Food choice in transition: adolescent autonomy, agency, and the food environment.

Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in which adolescent development can interact with sociocultural context and the food environment to influence food choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values beyond nutrition or health.

Beyond regulatory approaches to ethics: making space for ethical preparedness in healthcare research.

Centralised, compliance-focused approaches to research ethics have been normalised in practice. In this paper, we argue that the dominance of such systems has been driven by neoliberal approaches to governance, where the focus on controlling and individualising risk has led to an overemphasis of decontextualised ethical principles and the conflation of ethical requirements with the documentation of 'informed consent'. Using a UK-based case study, involving a point-of-care-genetic test as an illustration, we argue that rather than ensuring ethical practice such compliance-focused approaches may obstruct valuable research. We call for an approach that encourages researchers and research communities-including regulators, ethics committees, funders and publishers of academic research-to acquire skills to make morally appropriate decisions, and not base decision-making solely on compliance with prescriptive regulations. We call this 'ethical preparedness' and outline how a research ethics system might make space for this approach.

Using collaborative autoethnography to explore the teaching of qualitative research methods in medicine.

This article explores experiences of teaching qualitative research (QR) broadly, and qualitative methods (QM) more specifically in medicine, highlighting the challenges faced, and offering recommendations for overcoming them. Using collective online interviews, collaborative autoethnography (CAE) was employed to generate data comprising educator's reflective accounts of teaching QM in medical schools across two continents. Three main themes were identified through collaborative thematic analysis: making meaningful contributions from a marginalized position; finding our pedagogical feet; and recognizing the translational applicability and value of QR. We reflected on the marginalized positioning of QM in medical curricula and the underestimation of the value of QR to understanding pressing health issues. Analysis of these reflections pointed to a lack of formal training for educators and curriculum space for qualitative approaches. Our teaching pedagogies, developed through our own research experiences, self-reflection and student feedback, were primarily student-centered employing a range of novel approaches designed to foster skills and interest in the craft of QR, and introduce a greater appreciation of the significance of QR approaches to medicine. CAE further allowed us to identify some key recommendations that could help medical educators plan for teaching QM and other research methods more effectively in medicine. Future curriculum development should consider the benefits of exposing learners to a range of methods and approaches from across the qualitative-quantitative spectrum.

Recent UK retirees' views about the work-related factors which influenced their decision to retire: a qualitative study within the Health and Employment After Fifty (HEAF) cohort.

BACKGROUND: Lower birth rates and increasing longevity have resulted in ageing populations in European countries. These demographic changes place challenges on pension provision as numbers of those who are economically inactive and retired increase relative to those in paid work. Therefore, governments need workers to postpone retirement and work to older ages. Whilst health and wealth are important in retirement decision-making, considerably less is known about the effects of workplace factors. The aim of this study was to explore the views of recent UK retirees about the role that work-related factors played in their decision to retire. METHODS: This qualitative study was nested within the Health and Employment After Fifty (HEAF) cohort. People who had retired 3-6 years previously (not for health reasons) were purposively sampled to obtain the views of men and women from a range of socio-economic backgrounds and jobs. Semi-structured interviews were carried out by telephone using a pre-defined topic guide. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS: Seventeen interviews were conducted. Thematic analysis showed that retirement decisions were complex and multi-factorial but that work-related factors contributed to decision-making in two main ways. First, some work factors pushed participants towards retirement. These were perceptions that: workplace change had affected the way they were valued or increased pressure on them; work demands, including commuting, had intruded excessively on personal time, effects that were exacerbated by modern technology; work was draining, isolating or under-appreciated; and /or that work was causing physical strain or discomfort relative to their perception of their capacity. In contrast, work factors could also cause participants to pull back towards work, particularly: autonomy; supportive work colleagues; a sense of being appreciated; and perceived job flexibility. CONCLUSIONS: Recent retirees explained that their decision to retire was multi-factorial but work-related factors contributed importantly. Potentially, employers could: review workers' perceptions about their work; their capacity in relation to job demands; increase flexibility; and facilitate a supportive work community to encourage longer working lives.

Exploring the diet and physical activity behaviours of adolescents living in India and sub-Saharan Africa: a qualitative evidence synthesis.

OBJECTIVE: To carry out a qualitative evidence synthesis to explore what influences the diet and physical activity of adolescents living in five countries that constitute the Transforming Adolescent Lives through Nutrition (TALENT) consortium (Cote D'Ivoire, Ethiopia, India, South Africa and The Gambia). DESIGN: A search of electronic databases was conducted for qualitative articles published between 2000 and 2019. PARTICIPANTS: Studies that explore influences on the diets and physical activity habits of adolescents aged 10-19 years. RESULTS: Of the twelve included studies, none were identified from The Gambia or Cote D'Ivoire. The existing qualitative literature focussed on three major areas in relation to adolescents' diet and physical activity: (1) the influence of body image and self-esteem; (2) social and environmental influences and (3) poverty. The limited existing literature focusses heavily on girls' experiences particularly in relation to body image and dysfunctional eating practices. CONCLUSIONS: In-depth research exploring adolescents' perceptions of diet and physical activity is needed to better understand how both boys and girls, at different stages of adolescence, perceive health, diet and physical activity. More research with young people is required especially in countries where little exists to cover a wider range of issues that play a role in diet and physical activity.

What shapes adolescents' diet and physical activity habits in rural Konkan, India? Adolescents' and caregivers' perspectives.

OBJECTIVE: To explore, adolescents' and caregivers' perspectives, about shaping of diet and physical activity habits in rural Konkan, India. DESIGN: Five focus group discussions (FGD) were conducted with adolescents and two with caregivers. Data were analysed using thematic analysis. SETTING: FGD were conducted in secondary schools located in remote rural villages in the Ratnagiri district, Konkan region, Maharashtra, India. PARTICIPANTS: Forty-eight adolescents were recruited including twenty younger (10-12 years) and twenty-eight older (15-17 years) adolescents. Sixteen caregivers (all mothers) were also recruited. RESULTS: Three themes emerged from discussion: (i) adolescents' and caregivers' perceptions of the barriers to healthy diet and physical activity, (ii) acceptance of the status quo and (iii) salience of social and economic transition. Adolescents' basic dietary and physical activity needs were rarely met by the resources available and infrastructure of the villages. There were few opportunities for physical activity, other than performing household chores and walking long distances to school. Adolescents and their caregivers accepted these limitations and their inability to change them. Increased use of digital media and availability of junk foods marked the beginning of a social and economic transition. CONCLUSION: FGD with adolescents and their caregivers provided insights into factors influencing adolescent diet and physical activity in rural India. Scarcity of basic resources limited adolescent diet and opportunities for physical activity. To achieve current nutritional and physical activity recommendations for adolescents requires improved infrastructure in these settings, changes which may accompany the current Indian social and economic transition.

Social, economic and cultural influences on adolescent nutrition and physical activity in Jimma, Ethiopia: perspectives from adolescents and their caregivers.

OBJECTIVE: To explore influences on adolescent diet and physical activity, from the perspectives of adolescents and their caregivers, in Jimma, Ethiopia. DESIGN: Qualitative design, using focus group discussions (FGD). SETTING: A low-income setting in Jimma, Ethiopia. PARTICIPANTS: Five FGD with adolescents aged 10-12 years and 15-17 years (n 41) and three FGD with parents (n 22) were conducted. RESULTS: Adolescents displayed a holistic understanding of health comprising physical, social and psychological well-being. Social and cultural factors were perceived to be the main drivers of adolescent diet and physical activity. All participants indicated that caregivers dictated adolescents' diet, as families shared food from the same plate. Meals were primarily determined by caregivers, whose choices were driven by food affordability and accessibility. Older adolescents, particularly boys, had opportunities to make independent food choices outside of the home which were driven by taste and appearance, rather than nutritional value. Many felt that adolescent physical activity was heavily influenced by gender. Girls' activities included domestic work and family responsibilities, whereas boys had more free time to participate in outdoor games. Girls' safety was reported to be a concern to caregivers, who were fearful of permitting their daughters to share overcrowded outdoor spaces with strangers. CONCLUSIONS: Adolescents and caregivers spoke a range of social, economic and cultural influences on adolescent diet and physical activity. Adolescents, parents and the wider community need to be involved in the development and delivery of effective interventions that will take into consideration these social, economic and cultural factors.

Adolescent diet and physical activity in the context of economic, social and nutrition transition in rural Maharashtra, India: a qualitative study.

OBJECTIVE: To explore the perceptions of adolescents and their caregivers on drivers of diet and physical activity in rural India in the context of ongoing economic, social and nutrition transition. DESIGN: A qualitative study comprising eight focus group discussions (FGD) on factors affecting eating and physical activity patterns, perceptions of health and decision-making on food preparation. SETTING: Villages approximately 40-60 km from the city of Pune in the state of Maharashtra, India. PARTICIPANTS: Two FGD with adolescents aged 10-12 years (n 20), two with 15- to 17- year-olds (n 18) and four with their mothers (n 38). RESULTS: Dietary behaviour and physical activity of adolescents were perceived to be influenced by individual and interpersonal factors including adolescent autonomy, parental influence and negotiations between adolescents and caregivers. The home food environment, street food availability, household food security and exposure to television and digital media were described as influencing behaviour. The lack of facilities and infrastructure was regarded as barriers to physical activity as were insufficient resources for public transport, safe routes for walking and need for cycles, particularly for girls. It was suggested that schools take a lead role in providing healthy foods and that governments invest in facilities for physical activity. CONCLUSIONS: In this transitioning environment, that is representative of many parts of India and other Lower Middle Income Countries (LMIC), people perceive a need for interventions to improve adolescent diet and physical activity. Caregivers clearly felt that they had a stake in adolescent health, and so we would recommend the involvement of both adolescents and caregivers in intervention design.

Exploring influences on adolescent diet and physical activity in rural Gambia, West Africa: food insecurity, culture and the natural environment.

OBJECTIVE: To explore, from the perspectives of adolescents and caregivers, and using qualitative methods, influences on adolescent diet and physical activity in rural Gambia. DESIGN: Six focus group discussions (FGD) with adolescents and caregivers were conducted. Thematic analysis was employed across the data set. SETTING: Rural region of The Gambia, West Africa. PARTICIPANTS: Participants were selected using purposive sampling. Four FGD, conducted with forty adolescents, comprised: girls aged 10-12 years; boys aged 10-12 years; girls aged 15-17 years, boys aged 15-17 years. Twenty caregivers also participated in two FGD (mothers and fathers). RESULTS: All participants expressed an understanding of the association between salt and hypertension, sugary foods and diabetes, and dental health. Adolescents and caregivers suggested that adolescent nutrition and health were shaped by economic, social and cultural factors and the local environment. Adolescent diet was thought to be influenced by: affordability, seasonality and the receipt of remittances; gender norms, including differences in opportunities afforded to girls, and mother-led decision-making; cultural ceremonies and school holidays. Adolescent physical activity included walking or cycling to school, playing football and farming. Participants felt adolescent engagement in physical activity was influenced by gender, seasonality, cultural ceremonies and, to some extent, the availability of digital media. CONCLUSIONS: These novel insights into local understanding should be considered when formulating future interventions. Interventions need to address these interrelated factors, including misconceptions regarding diet and physical activity that may be harmful to health.

'I should be disease free, healthy and be happy in whatever I do': a cross-country analysis of drivers of adolescent diet and physical activity in different low- and middle-income contexts.

OBJECTIVE: To explore perceptions of how context shapes adolescent diet and physical activity in eight low- and middle-income (LMIC) sites at different stages of societal and economic transition. DESIGN: Novel qualitative secondary analysis of eight data sets generated as part of the international Transforming Adolescent Lives through Nutrition (TALENT) collaboration. SETTING: Diverse sites in India and Sub-Saharan Africa. PARTICIPANTS: Fifty-two focus group discussions with 491 participants (303 adolescents aged 10-17 years; 188 caregivers). RESULTS: Analysis of pooled qualitative data identified three themes: (1) transitions in generational nutrition education and knowledge; (2) transition in caregiver-adolescent power balance and (3) the implications of societal and economic transition for diet and physical activity. Adolescents in urban and peri-urban areas could readily access 'junk' food. Diets in rural settings were determined by tradition, seasonality and affordability. Physical activity was inhibited by site-specific factors including lack of space and crime in urban settings, and the prioritisation of academic performance. Gender influenced physical activity across all sites, with girls afforded fewer opportunities. CONCLUSIONS: Interventions to improve adolescent diet and physical activity in LMIC need to be complex, context-specific and responsive to transitions at the individual, economic and societal levels. Moreover, solutions need to acknowledge gender inequalities in different contexts, as well as structural and cultural influences on diet and physical activity in resource-limited settings. Programmes need to be effective in engaging and reconciling adolescents' and caregivers' perspectives. Consequently, there is a need for action at both the community-household level and also through policy.

Adolescent nutrition and physical activity in low-income suburbs of Abidjan, Côte d'lvoire: the gap between knowledge, aspirations and possibilities.

OBJECTIVE: To explore adolescents' perceptions, knowledge and behaviours regarding nutrition and physical activity in low-income districts of Abidjan, Côte d'Ivoire, taking into consideration their caregivers' perspectives. DESIGN: Two investigators conducted six focus group discussions. SETTING: The study was carried out in two low-income suburbs, Yopougon and Port-Bouët, in Abidjan, Côte d'Ivoire. PARTICIPANTS: Adolescents and their caregivers were recruited into the study via local head teachers and heads of settlement. RESULTS: Overall, seventy-two participants, including forty-six adolescents and twenty-six caregivers, took part. Participants demonstrated good nutrition knowledge, relating nutritional health to a balanced diet and hygiene. Sustained physical activity was reported. However, adopting good practices was challenging due to participant's economic circumstances. Their environment was a barrier to improving health due to dirtiness and violence, with a lack of space limiting the possibility to practice sport. Adolescents and their caregivers differed in their response to these constraints. Many caregivers felt powerless and suggested that a political response was the solution. Alternatively, adolescents were more likely to suggest new creative solutions such as youth-friendly centres within their community. CONCLUSIONS: Participants were aware that their nutritional habits were not in line with what they had learnt to be good nutritional practices due to socio-economic constraints. Physical activity was part of adolescent life, but opportunities to exercise were restricted by their environment. Strategies for improving adolescent health in these settings need to be developed in collaboration with adolescents in a manner that accommodates their opinions and solutions.

Conflicts between adolescents and their caregivers living in slums of Mumbai, India in relation to junk food consumption and physical activity.

OBJECTIVE: To explore influences on the diet and physical activity of adolescents living in Mumbai slums, from the perspectives of adolescents and their caregivers. DESIGN: Three investigators from Mumbai conducted six focus group discussions. SETTING: The study was conducted in suburban Mumbai slums. PARTICIPANTS: Thirty-six adolescents (aged 10-12 and 15-17 years) and twenty-three caregivers were recruited through convenience sampling. RESULTS: The findings highlighted the complex negotiations between adolescent and caregivers surrounding adolescent junk food consumption and physical activity opportunities. Caregivers learned recipes to prepare popular junk foods to encourage adolescents to eat more home-cooked, and less 'outside', food, yet adolescents still preferred to eat outside. To adolescents, the social aspect of eating junk food with friends was an important and enjoyable experience. Caregivers felt that they had no control over adolescents' food choices, whereas adolescents felt their diets were dictated by their parents. Adolescents wanted to be physically active but were encouraged to focus on their academic studies instead. Gender was also a key driver of physical activity, with girls given less priority to use outside spaces due to cultural and religious factors, and parental fears for their safety. CONCLUSIONS: These findings show that adolescents and caregivers have different agendas regarding adolescent diet. Adolescent girls have less opportunity for healthy exercise, and are more sedentary, than boys. Adolescents and caregivers need to be involved in designing effective interventions such as making space available for girls to be active, and smartphone games to encourage healthy eating or physical activity.

Glowing gels and pipettes aplenty: how do commercial stock image banks portray genetic tests?

News stories and patient-facing material about genetic tests are often illustrated by images, but the content of such images and the messages they propagate are rarely scrutinised. Stock image banks were searched to identify a hundred images relating to genetic tests and analysed using a multimodal critical discourse approach, aiming to identify what the images featured, how they were composed, and what they communicated about genetic testing. We found that images tended to focus on technical aspects of sample processing (for example, pipetting) and drew on older technologies (for example slab gel electrophoresis) when representing data arising from genetic tests. Composition choices like focussing images around pipette tips, or emphasising colour or brightness of electrophoretic bands, represented genetic testing as precise, unambiguous and illuminating. Only 7% of images featured a person having a genetic test, and only one image alluded to communication of genetic results. Current popular visual representations of genetic testing rarely highlight the possibility of uncertain or non-diagnostic outcomes, and may contribute to high public expectations of informativeness and certainty from such tests.

The ethical challenges of diversifying genomic data: A qualitative evidence synthesis.

This article aims to explore the ethical issues arising from attempts to diversify genomic data and include individuals from underserved groups in studies exploring the relationship between genomics and health. We employed a qualitative synthesis design, combining data from three sources: 1) a rapid review of empirical articles published between 2000 and 2022 with a primary or secondary focus on diversifying genomic data, or the inclusion of underserved groups and ethical issues arising from this, 2) an expert workshop and 3) a narrative review. Using these three sources we found that ethical issues are interconnected across structural factors and research practices. Structural issues include failing to engage with the politics of knowledge production, existing inequities, and their effects on how harms and benefits of genomics are distributed. Issues related to research practices include a lack of reflexivity, exploitative dynamics and the failure to prioritise meaningful co-production. Ethical issues arise from both the structure and the practice of research, which can inhibit researcher and participant opportunities to diversify data in an ethical way. Diverse data are not ethical in and of themselves, and without being attentive to the social, historical and political contexts that shape the lives of potential participants, endeavours to diversify genomic data run the risk of worsening existing inequities. Efforts to construct more representative genomic datasets need to develop ethical approaches that are situated within wider attempts to make the enterprise of genomics more equitable.

Immortal data: a qualitative exploration of patients' understandings of genomic data.

As ambitions to 'mainstream' genetic and genomic medicine in the UK advance, patients are increasingly exposed to information about genomic data. Unlike the results of many other medical investigations which are linked to the time of sample collection, genomic testing provides immortal data that do not change across time, and may have relevance for relatives and generations far beyond the patient's own lifespan. This immortality raises new ethical challenges for healthcare professionals, patients and families alike, such as ensuring consent for possible future interpretations; determining when genomic data are best sought (at birth, on illness etc) and reinterpreted; and balancing the confidentiality of patients and duties of care towards others. This paper reports on qualitative work exploring the perspectives of patients and relatives participating in genomic testing, and suggests that their engagements with this immortality are shaped by: the contrast between the simplicity of sample provision and information gathered; understandings of heritability; and notions of genomic data as a collective resource. We discuss the implications this holds for practice and argue that the immortality of genomic data must take a more prominent position in patient and healthcare professional interactions.

Re-imagining 'the patient': Linked lives and lessons from genomic medicine.

How 'the patient' is imagined has implications for ethical decision-making in clinical practice. Patients are predominantly conceived in an individualised manner as autonomous and independent decision-makers. Fields such as genomic medicine highlight the inadequacies of this conceptualisation as patients are likely to have family members who may be directly affected by the outcome of tests in others. Indeed, professional guidance has increasingly taken a view that genetic information should, at times, be regarded as of relevance to families, rather than individuals. What remains absent from discussions is an understanding of how those living through/with genomic testing articulate, construct, and represent patienthood, and what such understandings might mean for practice, particularly ethical decision-making. Employing the notion of 'linked lives' from lifecourse theory, this article presents findings from a UK-based qualitative longitudinal study following the experiences of those affected by the process and outcomes of genomic testing. The article argues that there is a discord between lived experiences and individualised notions of 'the patient' common in conventional bioethics, with participants predominantly locating their own decision-making within the matrix of linked lives in which they are embedded. In the quest to gain 'answers', many took an intra or intergenerational view, connecting their own experiences to those of past generations through familial narratives around probable explanations, and/or hopes and expectations for the health of imagined future generations. The article argues that a re-imagining of 'the patient', that reflects the complex and shifting nature of patienthood, will be imperative as genomic medicine is mainstreamed.

Young women's and midwives' perspectives on improving nutritional support in pregnancy: The babies, eating, and LifestyLe in adolescence (BELLA) study.

RATIONALE: Teenage pregnancy has a high risk of poor outcomes for both mother and baby. Teenage girls have the poorest diets of any population group in the UK, which compounds the risk of poor pregnancy outcomes. Pregnant teenagers trust advice from their midwives, but midwives feel they do not have time, confidence, or knowledge to discuss nutrition. OBJECTIVE: This study examined how the relationship between pregnant teenagers and their midwives could be utilised to deliver support to improve diet quality. METHOD: Qualitative interviews were conducted across three urban sites in the UK: Manchester, Doncaster, and Southampton with adolescent mothers and their midwives regarding diet and lifestyle, and what form of support would be helpful. In total, 106 young women and 20 midwives were interviewed. Most of the young mothers were 19 or younger (67%). Half had had their first child in the past year (52%) and 21% were pregnant during the study. Thematic analysis was used to identify ways to better support young mothers to eat well. RESULTS: Young women found it difficult to prioritise healthy eating; they often felt isolated and not in control of their own lives and wanted support from their midwife. Midwives felt that it was their role to support young mothers with diet in pregnancy but were anxious about initiating conversations and felt they lacked clear guidance. CONCLUSIONS: Pregnant teenagers and their midwives lack reliable resources and strategies for healthy eating support. An effective intervention to improve pregnant teenagers' diet quality must empower, inform, and motivate young mothers and their midwives, and enable connections between young mothers.

Big data, qualitative style: a breadth-and-depth method for working with large amounts of secondary qualitative data.

Archival storage of data sets from qualitative studies presents opportunities for combining small-scale data sets for reuse/secondary analysis. In this paper, we outline our approach to combining multiple qualitative data sets and explain why working with a corpus of 'big qual' data is a worthwhile endeavour. We present a new approach that iteratively combines recursive surface thematic mapping and in-depth interpretive work. Our breadth-and-depth method involves a series of steps: (1) surveying archived data sets to create a new assemblage of data; (2) recursive surface thematic mapping in dialogue with (3) preliminary 'test pit' analysis, remapping and repetition of preliminary analysis; and (4) in-depth analysis of the type that is familiar to most qualitative researchers. In so doing, we show how qualitative researchers can conduct 'big qual' analysis while retaining the distinctive order of knowledge about social processes that is the hallmark of rigorous qualitative research, with its integrity of attention to nuanced context and detail.

Timing of surgical intervention for developmental dysplasia of the hip: a randomised controlled trial (Hip 'Op).

BACKGROUND: Developmental dysplasia of the hip (DDH) is a very common congenital disorder, and late-presenting cases often require surgical treatment. Surgical reduction of the hip may be complicated by avascular necrosis (AVN), which occurs as a result of interruption to the femoral head blood supply during treatment and can result in long-term problems. Some surgeons delay surgical treatment until the ossific nucleus (ON) has developed, whereas others believe that the earlier the reduction is performed, the better the result. Currently there is no definitive evidence to support either strategy. OBJECTIVES: To determine, in children aged 12 weeks to 13 months, whether or not delayed surgical treatment of a congenitally dislocated hip reduces the incidence of AVN at 5 years of age. The main clinical outcome measures were incidence of AVN and the need for a secondary surgical procedure during 5 years' follow-up. In addition, to perform (1) a qualitative evaluation of the adopted strategy and (2) a health economic analysis based on NHS and societal costs. DESIGN: Phase III, unmasked, randomised controlled trial with qualitative and health economics analyses. Participants were randomised 1 : 1 to undergo either early or delayed surgery. SETTING: Paediatric orthopaedic surgical centres in the UK. PARTICIPANTS: Children aged 12 weeks to 13 months with DDH, either newly diagnosed or following failed splintage, and who required surgery. We had a target recruitment of 636 children. INTERVENTIONS: Surgical reduction of the hip performed as per the timing allocated at randomisation. MAIN OUTCOME MEASURES: Primary outcome - incidence of AVN at 5 years of age (according to the Kalamchi and MacEwen classification). Secondary outcomes - need for secondary surgery, presence or absence of the ON at the time of primary treatment, quality of life for the main carer and child, and a health economics and qualitative analysis. RESULTS: The trial closed early after reaching < 5% of the recruitment target. Fourteen patients were randomised to early treatment and 15 to delayed treatment. Implementation of rescue strategies did not improve recruitment. No primary outcome data were collected, and no meaningful conclusions could be made from the small number of non-qualitative secondary outcome data. The qualitative work generated rich data around three key themes: (1) access to, and experiences of, primary and secondary care; (2) the impact of surgery on family life; and (3) participants' experiences of being in the trial. LIMITATIONS: Overoptimistic estimates of numbers of eligible patients seen at recruiting centres during the planning of the trial, as well as an overestimation of the recruitment rate, may have also contributed to unrealistic expectations on achievable patient numbers. FUTURE WORK: There may be scope for investigation using routinely available data. CONCLUSIONS: Hip 'Op has highlighted the importance of accurate advance information on numbers of available eligible patients, as well as support from all participating investigators when conducting surgical research. Despite substantial consultation with parents of children in the planning stage, the level of non-participation experienced during recruitment was much higher than anticipated. The qualitative work has emphasised the need for appropriate advice and robust support for parents regarding the 'real-life' aspects of managing children with DDH. TRIAL REGISTRATION: Current Controlled Trials ISRCTN76958754. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 63. See the NIHR Journals Library website for further project information.