Evaluation of a complex intervention for prisoners with common mental health problems, near to and after release: the Engager randomised controlled trial

BACKGROUND

Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.

AIMS

This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.

METHOD

The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3-5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).

RESULTS

In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI -1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.

CONCLUSIONS

Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.

P–041 Reproductive concerns and sexual health in men with newly diagnosed testicular cancer prior to orchiectomy: preliminary results from an on-going study

Study question

What is the prevalence of reproductive concerns among patients with newly diagnosed testicular cancer (TC), and how do they rate their sexual health (SH).

Summary answer

Of 20 patients, 75% (n = 15) were moderate to highly concerned about decreased reproductive functioning. Twenty-four percent exhibited overall low SH.

What is known already

Currently, only little is known about reproductive concerns among TC patients. Furthermore, these concerns have not been investigated in a TC population prior to orchiectomy. One study among post-surgery TC patients two years after diagnosis, reported that 28% had high degree of reproductive concern. The literature indicates that TC patients’ sexual health is negatively affected due to altered body image and sexual dysfunction. However, studies regarding sexual health have primarily been performed on long term survivors of TC. Thus, little is known about SH in this population prior to treatment.

Study design, size, duration

The present cross-sectional study included patients from the fertility clinic in Horsens, Denmark. Patients were approached at their pre-scheduled appointment for cryopreservation of semen prior to orchiectomy. Enrolment started March, 2019 and is still on-going. Preliminary data is included from 21 enrolled patients.

Participants/materials, setting, methods

Patients newly diagnosed with TC, who were referred to the fertility clinic for semen cryopreservation prior to orchiectomy and other treatment modalities were invited. The patients responded to a questionnaire package of which reproductive concerns were assessed with seven questions with Likert scale response options ranging from 0 (not concerned) to 5 (highly concerned). SH was assessed with the validated 22-item questionnaire European Organization for Research and Treatment of Cancer Sexual health questionnaire (EORTC-SHQ).

Main results and the role of chance

A total of 37 patients met the inclusion criteria and of these 21 were enrolled in the study. Due to technical issues, only 20 out of 21 patients completed the full questionnaire package. Patients were asked about concerns regarding the ability to father children. Nine patients (45%) were moderately concerned, and six patients (30%) were highly concerned. When asked about their concerns of not being able to father children without fertility treatment, the answers were mostly unaffected with eight patients (40%) being moderately concerned, and seven patients (35%) highly concerned.

Four patients (20%) were highly concerned that decreased semen quality would affect future or present relationships. Patients were also asked if they felt sufficiently informed regarding the chance of fathering children without help from a fertility clinic following cancer treatment. Three patients (15%) reported that they were insufficiently informed, while four patients (20%) responded only to a little extend. Five patients (23,8%) scored ≤ 50 on the EORTC SHQ indicating that they had low SH. Eleven patients (52,3%) felt less masculine due to their disease. Furthermore, one patient (4,8%) scored ≤ 50 on the symptomatic scale, indicating that he had symptomatic sexual problems as fatigue and sexual pain.

Limitations, reasons for caution

The relatively low participant number is a limitation, making the results less generalizable. Furthermore, there is a risk of selection bias due to the moderate inclusion rate. Also, the questionnaire examining fertility related concerns were non validated, and focused mainly on the fertility-related aspects of reproductive concerns.

Wider implications of the findings: A considerable number of patients with newly diagnosed TC show substantial reproductive concerns as well as lowered sexual health. These worries could possibly be alleviated by more sufficient information from the health professionals already in the beginning of the treatment phase, reducing further emotional distress during the remaining treatment period.

Trial registration number

ClinicalTrials.gov ID:NCT03880994

Evaluation of a complex intervention (Engager) for prisoners with common mental health problems, near to and after release: study protocol for a randomised controlled trial

INTRODUCTION

The 'Engager' programme is a 'through-the-gate' intervention designed to support prisoners with common mental health problems as they transition from prison back into the community. The trial will evaluate the clinical and cost-effectiveness of the Engager intervention.

METHODS AND ANALYSIS

The study is a parallel two-group randomised controlled trial with 1:1 individual allocation to either: (a) the Engager intervention plus standard care (intervention group) or (b) standard care alone (control group) across two investigation centres (South West and North West of England). Two hundred and eighty prisoners meeting eligibility criteria will take part. Engager is a person-centred complex intervention delivered by practitioners and aimed at addressing offenders' mental health and social care needs. It comprises one-to-one support for participants prior to release from prison and for up to 20 weeks postrelease. The primary outcome is change in psychological distress measured by the Clinical Outcomes in Routine Evaluation-Outcome Measure at 6 months postrelease. Secondary outcomes include: assessment of subjective met/unmet need, drug and alcohol use, health-related quality of life and well-being-related quality of life measured at 3, 6 and 12 months postrelease; change in objective social domains, drug and alcohol dependence, service utilisation and perceived helpfulness of services and change in psychological constructs related to desistence at 6 and 12 months postrelease; and recidivism at 12 months postrelease. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action and look for unintended consequences. An economic evaluation will estimate the cost-effectiveness.

ETHICS AND DISSEMINATION

This study has been approved by the Wales Research Ethics Committee 3 (ref: 15/WA/0314) and the National Offender Management Service (ref: 2015-283). Findings will be disseminated to commissioners, clinicians and service users via papers and presentations.

TRIAL REGISTRATION NUMBER

ISRCTN11707331; Pre-results.

Evaluation of the effect of nurse education on patient-reported foot checks and foot care behaviour of people with diabetes receiving haemodialysis

AIMS

To assess whether a programme of nurse education increased the frequency with which nurses conducted foot checks on people with diabetes undergoing haemodialysis and to evaluate whether this influenced self-reported foot care behaviour.

METHODS

A non-randomized stepped-wedge design was used to evaluate a nurse education programme implemented in four UK National Health Service dialysis units. People with diabetes undergoing haemodialysis were invited to complete a questionnaire on the frequency of foot examination by health professionals, on the presence of foot problems and on their own foot care behaviour, using the Nottingham Assessment of Functional Foot-care (NAFF). An education session for nurses, including procedures for foot examination, was conducted sequentially in each of four haemodialysis units. The questionnaire was repeated at 2-monthly intervals.

RESULTS

The education session resulted in a significant increase in the reported number of foot examinations by nurses (P = 0.007). There was also a significant improvement in reported foot care behaviour (P < 0.001), but this occurred between the first and second 2-monthly assessments and was unrelated to the timing of the intervention.

CONCLUSIONS

A single education session can improve the routine checking of the feet of people with diabetes undergoing haemodialysis. The administration of the Nottingham Assessment of Functional Foot-care questionnaire was associated with improved self-reported foot care behaviour, reflecting greater awareness of risk in this population.

Using realist review to inform intervention development: methodological illustration and conceptual platform for collaborative care in offender mental health

BACKGROUND

This paper reports how we used a realist review, as part of a wider project to improve collaborative mental health care for prisoners with common mental health problems, to develop a conceptual platform. The importance of offenders gaining support for their mental health, and the need for practitioners across the health service, the criminal justice system, and the third sector to work together to achieve this is recognised internationally. However, the literature does not provide coherent analyses of how these ambitions can be achieved. This paper demonstrates how a realist review can be applied to inform complex intervention development that spans different locations, organisations, professions, and care sectors.

METHODS

We applied and developed a realist review for the purposes of intervention development, using a three-stage process. (1) An iterative database search strategy (extending beyond criminal justice and offender health) and groups of academics, practitioners, and people with lived experience were used to identify explanatory accounts (n = 347). (2) From these accounts, we developed consolidated explanatory accounts (n = 75). (3) The identified interactions between practitioners and offenders (within their organisational, social, and cultural contexts) were specified in a conceptual platform. We also specify, step by step, how these explanatory accounts were documented, consolidated, and built into a conceptual platform. This addresses an important methodological gap for social scientists and intervention developers about how to develop and articulate programme and implementation theory underpinning complex interventions.

RESULTS

An integrated person-centred system is proposed to improve collaborative mental health care for offenders with common mental health problems (near to and after release) by achieving consistency between the goals of different sectors and practitioners, enabling practitioners to apply scientific and experiential knowledge in working judiciously and reflectively, and building systems and aligning resources that are centred on offenders' health and social care needs.

CONCLUSIONS

As part of a broader programme of work, a realist review can make an important contribution to the specification of theoretically informed interventions that have the potential to improve health outcomes. Our conceptual platform has potential application in related systems of health and social care where integrated, and person-centred care is a goal.