"Even the dog has Attention Deficit Hyperactivity Disorder" (ADHD) A cross-cultural comparative study of parents’ and teachers’ knowledge and attitudes towards ADHD in Scotland and Romania

The aim of this research was to investigate the way in which ADHD is understood and constructed within Romania and Scotland, comparing and contrasting the discourses that constitute ADHD within different cultural contexts.Overall, this study employed a mixed method design based on a concurrent nested approach which was undertaken in 2 phases. In phase 1, 50 parents, 72 primary school teachers and 48 support staff from Scotland, and 50 parents, 86 primary school teachers and 57 support staff from Romania, completed a self-report questionnaire that measured their knowledge and attitudes towards ADHD. The statistical results showed that, for the knowledge of ADHD test, both sample of parents, teachers and support staff scored the highest at symptoms/diagnosis subscale. Parents,teachers and support staff from the Romanian sample scored the lowest at the treatment subscale whereas the Scottish respondents had difficulties in answering questions about the nature, causes and prognosis of ADHD. In terms of their self-reported attitudes, both samples of Scottish and Romanian parents, teachers and support staff scored the highest on the affective attitude subscale. Scottish teachers and support staff scored the lowest on the behavioural attitude subscale whereas Romanian teachers and support staff scored the lowest on the cognitive attitude subscale. On the other hand, both samples of Scottish and Romanian parents scored the lowest on the behavioural attitude subscale. These patterns were further explored in phase 2 of the study, where 5 Scottish and Romanian mothers, 3 Scottish and Romanian primary-school teachers and 3 Scottish and Romanian support staff were selected to take part in a semi-structured interview. Parents, teachers and support staff from both countries responded within a medical model of disability employing themes such as ADHD as a medical condition, the medicalisation of behaviour, behaviour as out of control or the specialness of ADHD. However, participants also adopted a social conceptualisation of ADHD, referring to ADHD as a social phenomenon, resisting medicalisation and describing the educational and medical "wrongs". Reflecting the uncertainty in the field, participants’ conceptualisation of ADHD expanded, modified or even shifted from one perspective to another. The cross-cultural comparisons used the Appadurai's theoretical framework of "scapes" to explain the global nature of ADHD as well as the differences between Scottish and Romanian parents, teachers and support staff in relation to the three most important results of this study: treatment of ADHD, inclusion of children diagnosed with ADHD in mainstream education and parents’ and teachers’ willingness to get involved. The findings have been used to develop a multidisciplinary framework for support, empowering teachers and parents with knowledge of ADHD and improving cross-professional relationships. The fundamental idea of this framework is that it moves beyond the deficit paradigm, helping teachers, parents and stakeholders to be alert and responsive to the various conceptualisations of ADHD and to understand how these schemata have come into existence in specific periods of time and in different cultural contexts

A balanced approach to identifying, prioritising and evaluating all potential consequences of quality improvement:modified Delphi study

Objectives Healthcare is a complex system, so quality improvement will commonly lead to unintended consequences which are rarely evaluated. In previous qualitative work, we proposed a framework for considering the range of these potential consequences, in terms of their desirability and the extent to which they were predictable or expected during planning. This paper elaborates on the previous findings, using consensus methods to examine what consequences should be identified, why and how to prioritise, evaluate and interpret all identified consequences, and what stakeholders should be involved throughout this process. Design Two-round modified Delphi consensus study. Setting and participants Both rounds were completed by 60 panellists from an academic, clinical or management background and experience in designing, implementing or evaluating quality improvement programmes. Results Panellists agreed that trade-offs (expected undesirable consequences) and unpleasant surprises (unexpected undesirable consequences) should be actively considered. Measurement of harmful consequences for patients, and those with high workload or financial impact was prioritised, and their evaluation could also involve the use of qualitative methods. Clinical teams were agreed as important to involve at all stages, from identifying potential consequences, prioritising which of those to systematically evaluate, undertaking appropriate evaluation and interpreting the findings. Patients were necessary in identifying consequences, managers in identifying and prioritising, and improvement advisors in interpreting the data. Conclusion There was consensus that a balanced approach to considering all the consequences of improvement can be achieved by carefully considering predictable trade-offs from the outset and deliberately pausing after implementation to identify any unexpected surprises and make an informed decision as to whether quantitative or qualitative evaluation is needed and feasible. Stakeholders' roles in in the process of identifying, prioritising, evaluating and interpreting potential consequences should be explicitly addressed within planning and revisited during and after implementation

Balancing measures or a balanced accounting of improvement impact:a qualitative analysis of individual and focus group interviews with improvement experts in Scotland

Background As quality improvement (QI) programmes have become progressively larger scale, the risks of implementation having unintended consequences are increasingly recognised. More routine use of balancing measures to monitor unintended consequences has been proposed to evaluate overall effectiveness, but in practice published improvement interventions hardly ever report identification or measurement of consequences other than intended goals of improvement. Methods We conducted 15 semistructured interviews and two focus groups with 24 improvement experts to explore the current understanding of balancing measures in QI and inform a more balanced accounting of the overall impact of improvement interventions. Data were analysed iteratively using the framework approach. Results Participants described the consequences of improvement in terms of desirability/undesirability and the extent to which they were expected/unexpected when planning improvement. Four types of consequences were defined: expected desirable consequences (goals); expected undesirable consequences (trade-offs); unexpected undesirable consequences (unpleasant surprises); and unexpected desirable consequences (pleasant surprises). Unexpected consequences were considered important but rarely measured in existing programmes, and an improvement pause to take stock after implementation would allow these to be more actively identified and managed. A balanced accounting of all consequences of improvement interventions can facilitate staff engagement and reduce resistance to change, but has to be offset against the cost of additional data collection. Conclusion Improvement measurement is usually focused on measuring intended goals, with minimal use of balancing measures which when used, typically monitor trade-offs expected before implementation. This paper proposes that improvers and leaders should seek a balanced accounting of all consequences of improvement across the life of an improvement programme, including deliberately pausing after implementation to identify and quantitatively or qualitatively evaluate any pleasant or unpleasant surprises

Perceived impact of formulating, implementing and enacting national mental health policies recommendations in practice:An exploratory qualitative study within child and adolescent mental health services in Scotland

OBJECTIVE: To understand the process of formulating, implementing and enacting national recommendations into practice, by exploring the interactions between government policymakers and national and local organisations supporting and delivering policy implementation within a Child and Adolescent Mental Health Service (CAMHS) context in Scotland. METHODS: Data collection involved 16 semi-structured individual and four focus group interviews with a purposeful sample of policymakers, national health and social care stakeholders and local outpatient and inpatient CAMHS teams representing three NHS health boards in Scotland. RESULTS: Study participants highlighted the challenges of navigating through evolving and often conflicting policy agendas, seen to not acknowledging the current evidence base or experiential learning from services and prior evaluations. Accounts of transformation fatigue often emerged from increased expectations for staff to adopt new approaches to accommodate constantly changing recommendations. Participants also reported a lack of integration and implementation support from national health and social care organisations, leading to duplication of effort and gaps in provision or waste. Policy recommendations were perceived as sometimes vague, lacking clarity about how to deliver service transformation using a whole-system approach. The collective narratives reflected increased tension between the need for local autonomy to innovate and the limitations created vertically by the relative inflexibility of policy recommendations, and horizontally by the proliferation of national organisations delivering the same transformation aims using different approaches in a resource-constrained environment. CONCLUSION: The findings contribute to the wider literature by offering an exploration of importance of evaluation and evidence uptake in policy formulation; the roles and remits in supporting the implementation of policy recommendations; and how the dynamics of central control and local autonomy might impact on the local enactment of policy recommendations

Linking financial development to environmental performance index—the case of Romania

To make steps in society towards a more sustainable future, countries must meet the targets established by the United Nations’ Sustainable Development Goals. Thus, factors that could impact the environmental indicators should be analysed. Therefore, this study aims to identify the correlations between financial development and environmental performance in Romania, during the period 1995–2018. Using composite indexes to assess financial development and the Environmental Performance Index (EPI) to express environmental performance, important results are obtained through the Canonical Cointegrating Regression (CCR) method. The explanatory variables used in the study are specific to the evaluation of the financial development of a country: access, depth and efficiency. The results show that, in the case of financial institutions, the access index and the depth index have a negative influence on the environmental performance index, while in the case of financial markets, the negative impact of the access index of financial markets can be observed. The efficiency index, both in the case of financial institutions and financial markets, generates a positive influence on environmental performance in Romania. Financial markets also address positive influences on the evolution of the environmental performance index