Screening for economic hardship at Child Health Care Centres: A qualitative study of stakeholders' perceptions and experiences of the Healthier Wealthier Families model in Sweden.

AIMS: The Healthier Wealthier Families model uses the child healthcare services as an access point to screen and connect parents experiencing economic hardship to municipal Budget and Debt Counselling services. This study aimed to explore the perceptions and experiences of the Healthier Wealthier Families model in a Swedish context. METHODS: Semi-structured interviews were conducted with three stakeholder groups: eligible parents who declined (n=10) and received (n=9) financial counselling; nurses (n=7); and financial counsellors (n=5). The data were analysed using thematic analysis. RESULTS: The analysis resulted in three main themes conveying the stigma of talking about finance, the connection between economic situation and family wellbeing, and the nuts and bolts of providing preventive financial counselling. CONCLUSIONS: A working model aiming to ameliorate child poverty in a societal service context needs to address the preconceptions and perceived mandate and role of the professionals, the prevalence of financial stigma in society, especially in relation to being a 'good' parent, and the current preoccupations and perceived financial needs and hopes of the families served.

Ameliorating epistemic injustice in practice: Communication strategies in a research project with refugee youth coresearchers.

INTRODUCTION: Many researchers want to include seldom involved groups, such as refugees and youth, in patient and public involvement (PPI), but experience a number of barriers. The PPI research community calls for critical evaluations that are prospective, data-based and conducted by researchers and public contributors together. In this study, we conducted a longitudinal evaluation of a core activity in all collaborations: communication strategies. The aim was to evaluate the communication strategies adopted throughout a research project with refugee youth coresearchers. METHODS: This article is based on the evaluation of a project where refugee youth were involved in the online adaptation of a group-based programme for youth with posttraumatic stress. Behavioural observations and field notes collected during the project were analysed with qualitative content analysis and a readability index, and discussed through the lens of epistemic injustice. The article was cowritten by researchers and refugee youth. FINDINGS: Four manifest categories were identified: Facilitating engagement through coplanning and circumstantial flexibility; Different needs require different channels; It's not just about the channel-facilitation skills matter; Finding a common language opens a communicative flow. In addition, a latent underlying theme reflecting the role of trust was identified: Interactive moments facilitate trust-trust facilitates richer involvement. CONCLUSION: At the core of the identified communication strategies were strengthening relationship-building and actively facilitating involvement. Establishing trusting relationships enabled refugee youth to share input. The communication strategies increased hermeneutical justice by contributing to a common understanding; thus, taking a step towards ameliorating epistemic injustice. PATIENT OR PUBLIC CONTRIBUTION: This article is a participatory analysis of a PPI process; it was written in collaboration between researchers and refugee youth coauthors, who were all previously involved in the evaluated project.

The Cantril Ladder as a Measure of Well-Being and Life Satisfaction Among Refugee Youth Experiencing Symptoms of Post-Traumatic Stress.

Given the number of refugee youth whom require mental health support, there is a need to provide community-based interventions that can be easily scaled-up at a low cost. Yet, safety procedures associated with community-based intervention require careful consideration. The Cantril Ladder is a visual scale used to assess life satisfaction. It could be a useful tool to track the well-being of participants throughout an intervention. However, concerns have been raised about the validity of single-item life satisfaction measures and it is recommended they are tested when used in specific populations. This is particularly relevant to the refugee youth population who experience ongoing stress due to concern for family, friends, housing, and schooling and whose perceptions of life satisfaction may differ to the cohorts the Cantril Ladder has previously been tested with. The purpose of this study was to explore the validity of the Cantril Ladder as a measure of well-being and life satisfaction in refugee youth experiencing post-traumatic stress symptoms by exploring the relationship between how the youth scored on the Cantril Ladder with their scores on measures of depression and self-efficacy. Hierarchical multiple linear regression was applied to self-reported survey data in order to test how refugee youth experiencing post-traumatic stress symptoms (n = 51) score on the Cantril Ladder compared with Patient Health Questionnaire-9 (PHQ-9) and General Self Efficacy Scale (GSE) scores. The mean Cantril Ladder score in the present sample was 5.33 (SD = 2.77). The PHQ-9 and GSE total scores together explained 19.1% of the variability in the Cantril Ladder score. The Cantril Ladder showed moderate concurrent validity with validated measures of depression and self-efficacy. These findings have important implications for intervention programs designed to support refugee youth experiencing post-traumatic stress, as the Cantril Ladder offers a promising way to track well-being throughout the program as part of a wider safety protocol procedure. Additional research is required to not only confirm these findings, but also to test the face validity of the Cantril Ladder for a more complete validation of life satisfaction.

Are We Ready to Really Hear the Voices of Those Concerned? Lessons Learned from Listening to and Involving Children in Child and Family Psychology Research.

A changing view of children, accelerated by the Convention of the Rights of the Child (UN in Convention on the rights of the child, UN Doc. A/RES/44/25, 1989, http://www2.ohchr.org/english/law/pdf/crc.pdf ) has shifted the landscape of child and family research over the last few decades. Once viewed with low credibility and operating outside the interpretive framework of adult researchers, the rights-bearing child is increasingly recognized not only as having the capacity but also the right to participate in research. More recently, this movement has transitioned from the direct engagement of children as research participants-now considered commonplace, although less so for those who are structurally vulnerable-to the involvement of children in research design, review, conduct, and dissemination. Yet, both practical and ethical challenges remain. While children have the right to participation, they also have the right to protection. In this commentary, we set out to: (i) lay forth epistemic, child rights, and child sociology arguments for doing research about, with and by children and youth; (ii) recount our own journey of including children and youth in research to demonstrate the unique knowledge and insights gained through these approaches; and (iii) offer lessons learned on how to engage children and youth in research, including the involvement of structurally vulnerable groups.

Ameliorating Child poverty through Connecting Economic Services with child health Services (ACCESS): study protocol for a randomised controlled trial of the healthier wealthier families model in Sweden.

BACKGROUND: Sweden is often held up as an example of a country with low child deprivation; yet, rates of relative deprivation are rising. Every municipality in Sweden is required to provide free, timely and accessible budget and debt counselling under the Social Services Act. The services have been encouraged to perform preventative practice with families; however, this has not been realised. The Healthier Wealthier Families (HWF) model embeds universal screening for economic hardship into child health services and creates a referral pathway to economic support services. Given the universal child health system in Sweden, which is freely available and has excellent coverage of the child population, implementation of the HWF model has potential to support families to access the freely available municipal budget and debt counselling and ultimately improve rates of child deprivation in Sweden. METHODS/DESIGN: We will conduct a two-arm randomised waitlist-control superiority trial to examine the effectiveness and cost-effectiveness of the HWF model in the Sweden. A longitudinal follow-up with the cohort will explore whether any effects are maintained in the longer-term. DISCUSSION: HWF is a collaborative and sustainable model that could maximise the effectiveness of current services to address child deprivation in Sweden. The study outlined in this protocol is the first effectiveness evaluation of the HWF model in Sweden and is a crucial step before HWF can be recommended for national implementation within the child health services. TRIAL REGISTRATION: Clinicaltrials.gov; NCT05511961. Prospectively registered on 23 August 2022. https://clinicaltrials.gov/ct2/show/NCT05511961.

Adaptation of the trauma group intervention 'Teaching Recovery Techniques' for online delivery: A participatory design and usability study.

Background: Video-telehealth delivery of trauma-based care is promising and may help address structural and perceptual barriers to receiving support. However, existing evidence relies heavily on samples from adult populations. There is potential to transfer existing child and adolescent trauma interventions to a video-telehealth delivery format; but, this requires careful consideration. The aim of this project was to adapt a group-based intervention called Teaching Recovery Techniques for online delivery and investigate the usability of the new intervention format. Methods: A qualitative needs assessment was performed (n = 3 intervention leaders, 4 youth), followed by participatory workshops and advisory panel consultation to generate adaptation recommendations. Usability testing was performed in two cycles; the first tested the adapted manual with intervention leaders (n = 5), and the second tested newly developed digital resources with youth (n = 5). Results: The needs assessment uncovered a number of issues that, when generating recommendations, were distilled into three topics: safety, participation and learning. Recommendations included safety rules, an emergency response protocol, communication strategies, and guidance on group composition and intervention delivery. Usability testing indicated acceptability but highlighted the need for more detailed and explicit guidance, particularly on safety processes. Discussion: The present study demonstrates the potential for delivery format to affect intervention feasibility and acceptability, and provides recommendations that can be used to guide the transfer of other group-based mental health interventions to an online format. The young people, parents and professionals involved in the project provided rich and varied perspectives, which illustrated the value of broad stakeholder engagement.

Experiences of children with disabilities during the COVID-19 pandemic in Sweden: a qualitative interview study.

BACKGROUND: The impact of the COVID-19 pandemic on people with disabilities has been described as a 'triple jeopardy'. Not only have they experienced the negative social impacts of disease control measures, but access to required health services has been affected, and, not least, they are at increased risk of severe outcomes from COVID-19. This study aimed to determine how children with disabilities have experienced the pandemic in Sweden and its impact on their lives. METHODS: Six children (5-13 years) were interviewed via video conferencing. An interview guide was adapted based on the children's communicative abilities and included augmentative and alternative communication support. Reflective field notes were included in the analysis. The data were analysed using qualitative content analysis. RESULTS: Two themes were identified: The child's knowledge of Corona raises anxiety and fear; and Boring Corona makes the child even lonelier. The children had knowledge about and were worried about COVID-19, primarily about illness and death of their grandparents. The children longed for their grandparents and other social contacts at school, and life was described as boring and lonely. Many families lacked adequate tools to communicate with their children about the pandemic. CONCLUSION: Given adequate support, children with disabilities and communication difficulties can give insights to their unique life situations. The interviewed children reported significant impact on their life and school life. Children were worried about their grandparents based on their knowledge about the virus. The enthusiasm with which the children engaged in the interviews is testament to the need and right of all children, regardless of communicative competence, to voice their experiences.

Tracking involvement over time: a longitudinal study of experiences among refugee parents involved as public contributors in health research.

PURPOSE: Patient and public involvement (PPI) is becoming more common in research, but has been problematized for lack of diversity. While PPI literature increasingly focuses on assessment of PPI on research, a focus on the contributors is less common. This study tracked the experiences of involvement among four refugee parents involved as public contributors in a child mental health trial, over three years. METHODS: The study used a longitudinal qualitative design with focus group discussions. Data were analysed using thematic analysis combined with a longitudinal analysis approach. RESULTS: The refugee parents' motivations for being involved changed from focusing on individual benefits to societal change. They initially viewed themselves as guests, which transformed into utilizing the group for social support. Time impacted trust-building positively, with continued collaboration strengthening trust. Practical aspects were dominant in the beginning, which shifted over time to allow more focus on research. They identified several learnings they gained from involvement. A discrepancy in how parents and researchers viewed involvement was identified, where parents saw researchers as owners of the research. CONCLUSIONS: To sustain successful PPI collaboration over time, researchers need to prioritize investment in time and resources, in communication, including working with interpreters, and in continued adjustments.

COVID-19 Information in Sweden: Opinions of Immigrants with Limited Proficiency in Swedish.

COVID-19 has highlighted the importance of health information for prevention of communicable disease. Knowledge about groups that have high risk is important to prevent disease transmission. In Sweden, immigrants have been identified as one such group. Yet, little is known about where they have sourced information about COVID-19 and their opinions toward it. The aim of this study was to describe the COVID-19 information sources used by immigrants with limited proficiency in Swedish as well as their opinions on how comprehensive the information has been, the importance of the recommendations and their possibility to follow them. A cross-sectional survey was conducted via introductory Swedish language classes in Region Uppsala (n = 855). The results showed the immigrants were using different information sources, with the majority using school, media and social media. The immigrants' opinions about COVID-19 information differed. Most reported they knew where to find information; however, over two-fifths reported the recommendations from the authorities should be more extensive. The majority reported it is important to follow the recommendations, whereas the possibility to follow the recommendations was more mixed. Age differences in opinions toward COVID-19 information were detected. Although the results were largely positive, there still appears to be a need for improvement in how immigrant groups with limited ability in the host country´s language are reached. Effective health communication that engages the whole nation is an important factor authorities should commit to as we face the current pandemic. This research suggests that an approach tailored by age could be helpful.

Feasibility of a randomised trial of Teaching Recovery Techniques (TRT) with refugee youth: results from a pilot of the Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT).

BACKGROUND: Although post-traumatic stress is prevalent among unaccompanied refugee minors (URM), there are few evidence-based psychological interventions for this group. Teaching Recovery Techniques (TRT) is a brief, manualised intervention for trauma-exposed youth, which has shown promising results in exploratory studies. The aim of the present study was to assess the feasibility of conducting a randomised controlled trial (RCT) evaluating the use of TRT among URM by investigating key uncertainties relating to recruitment, randomisation, intervention delivery and data collection. METHODS: A 3-month long non-blinded internal randomised pilot trial with a parallel-group design assessed the feasibility of a planned nationwide multi-site RCT. URM with or without granted asylum were eligible if they were 14 to 20 years old, had arrived in Sweden within the last 5 years and had screened positive for symptoms of post-traumatic stress disorder (PTSD). Quantitative data were collected pre- and post-intervention, and 18 weeks after randomisation. On-site individual randomisation (1:1) followed directly after pre-intervention assessment. Participants allocated to the intervention were offered seven weekly group-based TRT sessions. Quantitative pilot outcomes were analysed using descriptive statistics. Qualitative information was gathered through on-site observations and follow-up dialogue with group facilitators. A process for Decision-making after Pilot and feasibility Trials (ADePT) was used to support systematic decision-making in moving forward with the trial. RESULTS: Fifteen URM (mean age 17.73 years) with PTSD symptoms were recruited at two sites. Three of the youths were successfully randomised to either TRT or waitlist control (TRT n = 2, waitlist n = 1). Fourteen participants were offered TRT for ethical reasons, despite not being randomised. Six (43%) attended ≥ 4 of the seven sessions. Seventy-three percent of the participants completed at least two assessments, with a response rate of 53% at both post-intervention and follow-up. CONCLUSIONS: The findings demonstrated a need for amendments to the protocol, especially with regard to the procedures for recruitment and randomisation. Upon refinement of the study protocol and strategies, an adequately powered RCT was pursued, with data from this pilot study excluded. TRIAL REGISTRATION: ISRCTN47820795 , prospectively registered on 20 December 2018.

What has the COVID-19 pandemic taught us about conducting patient and public involvement remotely? Insights from a series of digital meeting observations.

BACKGROUND: During the COVID-19 pandemic many work tasks are being done remotely through digital meetings, including PPI in research. Yet, some PPI activities have been paused or cancelled altogether during the pandemic. In this commentary, we share our insights from observing digital meetings with researchers and public contributors, representing vulnerable groups. Additionally, we discuss how remote PPI activities can be understood and improved. MAIN BODY: As part of a PPI evaluation project, live observations were conducted by two trained observers, using a semi-structured observation protocol developed to objectively assess aspects of group dynamics in PPI research meetings with public contributors with experience of seeking refuge and parents facing economic hardship. This project's data collection is ongoing and the insights in this commentary is based on the observers' discussion. We discuss these insights through the lens of the Media Richness Theory, stating that the choice of media we communicate through should be guided by what kind of information we want to communicate to each other. The more complex the information is, the richer the media tool needs to be. For example, information in a text message is more easily misinterpreted than information given in person. This is because meeting in person gives us more information, for example through body language and tone of voice. Based on our experiences from observing digital research meetings, we give suggestions on how to improve digital meetings with public contributors. A few key points are: actively choosing which media to use; being prepared to guide contributors to the chosen media in a way that is suitable for them; and the increased importance of the person chairing the meeting to actively include all participants. CONCLUSIONS: We reach the conclusion that digital meetings with public contributors is possible, but that researchers need to make a commitment and actively work to solve practical issues. Finally, the format and structure of digital meetings should be co-created together with public contributors.

During the COVID-19 pandemic many work tasks are conducted remotely through digital meetings, including PPI in research. Yet, some PPI activities have been paused or cancelled during the pandemic. In this commentary, we share our insights from observing digital meetings with researchers and contributors with experience of seeking refuge and parents facing economic hardship, and discuss how remote collaborations can be improved. This is discussed through the lens of the Media Richness Theory, stating that the choice of media we communicate through should be guided by what kind of information we want to communicate to each other. The more complex the information is, the richer the media tool needs to be. For example, information in a text message is more easily misinterpreted than information given in person, since meeting in person gives us more information, for example through body language and tone of voice. Based on our experiences from observing digital research meetings, we give suggestions on how to improve digital meetings with public contributors. Some key points are: actively choosing which media to use; being prepared to guide contributors to the chosen media in a way that is suitable for them; and the increased importance of the person chairing the meeting to actively include all participants. We reach the conclusion that digital meetings with public contributors is possible, but that researchers need to make a commitment and actively work to solve practical issues. Finally, the format and structure of digital meetings should be co-created together with public contributors.

The Impact of the COVID-19 Pandemic and Societal Infection Control Measures on Children and Adolescents' Mental Health: A Scoping Review.

Background: The COVID-19 pandemic is primarily a crisis that affects people's physical health. However, it is well-known from previous epidemics and pandemics that there are other indirect negative impacts on mental health, among others. The purpose of this scoping review was to explore and summarise primary empirical research evidence on how the COVID-19 pandemic and societal infection control measures have impacted children and adolescents' mental health. Methods: A literature search was conducted in five scientific databases: PubMed, APA PsycINFO, Web of Science, CINHAL, and Social Science Premium Collection. The search string was designed using the Population (0-18 years), Exposure (COVID-19), Outcomes (mental health) framework. Mental health was defined broadly, covering mental well-being to mental disorders and psychiatric conditions. Results: Fifty-nine studies were included in the scoping review. Of these, 44 were cross-sectional and 15 were longitudinal studies. Most studies reported negative impact of the COVID-19 pandemic on child and adolescent mental health outcomes, yet the evidence was mixed. This was also the case for studies investigating societal control measures. Strong resilience, positive emotion regulation, physical activity, parental self-efficacy, family functioning and emotional regulation, and social support were reported as protective factors. On the contrary, emotional reactivity and experiential avoidance, exposure to excessive information, COVID-19 school concerns, presence of COVID-19 cases in the community, parental mental health problems, and high internet, social media and video game use were all identified as potentially harmful factors. Conclusions: Due to the methodological heterogeneity of the studies and geographical variation, it is challenging to draw definitive conclusions about the real impact of the COVID-19 pandemic on the mental health of children and adolescents. However, the existing body of research gives some insight to how parents, clinicians and policy makers can take action to mitigate the effects of COVID-19 and control measures. Interventions to promote physical activity and reduce screen time among children and adolescents are recommended, as well as parenting support programs.

Children's Expressions of Worry During the COVID-19 Pandemic in Sweden.

OBJECTIVE: Sweden is an international exception in its public health response to the COVID-19 pandemic, with a higher number of deaths, albeit not pediatric, compared with other Nordic countries. The objective of this study was to investigate what worries children and adolescents living in Sweden expressed in relation to the pandemic. METHODS: Using an anonymous web-survey, 1,047 children (4-12 years; N = 717) and adolescents (13-18 years; N = 330) responded to five background and four open-ended questions, one of which was: Is there anything that you are worried about when it comes to 'Corona'? The responses were coded using manifest content analysis. Interrater reliability was .95, assessed on the code level. RESULTS: Worry was common (77%); mostly (60%) related to disease or death of elderly relatives, parents, the child him/herself or general worry for the elderly/risk groups. Existential worry (15%) comprised worries about the future, including economy and worries about the world perishing or the contagion becoming uncontrollable. A developmental trajectory was evident in the nature of responses. Adolescents' worries about the future included missing out on their youth and employment. They also worried about society (6%), for example, the future of democracy and the world economy. There was no indication of socioeconomic status or geographic area (urban vs. rural) affecting the presence of worrisome thoughts. CONCLUSIONS: Worry about "Corona" was common. Universal preventative mental health intervention is warranted and could be conducted in the school setting. Intervention could be tailored by age, covering discussion on financial aspects with adolescents.

Social workers' perspectives on a medical home model for children and adolescents in out of home care - an interview study.

BACKGROUND: This study seeks to explore how social workers have perceived and experienced a medical home model for children and adolescents in out-of-home care in Uppsala County, Sweden. METHOD: A qualitative explorative study was conducted, which involved ten semi-structured individual telephone interviews with social workers. The study sample included employees within the social service, working in a specialised case unit who had experience of referring children and/or adolescents to the medical home model called Hälsofam. Data were analysed inductively using thematic analysis. RESULTS: The findings of the current study indicated that working with Hälsofam has offered social workers a way into the health care sector and an active collaborative working situation, with focus on organised work across the 'silos' of care services. However, the findings raised the question of whether or not all children and adolescents have the same possibility to receive care from Hälsofam. CONCLUSION: The findings indicated that the Hälsofam model had a positive impact on the interrelations between the social service and the health care sector. Yet, findings showed that personal views of the social worker and the societal situation in which they operate create limitations for providing care for every child and adolescent. This study adds to the extant literature for it addresses the limitations within the work of children and adolescents in out-of-home care.

Giving schools a nudge: can behavioural insights improve recruitment of schools to randomised controlled trials?

OBJECTIVE: It is widely acknowledged that recruitment to randomised controlled trials (RCTs) is challenging, particularly trials that operate across multiple sites. A research area in need of further high-quality evaluation, including RCTs, is school-based mental health interventions for refugee children and adolescents. However, engaging schools with interventions and associated evaluations can be challenging. This paper explores the application of behavioural insights, i.e. evidence-based understanding of how people behave and make decisions, to RCT recruitment at the school level via email communications. A pilot study of applying behavioural insights to mail outs attempting to recruit schools to a RCT of a trauma-focused group intervention for refugee children and adolescents experiencing symptoms of post-traumatic stress is reported. Rates of school involvement between the behavioural insights approach (n = 31) and a standard outreach approach (n = 65) are compared. RESULTS: Schools were more likely to give a positive response to the mail out designed using the behavioural insights framework than standard outreach. Accounts of recruitment strategies such as this are valuable additions to the literature on RCT methodology given the potential for recruitment issues to affect trial operations.

Readiness of Allied Professionals to Join the Mental Health Workforce: A Qualitative Evaluation of Trained Lay Trauma Counsellors' Experiences When Refugee Youth Disclose Suicidal Ideation.

The recent refugee crisis presented a huge challenge for the Swedish mental health workforce. Hence, innovative mental health workforce solutions were needed. Unaccompanied refugee minors (URM) are a particularly vulnerable refugee group. Teaching Recovery Techniques (TRT) was introduced as a community-based intervention utilising trained lay counsellors in a stepped model of care for refugee youth experiencing trauma symptoms. Professionals (e.g., teachers, social workers) can deliver the Cognitive Behavioural Therapy-based intervention after a brief training. A point of debate in this workforce solution is the readiness of trained lay counsellors to deal with potentially demanding situations like disclosure of suicidal ideation. This study aimed to explore the TRT trained lay counsellors' experiences of procedures upon URM's disclosure of suicidal ideation. Individual semi-structured interviews with TRT trained lay counsellors were conducted, then analysed using systemic text condensation. The analysis revealed four themes: "Importance of safety structures", "Collaboration is key", "Let sleeping dogs lie" and "Going the extra mile". Dealing with suicidal ideation is challenging and feelings of helplessness occur. Adding adequate supervision and specific training on suicidal ideation using role play is recommended. Collaboration between agencies and key stakeholders is essential when targeting refugee mental health in a stepped care model.

'I felt like a human being'-An exploratory, multi-method study of refugee involvement in the development of mental health intervention research.

BACKGROUND: Great advancements have been made in patient and public involvement (PPI), including the development of guidance on how to conduct, report and evaluate PPI. Despite these efforts, the evidence base remains relatively weak. A substantive methodological development is required. This is particularly important for vulnerable groups within society, for whom PPI can be challenging but has the potential to play a transformative role in shaping research. OBJECTIVES: To describe the group dynamic characteristics and immediate impact of PPI from the user representatives' perspective in a case study of refugee involvement in the development of mental health intervention research. To pilot and methodologically appraise the Active Involvement of Users in Research Observation Schedule and Questionnaire. DESIGN: The Active Involvement of Users in Research Observation Schedule and Questionnaire were administered together with a focus group discussion. SETTING: 'Refugee Advisors' were involved in the development of a randomized controlled trial protocol evaluating a brief group intervention for refugee children experiencing symptoms of post-traumatic stress in Sweden. RESULTS: The multi-method approach demonstrated good feasibility. There were clear examples of how the advisors influenced research development. The advisors described a perceived impact on the research, equality and acceptance, and knowledge gain. A sense of appreciation and empowerment was also interpreted. However, potential issues relating to the relevance of contributions and use of an interpreter were identified. DISCUSSION AND CONCLUSION: The methodological approach piloted in this study offers a promising, rigorous way to evaluate PPI. The research tools require further refinement and validation.