Mechanisms and context in the San Patrignano drug recovery community, Italy: a qualitative study to inform transfer to Scotland.

The San Patrignano drug recovery community, Italy, is regarded as one of the most successful in the world. However, if this model is to be transferred to other countries, it is necessary to clarify its underlying mechanisms and how far their success is context dependent. This qualitative study investigated these features of the San Patrignano model. Data collection included semi-structured interviews with six key stakeholders and 10 days' observational field notes. Data were synthesised using frameworks and analysis was informed by realist principles. Individual level mechanisms include: commitment to change, removal from former social environment, communal living, peer mentor with lived experience and meaningful work. These operate in the context of a free of charge, long term (3-4 year) residential community. Organisational level mechanisms are: visionary leadership, staff dedication, social enterprise and adaptable learning. Organisational contextual factors include: a gap in suitable provision for drug recovery and the region's high level of social capital. Articulating the programme theory of the recovery model and its contextual dependency helps clarify which elements should be transferred and how far they need to be adapted for different socio-cultural settings. The recognition of context is crucial when considering transfer of effective complex interventions across countries.

'It's not 9 to 5 recovery': the role of a recovery community in producing social bonds that support recovery.

AIM: To understand how the social networks of a new recovery community can help sustain recovery, focusing on processes of social identity change, in the context of the wider UK recovery movement. METHODS: A cross-sectional, mixed-methods social network analysis (SNA) of ego-network sociograms to map network transitions, using retrospective measures. Ten men were recruited from a peer-worker programme, in the South Ayrshire Alcohol and Drug Partnership (ADP), West of Scotland. Network measures were compared between two timepoints, just prior to current recovery and the present time. Measures included size and density, closeness of members, and their positive or negative influence, proportion of alcohol and other drug (AOD) using and recovery peers, and extent of separate subgroups. These were complemented with qualitative interview data. FINDINGS: There was a significant transition in network composition, with the replacing of AOD-using peers with recovery peers and a broader transformation from relationships being framed as negative to positive. However, there was no significant transition in network structure, with AOD-using and recovery networks both consisting of strong ties and a similar density of connections between people in the networks. CONCLUSIONS: The transition in network composition between pre-recovery and the present indicates a different set of social influences, while the similarities in network structure indicate that the recovery network replaced the role of the using network in providing close bonds. This helped reduce social isolation experienced in early-recovery and provided a pathway into more structured opportunities for volunteering and employment.

Are parenting practices associated with the same child outcomes in sub-Saharan African countries as in high-income countries? A review and synthesis.

INTRODUCTION: There is increasing interest in the transferability of parenting interventions from high-income countries (HICs) to low-income countries (LICs) in order to improve child development and health outcomes. This is based on the premise that associations between parenting practices and child outcomes are similar in both settings. Many parenting interventions in HICs are evidence-based, but less evidence exists on associations of parenting practices with child outcomes in LICs, in particular, sub-Saharan African (SSA) countries. This review synthesises evidence on the association of parenting practices with child outcomes in SSA in order to compare findings with those from HICs. METHODS: We searched electronic databases-Web of Science, ASSIA, Embase, IBSS and PsycINFO-to identify studies from SSA that reported quantitative associations between parenting practices and child health or psychosocial outcomes (eg, sexual and reproductive health (SRH), mental health, conduct disorders). Due to inconsistent conceptual framing of parenting across studies, we used a modified version of the international WHO classification of parenting dimensions to guide synthesis of the results. RESULTS: Forty-four studies met our inclusion criteria. They were conducted in 13 SSA countries and included cross-sectional and longitudinal studies, and were predominantly descriptive studies rather than intervention research. Synthesis of results showed that associations between patterns of parenting ('positive'/'harsh') and child outcomes (including SRH, mental health and conduct disorders) in studies from SSA were broadly similar to those found in HICs. CONCLUSIONS: These findings suggest that the impacts of parenting practices on child outcomes are similar across contrasting global regions and, therefore, parenting interventions from HICs might be successfully transferred to SSA, subject to appropriate adaptation. However, this review also highlights the paucity of evidence in this area and the urgent need for higher quality studies to confirm these findings to help develop effective parenting interventions in SSA.

Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom.

BACKGROUND: Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. OBJECTIVE: The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ?Delivering Assisted Living Lifestyles at Scale" (dallas) from 2012-2015. METHODS: The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem. RESULTS: We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness. CONCLUSIONS: Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.

Factors Affecting Participation in the eRedBook: A Personal Child Health Record.

A personal child health record called the eRedBook was recently piloted in the United Kingdom. A qualitative exploratory case study was used to examine how public health nurses engaged or recruited parents and what factors hindered participation. Interviews and focus groups were conducted with those implementing the eRedBook and those taking part in the pilot study. A range of project documentation was also reviewed. Thematic analysis using the framework approach was applied to draw out themes. Numerous socio-technical factors such as the usability of the software, concerns over data protection and costs, poor digital literacy skills and a lack of Internet connectivity emerged. These barriers need to be addressed before the eRedBook is implemented nationwide.

Delivering digital health and well-being at scale: lessons learned during the implementation of the dallas program in the United Kingdom.

OBJECTIVE: To identify implementation lessons from the United Kingdom Delivering Assisted Living Lifestyles at Scale (dallas) program-a large-scale, national technology program that aims to deliver a broad range of digital services and products to the public to promote health and well-being. MATERIALS AND METHODS: Prospective, longitudinal qualitative research study investigating implementation processes. Qualitative data collected includes semi-structured e-Health Implementation Toolkit-led interviews at baseline/mid-point (n = 38), quarterly evaluation, quarterly technical and barrier and solutions reports, observational logs, quarterly evaluation alignment interviews with project leads, observational data collected during meetings, and ethnographic data from dallas events (n > 200 distinct pieces of qualitative data). Data analysis was guided by Normalization Process Theory, a sociological theory that aids conceptualization of implementation issues in complex healthcare settings. RESULTS: Five key challenges were identified: 1) The challenge of establishing and maintaining large heterogeneous, multi-agency partnerships to deliver new models of healthcare; 2) The need for resilience in the face of barriers and set-backs including the backdrop of continually changing external environments; 3) The inherent tension between embracing innovative co-design and achieving delivery at pace and at scale; 4) The effects of branding and marketing issues in consumer healthcare settings; and 5) The challenge of interoperability and information governance, when commercial proprietary models are dominant. CONCLUSIONS: The magnitude and ambition of the dallas program provides a unique opportunity to investigate the macro level implementation challenges faced when designing and delivering digital health and wellness services at scale. Flexibility, adaptability, and resilience are key implementation facilitators when shifting to new digitally enabled models of care.

A quantitative trait locus for aortic smooth muscle cell number acting independently of blood pressure: implicating the angiotensin receptor AT1B gene as a candidate.

Vascular hyperplasia may be involved in the remodeling of vasculature. It was unknown whether there were genetic determinants for aortic smooth muscle cell number (SMCN) and, if so, whether they acted independently of those for blood pressure (BP). To unravel this issue, we utilized congenic strains previously constructed for BP studies. These strains were made by replacing various chromosome 2 segments of the Dahl salt-sensitive (S) rat with those of the Milan normotensive rat (MNS). We measured and compared SMCN in aortic cross-sectional areas and BPs of these strains. Consequently, a quantitative trait locus (QTL) for SMCN was localized to a chromosome region not containing a BP QTL, but harboring the locus for the angiotensin II receptor AT1B (Agtr1b). Agtr1b became a candidate for the SMCN QTL because 1) two significant mutations were found in the coding region between S and all congenic strains possessing the MNS alleles, and 2) contractile responses to angiotensin II were significantly and selectively reduced in congenic rats harboring the MNS alleles of the SMCN QTL compared with S rats. The current investigation presents the first line of evidence that a QTL for aortic SMCN exists, and it acts independently of QTLs for BP. The relevant congenic strains developed therein potentially provide novel mammalian models for the studies of vascular remodeling disorders.

HCaRG is a novel regulator of renal epithelial cell growth and differentiation causing G2M arrest.

We recently identified a novel calcium-regulated gene, HCaRG, that is highly expressed in the kidney and maps to a chromosomal locus determining kidney weight in rats. The mRNA levels of HCaRG negatively correlate with the proliferative status of the kidney cells. To investigate its role in renal epithelial cellular growth directly, we studied the human embryonic kidney cell line (HEK-293) stably transfected with either plasmid alone or plasmid containing rat HCaRG. [(3)H]thymidine incorporation was significantly lower in HCaRG clones. Although HCaRG clones exhibited some enhanced susceptibility to cell death, this was not the primary mechanism of reduced proliferation. Cell cycle analysis revealed a G(2)M phase accumulation in HCaRG clones that was associated with upregulation of p21(Cip1/WAF1) and downregulation of p27(Kip1). HCaRG clones had a greater protein content, larger cell size, and released 4.5- to 8-fold more of an atrial natriuretic peptide-like immunoreactivity compared with controls. In addition, HCaRG clones demonstrated the presence of differentiated junctions and a lower incidence of mitotic figures. Genistein treatment of wild-type HEK-293 cells mimicked several phenotypic characteristics associated with HCaRG overexpresssion, including increased cell size and increased release of atrial natriuretic peptide. Taken together, our results suggest that HCaRG is a regulator of renal epithelial cell growth and differentiation causing G(2)M cell cycle arrest.