Homelessness, Mental Health and Psychologically Informed Environments:Qualitative Exploration with People Experiencing Homelessness and Staff

This thesis consists of three sections: a systematic literature review (SLR), an empirical paper, and a critical appraisal. The research focuses on people experiencing homelessness (PEH), to understand experiences of accessing and engaging with mental health support, in addition to exploring psychologically informed environments (PIEs) in homelessness services. The SLR explores the perspectives of adults who have experienced homelessness in accessing support for their mental health. A systematic literature search identified 15 papers, synthesised using a meta-ethnographic approach to develop a line of argument synthesis. The results highlight many challenges faced by PEH when accessing mental health support. Themes included the intersectionality of stigma, the importance of relationships, service pressures, and feeling connected. The review recommends that services include people with lived experience of homelessness in service design and increase integration and collaboration across the system. The empirical paper explores what contributes to a successful PIE in a homelessness service from the perspectives of psychologists, staff, and service users. Qualitative semi-structured interviews and a grounded theory methodology captured participants’ accounts and developed a model to illustrate the components of a functioning PIE, the driving forces of systemic and engagement factors, and the service user and staff experiences at the centre. The theory highlights the importance of the relationship between the different elements; when the various factors worked together, a PIE was more stable for the service users and staff at the centre. The results highlight the complexity of implementing a PIE in a homelessness service. Recommendations for services include considering the wider contextual and systemic influences surrounding homelessness. The critical appraisal reflects on the research process and the role of the researcher at different stages of design, data collection, analysis, and interpretation. Further clinical implications and areas for future research are also explored

What do service users want from mental health social work? : A best-worst scaling analysis

Despite being a profession dedicated to the empowerment of service users, empirical study of mental health social work appears dominated by the perspectives of social workers themselves. What service users value is less often reported. This study, authored by a mix of academics and service users/carers, reports a Best–Worst Scaling analysis of ten social worker ‘qualities’, representing both those highly specialist to social work and those generic to other mental health professionals. Fieldwork was undertaken during 2018 with 144 working-age service users, living at home, in five regions of England. Of specialist social work qualities, service users rated ‘[the social worker] thinks about my whole life, not just my illness’ particularly highly, indicating that person-centred approaches drawing on the social model of mental health are crucial to defining social work. However, service users did not value help accessing other community resources, particularly those who had spent the longest time within mental health services. Continuity of care was the most highly valued of all, although this is arguably a system-level feature of support. The research can assist the profession to promote the added value of their work, focusing on their expertise in person-centred care and the social model of mental health

Perceptions of the social worker role in adult community mental health teams in England

From SAGE Publishing via Jisc Publications RouterHistory: epub 2020-05-09Publication status: PublishedFunder: National Institute for Health Research School for Social Care; Grant(s): C088/CM/UMDC-P112There is a growing recognition of the importance of the social work contribution within community mental health services. However, although many texts describe what the mental health social work contribution should be, little empirical evidence exists about their role in practice and the difference it might make to service users. This qualitative study sought to articulate this contribution through the voices of social workers and their multidisciplinary colleagues via focus group discussions across four English Mental Health Trusts. These considered the impact of the social worker on the service user. Thematic analysis resulted in the identification of three over-arching themes: social workers own perceptions of their contribution situated within the social model; the high value their colleagues placed on social work support and leadership in a range of situations and the concerns for service users if social workers were withdrawn from teams. Key findings were that social workers are the only professional group to lead on the social model; that this model enhances the whole teams’ practice and is required if service users are to be offered support that promotes long-term recovery and that without social workers, the community mental health team offer would be more transactional, less timely, with the potential for the loss of the service users’ voice. If social work is to make a full contribution to community mental health team practice, it must be clearly understood and provided with the support to enable social workers to operate to their full potential

Sensitivity Modeling Study for an Ozone Occurrence during the 1996 Paso Del Norte Ozone Campaign

Surface ozone pollution has been a persistent environmental problem in the US and Europe as well as the developing countries. A key prerequisite to find effective alternatives to meeting an ozone air quality standard is to understand the importance of local anthropogenic emissions, the significance of biogenic emissions, and the contribution of long-range transport. In this study, an air quality modeling system that includes chemistry and transport, CMAQ, an emission processing model, SMOKE, and a mesoscale numerical meteorological model, WRF, has been applied to investigate an ozone event occurring during the period of the 1996 Paso del Norte Ozone Campaign. The results show that the modeling system exhibits the capability to simulate this high ozone occurrence by providing a comparable temporal variation of surface ozone concentration at one station and to capture the spatial evolution of the event. Several sensitivity tests were also conducted to identify the contributions to high surface ozone concentration from eight VOC subspecies, biogenic VOCs, anthropogenic VOCs and long-range transportation of ozone and its precursors. It is found that the reductions of ETH, ISOP, PAR, OLE and FORM help to mitigate the surface ozone concentration, and like anthropogenic VOCs, biogenic VOC plays a nonnegligible role in ozone formation. But for this case, long-range transport of ozone and its precursors appears to produce an insignificant contribution

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

BackgroundOver half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.ObjectivesWe aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.DesignWe undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.SettingThe national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.ParticipantsPeople aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.Main outcome measuresThe trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.MethodsOwing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.ResultsOur reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.LimitationsOur chosen outcome measures may not reflect subtle outcomes valued by people with dementia.ConclusionsSeveral approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.Future workFurther work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.Study registrationCurrent Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information

A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice

Background All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application. Methods The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a ‘world café’ workshop (n = 56). Results We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention. Conclusions Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts

The Dementia Early Stage Cognitive Aids New Trial (DESCANT) intervention:A goal attainment scaling approach to promote self-management

Objectives This study investigated goals identified by people with dementia and their carers to promote the self‐management of symptoms and abilities; measured achievement using goal attainment scaling (GAS); and explored the reflections of Dementia Support Practitioners (DSPs) facilitating it. Methods and design Within this pragmatic randomised trial, DSPs gave memory aids, training and support to people with mild to moderate dementia and their carers at home. Data were collected across seven NHS Trusts in England and Wales (2016–2018) and abstracted from intervention records and semi‐structured interviews with DSPs delivering the intervention, supplemented by a subset of the trial dataset. Measures were created to permit quantification and descriptive analysis and interview data thematically analysed. A GAS measure for this intervention in this client group was derived. Results Engagement was high across the 117 participants and 293 goals were identified. These reflected individual circumstances and needs and enabled classification and assessment of their attainment. Seventeen goal types were identified across six domains: self‐care, household tasks, daily occupation, orientation, communication, and well‐being and safety. On average participants achieved nominally significant improvement regarding the specified goals of 1.4 with standard deviation of 0.6. Five interviews suggested that DSPs' experiences of goal setting were also positive. Conclusions GAS is useful for assessing psychosocial interventions for people with early‐stage dementia. It has a utility in identifying goals, promoting self‐management and providing a personalised outcome measure. There is a strong case for exploring whether these clear benefits translate to other interventions in other populations in other places

GIS and graph models for social, temporal and spatial digital analysis in heritage: The case-study of ancient Kingdom of Seville Late Gothic production

This article describes the development of a database management system (DBMS), to use as the basis for a dynamic spatial model or historical geographic information system (HGIS), and an abstract-relational model or dynamic graph model to allow historians and architects to visualise and analyse the complexity of built heritage on a territorial scale. Reutilisation, interoperability, standard terminology and usability were all taken into account in the development of the models. The database was developed within the framework of the International Late Gothic Network and involved an interdisciplinary team of architects, historians, geographers and computer scientists to ensure maximum adaptability of the methodology to other case studies. The result is a DBMS, a GIS model and a graph model, which we hope will provide useful tools for understanding, analysing and disseminating heritage

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707