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BackgroundPatient self-management, measured by the Patient Activation Measure (PAM), is associated with reduced healthcare utilisation and better health-related quality of life. Self-management in haemodialysis (HD) is challenging and may require support from clinicians with positive attitudes towards self-management, measured by the Clinician Support for PAM (CSPAM).ObjectivesTo assess whether kidney staff CSPAM scores are: 1) associated with their centre's patient PAM scores and 2) modifiable through staff coaching.MethodsBaseline PAM and CSPAM and six-month CSPAM were collected from HD patients and kidney staff respectively in seven UK kidney centres as part of a six-month breakthrough series collaborative (BTSC), which trained kidney staff in supporting patient independence with HD tasks. Firstly, multivariable linear regression analyses adjusted for patient characteristics were used to test the baseline association between centre-level staff CSPAM scores and patient PAM scores. Secondly, paired univariate and unpaired multivariable linear regression analyses were conducted to compare staff CSPAM scores at baseline and six months.Results236 PAM questionnaires (mean score = 55.5) and 89 CSPAM questionnaires (median score = 72.6) were analysed at baseline. There was no significant association between centre-level mean CSPAM scores and PAM scores in univariate analyses (P = 0.321). After adjusting for patient-level characteristics, increasing centre-level mean CSPAM score by 1 point resulted in a non-significant 0.3-point increase in PAM score (0.328 (95% CI: -0.157 to 0.812; P = 0.184). Paired (n = 37) and unpaired (n = 174) staff analyses showed a non-significant change in CSPAM scores following the BTSC intervention (mean change in CSPAM score in unpaired analysis = 1.339 (95% CI: -1.945 to 4.623; P = 0.422).ConclusionsLack of a significant: 1) association between CSPAM and PAM scores and 2) change in CSPAM scores suggest that modifying staff beliefs alone is less likely to influence patient self-management, requiring co-production between patients and staff.

Background Sexual assault referral centres have been established to provide an integrated service that includes forensic examination, health interventions and emotional support. However, it is unclear how the mental health and substance use needs are being addressed. Aim To identify what works for whom under what circumstances for people with mental health or substance use issues who attend sexual assault referral centres. Setting and sample Staff and adult survivors in English sexual assault referral centres and partner agency staff. Design A mixed-method multistage study using realist methodology comprising five work packages. This consisted of a systematic review and realist synthesis (work package 1); a national audit of sexual assault referral centres (work package 2); a cross-sectional prevalence study of mental health and drug and alcohol needs (work package 3); case studies in six sexual assault referral centre settings (work package 4), partner agencies and survivors; and secondary data analysis of outcomes of therapy for sexual assault survivors (work package 5). Findings There is a paucity of evidence identified in the review to support specific ways of addressing mental health and substance use. There is limited mental health expertise in sexual assault referral centres and limited use of screening tools based on the audit. In the prevalence study, participants (n = 78) reported high levels of psychological distress one to six weeks after sexual assault referral centre attendance (94% of people had symptoms of post-traumatic stress disorder). From work package 4 qualitative analysis, survivors identified how trauma-informed care potentially reduced risk of re-traumatisation. Sexual assault referral centre staff found having someone with mental health expertise in the team helpful not only in helping plan onward referrals but also in supporting staff. Both sexual assault referral centre staff and survivors highlighted challenges in onward referral, particularly to NHS mental health care, including gaps in provision and long waiting times. Work package 5 analysis demonstrated that people with recorded sexual assault had higher levels of baseline psychological distress and received more therapy but their average change scores at end point were similar to those without sexual trauma. Limitations The study was adversely affected by the pandemic. The data were collected during successive lockdowns when services were not operating as usual, as well as the overlay of anxiety and isolation due to the pandemic. Conclusions People who attend sexual assault centres have significant mental health and substance use needs. However, sexual assault referral centres vary in how they address these issues. Access to follow-up support from mental health services needs to be improved (especially for those deemed to have ‘complex’ needs) and there is some indication that co-located psychological therapies provision improves the survivor experience. Routine data analysis demonstrated that those with sexual assault can benefit from therapy but require more intensity than those without sexual assault. Future work Further research is needed to evaluate the effectiveness and cost-effectiveness of providing co-located psychological therapy in the sexual assault referral centres, as well as evaluating the long-term needs and outcomes of people who attend these centres. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (16/117/03) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 21. Trial registration This trial is registered as PROSPERO 2018 CRD42018119706 and ISRCTN 18208347. Plain language summary A sexual assault referral centre provides a service for people who have experienced a sexual assault. It offers emotional support, health checks, forensic examination (to collect physical evidence of assault) and advice. Many who experience sexual assault experience distress for some weeks and months afterwards, and some already have mental health problems. The aim of the study was to understand: What was the level of mental distress and substance use issues? How were mental health, drug and alcohol concerns picked up? What therapy or other support is available as part of the sexual assault referral centre service? How do sexual assault referral centres work with other agencies to ensure that people access the right help? What we did We undertook several studies including: Searching and examining published research (review). A survey that asked sexual assault referral centres how mental health and substance use are addressed. Questionnaires: survivors who had recently attended a sexual assault referral centre completed questionnaires on mental health, alcohol and drugs, and quality of life. Interviews with staff at sexual assault referral centres and survivors of assualts. Routine data: we analysed anonymous data from mental health services to compare how those with sexual assault benefit from psychological therapy. What we learnt We combined the findings from all the aspects of the study to conclude that most people who attend sexual assault referral centres have significant mental health needs; however, the response to these needs is variable within sexual assault referral centres. Survivors report that the sexual assault referral centres offer a caring and supportive service, but many also reported difficulties in accessing the right support afterwards. Where there was co-located psychological therapy, there were benefits for both survivors and the wider team. We also showed that, despite high needs, people surviving sexual assault can benefit from therapies but may need more therapy than those who have not experienced sexual assault. Scientific summary Background Sexual assault is a common but under-reported crime; the consequences can be devastating and wide-reaching, impacting on a person’s health, mental health, use of substances, as well as impacting on work, education and relationships. Sexual assault referral centres (SARCs) were established to provide an integrated service, offering forensic examination, sexual health, emergency contraception, pregnancy tests, and post-exposure prophylaxis to prevent HIV. SARC service specifications state that mental health problems should be identified and referrals made to address these needs. However, it is not clear how and when that assessment should happen, or by whom, and how best to offer mental health aftercare. Many people who attend a SARC had prior contact with mental health services (40%), so it is important to consider the needs of those with pre-existing mental ill health and those at risk of developing mental health problems as a result of the assault. An acute trauma response is a normal psychological reaction to sexual assault and many survivors will not require mental health care. However, it is important to identify and offer appropriate support to those with significant needs. Research aims To undertake a mixed-methods study using realist methodology to identify programme theories that will seek to identify the contexts and mechanisms involved in the identification, assessment and the pathways to care (outcomes): to undertake evidence reviews of global SARC provision for health outcomes (including mental health and substance use) (work package (WP) 1) to identify what models of SARCs currently exist in England (WP2) to identify the mental health and substance use needs of attendees of SARCs in England (WP3) to identify what services are available in SARCs in England, and to explore satisfaction with care, barriers to access and gaps in provision (WPs 2, 3 and 4) to understand from the perspective of the SARC workforce and their current practice, skills and training needs in terms of recognition of, and referral for, mental health and substance use issues (WP4) to obtain the survivor view on how they felt their emotional well-being was addressed by the SARC as well as by external services (WP4) to compare health outcomes for people who experience sexual assault and access bespoke SARC psychological therapies provision compared to those who experience sexual assault and are in mainstream mental health services (WP5) to produce a range of lay and academic outputs that will aim to identify and share good practice in SARC services related to identifying and supporting substance use and mental health among people who experience sexual assault to have an impact on care delivery. Setting and participants Staff who work in SARCs, representatives from relevant partner agencies, and survivors. Methods WP1 consisted of a systematic review that sought to address three questions: (1) how mental health and drug/alcohol issues were identified and assessed; (2) evidence for interventions that aimed to improve mental health and/or drug/alcohol issues following an attendance at a SARC; and (3) stakeholder views (including survivors) of how SARCs can promote and support mental health. WP2 was a national audit of SARCs in England, which collected information about skill mix, assessment, what mental health support was available, and partnerships with other agencies. A cluster analysis was performed to group SARCs by their similar responses to these key variables. WP3 was a prevalence study. The sample included people who had recently attended a SARC (data were collected between one and six weeks of attendance). Outcome measures Outcomes were measured using the following tools: Clinical Outcomes in Routine Evaluation 10 (CORE-10) Alcohol Use Disorders Identification Test (AUDIT-C) Primary Care PTSD Screen for DSM-5 (PC-PTSC-5) Recovering Quality of Life (ReQoL) Drug Abuse Screen Test (DAST) Structured Assessment of Personality Abbreviated Scale (SAPAS). Procedure Following informed consent, participants were sent an online questionnaire containing the outcome measures. The online responses were checked by a researcher to pick up any safeguarding issues. If there were any present, the researcher would contact the participant and assess their safety and well-being. Work package 4 case studies Documentary analysis was undertaken on policies and local documents including the SARC website and used to create a localised journey map for each SARC, which informed the interviews. Interviews and focus groups were conducted in the six case study sites and involved survivors, SARC staff and partner agencies (mental health services, drug and alcohol services, and third sector counselling and support services, e.g. rape counselling). Interviews were transcribed verbatim and contexts mechanisms and outcomes were coded in NVivo (Lumivero, Denver, CO). Within-SARC and between-SARC case study analyses were performed and programme theories were refined. Work package 5 secondary data analysis WP5 involved secondary data analysis of two separate datasets. The first used anonymised data on the outcomes of co-located psychological therapy services within one SARC. The second dataset was extracted from the anonymised Clinical Research Interactive Search (CRIS) anonymised routine data base from one NHS mental health organisation in England. A sample of people was selected who had a sexual assault identified in their notes and a comparison group of people who did not have that experience documented, who also had baseline and follow-up CORE-10 data following psychological therapy. Results Review: the most commonly reported method of assessing mental health and alcohol and/or drug use was using an unstructured and often unspecified assessment. Use of validated screening tools was rarely reported and where they were mentioned, this tended to be screening for post-traumatic stress disorder (PTSD) specifically. The most common support offered was ‘counselling’ but this was poorly described. There was limited mention of evidence-based therapies such as eye movement desensitisation reprocessing or cognitive behaviour therapy. There were five randomised controlled trials (RCTs) which evaluated psychoeducation tools. Overall, there was a lack of robust evidence to inform how best to address mental health and substance use in SARCs. A realist synthesis was undertaken to identify initial programme theories. WP2: In the audit, a 77% response rate was achieved. Few SARCs had mental health expertise in the team and 7% of SARCs had in-house or co-located psychosocial support. There were limited formal care pathways to partner agencies and respondents were less satisfied with level of integration with local mental health and alcohol/drug services compared with rape counselling and domestic violence services. WP3: Prevalence study – of the 275 people who gave consent to contact, successful contact was made with 157 (43%) and, of these, 78 were enrolled on the study; 76% scored moderate/severe distress on CORE-10; 94% of scores indicated PTSD; 63% of scores indicated a possible personality disorder; 12% were drinking at ‘risky’ alcohol levels (AUDIT-C) and 26% had a moderate to severe drug problem according to the DAST. In terms of quality of life, most (87%) had low quality of life from ReQoL scores. WP4: Case studies – SARC staff identified that the lack of having mental health expertise alongside fragmented care pathways meant that people who were identified as having continuing mental health needs were not able to efficiently get those needs met. In SARCs where there was in-house or co-located psychological support, this seemed to improve the speed and quality in which people received the right care at the right time. In addition, there were wider benefits to having a mental health professional in the team in terms of contributing to team discussions on care planning and referrals, as well as supporting staff in terms of informal support and reflection on practice. Survivors found the experience of the SARCs very helpful, specifically around the trauma-informed practices that helped them reframe their experiences, seeing themselves as survivors rather than victims. The survivors’ experiences of past and current mental health services was less positive owing to long waiting lists, limited sessions being offered due to resource issues, or not quite fitting into a service remit. WP5: In SARC 5, there was a stepped care model for counselling and therapy. Between April 2020 and December 2020, 467 people referred to counselling and 229 to psychological therapies. Those on the higher-intensity therapy track had higher needs at baseline and received more sessions than those referred for counselling. Despite this, the average change scores for both groups were similar at end of therapy. Reasons for disengagement with counselling were mainly about difficulty travelling to sessions (SARC 5 covers a large mainly rural area). There was less textual information regarding the therapy service but this information indicated that some referrals were not accepted because the person’s needs were too complex and were stepped up to other mental health provision. In the CRIS data analysis, the cohort identified as having been sexually assaulted compared with a control group had higher needs and complexity at baseline. They also had more sessions of therapy than those without a history of sexual assault. However, despite the baseline differences the sexual assault cohort has similar average change scores in the CORE-10 outcome data compared with the control group. Discussion There are high levels of mental health and alcohol/drug use needs in people who attend SARC, certainly as measured in the immediate period after SARC attendance, and many had pre-existing mental health or alcohol/drug use issues. However, there was limited evidence of integration of mental health and substance use interventions following SARC attendance, and few SARC staff has expertise in mental health. Most operated referral system to external agencies but this was deemed to be less than ideal as reported by all stakeholders. Survivors valued the support they received at the SARC from staff who used a trauma-informed approach. In comparison, survivors spoke less favourably about mainstream NHS mental health provision, citing a limited number of sessions, long waiting lists and unhelpful attitudes towards people who have been sexually assaulted. The quality of the local care pathways was hampered by complexity of local service providers, a lack of a single point of contact and perceived high threshold to access mental health and psychological therapies. Analysis of outcome data comparing people who had been sexually assaulted and those who had not (WP5) found that average change scores at follow-up were the same for both groups. This is an important finding, as it offers therapeutic optimism that therapy is beneficial for survivors of sexual assault, but also has resource implications that need to be addressed. Limitations The study was impacted by the COVID-19 pandemic, especially WP3. The target of 360 people was not achieved and, even after extending recruitment period by three months, only 78 were recruited from four of the six sites. This had a knock-on effect for recruitment for the survivor qualitative interviews. All the data were collected using remote methods, which worked well, and there were no issues related to this method in terms of people declining to participate. Implications for health care There is a need to for detailed specification for SARCs with regard to mental health and substance use. This would help address inconsistency in how this service is operationalised nationally. The specification should include raising awareness of SARCs to mental health and alcohol/drug services. The SARC would benefit from having access someone with a mental health background who can support the integration of standard practice in mental health identification and assessment, management of crisis and distress, as well as either providing in-house support or formalising pathways to local mental health, alcohol/drug services, and other relevant services. The implications for mental health services include improving routine enquiry about sexual violence, addressing the gaps in accessing support for those who have experienced sexual violence who may already be in mental health care, as well as being able to provide timely access to evidence based therapies for people who have multiple needs. Recommendations for research Further research should investigate whether routine screening improves access to mental health care and outcomes for survivors. There is a need for research to evaluate co-located bespoke therapy using a RCT to establish clinical and cost-effectiveness. In addition, there is a need to investigate how gaps in therapy provision can be addressed and evaluated, specifically for those who are perceived to have more ‘complex’ needs. Further research should investigate how to improve routine enquiry and recording of sexual violence in mental health and substance use. Conclusion People who attend SARCs have high levels of need in relation to mental health and alcohol/drug use, and clarity is required as to how these needs should identified and addressed by SARCs and partner agencies. The trauma-informed approach adopted by SARCs aids in survivor recovery and mental well-being. However, some survivors have multiple needs that may require intensive evidence-based therapies delivered by people who understand sexual trauma. There is a clear imperative for SARCs and partner agencies to develop closer relationships and agreed pathways so that survivors have their needs accurately identified and are referred to the right service for those needs. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (16/117/03) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 21. Trial registration This trial is registered as PROSPERO 2018 CRD42018119706 and ISRCTN 18208347.

Abstract Background Videoconferencing has been proposed as a way of improving access to healthcare for older adults in care homes. Despite this, effective uptake of videoconferencing remains varied. This study evaluates a videoconferencing service for care home staff seeking support from healthcare professionals for the care of residents. The aim was to explore factors affecting the uptake and sustainability of videoconferencing in care homes, to establish what works for whom, in which circumstances and respects. The findings informed recommendations for commissioners and strategic managers on how best to implement videoconferencing for remote healthcare provision in care homes for older adults. Methods Realist evaluation was used to develop, refine and test theories around the uptake and maintenance of videoconferencing in three care homes across Yorkshire and the Humber, England. The care homes were selected using maximum variation sampling regarding the extent to which they used videoconferencing. A developmental inquiry framework and realist interviews were used to identify Context, Mechanism and Outcome Configurations (CMOCs) regarding uptake and sustainability of the service. Participants included care home residents (aged > 65) and staff, relatives and strategic managers of care home chains. The interviews were an iterative process conducted alongside data analysis. Transcripts of audio recordings were entered into NVIVO 12, initially coded into themes, then hypotheses developed, refined and tested. Results Outcomes were generated in relation to two main contextual factors, these were: (1) communication culture in the home and (2) the prior knowledge and experience that staff have of videoconferencing. The key facilitators identified were aspects of leadership, social links within the home and psychological safety which promoted shared learning and confidence in using the technology. Conclusions Videoconferencing is a valuable tool, but successful implementation and sustainability are dependent on care home culture and staff training to promote confidence through positive and supported experiences.

Background Haemodialysis patients experience significant symptom burden and effects on health-related quality of life. Studies have shown increases in fluid overload, hospitalization and mortality immediately after the long interdialytic interval in thrice weekly in-centre haemodialysis patients, however the relationship between the dialytic interval and patient reported outcome measures (PROMs) has not been quantified and the extent to which dialysis day of PROM completion needs to be standardised is unknown. Methods Three times a week haemodialysis patients participating in a stepped wedge trial to increase patient participation in haemodialysis tasks completed PROMs (POS-S Renal symptom score and EQ-5D-5L) at recruitment, six, 12 and 18 months. Time from the long interdialytic interval, HD day of the week, and HD days vs non-HD days were included in mixed effects Linear Regression, estimating severity (none to overwhelming treated as 0 to 4) of 17 symptoms and EQ-5D-5L, adjusting for age, sex, time on HD, control versus intervention and Charlson Comorbidity Score. Results 517 patients completed 1659 YHS questionnaires that could be assigned HD day (510 on Mon/Tue/Sun, 549 on Wed/Thu/Tue, 308 on Fri/Sat/Thu and 269 on non-HD days). With the exception of restless legs and skin changes, there was no statistically significant change in symptom severity or EQ-5D-5L with increasing time from the long interdialytic interval. Patients who responded on non-HD days had higher severity of poor appetite, constipation, difficulty sleeping, poor mobility and depression (approximately 0.2 severity level), and lower EQ-5D-5L (-0.06, CI -0.09 to -0.03) compared to HD days. Conclusions Measuring symptom severity and EQ-5D-5L in haemodialysis populations does not need to account for dialysis schedule, but completion either on HD or non-HD days could introduce bias that may impact evaluation of interventions. Researchers should ensure completion of these instruments are standardized on either dialysis or non-dialysis days.

Realist approaches are increasingly used in studies of complex health interventions/evaluations to understand how programmes work, for whom and under what circumstances. Mixed-method data sources can be used to generate, refine and test realist programme theories, which explore causal links about the contexts that affect the mechanisms of an intervention and lead to the production of different outcomes. The realist approach provides a framework for a detailed understanding of how a programme functions, aiding with the implementation, refinement or adaptation of interventions. Documentary analysis provides an overview of the theoretical and practical functioning of a service and the ways it is structured to provide interventions. Data are often collected early in the evaluation and can include service specifications, organisational policies and procedures and routine audit data. This paper describes a two-stage process of documentary analysis, where data extraction forms and journey maps are used to explore how Sexual Assault Referral Centres (SARCs) in England respond to the mental health and substance use needs of users. Using documentary analysis as part of a sequential data collection process can be valuable in informing subsequent data sources (e.g qualitative interview schedules can be used to further test and refine theories from a documentary analysis). Considerations for researchers in applying documentary analysis include the value of keeping initial searches broad, to capture documents from a range of sources; the need for clarity about the prioritisation of data sources in the selection process; the benefit in establishing a standardised extraction form that incorporates the wider context within which the intervention functions; taking steps to ensure face validity and transferability during interpretation of data sources; the benefits of transforming information from the data extraction form into a visual journey map.

BackgroundCompared to in-centre, home hemodialysis is associated with superior outcomes. The impact on patient experience and clinical outcomes of consistently providing the choice and training to undertake hemodialysis-related treatment tasks in the in-centre setting is unknown.MethodsA stepped-wedge cluster randomised trial in 12 UK renal centres recruited prevalent in-centre hemodialysis patients with sites randomised into early and late participation in a 12-month breakthrough series collaborative that included data collection, learning events, Plan-Study-Do-Act cycles, and teleconferences repeated every 6 weeks, underpinned by a faculty, co-production, materials and a nursing course. The primary outcome was the proportion of patients undertaking five or more hemodialysis-related tasks or home hemodialysis. Secondary outcomes included independent hemodialysis, quality of life, symptoms, patient activation and hospitalisation. ISRCTN Registration Number 93999549.Results586 hemodialysis patients were recruited. The proportion performing 5 or more tasks or home hemodialysis increased from 45.6% to 52.3% (205 to 244/449, difference 6.2%, 95% CI 1.4 to 11%), however after analysis by step the adjusted odds ratio for the intervention was 1.63 (95% CI 0.94 to 2.81, P = 0.08). 28.3% of patients doing less than 5 tasks at baseline performed 5 or more at the end of the study (69/244, 95% CI 22.2-34.3%, adjusted odds ratio 3.71, 95% CI 1.66-8.31). Independent or home hemodialysis increased from 7.5% to 11.6% (32 to 49/423, difference 4.0%, 95% CI 1.0-7.0), but the remaining secondary endpoints were unaffected.ConclusionsOur intervention did not increase dialysis related tasks being performed by a prevalent population of centre based patients, but there was an increase in home hemodialysis as well as an increase in tasks among patients who were doing fewer than 5 at baseline. Further studies are required that examine interventions to engage people who dialyse at centres in their own care.

NHS vanguards, under-pressure to perform, required better contracting and data management arrangements with evaluation teams, to ensure that integrated service outcomes could be reported effectively. This communication reflects the experience of evaluating an NHS vanguard and suggests how academic teams can improve capacity for complex programme evaluation of rapid improvements in integrated services. This should be based on a shared commitment to data collection and management. Also, robust knowledge exchange processes can enable systems change and sustainability. The identifying features of the particular site have been withheld.

Abstract Background The study objective is to assess the effectiveness and economic impact of a structured programme to support patient involvement in centre-based haemodialysis and to understand what works for whom in what circumstances and why. It implements a program of Shared Haemodialysis Care (SHC) that aims to improve experience and outcomes for those who are treated with centre-based haemodialysis, and give more patients the confidence to dialyse independently both at centres and at home. Methods/Design The 24 month mixed methods cohort evaluation of 600 prevalent centre based HD patients is nested within a 30 month quality improvement program that aims to scale up SHC at 12 dialysis centres across England. SHC describes an intervention where patients who receive centre-based haemodialysis are given the opportunity to learn, engage with and undertake tasks associated with their treatment. Following a 6-month set up period, a phased implementation programme is initiated across 12 dialysis units using a randomised stepped wedge design with 6 centres participating in each of 2 steps, each lasting 6 months. The intervention utilises quality improvement methodologies involving rapid tests of change to determine the most appropriate mechanisms for implementation in the context of a learning collaborative. Running parallel with the stepped wedge intervention is a mixed methods cohort evaluation that employs patient questionnaires and interviews, and will link with routinely collected data at the end of the study period. The primary outcome measure is the number of patients performing at least 5 dialysis-related tasks collected using 3 monthly questionnaires. Secondary outcomes measures include: the number of people choosing to perform home haemodialysis or dialyse independently in-centre by the end of the study period; end-user recommendation; home dialysis establishment delay; staff impact and confidence; hospitalisation; infection and health economics. Discussion The results from this study will provide evidence of impact of SHC, barriers to patient and centre level adoption and inform development of future interventions to support its implementation. Trial registration ISRCTN Number: 93999549 , (retrospectively registered 1st May 2017); NIHR Research Portfolio: 31566

BackgroundSpecialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice.MethodsA systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted.ResultsWe included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services.ConclusionsThis review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

An increasing demand for care homes in the UK, has necessitated the evaluation of innovative methods for delivering more effective health care. Videoconferencing may be one way to meet this demand. However, there is a lack of literature on the provision of videoconferencing in England. This mixed-methods study aimed to map current attitudes, knowledge and provision of videoconferencing in the Yorkshire and Humber region of England. Qualitative interviews with care home managers, a scoping review and field notes from a Special Interest Group (SIG) informed the development of a descriptive convenience survey which was sent out to care home managers in the Yorkshire and Humber region of England. The survey had a 14% (n = 124) response rate. Of those who responded, 10% (n = 12) reported using videoconferencing for health care; with over 78% (n = 97) of respondents’ care homes being based in urban areas. Approximately 62% (n = 77) of the 124 respondents had heard of videoconferencing for health care provision. Of those who reported not using videoconferencing (n = 112), 39% (n = 48) said they would consider it but would need to know more. The top ranked reason for not introducing videoconferencing was the belief that residents would not be comfortable using videoconferencing to consult with a healthcare professional. The main reason for implementation was the need for speedier access to services. Those already using videoconferencing rated videoconferencing overall as being very good (50%) (n = 6) or good (42%) (n = 5). Those who were not using it in practice appeared sceptical before implementing videoconferencing. The main driver of uptake was the home’s current access to and satisfaction with traditionally delivered health care services.

A scoping review was conducted to map the research evidence on the use of videoconferencing for remote health care provision for older adults in care homes. The review aimed to identify the nature and extent of the existing evidence base. Databases used were Embase, Medline, Web of Science, and Cochrane Library Reviews. The review identified 26 articles for inclusion, of which 14 were case studies, making the most used study design. Papers described videoconferencing as being used for assessment, management of health care, clinical support, and diagnosis, with eight of the papers reporting the use of videoconferencing for more than one clinical purpose. A further eight papers reported the use of videoconferencing for assessment alone. The literature reported the collection of various types of data, with 12 papers describing the use of both qualitative and quantitative data. The outcomes mainly addressed staff satisfaction (n=9) and resident satisfaction (n=8). Current evidence supports the feasibility of videoconferencing in care homes. However, research needs to be undertaken to establish the contexts and mechanisms that underpin the successful implementation of videoconferencing in care homes and to define useful measures for success.

Background: The establishment of the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) was the culmination of a number of policy initiatives to bridge the gap between evidence and practice. CLAHRCs were created and funded to facilitate development of partnerships and connect the worlds of academia and practice in an effort to improve patient outcomes through the conduct and application of applied health research. Objectives: Our starting point was to test the theory that bringing higher education institutions and health-care organisations closer together catalyses knowledge mobilisation. The overall purpose was to develop explanatory theory regarding implementation through CLAHRCs and answer the question ‘what works, for whom, why and in what circumstances?’. The study objectives focused on identifying and tracking implementation mechanisms and processes over time; determining what influences whether or not and how research is used in CLAHRCs; investigating the role played by boundary objects in the success or failure of implementation; and determining whether or not and how CLAHRCs develop and sustain interactions and communities of practice. Methods: This study was a longitudinal realist evaluation using multiple qualitative case studies, incorporating stakeholder engagement and formative feedback. Three CLAHRCs were studied in depth over four rounds of data collection through a process of hypothesis generation, refining, testing and programme theory specification. Data collection included interviews, observation, documents, feedback sessions and an interpretive forum. Findings: Knowledge mobilisation in CLAHRCs was a function of a number of interconnected issues that provided more or less conducive conditions for collective action. The potential of CLAHRCs to close the metaphorical ‘know–do’ gap was dependent on historical regional relationships, their approach to engaging different communities, their architectures, what priorities were set and how, and providing additional resources for implementation, including investment in roles and activities to bridge and broker boundaries. Additionally, we observed a balance towards conducting research rather than implementing it. Key mechanisms of interpretations of collaborative action, opportunities for connectivity, facilitation, motivation, review and reflection, and unlocking barriers/releasing potential were important to the processes and outcomes of CLAHRCs. These mechanisms operated in different contexts including stakeholders’ positioning, or ‘where they were coming from’, governance arrangements, availability of resources, competing drivers, receptiveness to learning and evaluation, and alignment of structures, positions and resources. Preceding conditions influenced the course and journey of the CLAHRCs in a path-dependent way. We observed them evolving over time and their development led to the accumulation of different types of impacts, from those that were conceptual to, later in their life cycle, those that were more direct. Conclusions: Most studies of implementation focus on researching one-off projects, so a strength of this study was in researching a systems approach to knowledge mobilisation over time. Although CLAHRC-like approaches show promise, realising their full potential will require a longer and more sustained focus on relationship building, resource allocation and, in some cases, culture change. This reinforces the point that research implementation within a CLAHRC model is a long-term investment and one that is set within a life cycle of organisational collaboration. Funding: The National Institute for Health Research Health Services and Delivery Research programme.