Hope, Agency, and the Lived Experience of Violence: A Qualitative Systematic Review of Children's Perspectives on Domestic Violence and Abuse.

There is a large body of research on the impact of domestic violence and abuse (DVA) on children, mostly reporting survey data and focusing largely on psychological outcomes. Qualitative research on the views of children has the potential to enable a child-centered understanding of their experience of DVA, so their needs can be better met by professionals. This systematic review reports general findings from the ViOlence: Impact on Children Evidence Synthesis (VOICES) project that synthesized published qualitative research on the experiences of DVA from the perspective of children and young people. A thematic synthesis of 33 reports identified six themes: lived experience of DVA, children's agency and coping, turning points and transitions, managing relationships postseparation, impact of DVA on children, and children's expressions of hope for the future. We conclude that professionals working with children affected by DVA should be mindful of the diversity in children's experiences and listen carefully to children's own accounts.

Children's experiences and needs in situations of domestic violence: A secondary analysis of qualitative data from adult friends and family members of female survivors.

Estimates suggest that 15% of children in the United Kingdom have been exposed to at least one form of domestic violence (DV) during their childhood, with more than 3% having witnessed an incident during the past year. This exposure increases the risk of children suffering both short-term and long-term impacts, including effects on their behaviour, social development, physical and mental health, educational attainment and quality of life. In addition, children living in environments where there is DV are at higher risk of maltreatment. Adult relatives and friends of the family often observe the experiences of children in situations of DV, and have the potential to shed light in a way that children and survivors may struggle to articulate, or be reluctant to acknowledge or disclose. Such accounts are largely absent from existing research, and yet bring a perspective which can broaden our understanding of the impact that DV has on children. This paper reports a secondary analysis of qualitative data collected during 21 in-depth interviews with people across the United Kingdom who were a friend or family member of a woman experiencing DV. An inductive thematic analysis was undertaken and the themes generated were as follows: 'the context of DV: a chaotic and unpredictable home life'; 'the roles children assume within households where there is DV including: witness of, victim of and conduit of violence and abuse',; 'the impacts of DV on children'; and 'children's coping and resilience'. The implications of these findings are discussed using a basic needs model lens.

Time, monetary and other costs of participation in family-based child weight management interventions: qualitative and systematic review evidence.

BACKGROUND: Childhood overweight and obesity have health and economic impacts on individuals and the wider society. Families participating in weight management programmes may foresee or experience monetary and other costs which deter them from signing up to or completing programmes. This is recognised in the health economics literature, though within this sparse body of work, costs to families are often narrowly defined and not fully accounted for. A societal perspective incorporating a broader array of costs may provide a more accurate picture. This paper brings together a review of the health economics literature on the costs to families attending child weight management programmes with qualitative data from families participating in a programme to manage child overweight and obesity. METHODS: A search identified economic evaluation studies of lifestyle interventions in childhood obesity. The qualitative work drew on interviews with families who attended a weight management intervention in three UK regions. RESULTS: We identified four cost-effectiveness analyses that include information on costs to families. These were categorised as direct (e.g. monetary) and indirect (e.g. time) costs. Our analysis of qualitative data demonstrated that, for families who attended the programme, costs were associated both with participation on the scheme and with maintaining a healthy lifestyle afterwards. Respondents reported three kinds of cost: time-related, social/emotional and monetary. CONCLUSION: Societal approaches to measuring cost-effectiveness provide a framework for assessing the monetary and non-monetary costs borne by participants attending treatment programmes. From this perspective, all costs should be considered in any analysis of cost-effectiveness. Our data suggest that family costs are important, and may act as a barrier to the uptake, completion and maintenance of behaviours to reduce child obesity. These findings have implications for the development and implementation of child weight initiatives in particular, in relation to reducing inequalities in health.

What makes for a 'good' or 'bad' paediatric diabetes service from the viewpoint of children, young people, carers and clinicians? A synthesis of qualitative findings.

BACKGROUND: There is mounting evidence that experience of care is a crucial part of the pathway for successful management of long-term conditions. DESIGN AND OBJECTIVES: To carry out (1) a systematic mapping of qualitative evidence to inform selection of studies for the second stage of the review; and (2) a narrative synthesis addressing the question, What makes for a 'good' or a 'bad' paediatric diabetes service from the viewpoint of children, young people, carers and clinicians? RESULTS: The initial mapping identified 38 papers. From these, the findings of 20 diabetes-focused papers on the views on care of ≥650 children, parents and clinicians were synthesised. Only five studies included children under 11 years. Children and young people across all age groups valued positive, non-judgemental and relationship-based care that engaged with their social, as well as physical, health. Parents valued provision responsive to the circumstances of family life and coordinated across services. Clinicians wanting to engage with families beyond a child's immediate physical health described finding this hard to achieve in practice. LIMITATIONS: Socioeconomic status and ethnicity were poorly reported in the included studies. CONCLUSIONS: In dealing with diabetes, and engaging with social health in a way valued by children, parents and clinicians, not only structural change, such as more time for consultation, but new skills for reworking relations in the consultation may be required.

The unseen child and safeguarding: 'Did not attend' guidelines in the NHS.

BACKGROUND: Organisations in England's National Health Service (NHS) are required to have 'did not attend' (DNA) guidelines to help deal with the 'unseen child'. AIMS: To map DNA and associated guidelines in paediatric services, examine differences in safeguarding response and advice in the guidelines and explore the experience of guideline users. METHODS: A mapping approach was used to locate current DNA guidelines on English NHS organisations' websites. Analysis of the guidelines was supplemented with qualitative data from those who produce, monitor or use them. RESULTS: Fewer than 8% of English NHS organisations had up-to-date guidelines in the public domain, though a further 41% stated that they had a DNA/similar policy in place or had an out-of-date guideline on their website. Advice to healthcare providers about the steps to take when a child DNAs fell into five categories: reflection and review; direct interaction with the family; indirect interaction with the family; liaison with internal colleagues; and external referral. Interviews with eight individuals led to the identification of four themes. The management of information flows was central to the effective management of DNA. Respondents also reported seeking support and advice from others. While all respondents spoke about the importance of supporting the family, the child's needs were central to dealing with non-attendance, and respondents demonstrated awareness of wider risk discourses. CONCLUSIONS: We consider the implications of the work and suggest that evidence-informed guidelines developed nationally but tailored to specific services might be helpful for providers and users alike.

What works in practice: user and provider perspectives on the acceptability, affordability, implementation, and impact of a family-based intervention for child overweight and obesity delivered at scale.

BACKGROUND: As part of a study considering the impact of a child weight management programme when rolled out at scale following an RCT, this qualitative study focused on acceptability and implementation for providers and for families taking part. METHODS: Participants were selected on the basis of a maximum variation sample providing a range of experiences and social contexts. Qualitative interviews were conducted with 29 professionals who commissioned or delivered the programme, and 64 individuals from 23 families in 3 English regions. Topic guides were used as a tool rather than a rule, enabling participants to construct a narrative about their experiences. Transcripts were analysed using framework analysis. RESULTS: Practical problems such as transport, work schedules and competing demands on family time were common barriers to participation. Delivery partners often put considerable efforts into recruiting, retaining and motivating families, which increased uptake but also increased cost. Parents and providers valued skilled delivery staff. Some providers made adaptations to meet local social and cultural needs. Both providers and parents expressed concerns about long term outcomes, and how this was compromised by an obesogenic environment. Concerns about funding together with barriers to uptake and engagement could translate into barriers to commissioning. Where these barriers were not experienced, commissioners were enthusiastic about continuing the programme. CONCLUSIONS: Most families felt that they had gained something from the programme, but few felt that it had 'worked' for them. The demands on families including time and emotional work were experienced as difficult. For commissioners, an RCT with positive results was an important driver, but family barriers, alongside concerns about recruitment and retention, a desire for local adaptability with qualified motivated staff, and funding changes discouraged some from planning to use the intervention in future.

Mapping service activity: the example of childhood obesity schemes in England.

BACKGROUND: Childhood obesity is high on the policy agenda of wealthier nations, and many interventions have been developed to address it. This work describes an overview of schemes for obese and overweight children and young people in England, and the 'mapping' approach we used. METHODS: Our search strategy, inclusion criteria and coding frame had to be suitable for describing a potentially large number of schemes within a short timeframe. Data were collected from key informants, scheme publicity and reports, and via a web-survey. To be included, schemes had to be based in England, follow a structured programme lasting at least two weeks, promote healthy weight, and be delivered exclusively to overweight and/or obese children and young people (age range 4-18). Data were entered into a coding frame recording similar information for each scheme, including any underpinning research evidence, evaluation or monitoring reports. Priority questions were identified in consultation with colleagues from the Department of Health and the Cross Government Obesity Unit. RESULTS: Fifty-one schemes were identified. Some operated in multiple areas, and by using estimates of the number of schemes provided by multi-site scheme leads, we found that between 314 and 375 local programmes were running at any time. Uncertainty is largely due to the largest scheme provider undergoing rapid expansion at the time of the mapping exercise and therefore able to provide only an estimate of the number of programmes running. Many schemes were similar in their approach, had been recently established and were following NICE guidelines on interventions to promote healthy weight. Rigorous evaluation was rare. CONCLUSIONS: Our methods enabled us to produce a rapid overview of service activity across a wide geographic area and a range of organisations and sectors. In order to develop the evidence base for childhood obesity interventions, rigorous evaluation of these schemes is required. This overview can serve as a starting point for evaluations of interventions to address obesity. More generally, a rapid and systematic approach of this type is transferable to other types of service activity in health and social care, and may be a tool to inform public health planning.

Critical pathway for the management of acute heart failure at the Veterans Affairs San Diego Healthcare System: transforming performance measures into cardiac care.

BACKGROUND: Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. METHODS: The Veterans Affairs San Diego Healthcare System (VASDHCS) formed a multidisciplinary HF performance improvement team. The team set forth on the task of developing standard order sets for patients with ADHF. After analyzing local care processes, reviewing evidence of best care practices, and defining appropriate goals to satisfy the multidimensional needs of HF patient; the team developed a computerized pathway in a user-friendly format that is simple, yet comprehensive; and focuses on early stages of HF evaluation and treatment for patients presenting to the emergency department. RESULTS: Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care. This critical pathway for management of acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.

Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews.

BACKGROUND: The inclusion of qualitative studies in systematic reviews poses methodological challenges. This paper presents worked examples of two methods of data synthesis (textual narrative and thematic), used in relation to one review, with the aim of enabling researchers to consider the strength of different approaches. METHODS: A systematic review of lay perspectives of infant size and growth was conducted, locating 19 studies (including both qualitative and quantitative). The data extracted from these were synthesised using both a textual narrative and a thematic synthesis. RESULTS: The processes of both methods are presented, showing a stepwise progression to the final synthesis. Both methods led us to similar conclusions about lay views toward infant size and growth. Differences between methods lie in the way they dealt with study quality and heterogeneity. CONCLUSION: On the basis of the work reported here, we consider textual narrative and thematic synthesis have strengths and weaknesses in relation to different research questions. Thematic synthesis holds most potential for hypothesis generation, but may obscure heterogeneity and quality appraisal. Textual narrative synthesis is better able to describe the scope of existing research and account for the strength of evidence, but is less good at identifying commonality.

Peer and neighbourhood influences on teenage pregnancy and fertility: qualitative findings from research in English communities.

Geographic variation in teenage pregnancy is attributable to social and cultural, as well as demographic, factors. In some communities and social networks early childbearing may be acceptable, or even normative. It is these places that are the focus of policy initiatives. This paper reports the findings of a qualitative study of neighbourhood and peer influences on the transition from pregnancy to fertility among 15 young mothers in three English locations. Data were also collected from nine local health workers. The findings show that, from the mothers' perspective, there was no evidence that peers influenced behaviour. However, the data did suggest that early childbearing might be normative in some communities.

Extending systematic reviews to include evidence on implementation: methodological work on a review of community-based initiatives to prevent injuries.

Unintentional injury is a leading cause of mortality and disability among young and old. While evidence about the effectiveness of interventions in reducing injuries is accumulating, reviews of this evidence frequently fail to include details of implementation processes. Our research, of which the work reported here formed a part, had two main objectives: (1) to identify evidence about the implementation of interventions aimed at reducing unintentional injuries amongst children and young people; and (2) to explore methods for systematically reviewing evidence on implementation. Existing systematic reviews of the effectiveness of interventions aiming to reduce unintentional injuries in children and young people formed the starting point for the work reported here. In summary, many of the published papers we identified contained little information on implementation processes and, even when these were discussed, the extent to which authors' claims were based on research evidence was unclear. On the basis of the studies we reviewed implementation data were insufficiently strong to provide a sound evidence base for practitioners and policymakers. Notwithstanding this, we identified valuable data about the context in which such initiatives are implemented and the type of factors that might impinge on implementation. This work has implications in three areas: (1) researchers with an interest in evidence-based public health could be encouraged to consider implementation issues in the design of intervention studies; (2) funding bodies could be encouraged to prioritise intervention studies using mixed methods that will enable researchers to consider effectiveness and implementation; (3) journal editors could work towards increasing the quality of reporting on implementation issues through the development of guidelines.