text:
University of Michigan president fired for 'inappropriate relationship' with employee
Does our cop-turned-mayor distrust the NYPD?
Bill de Blasio's education legacy: Lofty promises, sweeping initiatives and uneven results
By Michael Elsen-Rooney
There is perhaps no issue that better captures Bill de Blasio's complex legacy — a mix of lofty promises, sweeping initiatives and uneven results — than education.
From the beginning of his tenure eight years ago, de Blasio used education to sharply distinguish himself from his predecessor Michael Bloomberg, who upended the city school system through an effort to centralize control, close underperforming public schools, and expand publicly funded privately run charter schools.
Mayor Bill de Blasio (Jeff Bachner/for New York Daily News)
"Bill de Blasio came into office as the anti-Bloomberg with a commitment to establish himself as the progressive who was going to dampen the expansion of charter schools and reduce test-based accountability," said Aaron Pallas, a professor at Columbia University's Teachers College.
De Blasio vowed to take a different approach, flooding low-performing schools with additional resources and ramping up a program that is now widely recognized as his signature achievement: Universal Pre-K.
Former New York City School Chancellor Richard A. Carranza (left) with Mayor Bill de Blasio at Public School 25 The Bilingual School in the Bronx on April 9, 2018. (Anthony DelMundo/New York Daily News)
Using a mix of state and city funds and a patchwork of district and community-run childcare programs, de Blasio's administration expanded the number of free preschool seats for 4-year-olds from about 19,000 in 2014 to a peak of nearly 70,000 — enough for any kid who wants one. In recent years, the Education Department has launched and expanded a similar program for 3-year-olds.
"I think Universal Pre-K is a big win," said Pallas. "He delivered on that promise quite effectively and that might be the most beneficial piece of his legacy."
Bruce Fuller, a professor of education and sociology at the University of California at Berkeley, said de Blasio was "quite visionary" in embracing a policy initiative that has since gained currency across the country and is a centerpiece of the federal Build Back Better bill.
Mayor Bill de Blasio, center, and Schools Chancellor Meisha Porter, right, talk with Pre-K students at Phyl's Academy, Wednesday, March 24, in the Brooklyn borough of New York. (Mark Lennihan)
But even de Blasio's marquee accomplishment comes with some asterisks.
The effort did not come with an equal investment in care for infants and toddlers, a time during which much of the brain's "architecture" is formed, said Shael Polakow-Suransky, the president of Bank Street College of Education and a former deputy schools chancellor under Bloomberg.
Also See: Mayor de Blasio's policing legacy — distrusted by both NYPD cops and reformers
"The absence of really meaningful investment there is an issue," he said.
Mayor Bill de Blasio and Schools Chancellor Richard A. Carranza announce 3,257 families are receiving offers to free, full-day, high-quality 3-K for All across six community school districts at the Learning Through Play Pre-K Center, in the Bronx, on Wednesday, May 23, 2018. (Ed Reed/Mayoral Photography Offi/Mayoral Photography Office)
And big gaps remain in the quality of Pre-K programs serving mostly white and Asian students and those serving mostly Black and Hispanic kids, said UC-Berkeley's Fuller.
"It's just an example of how you can have stellar intentions, but if you don't implement carefully, you can reproduce inequality in this city rather than reduce it," Fuller said.
Early childhood is not the only part of the school system where stubborn racial disparities have persisted, hampering efforts to chip away at inequality.
Despite early promises to take bold action to reduce the stark racial segregation across K-12 public schools, de Blasio's approach has been cautious and halting, experts say.
"There was a lot more rhetoric than actual change," Pallas said.
Mayor Bill de Blasio has lunch with students at Public School 130 in March 2019. (Jeff Bachner/for New York Daily News)
De Blasio launched an ill-fated campaign to repeal the state law requiring the use of a single exam for admission at specialized high schools including Stuyvesant, Brooklyn Tech and Bronx Science, whose admitted students were a combined 8% Black and Hispanic last year.
He declined to unilaterally change the admissions policies at the other five specialized high schools, a move some experts say was within de Blasio's legal authority despite his insistence otherwise.
The big changes de Blasio made to the complex admissions policies that help drive school segregation came late in his tenure and were propelled by the pandemic.
Education officials suspended the use of "academic screens" for middle schools last year and scrapped the controversial "Gifted and Talented" exam for 4-year-olds this year. Incoming mayor Eric Adams has signaled that he plans to reverse at least one of those changes
Pallas said De Blasio could have made his policies less vulnerable to reversal by acting "more boldly earlier in a way that could've potentially given evidence of some wins that would provide some public momentum and pressure to sustain these policies."
Other de Blasio education initiatives might have more staying power. The mayor funneled significant investments into the "community school" model where schools partner with outside organizations to provide services like physical and mental healthcare and food pantries, growing the number of community schools citywide to nearly 500 by the end of his tenure. A 2020 study found that the model helped schools improve attendance.
Pallas said the community school expansion "was an important thing to accomplish" even if the results were "incremental more than transformative."
De Blasio's stewardship of the public schools was tested like never before with the COVID-19 pandemic.
Some observers praised de Blasio's steadfast insistence that schools stay open for in-person learning during the health crisis, even as other big city school systems started last year fully remote.
But planning stumbles and last-minute decisions undercut those efforts, frustrating both educators and families. By last spring, when all schools were open for at least some in-person learning, just over a third of city public school families had chosen in-person school, with the rest remaining remote.
"The mayor definitely gets credit for opening school last year," said Polakow-Suransky, Bloomberg's deputy schools chancellor. "But the big caveat is because there wasn't a really strong clear plan that was in place at the beginning of the '20-'21 school year about how folks were going to be safe, principals and teachers and parents came into that year with a lot of trepidation, and it meant many, many, many families opted into the remote option."


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text:
Home Time Zones Time Change Dates Russia Samara
Time Change 2010 in Samara, Russia
Last change: 2010
1 hour Back
Time Zones:
Mar 28, 2010 - Daylight Saving Time Started
DST started on Sunday, March 28, 2010, 2:00:00 am. However, clocks were not changed because Samara switched time zones at the same time.
Europe Starts Daylight Saving Time March 28, 2010
Russia Reduces Number of Time Zones
Back 1 hour
Oct 31, 2010 - Daylight Saving Time Ended
When local daylight time was about to reach
Sunday, October 31, 2010, 3:00:00 am clocks were turned backward 1 hour to
Sunday, October 31, 2010, 2:00:00 am local standard time instead.
Sunrise and sunset were about 1 hour earlier on Oct 31, 2010 than the day before. There was more light in the morning.
Also called Fall Back and Winter Time.
Daylight Saving Ends in Europe on October 31, 2010
Russia Proposes International System of Time Zones
Other years: 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2023
Daylight Saving Time Info
About Daylight Saving Time
DST in year 2023
Upcoming time changes
History of Daylight Saving Time
Daylight Saving Time spelling
Daylight Saving Time History in Samara
Samara last observed Daylight Saving Time in 2010.
Samara has observed DST for 30 years between 1981 and 2010.
See Worldwide DST Statistics

redpajama_set_name: RedPajamaCommonCrawl


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Rudolf Vomáčka (in der Taufmatrik Womáčka; * 16. April 1847 in Mšeno, deutsch Wemschen, Königreich Böhmen, Kaisertum Österreich; † 12. August 1926 in Prag, Tschechoslowakei) war ein tschechischer leitender Baubeamter, Baumeister und Architekt des Historismus und Denkmalpfleger in Böhmen.

Leben

Familie
Rudolf Vomáčka wurde als Sohn des Bürgers und Schuhmachermeisters Ján Womáčka und seiner Ehefrau Barbora geborene Černá, Tochter eines Maurermeisters, in der mittelböhmischen Kleinstadt Mšeno bei Mělník (deutsch Melnik) geboren. Er war verheiratet mit Anna geborene Kutílková (* 4. August 1844; † 17. November 1920), einer Lehrerstochter aus Schützendorf bei Přibyslav (deutsch Primislau).  Seine Söhne Jaroslav und Rudolf (Vincenc) jun. (* 21. Mai 1882 in Leitomischl) waren ebenfalls als Architekten tätig. Er liegt mit seiner Frau auf dem Wolschaner Friedhof in Prag begraben.

Berufliche Laufbahn
Vomáčka studierte Bauingenieurwesen am Königlich Böhmischen Polytechnischen Institut in Prag, aus dem sich später die Tschechische Technische Universität Prag entwickelte. 1874 wurde er als Baupraktikant zum "Bauadjunkten für den Staatsdienst in Böhmen" ernannt und trat damit in den öffentlichen Dienst des Königreichs Böhmen ein.

Nach einer Zwischenstation als Adjunkt in Königgrätz und K.k. Bezirksingenieur in Leitomischl wurde er 1889  Baurat bei der Statthalterei in Prag; er war zuletzt Vorsteher der technischen Abteilung für Hochbau mit dem Titel und Charakter eines K.k. Oberbaurats. 1899 wurde er Vizepräses der "Kommission für die Abhaltung der II. Staatsprüfung aus dem Hochbaufache" der Böhmischen Technischen Hochschule in Prag.

Seit 1900 gehörte Vomáčka der K.k. Zentralkommission für die Erforschung und Erhaltung der Kunst- und historischen Denkmale (der nachmaligen Zentralkommission für Denkmalpflege) mit Sitz in Wien an, deren Mitglieder die Funktion von Konservatoren in den Gebieten der österreichischen Reichshälfte der Donaumonarchie wahrnahmen. Vomáčka war nacheinander zuständig für die Bezirkshauptmannschaften Hořowitz, Kralowitz, Rakonitz und Schlan sowie Kamenitz an der Linde, Mühlhausen,  Pilgram und Tabor. 1902 wurde er als erfahrener Konservator in das Komitee berufen, das die aufgekommenen Widerstände gegen die erfolgte malerische Ausstattung der renovierten Burg Karlštejn untersuchen sollte.

Im Jahr 1911 ließ er sich vom Dienst einstweilen beurlauben, blieb aber weiterhin in zahlreichen Kommissionen und Ausschüssen der Bauplanung und Denkmalpflege sowie als freier Architekt tätig.

Wirken und Bauwerke
Rudolf Vomáčkas Fachkompetenz und seine berufsbedingten amtlichen Entscheidungsbefugnisse im Planungs- und Genehmigungsprozess von Bauvorhaben machten ihn zu einem einflussreichen Mitgestalter der öffentlichen und sakralen Architektur in Böhmen in den letzten Jahrzehnten der Donaumonarchie.

Dienstliches Wirken
Bereits während seiner Tätigkeit in Leitomischl war er an der bautechnischen und -historischen Erfassung der evangelischen Kirche in Horní Čermná (deutsch Obertscherma, zeitweilig auch Ober Böhmisch-Rothwasser) im Adlergebirge sowie an der Planung des 1884 vom Maurermeister Ondřej Seifert aus Landskron ausgeführten Neubaus des dazugehörigen Pfarrhauses beteiligt, und er begleitete und kommentierte auch die Planung des Neubaus der 1890 vollendeten evangelischen Kirche in Pusté Rybné bei Zwittau (deutsch Wüst Rybny; heute Pustá Rybná). Schon von Prag aus führte er im Jahr 1897 die Renovierung und "Regotisierung" der Pfarrkirche Mariä Himmelfahrt in Charvatce bei Leitmeritz durch. Belegt sind auch unmittelbare Einflussnahmen auf die Planung für die evangelische Kirche in Opolany (deutsch Groß Opolan) bei Poděbrady (deutsch Podiebrad) und die bauliche Entwicklung der Kirche St. Martin in Dolní Újezd (deutsch Unteraujesd) bei Zwittau.

Sichtbar sind Vomáčkas Einflüsse auch in der Stadtentwicklung der Hauptstadt Prag um die Wende zum 20. Jahrhundert, insbesondere mit Blick auf den Ausbau des Campus Albertov in der Prager Neustadt infolge der Teilung der Universität 1882 in eine tschechische und eine deutsche, dessen planerische Gestalt Rudolf Vomáčka (zusammen mit August Kožíška und Bohumil Novotný) wesentlich mitverantwortete. Er plante 1901 die tschechischen und deutschen Anteile des Komplexes (z. B. das "tschechische" Chemische und Naturwissenschaftliche Institut und das "deutsche" Physiologische und Hygiene-Institut) in historistischer Interpretation des Vorhabens als Spiegelung des tschechisch-deutschen Schismas in unterschiedlichen Baustilen. Bis zum Ende des Ersten Weltkriegs wurden zwei Drittel der von Vomáčka projektierten Bauvorhaben verwirklicht. Die Kunsthistorikerin Michaela Marek charakterisierte ihn als "Techniker" und Vertreter einer konservativen Architektur.

Eigene Bauwerke
Deutlichste Zeugnisse des eigenständigen baumeisterlichen Schaffens von Rudolf Vomáčka sind die Profan- und vor allem die Sakralbauten, die er als Architekt entworfen und errichtet hat. Zu nennen wären hier für die Ersteren beispielhaft das gemeinsam mit Sylvestr Schapka entworfene neobarocke Gebäude der tschechischen Lehrerbildungsanstalt (heute die Základní Škola Kamená Stezka) in Kutná Hora (deutsch Kuttenberg) von 1905–1907, für die Letzteren die neugotischen Kirchen Hl. Erzengel Michael in Oloví (deutsch Bleistadt) bei Falkenau an der Eger von 1901–1902 und St. Prokop in Nýřany (deutsch Nürschan) bei Pilsen von 1903–1904, die neuromanischen Kirchen St. Prokop im Prager Stadtteil Braník von 1900–1904 und Mariä Himmelfahrt in Grunta (deutsch Grund) bei Kutná Hora von 1905–1908 (wohl gemeinsam mit seinem Sohn Jaroslav), schließlich die 1909–1911 gemeinsam mit seinem Sohn Rudolf jun. errichtete neugotische Friedhofskapelle St. Prokop in Charvatce, wo er bereits früher die Pfarrkirche renoviert und umgestaltet hatte (s. oben).

Architektur von Rudolf Vomáčka

Auszeichnungen
 Silbermedaille der Ausstellung der Architektur und des Ingenieurwesens in Prag 1898
 Ritter des Kaiserlich-Österreichischen Franz-Joseph-Ordens

Literatur
 Vladimír Prokop, Lukáš Smola: Biografický slovník sokolovského regionu [Biografisches Wörterbuch der Falkenauer Region]. Fornica Publishing, Sokolov 2009, S. 316. ISBN 978-80-87194-09-6
 Pavel Vlček et al.: Encyklopedie architektů, stavitelů, zedníků a kameníků v Čechách [Enzyklopädie der Architekten, Baumeister, Maurer und Steinmetze in Böhmen]. Vydala Academia, Praha 2004, S. 700. ISBN 80-200-0969-8 (Stichwort: Vomáčka Jaroslav, Vomáčka Rudolf – autoři projektu kostela Nanebevzetí Panny Marie v Gruntě [Urheber des Projekts Kirche Mariä Himmelfahrt in Grunta])

Weblinks
 Rudolf Vomáčka in der Datenbank der Středočeská vědecká knihovna v Kladně [Mittelböhmischen wissenschaftlichen Bibliothek in Kladno] (tschechisch; abgerufen am 1. Januar 2019)
 Rudolf Vomáčka im Internetauftritt seiner Geburtsstadt Mšeno (tschechisch; abgerufen am 1. Januar 2019)

Einzelnachweise

Person (Königreich Böhmen)
Beamter (Cisleithanien)
Regierungsbaumeister
Bauingenieur
Architekt (Tschechoslowakei)
Denkmalpfleger (Tschechoslowakei)
Träger des Franz-Joseph-Ordens (Ritter)
Tschechoslowake
Geboren 1847
Gestorben 1926
Mann

redpajama_set_name: RedPajamaWikipedia


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A couple of years ago, I decided I wanted to start learning how to fish. I had fished before as a kid but never was really interested in it. I do not know why I decided to start fishing but I am glad I did. Once I decided I wanted to learn about fishing, I wanted to learn as much as I could.
One of the bad things about trying to learn how to fish when you are in your twenties is lack of information. When you are younger you can always rely on your parents to teach you things but when you live one hundred miles away you cannot always do that.
Local bait-shops are a good source of info but can be somewhat intimidating for the newbie. The old-timers that usually run bait-shops are helpful but usually expect you to know something about fishing. It is also a little embarrassing standing in front of a bunch of good ole boys asking how to bait a hook.
Luckily for the beginning fisherman, there is another resource out there. On-line fishing forums are an excellent way to learn how to fish. On-line fishing forums are great because you can interact with other members by asking questions and you can also learn at your own pace.
The good thing about on-line fishing forums are that most of them are localized to where you are fishing. Most major lakes have some sort of on-line forum so all you have to do is a little Google searching to find one for you.
I learned everything from hot spots to access points by visiting fishing forums. In the beginning, I would check in daily to read everything that I could about fishing. The search option also helped me out if nobody was talking about a particular topic I was researching.
If you live in the Metro Detroit area like myself, I will share with you my two favorite websites. The original fishing forum that I frequented was the Lake Saint Clair Network. This site has everything you could think of about Lake Saint Clair. The site features forums on everything from boating to hunting to fishing.
The fishing forum has a lot of good people on it that have a wealth of info. Unfortunately, the quality of the posters have gone down in recent years. A lot of the people on the site from when I first started are no longer there because of shenanigans that can easily pop up on-line. However, the site recently went through some changes and is starting to get better.
I still check LSCN out from time to time but my new go to forum is the Michigan sportsman forum. The Michigan sportsman forum is awesome because it not only talks about Lake Saint Clair but also most of the other waterways in Michigan. The posters on Michigan sportsman forum do not put up with any bullying limiting the shenanigans but are not as eager to share hot spots as LSCN.
If you are interested in taking your fishing expertise to the next level, check out your local fishing forum on-line. I have listed the two sites that I monitor but there are many more. If you have a favorite site that you like, please feel free to share it in the comment section. I will make sure to check it out.


text:
Integrated programs for women with substance use issues and their children: a qualitative meta-synthesis of processes and outcomes
Wendy Sword1,
Susan Jack1,
Alison Niccols2,
Karen Milligan3,
Joanna Henderson4 &
Lehana Thabane5
Harm Reduction Journal volume 6, Article number: 32 (2009) Cite this article
There is a need for services that effectively and comprehensively address the complex needs of women with substance use issues and their children. A growing body of literature supports the relevance of integrated treatment programs that offer a wide range of services in centralized settings. Quantitative studies suggest that these programs are associated with positive outcomes. A qualitative meta-synthesis was conducted to provide insight into the processes that contribute to recovery in integrated programs and women's perceptions of benefits for themselves and their children.
A comprehensive search of published and unpublished literature to August 2009 was carried out for narrative reports of women's experiences and perceptions of integrated treatment programs. Eligibility for inclusion in the meta-synthesis was determined using defined criteria. Quality assessment was then conducted. Qualitative data and interpretations were extracted from studies of adequate quality, and were synthesized using a systematic and iterative process to create themes and overarching concepts.
A total of 15 documents were included in the meta-synthesis. Women experienced a number of psychosocial processes during treatment that played a role in their recovery and contributed to favourable outcomes. These included: development of a sense of self; development of personal agency; giving and receiving of social support; engagement with program staff; self-disclosure of challenges, feelings, and past experiences; recognizing patterns of destructive behaviour; and goal setting. A final process, the motivating presence of children, sustained women in their recovery journeys. Perceived outcomes included benefits for maternal and child well-being, and enhanced parenting capacity.
A number of distinct but interconnected processes emerged as being important to women's addiction recovery. Women experienced individual growth and transformative learning that led to a higher quality of life and improved interactions with their children. The findings support the need for programs to adopt practices that focus on improving maternal health and social functioning in an environment characterized by empowerment, safety, and connections. Women's relationships with their children require particular attention as positive parenting practices and family relationships can alter predispositions toward substance use later in life, thereby impacting favourably on the cycle of addiction and dysfunctional parenting.
The human and economic costs of substance use are considerable [1, 2]. Although rates of substance use generally are lower for women than for men [3–5], the physical and mental health consequences can be more profound for women [6]. Women who use alcohol and illicit drugs are at particular risk for hepatitis C and HIV infection, and are more likely to have psychiatric co-morbidity and multimorbidity [7]. In addition, substance use during pregnancy and while mothering has negative consequences for children, including risk for prematurity, impaired physical growth and development, physical and mental health problems, and development of substance use problems [8–11].
There is a need for services that effectively and comprehensively address the complex needs of women with substance use issues and their children. In addition to experiencing physical and mental health problems, these women often have personal histories of exposure to physical and sexual abuse and other relationship problems, negative or inadequate social support systems, inadequate income, unemployment, unstable housing, and involvement with the criminal justice system [12–14]. Conners and colleagues [9] suggested that an accumulation of these postnatal environmental risk conditions combined with prenatal substance exposure results in increased childhood vulnerability to poor outcomes. As these authors note, the issues mothers face can "limit their ability to provide for their child's physical and/or emotional needs" (p. 90). Maternal substance use has been associated with limited parenting capacity and an increased likelihood that children are exposed to maltreatment, including neglect [8, 15–17], factors that have negative developmental sequelae for children. Children of women with substance use issues are further compromised because they have limited opportunities to develop the social skills and relationships that can help to buffer against risk [9].
Historically there have been separate delivery systems to meet the diverse needs of women with substance use issues and their children. However, there is a growing body of literature reporting on integrated treatment programs that offer a wide range of services (e.g., addictions treatment, parent/parenting counseling, service linkages, and children's programming) in centralized settings for both women and children. These programs have primarily taken two forms: residential and outpatient. Intended treatment length can vary but generally ranges from 12 to 18 months in both types of programs.
Studies that have examined the effectiveness of integrated intervention programs suggest positive outcomes for women and children, including reduced substance use and improved mental health, parenting, and child development outcomes [18, 19]. However, the quality of the studies is variable and much of the quantitative research is limited by small sample sizes. This has resulted in inadequate statistical power and an inability to identify moderators of treatment impact.
In a systematic review of 38 studies on substance abuse treatment for women, Ashley, Marsden, and Brady [20] examined specific components of treatment programs and their association with outcomes. Programs with prenatal care or childcare were associated with better outcomes. Orwin, Francisco, and Bernichol [21] conducted a meta-analysis of studies on the effects of substance abuse treatment programs for women on their substance use, maternal well-being, and pregnancy outcomes. Findings suggested that enhancing women-only treatment programs with prenatal care or therapeutic childcare added value above and beyond the effects of standard women-only programs. In recent meta-analyses of the effectiveness of integrated programs for women with substance use issues and their children, we found positive impacts on length of stay, maternal substance use, maternal mental health, and birth outcomes (unpublished data).
While many quantitative studies have examined the effectiveness of integrated treatment programs, there also is a developing body of qualitative and mixed methods literature that encompasses studies conducted to describe the experiences and perceptions of pregnant women and mothers with young children who participate in such programs. As it is important to develop a better-informed understanding of the experiences of participating in integrated treatment programs from women's perspectives, a synthesis of these qualitative data is required.
Meta-analyses of quantitative data and qualitative meta-syntheses share many similar characteristics including: asking of a focused question; establishment of strict inclusion criteria to guide a comprehensive search of the available evidence; and critical appraisal of the located evidence. The two types of reviews are most distinct in the processes for synthesizing findings across included studies, with quantitative meta-analyses utilizing statistical methods to aggregate data and qualitative meta-syntheses characterized by the integration of common findings into narrative themes and the identification of overarching abstract concepts [22]. While quantitative meta-analyses have the power to answer questions about the effectiveness of interventions for specific populations and pre-determined outcomes, qualitative meta-syntheses add to our holistic understanding of issues by providing insight into the processes by which interventions work, factors that facilitate or inhibit the success or uptake of interventions, and the lived experiences of individuals. This paper describes the approach to, and findings of, a qualitative meta-synthesis of findings from women who participated in integrated treatment programs.
The purpose of the qualitative meta-synthesis was to bring individual, high-quality qualitative studies together through a process of comparison, translation, and synthesis of original findings [23]. The specific research questions guiding this meta-synthesis were: 1) What psychosocial processes occur in treatment that contribute to favourable outcomes? and 2) What are the perceived outcomes of integrated intervention programs for women with substance use issues and their children? The research was approved by the Hamilton Health Sciences/McMaster University Faculty of Health Sciences Research Ethics Board.
A comprehensive and systematic literature search for studies of outcomes and processes associated with integrated intervention programs for women with substance use issues and their children was conducted simultaneously for a quantitative meta-analysis and the qualitative meta-synthesis. The initial search captured literature published up to August 2007. We used three main strategies to identify outcome studies of intervention programs for women with substance abuse issues and their children: online bibliographic database searches; checking printed sources; and requests to researchers [24, 25]. First, we searched relevant bibliographic databases (PsycINFO, MedLine, PubMed, Web of Science, EMBASE, Proquest Dissertations, Sociological Abstracts, and CINAHL) for studies published in English, using the terms substance use/abuse, addiction, alcoholism, intervention, treatment, therapeutic, rehabilitation, women, child, mother, infant, mental health, parenting, prenatal, singly and in combination.
Secondly, we examined reference lists of retrieved articles for potentially relevant documents. In addition, we manually searched relevant journals in the area (Journal of Substance Abuse Treatment, Journal of Substance Use, Substance Use and Misuse, Journal of Psychoactive Drugs, Addiction, Journal of Drug Issues, The International Journal of the Addictions, Addictive Behaviors, and the Journal of Substance Abuse). Documents that appeared to be relevant on the basis of titles or abstracts were retrieved.
Finally, we searched for fugitive data (e.g., technical reports, unpublished data). All researchers identified through these searches, as well as researchers presenting at relevant conferences identified using Google and Cross Currents (Upcoming Events), were contacted by email to request any relevant published or unpublished data. Of the 200 researchers identified and emailed, 48% responded and 28 additional studies were identified. In total, 327 studies were retrieved (319 from literature searches and 28 through other forms of searching) and coded for eligibility. A hand-review of all retrieved studies resulted in the identification of 42 papers that included a report of narrative findings from a single qualitative or mixed methods study. The search was updated to capture any research published between the time of the initial search and August 2009, which yielded another three studies with narrative findings.
Inclusion/Exclusion Criteria
Inclusion and exclusion criteria were developed specifically for the purposes of the meta-analysis and meta-synthesis. Studies had to have explicitly and appropriately defined the study design, the population being served, the intervention and its components, and outcomes or, in the case of qualitative research, processes that contributed to outcomes. Table 1 lists the inclusion criteria used to determine eligibility for the qualitative meta-synthesis. For the purposes of this work, Creswell's [26] definition of qualitative research was used:
Table 1 Inclusion Criteria
Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. The researcher builds a complex, holistic picture, analyzes word, reports detailed views of informants, and conducts the study in a natural setting (p. 15).
Two of the authors (WS, SJ) with experience in qualitative research independently reviewed each research report for inclusion in the meta-synthesis. They then met to discuss their individual assessments; when a discrepancy occurred, discussion continued until consensus was met. In the end, 17 of the 45 documents were determined to have met the inclusion criteria. These 17 reports represented 14 distinct qualitative studies, with three reports discussing findings of one study [27–29] and two reports based on another single study [30, 31].
Given the lack of a gold standard for assessing the quality of qualitative research [32], we searched for a commonly used rating tool appropriate for our purposes. We chose to use the methodology checklist for qualitative studies developed by the National Institute for Health and Clinical Excellence [33]. The criteria in this tool were adapted from two checklists: criteria for evaluating qualitative studies [34] and 10 questions to help one make sense of qualitative research [35]. This methodology checklist for qualitative studies includes 13 criteria under six broad areas: aims of the research; study design; recruitment and data collection; data analysis; findings/interpretation; and implications of the research. The "Notes on the use of the methodology checklist" provided as an accompaniment to the checklist was consulted throughout the rating process. A summative rating was given based on whether all or most of the criteria were fulfilled (++), some of the criteria were fulfilled (+), or few or no criteria were fulfilled (-). The reviewers agreed that documents that met 10 or more of the 13 criteria would be assigned a ++ rating, those that met 4 to 9 criteria a + rating, and those that met 0 to 3 criteria a - rating. Because guidelines for using the methodology checklist for qualitative studies state that the latter rating implies a study is weak, we decided to exclude studies with this rating from the meta-synthesis.
The two authors who determined inclusion appropriateness also independently reviewed and rated each document for study quality. There was agreement that 7 of the 17 documents met all or most of the criteria (++), 8 met some criteria (+), and 2 met few or no criteria (-). There was disagreement on only one document in that one reviewer rated it ++ and the other reviewer +. As such, 15 reports (representing 12 studies) were deemed to be of adequate quality for inclusion in the meta-synthesis.
Synthesis Approach
We focused on data that pertained to psychosocial process that contributed to recovery and, secondly, to perceived outcomes for women and their children. Textual data that represented authors' findings and interpretations as well as verbatim data from study participants were extracted. These data were copied into Word documents, which were then imported into QSR International's NVivo7 program.
Thematic analysis of data was conducted using the approach suggested by Atkins et al. [36]. We first arranged the documents in chronological order, starting with the oldest. This allowed the meta-synthesis to capture developments in knowledge related to integrated programs for women with substance use issues and their children over the 14-year span of the studies. We then created a preliminary grid to display themes and concepts within each study under broad headings that reflected the purpose of the meta-synthesis: processes and outcomes.
The lead author independently analyzed the data from all documents while the second author analyzed the data from half the documents, specifically, alternate documents from the chronological list. Themes became increasingly refined through reciprocal translation, that is, the translation of studies into one another by comparing the themes and concepts in one account with those in others [36]. The conceptualization of ideas was further refined as the analysis proceeded using an iterative approach. That is, as new ideas emerged, articles that previously had been analyzed were reviewed a second time to look for instances of these ideas and to ensure consistency in the approach to coding.
The two lead authors met to discuss their findings part way through the analysis to discuss themes arising from the reciprocal translation. Much of the discussion focused on comparing and contrasting the more abstract analytical themes related to processes. After another period of independent coding of remaining documents, these authors met a second time to reach consensus on themes, which had become more refined and interpretive in nature. A higher order or synthesized translation was achieved.
Characteristics of Included Studies
The characteristics of the studies included in the meta-synthesis are presented in Table 2. Two of the reports were masters dissertations [37, 38], two were doctoral dissertations [27, 39], and one [18] was a Special Supplement published in the Journal of FAS International. The other documents were journal articles, with two of these reporting on Nardi's dissertation research [28, 29]. All of the studies were conducted in North America (eight in the United States and four in Canada). Most used a qualitative descriptive design and collected data using semi-structured face-to-face interviews. Six studies gathered data in whole or in part from women who had completed an integrated treatment program [37–42], and thus were positioned to report on outcomes perceived to be attributable to program participation.
Table 2 Study Characteristics
Women experienced a number of psychosocial processes during treatment that played a role in their recovery and contributed to favourable outcomes. These processes included: development of a sense of self; development of personal agency; giving and receiving of social support; engagement with program staff; self-disclosure of challenges, feelings and past experiences; recognizing patterns of destructive behaviour; and goal setting. A final process, the motivating presence of children, sustained women in their journey to recovery. The sources of these process themes are shown in Table 3.
Table 3 Summary of Sources for Process Themes and Outcomes
Development of a Sense of Self
One commonly identified process that emerged as part of addiction recovery and was first reported by Nardi [27–29] was development of a sense of self. This included development of a sense of self-worth, self-identity, and self as a partner in a relationship.
Nardi's [27–29] research revealed an increasing sense of self-worth during program involvement. As she noted [27], women "began to see themselves as persons who were changing and who deserved help" (p. 138). Women in this study also began to recognize they had strengths and needed to build on these strengths to improve their lives. Salmon, Joseph, Saylor, and Mann [43] commented on women's developing self-worth in relation to being "a better person when off drugs" (p. 243). Similarly, Kunkel [37] described how women's sense of personal worth developed in parallel with the desire for recovery and realization that they "don't even need drugs" (p. 79). While Kunkel found that women began to see themselves as having value independent of their children, women also described having value because they had children and because they were valuable to their children. Consistent with this notion of self-worth as a mother was the finding of another study that women started to value not just themselves but their parental selves in particular [31].
As women moved through the recovery process, Nardi [27] remarked that they began to form "an identity as a coherent, separate self" (p. 139). Wong [31] likewise commented on the development of self-identity in that women showed "an emerging ability to separate their own needs from those of others" (p. 127). At the same time, she noted that women developed an ability to integrate different aspects of self, including self as an addict, mother, woman, and daughter. As one woman in this study said, "If I didn't admit that I did have a drug problem then I wouldn't be a mother to my son" (p. 128) [31].
Another transformation that impacted self-identity was that women developed greater awareness of their children and their maternal roles [27–29]. Wong [31] remarked on women's developing maternal empathy and the ability to more easily identify with children's needs and emotions. As a result of an enhanced maternal identity, women not only became more conscious of responding to their children's needs, but also were able to bond with their children and began to view them more positively [27–29, 31]. Through the development of a positive parental self-concept women became motivated to learn parenting skills and overcome psychological barriers to parenting [31].
Nardi [27–29] noted that although it was important for women to be part of a group that did not require overly intimate relationships, the presence of other women and children enabled them to connect with others and to build relationships. They began to see themselves as partners in a parent-child relationship [27–29]. Ultimately, women experienced improved relationships with their children and an enhanced parental self-concept and parenting [31]. Women in Schreztman's [39] study reported that relationships with their children were important to staying sober.
Women also developed a capacity for healthy relationships and a sense of self as a partner in relationships with friends, partners, family members, program staff, and other program participants [27–30]. Baldwin, Rawlings, Marshall, Conger and Abbott [44] commented that women discovered "the importance of developing trusting relationships and positive friendships" (p. 381), which women noted required that they first trust themselves. In addition to an ability to trust others, some studies revealed other factors that may be important in developing capacity for relationships. For instance, de Guzman and colleagues [40] found that women developed the ability to identify and express their needs to others while Wong [31] reported that women developed the capacity to form partnerships with others to pursue mutual goals.
Group interaction and discussion were instrumental to self-development. Interactions with other mothers facilitated maternal self-awareness through role modeling, discussion, and positive feedback [27–29]. Group discussion also fostered self-examination of lives and choices and, ultimately, self-discovery in a safe environment [27–31, 42]. Additionally, the encouragement of group members was important to the building of self-esteem and maintaining faith in one's ability to be successful in achieving goals [18, 42].
Development of Personal Agency
Women experienced development of personal agency during program involvement. As defined by Smith and colleagues [45], personal agency is the capacity to achieve desired outcomes on one's own behalf through ability, choices, perseverance or planning. Women overcame powerlessness [30, 31] and began to discover "their own agency, power and growth" (p. 381) [44]. Recognition of strengths and having a sense of control contributed to improved self-esteem, self-worth, and confidence [31, 42, 44].
Development of personal agency fostered capacity for change. Women developed a willingness to accept personal responsibility for change, recognizing that they were the only ones who could regain control over their lives [37, 42, 44]. Women commented specifically on their capacity to decrease substance use and resist the urge to relapse, and on their confidence in being able to overcome their weaknesses and stay sober [37, 42]. An important aspect of change in substance use was the development of alternative coping skills, such as relaxation techniques, to replace substance use as a coping mechanism [28, 29, 40, 42]. Recognizing cues to relapse enabled women to plan in advance for confronting risks through the use of substitute coping responses [28, 29, 38].
Giving and Receiving of Social Support
Many of the studies highlighted the giving and receiving of social support as being instrumental to women's recovery. Nardi [28] described this support as being "embedded in the interpersonal interactions that took place at the program, and occurred in a feedback loop of give-and-take among women" (p. 85). Others similarly described the interactional nature of social support that occurred within treatment groups [18, 23, 37, 38, 43, 44]. Wong [30] commented that past experiences created ambivalence about seeking support, such that women had to learn "to trust the support at their own pace" (p. 167). The nature of the social support received within program groups might ultimately have enabled women to accept help without resentment, obligation, and pressure that can cause additional stress [27–29]. Moreover, some studies reported that the support often served to lessen or buffer women's multiple stressors [30, 31, 43].
Through interaction, women were afforded the opportunity to understand and work through their problems while being provided support and encouragement [30, 31, 46]. Positive relational experiences instilled confidence in their ability to be successful in the recovery process and enhanced perceptions of self and others [30, 42]. Women also gave and received feedback and advice to one another [38, 43]. In some instances, they learned from each other through role modeling of parental behaviour and sharing experiences [18, 27, 29]. Women ultimately felt that others respected and cared for them [38, 39]. The ability to mobilize the support of others suggests that in addition to developing personal agency, women also developed interpersonal agency [45].
The importance of social support being provided by others with a shared past is noteworthy. Within the group programs women felt safe and were able to talk with others who had similar experiences without being judged or manipulated [18, 27–29, 31, 38, 39, 42, 43]. In turn, they came to trust others [37, 38, 44]. Women were comfortable sharing their past and being open about their experiences because they felt understood and could provide understanding to others [18, 38, 41, 42].
Listening to the stories of women who were improving their lives gave women encouragement and a sense of hope [42]. Motivation for recovery also was prompted by hearing stories of women who had lost custody of their children [18, 37]. Finally, the relationships with other women in similar situations decreased feelings of isolation and disconnection and, in some instances, genuine friendships developed [18, 31, 38, 42].
Engagement with Program Staff
Engagement with staff emerged as a process that was central to women's participation in the programs and behaviour change. The non-judgmental approach of staff and attributes such as compassion, honesty, empathy, and respect facilitated the development of therapeutic relationships [18, 31, 38–40, 42]. These characteristics often were perceived to create a caring, safe, and supportive environment for recovery [31, 39, 43]. Additionally, feeling understood "as a whole person, and not just as a substance user" was important to women (p. 53) [18].
A non-directing approach by staff was important. Women valued being assisted to understand their problems and what contributed to them, and to identify strategies to address them [43, 46]. They also appreciated being able to set their own agendas at their own pace, being provided treatment options, and being supported in their choices and decisions [18, 42]. The ability of staff to listen also was significant to women in that it not only promoted understanding and facilitated problem solving, but also conveyed respect [18, 31, 39, 43].
Motz and colleagues [18] and Wong [30] commented that women's relationships within the treatment facility are transformative because they are growth-promoting and empowering. In contrast to previous, often complex and challenging relationships, the ones with staff are can be negotiated and are characterized by a sense of connectedness, openness, caring, and respect [18, 31, 40]. Wong reported that the characteristics of mother-staff interactions, such as the offering of empathy, were often paralleled by women in their interactions with their children [30].
Two studies reported on children's engagement with staff. Sword and colleagues [42] noted that women commented favourably on the staff's interaction with children and that children felt comfortable in the program while the report by Motz and colleagues [18] included a mother's remark about her daughter's closeness to a therapist and how she looked forward to seeing her. Valuing children's relationships with staff may be attributed, in part, to women's developing awareness of children's needs.
Self-disclosure
The nature of the relationship with group participants and staff facilitated self-disclosure, which was an important component of the recovery process [39]. As reported by de Guzman and colleagues [40], "women freely shared the challenges they faced with alcohol and drug use, free of judgment" (p. 1259). Schretzman [39] and Polansky and colleagues [41] similarly commented that women were able to open up, and felt comfortable sharing their feelings and their past in a safe environment. As such, they were able to be honest with themselves and others [31, 38].
Through self-disclosure, women were able to confront the past. Often this revolved around women's relationships with their mothers and the painful experiences of abandonment, neglect, and abuse [27–29, 31, 39, 41, 44]. Awareness of the negative impact of such relationships provided insight into parenting and fostered a more positive approach to parenting their own children [37, 41].
Recognizing Destructiveness Patterns
Another process fundamental to change and recovery was recognizing destructiveness patterns. Women were enabled to examine their lives and choices [27–29], and often began to recognize the extent of their substance use problem only after encountering women with similar difficulties and hearing their stories [37, 42]. They developed awareness not only of the impact of their drug or alcohol use on themselves and their body, but also the impact of other choices such as staying in abusive relationships and continuing contact with others with substance use issues [27–29, 43, 44]. Moreover, women became cognizant of the effects of their choices on their children [27–29, 38, 40]. While acknowledgement of the effect of substance use on their children promoted women's continued participation in program activities, they also had to overcome associated feelings of guilt and anxiety [30, 31, 38].
Given the negative influence of others who use substances, it was important that women had the opportunity to develop and maintain relationships with sober peers [39]. Such individuals served as motivating role models and sources of emotional support [39, 46]. Women's connectedness with sober peers contributed to feeling cared for and assisted women in maintaining sobriety [39].
An activity undertaken with the support of program staff that contributed to treatment success was goal setting. It was important that women's goals were realistic, and staff played a role in determining the appropriateness of goals in relation to the program's resources, time frame, and purpose as well as in relation to women's specific needs [40]. Goal setting was motivating for women and provided a means to prove to themselves that they could accomplish something meaningful [44]. Both the setting of and achieving of goals gave women a sense of pride and accomplishment [40]. Reviewing women's goals and progress towards them at the outset of each program session allowed for goals to be revised as women's needs and circumstance changed [40].
While personal goals were variable, women often entered treatment wanting to become better parents and to establish their parental role [30, 31, 37, 38]. An important goal for many women was maintaining or regaining custody of their children [38, 42]. In situations where children were under the protection of child welfare, women were motivated by the possibility of their children being returned to them [38].
Motivating Presence of Children
A major finding of Schretzman's study was the importance of having children present during treatment in that it helped sustain women's motivation in their recovery process [39]. Other research similarly noted the value of children's presence as a motivating influence [30, 31, 37, 38, 42], which is not surprising given the centrality of motherhood to women's identity and recovery. As Kunkel [37] commented, "Children's presence in treatment provides women with security and comfort in their role as parents and in their recovery" (p. 69). Wong also commented on the emotional support afforded women simply by having children in program [31]. In addition, their presence often contributed to an awareness of the urgency of dealing with recovery issues [39].
Women reflected on the value of learning to parent with their children by having them in the program [31, 37, 38]. Children's presence afforded a base for mothers to build on their parenting experience and to improve parenting skills through experimentation [31]. The availability of children also made it possible for women to re-establish relationships with them and to deal with the guilt associated with their past parenting behaviour by learning better parenting practices [31, 37–39]. In some instances, the program provided an opportunity for supervised visitation with children, which was emotionally satisfying to women [31, 42].
Perceived outcomes of participating in an integrated intervention program included: a maintained sense of personal agency; improvements in personal well-being; sustained sobriety or decreased substance use; establishment of positive social support networks; greater insight into self, others, and relationships; increased access to community services; and a more positive approach to professional relationships. Women also perceived that their capacity for parenting was enhanced in that they reported increased knowledge, skills, and confidence. They also identified improved maternal-child communication and relationships. Studies included in this meta-analysis did not explore women's perceptions of child health outcomes, with the exception of the study by Sword and colleagues in which women reported that program involvement had a positive impact on their children's behaviour and development [42]. The sources of specific outcome findings are shown in Table 3.
Maternal Outcomes
A sense of personal agency reportedly was maintained post-treatment. Women commented on their increased sense of control and confidence [42], and how they exercised personal power in making careful choices about with whom they associated and in enforcing boundaries in relationships [37]. As reported by Kunkel [37], they also demonstrated a "pro-active" approach to life that enabled them to continue with recovery activities and life goals (p. 61). Women were able to sustain sobriety or their decreased substance use, often with the assistance of an existing social network of sober friends or new support networks of substance-free associations [38, 39, 42], and exercised the self-discipline required for successful recovery [37].
Women experienced improved personal well-being and a readjustment of priorities in that they were more content with self and life, and had learned to relax and enjoy life and their successes [37]. Sword and colleagues [42] commented on women's employment readiness, which enabled them to achieve goals related to obtaining one's own pay cheque. In addition, women had greater insight into their strengths and weakness, and increased awareness of people and relationships [37]. It was noted that women had enhanced access to other services to benefit themselves and their children post-program [40, 42]. Kunkel [37] importantly observed that women had a more positive approach to professional relationships and entered them with a "spirit of cooperation" (p. 61).
Child Outcomes
The study by Sword and colleagues [42] was the only one to comment on child outcomes. Women observed that program involvement had a positive impact on children's behaviour and development, including their motor, social, and language skills.
Parenting Outcomes
A number of studies reported enhanced capacity for parenting as an outcome of program involvement. Women gained increased knowledge about parenting and learned new parenting skills, which they willingly applied at home with their children [38, 42]. They became knowledgeable about specific strategies, such as the use of rewards, and how to use positive discipline techniques [38, 42]. Women also learned the importance of verbal communication [38, 40, 41]. In particular, as reported by Polansky and colleagues [41], they came to appreciate the use of communication as an alternative to physical punishment, and its value in teaching and guiding children and in strengthening emotional bonds. In addition, women gained awareness of the importance of listening to their children [40, 41].
Through involvement in treatment programs, women developed increased understanding of children, their behaviour, and their needs [38, 40, 42]. Simpson [38] commented specifically on women's awareness of children's emotional needs. The enhanced understanding of children strengthened maternal relationships with them [42]. Women also described more positive engagement with their children [37, 38, 40]. This included involvement in day-to-day activities at home, such as having dinner or watching a movie together, and attending children's games as well as finding services to help children with their issues [38, 40].
Finally, women developed increased confidence in parenting and a positive identification with their parenting role [38]. As one woman in Simpson's [38] study said, "I can see how my perspective has changed in that I don't have to be a perfect mother in order to be a good mother...that every day doesn't have to be perfect" (p. 94).
Many distinct but interconnected processes emerged as being important to women's addiction recovery. For the purposes of this discussion and consistent with the findings of the meta-synthesis, recovery is not simply a process of reducing use of drugs and alcohol or attaining abstinence from drugs and alcohol. Rather, recovery is regarded as a process of "re-covering" oneself, that is, as a process of personal and individualized growth that unfolds along a continuum, leading to a higher quality of life [47, 48].
Through involvement in programs, women developed an enhanced sense of self. Development of a sense of self-worth is notable as women with substance use issues tend to have low levels of self-esteem [49] and pregnant women and mothers, in particular, experience stigma that negatively impacts their self-worth [50, 51]. Along with an improved self-worth, the development of a non-addict identity is an important aspect of recovery [52, 53]. Mothers with substance use issues often experience difficulties in developing a maternal identity, which is related to limited care giving experience, a focus on one's own needs for recovery, and addressing only the non-emotional needs of children [49]. The meta-synthesis revealed that integrated treatment programs support women in defining self in other roles, including self as mother.
As part of the recovery process, and related to the development of a non-addict identify, women also developed a capacity for relationships with their children and with others internal and external to the treatment program. This is an important aspect of recovery because women who use substances often have histories of physical, sexual or emotional abuse as children [54, 55]. These histories, along with socioeconomic circumstances and characteristics of drug-exposed children, can negatively affect parenting practices [56]. In addition, women with substance use issues often continue to experience abuse beyond childhood [55], which may negatively impact their abilities to engage in adult relationships.
Another finding of the meta-sythesis was that women developed personal agency through integrated treatment program involvement. Other first person accounts similarly describe people in recovery as active agents of change in their lives rather than passive recipients of services [48]. This cognitive resource plays an important role in promoting healthy behaviours, including continued abstinence [57]. As reflected in the findings of the meta-synthesis, an aspect of developing personal agency in recovery is learning and being able to implement adaptive coping strategies as alternatives to substance to cope with stress [47]. The lives of women with substance use issues tend to be characterized by chronic life stress related to issues such as abuse and traumatization, single parenting, inadequate income, family or social problems, health problems, and removal of children from the home [49, 58]. Because stress can trigger relapse, adaptive coping strategies are key resources that promote maintenance of recovery [47, 59].
The finding that women experienced the giving and receiving of social support within integrated treatment programs is noteworthy as women who use substances often experience social isolation and limited social support [49, 60]. Social support, including that of peers and helping professionals, is a key resource in recovery [47, 48, 61, 62]. As suggested by the meta-synthesis findings, social support may act to buffer against stress, a notion espoused by Tucker and colleagues [63] who found that women with greater social support reported less substance use. It is essential that women have social support systems that are constructive and provide support without enabling drug use [64]. Moreover, as noted by Kellogg and Kreek [52], a constructive social setting enables women to develop relational or interpersonal aspects of their self-identity, a component of self-development that emerged in the meta-synthesis.
Getting women to engage and participate in recovery activities is a first step to treatment retention and longer-term outcomes [38, 65]. Because staff members are key actors in this process [65], the finding that women engaged with program staff is important. Therapeutic relationships were characterized by acceptance, a non-judgmental attitude, openness, empathy, and respect. In a recent study, stronger therapeutic engagement, specifically program participation and rapport with staff, was found to be associated with higher treatment motivation and readiness and to better psychosocial functioning (e.g., higher self-esteem, self-efficacy, decision making, social consciousness) [66].
Therapeutic engagement with staff and the support of women with shared experiences facilitated self-disclosure of histories of neglect and abuse and substance use-related issues. In a study of women in recovery, "breaking the silence" by discussing abuse experiences assisted them in reshaping their sense of self and connecting to others [67]. Altering one's concept of self and committing to a newly established sense of identify was seen as integral to the process of recovery. Women in this study also reported that they began to understand their behaviour patterns, which enabled them to take action.
Recognizing destructiveness patterns was a theme revealed by the meta-synthesis. It is consistent with the concept of "truthful self-nurturing" that was identified by Kearney [68] as the basic process of women's addiction recovery in a review of 10 study reports of recovery processes. As she noted, women developed insight into the consequences of substance use, including harms to their children, and a gradual realization that alcohol and drug use caused more distress than it relieved. "Giving in to the hard truths" enabled women to engage in more healthful ways of caring for themselves and to develop positive relationships (p. 503) [68]. They became aware of the need for behaviour change, and while often women initially focused on simple goals such as eating and obtaining shelter, they progressed to more complex long-term goals [68].
Goal setting was another theme that emerged from the meta-synthesis. The ability to engage in future-oriented, goal-directed behaviour is central to the recovery process in substance use treatment [52]. Programs that are supportive and goal-directed demonstrate improved treatment participation and better outcomes [52, 69]. The need for women to act in a consistent self-directed manner to achieve goals underscores the importance of personal agency [52].
The qualitative meta-synthesis highlighted the motivating presence of children for women to remain in integrated treatment programs. The meta-analysis of quantitative studies of integrated treatment programs we conducted (unpublished data) revealed that, relative to non-integrated programs, having children present increases client engagement, possibly because pregnancy-, parenting-, and child-related services increase maternal motivation to actively engage and remain in treatment [42]. Creamer and McMurtrie [70] commented that women in treatment often have difficulty or are unwilling to separate themselves from their role as mother to focus exclusively on their own needs. They, too, identified that children can be motivators for staying in treatment. Moreover, because mothering can build self-esteem [70], the presence of children also contributes to women's development of sense of self.
The findings regarding outcomes are consistent with previous reviews and meta-analyses of quantitative studies in supporting the effectiveness of integrated programs in improving maternal engagement, substance use, and well-being. This qualitative meta-synthesis also identified positive outcomes of integrated programs for parenting knowledge, skills, and confidence, as well as child development and behaviour and the parent-child relationship. The lack of attention to child outcomes is an important omission of the qualitative studies conducted to date, especially given that integrated programs are designed to meet the needs of women and their children.
Strengths of this meta-synthesis include the use of: a systematic and comprehensive search strategy; criteria that were congruent with the defined purposes of the synthesis to make inclusion decisions; and a quality assessment checklist developed by the National Institute for Health and Clinical Excellence (NICE) [33]. Several of the studies were determined to be of high quality, and lower rankings tended to represent an absence of information (e.g. research methods unclear, study limitations not reported, inadequate discussion of study limitations) rather than explicit methodological inadequacies. Details about themes and verbatim quotes were extracted from the documents. These data were then synthesized using a systematic and iterative process to create high-order constructs or themes that reflected women's experiences. Finally, two of the authors independently determined whether reports met inclusion criteria, assessed quality, and analyzed the extracted data, with decisions made by consensus when there were differences. While we anticipated that conducting a thematic analysis of the studies in chronological order would capture developments in knowledge, we found no discernable developmental patterns. This most likely is related to the wide diversity in study aims and research methods.
The main limitation of this meta-synthesis is that it relied on data derived predominantly from simple qualitative descriptive studies. Within the hierarchy of qualitative evidence [71], descriptive studies are a weaker type of evidence compared to conceptual studies or generalizable qualitative studies conducted using more theoretical approaches such as grounded theory or phenomenology. Descriptive studies can confirm and describe characteristics of a phenomenon within a specific population and highlight context-specific issues, but may have limited transferability to contexts outside of the original study and limited utility for evidence-informed practice and policy development. While it has been argued that it is inappropriate to synthesize the findings of qualitative studies that have been carried out in diverse contexts and to generalize across studies, qualitative meta-syntheses can produce new understandings through conceptual development of shared meanings or generative mechanisms [22, 72].
The process findings of the meta-synthesis support the need for programs to adopt "wellness-oriented practices" that improve personal health and social functioning [47, 73]. Given the importance of a positive sense of self, inner strength, and social support in fostering these outcomes [73], the notion of a "healing environment" characterized by empowerment, safety, and connections becomes salient [50]. Covington [50] suggested that connections with treatment staff that are empathic, respectful, and compassionate contribute to the development of connections among program participants through modeling of similar behaviours. Such growth-promoting relationships with helping professionals and peers have been identified as having a key role in women's recovery and highlight the need to adopt a relational model of treatment [50, 51, 70].
Relational models of treatment take into account past and current family relationships, relationships with friends and partners, relationships with children, and relationships developed within the treatment context [50, 51]. Given women with substance use issues often have experienced multiple "disconnections" in their lives, including neglectful or abusive parenting, failed relationships, and experiences of violence in adulthood, it is important that they are assisted in developing healthy relationships with others [51, 62]. In addition to building relational skills, interactions within the group can contribute to the development of a non-addict identity [52] and also support transformative learning, which is an effective model for the recovery process [74].
The phases of transformative learning are congruent with many of the process findings of the qualitative meta-synthesis. An initial step of transformative learning is self-reflection during which an individual tries to make meaning of one's life and experiences [74]. Involvement with others is essential for learning to continue as "rational discourse" provides opportunity to listen to the opinions and experiences of others, prompting recognition of a shared process of transformation and exploration of options [74]. Acquisition of knowledge and skill to implement plans, planning of a course of action, and trying out new roles are other integral components that lead to action and ultimately maintenance and reintegration phases [74]. Because transformational learning can be painful [74], it is important that it occur in the context of a safe, supportive environment.
Women's relationships with their children need particular attention. Programs should provide support for the parenting role through a number of strategies, including: providing assistance in gaining insight into personal experiences with dysfunctional parenting and their influences on current parenting [49]; education on child behaviour and development [49]; opportunity to discuss the effect of substance use on children [49]; and practice of communication and discipline techniques [75]. As suggested by this meta-synthesis, having children present in the treatment program is highly motivating, and facilitates the development of parenting skills and the reestablishment of relationships with children. Positive parenting practices and enhanced family relationships influence healthy child outcomes and alter predispositions toward negative behaviours, thereby playing a significant role in breaking the cycle of addiction and dysfunctional parenting [49, 75, 76].
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This work was funded by the Canadian Institutes of Health Research (CIHR). Dr. Jack was supported by a CIHR New Investigator Personnel Award. Thank you to Ainsley Smith for her assistance with the literature retrieval and preparation of the manuscript.
School of Nursing, McMaster University, Hamilton, Ontario, Canada
Wendy Sword & Susan Jack
Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
Alison Niccols
Psychology and Research, Integra, Toronto, Ontario, Canada
Karen Milligan
Child, Youth & Family Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Joanna Henderson
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
Lehana Thabane
Wendy Sword
Susan Jack
Correspondence to Wendy Sword.
All authors contributed to the original study design. WS and SJ conducted the relevance and quality assessment, extracted data, carried out the thematic analysis, and prepared the draft of the manuscript. All authors read and approved the final manuscript.
Sword, W., Jack, S., Niccols, A. et al. Integrated programs for women with substance use issues and their children: a qualitative meta-synthesis of processes and outcomes. Harm Reduct J 6, 32 (2009). https://doi.org/10.1186/1477-7517-6-32
Personal Agency
Integrate Program


text:
VIA Home > Service revisions go into effect May 7
Service revisions go into effect May 7
01 MayService revisions go into effect May 7
Categorized Upcoming Service Changes
VIA Metropolitan Transit will implement service adjustments beginning Monday, May 7, 2018 to increase frequency on key routes, reduce wait times, and provide faster connections for VIA customers.
Three VIA routes will be upgraded to high-frequency service as part of VIA's ongoing partnership with the City of San Antonio to plan and fund service improvements throughout the area. They are:
• 3 San Pedro Skip – Service modified to operate every 12 minutes, approximately 6 a.m. to 6 p.m., Monday through Friday.
• 24 East Houston Frequent – Service modified to operate every 12 minutes, approximately 6 a.m. to 6 p.m., Monday through Friday. Route extended to serve Centro Plaza for all trips in addition to the frequency improvement. There will no longer be trips that turn around at N. Walters Street.
• 76 West Commerce Skip – Service modified to operate every 12 minutes, approximately 6 a.m. to 6 p.m., Monday through Friday.
Additional changes include route modifications due to ongoing roadwork by the City of Leon Valley and the Texas Department of Transportation. They are:
• 64 US 90 Express – Route modified to travel from Kel-Lac Transit Center to Loop 410 using W. Military Drive instead of U.S. Highway 90 West. Eastbound trips will no longer go to the Social Security Administration Offices. These route changes are the result of a construction project.
• 65 JBSA Express Lackland/USO – Route modified within Lackland to serve the Peterson Training Complex.
• 88 Bandera – Route modified to travel on Seneca Drive and Poss Road due to Evers Road construction between those streets.
The following routes will have minor schedule adjustments: 7, 21, 30, 42, 46, 77, 95, 96, 520, and 602. The following new route pairs will also go into effect: 4-28 and 62-89. Route 24 will no longer be paired with route 4.


My burdens are too much for me…is there any help?
If we could but remember to take Your yoke upon us, for You have no burden, where ours sometimes feels unbearable. We know Father that You see our circumstance and that you have compassion for us. Relieve us we pray, of the tendency to weigh ourselves down when You are willing to lift us up.
I have a secret…not really.
We know Father that temptation is delivered to us by Satan and that You permit the test. It is only by the power of the Holy Spirit in us that we can over come that which Satan delivers, primarily targeting those who love You. We would estimate that Your joy comes from our victories and Your grief from our failures.
Just how much license does our liberty give us?
You tell us that if we are insensitive to the needs of a weaker brother that we are sinning against You. That is a powerful reason for us to show patience when we are inclined to do otherwise.


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