Programming Theory Research Articles

Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review

BackgroundDespite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why.MethodsFollowing Pawson’s realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated.ResultsFrom 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients’ needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision.ConclusionsImplementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention’s goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients.Trial registrationPROSPERO (CRD42022335282).

How do urban green spaces influence heat-related mortality in elderly? A realist synthesis

BackgroundAn important consequence of climate change for urban health is heat-related mortality. Vulnerable groups, especially elderly, will be the most affected. A solution put forward in many reports and policy documents is the introduction or expansion of urban green spaces. While they have a proven effect in decreasing the ambient temperature and reducing heat related mortality, the causal pathways are far from clear. Moreover, results vary for different contexts, population types and characteristics of green spaces as they are ‘complex systems thrusted into complex systems’. To our knowledge, there is no systematic synthesis of the literature that examines the mechanisms by which and the circumstances under which green spaces work to decrease heat-related mortality for elderly.MethodsWe performed a realist synthesis– a theory-driven review method– to develop a complexity- and context-sensitive program theory. As a first step, a causal loop diagram was constructed which describes the possible pathways through which urban green spaces influence heat-related mortality in elderly. In a second step, one of the pathways - how they may lead to a reduction of heat-related mortality by increasing social capital - was further explored for underlying mechanisms, the context in which they work and the differentiated patterns of outcomes they generate. Literature was searched for evidence supporting or contradicting the initial programme theory, resulting in a refined theory.ResultsResults show how urban green space can impact on heat-related mortality in elderly by its influence on their exposure to outdoor and indoor heat, by improving their resilience as well as by affecting their access to treatment. Urban green spaces and their interactions with social capital affect the access to health information, social support, and the capacity for effective lobbying. Several mechanisms help to explain these observed demi-regularities, among others perceived behavioural control, perceived usefulness, receptiveness, ontological security, and self-interest. If and how they are triggered depends on the characteristics of the urban green space, the population, and other contextual factors.ConclusionLooking into the impact of urban green spaces on heat-related mortality in elderly, researchers and policy makers should take interest in the role of social capital.

Understanding how therapeutic exercise prescription changes outcomes important to patients with persistent non-specific low back pain: a realist review protocol

IntroductionPersistent low back pain (LBP) is the leading cause of disability worldwide, and therapeutic exercise is recommended as a first-line treatment in international guidelines. The effects of exercise on clinical outcomes of pain and physical function are small to moderate, despite broader impacts on cardiovascular systems, biological health, mood, and emotional well-being. Therapeutic exercise prescription is defined as exercise that is prescribed by a clinician for a health-related treatment. It is unknown how therapeutic exercise prescription creates effects on outcomes of importance. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain situations, settings, or populations to create an intended or unintended outcome (O). Our objective is to explore and understand the mechanisms by which therapeutic exercise prescription changes outcomes for people with persistent LBP.MethodsWe will develop initial programme theories based on preliminary data from a previous systematic review and consensus workshop. These theories will be modified with input from a steering group (experts), a stakeholder group (people with lived experience of exercise for persistent LBP and clinicians), and a scoping search of the published literature. An information specialist will design and undertake an iterative search strategy. These will be used to create CMO configurations, which will be refined and tested using the literature. The realist review will be reported following RAMESES guidance.DiscussionRealist reviews are uncommon in LBP research to date, yet those offer an opportunity to contrast with traditional methods of randomised controlled trials and systematic reviews and provide additional information regarding the contexts and mechanisms that may trigger certain outcomes. This can aid our understanding of the contextual features that may influence exercise prescription, such as for whom they are most effective, in what setting, how they are implemented and why. This realist synthesis will enhance our understanding of therapeutic exercise prescription to improve adherence and engagement and ultimately will provide clinically relevant recommendations regarding exercise prescription for those with persistent LBP.Systematic review registrationThe review has been registered with PROSPERO (CRD42017072023).

An exploration of analytical tools to conduct a realist synthesis and demonstrate programme theory development: An example from a realist review

Introduction A realist literature review involves iterative processes, with searches, appraisal and synthesis occurring simultaneously. Whilst this lends itself to theory development, the synthesis process often lacks transparency. This has led to unanticipated challenges for novice realist researchers, particularly PhD candidates. Methods The aim of this paper is to contribute to the realist methodological knowledge base by outlining the analytical tools of coding, consolidating and conceptual mapping used within a realist review. Specifically, how these techniques aid the synthesis process and demonstrate the development of valid and evidence informed programme theories. Results A worked example is provided to illustrate how; (i) coding techniques using realist logic can evidence a rigorous synthesis process; (ii) the use of consolidating techniques facilitates data management and aids theory development; and (iii) conceptual mapping demonstrates programme theory development. Conclusions Recommendations for novice realist researchers include defining and documenting the analytical tools for conducting a rigorous realist synthesis to provide transparency about how valid programme theories were developed. Plus, theory development checks can be built into the structure of the review process.

The application of operation research in the design of on-site construction organization

This article explores the integration of Operations Research (OR) principles in the design and management of on-site construction organizations. The first section introduces Operations Research as a multidisciplinary field that employs mathematical modelling, statistical analysis, and optimization techniques to enhance decision-making processes across various sectors. Key aspects such as mathematical modelling, optimization, decision analysis, simulation, queueing theory, linear programming, and game theory are highlighted. The second section focuses on the design of on-site construction organizations, emphasizing the structure and organization of resources, personnel, and processes essential for efficient project execution. Various key elements, including project management, site personnel, project support teams, engineering and design teams, health and safety personnel, procurement and supply chain, communication and coordination, equipment and maintenance, and environmental compliance, are discussed. The third section delves into the application of Operations Research techniques in the design and management of on-site construction organizations. It outlines how OR principles can be employed for resource allocation and optimization, project scheduling and planning, inventory management, equipment utilization, project costing and budgeting, risk management, supply chain management, human resource management, facility layout and design, and the development of decision support systems. The conclusion highlights that the strategic application of Operations Research methodologies contributes to enhanced efficiency, optimized resources, and improved decision-making throughout the construction project lifecycle. The integration of OR principles not only enhance the overall effectiveness of on-site construction organizations but also leads to cost savings, timely project completion, and improved project outcomes. As construction projects continue to grow in scale and complexity, the systematic and analytical approach provided by Operations Research becomes increasingly valuable in addressing the intricate challenges faced by construction stakeholders.

Integrated palliative care in oncology: a protocol for a realist synthesis

IntroductionEmerging evidence suggests improved quality of life, reduced symptom burden and lower health services costs when integrated palliative care and cancer care are implemented. Integrated palliative care aims to achieve...

Pedagogical effectiveness and improvement of the process of fostering a culture of safe behavior in primary school children

Introduction. The authors propose to comprehend the reasons for the relevance of the problem of forming a safety culture in pedagogical theory and practice and the need to build educational programs, directions that take into account the reality of modern childhood, the specific conditions of a person's growing up during this period, implementing all available options for the formation and accumulation of life experience by the child, in which the culture of safe behavior occupies one of the leading places. The purpose of the work is to identify the validity of the inclusion of the subjects of the system of additional education for children in the process of forming a culture of safe behavior of younger schoolchildren and to formulate the idea of the dissertation research. Materials and methods. In November-December 2023, a pilot study was conducted to establish the level of formation of basic concepts related to safe behavior in children who have reached primary school age. The methods of survey, content analysis, and conversation were used. The theoretical basis of the study is the concept of uncertainty as a condition of growing up in a changing world (A.G. Asmolov), the activity approach, the principle of complementarity in relation to pedagogical systems (N. Bohr), culturological and subject-object approaches to the study of childhood. The results are presented by the authors in full, and they testify to the well-known effectiveness of the work of preschool educational organizations and schools in the field of forming children's ideas about human safety in the environment. In preschool age, parents are active participants in this process for most children. In the course of the conversations, it was found that children form an indicative basis for activities based on a list of specific situations that may develop in everyday life, but its reproduction is difficult if it is not supported by the child's experience. The absence of situations of experience, teaching safe behavior only in the format of game activities in constructed situations with the use of any visuals, including information and communication technologies (rollers, videos, etc.), or in the format of classes using the explanatory and illustrative method do not allow us to draw conclusions about the formation of safe behavior skills in preschool children. Discussion and conclusion. The authors present a discussion of debatable issues related to the bias in favor of the theory of programs for the education of a culture of safe behavior, with insufficient operationality of the concepts of «danger» and «risk» for the purposes of education. Based on the results of the pilot study and theoretical analysis of some existing approaches, the inclusion in this process of subjects of additional education that carry out activities in the field of physical culture and sports, as a natural environment for the life of children, with pedagogical conditions for modeling situations of controlled danger in order to form real skills and experience of risk in children, is substantiated. This is the idea behind the intended dissertation research.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

ObjectiveTherapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of...

Understanding Australian general practice patients’ decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach

ObjectivesTo evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying...

Developing middle-range theories within a realist evaluation of how health committees support community capacity for health

Health committees link formalised health services and the community. However, ‘how, why, and for whom’ health committees work warrants further exploration. This article presents the development of a middle-range theory for how health committees work for building community capacity for health. Resulting programme theories from a realist evaluation in Uganda were synthesised for demi-regularities and supplemented by four key informant interviews – substantive theories were used to help explain the findings from the case studies to develop the final middle-range theories. Eighteen existing programme theories and 47 supporting context-mechanism-outcome configurations were synthesised into four middle-range theories for how health committees work for community capacity building for health at the individual, organisational, community and societal levels. The middle-range theories developed in this study provide important insight for those implementing health committees. Given the little guidance available for developing and refining middle-range theories, this study provides transparent methodological processes, which may assist future research.

A graphical method for causal program attribution in theory-based evaluation

We describe a simple yet rigorous graphical method for eliminating bias in theory-based program evaluation. The method is an application to social and international development program evaluation of the graphical causal models used to test medical treatments. We implement a graphical causal model for the World Bank’s well-known Bangladesh Integrated Nutrition Project. We show how to construct the graphical causal model to represent program theory in context in explicitly causal terms. We then show how to visually inspect the graphical causal model to distinguish causal from non-causal associations between variables in evaluation data. Finally, we show how to select a set of adjustment variables to neutralize non-causal associations, eliminating bias in all forms of causal inference—qualitative and quantitative, linear and non-linear.

Mindfulness-based interventions to support wellbeing of adults in low socio-economic settings: a realist review

BackgroundMindfulness as a modality involves training the innate human capacity for present-moment awareness with a view to cultivating a more harmonious and integrated life experience, especially in the face of hardship. Over the past four decades, the field of mindfulness has grown rapidly. Despite a substantial body of literature outlining the many benefits of mindfulness practice within a range of contexts and populations, the authors noticed that studies addressing the adaptation, application and value of mindfulness-based interventions (MBIs) for adults within socio-economically challenged setting were scant. To address this gap, we conducted a realist review of studies pertaining to MBIs within low socio-economic settings, to determine the extend and nature of research in this sector and culminating in a program theory which may be useful for the design of interventions going forward.MethodsWe selected realist review as the methodology as it is well suited to investigating the complex nature of social interventions. The value of realist review is that the exploration of the causal relationships between the mechanisms (M) within a specific context (C) towards particular outcomes (O) offers a deeper understanding of the intervention which may assist in more effective delivery going forward. The review follows the guidelines presented by the Realist and Meta-narrative Evidence Synthesis – Evolving Standards project.ResultsOf the 112 documents identified, 12 articles met the inclusion criteria. Of these 12 studies, 10 were conducted in the United States, with little representation across the rest of the globe. The interventions described in these articles were varied. We identified mechanisms that offered beneficial outcomes for participants across a range of contexts, with indications of how interventions might be adapted towards greater accessibility, acceptability, and feasibility within communities.ConclusionBy reviewing the various programs in their respective contexts, we developed a program theory for implementing socio-culturally adapted MBIs in low socio-economic settings. In the future, this program theory could be tested as a means to create a sense of wellbeing for people living in low socio-economic settings.

Understanding paramedic work in general practice in the UK: a rapid realist synthesis

BackgroundGeneral practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about ‘models of paramedic working in general practice’ in different UK contexts to understand their impact.MethodsThe rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories.ResultsEmpirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models.ConclusionsVariability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various ‘models of paramedic working’ in different contexts.

A stochastic two-stage microgrid formation strategy for enhancing distribution network resilience against earthquake event incorporating distributed energy resources, parking lots and responsive loads

The sustainability of energy systems has been severely affected in recent years by the quantity and intensity of high-impact, low-probability events. As a result, the resilience concept has been introduced to analyze the operation of networks against such events. This paper proposes a stochastic two-stage microgrid formation formulation to maximize the restored loads and enhance the resilience index of electrical distribution systems in the face of earthquake events. In this regard, an earthquake incident is modeled in the first step utilizing geographical data, peak ground acceleration and fragility curves. Then, a two-stage linear programming and graph theory is applied to form microgrids in response to the mentioned disturbances, where the variables in the planning and operating states are optimized in the first and second stages, respectively. The influence of different components including diesel generators, renewable energies, storage units and electric vehicles is investigated. In addition, the role of responsive loads and uncertainties related to line failure, load variation, renewable resources availability and electric vehicles are considered during the analysis. The results for various scenarios validate that the presented approach increases load supply capability and resiliency index by 38.7% and 38.8%, respectively.

Communities of practice to facilitate change in health professions education: A realist synthesis

BackgroundCommunities of practice could contribute to transformations in health professions education to meet complex and emerging challenges. However, little is known about the underlying mechanisms of communities of practice in this setting, and how context influences outcomes. ObjectiveTo understand when, why and how communities of practice with health professions education faculty work to facilitate higher education change. DesignA realist synthesis according to the RAMESES standards and steps described by Pawson and colleagues. Review methodsEarly scoping of the literature informed the development of an initial program theory to describe underlying assumptions about how communities of practice in higher education, implemented with health professions education faculty, were likely to work. The theory was tested and further refined through a realist synthesis. A systematic search for evidence using search terms ‘faculty’, ‘communities of practice’ and ‘higher education’ and related terms was supplemented with citation tracking and hand searching of significant authors and journals. Following study appraisal, data were extracted and synthesised from 21 manuscripts describing 16 communities of practice. The realist synthesis focused on identifying patterns in context-mechanism-outcome interactions, and the alignment with substantive theory. ResultsFrom the included manuscripts, ten context-mechanism-outcome configurations were identified that describe a range of individual, interpersonal and institutional outcomes of communities of practice with health professions education faculty and context-mechanism interactions that contribute to achieving these outcomes. ConclusionsThis study expands theoretical understandings of how and why communities of practice work. There is value in communities of practice in the higher education sector, primarily in the field of health professions education. Communities of practice implemented in the context of complex change with participants who have a desire to participate can facilitate change in health professions education, including institutional level changes, through reflection, experiential learning and creating a shared agenda for change. Findings from this study can be used by policy and decision-makers within health education to best apply communities of practice to achieve meaningful outcomes.

Qualitative realist evaluation of an occupational therapy intervention programme (ABLE), addressing ability to perform activities of daily living among persons with chronic conditions

BackgroundChronic conditions are associated with problems related to performance of activities of daily living (ADL) stressing a need to develop and evaluate intervention programmes addressing such problems. Hence, the ABLE programme was developed, and its feasibility evaluated. Implementing intervention programmes in community-based rehabilitation settings requires understanding of how the programme works in various contexts. Applying a realist evaluation approach, the aim of this study was to identify and evaluate interactions between contexts, mechanisms, and outcomes in the ABLE 2.0, to confirm, refine, or reject aspects of the initial programme theory.MethodsRealist evaluation using qualitative data collected in the ABLE 2.0 randomised controlled trial (n = 78). Based on the ABLE 2.0 initial programme theory, qualitative realist interviews were conducted among receivers (n = 8) and deliverers (n = 3) of the ABLE 2.0 in a Danish municipality. Transcripts were coded, and context-mechanism-outcome configurations were extracted and grouped into contiguous themes. Results were then held up against the initial programme theory.ResultsFour contiguous themes were identified including a total of n = 28 context-mechanism-outcome configurations: building a foundation for the entire intervention; establishing the focus for further intervention; identifying and implementing relevant compensatory solutions; and re-evaluating ADL ability to finalise intervention. Overall, the ABLE 2.0 initial programme theory was confirmed. The evaluation added information on core facilitating mechanisms including active involvement of the client in the problem-solving process, a collaborative working relationship, mutual confidence, and a consultative occupation-based process using compensatory solutions. Several contextual factors were required to activate the desired mechanisms in terms of supportive management, referral procedures encouraging the problem-solving process, delivery in the client’s home, skilled occupational therapists, and clients feeling ready for making changes.ConclusionsThe ABLE 2.0 represents a coherent problem-solving occupational therapy process, applicable across sex, age, and diagnoses with the potential to enhance ADL ability among persons with chronic conditions, when delivered as part of community-based rehabilitation services. Knowledge about the interactions between contextual factors, mechanisms, and outcomes in the ABLE 2.0 is central in case of future implementation of the programme in community-based rehabilitation settings.Trial registrationThe trial was prospectively registered on www.ClinicalTrials.gov (registration date: 05/03/2020; identifier: NCT04295837) prior to data collection that occurred between August 2020 and October 2021.

Understanding for whom, under what conditions, and how an integrated approach to atrial fibrillation service delivery works: a realist review.

To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work). A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context-mechanism-outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context-mechanism-outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway. It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF.

Community Group-Based Physical Activity Programs for Immigrant Older Adults: A Systematic Realist Review

Physical activity program interventions often lack sensitivity to the needs of older immigrant adults. The objective of this systematic realist review is to explain how, why, for whom, and under which circumstances community group-based physical activity programs work for immigrant older adults. The initial program theory was developed using prior research, team expertise, social cognitive theory, and knowledge user consultations. The program theory was tested and refined via a systematic review of the literature. Database searches were conducted in MEDLINE, EMBASE, CINAHL, Scopus, Cochrane Library, Sports Medicine and Education Index, and SPORTDiscus. A total of 22 sources of evidence met inclusion criteria and included intervention studies, systematic reviews, and a discussion paper. Intervention studies were appraised using the Mixed Methods Appraisal Tool. The final program theory constituted eight context–mechanism–outcome configurations that highlight the importance of facilitator characteristics, access to safe spaces, group dynamics, and social support. A limitation was the small number and variable quality of included evidence. Physical activity programs that target immigrant older adults must strengthen physical and psychological safety and maximize opportunities for role modeling and socialization. This research was supported by the Alberta Health Services Seniors Health Strategic Clinical Network and is registered in PROSPERO (ID#258179).

What works, how and in which contexts when supporting parents to implement intensive speech and language therapy at home for children with speech sound disorder? A protocol for a realist review

IntroductionSpeech and language therapists (SLTs) worldwide report challenges with providing recommended, evidence-based intervention intensity for children with speech sound disorder (SSD). Challenges such as service constraints and/or family contexts impact...

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis.

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway. To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment. To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK. Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites. A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines. From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan. Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment. No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement. This study is registered as PROSPERO CRD42021276671. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.