Providing sex and relationships education for looked-after children: a qualitative exploration of how personal and institutional factors promote or limit the experience of role ambiguity, conflict and overload among caregivers

Objectives: To explore how personal and institutional factors promote or limit caregivers promoting sexual health and relationships (SHR) among looked-after children (LAC). In so doing, develop existing research dominated by atheoretical accounts of the facilitators and barriers of SHR promotion in care settings. Design: Qualitative semistructured interview study. Setting: UK social services, residential children’s homes and foster care. Participants: 22 caregivers of LAC, including 9 foster carers, 8 residential carers and 5 social workers; half of whom had received SHR training. Methods: In-depth interviews explored barriers/facilitators to SHR discussions, and how these shaped caregivers’ experiences of discussing SHR with LAC. Data were systematically analysed using predetermined research questions and themes identified from reading transcripts. Role theory was used to explore caregivers’ understanding of their role. Results: SHR policies clarified role expectations and increased acceptability of discussing SHR. Training increased knowledge and confidence, and supported caregivers to reflect on how personally held values impacted practice. Identified training gaps were how to: (1) Discuss SHR with LAC demonstrating problematic sexual behaviours. (2) Record the SHR discussions that had occurred in LAC’s health plans. Contrary to previous findings, caregivers regularly discussed SHR with LAC. Competing demands on time resulted in prioritisation of discussions for sexually active LAC and those ‘at risk’ of sexual exploitation/harm. Interagency working addressed gaps in SHR provision. SHR discussions placed emotional burdens on caregivers. Caregivers worried about allegations being made against them by LAC. Managerial/ pastoral support and ‘safe care’ procedures minimised these harms. Conclusions: While acknowledging the existing level of SHR promotion for LAC there is scope to more firmly embed this into the role of caregivers. Care needs to be taken to avoid role ambiguity and tension when doing so. Providing SHR policies and training, promoting interagency working and providing pastoral support are important steps towards achieving this

Poly-substance use and sexual risk behaviours: a cross-sectional comparison of adolescents in mainstream and alternative education settings

Background: Surveys of young people under-represent those in alternative education settings (AES), potentially disguising health inequalities. We present the first quantitative UK evidence of health inequalities between AES and mainstream education school (MES) pupils, assessing whether observed inequalities are attributable to socioeconomic, familial, educational and peer factors. Methods: Cross-sectional, self-reported data on individual- and poly-substance use (PSU: combined tobacco, alcohol and cannabis use) and sexual risk-taking from 219 pupils in AES (mean age 15.9 years) were compared with data from 4024 pupils in MES (mean age 15.5 years). Data were collected from 2008 to 2009 as part of the quasi-experimental evaluation of Healthy Respect 2 (HR2). Results: AES pupils reported higher levels of substance use, including tobacco use, weekly drunkenness, using cannabis at least once a week and engaging in PSU at least once a week. AES pupils also reported higher levels of sexual health risk behaviours than their MES counterparts, including: earlier sexual activity; less protection against sexually transmitted infections (STIs); and having 3+ lifetime sexual partners. In multivariate analyses, inequalities in sexual risk-taking were fully explained after adjusting for higher deprivation, lower parental monitoring, lower parent-child connectedness, school disengagement and heightened intentions towards early parenthood among AES vs MES pupils. However, an increased risk (OR = 1.73, 95% CI 1.15, 2.60) of weekly PSU was found for AES vs MES pupils after adjusting for these factors and the influence of peer behaviours. Conclusion: AES pupils are more likely to engage in health risk behaviours, including PSU and sexual risk-taking, compared with MES pupils. AES pupils are a vulnerable group who may not be easily targeted by conventional population-level public health programmes. Health promotion interventions need to be tailored and contextualised for AES pupils, in particular for sexual health and PSU. These could be included within interventions designed to promote broader outcomes such as mental wellbeing, educational engagement, raise future aspirations and promote resilience

The bi-factor structure of the 17-item Hamilton Depression Rating Scale in persistent major depression; dimensional measurement of outcome

Background:The 17-item Hamilton Depression Rating Scale (HDRS17) is used world-wide as an observer-rated measure of depression in randomised controlled trials (RCTs) despite continued uncertainty regarding its factor structure. This study investigated the dimensionality of HDRS17 for patients undergoing treatment in UK mental health settings with moderate to severe persistent major depressive disorder (PMDD).Methods:Exploratory Structural Equational Modelling (ESEM) was performed to examine the HDRS17 factor structure for adult PMDD patients with HDRS17 score ≥16. Participants (n = 187) were drawn from a multicentre RCT conducted in UK community mental health settings evaluating the outcomes of a depression service comprising CBT and psychopharmacology within a collaborative care model, against treatment as usual (TAU). The construct stability across a 12-month follow-up was examined through a measurement equivalence/invariance (ME/I) procedure via ESEM.Results:ESEM showed HDRS17 had a bi-factor structure for PMDD patients (baseline mean (sd) HDRS17 22.6 (5.2); 87% PMDD >1 year) with an overall depression factor and two group factors: vegetative-worry and retardation-agitation, further complicated by negative item loading. This bi-factor structure was stable over 12 months follow up. Analysis of the HDRS6 showed it had a unidimensional structure, with positive item loading also stable over 12 months.Conclusions:In this cohort of moderate-severe PMDD the HDRS17 had a bi-factor structure stable across 12 months with negative item loading on domain specific factors, indicating that it may be more appropriate to multidimensional assessment of settled clinical states, with shorter unidimensional subscales such as the HDRS6 used as measures of change

Communicating about sexual health and relationships within local authority care placements

Background: Evidence from population-level studies demonstrates that adolescent sexual health outcomes are associated with social exclusion, and that certain groups, including young people looked after by local authorities often experience poorer sexual health outcomes. The poorer sexual health outcomes observed for looked after young people has led to the Scottish Government recommending that looked after young people be prioritised for the delivery of sexual health and relationships education, and that residential carers, foster carers and social workers should play a key role in the delivery of sexual health and relationships information to looked after young people. This recommendation builds on existing policy initiatives that have emphasised that parents should be routinely talking to their children about sexual health and relationships. Despite a growing research interest in the health of looked after young people, there is currently little known about how sexual health and relationships discussions are undertaken within the care setting. This is because much of the research that has been published to date has focussed upon identifying barriers to communication rather than establishing how communications are shaped by the characteristics of carers, looked after children and the wider context of the care system. In this thesis I hope to address this research gap by exploring what factors shape communications about sexual health and relationships within the care setting, and examining the extent to which connectedness, monitoring and supervision — parenting factors identified as promoting positive sexual health outcomes for adolescents within the wider literature — mediate these discussions. Methods: 54 in-depth qualitative interviews were conducted with looked after young people (aged 14-18), care leavers (aged 16-23), residential workers, foster carers and social workers in one local authority in Scotland between August and December 2011. Data were analysed thematically, with data collected from corporate parents and looked after young people used to compare and contrast experiences of talking about sexual health within the care setting. Findings: The results presented in this study demonstrate that there has been a perceived shift in attitudes towards talking to looked after young people about their sexual health, and that residential carers, foster carers and social workers believe that talking to young people about sexual health and relationships should be a core responsibility of the corporate parent. Despite this, the results of this study demonstrate that talking to young people about sexual health and relationship is a subject that is fraught with tensions, with many of the corporate parents interviewed expressing difficulties reconciling their own views about the appropriateness of talking to young people about sexual behaviours with their professional responsibility to inform and protect looked after young people from risk. Looking specifically at how communications about sexual health and relationships were undertaken within the care setting, the results of this study show that talking to young people in care about sexual health and relationships is mediated by the impact or pre-care and care histories, in particular maltreatment and poor attachment security, upon young people’s understandings of relationships and their ability to trust other people and seek out help and support. Whilst corporate parents emphasised the need for training to help them identify strategies for talking to young people about sexual health and relationships, the results of this study show that corporate parents are already undertaking sexual health and relationships work that is tailored to the age and stage of the child, and is balanced by the provision of monitoring and supervision to minimise risk. Conclusions: The results of this thesis show that discussions about sexual health and relationships need to be underpinned by a trusting relationship between corporate parents and looked after children. As such, an emphasis needs to be placed upon improving young people’s ability to trust other people. Improving permanency for young people in the care system, in conjunction with the development of attachment based sexual health practices, may result in the promotion of positive outcomes for looked after young people. Future policies and training relating to the provision of sexual health and relationships education within the care system should reflect this fact

How is the provision of residential care to children under the age of 12 associated with changes in children's behaviour and mental wellbeing?

Around 10% of children looked after in residential care in Scotland are aged 5-11. While there is a large body of evidence about the experiences of older children in residential care, little is known about the experiences of younger children in these settings. In this study we used routinely collected administrative data held by the Scottish Children’s Reporter Administration to: 1) identify common features in the familial, child protection and care histories of children under the age of 12 in residential care; 2) explore how being cared for in residential care prior to age 12 is associated with children's health and socioemotional wellbeing. Case file data from 135 children subject to compulsory measures of supervisions were examined. Our analysis indicated that younger children in residential care often have complex trauma histories, long histories of service involvement, and have often experienced repeat placement breakdowns that are attributed to the socioemotional and behavioural difficulties the children exhibit in placement. Being cared for in residential care provided a period of stability for younger children, with improvements seen in their socioemotional wellbeing and mental health in the 24 months following entry into residential care. Future research should focus on understanding the mechanisms underlying these changes

Recruiting hard-to-reach pregnant women at high psychosocial risk:strategies and costs from a randomised controlled trial

Abstract Background Recruiting participants to randomised controlled trials (RCTs) is often challenging, particularly when working with socially disadvantaged populations who are often termed ‘hard-to-reach’ in research. Here we report the recruitment strategies and costs for the Trial for Healthy Relationship Initiatives in the Very Early years (THRIVE), an RCT evaluating two group-based parenting interventions for pregnant women. Methods THRIVE aimed to recruit 500 pregnant women with additional health and social care needs in Scotland between 2014 and 2018. Three recruitment strategies were employed: (1) referrals from a health or social care practitioner or voluntary/community organisation (practitioner-led referral), (2) direct engagement with potential participants by research staff (researcher-led recruitment) and (3) self-referral in response to study advertising (self-referral). The number of referrals and recruited participants from each strategy is reported along with the overall cost of recruitment. The impact of recruitment activities and the changes in maternity policy/context on recruitment throughout the study are examined. Results THRIVE received 973 referrals: 684 (70%) from practitioners (mainly specialist and general midwives), 273 (28%) from research nurses and 16 (2%) self-referrals. The time spent in antenatal clinics by research nurses each month was positively correlated with the number of referrals received (r = 0.57; p < 0.001). Changes in maternity policies and contexts were reflected in the number of referrals received each month, with both positive and negative impacts throughout the trial. Overall, 50% of referred women were recruited to the trial. Women referred via self-referral, THRIVE research nurses and specialist midwives were most likely to go on to be recruited (81%, 58% and 57%, respectively). Key contributors to recruitment included engaging key groups of referrers, establishing a large flexible workforce to enable recruitment activities to adapt to changes in context throughout the study and identifying the most appropriate setting to engage with potential participants. The overall cost of recruitment was £377 per randomised participant. Conclusions Recruitment resulted from a combination of all three strategies. Our reflections on the successes and challenges of these strategies highlight the need for recruitment strategies to be flexible to adapt to complex interventions and real-world challenges. These findings will inform future research in similar hard-to-reach populations. Trial registration International Standard Randomised Controlled Trials Number Registry ISRCTN21656568 . Retrospectively registered on 28 February 201

Accounting for 'disclosure': Lesbian parents' identity management in home and school contexts.

This qualitative research explores working-class (educated) lesbian parents' identity management strategies within home and school contexts. Following an evaluation of epistemological debates and social science approaches to theorizing 'self, I highlight the utility of a feminist social constructionist approach to research, and the centrality of language and discourse in the constitution of lesbian parents' subjectivities. This work is informed by poststructuralist, feminist and psychological theories of identity and subjectivity and I take a 'relational approach' to explore ways in which historically and culturally specific ideologies and discourses of sexuality, family and parenting shape lesbian parents' discursive practices and subjectivities. Seven working-class (educated) lesbian parents from the north-east of England took part in interviews about their lesbian parent families and their interactions with their children, friends, family and school staff to explore how lesbian parents talk about their lesbian parent identity and disclosure/concealment of their sexuality. Specifically, a discursive analytic approach was utilized to explore lesbian parents' accounts for disclosure/concealment of their sexual identity and of their lesbian parenting/families, within home-school contexts. From this investigation I identified a key interpretative repertoire: 'sexuality as a form of knowledge' that the women used to construct homosexuality as normal, dangerous, private and progressive. A key finding from this investigation is the discursive strategy of 'positioning others' within constructions of sexuality. Interactive positioning functioned to rationalize accounts for disclosure or concealment of the women's sexuality at different discursive moments and contexts. I problematize existing essentialist models of 'coming out' and highlight how disclosure/concealment of sexual identity can be theorized as an 'accountable' activity which acknowledges the synthesis of culture and subjectivity at the point of discourse. This work also acknowledges ways in which class subjectivity can shape lesbian parents' discursive practices in their negotiation of 'difference'

Has untargeted sexual health promotion for young people reached its limit? a quasi-experimental study

Background Theoretically, there may be benefit in augmenting school-based sexual health education with sexual health services, but the outcomes are poorly understood. Healthy Respect 2 (HR2) combined sex education with youth-friendly sexual health services, media campaigns and branding, and encouraged joint working between health services, local government and the voluntary sector.This study examined whether HR2: (1) improved young people’s sexual health knowledge, attitudes, behaviour and use of sexual health services and (2) reduced socioeconomic inequalities in sexual health.Methods A quasi-experiment in which the intervention and comparison areas were matched for teenage pregnancy and terminations, and schools were matched by social deprivation. 5283 pupils aged 15–16 years (2269 intervention, 3014 comparison) were recruited to cross-sectional surveys in 2007, 2008 and 2009.Results The intervention improved males’ and, to a lesser extent, females’ sexual health knowledge. Males’ intention to use condoms, and reported use of condoms, was unaffected, compared with a reduction in both among males in the comparison arm. Although females exposed to the intervention became less accepting of condoms, there was no change in their intention to use condoms and reported condom use.Pupils became more tolerant of sexual coercion in both the intervention and comparison arms. Attitudes towards same-sex relationships remained largely unaffected. More pupils in the HR2 area used sexual health services, including those from lower socioeconomic backgrounds. This aside, sexual health inequalities remained.Conclusions Combining school-based sex education and sexual health clinics has a limited impact. Interventions that address the upstream causes of poor sexual health, such as a detrimental sociocultural environment, represent promising alternatives. These should prioritise the most vulnerable young people

CODIFI (Concordance in Diabetic Foot Ulcer Infection) : a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England

OBJECTIVE: To determine the extent of agreement and patterns of disagreement between wound swab and tissue samples in patients with an infected diabetic foot ulcer (DFU). DESIGN: Multicentre, prospective, cross-sectional study. SETTING: Primary and secondary care foot ulcer/diabetic outpatient clinics and hospital wards across England. PARTICIPANTS: Inclusion criteria: consenting patients aged ≥18 years; diabetes mellitus; suspected infected DFU. EXCLUSION CRITERIA: clinically inappropriate to take either sample. INTERVENTIONS: Wound swab obtained using Levine's technique; tissue samples collected using a sterile dermal curette or scalpel. OUTCOME MEASURES: Coprimary: reported presence, and number, of pathogens per sample; prevalence of resistance to antimicrobials among likely pathogens. Secondary: recommended change in antibiotic therapy based on blinded clinical review; adverse events; sampling costs. RESULTS: 400 consenting patients (79% male) from 25 centres.Most prevalent reported pathogens were Staphylococcus aureus (43.8%), Streptococcus (16.7%) and other aerobic Gram-positive cocci (70.6%). At least one potential pathogen was reported from 70.1% of wound swab and 86.1% of tissue samples. Pathogen results differed between sampling methods in 58% of patients, with more pathogens and fewer contaminants reported from tissue specimens.The majority of pathogens were reported significantly more frequently in tissue than wound swab samples (P<0.01), with equal disagreement for S. aureus and Pseudomonas aeruginosa. Blinded clinicians more often recommended a change in antibiotic regimen based on tissue compared with wound swab results (increase of 8.9%, 95% CI 2.65% to 15.3%). Ulcer pain and bleeding occurred more often after tissue collection versus wound swabs (pain: 9.3%, 1.3%; bleeding: 6.8%, 1.5%, respectively). CONCLUSION: Reports of tissue samples more frequently identified pathogens, and less frequently identified non-pathogens compared with wound swab samples. Blinded clinicians more often recommended changes in antibiotic therapy based on tissue compared with wound swab specimens. Further research is needed to determine the effect of the additional information provided by tissue samples. TRIAL REGISTRATION NUMBER: ISRCTN52608451

Exploring pathways to mental healthcare for urban Aboriginal young people: a qualitative interview study

Objectives To explore the perceptions of Aboriginal Community Controlled Health Service (ACCHS) staff involved in providing mental healthcare to Aboriginal young people of the current and ideal pathways to mental healthcare for urban Aboriginal young people attending ACCHSs, and to identify what additional supports staff may need to provide optimal mental healthcare to Aboriginal young people.The Study of Environment on Aboriginal Resilience and Child Health (SEARCH) is funded through the Australian National Health and Medical Research Council (grant numbers APP358457, APP1035378, APP1023998), and an Australian Primary Health Care Research Institute Centre for Research Excellence Grant