Implementation of violence risk assessments into forensic psychiatric care in Scotland

Background. A central role of mental health professionals within the criminal justice and forensic mental health system is the assessment, management and communication of an individual’s risk of future violence (Webster & Hucker, 2007). The current methodology favoured by clinicians is the structured professional judgement (SPJ) approach (Farrington, Joliffe & Johnstone, 2008). These instruments act as guides in clinical practice in that practitioners are encouraged to apply clinical judgement on the relevance of empirically validated risk factors to each client. In this way, identified risk factors can be directly used to inform individual care and treatment, i.e. risk management. Yet, research on SPJ tools is typically based on retrospective or pseudo-prospective designs, which lack in ecological validity. Furthermore, findings are based on risk assessments completed by researchers rather than clinicians. This is an issue as risk ratings differ significantly depending on professional background (de Ruiter & de Vogel, 2004). Aims. This thesis presents five studies with the aim of examining the link between violence risk assessment and management in vivo. This includes two studies focussing on the predictive validity of SPJ tools following clinical implementation; a description of the implementation procedure; a traditional research study on the predictive power of dynamic risk factors and a pilot evaluation of a short term risk assessment tool for imminent inpatient violence. Methodology. The primary research site was the State Hospital, the high secure psychiatric facility for mentally disordered offenders in Scotland and Northern Ireland. The research population consisted of 115 male forensic patients who were followed up across different risk settings for a mean of 31 months. The SPJ instruments under investigation were the HCR-20 (Webster et al, 1997), the SVR-20 (Boer, Hart, Kropp et al, 1997) and the RSVP (Hart et al, 2003). All assessments were exclusively completed by clinicians and resulted in active risk management strategies. Additionally, the predictive validity of dynamic risk factors was examined through psychometric measures of anger, impulsivity, psychiatric symptoms, unmet needs and imagined violence. The risk of imminent violence was assessed with the Dynamic Appraisal Situational Appraisal – Inpatient Version (DASA-IV, Ogloff & Daffern, 2006). Results and Conclusions. Findings indicate that clinically implemented SPJ tools are not predictive of future violence, both within and outwith secure settings. Comparison with a previous study at the State Hospital implies that the implementation process of the HCR- 20 facilitated the knowledge transfer from assessment to management, and therefore incidents were prevented. This noted the results also highlight that clinicians may accept risk tools into practice when these have not been scientifically scrutinised. This was the case with the RSVP in that there is little published data on the psychometric properties of this tool, yet its introduction replaced the SVR-20 across the State Hospital. With regards to dynamic risk factors, the severity and chronicity of psychiatric symptoms were the strongest predictors of violence. This is further corroborated by the finding that the DASA-IV predicted violence within 24 hours of ratings provided. All findings are discussed in the context of previous research and the experienced obstacles of implementing changes within NHS settings. Clinical implications and recommendations for violence assessment and management are provided in the light of acknowledged limitations

Learning From Incidents Questionnaire (LFIQ): the validation of an instrument designed to measure the quality of learning from incidents in organisations

Effective learning is essential for a safe workplace. Through learning from incidents (LFI), knowledge is applied and embedded within the work environment in ways that can prevent future incidents. In order to improve their LFI processes, such as incident reporting and analysis, or the dissemination of investigation outputs, organisations need an instrument that allows them to diagnose the quality and effectiveness of their LFI processes, making sure that LFI leads to positive safety outcomes. This paper outlines an instrument that measures the quality of LFI processes and practices: the Learning from Incident Questionnaire (LFIQ). The LFIQ identifies employees’ perceptions and experiences of LFI processes and practices. This paper describes the validation of the LFIQ instrument via a pilot study conducted at two energy companies involving 781 participants. Through factor analysis the instrument was shown to have sufficient validity to become a useful tool for industry; by gaining insight into employees’ perspectives on LFI, frontline managers and supervisors can have evidence on which to base improvements to the local work environment and prioritise areas for improvement

How can we make self-sampling packs for sexually transmitted infections and bloodborne viruses more inclusive? a qualitative study with people with mild learning disabilities and low health literacy

Objectives: 1.5 million people in the UK have mild to moderate learning disabilities. STIs and bloodborne viruses (BBVs) are over-represented in people experiencing broader health inequalities, which include those with mild learning disabilities. Self-managed care, including self-sampling for STIs/BBVs, is increasingly commonplace, requiring agency and health literacy. To inform the development of a partner notification trial, we explored barriers and facilitators to correct use of an STI/BBV self-sampling pack among people with mild learning disabilities. Methods: Using purposive and convenience sampling we conducted four interviews and five gender-specific focus groups with 25 people (13 women, 12 men) with mild learning disabilities (July-August 2018) in Scotland. We balanced deductive and inductive thematic analyses of audio transcripts to explore issues associated with barriers and facilitators to correct use of the pack. Results: All participants found at least one element of the pack challenging or impossible, but welcomed the opportunity to undertake sexual health screening without attending a clinic and welcomed the inclusion of condoms. Reported barriers to correct use included perceived overly complex STI/BBV information and instructions, feeling overwhelmed and the manual dexterity required for blood sampling. Many women struggled interpreting anatomical diagrams depicting vulvovaginal self-swabbing. Facilitators included pre-existing STI/BBV knowledge, familiarity with self-management, good social support and knowing that the service afforded privacy. Conclusion: In the first study to explore the usability of self-sampling packs for STI/BBV in people with learning disabilities, participants found it challenging to use the pack. Limiting information to the minimum required to inform decision-making, € easy read' formats, simple language, large font sizes and simpler diagrams could improve acceptability. However, some people will remain unable to engage with self-sampling at all. To avoid widening health inequalities, face-to-face options should continue to be provided for those unable or unwilling to engage with self-managed care

Is an opportunistic primary care-based intervention for non-responders to bowel screening feasible and acceptable?:A mixed-methods feasibility study in Scotland

Objectives We aimed to test whether a brief, opportunistic intervention in general practice was a feasible and acceptable way to engage with bowel screening non-responders. Design This was a feasibility study testing an intervention which comprised a brief conversation during routine consultation, provision of a patient leaflet and instructions to request a replacement faecal occult blood test kit. A mixed-methods approach to evaluation was adopted. Data were collected from proformas completed after each intervention, from the Bowel Screening Centre database and from questionnaires. Semi-structured interviews were carried out. We used descriptive statistics, content and framework analysis to determine intervention feasibility and acceptability. Participants Bowel screening non-responders (as defined by the Scottish Bowel Screening Centre) and primary care professionals working in five general practices in Lothian, Scotland. Primary and secondary outcome measures Several predefined feasibility parameters were assessed, including numbers of patients engaging in conversation, requesting a replacement kit and returning it, and willingness of primary care professionals to deliver the intervention. Results The intervention was offered to 258 patients in five general practices: 220 (87.0%) engaged with the intervention, 60 (23.3%) requested a new kit, 22 (8.5%) kits were completed and returned. Interviews and questionnaires suggest that the intervention was feasible, acceptable and consistent with an existing health prevention agenda. Reported challenges referred to work-related pressures, time constraints and practice priorities. Conclusions This intervention was acceptable and resulted in a modest increase in non-responders participating in bowel screening, although outlined challenges may affect sustained implementation. The strategy is also aligned with the increasing role of primary care in promoting bowel screening

Understanding the barriers and facilitators to using self-sampling packs for sexually transmitted infections and blood-borne viruses : thematic analyses for intervention optimization

Purpose: Self-sampling packs for sexually transmitted infections (STIs) and blood-borne viruses (BBVs) are widely offered. There are ongoing problems with reach and sample return rates. The packs have arisen without formal intervention development. This paper illustrates initial steps of an intervention optimization process to improve the packs. Methods: Eleven focus groups and seven interviews were conducted with convenience samples of patients recruited from sexual health clinics and members of the public (n = 56). To enable intervention optimization, firstly, we conducted an inductive appraisal of the behavioural system of using the pack to understand meaningful constituent behavioural domains. Subsequently, we conducted a thematic analysis of barriers and facilitators to enacting each sequential behavioural domain in preparation for future behaviour change wheel analysis. Results: Overall, we found that self-sampling packs were acceptable. Participants understood their overall logic and value as a pragmatic intervention that simultaneously facilitated and reduced barriers to individuals being tested for STIs and BBVs. However, at the level of each behavioural domain (e.g., reading leaflets, returning samples) problems with the pack were identified, as well as a series of potential optimizations, which might widen the reach of self-sampling and increase the return of viable samples. Conclusions: This paper provides an example of a pragmatic approach to optimizing an intervention already widely offered globally. The paper demonstrates the added value health psychological approaches offer; conceptualizing interventions in behavioural terms, pinpointing granular behavioural problems amenable for systematic further improvement

Going beyond ‘regular and casual’: development of a classification of sexual partner types to enhance partner notification for STIs

OBJECTIVES To develop a classification of sexual partner types for use in partner notification (PN) for STIs. METHODS A four-step process: (1) an iterative synthesis of five sources of evidence: scoping review of social and health sciences literature on partner types; analysis of relationship types in dating apps; systematic review of PN intervention content; and review of PN guidelines; qualitative interviews with public, patients and health professionals to generate an initial comprehensive classification; (2) multidisciplinary clinical expert consultation to revise the classification; (3) piloting of the revised classification in sexual health clinics during a randomised controlled trial of PN; (4) application of the Theoretical Domains Framework (TDF) to identify index patients' willingness to engage in PN for each partner type. RESULTS Five main partner types emerged from the evidence synthesis and consultation: 'established partner', 'new partner', 'occasional partner', 'one-off partner' and 'sex worker'. The types differed across several dimensions, including likely perceptions of sexual exclusivity, likelihood of sex reoccurring between index patient and sex partner. Sexual health professionals found the classification easy to operationalise. During the trial, they assigned all 3288 partners described by 2223 index patients to a category. The TDF analysis suggested that the partner types might be associated with different risks of STI reinfection, onward transmission and index patients' engagement with PN. CONCLUSIONS We developed an evidence-informed, useable classification of five sexual partner types to underpin PN practice and other STI prevention interventions. Analysis of biomedical, psychological and social factors that distinguish different partner types shows how each could warrant a tailored PN approach. This classification could facilitate the use of partner-centred outcomes. Additional studies are needed to determine the utility of the classification to improve measurement of the impact of PN strategies and help focus resources

Accelerated partner therapy (APT) partner notification for people with Chlamydia trachomatis: protocol for the Limiting Undetected Sexually Transmitted infections to RedUce Morbidity (LUSTRUM) APT cross-over cluster randomised controlled trial

Introduction: Partner notification (PN) is a process aiming to identify, test and treat the sex partners of people (index patients) with sexually transmitted infections (STIs). Accelerated partner therapy (APT) is a PN method whereby healthcare professionals assess sex partners, by telephone consultation, before giving the index patient antibiotics and STI self-sampling kits to deliver to their sex partner(s). The Limiting Undetected Sexually Transmitted infections to RedUce Morbidity programme aims to determine the effectiveness of APT in heterosexual women and men with chlamydia and determine whether APT could affect Chlamydia trachomatis transmission at population level. Methods and analysis: This protocol describes a cross-over cluster randomised controlled trial of APT, offered as an additional PN method, compared with standard PN. The trial is accompanied by an economic evaluation, transmission dynamic modelling and a qualitative process evaluation involving patients, partners and healthcare professionals. Clusters are 17 sexual health clinics in areas of England and Scotland with contrasting patient demographics. We will recruit 5440 heterosexual women and men with chlamydia, aged ≥16 years. The primary outcome is the proportion of index patients testing positive for C. trachomatis 12-16 weeks after the PN consultation. Secondary outcomes include: proportion of sex partners treated; cost effectiveness; model-predicted chlamydia prevalence; experiences of APT. The primary outcome analysis will be by intention-to-treat, fitting random effects logistic regression models that account for clustering of index patients within clinics and trial periods. The transmission dynamic model will be used to predict change in chlamydia prevalence following APT. The economic evaluation will use mathematical modelling outputs, taking a health service perspective. Qualitative data will be analysed using interpretative phenomenological analysis and framework analysis. Ethics and dissemination: This protocol received ethical approval from London—Chelsea Research Ethics Committee (18/LO/0773). Findings will be published with open access licences

Development of an evidence-based brief 'talking' intervention for non-responders to bowel screening for use in primary care:stakeholder interviews

Bowel cancer is the third most common cause of cancer death worldwide. Bowel screening has been shown to reduce mortality and primary care interventions have been successful in increasing uptake of screening. Using evidence-based theory to inform the development of such interventions has been shown to increase their effectiveness. This study aimed to develop and refine a brief evidence-based intervention for eligible individuals whom have not responded to their last bowel screening invitation (non-responders), for opportunistic use by primary care providers during routine consultations.The development of a brief intervention involving a conversation between primary care providers and non-responders was informed by a multi-faceted model comprising: research team workshop and meetings to draw on expertise; evidence from the literature regarding barriers to bowel screening and effective strategies to promote informed participation; relevant psychological theory, and intervention development and behaviour change guidance. Qualitative telephone interviews with 1) bowel screening stakeholders and 2) patient non-responders explored views regarding the acceptability of the intervention to help refine its content and process.The intervention provides a theory and evidence-based tool designed to be incorporated within current primary care practice. Bowel screening stakeholders were supportive of the intervention and recognised the importance of the role of primary care. Interviews highlighted the importance of brevity and simplicity to incorporate the intervention into routine clinical care. Non-responders similarly found the intervention acceptable, valuing a holistic approach to their care. Moreover, they expected their primary care provider to encourage participation.A theory-based brief conversation for use in a primary care consultation was acceptable to bowel screening stakeholders and potential recipients, reflecting a health promoting primary care ethos. Findings indicate that it is appropriate to test the intervention in primary care in a feasibility study

Improving sexual health through partner notification : the LUSTRUM mixed-methods research Programme including RCT of accelerated partner therapy

Background Sexually transmitted infections disproportionately affect young people and men who have sex with men. Chlamydia is Britain’s most common sexually transmitted infection. Partner notification is a key intervention to reduce transmission of sexually transmitted infections and human immunodeficiency virus but is hard to implement. Accelerated partner therapy is a promising new approach. Objectives determine the effectiveness, costs and acceptability of accelerated partner therapy for chlamydia in heterosexual people model the cost effectiveness of accelerated partner therapy and impact on chlamydia transmission develop and cost partner notification interventions for men who have sex with men. Design Mixed-methods study to develop a new sex partner classification and optimise accelerated partner therapy; cluster crossover randomised controlled trial of accelerated partner therapy, with process and cost-consequence evaluation; dynamic modelling and health economic evaluation; systematic review of economic studies of partner notification for sexually transmitted infections in men who have sex with men; qualitative research to co-design a novel partner notification intervention for men who have sex with men with bacterial sexually transmitted infections. Settings Sexual health clinics and community services in England and Scotland. Participants Women and men, including men who have sex with men and people with mild learning disabilities. Interventions Accelerated partner therapy offered as an additional partner notification method. Main outcome measures Proportion of index patients with positive repeat chlamydia test (primary outcome); proportion of sex partners treated; costs per major outcome averted and quality-adjusted life-year; predicted chlamydia prevalence; experiences of accelerated partner therapy. Data sources Randomised controlled trial: partnership type, resource use, outcomes, qualitative data: economic analysis, modelling and systematic review: resource use and unit costs from the randomised controlled trial, secondary sources. Results The sex partner classification defined five types. Accelerated partner therapy modifications included simplified self-sampling packs and creation of training films. We created a clinical management and partner notification data collection system. In the randomised controlled trial, all 17 enrolled clinics completed both periods; 1536 patients were enrolled in the intervention phase and 1724 were enrolled in the control phase. Six hundred and sixty-six (43%) of 1536 index patients in the intervention phase and 800 (46%) of 1724 in the control phase were tested for Chlamydia trachomatis at 12–24 weeks after contact tracing consultation; 31 (4.7%) in the intervention phase and 53 (6.6%) in the control phase had a positive Chlamydia trachomatis test result [adjusted odds ratio 0.66 (95% confidence interval 0.41 to 1.04); p = 0.071]. The proportion of index patients with ≥ 1 sex partner treated was 88.0% (775/881) in intervention and 84.6% (760/898) in control phase, adjusted odds ratio 1.27 (95% confidence interval 0.96 to 1.68; p = 0.10). Overall, 293/1536 (19.1%) index patients chose accelerated partner therapy for 305 partners, of which partner types were: committed/established, 166/305 (54.4%); new, 85/305 (27.9%); occasional, 45/305 (14.8%); and one-off, 9/305 (3.0%). Two hundred and forty-eight accepted accelerated partner therapy and 241 partners were sent accelerated partner therapy packs, 120/241 (49.8%) returned chlamydia/gonorrhoea samples (78/119, 65.5%, positive for chlamydia, no result in one), but only 60/241 (24.9%) human immunodeficiency virus and syphilis samples (all negative). The primary outcomes of the randomised trial were not statistically significantly different at the 5% level. However, the economic evaluation found that accelerated partner therapy could be less costly compared with routine care, and mathematical modelling of effects and costs extrapolated beyond the trial end points suggested that accelerated partner therapy could be more effective and less costly than routine care in terms of major outcome averted and quality-adjusted life-years’. Healthcare professionals did not always offer accelerated partner therapy but felt that a clinical management and partner notification data collection system enhanced data recording. Key elements of a multilevel intervention supporting men who have sex with men in partner notification included: modifying the cultural and social context of men who have sex with men communities; improving skills and changing services to facilitate partner notification for one-off partners; and working with dating app providers to explore digital partner notification options. The systematic review found no evaluations of partner notification for men who have sex with men. Modelling of gonorrhoea and human immunodeficiency virus co-infection in men who have sex with men was technically challenging. Limitations In the randomised controlled trial, enrolment, follow-up and repeat infections were lower than expected, so statistical power was lower than anticipated. We were unable to determine whether accelerated partner therapy sped up partner treatment. Mathematical modelling of gonorrhoea/human immunodeficiency virus co-infection in men who have sex with men remained at an experimental stage. It was not feasible to include healthcare professionals in the men who have sex with men intervention development due to the COVID-19 pandemic. Conclusions Although the evidence that the intervention reduces repeat infection was not conclusive, the trial results suggest that accelerated partner therapy can be safely offered as a contact tracing option and is also likely to be cost saving, but is best suited to sex partners with emotional connection to the index patient. The Programme’s findings about classification of sexual partner types can be implemented in sexual health care with auditable outcomes. Future work Further research is needed on how to increase uptake of accelerated partner therapy and increase sexually transmitted infections self-sampling by partners; understand how services can use partnership-type information to improve partner notification, especially for those currently underserved; overcome challenges in modelling sexually transmitted infections and human immunodeficiency virus co-infection in men who have sex with men; develop and evaluate an intervention to optimise partner notification among men who have sex with men, focusing on one-off partnerships. Trial registration This trial is registered as ISRCTN15996256. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0614-20009) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information