Clarity, conviction and coherence supports buy-in to positive youth sexual health services: focused results from a realist evaluation

Background: There is a call for sexual health services to support young people achieve sexual wellbeing in addition to treating or preventing sexual ill-health. Progress towards realising this ambition is limited. This study aimed to contribute theory and evidence explaining key processes to support local delivery of positive youth sexual health services. Methods: A realist evaluation was conducted, comprising four research cycles, with a total of 161 data sources, primarily from the UK. Theory was refined iteratively using existing substantive theories, secondary and primary research data (including interviews, documentary analysis, feedback workshops and a literature search of secondary case studies). A novel explanatory framework for articulating the theories was utilised. Results: The results focused on local level buy-in to positive services. Positive services were initiated when influential teams had clarity that positive services should acknowledge youth sexuality, support young people's holistic sexual wellbeing and involve users in design and delivery of services, and conviction that this was the best or right way to proceed. How positive services were operationalised differed according to whether the emphasis was placed on meeting service objectives or supporting young people to flourish. Teams were able to effect change in local services by improving coherence between a positive approach and existing processes and practices. For example, that a) users were involved in decision making, b) multi-disciplinary professional working was genuinely integrated, and c) evidence of positive services' impact was gathered from a breadth of sources. New services were fragile. Progress was frequently stymied due to a lack of shared understanding and limited compatibility between characteristics of a positive approach and the wider cultural and structural systems including medical hegemony and narrow accountability frameworks. These challenges were exacerbated by funding cuts. Conclusions: This study offers clarity on how positive youth sexual health services may be defined. It also articulates theory explaining how dissonance, at various levels, between positive models of sexual health service delivery and established cultural and structural systems may restrict their successful inception. Future policy and practice initiatives should be theoretically informed and address barriers at societal, organisational and interpersonal levels to stimulate change

Provision of positive sexual health services for young people: a realist evaluation

Background English and international policy calls for positive, comprehensive youth sexual health services (PCYSHS) that support young people to achieve sexual wellbeing. In practice, youth sexual health services are often oriented solely towards reducing unwanted conceptions and preventing sexually transmitted infections. This study aimed to develop theory and recommendations for practitioners to support delivery of PCYSHS. Methods A realist evaluation was undertaken to uncover what works, for whom, and under what conditions, to deliver PCYSHS. We developed concepts and initial theories, in which we combined existing substantive theory with a logic model based on stakeholder's tacit knowledge, observational visits, and data that were relevant to underlying causal processes, extracted from academic and policy literature (27 sources). Academic sources were identified via a systematic search of four electronic databases. Search terms were “sexual health”, combined with “sex positive”, “young people”, “service”, and synonyms (“reproductive health”, “sexual subjectivity”, “sexual rights”, “holistic”, “integrated”, “reproductive rights”, “preventative”, “comprehensive”, “young”, “youth” “teen*”, “adolescen*”, “intervention*”, “framework*”, “paradigm*”, “programme*”, “model*”, “trial*”, “pilot*”) with no date restrictions. We selected papers relating to whole system transformation to PCYSHS in developed countries, written in English. Papers that considered only education settings, one-off interventions, or information resources were excluded. Papers were appraised by rigour and relevance in accordance with realist methodology guidelines. Evidence was then gathered from case studies of three services in England that had attempted implementation of PCYSHS. Data were derived via stakeholder interviews (n=24), social and print media (15), service specifications (5), and evaluation and consultation documentation (5). Analysis of these data (Nvivo, version 10) was directed at substantiating, refining, or refuting the initial theories. Ethics approval was given by Sheffield Hallam University Research Ethics Committee. Findings 76 sources contributed to the development and testing of programme theories. The theories articulated how local buy-in to PCYSHS could be led by the following factors: clarity of both the concept and individual role; conviction in the approach to bring about positive change for young people; and coherence with local and national priorities. The theories suggested the mechanisms by which these factors work and showed the ways in which outcomes are contextually dependent. Interpretation This study explains some of the challenges of translating the policy ambition of PCYSHS into practice. The realist inquiry found theoretical mechanisms that might affect delivery of PCYSHS and the contextual conditions that could hinder or enable them. These theories can help inform the development and evaluation of PCYSHS initiatives

The influence of dysphoria and depression on mental state decoding

Prior research found conflicting results concerning the relationship between depression and mental state decoding ability as assessed by the ‘Eyes Test’ developed by Baron-Cohen and colleagues. In some studies the relationship is negative, suggesting that depressed persons are worse than controls in decoding mental states on the basis of information from the eye region of others' faces. Other research points to a positive relation between depression and mental state decoding. We report a study of mental state decoding ability in two samples of university students, one a group of students attending the university's counseling service, the other a group of normal college students. The results are consistent in showing a negative relation between depression and mental state decoding ability. Possible reasons for discrepancies in research results are discussed

Depression in Visual Impairment Trial (DEPVIT): A Randomized Clinical Trial of Depression Treatments in People With Low Vision

Purpose: The purpose of this study was to compare two interventions for depression, problem solving treatment (PST) and referral to the patient\u27s physician, with a waiting-list control group in people with sight loss and depressive symptoms. Methods: This was an assessor-masked, exploratory, multicenter, randomized clinical trial, with concurrent economic analysis. Of 1008 consecutive attendees at 14 low-vision rehabilitation centers in Britain, 43% (n = 430) screened positive for depressive symptoms on the Geriatric Depression Scale and 85 of these attendees participated in the trial. Eligible participants were randomized in the ratio 1:1:1 to PST, referral to their physician, or a waiting-list control arm. PST is a manualized talking intervention delivered by a trained therapist who teaches people over six to eight sessions to implement a seven-step method for solving their problems. Referral to the physician involved sending a referral letter to the person\u27s physician, encouraging him or her to consider treatment according to the stepped care protocol recommended by the U.K.\u27s National Institute of Health and Care Excellence. The primary outcome was change in depressive symptoms (6 months after baseline) as determined by the Beck Depression Inventory. Results: At 6 months, Beck Depression Inventory scores reduced by 1.05 (SD 8.85), 2.11 (SD 7.60), and 2.68 (SD 7.93) in the waiting-list control, referral, and PST arms, respectively. The cost per patient of the PST intervention was £1176 in Wales and £1296 in London. Conclusions: Depressive symptoms improved most in the PST group and least in the control group. However, the change was small and the uncertainty of the measurements relatively large

The depression in visual impairment trial (DEPVIT): trial design and protocol

<b>Background</b> The prevalence of depression in people with a visual disability is high but screening for depression and referral for treatment is not yet an integral part of visual rehabilitation service provision. One reason for this may be that there is no good evidence about the effectiveness of treatments in this patient group. This study is the first to evaluate the effect of depression treatments on people with a visual impairment and co morbid depression.<p></p> <b>Methods/design</b> The study is an exploratory, multicentre, individually randomised waiting list controlled trial. Participants will be randomised to receive Problem Solving Therapy (PST), a ‘referral to the GP’ requesting treatment according to the NICE’s ‘stepped care’ recommendations or the waiting list arm of the trial. The primary outcome measure is change (from randomisation) in depressive symptoms as measured by the Beck’s Depression Inventory (BDI-II) at 6 months. Secondary outcomes include change in depressive symptoms at 3 months, change in visual function as measured with the near vision subscale of the VFQ-48 and 7 item NEI-VFQ at 3 and 6 months, change in generic health related quality of life (EQ5D), the costs associated with PST, estimates of incremental cost effectiveness, and recruitment rate estimation.<p></p> <b>Discussion</b> Depression is prevalent in people with disabling visual impairment. This exploratory study will establish depression screening and referral for treatment in visual rehabilitation clinics in the UK. It will be the first to explore the efficacy of PST and the effectiveness of NICE’s ‘stepped care’ approach to the treatment of depression in people with a visual impairment.<p></p&gt

The organisation and outcomes of supported employment in Britain

The study involved a questionnaire survey of all Supported Employment Agencies in Great Britain. The Agencies who responded (numbering 101 or 48%) supported in jobs, 90.3% those supported worked for under 16 hours per week and 30% small amount up to limits allowing them to retain their welfare benefit income. Of supported workers, 78% employment. Job Coach support was found to fall over time to a mean of one hour per week by the eighth month of work while mean hours worked remained stable in the first year at around 16 hours per week. A cost : benefit analysis showed workers gained {\pounds}2.47 for every {\pounds}1 they lost in taking up employment, and taxpayers received 43p back in savings for each {\pounds}1 invested

The cost-effectiveness of supported employment for people with severe intellectual disabilities and high support needs: a pilot study

The costs and outcomes of supporting seven people with severe intellectual disabilities and high support needs in part-time employment were compared with those of a Special Needs Unit (SNU) of a day centre, both within-subject and against an equal-sized comparison group. The income of those employed was described. Direct observation of the employment activities and representative SNU activities were undertaken to assess participant engagement in activity and receipt of assistance, social contact in general and social contact from people other than paid staff. Costs of providing service support were calculated taking account of staff : service user ratios, staff identities and wage rates and service-administrative and management overheads. Employment was associated with greater receipt of assistance, higher task-related engagement in activity and more social contact from people other than paid staff. SNU activities were associated with greater receipt of social contact. Supporting people in employment was more expensive than in the SNU. Cost-effectiveness ratios of producing assistance and engagement in activities were equivalent across the comparative contexts. The SNU was more cost-effective in producing social involvement; employment in producing social contact from people other than paid staff