Survival, Signaling, and Security: Foster Carers' and Residential Carers' Accounts of Self-Harming Practices Among Children and Young People in Care.

Research on clinicians' interpretations of self-harming practices has shown that they can often be negative. To date there has been limited consideration of other professionals' narratives, notably those working in social care. This article presents focus group and interview data generated with foster carers ( n = 15) and residential carers ( n = 15) to explore the symbolic meanings ascribed to self-harm among the children and young people they care for. Three repertoires of interpretation are presented: survival, which conceives self-harm as a mechanism for redefining the identity of "looked-after"; signaling, which understands self-harm as a communicative tool for the expression of emotion; and security, which sees self-harming practices as testing the authenticity and safety of the caring relationship. Through their focus on sociocultural narratives, carers position themselves as experts on self-harm due to their intimacy with young people's social worlds. This construction potentially creates distance from health professionals, which is problematic given the current privileging of interprofessional working.

Family-focused intervention to promote adolescent mental health and well-being in Moldova and North Macedonia (FLOURISH): feasibility study protocol.

INTRODUCTION: Family-Focused Adolescent & Lifelong Health Promotion (FLOURISH) project will adapt, implement and evaluate a programme to support adolescent mental health and well-being through strategies, such as strengthening parenting practices, adolescent-caregiver relationships, adolescent and parent socioemotional skills, and social support. METHODS AND ANALYSIS: The project will focus on adolescents aged 10-14 years and their caregivers in North Macedonia and Moldova. The countries were selected based on implementation readiness of two organisations and a need for accessible evidence-informed services to help mitigate health risks due to economic, social and political challenges. Parenting for Lifelong Health (PLH) for Parents and Teens is a family-based programme developed for low-resource settings. PLH has been adapted with input from advisory groups. The programme includes additional components to strengthen impacts on adolescents: adolescent mental health tools, based on UNICEF's Helping Adolescents Thrive, adolescent peer support and participation booster. This pilot is first of three study phases. The pilot will be a feasibility testing of the adapted intervention and the assessment and implementation procedures to determine further refinements. The pilot will examine if the adapted programme is acceptable for adolescents, their families and providers, explore contextual factors relevant to embedding this programme into longer-term scale-up and investigate whether the programme can be delivered with fidelity and participation; whether the participants report changes in adolescent emotional and behavioural problems, well-being and other outcomes; and whether the study tools are feasible and appropriate. Pre-post adolescent and caregiver questionnaires will provide outcome data. Process evaluation will include attendance and fidelity data, and focus groups. We will examine delivery cost and resource requirements. ETHICS AND DISSEMINATION: The study was approved at the University of Klagenfurt (Austria), Medical Faculty at St. Cyril and Methodius University (North Macedonia) and National Committee of Ethical Expertise for Clinical Trials (Moldova). Through stakeholder engagement and dissemination, FLOURISH will advance scale-up of open-source family interventions. TRIAL REGISTRATION NUMBER: Trial registration: ID101095528; project page: https://www.flourish-study.org/about.html; https://www.linkedin.com/company/flourish-study/.

Adapting population health interventions for new contexts: qualitative interviews understanding the experiences, practices and challenges of researchers, funders and journal editors.

OBJECTIVES: Research on the adaptation of population health interventions for implementation in new contexts is rapidly expanding. This has been accompanied by a recent increase in the number of frameworks and guidance to support adaptation processes. Nevertheless, there remains limited exploration of the real-world experiences of undertaking intervention adaptation, notably the challenges encountered by different groups of stakeholders, and how these are managed. Understanding experiences is imperative in ensuring that guidance to support adaptation has practical utility. This qualitative study examines researcher and stakeholder experiences of funding, conducting and reporting adaptation research. SETTING: Adaptation studies. PARTICIPANTS: Participants/cases were purposefully sampled to represent a range of adapted interventions, types of evaluations, expertise and countries. Semistructured interviews were conducted with a sample of researchers (n=23), representatives from research funding panels (n=6), journal editors (n=5) and practitioners (n=3). MEASURES: A case study research design was used. Data were analysed using the framework approach. Overarching themes were discussed within the study team, with further iterative refinement of subthemes. RESULTS: The results generated four central themes. The first three relate to the experience of intervention adaptation (1) involving stakeholders throughout the adaptation process and how to integrate the evidence base with experience; (2) selecting the intervention and negotiating the mismatch between the original and the new context; and (3) the complexity and uncertainty when deciding the re-evaluation process. The final theme (4) reflects on participants' experiences of using adaptation frameworks in practice, considering recommendations for future guidance development and refinement. CONCLUSION: This study highlights the range of complexities and challenges experienced in funding, conducting and reporting research on intervention adaptation. Moving forward, guidance can be helpful in systematising processes, provided that it remains responsive to local contexts and encourage innovative practice.

ADAPT study: adaptation of evidence-informed complex population health interventions for implementation and/or re-evaluation in new contexts: protocol for a Delphi consensus exercise to develop guidance.

INTRODUCTION: Complex population health interventions that are effective in one context may not be effective elsewhere, and may even be harmful. As such, an intervention may require adaptation to ensure it fits with a new context. To date, there is no overarching guidance to help researchers to adapt and evaluate interventions in new contexts, and no criteria to support research funders or journals assess proposed or reported adaptations or evaluation. There is limited assistance for policy-makers and practitioners to decide if evidence-informed interventions are appropriate to their context, or if adaptation and further evaluation is needed. This Delphi exercise will contribute to the development of guidance for these communities to support the adaptation, implementation and/or re-evaluation of complex population health interventions in new contexts. METHODS: We will conduct a Delphi consensus exercise to gather expert opinion from researchers, research funders, journal editors and policy-makers. Expert opinion will be sought on: appropriate definitions and concepts, identifying key methodological considerations and establishing adaptations and processes to be undertaken during adaptation of complex population health interventions in new contexts. ETHICS AND DISSEMINATION: Ethics approval for the Delphi exercise has been obtained from the University of Glasgow and and the RAND institutional research board. Dissemination of the results of this study will be through peer-reviewed publications, workshops at national and international conferences, and a summary of the guidance developed for key organisations and stakeholders.

From complex social interventions to interventions in complex social systems: Future directions and unresolved questions for intervention development and evaluation.

Complex systems approaches to social intervention research are increasingly advocated. However, there have been few attempts to consider how models of intervention science, such as the UK's Medical Research Council complex interventions framework, might be reframed through a complex systems lens. This article identifies some key areas in which this framework might be reconceptualized, and a number of priority areas where further development is needed if alignment with a systems perspective is to be achieved. We argue that a complex systems perspective broadens the parameters of 'relevant' evidence and theory for intervention development, before discussing challenges in defining feasibility in dynamic terms. We argue that whole systems evaluations may be neither attainable, nor necessary; acknowledgment of complexity does not mean that evaluations must be complex, or investigate all facets of complexity. However, a systems lens may add value to evaluation design through guiding identification of key uncertainties, and informing decisions such as timings of follow-up assessments.

Mapping the evidence about what works to safely reduce the entry of children and young people into statutory care: a systematic scoping review protocol.

INTRODUCTION: The increasing number of children and young people entering statutory care in the UK is a significant social, health and educational priority. Development of effective approaches to safely reduce this number remains a complex but critical issue. Despite a proliferation in interventions, evidence summaries are limited. The present protocol outlines a scoping review of research evidence to identify what works in safely reducing the number of children and young people (aged ≤18 years) entering statutory social care. The mapping of evidence gaps, clusters and uncertainties will inform the research programme of the newly funded Department for Education's What Works Centre for Children's Social Care. METHODS AND ANALYSIS: The review uses Arksey and O'Malley's scoping review methodology. Electronic database and website searches will identify studies targeting reduction of care entry, reduction of care re-entry and increase in post-care reunification. Supplementary searching techniques will include international expert consultation. Abstracts and full-text studies will be independently screened by two reviewers. Ten per cent of data abstraction will be independently conducted by two reviewers, with the remainder being extracted and then verified by a second reviewer. Descriptive numerical summaries and a thematic qualitative synthesis will be generated. Evidence will be synthesised according to primary outcome, intervention point (mapped across socioecological domains) and the realist EMMIE categorisation of evidence type (Effectiveness; Mechanisms of change; Moderators; Implementation; Economic evaluation). ETHICS AND DISSEMINATION: Outputs will be a conceptual evidence map, a descriptive table quantitatively summarising evidence and a qualitative narrative summary. Results will be disseminated through a peer-reviewed publication, conference presentations, the What Works Centre website, and knowledge translation events with policy-makers and practitioners. Findings will inform the primary research programme of the What Works Centre for Children's Social Care and the subsequent suite of systematic reviews to be conducted by the Centre in this substantive area.

School, Peer and Family Relationships and Adolescent Substance Use, Subjective Wellbeing and Mental Health Symptoms in Wales: a Cross Sectional Study.

Positive relationships with family, friends and school staff are consistently linked with health and wellbeing during adolescence, though fewer studies explore how these micro-systems interact to influence adolescent health. This study tests the independent and interacting roles of family, peer and school relationships in predicting substance use, subjective wellbeing and mental health symptoms among 11-16 year olds in Wales. It presents cross-sectional analyses of the 2013 Health Behaviour in School-aged Children survey, completed by 9055 young people aged 11-16 years. Multilevel logistic regression analyses are used to test associations of family communication, family support, relationships with school staff, school peer connectedness, and support from friends, with tobacco use, cannabis use, alcohol use, subjective wellbeing and mental health symptoms. Positive relationships with family and school staff were consistently associated with better outcomes. Support from friends was associated with higher use of all substances, while higher school peer connectedness was associated with better subjective wellbeing and mental health. Better relationships with school staff were most strongly associated with positive subjective wellbeing, and fewer mental health symptoms where pupils reported less family support. Support from friends was associated with higher cannabis use and worse mental health among pupils with lower family support. Relationships with family and school staff may be important in protecting young people against substance use, and improving wellbeing and mental health. Interventions focused on student-staff relationships may be important for young people with less family support. Interventions based on peer support should be mindful of potential harmful effects for pupils with less support from family.

What theory, for whom and in which context? Reflections on the application of theory in the development and evaluation of complex population health interventions.

Recent years have seen a growing emphasis on the value of building and testing middle range theory throughout the development and evaluation of complex population health interventions. We agree that a coherent theoretical basis for intervention development, and use of evaluation to test key causal assumptions and build theory, are crucial. However, in this editorial, we argue that such recommendations have often been operationalised in somewhat simplistic terms with potentially perverse consequences, and that an uncritical assumption that an intervention explicitly based on theory is inherently superior carries significant risks. We first argue that the drive for theory-based approaches may have exacerbated a propensity to select 'off-the-shelf' theories, leading to the selection of inappropriate theories which distract attention from the mechanisms through which a problem is actually sustained. Second, we discuss a tendency toward over-reliance on individual-level theorising. Finally, we discuss the relatively slow progress of population health intervention research in attending to issues of context, and the ecological fit of interventions with the systems whose functioning they attempt to change. We argue that while researchers should consider a broad range of potential theoretical perspectives on a given population health problem, citing a popular off-the-shelf theory as having informed an intervention and its evaluation does not inherently make for better science. Before identifying or developing a theory of change, researchers should develop a clear understanding of how the problem under consideration is created and sustained in context. A broader conceptualisation of theory that reaches across disciplines is vital if theory is to enhance, rather than constrain, the contribution of intervention research. Finally, intervention researchers need to move away from viewing interventions as discrete packages of components which can be described in isolation from their contexts, and better understand the systems into which change is being introduced.

Comparison of substance use, subjective well-being and interpersonal relationships among young people in foster care and private households: a cross sectional analysis of the School Health Research Network survey in Wales.

OBJECTIVE: To investigate the association of living in foster care (FC) with substance use and subjective well-being in a sample of secondary school students (11-16 years) in Wales in 2015/16, and to examine whether these associations are attenuated by the perceived quality of interpersonal relationships. DESIGN: Cross-sectional, population-based health behaviour and lifestyle questionnaire. SETTING AND PARTICIPANTS: Wales, UK; young people who took part in the 2015/16 School Health Research Network (SHRN) questionnaire (n=32 479). PRIMARY OUTCOME: Health behaviours among young people in FC were compared with those from private households. RESULTS: The prevalence of all adverse outcomes was higher among young people in FC. Those in FC were significantly more likely to report mephedrone use (OR=9.24, 95% CI 5.60 to 15.34), multiple substance misuse behaviours (OR=3.72, 95% CI 2.30 to 6.00), poorer relationships with peers (RR=1.88, 95% CI 1.23 to 2.88) and teachers (RR=1.83, 95% CI 1.31 to 2.56), having experienced bullying (OR=1.80, 95% CI 1.38 to 2.35), dating violence (OR=1.66, 95% CI 1.13 to 2.43) and poor well-being (RR=1.72, 95% CI 1.20 to 2.46). The association between FC and substance use remained significant, though was attenuated after accounting for relationship variables. The association between FC and subjective well-being became non-significant after adjustment for relationship variables. CONCLUSIONS: Young people living in FC experience significantly worse outcomes than young people not in care, likely due to a range of care and precare factors, which impact adversely on subsequent social relationships. The analyses are consistent with the hypothesis that the associations of FC with substance use and life satisfaction are partially explained by poorer quality social relationships. Large scale, longitudinal studies are required to investigate the relationship between being in care and health, educational and social outcomes. Mental health interventions and interventions to reduce substance use and improve well-being in FC should include a focus on supporting healthy social relationships.

Realist complex intervention science: Applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions.

The integration of realist evaluation principles within randomised controlled trials ('realist RCTs') enables evaluations of complex interventions to answer questions about what works, for whom and under what circumstances. This allows evaluators to better develop and refine mid-level programme theories. However, this is only one phase in the process of developing and evaluating complex interventions. We describe and exemplify how social scientists can integrate realist principles across all phases of the Medical Research Council framework. Intervention development, modelling, and feasibility and pilot studies need to theorise the contextual conditions necessary for intervention mechanisms to be activated. Where interventions are scaled up and translated into routine practice, realist principles also have much to offer in facilitating knowledge about longer-term sustainability, benefits and harms. Integrating a realist approach across all phases of complex intervention science is vital for considering the feasibility and likely effects of interventions for different localities and population subgroups.