Realist Approach Research Articles

Communication partner training for student health and social care professionals engaging with people with stroke acquired communication difficulties: A protocol for a realist review.

Background Stroke acquired communication impairments impede effective communication. Consequently, in stroke care, communicative interactions can be challenging for both patients and staff and can predispose patients to increased risk of preventable adverse events. Communication partner training (CPT) can mitigate such negative outcomes by optimising communicative interactions. Providing CPT to student health and social care professionals (SH&SCPs) has the potential to enhance their clinical expertise and experiences and enhance the future clinical care of patients with stroke acquired communication impairments. This research aims to expand our understanding of how CPT is operationalised for SH&SCPs in higher education institutions and determine: what works; for whom; in what contexts; how and why? Methods This review is Phase 1 of a research project employing a realist approach with public and patient involvement (PPI). It incorporates five iterative steps: 1.) Clarifying the scope; 2.) Searching for evidence; 3.) Selecting and appraising evidence; 4.) Data extraction; 5.) Synthesising data and developing a middle range theory explaining how CPT is expected to work for SH&SCPs. An advisory panel, including PPI advisors, content advisors, student advisors, realist advisors and educationalist advisor has been set up to consult throughout the review and collaboratively agree the middle range theory. Discussion While there is an evolving evidence base for CPT, including stroke specific CPT for SH&SCPs, it is acknowledged that there are challenges to its implementation in complex real-world settings. In combining empirical evidence with theoretical understanding, realist review permits synthesis of data from diverse sources and goes beyond determining efficacy to explore generative causation and solutions for real world practice. A middle range realist programme theory that coherently explains how CPT is expected to work when teaching SH&SCPs to communicate with people with stroke acquired communication impairments will provide educators with new insights into CPT development and implementation in their higher education institutions.

The Process of Security Achievement Based on the Approach of Islamic Political Jurisprudence, Realism, and Liberalism

The study of security is one of the important and vital subjects in security studies, and the Islamic school of thought, along with other schools, has a specific perspective on security studies. The importance and necessity of research lie in the comparative explanation of the superiority of the theory of Islamic political jurisprudence in the field of the method of security studies. The question that this article aims to answer is how the process of security studies can be realized based on the principles of Islamic political jurisprudence and what prominences it possesses compared to the approaches of other schools in security studies. The research hypothesis is that Islamic principles have advantages over the other two schools in the process of the method of security studies. The research method used is descriptive-analytical, and library tools have been utilized. The results obtained in this study indicate that in the process of security studies, methods ranging from "force" and "power" to "persuasion" are employed. According to the democratic approach, persuasion is emphasized. However, in the liberal school, a dual policy can be observed, as they use the component of "persuasion" against liberals and the component of "force" against non-liberal countries. In Islamic political jurisprudence, comprehensive security can be achieved through adherence to religious teachings.

Introduction to translating Etkind

Abstract The text is a translation from Russian of the first chapter of Soviet theorist Efim Etkind’s 1963 work Poeziia i perevod [Poetry and Translation], in slightly abridged form. Etkind is a vital figure within the translation milieu of the ‘Thaw’ era of the late 1950s and early 1960s, when there was a policy of de-Stalinization and a degree of liberalization. Etkind’s insightful work on poetry translation using comparative stylistics reflected, in some ways, the cultural-political environment of the time. It differed radically from the Realist approach of Ivan Kashkin, who was influenced by Socialist Realism and Stalin-era rhetoric. Etkind pushed the boundaries of what could be said about translation. His apparently apolitical approach was in fact strongly politicized in the Soviet context, and his choice of authors and translators to discuss evidenced his sympathy for those out of favor with the regime and for fellow Jews.

Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study

BackgroundSuicide is a leading cause of maternal death during pregnancy and the year after birth (the perinatal period). While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK [1], the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth [2]. Qualitative research into perinatal suicide attempts is crucial to understand the experiences, motives and the circumstances surrounding these events, but this has largely been unexplored.AimOur study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt.MethodsThrough iterative feedback from a group of women with lived experience of perinatal mental illness and relevant stakeholders, a qualitative study design was developed. We recruited women and birthing people (N = 11) in the UK who self-reported as having undertaken a suicide attempt. Interviews were conducted virtually, recorded and transcribed. Using NVivo software, a critical realist approach to Thematic Analysis was followed, and themes were developed.ResultsThree key themes were identified that contributed to the perinatal suicide attempt. The first theme ‘Trauma and Adversities’ captures the traumatic events and life adversities with which participants started their pregnancy journeys. The second theme, ‘Disillusionment with Motherhood’ brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. The third theme, ‘Entrapment and Despair’, presents a range of factors that leads to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control.ConclusionsFeelings of entrapment and despair in women who are struggling with motherhood, alongside a background of traumatic events and life adversities may indicate warning signs of a perinatal suicide. Meaningful enquiry around these factors could lead to timely detection, thus improving care and potentially prevent future maternal suicides.

Mechanisms That Promote and Support Family Preservation for Children at the Edge of Care: A Realist Synthesis

Children in care of the state are amongst the most disadvantaged in society. They have often experienced adverse childhood experiences leading to their care entry including abuse and neglect. Longitudinal data suggests problems children in care of the state experience within adolescence persist into adulthood, showing “a continuing legacy of adversity.” Emerging literature shows that edge of care interventions can bring about benefits. These interventions support families to meet their child’s needs and prevent, or reduce, the likelihood of children going into care. However, it is not clear how or why these interventions work. It is important to develop this understanding to inform the development of effective, theory-informed practice to benefit this population. We reviewed and synthesised published literature to expose mechanisms by which interventions may promote and support family preservation for children at the edge of care. Our synthesis uses a realist approach to examine mechanisms by which interventions, in various contexts, can promote and support family preservation for children at the edge of care. Previous work by the team shaped the initial search strategy and in line with RAMESES realist review guidelines, no restrictions were placed on the types of study to be included in the synthesis. From 7,530 potentially relevant references identified, 61 papers were included in final extraction. Extracted data was themed, prior to developing narrative and formulating programme theories. Effective edge of care service operation seemed to be based on four core programme theories pertaining to the need for family skills training, home-based delivery, dedicated worker, and rapid response to need.

Interviews with policymakers in Australian health policy: Understanding the process of policy development.

To determine the barriers and enablers oral health and chronic disease policymakers identify during policy development. Semi-structured interview questions were developed utilizing an interview guide and applying a knowledge mobilization framework. Reflective thematic analysis of the data was completed based on the research of Braun and Clarke encompassing a critical realist approach. Twelve policymakers were interviewed. Policymakers reported barriers to accessing evidence including the sheer volume of information and a lack of: research summaries, comprehensive oral health data sets, open access articles, consistency of reporting, and time. They did find relationships with experts and intermediaries crucial at times to policy development. Co-creation of research was also a key enabler for policymakers. This study highlights that policymakers find evidence crucial during the development of policy and often use it to advocate for policies. However, the links between poor oral health; and cardiovascular disease, diabetes, and cognitive impairment are not well recognized among chronic disease policymakers. It is important that oral health researchers and policymakers work to close this gap. The treatment of poor oral health is a global population health issue. It is imperative that evidence of these links is implemented into health policy for the treatment and prevention of chronic diseases and improved quality of life for individuals living with chronic diseases.

Three Approaches to Logical Correctness

This paper outlines three broad ways one might think about logical correctness: the Realist approach, the One-Language approach and my own Neo-Carnapian view. Although the realist and one-language views have dominated the philosophy of logic in recent years, I argue against them, favouring of the Neo-Carnapian approach.

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England.

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives. Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners. Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward. Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

National Rural Health Mission reforms in light of decentralised planning in Kerala, India: a realist analysis of data from three witness seminars

BackgroundThe People’s Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history.MethodsWe employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning.ResultsTwo CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM’s frontline health workers, ASHAs, emerged as leaders in LSGs.ConclusionThe synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation – these contradictions may vex progress going forward and warrant further study.

Navigating the Post-Unipolar World amidst Current Wars: Implications for Nepal

This article explores the road to and implications of the Russo-Ukraine and the Hamas-Israel wars as the consequences of a rapidly transforming great power politics, transitioning from unipolarity to multipolarity. Drawing from scholarly perspectives and open-source resources, the effort has been to give an outlook extending beyond the wars themselves. The focus is on exploring the potential repercussions of this geopolitical shift the world over, but more importantly for a small country like Nepal. A bifocal lens of that of John J. Mearsheimer's realist approach and that of Graham Allison's Thucydides Trap is used to gauge Iinto the state of affairs of Eastern Europe and the Middle East to highlight the examples of such consequences. The conclusion extrapolates the conspicuous duality in the relationship between the great powers- The United States, China, and Russia and analyzes its potential implications for Nepal, drawing insights from the consequences of the Russo-Ukraine and Hamas-Israel wars.

The Implications of Great Power Politics in the Decade Long Syrian Civil War

This research analyzes the implications US and Russian involvement has had as two great powers in the Syrian civil war for international relations in the Middle East as well as for the relations between Washington and Moscow. Using a structural realist approach, this study suggests that the actions of both the US and Russia have mostly been defined by geopolitical status-quo concerns. As a result, they have preferred that their great power play be contained in Syria. As key findings, this study puts forward that the US-Russia showdown in Syria has prolonged the destruction and shaken US alliances in the region while allowing Iran as a key US adversary in the region to extend its influence deep into the region under cover of Russia. Furthermore, contrary to their broader escalatory security policies, Russia and the US have adopted containment approaches and avoided direct confrontation using Cold War tools.

Community mobilisation approaches to preventing adolescent multiple risk behaviour: a realist review

BackgroundAdolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts.MethodsThis realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological s, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory.FindingsWe reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired.ConclusionsFor community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts.Systematic review registrationPROSPERO CRD42020205342

Reconciling China’s maritime discourses of nationalism and international engagement with left Confucian logic

China’s discursive combination of nationalism and international engagement with its maritime neighbours seems self-defeating. To explain why this narrative strategy has been deemed apt, previous studies have predominantly followed a realist approach and contended that China’s international engagement is pure statecraft to help its national rejuvenation efforts. As the merits of Confucianism increasingly affect contemporary Chinese socialism, this paper interprets the internarrativity of left Confucian ethics, Chinese nationalism and international engagement in East China Sea geopolitics. It argues that China tends to identify itself as a contributor to common material interest in the international community. With the notion of graded love, the contribution to the people of the world does not undermine the self-interests. China’s national defence is often allegedly conducted alongside the defence of the existing order enabling its contribution. China does not aim to challenge the order per se, but it challenges the US and its allies’ collective interpretations of it. This situation leads to antagonistic peace when the US-led alliance is unstable. However, if the US’s geopolitical alliance is strong enough to withstand the solipsistic interpretation of the order, the Chinese dream of national rejuvenation can be better realized.

Agricultural extension officers' adoption of ICT‐based extension services: A critical realist approach in Mali

AbstractInformation and communication technology enables extension services to farmers in developing countries. Although they have been deployed and adopted by farmers, the causal mechanisms (i.e., processes through which a result is brought about) underlying their adoption and use have not been adequately studied. This study uses the Critical Realism philosophical perspective to understand and integrate the various factors into a consistent and coherent model for adopting information and communication technology‐based extension services by agricultural extension officers in Mali. The study gathered data from 26 extension officers and farmers in Koulikoro and Segou, Mali. We analyzed the data using thematic analysis with the help of the qualitative data analysis software NVivo. The results revealed that the successful adoption of information and communication technology based extension services is the leading factor that can cause extension officers' satisfaction with agricultural extension services. This satisfaction drives societal change, that is, farmers improving their knowledge of extension services and extension officers efficiently disseminating them. In turn, this change may result in higher yield and, thus, better productivity. These findings guide policymakers, managers, and network providers for higher productivity in developing countries.

Penerapan Gaya Penyutradaraan Dengan Penguatan Tokoh Menggunakan Pendekatan Reaslisme Dalam Film Genius Dari Syurga

The film Genius From Heaven tells the story of a child, he is depicted as very depressed about the conflict he is currently facing. The role of a father in children with autism who can educate the public. It is hoped that this process will provide education to the public about autism sufferers, especially regarding their care. Autism sufferers also have various unique characters and sometimes their emotions often change. With a realist approach, it is hoped that this film can depict in real terms the process and struggle experienced by the main character to prove that he has other abilities that his father did not know at all.

Exploring pathways to optimise care in malignant bowel obstruction (EPOC): Protocol for a three-phase critical realist approach to theory-led intervention development for shared decision-making.

Malignant bowel obstruction is a distressing complication of cancer, causing pain, nausea and vomiting, and often has a poor prognosis. Severe and rapidly developing symptoms, a lack of robust clinical guidelines and the need for multidisciplinary input make treatment decision-making challenging. Sharing decision-making with people with malignant bowel obstruction and their caregivers can be difficult, and inconsistent communication creates serious deficiencies in care by amplifying patients' distress and uncertainty. Little attention has been paid to the implicit influences on this process-for example, the role of discipline-related norms and the beliefs of decision-makers. This study will explore how these processes work and develop interventions to improve shared decision-making. Exploring Pathways to Optimise Care (EPOC) is a three-phase study set within a critical realist framework: (i) realist review, to develop explanatory theory describing collaborative decision-making in the management of malignant bowel obstruction; (ii) an in-depth interview study using modified grounded theory to explore the active ingredients of this collaboration in practice settings; and (iii) the presentation to stakeholders (practitioners, patients and caregivers) of integrated results from Phase I (theory developed from the literature) and Phase II (theory developed from current practice) as a basis for intervention mapping. We aim to produce recommendations to address the challenges, and to develop a set of tools to (i) aid interaction around shared decision-making and (ii) aid interprofessional interaction around the management of this condition. Registration details: The realist review is registered with PROSPERO (CRD42022308251).

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.

“It felt a bit wartime”: Teacher perspectives of social and emotional well‐being support in primary schools during Covid‐19

AbstractAlthough primary schools in the UK were required to provide access to remote learning for pupils during Covid‐19 mandated school closures, there was less clarity for teachers and school leaders about expectations and priorities relating to the provision of social and emotional well‐being support for children at home during this period. Using an existing whole‐school approaches (WSA) framework we aimed to understand the extent to which well‐being support was a priority for primary schools during closures, what structures were in place to support well‐being, what factors facilitated or inhibited provision of remote pastoral care, and how schools supported pupil reintegration following school reopening. Twenty semi‐structured qualitative interviews were conducted with teachers and school leaders in primary schools in three counties of southern England during February and March 2020. A hybrid inductive‐deductive thematic analysis approach was used with a critical realist approach. Findings indicate that school closures were associated with radically disrupted home–school partnerships. Lack of national and local policy guidance limited the extent to which schools adapted remote well‐being provision and maintained contact with families. This disruption contributed to a decline in children's emotional well‐being, particularly for those children from disadvantaged backgrounds. Covid recovery recommendations center on a renewed emphasis on universal, ethos‐focused interventions and a strength‐based focus on curriculum change.

"Early intervention isn't an option, it's a necessity": learning from implementation facilitators and challenges from the rapid scaling of an early intervention eating disorders programme in England.

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has shown promising outcomes for young people with an eating disorder, leading to national scaling and implementation across England. Between 2020 and 2023, the national implementation of FREED was supported by the Academic Health Science Networks (AHSNs), which are publicly funded organisations with the mission to spread innovations at scale and pace. This study aimed to investigate the views and experiences of AHSN programme leads on the national roll-out of FREED and the perceived sustainability of the model. Semi-structured interviews were conducted with 13 programme leads across the AHSNs with direct experience supporting the national implementation of FREED. Thematic analysis was adopted using a critical realist approach. Initial sub-themes were inductively generated and then organised under seven larger themes representing the domains of the Non-adoption, Abandonment, and Challenges to Scale-Up, Spread and Sustainability (NASSS) framework. Each sub-theme was classified as a facilitator and/or barrier and then each larger theme/domain was assessed for its complexity (simple, complicated, complex). Data analysis revealed 28 sub-themes, 10 identified as facilitators, 13 as barriers, and five as both. Two domains were classed as simple, three as complicated, and two as complex. Sub-themes ranged from illness-related complexities to organisational pressures. Key facilitators included a high-value proposition for FREED and a supportive network. Key barriers included staffing issues and illness-related factors that challenge early intervention. Participants described broad support for FREED but desired sustained investment for continued provision and improving implementation fidelity. Future development areas raised by participants included enlarging the evidence base for early intervention, increasing associated training opportunities, and widening the reach of FREED. Results offer learning for early intervention in eating disorders and the scaling of new health initiatives.

African American Parents’ experience with early childhood mental health and child welfare services: Racism and seeking understanding

BackgroundImpacts of child maltreatment and child welfare involvement on young children are significant and early childhood mental health services are important to reduce risk factors for them. However, racial disparities limit access to mental health services. ObjectiveThe purpose of this study is to understand the experience and perspective of birth parents accessing mental health services for their child welfare-involved toddlers and preschoolers aged 1.5 to 5 years. Specifically, this study seeks to examine racism and service disparities among African American parents. To our knowledge, there is no study examining birth parents’ perspectives on mental health services for young children.Participants & Setting: This study collected original qualitative data using semi-structured interviews. Nine African American participants shared their experiences from February 2018 to November 2019. MethodsQualitative data analysis used a pragmatic realist approach to understand the complex phenomenon of parents’ experience accessing services. NVivo 12 was used for qualitative analysis to help condense themes for the study. Quantitative descriptive analysis using Stata 14.2 provided the sample description. ResultsEquity and understanding was a main theme with three sub-themes; racism, child welfare understanding the family, and mental health provider understanding the family. Participants experienced racism, creating a mistrust of mental health providers and child welfare workers. ConclusionImplications for policy and practice to improve equity and understanding of families in child welfare are discussed. Future research can build on this study by examining how racism impacts service use and how interventions can increase understanding of families using child welfare and mental health services.