Adult Stakeholders Research Articles

Using systems thinking to leverage adolescent sexual and reproductive health in rural Latino communities

Disparities in adolescent sexual and reproductive health (SRH) outcomes in rural areas of the USA persist as a concern in achieving health equity for youth. A growing body of literature recognises that improving adolescents’ health necessitates systems thinking to address the culture and environment in which adolescents live. This paper uses systems thinking to identify leverage points to improve adolescent SRH in rural Latino communities in California. We conducted focus group discussions with 22 young people and interviewed 10 adult stakeholders to centre the perspectives of youth and youth-serving professionals. Transcripts were coded and analysed using systems thinking. Five themes were developed: (1) community and cultural norms can be a source of both support and stigma for youth; (2) families are key to supporting health education and services; (3) rural schools provide a central hub for programme delivery; (4) community-based organisations can work to serve rural youth, but limited resources and transport are challenges; and (5) youth face considerable barriers accessing SRH services in their communities. Using systems thinking to identify leverage points and gaps in interactions between system components influencing youth can aid in the development of more holistic and culturally responsive approaches for rural youth SRH.

Exploring UK adult and policy stakeholder perspectives on obesity prevention policy and inequalities

Abstract In England, 14 obesity strategies have been published, including 689 proposed policies, while rates of obesity persist, and inequalities worsen. This study explores adults’ attitudes in relation to food-related obesity policy and how socioeconomic inequalities in obesity are considered throughout the policy process through the perspective of policy stakeholders (PSH). 31 semi-structured interviews with UK-based adults (GPP) (18+) and 14 interviews with PSH categorised as government officials, academics, and advocacy group representatives were conducted and analysed using Braun and Clarke’s thematic analysis. Both PSH and GPP attributed obesity causation primarily to the food environment rather than to individual behaviour. The PSH identified the food industry’s role in shaping the environment. Level of deprivation was believed to exacerbate the barriers to healthy weight in both samples. All participants agreed that, in the UK, there was an unequal opportunity to attain a healthy diet. A disconnect was found between the GPP perspectives towards the barriers to healthy weight and their attitudes towards policy action. The GPP described mistrust in the government’s motives and willingness, fuelling the perspective that policy lacked impact and was disconnected from their lived experiences, particularly among participants of lower socioeconomic status and higher weight classifications. The PSH raised concerns regarding barriers to policy implementation, including inconsistent government commitment, competing priorities, and resistance to state intervention. PSH suggested that it was unfeasible to prioritise inequalities while population rates remain high, and the failure of implement proposed policies continue. This study shows the necessity of incorporating a health equity lens, breaking down policy silos, and amplifying community voices in the policy process to challenge assumptions regarding lived experiences and ensure healthier equitable policy outcomes. Key messages • The study shows the importance of integrating a health equity lens, breaking policy silos, and amplifying community voices to challenge assumptions and achieve more equitable policy outcomes. • Obesity policy requires greater consideration to inequalities to strengthen policy impact as demonstrated by all participants recalling the unequal opportunity to sustain a healthy weight in the UK.

Adult stakeholders' perspectives on supporting or undermining the mental health of sexual and gender minoritised adolescents.

To explore adult stakeholders' perspectives on what supports or undermines the mental health of sexual and gender minoritised adolescents (SGMA) in everyday life in order to better understand how to foster supportive psychosocial environments for SGMA. Descriptive qualitative study design, using framework analysis. Semi-structured interviews were conducted remotely with 16 UK-based adult stakeholders which included parents of SGMA, health and social care professionals, community-based professionals, and professionals who commission services related to adolescent health and well-being. Nine themes were identified that represented barriers and enablers of fostering psychosocial environments that are supportive of SGMA mental health. Example barrier themes include SGMA 'facing chronic and acute safety threats and stress', 'psychological responses to social connection losses and navigating alienation', 'digital exposure and online risk and vulnerability' and 'conflicting messages, resulting divisions and adult distancing'. Example enablers include 'exploring, owning, and changing (personal) identities', 'advocating alongside adolescents whilst containing oneself as the adult in the situation' and 'personally fostering adolescents' psychological safety and inclusion'. Adult stakeholders report that SGMA are often exposed to environments hostile to key aspects of their identity which then by extension undermines their mental health. These experiences can threaten their sense of safety and evolving identity. Practitioners in particular should be aware of the stressors relating to SGMA identity and minoritisation experiences in order to develop the psychological safety and sense of inclusion needed for SGMA to trust in the relationship and the support offered.

Co-designing place-based co-located health and wellbeing infrastructure and services with high school students, educators, and health service providers

This research involved working with high school students, teachers, Guidance Officers/School Counsellors, and other stakeholders, to co-design a new Community Hub to be co-located at a high school in a high-priority community. This article describes the co-design processes undertaken to engage children and young people and adult stakeholders in the ideation and design phase of infrastructure and service development to support health and wellbeing needs of a high priority community (low service uptake/high health needs). The key insights developed from these engagement processes pointed a way forward for the next stages of infrastructure and service delivery development and led to the development of several visual depictions of the complexities of stakeholder interests. This article argues that meaningful engagement of potential future users of place-based integrated health and wellbeing services enables responsive infrastructure designs that meet future needs of both target communities and service providers.

Taiwanese youth’s imagination of good citizens through environmental policy controversy deliberations

What does it mean to be a good citizen when coping with sustainability challenges in politically polarized and values-conflicting contexts? This study explores Taiwanese students’ imagination of good citizens as they deliberate over a highly controversial local environmental policy. Tracing five focal students’ learning trajectories, this study unpacks how the students perceive their own and the adult stakeholders’ roles in this controversy. Results revealed students’ consistent distrust of the adult stakeholders. Nevertheless, they developed expectations of the stakeholders as they learned more about the political complexities of this issue. Students’ imaginations about good citizens include four elements: engaging in public issues, respecting different opinions, rational communication, and addressing the local’s concerns and needs. Based on the results, I argue that pluralistic values are needed for preparing citizens to cope with sustainability challenges in multicultural and pluralistic societies.

Use of systems thinking and adapted group model building methods to understand patterns of technology use among older adults with type 1 diabetes: a preliminary process evaluation

BackgroundA growing number of older adults (ages 65+) live with Type 1 diabetes. Simultaneously, technologies such as continuous glucose monitoring (CGM) have become standard of care. There is thus a need to understand better the complex dynamics that promote use of CGM (and other care innovations) over time in this age group. Our aim was to adapt methods from systems thinking, specifically a participatory approach to system dynamics modeling called group model building (GMB), to model the complex experiences that may underlie different trajectories of CGM use among this population. Herein, we report on the feasibility, strengths, and limitations of this methodology.MethodsWe conducted a series of GMB workshops and validation interviews to collect data in the form of questionnaires, diagrams, and recordings of group discussion. Data were integrated into a conceptual diagram of the “system” of factors associated with uptake and use of CGM over time. We evaluate the feasibility of each aspect of the study, including the teaching of systems thinking to older adult participants. We collected participant feedback on positive aspects of their experiences and areas for improvement.ResultsWe completed nine GMB workshops with older adults and their caregivers (N = 33). Each three-hour in-person workshop comprised: (1) questionnaires; (2) the GMB session, including both didactic components and structured activities; and (3) a brief focus group discussion. Within the GMB session, individual drawing activities proved to be the most challenging for participants, while group activities and discussion of relevant dynamics over time for illustrative (i.e., realistic but not real) patients yielded rich engagement and sufficient information for system diagramming. Study participants liked the opportunity to share experiences with peers, learning and enhancing their knowledge, peer support, age-specific discussions, the workshop pace and structure, and the systems thinking framework. Participants gave mixed feedback on the workshop duration.ConclusionsThe study demonstrates preliminary feasibility, acceptability, and the value of GMB for engaging older adults about key determinants of complex health behaviors over time. To our knowledge, few studies have extended participatory systems science methods to older adult stakeholders. Future studies may utilize this methodology to inform novel approaches for supporting health across the lifespan.

Reading in Relation: Youth Mentors and Adults Co-Constructing Teaching and Learning in a High School Literacy Classroom

Most schools operate as hierarchical structures, where adult stakeholders largely dictate what counts as knowledge and how to teach it. While previous scholarship has documented the promise of youth-led initiatives to trouble hierarchical structures, these explorations tend to occur outside of schools and do not typically account for the kinds of changes in relations between youth and adults necessary to disrupt hierarchical structures from within. Using third-generation cultural-historical activity theory as our theoretical framework, in this study we explore the shifts in subject-subject relations that emerged as high school youth literacy mentors, their teacher, and university researchers participated in iterative processes of co-configuration to open up new possibilities for literacy learning at their public school. We examine how youth mentors and adults co-designed and co-taught the Literacy Mentorship Class (LMC) while increasingly engaging contradictions as double binds within the Literacy Mentorship Debrief (LMD). We trace how evolving subject-subject relations in the LMD contributed to shifts in divisions of labor, rules, objects, and mediating artifacts in and beyond the LMC. Ultimately, we propose debriefs as a set of reflective practices to facilitate future possibilities for co-configuration among youth and adults that can be responsive to the particularities of any school community.

Feasibility and acceptability of a novel biomedical device to prevent neonatal hypothermia and augment Kangaroo Mother Care in Kenya: Qualitative analysis of focus group discussions and key Informant Interviews.

Hypothermia is a leading newborn complication, especially among premature and/or low birth weight infants. Within low/middle-income countries where incubators and radiant warmers are often in short supply, leading to gaps in the thermal care chain, neonatal hypothermia underlies high rates of newborn morbidity and mortality. Kangaroo Mother Care/Skin-to-skin care is an effective method for prevention of hypothermia in premature and low birthweight babies but can be very burdensome for families and healthcare providers. Our international multidisciplinary team has developed a prototype for a wearable biomedical device ("NeoWarm") to provide continuous thermal care and augment kangaroo mother care practices in low-resource settings. The objective of this study was to assess the feasibility and acceptability of NeoWarm and to obtain user design feedback for an early prototype from among adult end-users in Western Kenya. We performed key informant interviews (n = 17) among healthcare providers and 5 focus group discussions (FGDs) among 3 groups of adult stakeholders of premature babies, including: (1) parents/family members of premature babies aged 6 weeks or less (3 FGDs); (2) healthcare providers of newborns (e.g., nurses; physicians; 1 FGD); (3) community opinion leaders and stakeholders (e.g., traditional birth attendants; pastors; village elders; 1 FGD). Content and thematic analyses of transcripts indicate that NeoWarm is acceptable and feasible in promoting facility-based kangaroo mother care in the Kenyan setting. Novel findings derived from respondents include (1) the ability of the device to potentially overcome several barriers to traditional kangaroo mother care methods and (2) user-driven encouragement to expand the use case of the device to potentially include community-based kangaroo mother care and neonatal transport. User design feedback obtained during the interviews informed several key design iterations for subsequent prototypes of the device.

Development of a school-based programme for mental health promotion and prevention among adolescents in Nepal and South Africa

IntroductionAdolescence is a critical time for mental health promotion and prevention and establishing healthy behaviours. Implementing universal, school-based psychosocial interventions can improve short- and long-term health trajectories for adolescents. While these interventions may offer important opportunities for fostering skills and relationships, few school-based interventions have been developed for and tested in low- and middle-income countries (LMICs) where adolescent mental health needs may be significant and under-served. This manuscript details the development of a multi-component, universal school-based intervention, Health Action in ScHools for a Thriving Adolescent Generation (HASHTAG), for adolescents aged 12–15 years in Nepal and South Africa. Methods and resultsWe describe HASHTAG's development over four phases, combining methods and results as each phase was iteratively conducted between 2018 and 2021. Phase 1 included a systematic review and components analysis, building from WHO guidelines for adolescent mental health. Seven components were strongly supported by the evidence: emotional regulation, stress management, mindfulness, problem-solving, interpersonal skills, assertiveness training, and alcohol and drug education. Phase 2 encompassed site selection, theory of change development, and formative research engagements; research teams in each site engaged adolescents and key adult stakeholders to identify priorities for intervention. Stakeholders voiced preferences for external facilitators and key content and delivery for intervention sessions. These findings informed Phase 3, a draft manual of HASHTAG, including a whole-school component, called Thriving Environment in Schools, and a classroom-based, six-session component, Thrive Together. In Phase 4, participants engaged in consultative workshops to review and contextualise content by country, preparing HASHTAG for implementation in a feasibility trial. Minor adaptations were made in Nepal, including using school nurses and adjusting take-home materials; both country's workshops identified practical considerations for implementing activities. ConclusionsHASHTAG was designed around core evidence-based components to increase translatability across LMICs, while enabling country-specific tailoring to enhance feasibility. Future research will test whether this multi-component, whole-school approach can improve adolescent mental health.

A causeway to impact: A proposed new integrated framework for intergenerational community‐based participatory action research

AbstractOver recent decades there has been growing interest in amplifying children and young people's views (CYP) within policy debates. Despite this, they are rarely invited to participate in key policy‐making discussions, and when they are, this tends to be tokenistic. This paper presents an intergenerational methodological framework ‘The Causeway Approach’, inspired by the mythology of the Giant's Causeway, which addresses the challenge of CYP's voices being drowned out by adult stakeholders. This contextualised approach has significant potential to benefit CYP and communities through capacity building, strengthening of social capital and fostering intergenerational connections.

Development of Youth-Centered Health Messaging Posters for High School-Based Health Clinics in Hawaii.

Youth may be reluctant to seek health care from school health providers due to feeling embarrassed or stigmatized in the health office environment or worried about their confidentiality. The purpose of this project was to create a set of youth-centered health posters that promote youth engagement with nursing staff and to standardize health messaging across high schools in Hawaii school-based clinics. Two community advisory boards, 1 composed of 10 youth stakeholders (mean age 17 years) and the other of 7 adult stakeholders, informed poster development utilizing web-based discussion groups. The discussions were transcribed, and additional data was collected using field notes and anonymous digital messages. Adult advisory board members also provided feedback on suggested poster text through an online survey. Youth and adult advisory board participants identified 4 key health concerns facing youth: confidentiality, sexual health, relationships, and mental health. Based on input from the 2 advisory boards, 4 posters were developed, each centered on 1 key health issue. School-based posters can convey important messages to help youth understand their health care rights and responsibilities, as well as identify important issues open for discussion with nurses. Posters are an underutilized tool for school health providers to create welcoming, inclusive health care environments and facilitate health-related conversations with youth. This paper describes participant feedback about the characteristics of a memorable poster and briefly outlines current knowledge and recommendations for school health providers regarding each of the 4 health issues.

248 Influence of self-efficacy on older adults’ perspectives and engagement with technology

Abstract Background Self-efficacy has been demonstrated to influence individuals’ perspectives and preferences in relation to technology use, and informs disparities observed among older adults in terms of their access and use of information communication technology. However, research exploring the effects of technological self-efficacy on the consequent virtual engagement among older adults is scarce. The relationship between self-efficacy and varying levels of technology use and proficiency needs to be considered. These factors not only shape older adults’ perspectives on technology use but also impact their adaptation and engagement in critical areas of daily life: including information access, advocacy, and social participation. This paper investigates the relationship between the adoption of and attitudes towards technology among older people, the role of self-efficacy in informing these attitudes, and the level of use or perceived usefulness of technology. Methods The study draws on in-depth interviews with older adult members (n = 40) and stakeholders (n = 30) of a nationally representative membership-based grassroots older adult organisation in Ireland. The semi-structured interviews explored individuals’ experiences of technology use, focusing on daily routines, social connectedness, information access, and civic participation. Results Findings reveal that narratives about daily routines involving technology are influenced by perceptions of self-efficacy in relation to technology in general. However, this self-efficacy is also influenced by other factors that influenced interaction with technology in the daily lives of older people. Dependence on social support can paradoxically impair self-efficacy when such support is withdrawn. An ideology of individual responsibility sometimes led participants to view themselves as the problem when struggling with digital engagement, contributing to a lack of confidence and motivation. Conclusion While technology development for older people is progressing, there is less consideration of the correlation between technology adoption rates and self-efficacy. This paper proposes interventions to empower individuals, enrich virtual engagement, and reduce technological inequalities. Understanding these dynamics could help shape inclusive technological engagement practices and policies for older adults.

Co-Creation of a School-Based Motor Competence and Mental Health Intervention: Move Well, Feel Good.

Low motor competence (MC) and inhibited psychosocial development are associated with mental health difficulties. Improving children's MC through school-based physical activity interventions emphasising psychosocial development may therefore be a mechanism for promoting positive mental health. This study describes and provides reflective insights into the co-creation of 'Move Well Feel Good', a primary school physical activity intervention to improve children's MC and mental health. Class teachers, school leaders, physical activity specialists, and children (aged 8-9 years) participated in a series of co-creation workshops. Stakeholders' knowledge and experiences were integrated with existing research evidence using creative methods (e.g., post-it note tasks, worksheets, and drawings) to facilitate discussion. The co-creation process culminated in stakeholder consensus voting for one of three proposed intervention ideas. Children cited physical and mental health benefits, enjoyment with friends, and high perceived competence as motives for being physically active. Opportunities to develop MC across the different segments of the school day were identified by adult stakeholders, who perceived children's lack of resilience, an overloaded curriculum, and poor parental support for physical activity as barriers to intervention implementation. The chosen intervention idea received six out of a possible twelve votes. Co-creation projects are specific to the contexts in which they are implemented. This study reinforces the complex nature of school-based intervention development and highlights the value of engaging with stakeholders in co-creation processes.

The Toy Brick as a Communicative Device for Amplifying Children’s Voices in Research

The Toy Brick as a Communicative Device for Amplifying Children’s Voices in Research

Adult Stakeholders’ Perspectives on the Content, Design, and Dissemination of Sexual and Gender Minority Adolescent-Centered PrEP Campaigns

Adult Stakeholders’ Perspectives on the Content, Design, and Dissemination of Sexual and Gender Minority Adolescent-Centered PrEP Campaigns

Care Workers and Managers’ Experiences of Implementing Infection Control Guidance in an Epidemic Context: A Qualitative Study in the South East of England, during the COVID-19 Prevaccination Era

The national response to COVID-19 has had a severe impact on adult social care settings, with high mortality amongst people receiving and providing care in England. Care workers had to rapidly adapt to new infection control measures to protect themselves, their colleagues, and the people receiving care. Infection control in residential and domiciliary care is always complex, but COVID-19 infection control measures impacted exceptionally on care workers’ working and everyday lives. We undertook qualitative interviews with care workers and managers (n = 10) in residential and domiciliary care for older people in the Southeast England during the first wave of the pandemic to understand their experiences, solutions, and concerns to implement guidance in practice. Data were analysed using framework analysis, and the following eight themes were identified: (1) Increasing visibility and support for the sector; (2) the impact of negative messaging about the sector; (3) feelings of isolation; (4) accessibility and usability of guidance; (5) social care staff as agents in producing and sharing good practice; (6) managing expectations and the impact of conflicting messages in the media; (7) improving communication with hospitals; and (8) problems in the early pandemic. The findings reveal widespread concerns for the marginalisation of the sector in the policy response and the inadequacy of infection control guidance. Guidance would benefit from a better understanding of domiciliary and residential care settings. This might involve the following steps: (a) coproduction of guidance with adult social care stakeholders, including those in direct-care roles and (b) a shift away from a clinical model of infection control towards a more flexible approach that attends to the inherent variability of care settings.

Understanding school food systems to support the development and implementation of food based policies and interventions

BackgroundSchools provide opportunities to improve the quality of children's diet, whilst reducing inequalities in childhood diet and health. Evidence supports whole school approaches, including consistency in food quality, eating culture and food education. However, such approaches are often poorly implemented due to the highly complex environments in which schools operate. We aimed to develop a school food systems map using a systems thinking approach to help identify the key factors influencing primary school children’s dietary choice.MethodsEight workshops were conducted with 80 children (from schools from varying locations (region of England/UK; urban/rural), deprivation levels and prioritisation of school food policies)) and 11 workshops were held with 82 adult stakeholders across the UK (principals, teachers, caterers, school governors, parents, and local and voluntary sector organisations) to identify factors that influence food choice in children across a school day and their inter-relationships. Initial exploratory workshops started with a ‘blank canvas’ using a group model building approach. Later workshops consolidated findings and supported a wider discussion of factors, relationships and influences within the systems map. Strengths of the relationship between factors/nodes were agreed by stakeholders and individually depicted on the map. We facilitated an additional eight interactive, in-person workshops with children to map their activities across a whole school day to enable the production of a journey map which was shared with stakeholders in workshops to facilitate discussion.ResultsThe final ‘CONNECTS-Food’ systems map included 202 factors that were grouped into 27 nodes. Thematic analysis identified four key themes: leadership and curriculum; child food preference; home environment; and school food environment. Network analysis highlighted key factors that influence child diet across a school day, which were largely in keeping with the thematic analysis; including: 'available funds/resources', 'awareness of initiatives and resources', 'child food preference and intake', 'eligibility of free school meals', 'family circumstances and eating behaviours', 'peer/social norms', 'priorities of head teachers and senior leaders'.ConclusionsOur systems map demonstrates the need to consider factors external to schools and their food environments. The map supports the identification of potential actions, interventions and policies to facilitate a systems-wide positive impact on children’s diets.

DEVELOPMENT OF ADULT LEARNERS’ 21ST CENTURY SKILLS IN GREENLAND: FIELD WORK ANALYSIS

The expansion of adult education has been presented as an effective strategy to solve the issues in adult employment. The aim of the present research is to analyse the field work carried out in Nuuk (Greenland) on the development of adult learners’ 21st century skills in Greenland underpinning the elaboration of implications for adult education in Greenland. The methods of the present research comprise both theoretical and empirical methods. The empirical study was based on fieldwork. Two on-site visits in Nuuk between the 8-12th August 2022 were carried out. Observation and participant observation were implemented. A semi-structured interview with two interviewees was conducted. The literature review allows for a conclusion that adult education in Greenland is mentioned neither in Greenland educational policy documents or scientific publications. Despite that, the analysis of the implemented fieldwork allows drawing a conclusion that adult education has been established on a municipal level like the centre Majoriaq, and on a non-governmental level like Kofoeds Skole. Both theoretical and empirical analysis contribute to the conclusion that adult learners’ 21st century skills in Greenland are being developed. However, these skills would need more joint work from all the adult education stakeholders.

The Criteria to Identify Pornography That Can Support Healthy Sexual Development for Young Adults: Results of an International Delphi Panel

Pornography is not homogenous. There is a paucity of research that offers guidance to young adults and adult stakeholders interested in navigating the available range of pornography to find materials that support healthy sexual development for young adults. Drawing on the expertise of a Delphi Panel of experts from a range of relevant areas this article offers six criteria for assessing whether pornography can support healthy sexual development: includes a variety of sexual practices; includes a variety of body types, genders and races; shows negotiation of consent on screen; is known to be ethically produced; focuses on pleasure for all participants; shows safe sex. The article identifies four pornographic websites that may meet these criteria: Sex School, Make Love Not Porn, PinkLabel.TV and Lust Cinema.

A digital innovation typology: Navigating the complexity of emerging technologies to negotiate health systems research with young people.

This study aims to explore young people's perspectives of emerging technologies and health systems research in an adolescent health community of practice. The context of this integrated knowledge translation study is the Wellbeing Health & Youth Centre of Research Excellence in Adolescent Health. A theory-building, non-systematic review was conducted to examine the concepts and interrelationships of emerging technologies associated with digital innovation and health systems. This typology informed the design of an online workshop with young people to explore their views, concerns, and ideas about health systems research. A digital innovation typology was identified to differentiate and explain emerging technology concepts and interrelationships that can be applied to the health systems context. Aligned with this typology, youth perspectives about digital health challenges and opportunities were identified to support future research, policy, and practice. The integrated findings from this study can assist the navigation of complex emerging technologies, and the negotiation of equitable health systems research, between youth and adult stakeholders. Further, with these typology-related resources, mutual learning and the public involvement of young people in health systems research and priority setting agendas can be supported.