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Conventional systematic reviews offer few insights into for whom and how interventions work. 'Realist reviews' examine such questions via examining 'context-mechanism-outcome configurations' (CMOCs) but are insufficiently rigorous in how evidence is identified, assessed and synthesised. We developed 'realist systematic reviews', addressing similar questions to realist reviews but using rigorous methods. We applied this to synthesising evidence on school-based prevention of dating and relationship violence (DRV) and gender-based violence (GBV). This paper reflects on overall methods and findings, drawing on papers reporting each analysis. Drawing on intervention descriptions, theories of change and process evaluations, we developed initial CMOC hypotheses: interventions triggering 'school-transformation' mechanisms (preventing violence by changing school environments) will achieve larger effects than those triggering 'basic-safety' (stopping violence by emphasising its unacceptability) or 'positive-development' (developing students' broader skills and relationships) mechanisms; however, school transformation would only work in schools with high organisational capacity. We used various innovative analyses, some of which aimed to test these hypotheses and some of which were inductive, drawing on available findings to augment and refine the CMOCs. Overall, interventions were effective in reducing long-term DRV but not GBV or short-term DRV. DRV prevention occurred most effectively via the 'basic-safety' mechanism. 'School-transformation' mechanisms were more effective in preventing GBV but only in high-income countries. Impacts on long-term DRV victimisation were greater when working with a critical mass of participating girls. Impacts on long-term DRV perpetration were greater for boys. Interventions were more effective when focusing on skills, attitudes and relationships, or lacking parental involvement or victim stories. Our method provided novel insights and should be useful to policy-makers seeking the best interventions for their contexts and the most information to inform implementation.

Dating and relationship violence (DRV) and gender-based violence (GBV) among children and young people incur a high cost to individuals and society. School-based interventions present an opportunity to prevent DRV and GBV early in individuals' lives. However, with school resources under pressure, policymakers require guidance on the economics of implementing interventions. As part of a large systematic review funded by the National Institute for Health and Care Research (NIHR), we searched for economic evaluations and costing studies of school-based interventions for DRV and GBV. No formal economic evaluations were identified. Seven studies reporting costs, cost savings, or resource use for eight interventions were identified. The largest costs of implementing interventions were related to staff training and salaries but savings could be made by implementing interventions on a large scale. The potential cost savings of avoided DRV and GBV far outweighed the costs of implementation.

Purpose Healthcare settings remain important contexts for the identification of intimate partner violence (IPV); however, identification strategies for IPV are diverse and work in complex ways that may differ across contexts. To understand how, rather than if, IPV identification strategies work, we undertook a systematic review of reviews with realist synthesis. Methods We undertook a search of five databases for full-text, peer-reviewed systematic reviews addressing identification strategies for IPV in healthcare contexts. We screened titles and full texts in duplicate and independently, appraised included systematic reviews and synthesized them using methods from realist synthesis to develop context-mechanism-outcome configurations (CMOCs). Results We included 29 reviews reported in 32 publications. Our findings were summarized in four CMOCs at system, system-clinician, clinician and patient levels. CMOCs underscored the role of supportive clinical and practice contexts, patient-provider relationships and continuity of care to ensure the benefits, and reduce the potential harms, of a range of identification strategies. CMOCs also highlighted the importance of supporting clinicians through clinical policies and protocols to ensure a consistent, safe and effective response to IPV. Conclusions Future work should address how supportive clinical contexts that facilitate effective inquiry, disclosure, and referral to services can be created, acknowledging that what works in one context may not work in another. Included systematic reviews did not permit exploration of how racial and ethnic diversity relate to identification strategies. This is an area requiring urgent research to inform clinical practice., Author(s): G. J. Melendez-Torres [sup.1] , Elizabeth Burgess Dowdell [sup.2] , Susan J. Kelley [sup.3] , Annie Lewis-O'Connor [sup.4] Author Affiliations: (1) https://ror.org/03yghzc09, grid.8391.3, 0000 0004 1936 8024, Faculty of [...]

School-based interventions for preventing dating and relationship violence (DRV) and gender-based violence (GBV) are an important way of attempting to prevent and reduce the significant amount of DRV and GBV that occurs in schools. A theoretical understanding of how these interventions are likely to cause change is essential for developing and evaluating effectiveness, so developing an overarching theory of change for school-based interventions to prevent DRV and GBV was the first step in our systematic review. Theoretical data were synthesised from 68 outcome evaluations using methods common to qualitative synthesis. Specifically, we used a meta-ethnographic approach to develop a line-of-argument for an overarching theory of change and Markham and Aveyard's (2003, Social Science & Medicine, 56, 1209) theory of human functioning and school organisation as a framework for structuring the concepts. The overall theory of change generated was that by strengthening relationships between and among staff and students, between the classroom and the wider school, and between schools and communities, and by increasing students' sense of belonging with student-centred learning opportunities, schools would encourage student commitment to the school and its values, prosocial behaviour and avoidance of violence and aggression. The theory of human functioning informed our understanding of the mechanisms of action but from our analysis we found that it required refinement to address the importance of context and student agency.

Evidence from intervention evaluations suggests that achieving meaningful and lasting social, behavioural and attitudinal change from relationships, sex and health education (RSHE) in schools requires more than just a curriculum. Whole-school approaches appear particularly promising since they work at multiple levels. For instance, they may: engage with carers, communities and local services; address iniquitous cultures and norms; change school policies and practices; and actively involve young people themselves. They have also been advocated to tackle sexual harassment and abuse in schools. Currently, however, such approaches have not been rigorously evaluated in the UK. This article focuses on the whole-school elements of two recent RSHE pilot studies conducted in English secondary schools. We describe how these elements were variably enacted in different settings. We analyse contextual factors that help account for these differences, including: teacher and departmental professional identity and autonomy; broader education policy including high-stakes testing and school inspection judgements; the significance of support staff; and staff-student relationships and partnerships. We argue that the likely impact of whole-school approaches and RSHE in schools more generally will depend on attending to all of these factors. The paper contributes firstly to debates about the theory and practice of RSHE by highlighting the significance of processes and cultures beyond the classroom in enabling or constraining positive change. Secondly it contributes to scholarship that elucidates the role of contexts, broadly defined, in understanding the enactment of policy and practice.

Objectives: Whole-school interventions and programmes aim to change school environments to promote health. Previous reviews suggest these are often inappropriately informed by individualistic psychological theories. We undertook a systematic review of whole-school interventions to prevent substance use and violence. This paper reports on a synthesis of theories of change, assessing whether these aligned with, and suggested refinements to, the theory of human functioning and school organisation, a more encompassing, sociological theory. This theory proposes that schools improve health by promoting student commitment, achieved by eroding various 'boundaries' (e.g. between staff and students) and reframing provision based on student needs so that students commit more fully to school 'instructional' (learning) and 'regulatory' (behaviour) orders. Setting: International. Design: Systematic review. Methods: The study involved systematic searches, data extraction and quality assessment. Theories of change were synthesised using a best-fit framework. Results: Despite only one intervention being explicitly informed by the theory of human functioning and school organisation, the theories of change of most interventions aligned (at least in part) with aspects of this theory. Synthesis suggested various refinements to the theory. First, it suggested specific activities that can modify boundaries and reframing to increase student commitment. Second, it refined the concept of reframing to include building learning on existing student knowledge using a 'constructivist' approach. Third, it suggested future intervention might usefully seek to erode boundaries between the 'instructional' and 'regulatory' orders of the school to create a single 'developmental' order. Finally, it recognised that whole-school interventions might prevent violence and substance use among students in ways other than by building student commitment. Conclusion: Our refined theory of change provides a firmer basis for interventions. Future work is needed to examine empirical support for the refined theory.

Learning Together is a whole-school intervention, evaluated using a randomized controlled trial in southeast England, which reduced bullying and improved physical and mental health. This paper examines trial data using fuzzy-set qualitative comparative analysis to test hypotheses derived from embedded qualitative research about potential causal pathways. Analyses suggested that the intervention worked via three mechanisms: improving student commitment to school; improving student pro-social skills; and de-escalating conflict and bullying. Evidence also suggests that these mechanisms may have been activated via other resources in schools not receiving Learning Together resources. The analysis suggests which contextual features may be important for activating these mechanisms.

The mental health and wellbeing of children and young people who have been in care, primarily foster care, kinship care or residential care, remains a public health priority. The Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) synthesized evidence for the effectiveness of interventions targeting: subjective wellbeing; mental, behavioral and neurodevelopmental disorders; and suicide-related outcomes. Searches were conducted in 16 bibliographic databases and 22 websites between 1990 and 2022. This was supplemented by citation tracking, screening of relevant systematic reviews, and expert recommendation. We identified 35 interventions, with 44 evaluations via randomized controlled trials. Through meta-analyses, we found that interventions have a small beneficial impact on a variety of mental health outcomes in the short term (0–6 months). Interventions improved total social, emotional, and behavioral problems (d = −0.15, 95% CI [−0.28, −0.02]), social-emotional functioning difficulties (d = −0.18, 95% CI [−0.31, −0.05]), externalizing problem behaviors (d = −0.30, 95% CI [−0.53, −0.08]), internalizing problem behaviors (d = −0.35, 95% CI [−0.61, −0.08]); and depression and anxiety (d = −0.26, 95% CI [−0.40, −0.13]). Interventions did not demonstrate any effectiveness for outcomes assessed in the longer term (>6 months). Certainty of effectiveness was limited by risk of bias and imprecision. There was limited available evidence for interventions targeting subjective wellbeing and suicide-related outcomes. Future intervention design and delivery must ensure that programs are sufficient to activate causal mechanisms and facilitate change. Evaluation research should use a robust methodology. PROSPERO Registration: CRD42020177478 [ABSTRACT FROM AUTHOR]

Young people's wellbeing is often lowest where they assume a relatively low position within their school's socioeconomic hierarchy, for example, among poorer children attending more affluent schools. Transition to secondary school is a period during which young people typically enter an environment which is more socioeconomically diverse than their primary school. Young people joining a school with a higher socioeconomic status intake relative to their primary school may assume a relatively lowered position within their school's socioeconomic hierarchy, experiencing a detriment to their wellbeing as a consequence. This article draws on data from 45,055 pupils in Years 7 and 8, from 193 secondary schools in Wales, who completed the 2017 Student Health Research Network (SHRN) Student Health and Wellbeing (SHW) survey. Pupils reported which primary school they previously attended, and survey data on wellbeing were linked to publicly available data on the free school meal entitlement of schools attended. In cross-classified linear mixed-effects models, with primary and secondary school as levels, mental wellbeing varied significantly according to both primary and secondary school attended. A higher school-level deprivation was associated with worse mental wellbeing in both cases. Mental wellbeing was significantly predicted by the relative affluence of a child's primary and secondary school, with movement to a secondary school of higher overall socioeconomic status associated with lowered wellbeing. These findings highlight transition to secondary school as a key point in which socioeconomic inequality in wellbeing may widen, and thus as an important focal point for intervention to reduce health inequalities.

The incorporation of evidence derived from multiple research designs into one single synthesis can enhance the utility of systematic reviews making them more worthwhile, useful, and insightful. Methodological guidance for mixed-methods synthesis continues to emerge and evolve but broadly involves a sequential, parallel, or convergent approach according to the degree of independence between individual syntheses before they are combined. We present two case studies in which we used novel and innovative methods to draw together the findings from individual but related quantitative and qualitative syntheses to aid interpretation of the overall evidence base. Our approach moved beyond making a choice between parallel, sequential, or convergent methods to interweave the findings of individual reviews and offers three key innovations to mixed-methods synthesis methods: (1) The use of intersubjective questions to understand the findings of the individual reviews through different lenses; (2) Immersion of key reviewers in the entirety of the evidence base; and (3) Commencing the process during the final stages of the synthesis of individual reviews, at a point where reviewers are developing an understanding of initial findings. Underlying our approach is the process of exploration and identification of links between and across review findings, an approach that is fundamental to all evidence syntheses but usually occurs at the level of the study. Adapting existing methods for exploring and identifying patterns and links between and across studies to interweave the findings between and across reviews may prove valuable.

Interventions that train parents to share picture books with children are seen as a strategy for supporting child language development. We conducted meta-analyses using robust variance estimation modeling on results from 19 RCTs (N[subscript total] = 2,594; M[subscript child age] = 1-6 years). Overall, book-sharing interventions had a small sized effect on both expressive language (d = 0.41) and receptive language (d = 0.26). They had a large effect on caregiver book-sharing competence (d = 1.01). The impact of the intervention on child language was moderated by intervention dosage, with lower dosage associated with a minimal impact. Child age and caregiver education level were unrelated to child outcome. This review and meta-analysis confirms the promise of book-sharing interventions for enhancing and accelerating child language development.

This study evaluated The Grassroot Project, a middle school sexual health promotion program in Washington, DC that uses university-level athlete role models and sports-based games. Seven schools were allocated to immediate (n = 160) or delayed intervention (n = 166). Students were tested before and immediately after the intervention on attitudes and self-efficacy to avoid sexual risk, intentions to avoid or engage in sexual intercourse, HIV stigma, and endorsement of violent behaviors. There was no evidence of differences between groups; however, the intervention has promise in respect of key outcome domains. This research justifies future longitudinal evaluation to assess behavioral and biomedical outcomes.

Adolescent dating and relationship violence is associated with health harms and is an important topic for sex education. School-based interventions addressing this have been effective in the USA, but schools in England confront pressures that might hinder implementation. We assessed the feasibility of, and contextual enablers/barriers to implementing Project Respect, a whole-school intervention. We conducted a pilot trial with process evaluation in six English secondary schools. Intervention comprised: training; policy-review; mapping and patrolling 'hotspots'; parent information; help-seeking app; and a curriculum (including student-led campaigns) targeting dating violence. Process evaluation included assessments of fidelity and interviews with the trainer and school staff. Schools delivered training and lessons partially or completely and made parent and app information available. Two schools conducted policy reviews; none patrolled hotspots or implemented campaigns. Implementation was strengthened where staff saw dating violence as a priority. Delivery was undermined where staff were insufficiently involved, lacked time for planning or struggled to timetable lessons, and where new school challenges undermined engagement. School-based health interventions must work to build staff buy-in and ensure they do not overburden schools. Dating and relationship violence might best be addressed in this context as a broader aspect of sex education.

Qualitative comparative analysis (QCA) was originally developed as a tool for cross-national comparisons in macrosociology, but its use in evaluation and evidence synthesis of complex interventions is rapidly developing. QCA is theory-driven and relies on Boolean logic to identify pathways to an outcome (e.g., is the intervention effective or not?). We use the example of two linked systematic reviews on weight management programs (WMPs) for adults--one focusing on user views (a "views synthesis") and one focusing on the effectiveness of WMPs incorporating dietary and physical activity--to demonstrate how a synthesis of user views can supply a working theory to structure a QCA. We discuss how a views synthesis is especially apt to supply this working theory because user views can (a) represent a "middle-range theory" of the intervention; (b) bring a participatory, democratic perspective; and (c) provide an idiographic understanding of how the intervention works that external taxonomies may not be able to furnish. We then discuss the practical role that the views synthesis played in our QCA examining pathways to effectiveness: (a) by suggesting specific intervention features and sharpening the focus on the most salient features to be examined, (b) by supporting interpretation of findings, and (c) by bounding data analysis to prevent data dredging.

Background: The costs associated with healthcare are of critical importance to both decision-makers and users, given the limited resources allocated to the health sector. However, the available scientific evidence on healthcare costs in low- and middle-income countries, such as Peru, is scarce. In the Peruvian context, the health system is fragmented, and the private health insurance and its financing models have received less research attention. We aimed to analyse user cost-sharing and associated factors within the private healthcare system. Methods: Our study was cross-sectional, using open data from the Electronic Transaction Model of Standardized Billing Data—TEDEF-SUSALUD, between 2021–2022. Our unit of analysis is the user's medical bills. We considered the total amount of cost-sharing, proportion of total payments as cost-sharing, and cost-sharing as a proportion of minimum salaries. We use a multiple regression model to perform the analyses. Results: Our study included 5,286,556 health services provided to users of the private health insurance in Peru. We found a significant difference was observed in the cost-sharing for hospitalization-related services, with an average of 419.64 soles per day (95% CI: 413.44 to 425.85). Also, we identified that for hospitalization-related services per day is, on average, 0.41 (95% CI: 0.41 to 0.41) minimum salaries more expensive than outpatient care, although cost-sharing per day of hospitalization represent on average only 14% of the total amount submitted. Conclusions: Our study provides a detailed overview of cost-sharing in the private healthcare system in Peru and the factors associated with them. Policymakers can use the study's finding that higher cost-sharing for inpatient hospitalization compared to outpatient care in private insurance can create inequities in access to healthcare to design policies aimed at reducing these costs and promoting a more equitable and accessible healthcare system in Peru. [ABSTRACT FROM AUTHOR]