Leanne Sawle

This article arises from a theory-informed, sequential, mixed methods project which combined a survey and multiple nested case studies to examine implementation and experience in the context of mental health crisis services for children and young people in England and Wales. Its primary contribution to mixed methods research is to show how theory, mixed methods and case studies can be practicably brought together to improve understanding of complex interventions introduced into complex systems. It makes a further contribution through a reflective exploration of the implementation of mixed methods research in sensitive fields involving vulnerable groups, by specifically exploring: participation and engagement; and fieldwork flexibility, power and control.

Introduction: Eradication of human papillomavirus (HPV) is a global public health priority. It is linked to approximately 5% of all cancers, causing almost all cases of cervical cancer, nearly 90% of anal cancers and a significant proportion of oropharyngeal, penile, vaginal and vulval cancers. HPV vaccination can provide protection when 90% coverage is reached. However, many countries are yet to achieve this threshold. Uptake in Romania, Bulgaria and Croatia has been low historically, and although rates are increasing, vaccine coverage remains significantly lower than the recommended WHO rate of 90%. This systematic review sought to identify the barriers and enablers to HPV vaccine uptake in these three countries. Methods: The Joanna Briggs Institute (JBI) convergent integrated methodological framework for mixed methods systematic reviews was employed. Seven databases were searched from inception to April 2024. No restrictions were imposed on language or setting. All included studies were critically appraised with JBI Critical Appraisal tools. Data extraction was performed using standardised tools with an emphasis on equity, followed by data transformation and data synthesis. Each stage was conducted by two independent reviewers. Bronfenbrenner’s socio-ecological model was applied as a theoretical lens. Results: A total of 402 findings from 31 studies were extracted and aggregated to form 65 categories. These were further combined in a meta-synthesis which yielded 13 synthesised findings. The meta synthesis identified commonalities across each country’s findings: attitudes towards HPV vaccination were characterised by distrust and misconceptions; knowledge deficits existed particularly in relation to gender neutral provision; and a lack of consensus among health professionals concerning the efficacy and safety of the vaccine impacted intention and uptake. Conclusions: Barriers and enablers to HPV vaccine uptake centred on knowledge and trust. Public health interventions that address the concerns of young people, parents and health professionals are pivotal to improving HPV vaccine coverage across the three countries. Contemporaneous research to further explore the social, cultural and political factors that impede acceptance of the HPV vaccine is also required. PROSPERO registration number: CRD42024523200.

Background One in six five 16-year-olds have a probable mental health difficulty. Of these, almost half of older teenagers and a quarter of 11–16-year-olds report having self-harmed or attempted suicide. Currently, there is little research into mental health crisis services for young people, with little understanding of what services exist, who uses them, or what works best. Question ‘How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services’? Objectives To describe National Health Service (NHS), local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales. To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services. To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families. Methods A sequential mixed methods approach, underpinned by normalisation process theory will be employed. A survey will create a detailed record of how crisis responses across England and Wales are organised, implemented and used. Subsequently, eight contrasting services in relation to geographic and socioeconomic setting, populations served, and service configuration will be identified as case studies. Interviews will be conducted with children, young people and parents/carers who have used the service, as well as commissioners, managers and practitioners. Operational policies and service usage data will also be examined. Analysis of how each service is provided, experienced, implemented and sustained will be conducted both inductively and deductively, reflecting normalisation process theory constructs.

Background One in six five -16-year-olds have a probable mental health difficulty. Of these, almost half of older teenagers and a quarter of 11–16-year-olds report having self-harmed or attempted suicide. Currently, there is little research into mental health crisis services for young people, with little understanding of what services exist, who uses them, or what works best. Question ‘How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services’? Objectives 1. To describe National Health Service (NHS), local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales. 2. To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services. 3. To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families. Methods A sequential mixed methods approach, underpinned by normalisation process theory will be employed. A survey will create a detailed record of how crisis responses across England and Wales are organised, implemented and used. Subsequently, eight contrasting services in relation to geographic and socioeconomic setting, populations served, and service configuration will be identified as case studies. Interviews will be conducted with children, young people and parents/carers who have used the service, as well as commissioners, managers and practitioners. Operational policies and service usage data will also be examined. Analysis of how each service is provided, experienced, implemented and sustained will be conducted both inductively and deductively, reflecting normalisation process theory constructs.