Silos and rigid processes: Barriers to the successful implementation of the Older prisoner Health and Social Care Assessment and Plan

Older adults are the fastest growing sub-group in prisons. They have complex health, social care and custodial needs and often the support they receive is sub-optimal. The Older prisoner Health and Social Care Assessment and Plan (OHSCAP) aimed to better meet these inter-related needs. As part of a wider study, a randomised controlled trial was conducted to evaluate the OHSCAPs effectiveness in meeting older prisoners' health, social care and custodial needs in comparison to treatment as usual. This article describes the nested qualitative study which aimed to explore the barriers and facilitators to the effective implementation of the OHSCAP. Semi-structured interviews were conducted with older adults (n = 14) and staff members t (n = 12). Data was analysed using the framework method. Three overarching key themes were identified. These were: (1) balancing care and custodial requirements; (2) prison, health and social care silos; and (3) rigid prison processes. Prison is an important opportunity to engage residents and improve public health. Cultural and strategic change is required for health, social care and custodial interventions, such as the OHSCAP, to be successfully implemented into prison settings.

Health professionals' experiences of and attitudes towards mental healthcare for migrants and refugees in Europe: A qualitative systematic review

Migrants living in Europe constitute over half of the world's international migrants and are at higher risk of poor mental health than non-migrants, yet also face more barriers in accessing and engaging with services. Furthermore, the quality of care received is shaped by the experiences and attitudes of health professionals. The aim of this review was to identify professionals' attitudes towards migrants receiving mental healthcare and their perceptions of barriers and facilitators to service provision. Four electronic databases were searched, and 23 studies met the inclusion criteria. Using thematic synthesis, we identified three themes: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals' emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Professionals employed multiple strategies to overcome challenges in providing care yet attitudes towards this patient group were polarized. Professionals described mental health issues as being inseparable from material and social disadvantage, highlighting a need for effective collaboration between health services and voluntary organizations, and partnerships with migrant communities. Specialist supervision, reflective practice, increased training for professionals, and the adoption of a person-centered approach are also needed to overcome the current challenges in meeting migrants' needs. The challenges experienced by health professionals in attempting to meet migrant needs reflect frustrations in being part of a system with insufficient resources and without universal access to care that effectively stigmatizes the migrant status.

The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis

BACKGROUND

Evidence-based psychosocial treatments for schizophrenia founded on Western belief systems and values may not be efficacious in different cultures without adaptation. This systematic review analyses the nature and outcomes of culturally-adapted psychosocial interventions in schizophrenia, examining how interventions have been adapted, their efficacy and what features drive heterogeneity in outcome.

METHOD

Articles identified by searching electronic databases from inception to 3 March 2016, reference lists and previous reviews were independently screened by two authors for eligible controlled trials. Data on the nature of adaptations was analysed inductively using thematic analyses. Meta-analyses were conducted using random effects models to calculate effect sizes (Hedges' g) for symptoms.

RESULTS

Forty-six studies with 7828 participants were included, seven adapted for minority populations. Cultural adaptations were grouped into nine themes: language, concepts and illness models, family, communication, content, cultural norms and practices, context and delivery, therapeutic alliance, and treatment goals. Meta-analyses showed significant post-treatment effects in favour of adapted interventions for total symptom severity (n = 2345, g: -0.23, 95% confidence interval (CI) -0.36 to -0.09), positive (n = 1152, g: -0.56, 95% CI -0.86 to -0.26), negative (n = 855, g: -0.39, 95% CI -0.63 to -0.15), and general (n = 525, g: -0.75, CI -1.21 to -0.29) symptoms.

CONCLUSIONS

The adaptation process can be described within a framework that serves as a benchmark for development or assessment of future adaptations. Culturally adapted interventions were more efficacious than usual treatment in proportion to the degree of adaptation. There is insufficient evidence to show that adapted interventions are better than non-adapted interventions. Features of context, intervention and design influenced efficacy. Investigating whether adaptation improves efficacy, most importantly amongst ethnic minorities, requires better designed trials with comparisons against unadapted interventions.

Contemporary women's secure psychiatric services in the United Kingdom: A qualitative analysis of staff views

WHAT IS KNOWN ON THE SUBJECT?: Three pilot UK-only Women's Enhanced Medium Secure Services (WEMSS) was opened in 2007 to support women's movement from high secure care and provide a bespoke, women-only service. Evidence suggests that women's secure services are particularly challenging environments to work in and staffing issues (e.g., high turnover) can cause difficulties in establishing a therapeutic environment. Research in this area has focused on the experiences of service users. Studies which have examined staff views have focused on their feelings towards women in their care and the emotional burden of working in women's secure services. No papers have made a direct comparison between staff working in different services. WHAT DOES THIS STUDY ADD TO EXISTING KNOWLEDGE?: This is the first study to explore the views and experiences of staff in the three UK WEMSS pilot services and contrast them with staff from women's medium secure services. Drawing upon data from eighteen semi-structured interviews (nine WEMSS, nine non-WEMSS), key themes cover staff perceptions of factors important for women's recovery and their views on operational aspects of services. This study extends our understanding of the experiences of staff working with women in secure care and bears relevance for staff working internationally, as well as in UK services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The study reveals the importance of induction and training for bank and agency staff working in women's secure services. Further, regular clinical supervision should be mandatory for all staff so they are adequately supported.

ABSTRACT

Introduction Women's Enhanced Medium Secure Services (WEMSS) is bespoke, gender-sensitive services which opened in the UK in 2007 at three pilot sites. This study is the first of its kind to explore the experiences of WEMSS staff, directly comparing them to staff in a standard medium secure service for women. The literature to date has focused on the experiences of service users or staff views on working with women in secure care. Aim This qualitative study, embedded in a multimethod evaluation of WEMSS, aimed to explore the views and experiences of staff in WEMSS and comparator medium secure services. Methods Qualitative interviews took place with nine WEMSS staff and nine comparator medium secure staff. Interviews focused on factors important for recovery, barriers to facilitating recovery and operational aspects of the service. Discussion This study provides a rare insight into the perspectives of staff working in UK women's secure services, an under-researched area in the UK and internationally. Findings suggest that the success of services, including WEMSS, is compromised by operational factors such as the use of bank staff. Implications for practice Comprehensive training and supervision should be mandatory for all staff, so best practice is met and staff adequately supported.

Immediate direct peripheral vasoconstriction in response to hyperinsulinemia and metformin in the anesthetized pig

Elevated levels of insulin have been reported to induce both an arterial vasodilation mediated by nitric oxide (NO), and vasoconstriction mediated by endothelin and reactive oxygen radicals. Metformin, used to control blood glucose levels in type 2 diabetes, has also been shown to cause NO-mediated dilation of conduit arteries. It is possible that these contradictory vascular effects are due to a non-direct action on arteries. Therefore, the direct effect of high levels of insulin and metformin infusion on resistance artery diameter was evaluated. Experiments were carried out on the anesthetized pig; blood flow and pressure were measured in the iliac artery. An adjustable snare was applied to the iliac above the pressure and flow measurement site to induce step decreases (3-4 occlusions at 5 min intervals were performed for each infusion) in blood flow, and hence iliac pressure, and the conductance (deltaflow / deltapressure) calculated. Saline, insulin (20 and 40 mUSP/l/min), and metformin (1 microg/ml/min) were infused separately downstream of the adjustable snare and their effect on arterial conductance assessed. Insulin at both infusion rates and metformin caused a significant reduction in peripheral vascular conductance. In conclusion, hyperinsulinemia and metformin infusion constrict resistance arterial vessels in vivo.

Responses of iliac conduit artery and hindlimb resistance vessels to luminal hyperfructosemia in the anaesthetized pig

AIMS

High fructose levels are found in diabetes mellitus, associated with high corn syrup diets, and have been claimed to cause hypertension. As the direct effects on conduit and resistance arteries have not been previously reported, we measured these in vivo in the anaesthetized pig with instrumented iliac arteries.

METHODS

Experiments were performed on the iliac artery preparation in the anaesthetized pig: blood flow, diameter and pressure were measured in the iliac.

RESULTS

The change in diameter of an occluded iliac artery segment filled with hyperfructosemic (15 μm) blood was 89.5 ± 22.1 μm (mean ± SE), contrasted with 7.7 ± 13.06 μm control (P = 0.005, paired t-test, n = 6). There was no significant difference when compared with blood containing both hyperfructosemic blood and the nitric oxide synthesis inhibitor, N(G)-nitro-l-arginine methyl ester (250 μg mL(-1)). Step changes in pressure and flow were achieved by progressive arterial stenosis during control saline and 15 μm min(-1) fructose downstream intra-arterial infusions. Linear regression of the step changes in blood pressure versus the instantaneous step changes in blood flow showed a statistically significant decrease in slope of the conductance (P < 0.001, analysis of covariance), indicating an increase in instantaneous peripheral vascular resistance. Peripheral autoregulation and conduit artery shear-stress-mediated dilatation were not significantly altered.

CONCLUSION

An elevated level of fructose caused dilatation of a conduit artery but constriction of resistance vessels. The latter effect could account, if maintained long-term, for the hypertension claimed to be due to hyperfuctosemia.

Ventilatory drive is enhanced in male and female rats following chronic intermittent hypoxia

Obstructive sleep apnoea is characterized by chronic intermittent hypoxia (CIH) due to recurrent apnoea. We have developed a rat model of CIH, which shows evidence of impaired respiratory muscle function. In this study, we wished to characterize the ventilatory effects of CIH in conscious male and female animals. Adult male (n=14) and female (n=8) Wistar rats were used. Animals were placed in chambers daily for 8 h with free access to food and water. The gas supply to one half of the chambers alternated between air and nitrogen every 90 s, for 8 h per day, reducing ambient oxygen concentration in the chambers to 5% at the nadir (intermittent hypoxia; n=7 male, n=4 female). Air supplying the other chambers was switched every 90 s to air from a separate source, at the same flow rates, and animals in these chambers served as controls (n=7 male, n=4 female). Ventilatory measurements were made in conscious animals (typically sleeping) after 10 days using whole-body plethysmography. Normoxic ventilation was increased in both male and female CIH-treated rats compared to controls but this did not achieve statistical significance. However, ventilatory drive was increased in CIH-treated rats of both sexes as evidenced by significant increases in mean and peak inspiratory flow. Ventilatory responses to acute hypoxia (F(I)O(2) = 0.10; 6 min) and hyperoxic hypercapnia (F(I)CO(2) = 0.05; 6 min) were unaffected by CIH treatment in male and female rats (P>0.05, ANOVA). We conclude that CIH increases respiratory drive in adult rats. We speculate that this represents a form of neural plasticity that may compensate for respiratory muscle impairment that occurs in this animal model.