In memoriam: the contributions to public health research of Farah Jamal, BA, MSc, PhD

Although it might be assumed that most public health programmes involving social or behavioural rather than clinical interventions are unlikely to be iatrogenic, it is well established that they can sometimes cause serious harms. However, the assessment of adverse effects remains a neglected topic in evaluations of public health interventions. In this paper, we first argue for the importance of evaluations of public health interventions not only aiming to examine potential harms but also the mechanisms that might underlie these harms so that they might be avoided in the future. Second, we examine empirically whether protocols for the evaluation of public health interventions do examine harmful outcomes and underlying mechanisms and, if so, how. Third, we suggest a new process by which evaluators might develop 'dark logic models' to guide the evaluation of potential harms and underlying mechanisms, which includes: theorisation of agency-structure interactions; building comparative understanding across similar interventions via reciprocal and refutational translation; and consultation with local actors to identify how mechanisms might be derailed, leading to harmful consequences. We refer to the evaluation of a youth work intervention which unexpectedly appeared to increase the rate of teenage pregnancy it was aiming to reduce, and apply our proposed process retrospectively to see how this might have strengthened the evaluation. We conclude that the theorisation of dark logic models is critical to prevent replication of harms. It is not intended to replace but rather to inform empirical evaluation.

Background Randomised controlled trials (RCTs) of social interventions are often criticised as failing to open the ‘black box’ whereby they only address questions about ‘what works’ without explaining the underlying processes of implementation and mechanisms of action, and how these vary by contextual characteristics of person and place. Realist RCTs are proposed as an approach to evaluation science that addresses these gaps while preserving the strengths of RCTs in providing evidence with strong internal validity in estimating effects. Methods In the context of growing interest in designing and conducting realist trials, there is an urgent need to offer a worked example to provide guidance on how such an approach might be practically taken forward. The aim of this paper is to outline a three-staged theoretical and methodological process of undertaking a realist RCT using the example of the evaluation of a whole-school restorative intervention aiming to reduce aggression and bullying in English secondary schools. Discussion First, informed by the findings of our initial pilot trial and sociological theory, we elaborate our theory of change and specific a priori hypotheses about how intervention mechanisms interact with context to produce outcomes. Second, we describe how we will use emerging findings from the integral process evaluation within the RCT to refine, and add to, these a priori hypotheses before the collection of quantitative, follow-up data. Third, we will test our hypotheses using a combination of process and outcome data via quantitative analyses of effect mediation (examining mechanisms) and moderation (examining contextual contingencies). The results are then used to refine and further develop the theory of change. Conclusion The aim of the realist RCT approach is thus not merely to assess whether the intervention is effective or not, but to develop empirically informed mid-range theory through a three-stage process. There are important implications for those involved with reporting and reviewing RCTs, including the use of new, iterative protocols. Trial registration Current Controlled Trials ISRCTN10751359 (Registered 11 March 2014)

Background There is increasing interest in promoting young people’s health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students’ health behaviours, or how students’ backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people’s health? Methods Systematic review of qualitative studies. Sixteen databases were searched, eliciting 62, 329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare’s meta-ethnographic approach. Results Nineteen qualitative studies were synthesised to explore processes through which school-level influences on young people’s health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised ‘hotspots’ at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools’ organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of ‘escape’, either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard’s theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people’s agency and student-led ‘systems’ in constituting school environments and generating health risks. Conclusion Institutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.