Stakeholder characteristics
Forty-one stakeholders were involved across six co-production workshops. There were 24 mothers involved over four workshops: workshop one (n=12), workshop two (n=5), workshop three (n=5), and workshop four (n=2). Workshop five (n=6) comprised of fathers and workshop six (n=11) comprised of young people aged 13-18 years. No other demographic details were collected.
Intervention principles
The intervention principles identified for families experiencing multiple and interacting adversities are outlined below. These principles provide insights into the ways in which mothers, fathers, and young people perceived an intervention may bring about positive change and are organised under three themes: (1) building a network to reduce isolation; (2) establishing a trauma-informed approach; and (3) tailoring support to the family’s needs and focusing on their strengths.
Building a network to reduce isolation: “Support is out there but we don’t know about it”.
Approaches which aim to reduce the isolation felt by parents and young people who experience multiple and interacting adversities were thought to be important. Building a network was identified as a possible solution to address such feelings and experiences of loneliness, which could be achieved through increasing awareness of community services through a specified practitioner and providing access to peer support. Parents and young people recognised that there were already many different support services and groups in their local area targeting the different risk factors or with an aim to reduce isolation and loneliness, for instance group support for substance use. However, the problem was that they did not know what options were available to them, how to find out about them, or how to access them. Within formal appointments with healthcare practitioners, parents felt that appointment times were not long enough to discuss additional support needs such as meeting people in similar situations to themselves, what services were available to them, or their concerns over issues relating to poverty. Moreover, finding local services without the help of practitioners could be confusing and challenging. Stakeholders across the different workshops highlighted the importance of peer support, community, and informal contacts and networks as a key strategy of knowing which services and opportunities are available to them. Many shared that developing a formal approach to identify the right support would be useful, including an informational booklet, a digital application, or central contact person. Based on stakeholder preference across the workshops, conversations mainly focused on a specified contact person.
Mothers with lived experience of multiple and interacting adversities shared the insight that they wanted a person in the role of a “companion, buddy, or befriending service” who could support access into different services and provide emotional support throughout that journey. Some mothers had found this type of support from HomeStart or their Children's Centre but this was not typical for all. The principle was that the supporter could initially accompany them to services, but over time help the parent develop skills, strategies, and confidence, to empower them to attend services or meetings independently in the future. Likewise, fathers spoke of wanting someone to “walk alongside” them during the process of being referred onto and waiting to attend different services, as they had experienced anxiety of being moved through different services without support. Young people also stated that they would like to have a "buffer person” who could support them to access and engage with specialised support or interventions (e.g., Children and Adolescent Mental Health Services). This person was thought to help young people overcome social anxiety and lack of self-confidence when accessing services on their own, as well as being a friendly person to rely on during waitlist times. This person would be knowledgeable about available support services and be able to link them to support, rather than attempting to find support themselves.
For parents (both mothers and fathers), peers with lived experience of family adversities were discussed as important to help them navigate access to support, which also provided opportunity for shared understanding and empathy. They felt that talking to someone who had similar experiences to themselves would help them overcome the fear of judgement and stigma often felt when in formal consultations with practitioners. The opportunity to meet peers could also encourage hope and aspirations, as stories could be inspirational, wherein parents could learn from their peers “navigation of the support system”. Fathers found peer support as an important element of their journey as they were able to talk and create connections with dads in similar circumstances, often feeling left out and isolated from formal support services. Peer support may also be useful for young people but only in a controlled environment with strict rules about disclosure and confidentiality. Young people emphasised that peer support would mainly be beneficial if the peer mentor was going along to different activities with them.
Establishing a trauma-informed approach: “We need to feel understood”.
Approaches which aim to address and understand the trauma experienced by parents and young people living with multiple and interacting adversities were perceived to be important. Stakeholders wanted their experiences of mental health, substance use, domestic violence and abuse, and/or poverty to be understood by the practitioners they encounter, whether within health and social care or voluntary and community sector organisations. Parents and young people provided the insight that specialised training for practitioners would be useful within current support and practice, as well as having time to slowly build trusting relationships with practitioners. Both solutions were thought to have the potential to address parents and young people’s feelings of being misunderstood, and issues with trauma and stigma.
Many parents shared concerns around disclosing mental health problems, substance use, or domestic violence during appointments with practitioners due to the fear and stigma of how the practitioner might respond, of child protection services involvement, as well as previously experiencing discrimination from practitioners, impacting their self-esteem. For instance, stakeholders discussed that if a parent is told by a healthcare practitioner that they will not be provided with mental health support until they have reduced their substance use this can be a highly stigmatising and traumatic experience for the individual if not handled in an understanding and sensitive way by the practitioner. They felt that parents would need to be supported concurrently with their differing needs, with joined up services for individual risk factors (e.g., mental health and substance use services) or a bridging practitioner between the different services. At the least, parents discussed that they wanted practitioners to understand the lived experiences of parents with multiple and interacting adversities. Furthermore, parents believed that practitioners needed to be aware of the possibility of retraumatising the parent by directly and bluntly asking about their childhoods, experienced violence, mental health, or substance use within appointments and there needed to be sufficient external support in place if this was the case. Fathers indicated that direct questions about their mental health made them lose engagement quickly, but questions such as “How are things at home and at work?" facilitated conversations more effectively and felt less threatening. Young people also thought it was important to first discuss things other than mental health or problems at home, like talking about hobbies, TV, or shared interests. Whilst parents thought it could be useful to ask about financial situations in healthcare appointments, they thought it could be stigmatising and that practitioners would need to ask this question in a non-threatening way e.g., “do you ever struggle to make ends meet?” The characteristics of the practitioner and their questioning were therefore crucial in how parents and young people engaged with support; they needed to be sensitive and tactful. Stakeholders felt that training for practitioners could build the confidence of the practitioner whilst also improving the practitioner-client relationship and the families experience of support. It was discussed that such training could include, awareness raising that there is an interaction between different family adversities and the lived experience of poverty, examples of how to respond compassionately through changes to language and behaviours and how to ask questions appropriately, as well as how to resist re-traumatisation of parents and young people.
Parents and young people reported preferring relational interactions and a graduated trust building approach to support. However, within short appointment times, it was difficult to develop such a trusting relationship with a health or social-care practitioner. Therefore, there was a need for an honest, transparent, and understanding practitioner, who may be external to their standard health or social care appointments, with whom they could slowly build a relationship. This approach was thought to include talking to a practitioner about things that were not directly related to support or their problems and participating in activities together like having a coffee or going for a walk, which helped to build trusting relationships and “broke the ice”. This gradual process allowed families to feel more connected to the practitioner and able to be open about their experiences and what support they needed. Continuity in the person providing support was also important, as stakeholders did not want to have to repeatedly tell their stories to different people, as this could also be traumatising.
Tailoring support to the family’s needs and focusing on their strengths: “We need support for each family member”.
Approaches which aim to address the needs and understand the strengths of different family members were important. Mothers, fathers, and young people all discussed how current services may not be as inclusive to their individual needs as they would have liked. Mothers wanted to be provided with opportunities that focused on their individual needs and strengths, and not on them as a mother, including finding opportunities to pursue passions such as art or outdoor activities. Mothers also felt that services should be separate for different family members, linking up only if or when needed, allowing for privacy. Separate support was also discussed as crucial in the case of disclosed or undisclosed domestic violence and abuse within the family. Fathers acknowledged that services were not typically focused on, inclusive of, or accessible to dads. Whilst fathers recognised that the forms of support that they would need were similar to that of mothers, they often felt excluded from informational leaflets, appointments, and discussions, which were usually targeted towards the mother. As an example, they cited midwives, where they felt additional training could ensure that they consider the needs of the father and recognise that the whole family needs support, not just the mother and child. Fathers wanted to be included in appointments, either together with other family members or separately but with an effort from practitioners to understand their perspective.
Similarly, young people discussed that practitioners who are supporting parents could also seek to identify whether their children, especially of adolescent age, may also need their own support as well. Young people felt confidentiality or lack thereof was a major issue regarding support that included other family members. They wanted support separate from their parents, where they felt respected and acknowledged as their own person. Having support tailored to their own needs, rather than the needs of the family, would allow young people to feel safe and not fear reprisals or increased problems if issues were disclosed in front of their parents. There was a felt conflict between practitioners being able to safeguard the child whilst also providing them with confidential support. Young people felt that when appropriate, practitioners should involve young people directly in decisions about their care so that they know what is happening and can prepare themselves, especially if that meant a practitioner needed to tell parents about what a young person discussed in their appointment. Young people also felt that support should be age-appropriate and tailored to be inclusive of those from different backgrounds, cultures, or genders. Schools were also identified as a place where young people could potentially access support, as it is separate from the family. However, there is significant variation in schools, and particularly in their resources to support young people in this way. In addition, it was important that support within school did not further stigmatise or single out young people, for example, being taken out in the middle of a class for support was viewed as embarrassing.
All stakeholders expressed the need for flexibility and adaptability of an intervention, where they could choose when they access (e.g., weekday/weekend, day/evening), how they access (e.g., phone call, text, in person) or where a service is situated (e.g., healthcare, community, home, school). It was felt that the intensity and frequency of support being provided needed to be varied and tailored to different family members. Being provided with such choices, as well as being supported to develop their own goals and skills was thought to help empower families.
Poverty was seen as a barrier to accessing support and impacted on the whole family’s wellbeing, but parents felt there was not a “quick fix approach” to addressing poverty issues. A tailored approach that suited the needs of the family and their financial situation was thought to be of most use to parents. Being provided with financial advice and information by a practitioner, or having referrals made into services to address welfare or housing issues were discussed as being useful by parents. Parents also wanted to be offered choices so they could decide what would be of most benefit to them financially, including being offered cheaper or discounted extracurricular activities, being provided with vouchers for food, or being provided with vouchers specifically for their children. Where parents are provided with an unconditional cash transfer, this was thought to not be sustainable, as parents would need other forms of support in conjunction. Importantly, the provision of free childcare or creche support when accessing services was also discussed as necessary for parents of young children, which could allow them to access support and gives them time and space to process and reflect on the session before stepping back into childcare responsibilities.