relationships with people in later life.

Defining and researching the concept of resilience in LGBT+ later life: Findings from a mixed study systematic review

Within the literature, resilience is described as either a trait, an outcome or a process and no universal definition exists. A growing body of research shows that older LGBT+ adults show signs of resilience despite facing multiple inequalities that negatively impact their health and social wellbeing. The aim of this review was to examine how resilience is defined in LGBT+ ageing research and how it is studied. A mixed-study systematic search of peer-reviewed research papers published before June 2022 was conducted using the electronic databases CINAHL, Embase, Medline, PsycInfo, Social Science Database and Web of Science. This resulted in the screening of 7101 papers 27 of which matched the inclusion criteria. A quality appraisal was conducted using the Mixed Methods Appraisal Tool. Findings show that papers often lack a clear definition of resilience and application of resilience theory within the studies, although many of the papers conceptualised resilience as either a trait, process or an outcome. However, resilience was rarely the primary focus of the studies and was researched using a variety of measurement instruments and conceptual frameworks. Given the socioeconomic disparities, diverse social relations, histories of discrimination and stigma, and acts of resistance that have shaped the lives of older LGBT+ populations, resilience is a topic of growing interest for researchers and practitioners. Clear definitions of resilience and application of resilience theory could help improve methods used to study the concept and lead to more robust findings and the development of effective interventions. Greater clarity on the concept of resilience could also broaden the focus of research that informs policies and practice, and support practitioner training in resilience and the particular experiences of older LGBT+ adults.

"It's a Living Experience": Bereavement by Suicide in Later Life

Bereavement by suicide for people in later life is significantly under-researched. Research on ageing and suicide has yet to address the experiences of those bereaved by suicide and how such a devastating loss affects the ageing experience. Objectives: We explored the substantive issues involved in bereavement by suicide and its impact on later life. Methods: This was a co-produced qualitative study. Peer researchers with lived experience conducted in-depth interviews with twenty-four people aged 60-92 years. A phenomenological approach informed the data analysis. Main Findings: Themes described included (1) moral injury and trauma; (2) the rippling effect on wider family and networks; (3) transitions and adaptations of bereaved people and how their 'living experience' impacted on ageing. Conclusions: It is important to understand how individual experiences of suicide intersect with ageing and the significance of targeted assessment and intervention for those bereaved by suicide in ageing policies and support.

Doing the right thing and getting it right: professional perspectives in social work on supporting parents from gender diverse communities

BACKGROUND

Despite significant shifts in legislative, political, cultural and social contexts, which have improved our understanding of diverse gender identities and family life, this remains under-explored within social work and social care. Trans and non-binary (TNB) parenting experiences are marginalized within mainstream professional practice and action is required to address these inequalities.

AIMS

This study explored the practices and meaning of 'parenting' and 'caring' for care professionals in families with parents with diverse gender identities in the UK. It aimed to capture a snapshot of the current state of practice knowledge and perceived practice challenges.

METHODS

A qualitative study design involving thematic analysis from detailed consultation with twenty-five relevant stakeholders in the proxy roles identified from a systematic review on what is known about trans parenting from the research evidence.

RESULTS

The complexity of systems for supporting families creates barriers to change, with a lack of training and development in the knowledge and skills of the workforce. Intersecting these themes was a strong values framework and examples of best practice provided, which social workers can use to navigate, understand, and support TNB parents and their experiences, particularly at an individual level, as a means to effect change.

DISCUSSION

Focusing on human rights, tailoring work to the specific needs of individuals and families, and affirming the diversity of family life requires professionals to take active responsibility and be more accountable in educating themselves and others on these rights. Professionals also need to reach out to the TNB community to include them in improving services as well as being active in their own organizations to ensure these are inclusive and responsive.

Social support and unmet needs among older trans and gender non-conforming people during the COVID-19 'lockdown' in the UK

Background

Previous research has suggested that older trans and gender non-conforming (TGNC) people may face particular challenges related to stigma, social exclusion and discrimination in later life. However, direct data on social support and needs in older TGNC population both internationally and within the UK is limited due to the small, dispersed nature of this population, and the absence of specific data collection on aging TGNC populations. During the UK COVID-19 lockdown in summer 2020, older people and those with long-term health conditions were advised to adopt particular precautions.

Aims

This study aimed to explore older TGNC people's social support networks, key concerns and unmet needs during the COVID-19 'lockdown'.

Methods

A UK cross-sectional survey of LGBT + people aged 60+ (n = 375) was undertaken during the lockdown. This paper analyses responses from the subset (n = 38) of TGNC participants.

Results

The majority of TGNC respondents described diverse social networks, often centered around friends and non-kin social networks, although partners and adult children were also significant for some. In most cases, those with existing strong networks continued to maintain social connections during lockdown, albeit with some regrets about loss of activities and face-to-face connection. However, a minority of respondents had experienced greater challenges prior to lockdown, and may have been at increased vulnerability during the pandemic, for example indicating that they had no-one to call on for practical support in an emergency. When asked about unmet needs and challenges, social isolation was repeatedly raised as the most frequent concern. Several respondents also mentioned issues specifically affecting TGNC communities, including access to gender affirming care and a perceived rise in social intolerance.

Conclusions

Health and social care providers should be aware of the diversity of support networks within TGNC communities. There may also be benefits in community sector interventions to help older TGNC build and maintain strong social networks.

Physical and mental well-being, risk and protective factors among older lesbians /gay women in the United Kingdom during the initial COVID-19 2020 lockdown

This article reports on a subset of findings from a recent UK survey of the impact of COVID-19 on older LGBT+ people in the UK. It considers the responses of 149 lesbian/gay women (137 cisgender, 12 trans) to questions relating to physical and mental health and wellbeing. Findings indicate that those women - in couples and singles - who were happy with their living circumstances pre-COVID showed stoicism, adaptability, and determined positivity in response to the pandemic and associated lockdown. Some even reported an improved quality of life, better personal relationships and increased neighborly support. By contrast, those women who were very unhappy with their circumstances prior to COVID-19 - generally women who lived alone and experienced a mismatch between their actual and desired social network - either remained unhappy or became more unhappy, due to its impact on fragile support systems. For trans women, formal support from trans/LGBT+ specific networks - online during COVID lockdown - were central to their wellbeing. Having access to, and being able to use, online technologies were essential to good mental health during lockdown. These findings reaffirm the diversity among older lesbians/gay women as well as highlighting how COVID-19 has acted as a magnifier to their preexisting circumstances. The narratives of those doing well - generally better-networked, intentionally positive and engaged in practices which promote their well-being - may offer insights for supporting those who find their lives more challenging, both during a public health crisis and more generally.

Dog-assisted interventions in care homes: A qualitative exploration of the nature, meaning and impact of interactions for older people

Dog-assisted interventions (DAI) have been shown to have a wide-range of potential benefits for older adults living in care homes. Yet, there is a lack of published qualitative research which explores the experiences of care home residents, staff and dog-owner volunteers involved in DAI to fully understand its meaning, impact and value. This study aimed to explore the impact of a DAI on the social and emotional wellbeing of older residents living in care homes. The research employed a qualitative study design comprising overt, naturalistic researcher observation of weekly DAI sessions with 54 older adult residents across four participating care homes in the South East region of England over 3 months in 2018. Data were also collected through focus groups with 12 care home staff and 7 dog-owner volunteers. The data from the observations and focus groups was individually coded followed by thematic analysis across the three data sources. Findings demonstrated there were clear benefits for older people who engaged with DAI, as well as for dog-owners and to some extent for care home staff members. Benefits included sensory, emotional stimulation and opportunities for social interaction, reminiscence on early life experiences and these were supported by the development of some new social relationships. While there were some environmental challenges to implementing DAI, the findings confirm its value for care home residents, with minimal drawbacks from an organizational standpoint. As a low cost intervention, adoption of DAI in care home settings appeared to strengthen relationships between residents and staff and enable wider relationships with an external community resource.

Community Based Interventions for Problematic Substance Use in Later Life: A Systematic Review of Evaluated Studies and Their Outcomes

Problematic substance use (PSU) in later life is a growing global problem of significant concern in tandem with a rapidly ageing global population. Prevention and interventions specifically designed for older people are not common, and those designed for mixed-age groups may fail to address the unique and sometimes complex needs of ageing communities. We report findings from a systematic review of the empirical evidence from studies which formally evaluated interventions used with older people and reported their outcomes. Nineteen studies were included, of which thirteen focused solely on alcohol-related problems. Eight interventions utilised different types of screening, brief advice and education. The remaining drew on behavioural, narrative and integrated or multi-disciplinary approaches, which aimed to meet older people's needs holistically. Quality assessment of study design helped to review evaluation practice. Findings point to recommendations for sustainable and well-designed intervention strategies for PSU in later life, which purposefully align with other areas of health and well-being and are delivered in locations where older people normally seek, or receive, help. There is further scope for engagement with older people's own perspectives on their needs and help-seeking behaviours. Economic evaluation of the outcome of interventions would also be useful to establish the value of investing in targeted services to this underserved population.

Applying a Capabilities Approach to Understanding Older LGBT People's Disclosures of Identity in Community Primary Care

Internationally, there is increasing recognition that lesbian, gay, bisexual and trans (LGBT) populations experience substantial public health inequalities and require interventions to address these inequalities, yet data on this population is often not routinely collected. This paper considers the case study of the UK, where there are proposals to improve government and health data collection on LGBT populations, but also a degree of apparent uncertainty over the purpose and relevance of information about LGBT status in healthcare. This paper applies a health capabilities framework, arguing that the value of health information about LGBT status should be assessed according to whether it improves LGBT people’s capability to achieve good health. We draw upon 36 older LGBT people’s qualitative accounts of disclosing LGBT status within UK general practice healthcare. Participants’ accounts of the benefits and risks of disclosure could be mapped against multiple domains of capability, including those that closely align with biomedical accounts (e.g., longevity and physical health), but also more holistic considerations (e.g., emotion and affiliation). However, across all domains, individuals tend to assess capabilities at an individual level, with relatively little reference to population-level impact of disclosure. Clearer articulation of the benefits of disclosure and data collection for the collective capabilities of LGBT populations may be a beneficial strategy for improving the quality of information on LGBT populations.

Educating health and social care practitioners on the experiences and needs of older LGBT+ adults: Findings from a systematic review

AIM(S)

To report review findings into interventions used to educate the health and social care workforce on the experiences and needs of LGBT+ older adults.

BACKGROUND

Research demonstrates that inequalities in outcomes on health and social well-being for LGBT+ older adults are perpetuated by the cumulative disadvantages from discrimination and social exclusion throughout the life course and a lack of culturally competent workforce.

METHODS

A systematic search of peer-reviewed papers published before February 2020 was conducted in electronic databases. The search resulted in a screening of 2,509 papers with nine matching the inclusion criteria, which were rated using the MERSQI quality measure.

RESULTS

Studies demonstrated some positive outcomes of interventions, especially an increase in knowledge, but less so in skills and attitudes.

DISCUSSION

More robust designs such as randomized controlled trials, the use of standardized measures and a focus more on the longitudinal impact of educational interventions could improve the quality of study designs.

CONCLUSION(S)

Diversification of intervention content and patient and public involvement in the design, delivery and evaluation of educational interventions could improve efforts and have a more sustained impact on LGBT+ ageing inequalities.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers have important roles in supporting staff education and ensuring LGBT+ inclusive practice.

Dog-assisted interventions and outcomes for older adults in residential long-term care facilities: A systematic review and meta-analysis

OBJECTIVE

To comprehensively review studies on dog-assisted interventions (DAIs) among older people in residential long-term care facilities (RLTCFs) and to provide an overview of their interventions, outcomes and methodological quality.

METHOD

We searched 18 electronic databases to identify English articles (published January 2000-December 2019) reporting on well-defined DAIs targeting older adults (≥65 years) in RLTCF. Data were extracted by two independent reviewers. Descriptive statistics were produced for quantitative studies, with key themes identified among qualitative studies. Where possible, estimates were pooled from randomised controlled trials using random effects meta-analyses.

RESULTS

Forty-three relevant studies (39 quantitative; 4 qualitative) were identified. The majority of quantitative studies were assessed as low-quality according to the MMAT criteria (n = 26, 67%). Almost half of the quantitative studies (n = 18, 46%) found no significant changes over time or between groups across outcomes measured. The most salient intervention effects included improved social functioning (n = 10), reduced depressive symptoms (n = 6) and loneliness (n = 5). A random-effects meta-analysis revealed a medium effect in favour of DAT on reducing depressive or loneliness symptoms (pooled SMD: 0.66, 95%CI 0.21-1.11; I²  = 50.5; five trials), relative to treatment as usual. However, compared to treatment as usual, no overall effect of DAI on activities of daily living was detected (p = .737). Key themes from qualitative studies included (a) animals as effective transitional objects, (b) the therapeutic value of pets and (c) the significance of the care environment and stakeholders in facilitating DAI.

IMPLICATIONS FOR PRACTICE

The findings of this review indicate that while DAI has value for older people in RLTCF, challenges remain in accurately measuring its impact to provide a stronger evidence-base. Standardisation of DAI service design, delivery and evaluation is required for future research and practice in providing holistic care for older adults.

Older LGBT+ health inequalities in the UK: setting a research agenda

Lesbian, gay, bisexual and trans+ (LGBT+) people report poorer health than the general population and worse experiences of healthcare particularly cancer, palliative/end-of-life, dementia and mental health provision. This is attributable to: (a) social inequalities, including 'minority stress'; (b) associated health-risk behaviours (eg, smoking, excessive drug/alcohol use, obesity); (c) loneliness and isolation, affecting physical/mental health and mortality; (d) anticipated/experienced discrimination and (e) inadequate understandings of needs among healthcare providers. Older LGBT+ people are particularly affected, due to the effects of both cumulative disadvantage and ageing. There is a need for greater and more robust research data to support growing international and national government initiatives aimed at addressing these health inequalities. We identify seven key research strategies: (1) Production of large data sets; (2) Comparative data collection; (3) Addressing diversity and intersectionality among LGBT+ older people; (4) Investigation of healthcare services' capacity to deliver LGBT+ affirmative healthcare and associated education and training needs; (5) Identification of effective health promotion and/or treatment interventions for older LGBT+ people, and subgroups within this umbrella category; (6) Development of an (older) LGBT+ health equity model; (7) Utilisation of social justice concepts to ensure meaningful, change-orientated data production which will inform and support government policy, health promotion and healthcare interventions.

Preventing and responding to depression, self-harm, and suicide in older people living in long term care settings: a systematic review

Objective: The well documented demographic shift to an aging population means that more people will in future be in need of long term residential care. Previous research has reported an increased risk of mental health issues and suicidal ideation among older people living in residential care settings. However, there is little information on the actual prevalence of depression, self-harm, and suicidal behavior in this population, how it is measured and how care homes respond to these issues. Method: This systematic review of international literature addressed three research questions relating to; the prevalence of mental health problems in this population; how they are identified and; how care homes try to prevent or respond to mental health issues. Results: Findings showed higher reported rates of depression and suicidal behavior in care home residents compared to matched age groups in the community, variation in the use of standardised measures across studies and, interventions almost exclusively focused on increasing staff knowledge about mental health but with an absence of involvement of older people themselves in these programmes. Conclusion: We discuss the implications of these findings in the context of addressing mental health difficulties experienced by older people in residential care and future research in this area.

'Dignity and respect': An example of service user leadership and co-production in mental health research

This paper explores the methodological aspects of a user‐led study investigating mental health service user experiences of targeted violence and abuse (often called 'hate crime'). 'Keeping Control' was a 16‐month qualitative study, undertaken in the context of adult safeguarding reforms in England. By collecting data on service user concepts and experiences, the research sought to address a gap in research and practice knowledge relating to targeted violence, abuse and hostility against people with mental health problems. In this paper, we discuss the significance of the design and methodology used for this study, with a particular focus on the interviews with service users. The research was both user‐led and carried out in collaboration with practitioners and academics, a form of research co‐production. Our aim is to inform researchers, practitioners and policymakers about the value of user leadership in co‐productive research with practitioners, particularly for a highly sensitive and potentially distressing topic.

What do we know about transgender parenting?: Findings from a systematic review

Transgender issues are under-explored and marginalised within mainstream social work and social care professional practice. The experience of gender transition has a profound impact on the individuals who have diverse gender identities and their family members. We present findings from a systematic review of studies concerning the experiences of transgender parenting conducted during January-September 2017. We took a life course approach, examining the research studies that investigated the experience of people identifying as transgender, who were already parents at the time of their transition or who wished to be parents following transition. The review evaluated existing findings from empirical research on transgender parenting and grandparenting to establish how trans people negotiate their relationships with children following transition, and sought to consider the implications for professional practice with trans people in relation to how best to support them with their family caring roles. We used the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Empirical studies published from 1 January 1990 to 31 April 2017 in the English language, and which had transgender parenting as a significant focus, were included in the review. Twenty-six studies met the criteria. Key themes reported are: how trans people negotiate their relationships with children following disclosure and transition; the impact of parental transitioning on children; relationships with wider families; trans people's desires to be parents; and the role of professional practice to support trans families. We discuss how the material from the review can inform social work education and practice, including to help identify future research, education and practice priorities in this area.

How do older people discuss their own sexuality? A systematic review of qualitative research studies

This study captured older people's attitudes and concerns about sex and sexuality in later life by synthesising qualitative research published on this issue. The systematic review was conducted between November 2015 and June 2016 based on a pre-determined protocol. Key words were used to ensure a precise search strategy. Empirically based, qualitative literature from 18 databases was found. Twenty studies met the inclusion criteria. Thomas and Harden's thematic synthesis was used to generate 'analytical themes' which summarise this body of literature. Three main themes were identified: (a) social legitimacy for sexuality in later life; (b) health, not age, is what truly impacts sexuality, and (c) the hegemony of penetrative sex. The themes illustrate the complex and delicate relation between ageing and sexuality. Older adults facing health issues that affect sexual function adopt broader definitions of sexuality and sexual activity.

Turning the Co-Production Corner: Methodological Reflections from an Action Research Project to Promote LGBT Inclusion in Care Homes for Older People

Background: Older lesbian, gay, bisexual and trans (LGBT) residents are often invisible in long-term care settings. This article presents findings from a community-based action research project, which attempted to address this invisibility through co-produced research with LGBT community members. Particular Question: What conditions enable co-produced research to emerge in long-term residential care settings for older people? Aims of Project: To analyse outcomes and challenges of action-oriented, co-produced research in the given context. In particular, we explore how co-production as a collaborative approach to action-orientated research can emerge during the research/fieldwork process; and reflect critically on the ethics and effectiveness of this approach in advancing inclusion in context. Methods: The project was implemented across six residential care homes in England. Reflections are based on qualitative evaluation data gathered pre- and post-project, which includes 37 interviews with care home staff, managers and community advisors (two of whom are co-authors). Results and Conclusions: We discuss how the co-production turn emerged during research and evaluate how the politics of this approach helped advance inclusion—itself crucial to well-being. We argue for the value of co-produced research in instigating organizational change in older people’s care environments and of non-didactic storytelling in LGBT awareness-raising amongst staff.

Developing inclusive residential care for older lesbian, gay, bisexual and trans (LGBT) people: An evaluation of the Care Home Challenge action research project

There have been substantial achievements in legislative and human rights for lesbian, gay, bisexual and transgender (LGBT) older people and their visibility in health and social care has equally increased. These appear to have surpassed the ability of care services to meet their needs given documented concerns about the accessibility, inclusiveness and safety of care services particularly institutionalised care. This requires systemic change not easy to operationalise. This paper describes an action research initiative where six care homes belonging to a national care provider, collaborated to assess and develop their services with the support of local LGBT "Community Advisors" and academic partners. Framed within Rogers' (2003) change management framework and combined with a participatory leadership approach, a programme of intervention was implemented comprising structured activities around seven key areas thought to promote LGBT inclusion. A formal evaluation was conducted involving 35 pre- and post-intervention qualitative interviews with 18 people (community advisors; care home managers and senior managers). The findings are presented across three key themes (1) starting points on the journey; (2) challenges encountered along the journey (organisational and interpersonal); and (3) making change happen; opportunities, initiatives and gains. We make recommendations on the value of a programme approach for achieving tangible outcomes that demonstrate increased inclusion for older LGBT people living in long-term care settings.

Going solo: Findings from a survey of women aging without a partner and who do not have children

Greater longevity in the UK population has led to the increasing diversity of women experiencing aging in a multitude of ways. Internationally, gender inequalities in aging are still relatively invisible within both government policy and everyday life for particular groups of women. This article explores the concept of women growing older "solo"-by which we mean women who find themselves nonpartnered and aging without children as they move into later life. We report on the findings from a mixed-methods survey of 76 solo women in the UK aged 50 years and over, used to provide a broader overview of the issues and challenges they face as they move into later life. Qualitative data from the survey captured respondents' perspectives about the links between their relationships status and well-being in later life and highlighted specific cumulative disadvantages emerging for some women as a result of their solo lifestyles. We discuss two key themes that were identified, "solo-loneliness" and "meaningful futures," in conjunction with the relevant literature and make suggestions for future research within gender and aging studies that could enhance more positive approaches to solo lifestyles.

Quality improvement through the paradigm of learning

Purpose

– Achieving meaningful participation and co-production for older people in care requires radical approaches. The purpose of this paper is to explore an innovation where learning interventions were introduced into care settings and older people matched to community-based learning mentors to develop partnerships. The authors explore how the concept of learning might be used as a paradigm to raise the quality of care in institutionalised settings using a co-productive and relationship-based approach to promote wellbeing.

Design/methodology/approach

– A structured evaluation drew on qualitative data captured from interviews with older people (n=25) and learning mentors (n=22) to reflect on the potential benefits and challenges involved when introducing learning interventions in care settings. This was contextualised alongside data captured from stakeholders (n=10) including a care home manager, social care and education commissioners, trustees and project staff to assess the interdisciplinary contribution of lifelong learning to quality improvement.

Findings

– Introducing learning interventions to older people within care settings promoted participation, advocacy and relationship-based care which in turn helped to create a positive culture. Given the current challenges to improve quality in care services, drawing on a paradigm of learning may encourage older people to retain their independence as care homes strive towards a person-centred approach. Promoting social activities and leisure using learning was found to foster closer working relationships between older people and the wider community. These had a levelling effect through reciprocity, using an asset based approach. There were benefits for the care provider as the partnerships formed enabled people to raise both individual and collective concerns about care and support.

Originality/value

– Raising and sustaining the quality of support for older people requires input from the wider public sector beyond health and social care. Purposeful engagement with other disciplines such as learning and leisure offers the potential to realise a more sustainable model of user choice, person-centred support and user involvement. Being engaged through learning can nourish membership in the community for marginalised populations such as older people living in care homes.

Funny things happen at the Grange: Introducing comedy activities in day services to older people with dementia – innovative practice

This paper shares outcomes from the evaluation of a community project where comedy activities were introduced into a day centre for older people with dementia as a result of a partnership between the day centre, a local university and a specialist comedy provider. Four workshops were provided using improvisatory activities and comedy, as a medium to engage older people in reflecting on aspects of their care environment. The main output resulted in a 30 minute ‘mockumentary’ of the ‘Her Majesty the Queen’ visiting the day centre, in the form of a digital reusable learning object to be used by social work and mental health professionals. The evaluation demonstrated some additional outcomes for those involved and highlighted the benefits of laughter and fun in promoting a positive climate.