Parental decision making about safer sleep practices: A qualitative study of the perspectives of families with additional health and social care needs.

INTRODUCTION: Despite a decline in Sudden Unexpected Death in Infancy in the UK since 2004, inequalities have widened with higher rates among families from deprived backgrounds and those known to child protection services. Almost all cases involve parents who had engaged in unsafe sleeping practices despite awareness of safer sleeping advice. OBJECTIVE: To understand the perspectives surrounding safer sleep of families supported by statutory child protection agencies, and use behavior change theory to inform how approaches to providing safer sleep advice to these families may be modified. PARTICIPANTS AND SETTING: We interviewed 14 mothers, 2 fathers and one grandmother, who had recent contact with child protection services in northeast England. METHODS: In-depth, semi-structured interviews, with purposive sampling. The COM-B model (Capability, Opportunity, and Motivation) structured our analysis. RESULTS: Parents described how anxiety, sleep deprivation, settling infants, illness, and a desire to bond with infants influence their decision making about sleep. Parents valued credible, trusted sources and understanding how safer sleep practices protect infants. Responses to questions about 'out of routine' situations suggested social pressures surrounding routines and 'good parenting' may preclude parents from acknowledging risks and planning for these situations. CONCLUSION: Open conversations tailored to the needs of families, focused upon understanding why and when parent(s) do or do not follow safer sleep guidance seem a promising way of promoting safer sleep practices. Safer sleep discussions with these families are likely to be best delivered as part of wider infant care by professionals who have an established and continuing trusting relationship with parents. While advice and information should be provided by any professional in contact with the family with the necessary expertise, sensitive conversations around sleeping practices, particularly co-sleeping, may be more easily facilitated by professionals where the statutory responsibility for safeguarding is less apparent.

Mindfulness-enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents.

BACKGROUND: Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long-term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another's behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non-compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills-based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills-based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes. OBJECTIVES: To assess the effectiveness of mindfulness-enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents. SEARCH METHODS: We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index - Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field. SELECTION CRITERIA: We included randomised and quasi-randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness-enhanced parent training programmes compared with a no-intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills-based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one-to-one or group-basis, with a well-defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present-focused attention and non-judgemental acceptance. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane procedures. MAIN RESULTS: Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness-enhanced parent training programme with a no-treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no-treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self-compassion, and no adverse effects were reported in any of the studies. Mindfulness-enhanced parent training programmes compared to a no-treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) -0.46, 95% confidence interval (CI) -0.96 to 0.03; P = 0.06, I2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD -0.50, 95% CI -0.96 to -0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD -0.79, 95% CI -1.80 to 0.23; P = 0.13, I2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI -0.14 to 0.56; P = 0.24, I2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness-enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD -0.09, 95% CI -0.58 to 0.40; P = 0.71, I2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI -0.16 to 0.42; P = 0.37, I2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI -0.19 to 0.41; P = 0.48, I2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD -0.24, 95% CI -0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD -0.51, 95% CI -0.84 to -0.18; P = 0.002, I2 = 2%; 3 studies, 150 participants; low certainty evidence). AUTHORS' CONCLUSIONS: Mindfulness-enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills-based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high-quality studies are produced.

Payer and Developer perspectives on alternative payment models.

OBJECTIVE: To understand the use of alternative payment models to address the reimbursement challenges of cell and gene therapies (CGT) in the U.S.A.. METHODS: A literature search focused on CGT reimbursement in the U.S. market was conducted to identify information gaps and inform survey development. U.S. developers (n = 100) and payers (n = 195) were invited to complete an online survey between June and August 2022. RESULTS: The overall response rate was 16%; payer respondents represented 98 plans covering 338 million lives. Most developers (81%) and payers (84%) had implemented or were planning to implement at least one alternative payment model. Payers pursued these models to 'reduce product performance uncertainties' (81%), 'align therapy costs with benefits' (58%), and 'manage actuarial uncertainty' (54%). Developers aimed to 'streamline patient access' (92%) and 'mitigate budget impact' (77%). Common perceived barriers included increased administrative burden (developers 79% and payers 67%), defining performance measures (developers 71%, payers 83%) and addressing patient mobility (developers 71% and payers 63%). Both parties expressed a willingness to use real-world evidence for contract adjudication. CONCLUSION: Although limited by the number of participants, this survey indicates early discussions coupled with understanding motivations are essential for developing contracts that appeal to both parties and ensure patient access.

Feasibility and acceptability of using the Alarm Distress BaBy (ADBB) scale within universal health visiting practice in England: a mixed-methods study protocol.

INTRODUCTION: The Alarm Distress BaBy (ADBB) scale developed by Guedeney and Fermanian in 2001, is a validated screening tool designed for use by healthcare practitioners to identify infant social withdrawal. This study will explore the acceptability and feasibility of the use of the full ADBB scale and a modified ADBB (m-ADBB) scale as part of routine health visiting visits in England. METHODS AND ANALYSIS: A mixed methods sequential exploratory design will be used. Five health visitors will be trained in using the ADBB scale and 20 in the m-ADBB scale, from two National Health Service sites in England. Qualitative semi-structured interviews will be carried out with health visitors after they receive the training and again 2 months after using the scales in routine family health visits. Quantitative data will also be collected from the same participants for a range of items during the study period. The theoretical framework of Normalisation Process Theory will underpin the study, to provide in-depth explanations of the implementation process. Qualitative data will be analysed using thematic analysis. Quantitative data will be analysed using descriptive analysis. ETHICS AND DISSEMINATION: Ethical approval was granted by the University of Oxford Departmental Research Ethics Committee. Dissemination of results will be via organisational websites, social media platforms, newsletters, professional networks, conferences and journal articles.

Systematic review and narrative synthesis of the key barriers and facilitators to the delivery and uptake of primary healthcare services to women in Pakistan.

OBJECTIVES: The objective of this review is to (1) identify barriers and facilitators with respect to women's health services at a primary care level based on a systematic review and narrative synthesis and (2) to conclude with recommendations for better services and uptake. DESIGN: Systematic review and narrative synthesis. DATA SOURCES: PubMed, BMC Medicine, Medline, CINAHL and the Cochrane Library. Grey literature was also searched. ELIGIBILITY CRITERIA: Qualitative, quantitative and mixed studies were included in the review. DATA EXTRACTION AND SYNTHESIS: The search took place at the beginning of June 2021 and was completed at the end of August 2021. Studies were included in the review based on the Sample, Phenomenon of Interest, Design, Evaluation, Research type criteria. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Data were synthesised using a narrative synthesis approach. RESULTS: A total of 33 studies were included in the review. We identified six barriers to the delivery of effective primary healthcare for women's health which have been organised under two core themes of 'service barriers' and 'family/cultural barriers'. Ten barriers to the uptake of primary healthcare for women have been identified, under three core themes of 'perceptions about healthcare service', 'cultural factors' and 'practical issues'. Three facilitators of primary healthcare delivery for women were identified: 'motivating community health workers (CHWs) with continued training, salary, and supervision' and 'selection of CHWs on the basis of certain characteristics'. Five facilitators of the uptake of primary healthcare services for women were identified, under two core themes of 'development of trust and acceptance' and 'use of technology'. CONCLUSIONS: Change is needed not only to address the limitations of the primary healthcare services themselves, but also the cultural practices and limited awareness and literacy that prevent the uptake of healthcare services by women, in addition to the wider infrastructure in terms of the provision of financial support, public transport and child care centres. PROSPERO REGISTRATION NUMBER: CRD42020203472.

How are parental mental health and parenting practices associated with externalizing behaviors among young children with autism in China? A cross-sectional study and indirect effect analysis.

Children with autism are more likely to exhibit externalizing behaviors than children without autism. A cross-sectional study was undertaken to investigate how parental mental health status and parenting practices contributed to the variance in externalizing behaviors among families of young children with autism in Chinese mainland, and whether parenting behaviors had any indirect effects on the relationship between parental mental health symptoms and externalizing behaviors. Data were drawn from the baseline assessment of a quasi-experimental study of a parent training program delivered to Chinese caregivers of children with autism aged 3 to 6 from diverse backgrounds (N = 111). Results showed that parental mental health symptoms and parenting behaviors explained the variance in child externalizing behaviors. Parental mental health problems and parental over-reactivity were linked to higher levels of child externalizing behaviors, whereas positive parenting was associated with less frequent externalizing behaviors. Positive parenting partially explained the relationship between parental mental health symptoms and externalizing behaviors. The findings of this study highlight the importance of actively attending to the psychological and parenting needs of caregivers in autism treatment programs. It points to the need for the development of culturally sensitive strategies to promote parental mental health and increase the use of positive parenting skills among parents of children with autism.

PROTOCOL: What is the effect of intergenerational activities on the wellbeing and mental health of children and young people?

This is the protocol for a Campbell systematic review. The objectives are as follows: this systematic review will examine the impact of intergenerational interventions on the wellbeing and mental health in children and young people and will identify areas for future research as well as key messages for service commissioners.

For-profit outsourcing and its effects on placement stability and locality for children in care in England, 2011-2022: A longitudinal ecological analysis.

BACKGROUND: The responsibility of local authorities in England to provide children in care with stable, local placements has become increasingly difficult due to the rising number of children in need of care and a shortage of available placements. It is unclear if the trend of outsourcing children's social care to private companies has exacerbated this challenge. This paper examines how the outsourcing of children's social care to the private market has influenced placement locality and long-term stability over time. METHODS: We created a novel dataset of multiple administrative data sources on the outsourcing, placement locality and stability, and characteristics of children in care between 2011 and 2022. We conducted time-series fixed-effects regression analysis of the impact of for-profit outsourcing on placement locality and stability from 2011 to 2022. RESULTS: Our fully adjusted models demonstrate that for-profit outsourcing is consistently associated with more children being placed outside their home local authority and greater placement instability. We found that an increase of 1 % point of for-profit outsourcing was associated with an average increase of 0.10 % points (95 % CI 0.02-0.17; p = 0.01) more children experiencing placement disruption, and 0.23 % points (95 % CI 0.15-0.30; p < 0.001) more children being placed outside their home local authority. We estimate that an additional 17,001 (95 % CI 9015-24,987) out-of-area placements can be attributed to increases in for-profit provision. DISCUSSION: Our analyses show that placement stability and distance have deteriorated or stagnated over the last decade, and that the local authorities that rely most on outsourcing have the highest rates of placement disruptions and out-of-area placements.

Non-familial intergenerational interventions and their impact on social and mental wellbeing of both younger and older people-A mapping review and evidence and gap map.

Background: Opportunities for social connection between generations in the UK have diminished over the last few decades because of changes in the way that we live and work. The decline in communal spaces such as libraries, youth clubs and community centres mean that there are fewer opportunities to meet and mix socially with other generations outside our own families. Increased working hours, improved technology, changes in family patterns, relationship breakdowns within families and migration are also believed to be contributory factors to generation segregation. There are many potential economic, social and political impacts of generations living separate and parallel lives, for example, higher health and social care costs, an undermining of trust between generations reduced social capital, a reliance on the media to form understanding of others' viewpoints and higher levels of anxiety and loneliness. Intergenerational programmes and activities can take many forms and are delivered in many settings.  Evidence suggests that intergenerational activity can have a positive impact on participants, for example, in reducing loneliness and exclusion for both older people and children and young people, improving mental health, increasing mutual understanding and addressing important issues such as ageism, housing and care. There are currently no other EGMs that exist that address this type of intervention; however, it would complement existing EGMs addressing child welfare. Objectives: To identify, appraise and bring together the evidence on the use of intergenerational practice, to answer the following specific research questions: What is the volume, nature and diversity of research on, and evaluation of, intergenerational practice and learning?What approaches have been used to deliver intergenerational activities and programmes that may be relevant to providing such services during and in the subsequent recovery from the COVID-19 pandemic?What promising intergenerational activities and programmes have been developed and are being used but have not yet been subject to formal evaluation? Search Methods: We searched MEDLINE (via OvidSp), EMBASE (via OvidSp), PsycINFO (via OvidSp), CINAHL (via EBSCOHost), Social Policy and Practice (via OvidSp), Health Management Information Consortium (via OvidSp), Ageline (via EBSCOhost), ASSIA (via ProQuest), Social Science Citations Index (via Web of Science), ERIC (via EBSCOhost), Community Care Inform Children, Research in Practice for Children, ChildData (via Social Policy and Practice), the Campbell Library, the Cochrane Database of Systematic Reviews and the CENTRAL database between 22 and 30 July 2021. We searched for additional grey literature via the Conference Proceedings Citation Index (via Web of Science) and ProQuest Dissertation & Theses Global and via relevant organisation websites, for example, Age UK, Age International, the Centre for Ageing Better, Barnado's, Children's Commission, UNICEF, Generations Working Together, the Intergenerational Foundation, Linking Generations and The Beth Johnson Foundation) and the Ottawa initiative called Older Adults and Students for Intergenerational support. Selection Criteria: Any intervention that brings older and younger people together with the purpose of interacting to achieve positive health and/or social and/or educational outcomes from any study design including systematic reviews, randomised controlled studies, observational studies, surveys and qualitative studies are included. The titles and abstracts, and later full texts, of records identified by the search methods were screened against inclusion criteria by two independent reviewers. Data Collection and Analysis: Data extraction was undertaken by one reviewer and checked by a second with any inconsistencies identified and resolved through discussion. The data extraction tool was developed on EPPI reviewer and was modified and tested through stakeholder and advisor consultation, and piloting of the process. The tool was informed by the research question and the structure of the map. We did not undertake quality appraisal of the included studies. Main Results: Our searches identified 12,056 references, after screening 500 research articles were included in the evidence gap map conducted across 27 countries. We identified 26 systematic reviews, 236 quantitative comparative studies (of which 38 were randomised controlled trials), 227 were qualitative studies (or had a qualitative element), 105 were observational studies (or had elements of observational methods) and 82 used a mixed methods approach. The outcomes reported in the research cover mental health (n = 73), physical health (n = 62), attainment and knowledge (n = 165), agency (n = 174), mental wellbeing (n = 224), loneliness and social isolation (n = 54), attitudes towards the other generation (n = 283), intergenerational interactions (n = 196), peer interactions (n = 30) and health promotion (n = 23) and including mutual outcomes such as the impact on community (n = 37) and perceptions on the sense of community (n = 43). Gaps in the evidence that were identified include: research that reports on mutual, societal and community outcomes of intergenerational interventions; more research on interventions classified as levels 1-4 and level 7 on the Intergenerational Engagement Scale, mental health, loneliness, social isolation, peer interactions, physical health and health promotion outcomes in children and young people; health promotion in older people; outcomes centred on care giver wellbeing, mental health and attitudes; economic outcomes; process outcomes and adverse or unexpected outcomes. Authors' Conclusions: Whilst a substantional amount of research on intergenerational interventions has been identified in this EGM, as well as the gaps identified above, there is a need to explore promising interventions not yet formally evaluated. Research on this topic is gradually increasing, and systematic reviews will be important to determine how and why interventions are or are not beneficial. However, the primary research needs to build more cohesively so that the findings can be comparable and avoid research waste. The EGM presented here will nevertheless be a useful resource for decision-makers allowing them to explore the evidence with regard to the different interventions that may be relevant to their population needs and the settings or resources available to them.

Measuring Violence Against Children: A COSMIN Systematic Review of the Psychometric Properties of Child and Adolescent Self-Report Measures.

Research on violence against children (VAC) requires meaningful, valid, and reliable self-report by children. Many instruments have been used globally and decisions to select suitable measures are complex. This review identifies child and adolescent self-report measures that are most likely to yield valid, reliable, and comparable data in this field. A systematic review (PROSPERO: CRD4201706) was conducted using the 2018 Consensus-based Standards for the selection of health Measurement Instrument (COSMIN) criteria. Six electronic databases and gray literature were searched. Manuscripts published in English and describing the development and psychometric qualities of child/adolescent self-report instruments were included. Thirty-nine original instruments and 13 adaptations were identified in 124 studies. The quality of evidence ranged from "very low" to "high" depending on the measure and the psychometric properties assessed. Most measures were not widely used, and some have been applied in many settings despite limited evidence of their psychometric rigor. Few studies assessed content validity, particularly with children. The ACE, CTQ, CTS-PC, CECA, ICAST, and JVQ have the best psychometric properties. An overview of items measuring frequency, onset, duration, perpetrators, and locations is provided as well as an assessment of the practicalities for administration to help researchers select the instrument best suited for their research questions. This comprehensive review shows the strengths and weaknesses of VAC research instruments. Six measures that have sufficient psychometric properties are recommended for use in research, with the caveat that extensive piloting is carried out to ensure sufficient content validity for the local context and population.

Unpacking School-Based Child Sexual Abuse Prevention Programs: A Realist Review.

Background: Existing efforts to understand school-based child sexual abuse (CSA) prevention programs mainly focus on the effectiveness of these programs in increasing participants' CSA knowledge and self-protective skills. There are currently no reviews addressing the underpinning pathways leading to these outcomes. In order to increase our understanding about the underpinning causal and contextual factors and inform the further development of school-based CSA prevention programs, a realist review was conducted to synthesize existing evidence from a broad range of data. Methods: An iterative search of electronic databases and grey literature was conducted, supplemented with citation tracking to locate relevant literature. For quantitative evidence, we considered evaluation studies that focused on students aged 5-18 years, who were enrolled in primary or secondary schools; for other types/formats of studies/documents, no population restrictions were applied. We included school-based CSA prevention programs that focused on improving knowledge of CSA or self-protective skills. Outcomes of interest included knowledge of CSA or self-protective skills. We did not apply methodological filters in terms of the types of studies to be included. Thematic content analysis was conducted to synthesize data. Results: Sixty-two studies were included. Five themes and five overarching Context-Strategy-Mechanism-Outcome configurations (CSMOs) that contributed to the success of school-based CSA interventions were identified, including tailoring programs to participants' cognitive developmental levels, repeated exposure of key concepts and skills, utilization of interactive delivery methods and positive feedback, delivery of positive information and application of the 'train-the-trainer' model. Implications: Findings from this realist review provide insights into the underlying program theory of school-based CSA prevention programs, which can aid in the development and implementation of these programs in the future.

A family perspective on parental psychosis: An interpretative phenomenological analysis study.

OBJECTIVES: While one third of people with a psychotic disorder are a parent, there has been little research to date examining the consequences of this from a whole family perspective. This study investigates families where a parent has experienced an episode of psychosis and compares and contrasts the family members' perspectives. DESIGN: This study was rooted in phenomenology and data were derived from in-depth semi-structured interviews. METHODS: Parents with a psychotic disorder who had a child aged between 3 and 11 in a UK NHS Trust were invited to take part in the study. Semi-structured interviews were conducted with these parents, with their child (if they were between the ages of 8 and 11), and with their partner or another close family member. Data were analysed using multiperspectival interpretive phenomenological analysis (m-IPA). RESULTS: Thirteen participants took part comprising of five parents, four children, three partners and one grandmother. Four themes were developed using m-IPA: (1) Parental psychosis impacts the whole family, (2) Psychosis and my role as a parent, (3) Secrecy and concealment surrounding parental psychosis, and (4) Pressures and vulnerabilities within the family system. CONCLUSION: Psychosis had a negative impact on all family members and secrecy existed between family members. The children in particular only had partial information about their parent's mental illness, which left them worried and confused. More work is needed to support these families to explain psychosis to the children.

Outsourcing and children's social care: A longitudinal analysis of inspection outcomes among English children's homes and local authorities.

Most residential children's social care services in England, including children's homes, are operated by for-profit companies, but the implications of this development are not well understood. This paper aims to address this gap by undertaking the first longitudinal and comprehensive evaluation of the associations between for-profit outsourcing and quality of service provision among English local authorities and children's homes. To enable investigation of the implications of outsourcing children's residential social care services, we create and analyse a novel and longitudinal dataset covering more than 13,000 children's home inspections by Ofsted (the independent regulator of children's social care in England) over a period of 7 years (2014-2021). We also investigate the association between Ofsted local authority (LA) ratings and the reliance of LAs on for-profit and third sector outsourcing of children in care placements. Our analysis shows that for-profit providers are statistically significantly more likely to be rated of lower quality than both public and third sector services. For-profit children's homes also violate a greater number of requirements and receive more recommendations compared to other ownership types. These findings are robust to model specification and consistent over the full analysed period. At LA level, we find provisional evidence that LA Ofsted ratings are negatively correlated with the percentage of for-profit outsourcing, suggesting that LAs which outsource a greater amount of their children in care placements perform less well than those which do not. These findings are of significant concern given the focus of these services on society's most vulnerable service users. However, caution is needed in terms of regulating the sector going forward, as the role of for-profit provision cannot be replaced without substantial coordination and long-term planning.

Study protocol: a mixed-methods study to evaluate which health visiting models in England are most promising for mitigating the harms of adverse childhood experiences.

INTRODUCTION: Exposure to adverse childhood experiences (ACEs) is associated with poorer health outcomes throughout life. In England, health visiting is a long-standing, nationally implemented service that aims to prevent and mitigate the impact of adversity in early childhood, including for children exposed to ACEs. A range of health visiting service delivery practices exist across England (from the minimum five recommended contacts to tailored intensive interventions), but there is a lack of evidence on who receives what services, how this varies across local authorities (LAs) and the associated outcomes. METHODS AND ANALYSIS: This study will integrate findings from analysis of individual-level, deidentified administrative data related to hospital admissions (Hospital Episode Statistics (HES)) and health visiting contacts (Community Services Data Set (CSDS)), aggregate LA-level data, in-depth case studies in up to six LAs (including interviews with mothers), a national survey of health visiting services, and workshops with stakeholders and experts by experience. We will use an empirical-to-conceptual approach to develop a typology of health visiting service delivery in England, starting with a data-driven classification generated from latent class analysis of CSDS-HES data, which will be refined based on all other available qualitative and quantitative data. We will then evaluate which models of health visiting are most promising for mitigating the impact of ACEs on child and maternal outcomes using CSDS-HES data for a cohort of children born on 1 April 2015 to 31 March 2019. ETHICS AND DISSEMINATION: The University College London Institute of Education Research Ethics Committee approved this study. Results will be submitted for publication in a peer-reviewed journal and summaries will be provided to key stakeholders including the funders, policy-makers, local commissioners and families.

Parenting and psychosis: An experience sampling methodology study investigating the inter-relationship between stress from parenting and positive psychotic symptoms.

OBJECTIVES: There is a strong association between stress and psychotic symptoms, and this study examined the bidirectional nature of this relationship in parents with psychosis, with negative affect as a mediator and a range of other psychosocial factors included as covariates. It also examined whether stress from parenting had a larger impact on psychosis than non-parenting stress. DESIGN: The study used a within-participants repeated measures design, using experience sampling methodology (ESM). ESM is a self-report surveying technique completed over an intensive longitudinal period. Participants completed six surveys a day, for 10 days. METHODS: Thirty-five participants with psychosis who were a parent to a child between the ages of 2 and 16 took part. Study phones alerted participants to complete surveys by beeping at semi-random intervals over 10 days. Multi-level modelling was used with surveys at Level-1 and participants at Level-2. Predictor variables were time-lagged in order to infer directionality. RESULTS: Parenting stress was found to predict psychotic symptoms, and this relationship was mediated by negative affect. The reverse direction was also confirmed. Few of the additional psychosocial factors were found to have a significant impact on the models' estimations. Parenting stress was not found to have a larger impact on psychosis than other sources of stress. CONCLUSIONS: This study provides further evidence of the bidirectional relationship between stress and psychosis in the context of parenting. Further research should explore if parenting stress plays a unique role in predicting psychotic symptoms by comparing parents and non-parents with psychosis.

A modified video-feedback intervention for carers of foster children aged 6 years and under with reactive attachment disorder: a feasibility study and pilot RCT.

BACKGROUND: Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder. However, access to interventions varies widely and there are no evidence-based interventions for this disorder. OBJECTIVES: (1) To adapt an existing video-feedback intervention to meet the specific needs of foster children in the UK with reactive attachment symptoms, (2) to conduct a case series to road-test the treatment manual and study procedures, (3) to conduct a scoping study of the key hurdles in a pilot trial and (4) to conduct a pilot randomised controlled trial of the adapted intervention to determine the feasibility of a future full-scale trial. DESIGN: This was a mixed-methods study. The adapted treatment manual was developed with expert input and tested on a small case series. Qualitative interviews with key stakeholders were used in the scoping study in preparation for the trial and later with foster carers who received the new intervention. The final stage was a feasibility and pilot randomised controlled trial of the new intervention, compared with usual care. Researchers assessing the outcomes were blinded to group assignment. SETTING: The study was set in outpatient child and adolescent mental health services and partner social services departments. Sites included urban and rural/semirural areas. PARTICIPANTS: Participants were foster carers with children aged ≤ 6 years presenting with difficulties in the domain of reactive attachment disorder. Key stakeholders included children's services managers and mental health service practitioners in the scoping study. Foster carers who received the modified intervention participated in qualitative interviews. INTERVENTION: The video-feedback intervention to promote positive parenting and sensitive discipline is an extensively evaluated and effective treatment approach. This intervention was modified (based on the adapted version for foster care in the Netherlands) to suit the needs of young children with reactive attachment symptoms in foster care in the UK and was delivered to improve the sensitive responding of foster carers, foster carer-child relationships and child outcomes. The modified intervention was delivered in-home by trained mental health professionals over a period of 4-6 months. MAIN OUTCOME MEASURE: The main outcome was reactive attachment symptom scores on the Disturbances of Attachment Interview. RESULTS: A series of minor changes to the intervention programme were introduced, which focused on improving its suitability for the UK foster care context. Challenges in recruitment meant that, despite numerous modifications to the protocol and the inclusion of additional sites, only 30 families (target, n = 40) were recruited to the randomised controlled trial (15 allocated to each group). However, most other trial parameters were deemed feasible and acceptable, particularly the high levels of data and treatment completeness. All randomised families were available for baseline analyses, but two in the treatment arm were not available for post-treatment analyses. The revised intervention was positively received by practitioners and foster carers. LIMITATIONS: Only three-quarters of the target sample size was recruited. Furthermore, the sites' own exclusion of potential participants and the low return rates of screening questionnaires raise the possibility of non-randomness of non-responses. CONCLUSION: A larger-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended. Central resourcing of intervention capacity to supplement NHS staff is also recommended. TRIAL REGISTRATION: This trial is registered as ISRCTN18374094. FUNDING: This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 35. See the NIHR Journals Library website for further project information.

Children in foster care typically have had a very difficult start in life, often as a result of abuse or neglect within their family of origin, and separation from caregivers. These children can find it difficult to trust new adults, and in some cases difficulties in attachment may justify a diagnosis of reactive attachment disorder. This disorder is a pattern of behaviour among young children who have received extremely insufficient early care, whereby they fail to seek or respond to comfort from carers when hurt or distressed, and they can be very withdrawn. There are currently no evidence-based treatments for reactive attachment disorder. The Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline is a treatment programme that was developed to promote secure attachments in young children and to help parents deal with difficult behaviour. A practitioner films the child and parent interacting at home and provides feedback in the following session. This treatment was previously adapted for use in foster care in the Netherlands. In this study, we modified the treatment further to ensure that it appropriately addressed the needs of young children in foster care in the UK who present with reactive attachment disorder symptoms. We then worked with local authorities and linked mental health services to develop a system for identifying young children in foster care in need of this treatment. Finally, we conducted a small (pilot) study to gather information about the best way to provide the modified treatment in this context. The revised treatment was positively received by practitioners and foster carers. The majority of the processes involved in running a trial also worked well (e.g. good levels of attendance at assessments and at the treatment sessions). However, we encountered significant difficulties in recruiting foster carers to the study. We concluded that a full-scale trial would be very valuable, and could potentially be undertaken if difficulties with recruitment are overcome. We recommend that greater resources be provided to local authorities to help them engage and recruit foster carers.

Narrative synthesis systematic review of Pakistani women's health outcomes from primary care interventions.

OBJECTIVE: Women living in Pakistan have complex health problems including infectious and non-communicable diseases, accident and injuries, and mental health problems. While a majority of these women rely on primary healthcare services for all of their healthcare needs, there has to date been no overview of the extent of their effectiveness. The objective of this review was to (1) synthesise the available evidence regarding the effectiveness of primary care based interventions aimed at improving women's mental and physical health and (2) identify the factors that promote effectiveness for women's health outcomes. METHODS: Five academic databases were searched, including PubMed, BMC Medicine, Medline, CINAHL and the Cochrane Library. A search was also made of the grey literature. The quality of included studies was assessed using a standardised critical appraisal tool, and the findings summarised using a narrative synthesis. RESULTS: In total, 18 studies were included in the review. Eight involved evaluations of counselling interventions, three health education and awareness interventions, two social and psychosocial interventions, and five were evaluations of combination interventions. Twelve of the included studies were randomised controlled trials. Of these 14 reported significant outcomes, and 4 further interventions showed partially favourable results. However, interventions mostly targeted women's mental or reproductive health. CONCLUSIONS: While the evidence is limited in terms of quality and what has been evaluated, a number of interventions appear to be effective in improving outcomes for women. The three key approaches include the adoption of an active door-to-door and group-based approach; utilisation of community peers who can deliver care cost-effectively and who are more accepted in the community; and the integration of financial vouchers to support uptake in poor populations. PROSPERO REGISTRATION NUMBER: CRD42020203472.

Children in foster care with symptoms of reactive attachment disorder: feasibility randomised controlled trial of a modified video-feedback parenting intervention.

BACKGROUND: Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder (RAD). However, access to interventions varies widely, and there are no evidence-based interventions for RAD. AIMS: To modify an existing parenting intervention for children with RAD in the UK foster care setting, and test the feasibility of conducting a randomised controlled trial (RCT) of the modified intervention. METHOD: The intervention was modified with expert input and tested on a case series. A feasibility and pilot RCT compared the new intervention with usual care. Foster carers and children in their care aged ≤6 years were recruited across nine local authorities, with 1:1 allocation and blind post-treatment assessments. The modified intervention was delivered in-home by trained mental health professionals over 4-6 months. Children were assessed for RAD symptoms, attachment quality and emotional/behavioural difficulties, and foster carers were assessed for sensitivity and stress. RESULTS: Minimal changes to the intervention programme were necessary, and focused on improving its suitability for the UK foster care context. Recruitment was challenging, and remained below target despite modifications to the protocol and the inclusion of additional sites. Thirty families were recruited to the RCT; 15 were allocated to each group. Most other feasibility outcomes were favourable, particularly high numbers of data and treatment completeness. The revised intervention was positively received by practitioners and foster carers. CONCLUSIONS: A large-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended.

COVID-19 in the context of pregnancy, infancy and parenting (CoCoPIP) study: protocol for a longitudinal study of parental mental health, social interactions, physical growth and cognitive development of infants during the pandemic.

INTRODUCTION: While the secondary impact of the COVID-19 pandemic on the psychological well-being of pregnant women and parents has become apparent over the past year, the impact of these changes on early social interactions, physical growth and cognitive development of their infants is unknown, as is the way in which a range of COVID-19-related changes have mediated this impact. This study (CoCoPIP) will investigate: (1) how parent's experiences of the social, medical and financial changes during the pandemic have impacted prenatal and postnatal parental mental health and parent-infant social interaction; and (2) the extent to which these COVID-19-related changes in parental prenatal and postnatal mental health and social interaction are associated with fetal and infant development. METHODS AND ANALYSIS: The CoCoPIP study is a national online survey initiated in July 2020. This ongoing study (n=1700 families currently enrolled as of 6 May 2021) involves both quantitative and qualitative data being collected across pregnancy and infancy. It is designed to identify the longitudinal impact of the pandemic from pregnancy to 2 years of age as assessed using a range of parent- and self-report measures, with the aim of identifying if stress-associated moderators (ie, loss of income, COVID-19 illness, access to ante/postnatal support) appear to impact parental mental health, and in turn, infant development. In addition, we aim to document individual differences in social and cognitive development in toddlers who were born during restrictions intended to mitigate COVID-19 spread (eg, social distancing, national lockdowns). ETHICS AND DISSEMINATION: Ethical approval was given by the University of Cambridge, Psychology Research Ethics Committee (PRE.2020.077). Findings will be made available via community engagement, public forums (eg, social media,) and to national (eg, NHS England) and local (Cambridge Universities Hospitals NHS Foundation Trust) healthcare partners. Results will be submitted for publication in peer-reviews journals.

Expectant parents' perceptions of healthcare and support during COVID-19 in the UK: a thematic analysis.

BACKGROUND: In response to the COVID-19 pandemic, expectant parents experienced changes in the availability and uptake of both National Health Service (NHS) community and hospital-based healthcare. OBJECTIVE: To examine how COVID-19 and its societal related restrictions have impacted the provision of healthcare support for pregnant women during the COVID-19 pandemic. METHOD: A thematic analysis using an inductive approach was undertaken using data from open-ended responses to the national COVID in Context of Pregnancy, Infancy and Parenting (CoCoPIP) Study online survey (n = 507 families). FINDINGS: The overarching theme identified was the way in which the changes to healthcare provision increased parents' anxiety levels, and feelings of not being supported. Five sub-themes, associated with the first wave of the pandemic, were identified: (1) rushed and/or fewer antenatal appointments, (2) lack of sympathy from healthcare workers, (3) lack of face-to-face appointments, (4) requirement to attend appointments without a partner, and (5) requirement to use PPE. A sentiment analysis, that used quantitative techniques, revealed participant responses to be predominantly negative (50.1%), with a smaller proportion of positive (21.8%) and neutral (28.1%) responses found. CONCLUSION: This study provides evidence indicating that the changes to healthcare services for pregnant women during the pandemic increased feelings of anxiety and have left women feeling inadequately supported. Our findings highlight the need for compensatory social and emotional support for new and expectant parents while COVID-19 related restrictions continue to impact on family life and society.