The contribution of a complex systems-based approach to progressive social resilience.

The use of resilience in social practice has evolved from a theoretical framework at the intersection between individuals and their social ecology. Critics argue this theory still results in policies and practices that are too individualised, with the potential for negative social consequences. This paper further critiques contemporary understanding of resilience theory and its application. It juxtaposes complex systems theory with a social inequalities oriented resilience practice. This provides a paradoxical approach. It is acknowledged that state and public policy decisions and actions can be anti-resilient, undermining community and social resilience that already exists in the form of social relationships, self-organisation and co-production. Nevertheless, collective social resilience also illustrates the potential of local and service user organisations to contribute to an overall transformational change process.

'It is still coming from the centre and coming out': The material conditions adding to over-bureaucratised patient and public involvement for commissioning health and care in England.

OBJECTIVE: To understand how materiality affects patient and public involvement (PPI) for commissioning and leading health and care services in the English National Health Service (NHS) context. CONTEXT: From April 2013 groups of general practitioners (GPs) became members of NHS clinical commissioning groups (CCGs) to assess needs and procure core health services for and with local communities. Since July 2022, integrated care systems (ICSs) have subsumed this responsibility. NHS reorganisations have been driven by the promise of more effective and efficient health care and have led to a long history of PPI on economic, political, and moral grounds. Few studies researching PPI in clinical commissioning exist and fewer still have explored a more agentic understanding of materiality and its impact on PPI. STUDY DESIGN: A focused ethnography was used to examine PPI for clinical commissioning within two CCG case study sites in England. Three CCG Governing Body lay representatives, nine GP commissioners and seven service user representatives took part in focus groups and/or were interviewed. Fifteen nonparticipant observations were also carried out at CCG meetings and the associated materiality was examined. FINDINGS: The materiality of activities involved in clinical commissioning influences and shapes the nature of PPI. These forms of materiality may dilute and subvert meaningful engagement and involvement that relies on trust, leadership, learning, and partnership working. CONCLUSION: System leaders in ICSs should consider the significance of materiality in centrally driven processes involved in PPI commissioning to reduce barriers and ensure meaningful partnerships within local communities. PATIENT AND PUBLIC CONTRIBUTION: The study design ensured PPI throughout the research process in keeping with contemporary research practice guidance. The project steering committee included service users with current or recent PPI clinical commissioning experience outside of the study sites. There was PPI involvement in the original study proposal and its development including the bid for doctoral funds on which this study is based. All were involved in assessing the rigour of the data collection, interpretation of the findings and ensuring the project remained true to the aims of the study. Two members have also participated in presentation of the study findings.

Youth Resilience to Drought: Learning from a Group of South African Adolescents.

Exposure to drought is on the increase, also in sub-Saharan Africa. Even so, little attention has been paid to what supports youth resilience to the stressors associated with drought. In response, this article reports a secondary analysis of qualitative data generated in a phenomenological study with 25 South African adolescents (average age 15.6; majority Sepedi-speaking) from a drought-impacted and structurally disadvantaged community. The thematic findings show the importance of personal, relational, and structural resources that fit with youths' sociocultural context. Essentially, proactive collaboration between adolescents and their social ecologies is necessary to co-advance socially just responses to the challenges associated with drought.

Resilience-based alcohol education: developing an intervention, evaluating feasibility and barriers to implementation using mixed-methods.

Alcohol education must ensure that young people have appropriate information, motivation and skills. This article describes the fifth phase in a program of intervention development based on principles of social marketing and intervention mapping. The aim was to enhance drink refusal self-efficacy (DRSE) and help develop skills for non-drinking or moderate drinking. We conducted a mixed-methods feasibility trial that measured intervention effects among 277 UK secondary school students aged 14-16, and used qualitative methods to explore four teachers' experiences of delivering the intervention. The intervention did not produce the desired changes in DRSE or alcohol use, but nor did it increase alcohol use. In the qualitative process evaluation, time constraints, pressure to prioritize other topics, awkwardness and embarrassment were identified as barriers to fidelitous delivery. A more intense and/or more prolonged intervention delivered with greater fidelity may have produced the desired changes in DRSE and alcohol use. This study illustrates how principles of social marketing and intervention mapping can aid development of resilience-based education designed to help students develop skills to drink moderately, or not drink. It also highlights the need to consider the constraints of micro-social (school) and macro-social (societal) cultures when designing alcohol education.

Bounce Forward: A School-Based Prevention Programme for Building Resilience in a Socioeconomically Disadvantaged Context.

Socioeconomic status is a strong predictor of normative development and well-being in young people. It is well-known that growing up in a socioeconomically disadvantaged context may lead to negative outcomes, both in childhood and in adulthood. Early intervention and prevention programmes are crucial for building resilience and improving health, well-being and equity. Bounce Forward is a school-based prevention programme implemented in Blackpool, a town in the United Kingdom facing multiple challenges. It was part of a whole town resilience approach and nascent global social movement known as the "Resilience Revolution." Between 2017 and 2019, the programme was delivered in all Year 5 classes at every primary school in Blackpool (n school = 36), reaching out to 3,134 students (ages 9-10; 50.4% male). The programme aimed to increase resilience in young people by building knowledge and skills about mental health and resilience through 10 sessions. In the current study, we longitudinally examined a range of protective factors, which are relevant to young people's resilience, as well as their mental health outcomes at three time points: before they participated in Bounce Forward, at the end of the programme, and 3-5 months later, when they started Year 6. The current sample included 441 Year 5 students (54.2% male) from 11 primary schools in Blackpool. Nineteen teaching staff also participated in the study and provided qualitative data regarding the impact of the programme on their students. Results showed improvement in some areas of young people's resilience after taking part in Bounce Forward. We also identified gender differences in several protective factors, indicating that boys may need further support. Teaching staff highlighted improvements in various areas; and also observed that their students have been using the strategies that they learnt from the programme. Altogether, findings suggested that young people benefitted from Bounce Forward. The programme is sustainable, offering a free to download teacher resource pack that allows schools to self-deliver it.

Collaboration in the design and delivery of a mental health Recovery College course: experiences of students and tutors.

BACKGROUND: Recovery Colleges address mental health challenges using an educative approach underpinned by a collaborative recovery orientated philosophy. Research has been limited with no studies identified reporting research on the design and delivery of a specific course. AIMS: To understand how Recovery College students and tutors experience the design and delivery of a mental health Recovery College course, specifically the "'Building Resilience" course. METHOD: Thematic analysis of qualitative data related to the experience and process of collaboration in recovery college course design and delivery. Data included 13 qualitative individual interviews with course students and tutors and "naturally occurring" data generated through course preparation and delivery. RESULTS: Findings drew attention to the centrality of: prior experience and design related to students, tutors and the course structure; co-delivery related to tutors and co-learner impacts; and to the course methods and environment. CONCLUSIONS: Commitment to collaboration in design and delivery of Recovery College courses can mobilise the diverse experiences and expertise of tutors and students. The environment and methods of learning have a significant impact and should be considered alongside content. Boundaries between people and areas of knowledge and experience that arise can be viewed as sources of creativity that can enrich courses.

Validity and reliability of the Mexican resilience measurement scale in families of children with chronic conditions.

BACKGROUND: The resilience to face disease is a process of positive adaptation despite the loss of health. It involves developing vitality and skills to overcome the negative effects of adversity, risks, and vulnerability caused by disease. In Mexico, the Mexican Resilience Measurement Scale (RESI-M) has been validated with a general population and has a five-factor structure. However, this scale does not allow evaluation of resilience in specific subpopulations, such as caregivers. METHOD: This study investigated the psychometric properties of RESI-M in 446 family caregivers of children with chronic diseases. A confirmatory factor analysis (CFA) was performed, internal consistency values were calculated using Cronbach's alpha coefficient, and mean comparisons were determined using t-tests. RESULTS: The expected five-factor model showed an adequate fit with the data based on a maximum likelihood test. The internal consistency for each factor ranged from .76 to .93, and the global internal consistency was .95. No average difference in RESI-M and its factors was found between women and men. CONCLUSION: The RESI-M showed internal consistency and its model of five correlated factors was valid among family caregivers of children with chronic diseases.

Staying in the 'sweet spot': A resilience-based analysis of the lived experience of low-risk drinking and abstention among British youth.

OBJECTIVE: The aim of this study was to understand how and why young people drink less or not at all when with their peers. Understanding the subjective experiences of moderate or non-drinkers may help identify protective processes facilitating resilience to cultural norm and influences that encourage excessive alcohol consumption among young people. DESIGN: Semi-structured interviews were conducted with 25 moderate- or non-drinkers aged 17-25 years (13 young women) living in South East England. Interviews explored recent experiences of social situations and encounters that did or did not involve alcohol. Transcripts were analysed using Interpretative Phenomenological Analysis. RESULTS: Analysis identified six conceptually coherent themes clustering within a superordinate theme of a healthy experience of moderate alcohol use or abstention: 'the sweet spot'. These themes were: feeling good in the body, feeling like you can be who you are, feeling like you belong, making a free choice, enjoying the moment, and feeling safe and secure. CONCLUSIONS: This resilience-based analysis showed how non-drinking and moderate-drinking may be experienced as a positive and proactive choice. Understanding the subjective experiences of young people may aid development of specific, realistic interventions to promote moderate drinking and abstention among young people in drinking cultures.

Using qualitative methods within a mixed-methods approach to developing and evaluating interventions to address harmful alcohol use among young people.

OBJECTIVE: This article illustrates how qualitative methods can be used in the development and evaluation of behavior change interventions. Although many campaigns advise young people to drink responsibly, few clarify how to convert this general advice into specific behavioral strategies. Resilience-based approaches argue that treating young non-drinkers and moderate drinkers as "experts" in responsible alcohol use may facilitate co-creation of acceptable interventions that focus on how to change behavior. METHOD: Four distinct phases of intervention development were linked to past research and future developments. RESULTS: First, analysis of correlates of alcohol use using data from a survey of 1,412 people aged 16-21 indicated that alcohol harm-reduction interventions should help young people to develop skills and strategies to resist alcohol. Second, interpretative phenomenological analysis of 25 interviews with people purposively selected from among the survey sample identified general strategies and specific tactics used by young people to manage opportunities to drink. Third, insights from the first 2 phases and past qualitative research guided development of video resources to be use in school-based alcohol education to illustrate strategies and tactics for moderate or non-use of alcohol. Fourth, 18 focus groups with students and teachers were used to evaluate the video: structured thematic analysis indicated that after revision the video would be a valuable addition to school-based alcohol education. CONCLUSIONS: Findings from the 4 phases highlight the value of using different qualitative and quantitative methods as part of a program of work designed to inform the development, refinement, and evaluation of health psychology interventions.

Resilient moves: Tinkering with practice theory to generate new ways of thinking about using resilience.

Recent public health policies have re-endorsed the key role all health and social care professionals have in tackling the social determinants of health inequalities. With inequalities firmly entrenched, and much theorising focused on reproduction rather than transformation, sustaining practitioner commitment and engagement with this work and maintaining confidence in achieving change is challenging. One increasingly popular way to intervene in practice to begin to address inequalities has been the use of resilience, even though resilience is frequently critiqued for its collusion with neoliberal imperatives in favouring individualised rather than socio-political responses. This article examines these concerns through the use of the practice turn and specifically 'slim-line' practice theory and 'tinkering' to explore the potential for reframing resilience theory and practice. Using an original data set derived from evaluations of resilience-based programmes, held with parents and practitioners between 2008 and 2012, this article re-examines participants' understandings of resilience. We show how practice theory reveals entangled and emergent meanings, competencies and materials that constitute resilience as a social practice comprised of resilient moves. The implications of this reframing are discussed in relation to ontology, agency and change; but also for resilience theory and practice and public health practices more generally. In conclusion, we argue practice theory's attention to context as more than mere backdrop to action helps shift inequality theorising beyond the individual and reproduction towards deeper, detailed social understandings of transformation and change.

How alike are young non-drinkers, former-drinkers, low-risk drinkers, and hazardous drinkers?

The aim of this study was to examine whether - in terms of personality characteristics and beliefs--former-drinkers and people who have never consumed alcohol exist on a continuum that includes low-risk drinkers and hazardous drinkers, or are distinct groups. An online questionnaire hosted on a secure server was completed by 1418 young people (642 men and 776 women) aged 16-21 living in South-East England. Participants' scores on the Alcohol Use Disorders Identification Test (AUDIT) were used to classify them as non-drinkers, former-drinkers, low-risk drinkers or hazardous drinkers. Multinomial logistic regression identified eight significant multivariate correlates that explained 39% of the variance in men's AUDIT category membership (χ(2)(24) = 263.32, p < .01), and seven significant multivariate correlates that explained 41% of the variance in women's AUDIT category membership (χ(2)(21) = 332.91, p < .01). The results suggest that non-drinkers and former-drinkers are more similar to each other than they are to both low risk and hazardous drinkers. We should not, therefore, treat these groups of young people as representing a drinking continuum. In particular, interventions for high risk young drinkers may be more effective if distinguished from general campaigns intended for all young people.

Which alcohol control strategies do young people think are effective?

INTRODUCTION AND AIMS: The aims of this study were to examine young people's belief in the effectiveness of various alcohol control strategies and to identify demographic, attitudinal and behavioural correlates of perceived effectiveness. DESIGN AND METHODS: An online questionnaire hosted on a secure server was completed by 1418 men and women aged 16-21 years living in South-East England. It assessed the perceived effectiveness of various alcohol control strategies. Key correlates included sensation seeking, impulsivity, conscientiousness, alcohol outcome expectancies, drink refusal self-efficacy, perceived peer alcohol use and Alcohol Use Disorders Identification Test scores. RESULTS: The most effective strategies were perceived to be enforcing responsible service legislation, strictly monitoring late-night licensed premises and teaching alcohol refusal skills. Greater belief in the effectiveness of alcohol control strategies was expressed by older participants, those who consumed less alcohol and those who expected more negative outcomes from alcohol consumption. DISCUSSION AND CONCLUSIONS: The data suggest that in order to increase the perceived effectiveness of alcohol control strategies, we may need to address young people's beliefs about the negative outcomes of alcohol use. Strategies that young people believe are effective may be easier to implement, but this does not imply that unpopular but effective strategies should not be tried.

Supporting workers with mental health problems to retain employment: users' experiences of a UK job retention project.

OBJECTIVES: To understand experiences and perspectives of job retention project users in relation to challenges faced and support received; to develop explanatory insight into effective interventions. PARTICIPANTS: 14 employed users of a United Kingdom job retention project, with a range of mental health problems. METHODS: Semi-structured individual interviews which were collaboratively designed with service users. Data analysis involved deductive & inductive thematic analysis, constant comparative analysis, and service user collaboration. RESULTS: Participants' feelings of guilt and self blame were a major obstacle to job retention. The project helped them address these by supporting a reappraisal of their situation. This assisted identification of job accommodations and adjustments and confidence in self advocacy. Thus an important basis for improved dialogue with their employer was established. A peer support group provided an important adjunct to individual project worker interventions. 10 participants retained employment; three of those who did not were helped to retain work aspirations. CONCLUSIONS: The project effectively used a multi-faceted approach involving a person - environment-occupation focus on the worker, their work, and workplace. Such complex interventions may offer more promise than those interventions (such as cognitive behavioural therapy) which have a primary focus on the individual worker.

Attuned practice: a service user study of specialist child and adolescent mental health, UK.

AIMS: Best practice emphasises user involvement. This exploratory study addresses the views of teenage clients and their parents on service delivery in a specialist Child and Adolescent Mental Health Service (CAMHS) serving a population of 250,000. It aims to explore some of the complexities inherent in children's services when parents are integral to modes of treatment. METHODS: Twenty-seven teenage clients from specialist CAMHS were recruited with their parents (n=30). All were white British, 11 boys and 16 girls, from a range of socioeconomic backgrounds. Focus groups were employed using a series of structured interactive technique to elicit information, preceded by home visits. Analysis of interview data followed standard approaches to qualitative data analysis. Descriptive statistics were generated from both home interview data and focus groups. RESULTS: Three themes emerged: the core values implicated in establishing a therapeutic alliance; the style of therapy and mode of practice (i.e. its inclusiveness of different family members). PRACTICE IMPLICATIONS: Core therapeutic skills are of fundamental importance. Our paper supplements a model of organisational user involvement with a model of therapeutic user involvement for use in negotiating mode of practice. CONCLUSIONS: This exploratory study was a collaboration between service users, researchers and health professionals exploring three important themes of therapy and the complexities inherent in children's services. The process of eliciting views was therapeutic in itself leading to the formation of a parent-led self-help group. The design can be replicated in other specialist CAMHS to achieve attuned practice.

Health 'care' interventions: making health inequalities worse, not better?

AIM: The aim of this paper is to present a model, the 'Effect of the Professional Ego', which provides a psychodynamically informed analytical framework for examining professional practice in arenas where issues of inequalities need to be addressed. BACKGROUND: There is a great deal of literature on the psychosocial aspects of inequalities in health care provision. However, the impact of intrapsychic and professional cultural elements has not been explored in this context. Moreover, the body of work which does explore these elements in relation to health care workers does not address how they might impact on health inequalities. DISCUSSION: Drawing on empirical work, we discuss ways in which intrapsychic and professional cultural elements feed into the dynamic between clients and health care professionals in a way which can subvert espoused, positive client health outcomes. Based on this discussion, we propose the Effect of the Professional Ego model, which identifies two main aspects of the professional ego - the grandiose self and self-preservation - and how they influence the professional/client dynamic. CONCLUSION: Systematic self-reflection on the part of professionals would be a valuable contribution to the development of professional practice. This applies particularly to conceptualizing the links between the actions of service providers and the adverse health of clients.

The role of the Internet in patient-practitioner relationships: findings from a qualitative research study.

BACKGROUND: Studies suggest that there has been an increase in the use of the Internet by patients in many Western societies. However, despite the many texts available on health and the Internet, not much is known about how much patients actually use the Internet to look up health information in their daily lives. We know little about what meaning this activity has for their experience of health and illness, and for their relationship with health-care practitioners. OBJECTIVE: To explore patients' and practitioners' use of the Internet and to consider whether use of the Internet is changing relationships between patients and health-care practitioners. METHOD: The study used qualitative interviews and observations of patient-practitioner interaction. Our purposive sample of 47 patients (32 women and 15 men) had all had contact with the health services for information/treatment in relation to hormone replacement therapy (HRT)/menopause and Viagra/erectile dysfunction. The setting for the research was in general practitioners' surgeries, specialist clinics and patients' homes in the United Kingdom. Participants reflected a wide range of socio-economic groups, but most were white and British born, which, given the ethnic make-up of the town in which we conducted the research, was not surprising. In addition to patients, we interviewed 10 health-care practitioners (4 consultant doctors, 3 GPs, 2 specialist nurses, and a psychologist) about their own health information seeking practices (HISPs) and those of their patients. RESULTS: Use of the Internet can increase patients' knowledge about their health conditions, although patients in our study were often too overwhelmed by the information available on the Internet to make an informed decision about their own care. Patients have a great deal of trust in their health-care practitioners. Health-care practitioners need to improve their own skills in Internet use. Hype around Internet use by patients appears to exceed the reality of Internet use. CONCLUSIONS: Our qualitative study suggests that use of the Internet is contributing to subtle changes in the relationship between health-care practitioners and their patients, rather than effecting the dramatic transformation some people envisage for it.

Research into EPRs: how midwives really feel.

This article describes some of the findings of a two-year research project entitled The use of electronic patient records (EPRs) in maternity services: professional and public acceptability, commissioned by the Department of Health (DH). The main methods used were: --Literature review. --A national telephone survey of heads of midwifery (HOMs) in England (2001). --Case studies of maternity services in four NHS Trusts (2002). One of the findings of the research was that midwives and HOMs considered they had little knowledge of what EPRs are, and most were confused about whether their existing maternity information system (MIS) constituted an EPR system. The exact nature of EPRs was also contested among information technology (IT) professionals and NHS Trusts' EPR development strategies varied. Each Trust was, and still is, developing their own response to Information for health (NHS executive, 1998). Broadly speaking, these fell into one of two main categories of approach to EPR development. First, a 'best of breed' approach meant that departmental information systems, such as MISs were to be part of future EPR systems, and these specialist systems would become part of an inter-connected EPR system by being gradually connected with other departmental and Trust-wide information systems. Second, a 'big bang' or 'one-system' approach meant all departmental systems were in the process of being replaced by a single supplier's system for the whole Trust, and specialist departments were expected to meet their information needs by using specialist modules within this system. The relative merits of each approach were hotly debated both locally and nationally during the course of the research project. Another finding was that midwives had little interest in EPRs, although the views expressed were contradictory. While midwives were not interested in being involved in EPR developments, they did want to see midwifery interests represented. Nearly all midwives and midwifery managers expected their perspective to be provided by the 'IT midwife'. The definition of this role varied in different services. Also, the research found that not all IT midwives were accepted by colleagues as appropriate representatives of their needs. At a time when there are increasing pressures on midwives to expand their role, (Department of Health, 1999: RCM, 2002b) we argue that midwives should play a more proactive role in the development of EPRs. The example is given of the claim that EPR systems save practitioners time (NHS executive, 1998). The research showed that maternity EPR systems consumed more time for midwives than they saved, although where midwives could see the clinical value of having the system this burden was considered more acceptable. Midwives should ask more questions about the value of the information systems they use and the new EPR systems that are being rolled out, and this needs to be encouraged by midwifery educators.

'Ignorance is bliss sometimes': constraints on the emergence of the 'informed patient' in the changing landscapes of health information.

In this paper we describe and analyse results from an empirical study designed to provide insight into factors facilitating and/or inhibiting the emergence of the much-heralded 'informed patient' and its sociological equivalent, the 'reflexive patient' or 'reflexive consumer'. In particular, we seek to examine the relationship between information and empowerment in a healthcare context and assess the significance of the Internet in mediating this relationship. The paper draws on data from interviews with 32 mid-life women concerned to know about HRT for the relief of menopausal symptoms. Having analysed these women's 'information practices', we conclude that constraints on the emergence of the informed patient identity exist within both patient and practitioner communities and within the space occupied by both in the medical encounter. In particular, in this paper we identify a tension caused by the emphasis on 'information for choice' in the informed patient discourse which itself obscures the potential conflict between lay and expert/medical knowledges in the clinical encounter.

Helping health and social care professionals to develop an 'inequalities imagination': a model for use in education and practice.

BACKGROUND: The 'inequalities imagination model' originated from our own research, and led to findings and recommendations regarding clinical and education issues. This article focuses on the creation of the model which, we suggest, could be used to facilitate the development of an 'inequalities imagination' in health and social care professionals. AIM: To describe and critically analyse the thinking that led to the concept of an 'inequalities imagination' and provide the framework for the theoretical model. METHODOLOGICAL APPROACH: Influencing concepts from the fields of social work, sociology, nursing and midwifery, and debates around antidiscriminatory and antioppressive practice, cultural safety, cultural competence and individualized care are analysed. INEQUALITIES IMAGINATION MODEL: Ideas generated from an analysis of the concepts of antidiscriminatory/anti-oppressive practice and from the research data led us to conceptualize a flexible model that incorporated issues of individual and structural agency and a broad definition of disadvantage. The literature review underpinning the theoretical framework means that the model has the potential to be truly interdisciplinary. CONCLUSIONS: Professional educators face a difficult task in preparing practitioners to work with clients in ways that take account of differences in background and lifestyle and which respect human rights and dignity. The model makes explicit a process that enables practitioners to think about their current practice and move towards a greater understanding and awareness of the way they work with disadvantaged clients, and ways in which they prepare others to do so. We suggest that professionals develop an 'inequalities imagination' in order to enhance equality of care. The development of an 'inequalities imagination' helps practitioners to bridge the gap between the challenges they face in day-to-day practice and what they need to achieve to aspire to provide equality of care to all.