Sarah Winstanley

BACKGROUND: Understanding of doctors' attitudes towards disclosing their own mental illness has improved but assumptions are still made. AIMS: To investigate doctors' attitudes to disclosing mental illness and the obstacles and enablers to seeking support. METHODS: An anonymous, UK-wide online survey of doctors with and without a history of mental illness. The main outcome measure was likelihood of workplace disclosure of mental illness. RESULTS: In total, 1954 doctors responded and 60% had experienced mental illness. There was a discrepancy between how doctors think they might behave and how they actually behaved when experiencing mental illness. Younger doctors were least likely to disclose, as were trainees. There were multiple obstacles which varied across age and training grade. CONCLUSIONS: For all doctors, regardless of role, this study found that what they think they would do is different to what they actually do when they become unwell. Trainees, staff and associate speciality doctors and locums appeared most vulnerable, being reluctant to disclose mental ill health. Doctors continued to have concerns about disclosure and a lack of care pathways was evident. Concerns about being labelled, confidentiality and not understanding the support structures available were identified as key obstacles to disclosure. Addressing obstacles and enablers is imperative to shape future interventions.

Purpose - Randomised controlled trials (RCTs) have been offered a privileged position in terms of the evidence base for preventive interventions for children, but practical and theoretical issues challenge this research methodology. This paper aims to address this issue.
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\nDesign/methodology/approach - This paper analyses practical and methodological issues of using RCTs within children's preventive services and presents the results of a qualitative study using data collected from parents who were asked to take part in an RCT of a preventive intervention.
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\nFindings - Well recognised issues include the impossibility of blinding participants, the problem of identifying a pre-eminent outcome measure for complex interventions, and problems with limiting access to equivalent interventions in real world settings. A further theoretical problem is the exclusion from RCTs of families who are most ready to change, resulting in a reduced level of intervention effectiveness. Qualitative evidence from one recent RCT suggests that this problem could be operating in some prevention trials. Increasing sample sizes can overcome some of these problems, but the cost of the necessarily huge trials becomes disproportionate to the intervention?
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\nOriginality/value - Given the limitations on RCTs in preventive settings, the paper argues their privileged position in terms of research evidence maybe undeserved.

OBJECTIVE: To evaluate the effectiveness and cost utility of a universally provided early years parenting programme. DESIGN: Multicentre randomised controlled trial with cost-effectiveness analysis. SETTING: Early years centres in four deprived areas of South Wales. PARTICIPANTS: Families with children aged between 2 and 4 years. 286 families were recruited and randomly allocated to the intervention or waiting list control. INTERVENTION: The Family Links Nurturing Programme (FLNP), a 10-week course with weekly 2 h facilitated group sessions. MAIN OUTCOME MEASURES: Negative and supportive parenting, child and parental well-being and costs assessed before the intervention, following the course (3 months) and at 9 months using standardised measures. RESULTS: There were no significant differences in primary or secondary outcomes between trial arms at 3 or 9 months. With '+' indicating improvement, difference in change in negative parenting score at 9 months was +0.90 (95%CI -1.90 to 3.69); in supportive parenting, +0.17 (95%CI -0.61 to 0.94); and 12 of the 17 secondary outcomes showed a non-significant positive effect in the FLNP arm. Based on changes in parental well-being (SF-12), the cost per quality-adjusted life year (QALY) gained was estimated to be £34 913 (range 21 485-46 578) over 5 years and £18 954 (range 11 664-25 287) over 10 years. Probability of cost per QALY gained below £30 000 was 47% at 5 years and 57% at 10 years. Attendance was low: 34% of intervention families attended no sessions (n=48); only 47% completed the course (n=68). Also, 19% of control families attended a parenting programme before 9-month follow-up. CONCLUSIONS: Our trial has not found evidence of clinical or cost utility for the FLNP in a universal setting. However, low levels of exposure and contamination mean that uncertainty remains. TRIAL REGISTRATION: The trial is registered with Current Controlled Trials ISRCTN13919732.

BACKGROUND: Sub-optimal parenting is a common risk factor for a wide range of negative health, social and educational outcomes. Most parenting programmes have been developed in the USA in the context of delinquency prevention for targeted or indicated groups and the main theoretical underpinning for these programmes is behaviour management. The Family Links Nurturing Programme (FLNP) focuses on family relationships as well as behaviour management and is offered on a universal basis. As a result it may be better placed to improve health and educational outcomes. Developed in the UK voluntary sector, FLNP is popular with practitioners, has impressed policy makers throughout the UK, has been found to be effective in before/after and qualitative studies, but lacks a randomised controlled trial (RCT) evidence base. METHODS/DESIGN: A multi-centre, investigator blind, randomised controlled trial of the FLNP with a target sample of 288 south Wales families who have a child aged 2-4 yrs living in or near to Flying Start/Sure Start areas. Changes in parenting, parent child relations and parent and child wellbeing are assessed with validated measures immediately and at 6 months post intervention. Economic components include cost consequences and cost utility analyses based on parental ranking of states of quality of life. Attendance and completion rates and fidelity to the FLNP course delivery are assessed. A nested qualitative study will assess reasons for participation and non-participation and the perceived value of the programme to families. By the end of May 2010, 287 families have been recruited into the trial across four areas of south Wales. Recruitment has not met the planned timescales with barriers including professional anxiety about families entering the control arm of the trial, family concern about video and audio recording, programme facilitator concern about the recording of FLNP sessions for fidelity purposes and delays due to the new UK research governance procedures. DISCUSSION: Whilst there are strong theoretical arguments to support universal provision of parenting programmes, few universal programmes have been subjected to randomised controlled trials. In this paper we describe a RCT protocol with quantitative and qualitative outcome measures and an economic evaluation designed to provide clear evidence with regard to effectiveness and costs. We describe challenges implementing the protocol and how we are addressing these. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13919732.

Reflecting on our work with girls, we discuss what we have learned about how they experience rape culture and engage in activism to confront it. We explore how rape culture manifests in the lives of adolescent girls who are between 10 and 15 years of age in Calgary, Canada. We then demonstrate how groups of girls have moved from awareness to collective action meant to challenge rape culture and consider the impact that this action has had on them. Our aim is to show how popular education and feminist methodologies are effective in supporting girls’ activism on issues like rape culture so that others working in community with girls may gain new tools that might aid their work.