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

What consultation resources are available to support delivery of integrated sexual and reproductive health services? A scoping review

Background: Contraceptive and sexual healthcare is increasingly delivered in an integrated setting in the UK and worldwide, requiring staff to be competent in differing styles of delivery, and to have a wide knowledge base. Objectives: We did a scoping review of the literature for evidence of the resources that exist for healthcare professionals to guide or structure the process of conducting an integrated sexual and reproductive health (SRH) consultation. Eligibility criteria: Articles were included in the review if (1) their primary focus was a consultation resource related to one or more aspects of an SRH consultation and (2) they provided details of the resource and/or its application including evaluation of use. Sources of evidence: Peer-reviewed articles published in English, published non-peer-reviewed guides, and web-based guidelines addressing the conduct of a contraception or sexual health consultation were included. Date range: 1998-December 2018. Searches were carried out in the databases AMED (Ovid), ASSIA (ProQuest), CINAHL Complete (EBSCO), Cochrane Library (Wiley), HMIC (NHS Evidence), Medline (EBSCO), PsycINFO (Proquest) and Scopus (Elsevier) on 10 February 2017, and incremental searching performed until December 2018. Results: A total of 12 peer-reviewed journal articles, two web-published guidelines from the Faculty of Sexual & Reproductive Healthcare and three published, non-peer-reviewed resources were included. Conclusion: Many resources exist to guide either the contraceptive or sexual health consultations, but there is a lack of a comprehensive consultation resource to guide the conduct of an integrated consultation

Mixed methods Participatory Action Research to inform service design based on the Capabilities Approach, in the North of England

Proponents of the Capabilities Approach advocate that young people should be able to live lives they have reason to value, supported by public services. Mixed-methods Participatory Action Research involving 47 young people aged 13–16, five practitioners, and one commissioner was carried out to develop a local Capabilities Framework. The framework had five themes: ‘people and relationships’, ‘places, spaces and time for me’, ‘learning and skills’, ‘freedoms, rights and responsibilities’ and ‘health and wellbeing’. Recommendations for service design include cross-sector working to support the promotion of social opportunities and services, and interventions focused on the strengths of each young person

Behaviour change practices in exercise referral schemes: developing realist programme theory of implementation

Abstract: Background: Exercise Referral Schemes have been delivered worldwide in developed countries to augment physical activity levels in sedentary patients with a range of health issues, despite their utility being questioned. Understanding the implementation mechanisms of behaviour change practices is important to avoid inappropriate decommissioning and support future service planning. The aim of this study was to develop initial theories to understand what influences the behaviour change practices of Exercise Referral practitioners within the United Kingdom. Methods: An eight-month focused ethnography was undertaken, to carry out the first phase of a realist evaluation, which included participant observation, interviews, document analysis, and reflexive journaling. A comprehensive implementation framework (Consolidated Framework for Implementation Research) was adopted providing an extensive menu of determinants. Mechanisms were categorised based on the Theoretical Domains Framework (within the Capability, Opportunity, Motivation, Behaviour model) providing an explanatory tool linking the levels of the framework. Results: Three programme theories are proposed. Firstly, motivation and capability are influenced when behaviour change oriented planning and training are in place. Secondly, motivation is influenced if leadership is supportive of behaviour change practice. Lastly, integration between health professionals and practitioners will influence motivation and capability. The conditions necessary to influence motivation and capability include a person-centred climate, cognizant practitioners, and established communities of practice. Conclusions: The findings are the first to articulate the necessary elements for the implementation of behaviour change practices in Exercise Referral services. These results outline emerging theories about the conditions, resources, and explanations of behaviour change implementation that can inform service development

Embedded researchers as part of a whole systems approach to physical activity: reflections and recommendations

Whole systems approaches are increasingly being advocated as a way of responding to complex public health priorities such as obesity and physical inactivity. Due to the complex and adaptive nature of such systems, researchers are increasingly being embedded within host organisations (i.e., those which facilitate the whole systems approach) to work with key stakeholders to illuminate and understand mechanisms of change and develop a culture of continuous improvement. While previous literature has reported on the benefits and challenges of embedded researchers in health care, little is known about the experiences and learnings of those situated within these complex whole systems approaches. In this paper, we present our reflections of being embedded researchers within four distinct whole systems approaches and outline recommendations and considerations for commissioners working with or seeking support from an embedded researcher