How to improve the system of care for adolescents with emotional and behavioural problems from the perspective of care providers: a concept mapping approach.

BACKGROUND: Emotional and behavioural problems (EBP) are the most common mental health issues during adolescence, and their incidence has increased in recent years. The system of care for adolescents with EBP is known to have several problems, making the provision of care less than optimal, and attention needs to be given to potential improvements. We, therefore, aimed to examine what needs to be done to improve the system of care for adolescents with EBP and to assess the urgency and feasibility of the proposed measures from the perspective of care providers. METHODS: We used Concept mapping, a participatory mixed-method research, based on qualitative data collection and quantitative data analysis. A total of 33 stakeholders from 17 institutions participated in our study, including psychologists, pedagogues for children with special needs, teachers, educational counsellors, social workers and child psychiatrists. RESULTS: Respondents identified 43 ideas for improving of the system of care for adolescents with EBP grouped into 5 clusters related to increasing the competencies of care providers, changes at schools and school systems, support for existing services, transparency of the care system in institutions and public administration, and the adjustment of legislative conditions. The most urgent and feasible proposals were related to the support of awareness-raising activities on the topic of EBP, the creation of effective screening tools for the identification of EBP in adolescents, strengthening the role of parents in the process of care, comprehensive work with the family, creation of multidisciplinary support teams and intersectoral cooperation. CONCLUSIONS: Measures which are more accessible and responsive to the pitfalls of the care system, together with those strengthening the role of families and schools, have greater potential for improvements which are in favour of adolescents with EBP. Care providers should be invited more often and much more involved in the discussion and the co-creation of measures to improve the system of care for adolescents with EBP.

How to improve access to health care for Roma living in social exclusion: a concept mapping study.

BACKGROUND: Half of the people living in social exclusion in the Czech Republic are of Roma origin. The worse health of Roma could be partly explained by numerous barriers to accessing health care. Therefore, our study aimed to explore the perceptions of various stakeholders and experts who may have an impact on the inclusion of Roma and/or their access to health care on how to improve health care access for Roma living in social exclusion in the Czech Republic. METHODS: We conducted a concept mapping study and obtained data from 32 participants from health and social services, policymakers and others who were involved in different study phases (brainstorming, sorting, rating, interpretation). RESULTS: Out of 64 proposed measures sorted into six distinct clusters, 20 were rated as the most urgent and the most feasible and should be implemented with a priority to improve access to health care for Roma living in social exclusion. The proposed measures covered various topics, such as education and awareness of the target group as well as education and supervision of helping professionals, strengthening capacities and streamlining the health care system, health promotion and associated services and increasing the local and financial accessibility of health care. Overall, measures concerning the education and supervision of helping professionals were rated as both the most urgent and the most feasible. Individual priority measures targeted, for example, the health needs assessment of Roma living in social exclusion to set up interventions or to include topics such as participation, empowerment, cultural competence and communication training in the curricula of health care and helping professionals in postgraduate and continuing studies. CONCLUSIONS: Stakeholders proposed a set of relevant and acceptable measures that may help improve access to health care for Roma living in social exclusion. The way they rated the proposed measures reflects both the current unfavourable mainstream and public discourse concerning Roma living in social exclusion and the most acute policy issues identified by several European and national bodies.

Does family communication moderate the association between adverse childhood experiences and emotional and behavioural problems?

BACKGROUND: Adverse childhood experiences (ACEs) and poor family support and communication can increase emotional and behavioural problems (EBP). Therefore, we assessed the association of difficult communication with mother and with father separately with both emotional and behavioural problems (EBP), and whether adolescents' communication with mother and with father moderates the association of adverse childhood experiences (ACE) with the EBP of adolescents. METHODS: We used data from the Health Behaviour in School-aged Children study conducted in 2018 in Slovakia, comprising 5202 adolescents aged from 11 to 15 (mean age 13.53; 49.3% boys). EBP were measured using the Strengths and Difficulties Questionnaire. We used generalized linear regression adjusted for age, gender and family affluence to explore the modification of the associations between ACE and EBP by communication (easy vs. difficult communication) with mother and father. RESULTS: Difficult communication or a complete lack of communication due to the absence of mother and father increased the probability of emotional (exp (b): 0.96, 95% CI: 0.92|1.00; and 0.95, 95% CI: 0.91|0.99, respectively) and also of behavioural problems (exp (b): 0.96, 95% CI: 0.92|1.00; and 0.94, 95% CI: 0.90|0.97, respectively). We found a statistically significant interaction of communication with father on the association of ACE with EBP, showing that the joint effects were less than multiplicative. CONCLUSION: Difficult communication with mother and father is related to EBP among adolescents, and adolescents' communication with father moderates the association of ACE with both emotional and behavioural problems among adolescents.

Is risk-taking behaviour more prevalent among adolescents with learning disabilities?

Background: Reports from schools indicate that adolescents with learning disabilities (LD) frequently show risk-taking behaviour (RTB), but evidence is lacking. The aim of the study was to assess the associations between LD status and RTBs among Slovak adolescents and to explore whether family affluence and family composition have a moderating or mediating role in these associations. Data from the Slovak national HBSC study 2014 were analyzed. The sample comprised 1549 15-year-old adolescents (mean age: 15.4; 52.5% boys). RTBs were defined as early sexual experience, truancy, fighting, bullying, early smoking initiation and drunkenness. The associations between LD status and RTBs were assessed using binary logistic regression; the mediating as well as moderating role of family affluence and family composition was explored as well. Adolescents with LD are two times more likely to be engaged in early sexual experiences (OR 2.39; 95% CI 1.45-3.95), fighting (OR 1.72; 95% CI 1.01-2.95) and bullying (OR 2.08; 95% CI 1.26-3.44), but not in early smoking initiation, drunkenness or truancy. Family affluence and family composition did not moderate or mediate these associations. Adolescents with LD are at high risk of early sexual experiences, fighting and bullying but not of smoking initiation, drunkenness or truancy. Non-intact and poor families do not increase the risks associated with LD status of adolescents; however, in these families adolescents with LD are more prevalent.

Differences between Roma and non-Roma in how social support from family and friends helps to overcome health care accessibility problems.

BACKGROUND: Roma are the most deprived ethnic minority in Slovakia, suffering from discrimination, poverty and social exclusion. Problematic access to good quality health care as result of institutional and interpersonal discrimination affects their health; therefore, factors which affect health care accessibility of Roma are of high importance for public health and policy makers. The aim of this study was to explore the association between health care accessibility problems and ethnicity and how different levels of social support from family and friends affect this association. METHODS: We used data from the cross-sectional HepaMeta study conducted in 2011 in Slovakia. The final sample comprised 452 Roma (mean age = 34.7; 35.2% men) and 403 (mean age = 33.5; 45.9% men) non-Roma respondents. RESULTS: Roma in comparison with non-Roma have a more than 3-times higher chance of reporting health care accessibility problems. Social support from family and friends significantly decreases the likelihood of reporting health care accessibility problems in both Roma and non-Roma, while the family seems to be the more important factor. CONCLUSION: The worse access to health care of Roma living in so-called settlements seems to be partially mediated by social support. Interventions should focus on Roma health mediators and community workers who can identify influential individuals who are able to change a community's fear and distrust and persuade and teach Roma to seek and appropriately use health care services.

Early Childhood in Marginalized Roma Communities: Health Risks and Health Outcomes.

Objectives: This study aims to compare selected early childhood health risks and health outcomes of children from marginalized Roma communities (MRCs) in Slovakia with those of the majority. Methods: We obtained cross-sectional data from mother-child dyads from the majority (N = 109) and MRCs (N = 143) via questionnaires and from medical records. Socioeconomic status, health risks and health outcomes were compared using chi-square and Mann-Whitney U tests in SPSS. Results: Mothers from MRCs reported significantly worse socioeconomic status. Air quality in the households in MRCs was significantly worse, affected by heating with stoves, burning fresh wood and indoor smoking. The diet composition of children from MRCs was characterized by shorter breastfeeding and unhealthy diet composition less fresh fruits and vegetables, more processed meat products, and sweet and salty snacks. Children from MRCs more often suffered from respiratory and diarrheal diseases, used antibiotics and were hospitalized. Conclusion: The health and healthy development of children living in MRCs is endangered by various poverty-related factors. Persistent differences in exposures and health in early childhood should be a priority goal of the state's social and health policies.

Medical Professionals' Responses to a Patient Safety Incident in Healthcare.

Objectives: Patient safety incidents (PSIs) are common in healthcare. Open communication facilitated by psychological safety in healthcare could contribute to the prevention of PSIs and enhance patient safety. The aim of the study was to explore medical professionals' responses to a PSI in relation to psychological safety in Slovak healthcare. Methods: Sixteen individual semi-structured interviews with Slovak medical professionals were performed. Obtained qualitative data were transcribed verbatim and analysed using the conventional content analysis method and the consensual qualitative research method. Results: We identified eight responses to a PSI from medical professionals themselves as well as their colleagues, many of which were active and with regard to ensuring patient safety (e.g., notification), but some of them were passive and ultimately threatening patients' safety (e.g., silence). Five superiors' responses to the PSI were identified, both positive (e.g., supportive) and negative (e.g., exaggerated, sharp). Conclusion: Medical professionals' responses to a PSI are diverse, indicating a potential for enhancing psychological safety in healthcare.

Perceptions of healthcare providers on benefits, risks and barriers regarding intradialytic exercise among haemodialysis patients.

PURPOSE: Clinical guidelines call for the inclusion of exercise interventions in every patient's dialysis session, but these recommendations are rarely adopted. Healthcare providers play a key role in this. Therefore, the aim of this study was to explore how healthcare providers perceive the benefits, risks and barriers of intradialytic exercise (IDE). METHODS: We conducted 21 individual, semi-structured interviews with 11 nurses, 5 nephrologists, 3 training assistants and 2 managers from two dialysis centres in Slovakia. Verbatim transcripts of digitally recorded interviews were thematically analysed using MAXQDA®. RESULTS: Participants reported the benefits of IDE as improvements in patients' physical and psychosocial functioning, independence and self-efficacy, clinical profile and quality of therapy. As risks of IDE, they most frequently reported exercise-related damage to vascular access, insufficient individualization of training and musculoskeletal injuries. The presence of psychological problems among patients was reported as a major barrier for initiating and maintaining patients' exercise. Other reported barriers included limitations in financial and personnel resources of haemodialysis care. CONCLUSIONS: Safe and sustainable implementation of IDE, which might improve a patient's well-being, need to be prescribed in alignment with the patient's clinical profile, be delivered individually according to the patient's characteristics and requires adjustments in the available resources.

Barriers to HPV vaccination in marginalized Roma communities in Slovakia.

Introduction: Limited access to healthcare services leads to lower vaccination rates in marginalized Roma communities (MRCs). This study aimed to explore health system barriers to HPV vaccination faced by people from MRCs from multiple perspectives. Methods: The qualitative study was conducted in Slovakia in 2021/22 with 43 community members and health professionals. Data were analyzed using a combination of content analysis and consensual qualitative research. Results: A substantial barrier to vaccination is limited coverage of vaccination expenses for certain age categories by health insurance. Moreover, Slovakia faces a significant shortage of healthcare personnel, leading to work overload and a lack of capacity and motivation to address HPV vaccination. Impaired relationships between health care providers and people from MRCs lead to the avoidance of healthcare services, which contributes to insufficient delivery of information and a lack of awareness regarding HPV-related diseases and vaccination. Conclusion: Strengthening the capacities of health care providers, expanding the age group covered by health insurance and providing tailored information to people from MRCs are necessary prerequisites to increase the availability of HPV vaccination and enable people to make informed decisions about HPV vaccination.

"I could do almost nothing without digital technology": a qualitative exploration of adolescents' perception of the risks and challenges of digital technology.

Background: The fast development of digital technology and of its use at even younger ages is significantly shaping the current generation of adolescents. This is leading to an almost unlimited accessibility that provides a large number of opportunities, but also to many challenges that adolescents have to face. The aim of our study was to explore the perceptions adolescents have of the risks of digital technology. Methods: We conducted online semi-structured interviews as a part of the international Health Behaviour in School-aged Children study. The sample consisted of 15 Slovak adolescents (mean age: 15.33; 20% boys). To analyse our data, we used consensual qualitative research and thematic analysis. Findings: Our findings confirmed that adolescents are aware of the risks associated with the use of digital technology. Regarding their specific types of the perceived risks, we identified four main themes: 1. dependence on the functionality of technology; 2. problematic control; 3. vulnerability in the virtual environment; 4. health risks. Adolescents thus want technology that is functional, safe and does not endanger their health. Conclusion: Despite the fact that adolescents know of the risks they may experience due the digital technology, they still use it. Preventive strategies should focus on functionality, safety and healthiness; furthermore, they should support the constant development of adolescents' digital awareness and raising their awareness about effective and non-threating use of technology.

Desirable but not feasible: Measures and interventions to promote early childhood health and development in marginalized Roma communities in Slovakia.

Roma are the largest and most disadvantaged ethnic minority in Europe often facing generational poverty, and limited access to education, employment, housing, and various types of services. Despite many international and national initiatives, children from marginalized Roma communities face multiple risks and are being disadvantaged as early as from conception onward. We, therefore, aimed to identify measures and/or interventions targeting equity in early childhood health and development in marginalized Roma communities which implementation is considered to be urgent but not feasible. We used a group concept mapping approach-a participatory mixed research method-and involved 40 experts and professionals from research, policy and practice. From 90 measures and interventions proposed to achieve early childhood equity for children from marginalized Roma communities, 23 measures were identified as urgent but not feasible. These concerned particularly measures and interventions targeting living conditions (including access to income, access to housing, and basic infrastructure for families) and public resources for instrumental support (covering mainly topics related to financial and institutional frameworks). Our results reflect the most pressing issues in the area of equality, inclusion and participation of Roma and expose barriers to implementation which are likely to arise from public and political discourses perpetrating a negative image of Roma, constructing them as less deserving. Measures to overcome persistent prejudices against Roma need to be implemented along with the measures targeting equity in early childhood health and development.

Technology supports me: Perceptions of the benefits of digital technology in adolescents.

Background: Technology plays a significant role in the lives of adolescents. Our knowledge is predominantly based on research exploring the risks associated with it, but adolescents also feel that technology supports their lives. This has received less consideration. Therefore, we aim to examine how adolescents perceive the benefits of digital technology. Methods: We used qualitative data collected as part of the international Health Behaviour in School-Aged Children study. We conducted online, semi-structured interviews with 15 Slovak adolescents who came from three different types of secondary schools based on their graduation systems (mean age: 15.33; 20% boys). The data were analyzed using consensual qualitative research and thematic analysis. Results: We identified five main themes based on the comments of adolescents: 1. I know (source of information, formal and non-formal education); 2. I can (smart device, helpful tool); 3. I am connected/included (social interactions); 4. I have my comfortable place (leisure time, creating my alternative world); and 5. I work on my future (self-development). Conclusion: Adolescents perceived digital technology as mostly supportive and a helpful tool in their lives. The potential benefits of digital technology should be better reflected in public perception and policy, as the societal debate is mostly dominated by perceived disadvantages and risks.

Are Adverse Childhood Experiences Associated With Being in the System of Care?

Background: Adverse childhood experiences (ACEs) can cause serious mental problems in adolescents and therefore may expected to be associated with higher use of psychosocial care, potentially varying by type of specific ACE. The aim of our study is to explore the association of the number of ACE and types of specific ACE with entering and using psychosocial care. Methods: We used data from the Slovak Care4Youth cohort study, comprising 509 adolescents from 10 to 16 years old (mean age 13.2 years, 48.6% boys). We used logistic regression models adjusted for age, gender, and family affluence to explore the associations of number and type of specific ACE with the use of psychosocial care. Results: Having three or more ACE as well as experiencing some specific ACE (death of a mother/father, death of somebody else you love, problems of a parent with alcohol or drugs, conflicts or physical fights between parents, and separation/divorce of parents) increased the likelihood of using psychosocial care. Regarding experience with the death of somebody else you love, we found a decreased likelihood of the use of psychosocial care. Conclusion: Experiencing ACE above a certain threshold (three or more) and parent-related ACE increase the likelihood of adolescent care use.

The Association of Family-Related Adversity With Fighting in Adolescents: Does Hopelessness Mediate This Association?

Objectives: To explore the association of family-related adversities with physical fighting, and whether this association is mediated by hopelessness. Methods: The sample consisted of 3712 Slovak adolescents (mean age: 13.9, 50.7% girls). Participants answered questions regarding experienced family-related adversities, involvement in physical fighting in the last 12 months and the Hopelessness Questionnaire. First, the association of family adversities in general with fighting and of each of family-related adversity separately was assessed using linear regression models and second, mediation was assessed using the a*b product method with bootstrapped 95% confidence intervals Results: Adolescents who had experienced at least one family adversity reported more frequent fighting. Similarly, each of reported family adversities (death of a parent, substance abuse problems of a parent, conflicts/physical fights, divorce) was associated with more frequent fighting among adolescents. The mediation effect of hopelessness was found in each association of family-related adversity with fighting. Conclusion: These findings suggest that interventions to support adolescents who had experienced family adversities could among other things be directed at better coping with hopelessness.

Does Resilience Mediate the Association of Adverse Early Childhood Experiences With Emotional and Behavioural Problems?

Objectives: To explore the role of resilience as a mediator in the association between adverse childhood experiences (ACE) and emotional and behavioural problems (EBP) among adolescents. Methods: We used data from the Slovak 2018 Health Behaviour in School-aged Children study, comprising 2,839 adolescents aged 13-15 (mean age 13.93; 49.6% boys). We used multivariate linear regression performed on 5000 bootstrap samples adjusted for age, gender, family affluence to explore mediation of the associations between ACE (measured using the adapted Adverse Childhood Experience Questionnaire) and EBP (measured using the Strengths and Difficulties Questionnaire) by resilience (measured with the Child and Youth Resilience Measure). Results: We found ACE [B = 0.78; 95% confidence interval (CI): 0.67|0.90] and resilience (B = -0.73; 95% CI: -0.79|-0.67) to be significantly associated with EBP. The association of ACE and EBP was mediated by resilience. The mediated indirect effect of resilience was ab = 0.25; 95% CI: 0.18|0.32. Conclusion: Resilience seems to play a mediator role in the relationship between ACE and EBP. Helping adolescents with ACE to build and use internal and external sources of resilience can decrease the negative impact of ACE on EBP.

Does Schoolmate and Teacher Support Buffer against the Effect of Adverse Childhood Experiences on Emotional and Behavioural Problems?

This study aims to explore the associations of schoolmate and teacher support with emotional and behavioural problems (EBP) and whether schoolmate and teacher support affects the associations of adverse childhood experiences (ACE) and of EBP in adolescence. We obtained data from 5220 students aged from 11 to 15 (48.7% boys), who participated in the Health Behaviour in a School-aged Children study (2018, Slovakia). Using logistic regression adjusted for gender, age and family affluence we assessed the modification of the relations of ACE and EBP by schoolmate and teacher support. Schoolmate and teacher support decreased the probability of EBP (Odds Ratios, 95% confidence intervals: 0.76, 0.74|0.79; and 0.86, 0.83|0.89, respectively). However, we found no statistically significant interactions of schoolmate and teacher support regarding the association of ACE with EBP. Schoolmate and teacher support decreased the likelihood of EBP among adolescents but do not buffer the relation of any previous ACE with EBP.

Adolescent Enrollment in Psychosocial Care: Do Parents Make a Difference?

Care for adolescents with emotional and behavioral problems (EBP) is frequently unequally distributed. Parents may play a role in the access to this care. Therefore, the aim was to explore the association between parental characteristics and their adolescent's enrollment in psychosocial care. We used data from the Care4Youth cohort study. Our sample consisted of 446 adolescents (mean age 13.22 years, 48% boys) and 382 parents (mean age 42.95 years, 14% males). EBP combined with enrollment created four groups: 1, no EBP/no care; 2, no EBP/care; 3, EBP/no care; 4, EBP/care. We assessed differences in parental characteristics among the groups. Group 2 had a significantly lower socioeconomic position (p < 0.01), more psychological distress (p < 0.001), poorer supervision (p < 0.001) and lower family social support (p < 0.05) than Group 1. Group 4 had a significantly lower socioeconomic position (p < 0.01) and poorer supervision (p < 0.001) than Group 1. Group 3 had significantly poorer supervision (p < 0.001) than Group 4. The poor supervision in Group 3 requires attention, as these adolescents receive no care. The quality of parental supervision should be addressed generally, e.g., by providing better parenting support and more parental training.

Test-Retest Reliability of a Questionnaire on Motives for Physical Activity among Adolescents.

The aim of this study was to investigate the test-retest reliability of the motives for undertaking physical activity (PA) items from the Health Behavior in School-Aged Children (HBSC) study questionnaire among Slovak and Czech adolescents and to determine whether this reliability differs by gender, age group and country. We obtained data from 580 students aged 11 and 15 years old (51.2% boys) who participated in a test and retest study with a four-week interval in 2013 via the Health Behavior in School-Aged Children cross-sectional study in the Czech Republic and Slovakia. We estimated the test-retest reliability of all 13 dichotomized motives by using Intraclass Correlation Coefficients (ICC) and Cohen's Kappa statistics, for continuous and dichotomized motives, respectively. Test-retest reliability showed moderate agreement for nine motives (ICC from 0.41 to 0.60) and fair agreement for four motives (ICC from 0.33 to 0.40). Kappa statistics were similarly moderate to large (0.33 to 0.61), except for three motives with small or trivial correlations. The motives "To improve my health" and "To enjoy the feeling of using my body" had consistently low Kappas and correlations. Overall, the results of this study suggest that most questions on motives for PA on the HBSC questionnaire have acceptable test-retest characteristics for use among adolescents.

What role do family composition and functioning play in emotional and behavioural problems among adolescent boys and girls?

OBJECTIVES: The aim was to explore the associations of family composition, family support and communication with emotional and behavioural problems among adolescents as well as a possible moderating effect of gender on these associations. METHODS: Data from the Health Behaviour in School-aged Children study conducted in 2014 in Slovakia were used. The final sample consisted of 2908 students (mean age 14.36; 49.7% boys). We explored the association using generalized linear models. RESULTS: We found that non-intact family was significantly associated with a higher score in emotional and behavioural problems. Family support and communication were found to be significantly associated with a lower score in emotional and behavioural problems. Significant interactions of gender and family communication with emotional and behavioural problems were found, showing that family communication decreased emotional and behavioural problems only in girls. CONCLUSIONS: Family composition, family support and communication play an important role in the occurrence of emotional and behavioural problems in adolescence. Family communication lowers these problems only in girls. Prevention and intervention programmes could be focused on parent-child communication strategies with the importance of differences in the needs of boys and girls.

Crisis in the Family and Positive Youth Development: The Role of Family Functioning.

The family is a very important institution that provides relationships and contexts in which adolescents are included and where the trajectory of positive development can be activated. A family crisis can affect family functioning and endanger adolescent development. Therefore, we aimed to explore the association of crisis in the family with positive youth development (PYD), and further, whether adolescent-perceived family functioning mediates or moderates this relation. The sample consisted of Slovak adolescents (N = 341, 44% boys, mean age = 13.16) who completed questionnaires that included questions on family crisis and joint family activities, the Alabama parenting questionnaire and the Very Short PYD questionnaire in the baseline measurement of the Care4Youth cohort study. We found a positive association of perceived positive parenting (B = 0.51; p < 0.001) and family activities (B = 0.50; p < 0.001) with PYD, whereas crisis in the family (B = -0.42; p = 0.01) and perceived poor supervision (B = -0.30; p < 0.001) were negatively associated with PYD. Using serial mediation model, we found following pathway which connected crisis in the family with PYD: crisis in the family → perceived poor parental supervision → joint family activities → PYD. This implies that family interventions and counselling to support parenting skills, especially parental supervision and family activities, to those with the signs of an ongoing family crisis may help to counteract the negative effect of the family crisis on PYD.