Remote working in public involvement: findings from a mixed methods study.

BACKGROUND: This paper considers remote working in patient public involvement and engagement (PPIE) in health and social care research. With the advent of the Covid-19 pandemic and associated lock-down measures in the UK (from March 2020), PPIE activities switched to using remote methods (e.g., online meetings), to undertake involvement. Our study sought to understand the barriers to and facilitators for remote working in PPIE by exploring public contributors' and PPIE professionals' (people employed by organisations to facilitate and organise PPIE), experiences of working remotely, using online and digital technologies. A particular focus of our project was to consider how the 'digital divide' might negatively impact on diversity and inclusion in PPIE in health and social care research. METHODS: We used a mixed method approach: online surveys with public contributors involved in health and social care research, online surveys with public involvement professionals, and qualitative interviews with public contributors. We co-produced the study with public contributors from its inception, design, subsequent data analysis and writing outputs, to embed public involvement throughout the study. RESULTS: We had 244 respondents to the public contributor survey and 65 for the public involvement professionals (PIPs) survey and conducted 22 qualitative interviews. Our results suggest public contributors adapted well to working remotely and they were very positive about the experience. For many, their PPIE activities increased in amount and variety, and they had learnt new skills. There were both benefits and drawbacks to working remotely. Due to ongoing Covid restrictions during the research project, we were unable to include people who did not have access to digital tools and our findings have to be interpreted in this light. CONCLUSION: Participants generally favoured a mixture of face-to-face and remote working. We suggest the following good practice recommendations for remote working in PPIE: the importance of a good moderator and/or chair to ensure everyone can participate fully; account for individual needs of public contributors when planning meetings; provide a small expenses payment alongside public contributor fees to cover phone/electricity or WiFi charges; and continue the individual support that was often offered to public contributors during the pandemic.

This paper looks at remote working in patient public involvement and engagement (PPIE) in health and social care research. When the Covid-19 pandemic began and the UK went into lock-down in March 2020, PPIE activities began to use remote working methods, such as Zoom or Teams online meetings. We co-developed a study to understand the experiences of both public contributors and PPIE professionals, those who are employed to organise PPIE, of working remotely. We were particularly interested in how remote working might affect diversity and inclusion in PPIE in health and social care research. We ran online surveys for public contributors and public involvement professionals and conducted semi-structured interviews with public contributors. We co-produced the study with public contributors to embed public involvement throughout the study. We had 244 respondents to the public contributor survey, 65 for the public involvement professionals survey and conducted 22 qualitative interviews. Due to ongoing Covid restrictions during the research project we could not include people who did not have access to digital tools, and this is a limitation of our project. We found that public contributors generally liked working remotely and, for many, their PPIE activities increased. There were both benefits and drawbacks to working remotely. From our findings, we have made a number of suggestions for how to run remote meetings in PPIE and what to prioritise based on the areas public contributors thought were important (such as one-to-one support).

Facilitating Perinatal Access to Resources and Support (PeARS): a feasibility study with external pilot of a novel intervention.

BACKGROUND: Up to 50% of women in areas of high socio-economic deprivation are at risk of developing depressive symptoms in pregnancy. Feeling well supported, can facilitate good mental health perinatally. A brief, innovative intervention to facilitate access to support and resources was developed and tested. This included one antenatal and one postnatal session, each with three evidence-based components: i) support from a non-professional peer to enable a woman to identify her needs; ii) information about local community services and signposting; and iii) development of a personalised If-Then plan to access that support. The aims were to evaluate the intervention and research methods for feasibility and acceptability for perinatal women, maternity care providers and peers, and provide preliminary effectiveness indications. METHODS: Pregnant women living in an area of high deprivation were recruited from community-based antenatal clinics and randomised to intervention or control condition (a booklet about local resources). Outcome measures included women's use of community services by 34 + weeks gestation and 6 months postnatally; mental health and wellbeing measures, and plan implementation. Interviews and focus groups were conducted with women participants, providers, and peers. Data were analysed using framework analysis. Recruitment and retention of peers and participants, intervention fidelity, and acceptability of outcome measures were recorded. RESULTS: Peer facilitators could be recruited, trained, retained and provide the intervention with fidelity. One hundred twenty six women were recruited and randomised, 85% lived in the 1% most deprived UK areas. Recruitment constituted 39% of those eligible, improving to 54% after midwifery liaison. Sixty five percent were retained at 6 months postnatally. Women welcomed the intervention, and found it helpful to plan access to community services. Providers strongly supported the intervention philosophy and integrated this easily into services. The study was not powered to detect significant group differences but there were positive trends in community service use, particularly postnatally. No differences were evident in mental health and wellbeing. CONCLUSIONS: This intervention was well received and easily integrated into existing services. Women living in highly deprived areas could be recruited, randomised and retained. Measures were acceptable. Peer facilitators were successfully trained and retained. Full effectiveness studies are warranted.

Social prescribing for people with mental health needs living in disadvantaged communities: the Life Rooms model.

BACKGROUND: People live socially complex lives and have different health care needs influenced by socio-economic factors such as deprivation, unemployment, and poor housing. Lack of access to community based social care results in people seeking social support from health care services. This study explores the Life Rooms as a social prescribing model addressing the social determinants of mental health by providing support and access to resources in a local community setting. With an aim to identify key elements that contribute toward enhancing the effectiveness of the Life Rooms social prescribing approach. METHODS: Data were obtained through six semi-structured focus groups with mental health service users from two locations in the North West of the UK. Postcode data was collected to generate an Index for Multiple Deprivation (IMD) score, to understand their socio-economic background. Data were analysed using thematic analysis. RESULTS: A total of 18 participants took part in the study. The majority of participants came from disadvantaged backgrounds; 14 participants measuring 3 and below in terms of overall IMD scores and 9 participants belonged to the poorest decile (IMD score = 1). Participants reported on different elements of the Life Rooms which they found as an effective approach to care. Four main themes emerged from the data: 1) social belonging: being able to just 'be' 2) resourceful and accessible; 3) social inclusion and connectedness; and 4) moving forward: self-development and independence. CONCLUSION: Findings support the need and benefit social prescribing to improve mental health wellbeing and reduce the burden of mental illness.

Approaches to the prevention of postnatal depression and anxiety - a review of the literature.

Introduction: Poor maternal mental health during the perinatal period has been shown to have potentially long-lasting effects for mother and child. In recognition of this, maternal mental health is receiving increased attention from political and healthcare organizations, with a growing focus on preventing the onset of common mental health disorders. Objective: The objective for this review is to provide an update of randomized controlled trials examining the use of interventions targeted to prevent the onset of postnatal depression and anxiety in nondiagnostic populations with universal or selected samples. Methods: A total of four databases, EBSCO Host, Science Direct, Scopus, and Web of Science, incorporating PsychINFO were searched and papers selected according to clearly specified inclusion criteria. A large Health Technology review was published in 2016, for which the final search was conducted in December 2012. Therefore inclusion criteria were studies published from January 2013 onwards, available in English language, had a focus on prevention of postnatal maternal depression and anxiety, and used psychological interventions. Drug intervention trials were excluded. Findings: 12 studies were identified as examining antenatal or postnatal intervention trials with an aim of preventing maternal postnatal depression and/or anxiety. There continues to be limited evidence to recommend specific prevention strategies for universal samples without further testing. There is evidence to suggest the use of rational-emotive behavioral therapy in an antenatal sample may have some utility, and the use of psychotherapy-based interventions in a postnatal setting is also supported although both require further investigation. Additionally, there is a need to gather information on acceptability, as many trials were hindered by poor adherence to interventions and high attrition that were otherwise unexplained.

A haven of green space: learning from a pilot pre-post evaluation of a school-based social and therapeutic horticulture intervention with children.

BACKGROUND: Research suggests outdoor activity in green spaces is important for children's mental, emotional and social wellbeing. A recognised green space intervention is "Social and Therapeutic Horticulture" (STH). We discuss findings from a pilot STH intervention, "A Haven of Green Space" conducted in North West England. The target group were school children aged 9-15 years experiencing behavioural, emotional and social difficulties. This exploratory study aims to assess the mental wellbeing of the children pre- and post-intervention, and assess the value of the evaluation methods and "Five Ways to Wellbeing" evaluation framework. METHODS: The intervention involved 6 monthly sessions with two horticulturists and a psychotherapist. Sessions were participatory with the development of selected greenspaces at each school directed by the children. Evaluation was situated in the "Five Ways to Wellbeing" framework, using a mixed-methods pre- post-evaluation design. Existing public mental health evaluation methodologies were adapted for use with school children: Mental Well Being Impact Assessment (MWIA) and Wellbeing Check Cards. The MWIA was analysed qualitatively identifying over-arching themes. The quantitative wellbeing check cards were analysed by mean score comparison. RESULTS: Results were collected from 36 children across the three participating schools, and suggest that the Haven Green Space intervention was associated with improved mental wellbeing. MWIA factors relating to mental wellbeing ("emotional wellbeing" and "self-help") were positively impacted in all three schools. However, findings from the wellbeing check cards challenge this, with worsening scores across many domains. CONCLUSIONS: A key study limitation is the pilot nature of the intervention and challenges in adapting evaluation methods to context and age-range. However, results indicate that group based socially interactive horticulture activities facilitated by trained therapists are associated with positive impacts upon the mental and emotional wellbeing of children experiencing behavioural, emotional and social difficulties. Further research is needed to verify this, and to support using the "Five Ways" in intervention development and evaluation. Finally, we recommend continued efforts to develop age-appropriate evaluation methods.

Evaluating feasibility and acceptability of a local psycho-educational intervention for pregnant women with common mental problems affected by armed conflict in Swat, Pakistan: A parallel randomized controlled feasibility trial.

BACKGROUND: The current research was conducted in the Swat valley, where widespread conflict and militancy had been experienced prior to the field activities. The aim of this trial was to evaluate the feasibility and acceptability of a locally developed psycho-educational intervention. METHODS: This mixed-methods study incorporated a quantitative and qualitative component. For the quantitative component, trial participants were identified from a cross-sectional study conducted in the earlier phase of the research, with Self-Reporting Questionnaire (SRQ) score of ≥9. Participants with suicidal ideation, severe mental or medical illness, recently given birth or living with another woman with an SRQ score of 9 or above were excluded. Participants fulfilling eligibility were randomized on a 1:1 allocation ratio using simple randomization to the psycho-educational intervention or routine care arm. The intervention arm received two psycho-educational sessions at their homes delivered by local community health worker from the study area. The primary outcome was help-seeking for psychological distress, measured by a semi-structured interview by a researcher blind to the allocation status at 2 months post-intervention. Secondary outcomes include psychological distress and social support measured by SRQ and Multidimensional Scale of Perceived Social Support (MSPSS), respectively, at 2 months post-intervention. Intervention acceptability was explored through in-depth interviews. RESULTS: Local community health workers with no mental health experience successfully delivered the psycho-educational sessions in the community. The uptake of intervention was good and the intervention was taken well by the families and the community health workers. The outcome evaluation was not powered; however, more women sought assistance for their distress from their community health workers in the intervention arm, compared to women in the control arm. CONCLUSION: This trial showed good acceptance and feasible delivery of a locally developed psycho-educational intervention through community health workers following conflict, giving way for further adaptation and evaluation.

Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study.

BACKGROUND: Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions. METHODS: We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data. RESULTS: Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement. CONCLUSIONS: We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model. TRIAL REGISTRATION: Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.

Psychological distress and its associations with past events in pregnant women affected by armed conflict in Swat, Pakistan: a cross sectional study.

BACKGROUND: The public health significance of maternal mental health is well established. Armed conflicts expose populations to events that could have long-term negative consequences for mental health of pregnant women and their children. This study explores the prevalence and associated risk factors for psychological distress of women during pregnancy, including exposure to past conflict-related potentially traumatic events, in a population exposed to armed conflict in the Swat region of Pakistan. METHODS: A community-based cross-sectional survey of 349 pregnant women in two union councils in Swat was conducted. Psychological distress was measured using the Self-Reporting Questionnaire (SRQ). Conflict-related potentially traumatic events (PTEs) were measured through an adapted version of the Harvard Trauma Questionnaire. Information was also collected on major life events (Life Events Checklist), social support (Multidimensional Scale of Perceived Social Support), and demographic and socio-economic variables. RESULTS: Prevalence of current psychological distress was 38.1 % (95 % CI: 33.1, 43.3). Psychological distress was significantly associated with three or more potentially traumatic events (PTEs) experienced during the conflict (OR = 2.62, 95 % CI: 1.22, 5.61); three or more major life events in the year following the conflict (OR = 3.25, 95 % CI: 1.82, 5.82) and inversely associated with family support (OR = 0.91, 95 % CI: 0.88, 0.95). CONCLUSION: This is one of the first community based cross sectional surveys in Swat valley, Pakistan to assess the prevalence of psychological distress during pregnancy in an area affected by conflict. Over a third of women show evidence of significant psychological distress. Exposure to potentially traumatic events remained independently associated with psychological distress 1 year after conflict ended, suggesting that conflict exposure may have long-term impacts upon maternal mental health. Combining this with findings relating to the cumulative impact of major life-events, and the protective factor of family support highlights the importance of developing culturally appropriate psychological interventions accessible to pregnant women rebuilding their lives following conflict.

Perinatal distress and depression in Malawi: an exploratory qualitative study of stressors, supports and symptoms.

Quantitative studies have demonstrated that depression and anxiety in the perinatal period are common amongst women in low- and middle-income countries and are associated with a range of psychosocial and health-related stressors. In this exploratory qualitative study conducted in southern Malawi, we investigated the thoughts and emotions experienced by women in pregnancy and the postnatal period, their expectations of support from husband and others, problems and difficulties faced and the impact of these on psychological wellbeing. We conducted 11 focus group discussions with a total of 98 parous women. A thematic analysis approach was used. Three major themes were identified: pregnancy as a time of uncertainty, the husband (and others) as support and stressor, and the impact of stressors on mental health. Pregnancy was seen as bringing uncertainty about the survival and wellbeing of both mother and unborn child. Poverty, lack of support, HIV, witchcraft and child illness were identified as causes of worry in the perinatal period. Husbands were expected to provide emotional, financial and practical support, with wider family and friends having a lesser role. Infidelity, abuse and abandonment were seen as key stressors in the perinatal period. Exposure to stressors was understood to lead to altered mental states, the symptoms of which are consistent with the concept of common perinatal mental disorder. This study confirms and expands on evidence from quantitative studies and provides formative data for the development of a psychosocial intervention for common perinatal mental disorder in Malawi.

Exploring health inequalities through the lens of an ethnographic study of healthy eating provision in the early years sector.

The social determinants of health are increasingly receiving international attention since the publication of the World Health Organization's Commission on the Social Determinants of Health in 2008. How different determinants affect health is much debated. Contrasting suggestions include, for example, a major link with socio-economic inequalities, lack of social status and psychosocial stress or the extent of the welfare state. Others emphasise the need to understand the socio-cultural contexts of specific situations. Diet-related health is a good example of the relationship between poor health outcomes and deprivation. The aim of this paper is to explore the specific conditions and contexts that might reduce or exacerbate the provision of a healthy diet to children under 5 years in a range of nurseries supported by the Sure Start Local Programmes initiative in Liverpool. An ethnographic approach was taken to gather data from six nurseries, combining observation at the nurseries with interviews with owners and or managers (10), cooks (6), staff (12) and parents (2). The findings reveal the complex way different issues work together to support or hinder a nursery to develop a healthy eating culture and how relative inequalities, in general, are outworked. While recognising the importance of social status leading to poor health due to psychosocial stress, the findings tend to emphasise the importance of a strong welfare state and taking an early years of life-course approach in reducing health inequalities.

Caught in a dilemma: why do non-smoking women in China support the smoking behaviors of men in their families?

Intimate relationships influence family members' health practices. Although cigarette smoking in China is predominantly a male behavior, (non-smoking) women's roles should be taken into account for the development of home-smoking interventions. Drawing on ethnographic interviews with 22 families in a rural area of China, this article explores non-smoking women's attitudes towards male smoking. The findings suggest that women's ability to influence male behavior is largely determined by culturally defined gender roles, underpinned by ideologies of familism and collectivism. Despite concerns about the adverse results of smoking to their family members and households, non-smoking women ultimately maintain the (male) smokers' argument that smoking plays an important role in construction and maintenance of intra- and extra-family relationships. By accepting male smoking and men's engagement in the social practice of smoking and cigarette exchanges, women maintain their identities as supportive wives, filial daughters/in-law and responsible family members who pursue family collective interests at the expense of their own personal beliefs. Future smoking control initiatives that target non-smoking women to influence male smoking should take into account the women's overarching need to maintain the status and harmony of their families.

The space of access to primary mental health care: a qualitative case study.

Guided by theoretical perspectives of relational social science, this paper draws on reanalyses of multiple qualitative datasets related to a multi-ethnic, economically disadvantaged area in Liverpool, UK, with the aim to advance general understanding of access to primary mental health care while using local Somali minority as an instrumental focus. The findings generate a novel concept: the space of access. The shape and dynamics of the space of access are determined by at least four fields of tensions: understandings of area and community; cognitive mapping of mental well-being, illness and care; positioning of primary care services; and dynamics of resources beyond the 'medical zone' of care. The conclusions indicate a need for de-centring and re-connecting the role of medical professionals within primary care which itself needs to be transformed by endorsement of multiple avenues of access to diverse support and intrepid communication among all involved actors.

Intersectionality and gender mainstreaming in international health: using a feminist participatory action research process to analyse voices and debates from the global south and north.

Critiques of gender mainstreaming (GM) as the officially agreed strategy to promote gender equity in health internationally have reached a critical mass. There has been a notable lack of dialogue between gender advocates in the global north and south, from policy and practice, governments and non-governmental organisations (NGOs). This paper contributes to the debate on the shape of future action for gender equity in health, by uniquely bringing together the voices of disparate actors, first heard in a series of four seminars held during 2008 and 2009, involving almost 200 participants from 15 different country contexts. The series used (Feminist) Participatory Action Research (FPAR) methodology to create a productive dialogue on the developing theory around GM and the at times disconnected empirical experience of policy and practice. We analyse the debates and experiences shared at the seminar series using concrete, context specific examples from research, advocacy, policy and programme development perspectives, as presented by participants from southern and northern settings, including Kenya, Mozambique, India, the Democratic Republic of Congo, Canada and Australia. Focussing on key discussions around sexualities and (dis)ability and their interactions with gender, we explore issues around intersectionality across the five key themes for research and action identified by participants: (1) Addressing the disconnect between gender mainstreaming praxis and contemporary feminist theory; (2) Developing appropriate analysis methodologies; (3) Developing a coherent theory of change; (4) Seeking resolution to the dilemmas and uncertainties around the 'place' of men and boys in GM as a feminist project; and (5) Developing a politics of intersectionality. We conclude that there needs to be a coherent and inclusive strategic direction to improve policy and practice for promoting gender equity in health which requires the full and equal participation of practitioners and policy makers working alongside their academic partners.

Young children's food in Liverpool day-care settings: a qualitative study of pre-school nutrition policy and practice.

OBJECTIVE: To explore nutrition and food provision in pre-school nurseries in order to develop interventions to promote healthy eating in early years settings, especially across deprived communities. DESIGN: An ethnographic approach was used combining participant observation with semi-structured interviews. Research participants were selected purposively using convenience sampling. SETTING: Community pre-school nurseries. SUBJECTS: Nursery managers (n 9), cooks (n 6), staff (n 12), parents (n 12) and children at six nurseries (four private and two attached to children's centres) in Liverpool, UK. RESULTS: Private nurseries had minimal access to information and guidelines. Most nurseries did not have a specific healthy eating policy but used menu planning to maintain a focus on healthy eating. No staff had training in healthy eating for children under the age of 5 years. However, enthusiasm and interest were widespread. The level and depth of communication between the nursery and parents was important. Meal times can be an important means of developing social skills and achieving Early Years Foundation Stage competencies. CONCLUSIONS: Nurseries are genuinely interested in providing appropriate healthy food for under-5s but require support. This includes: improved mechanisms for effective communication between all government levels as well as with nurseries; and funded training for cooks and managers in menu planning, cost-effective food sourcing and food preparation. Interventions to support healthy eating habits in young children developed at the area level need to be counterbalanced by continued appropriate national-level public health initiatives to address socio-economic differences.

Healthy eating in early years settings: a review of current national to local guidance for North West England.

OBJECTIVE: To determine the extent to which national and local UK guidelines for the early years sector address key recommendations for encouraging healthy eating based on best available evidence. DESIGN: Phase 1 comprised a literature review to identify new evidence to assess current relevance of the Caroline Walker Trust (CWT) 'Eating well for under-5 s in child care' guidelines. Phase 2 assessed the completeness of seven local to national-level government guidelines by comparison with the 'gold standard' CWT guidelines. SETTING: Desk-based review using secondary data. SUBJECTS: Research literature and statutory guidelines on healthy eating in early years settings. RESULTS: Phase 1 retrieved seventy-five papers, of which sixty were excluded as they addressed compliance with nutritional and food-based standards only. One report examined a social marketing tool and was deemed too narrow. The remaining fourteen documents assessed interventions to encourage healthy eating in early years settings. Following quality assessment, seven documents were included. Nine key recommendations were identified: (i) role of government; (ii) early years setting policy/guidelines; (iii) training; (iv) menu planning; (v) parents; (vi) atmosphere and encouragement; (vii) learning through food; (viii) sustainability; and (ix) equal opportunities. Phase 2 identified that all seven guidelines included the nine key recommendations but sporadic cover of sub-key recommendations. CONCLUSIONS: More detail is needed on how early years settings can encourage children to eat healthily. Research is required to develop second-layer guidance for interactive materials. Clear processes of communication and support for parents are required. Ways food relates to children's wider learning and social development need further thought, requiring collaboration between the Department of Health and the Department for Education.