Patient education interventions for the management of inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD) is a life-long condition for which currently there is no cure. Patient educational interventions deliver structured information to their recipients. Evidence suggests patient education can have positive effects in other chronic diseases. OBJECTIVES: To identify the different types of educational interventions, how they are delivered, and to determine their effectiveness and safety in people with IBD. SEARCH METHODS: On 27 November 2022, we searched CENTRAL, Embase, MEDLINE, ClinicalTrials.gov, and WHO ICTRP with no limitations to language, date, document type, or publication status. Any type of formal or informal educational intervention, lasting for any time, that had content focused directly on knowledge about IBD or skills needed for direct management of IBD or its symptoms was included. Delivery methods included face-to-face or remote educational sessions, workshops, guided study via the use of printed or online materials, the use of mobile applications, or any other method that delivers information to patients. SELECTION CRITERIA: All published, unpublished and ongoing randomised control trials (RCTs) that compare educational interventions targeted at people with IBD to any other type of intervention or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted data extraction and risk of bias assessment of the included studies. We analysed data using Review Manager Web. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology. MAIN RESULTS: We included 14 studies with a total of 2708 randomised participants, aged 11 to 75 years. Two studies examined populations who all had ulcerative colitis (UC); the remaining studies examined a mix of IBD patients (UC and Crohn's disease). Studies considered a range of disease activity states. The length of the interventions ranged from 30 minutes to 12 months. Education was provided in the form of in-person workshops/lectures, and remotely via printed materials or multimedia, smartphones and internet learning. Thirteen studies compared patient education interventions plus standard care against standard care alone. The interventions included seminars, information booklets, text messages, e-learning, a multi professional group-based programme, guidebooks, a staff-delivered programme based on an illustrated book, a standardised programme followed by group session, lectures alternating with group therapy, educational sessions based on an IBD guidebook, internet blog access and text messages, a structured education programme, and interactive videos. Risk of bias findings were concerning in all judgement areas across all studies. No single study was free of unclear or high of bias judgements. Reporting of most outcomes in a homogeneous fashion was limited, with quality of life at study end reported most commonly in six of the 14 studies which allowed for meta-analysis, with all other outcomes reported in a more heterogeneous manner that limited wider analysis. Two studies provided data on disease activity. There was no clear difference in disease activity when patient education (n = 277) combined with standard care was compared to standard care (n = 202). Patient education combined with standard care is probably equivalent to standard care in reducing disease activity in patients with IBD (standardised mean difference (SMD) -0.03, 95% CI -0.25 to 0.20), moderate-certainty evidence. Two studies provided continuous data on flare-up/relapse. There was no clear difference for flare-ups or relapse when patient education (n = 515) combined with standard care was compared to standard care (n = 507), as a continuous outcome. Patient education combined with standard care is probably equivalent to standard care in reducing flare-ups or relapse in patients with IBD (MD -0.00, 95% CI -0.06 to 0.05; moderate-certainty evidence). Three studies provided dichotomous data on flare-up/relapse. The evidence is very uncertain on whether patient education combined with standard care (n = 157) is different to standard care (n = 150) in reducing flare-ups or relapse in patients with IBD (RR 0.94, 95% CI 0.41 to 2.18; very low-certainty evidence). Six studies provided data on quality of life. There was no clear difference in quality of life when patient education combined with standard care (n = 721) was compared to standard care (n = 643). Patient education combined with standard care is probably equivalent to standard care in improving quality of life in patients with IBD (SMD 0.08, 95% CI -0.03 to 0.18; moderate-certainty evidence). The included studies did not report major differences on healthcare access. Medication adherence, patient knowledge and change in quality of life showed conflicting results that varied between no major differences and differences in favour of the educational interventions. Only five studies reported on adverse events. Four reported zero total adverse events and one reported one case of breast cancer and two cases of surgery in their interventions groups, and zero adverse events in their control group. Two studies compared delivery methods of patient education, specifically: web-based patient education interventions versus colour-printed books or text messages; and one study compared frequency of patient education, specifically: weekly educational text messages versus once every other week educational text messages. These did not show major differences for disease activity and quality of life. Other outcomes were not reported. AUTHORS' CONCLUSIONS: The ways in which patient educational support surrounding IBD may impact on disease outcomes is complex. There is evidence that education added to standard care is probably of no benefit to disease activity or quality of life when compared with standard care, and may be of no benefit for occurrence of relapse when compared with standard care. However, as there was a paucity of specific information regarding the components of education or standard care, the utility of these findings is questionable. Further research on the impact of education on our primary outcomes of disease activity, flare-ups/relapse and quality of life is probably not indicated. However, further research is necessary, which should focus on reporting details of the educational interventions and study outcomes that educational interventions could be directly targeted to address, such as healthcare access and medication adherence. These should be informed by direct engagement with stakeholders and people affected by Crohn's and colitis.

ANTECEDENTES: La enfermedad inflamatoria intestinal (EII) es una enfermedad crónica para la que no existe cura en la actualidad. Las intervenciones educativas para pacientes proporcionan información estructurada a sus destinatarios. La evidencia sugiere que la educación del paciente puede tener efectos positivos en otras enfermedades crónicas. OBJETIVOS: Identificar los diferentes tipos de intervenciones educativas, cómo se realizan y determinar su eficacia y seguridad en personas con EII. MÉTODOS DE BÚSQUEDA: El 27 de noviembre de 2022 se realizaron búsquedas en CENTRAL, Embase, MEDLINE, ClinicalTrials.gov y la ICTRP de la OMS sin limitaciones de idioma, fecha, tipo de documento o estado de publicación. Se incluyó cualquier tipo de intervención educativa formal o informal, de cualquier duración, cuyo contenido se centrara directamente en los conocimientos sobre la EII o en las habilidades necesarias para el control directo de la EII o sus síntomas. Los métodos de entrega incluyeron sesiones educativas presenciales o a distancia, talleres, estudio guiado mediante el uso de materiales impresos o en línea, el uso de aplicaciones móviles o cualquier otro método que proporcionara información a los pacientes. CRITERIOS DE SELECCIÓN: Todos los ensayos controlados aleatorizados (ECA) publicados, no publicados y en curso que comparen intervenciones educativas dirigidas a personas con EII con cualquier otro tipo de intervención o ninguna intervención. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos autores de la revisión realizaron de forma independiente la extracción de los datos y la evaluación del riesgo de sesgo de los estudios incluidos. Los datos se analizaron mediante Review Manager Web. Los desenlaces dicotómicos y continuos se expresaron como razones de riesgos (RR) y diferencias de medias (DM) con intervalos de confianza (IC) del 95%. La certeza de la evidencia se evaluó mediante el método GRADE. RESULTADOS PRINCIPALES: Se incluyeron 14 estudios con un total de 2708 participantes asignados al azar, de edades comprendidas entre los 11 y los 75 años. Dos estudios examinaron poblaciones que tenían todas colitis ulcerosa (CU); los estudios restantes examinaron una mezcla de pacientes con EII (CU y enfermedad de Crohn). Los estudios consideraron una serie de estados de actividad de la enfermedad. La duración de las intervenciones osciló entre 30 minutos y 12 meses. La educación se impartió en forma de talleres/conferencias presenciales y a distancia mediante material impreso o multimedia, teléfonos inteligentes y aprendizaje por Internet. Trece estudios compararon las intervenciones educativas para pacientes más la atención estándar con la atención estándar sola. Las intervenciones incluyeron seminarios, folletos informativos, mensajes de texto, aprendizaje electrónico, un programa multiprofesional basado en grupos, guías, un programa impartido por el personal basado en un libro ilustrado, un programa estandarizado seguido de una terapia grupal, conferencias alternadas con terapia grupal, sesiones educativas basadas en una guía sobre la EII, acceso a blogs de Internet y mensajes de texto, un programa educativo estructurado y vídeos interactivos. Los hallazgos de riesgo de sesgo fueron preocupantes en todas las áreas de valoración en todos los estudios. Ningún estudio estuvo libre de valoraciones de sesgo incierto o alto. El informe de la mayoría de los desenlaces de forma homogénea fue limitado, con la calidad de vida al final del estudio informada con mayor frecuencia en seis de los 14 estudios que permitieron el metanálisis, y todos los demás desenlaces fueron informados de forma más heterogénea, lo que impidió un análisis más amplio. Dos estudios proporcionaron datos sobre la actividad de la enfermedad. No hubo diferencias claras en la actividad de la enfermedad cuando se comparó la educación del paciente (n = 277) combinada con la atención estándar con la atención estándar sola (n = 202). La educación del paciente combinada con la atención estándar es probablemente equivalente a la atención estándar en la reducción de la actividad de la enfermedad en pacientes con EII (diferencia de medias estandarizada [DME] ­0,03; IC del 95%: ­0,25 a 0,20), evidencia de certeza moderada. Dos estudios proporcionaron datos continuos sobre las exacerbaciones/recaídas. No hubo diferencias claras en las exacerbaciones o recaídas cuando se comparó la educación del paciente (n = 515) combinada con la atención estándar con la atención estándar sola (n = 507), como desenlace continuo. La educación del paciente combinada con la atención estándar es probablemente equivalente a la atención estándar en la reducción de las exacerbaciones o recaídas en pacientes con EII (DM ­0,00; IC del 95%: ­0,06 a 0,05; evidencia de certeza moderada). Tres estudios proporcionaron datos dicotómicos sobre las exacerbaciones/recaídas. La evidencia es muy incierta en cuanto a si la educación del paciente combinada con la atención estándar (n = 157) es diferente de la atención estándar (n = 150) en la reducción de las exacerbaciones o recaídas en pacientes con EII (RR 0,94; IC del 95%: 0,41 a 2,18; evidencia de certeza muy baja). Seis estudios proporcionaron datos sobre la calidad de vida. No hubo diferencias claras en la calidad de vida cuando se comparó la educación del paciente combinada con la atención estándar (n = 721) con la atención estándar sola (n = 643). La educación del paciente combinada con la atención estándar es probablemente equivalente a la atención estándar para mejorar la calidad de vida en los pacientes con EII (DME 0,08; IC del 95%: ­0,03 a 0,18; evidencia de certeza moderada). Los estudios incluidos no informaron de diferencias importantes en el acceso a la asistencia sanitaria. La adherencia a la medicación, el conocimiento de los pacientes y el cambio en la calidad de vida mostraron resultados contradictorios que oscilaron entre la falta de diferencias importantes y las diferencias a favor de las intervenciones educativas. Solo cinco estudios informaron sobre los eventos adversos. Cuatro informaron cero eventos adversos totales y uno informó un caso de cáncer de mama y dos casos de cirugía en sus grupos de intervención, y cero eventos adversos en su grupo de control. Dos estudios compararon los métodos de entrega de la educación del paciente, en concreto: intervenciones educativas para pacientes a través de la web versus libros impresos a color o mensajes de texto; y un estudio comparó la frecuencia de la educación del paciente, en concreto: mensajes de texto educativos semanales versus mensajes de texto educativos una vez cada dos semanas. Estos no mostraron diferencias importantes en cuanto a la actividad de la enfermedad y la calidad de vida. No se informaron otros desenlaces. CONCLUSIONES DE LOS AUTORES: Las formas en que el apoyo educativo al paciente en torno a la EII podría influir en los desenlaces de la enfermedad son complejas. Existe evidencia de que la educación añadida a la atención estándar probablemente no tenga efectos beneficiosos en la actividad de la enfermedad o la calidad de vida en comparación con la atención estándar, y podría no tener beneficios en la aparición de recaídas en comparación con la atención estándar. Sin embargo, como hubo escasa información específica sobre los componentes de la educación o la atención estándar, la utilidad de estos hallazgos es cuestionable. Probablemente no esté indicado investigar más sobre el impacto de la educación en los desenlaces principales de la actividad de la enfermedad, las exacerbaciones/recaídas ni la calidad de vida. Sin embargo, se necesitan más estudios de investigación que deberían centrarse en informar sobre los detalles de las intervenciones educativas y estudiar los desenlaces que las intervenciones educativas podrían abordar directamente, como el acceso a la atención sanitaria y la adherencia a la medicación. Éstas deben basarse en el compromiso directo con las partes interesadas y las personas afectadas por la enfermedad de Crohn y la colitis.

Remote care through telehealth for people with inflammatory bowel disease.

BACKGROUND: People with inflammatory bowel disease (IBD) require intensive follow-up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web-based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID-19) pandemic, which led to increased self- and remote-management. OBJECTIVES: To identify the communication technologies used to achieve remote healthcare for people with inflammatory bowel disease and to assess their effectiveness. SEARCH METHODS: On 13 January 2022, we searched CENTRAL, Embase, MEDLINE, three other databases, and three trials registries with no limitations on language, date, document type, or publication status. SELECTION CRITERIA: All published, unpublished, and ongoing randomised controlled trials (RCTs) that evaluated telehealth interventions targeted at people with IBD versus any other type of intervention or no intervention. We did not include studies based on digital patient information resources or education resources, unless they formed part of a wider package including an element of telehealth. We excluded studies where remote monitoring of blood or faecal tests was the only form of monitoring. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included studies and assessed their risk of bias. We analysed studies on adult and paediatric populations separately. We expressed the effects of dichotomous outcomes as risk ratios (RRs) and the effects of continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), each with their 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology. MAIN RESULTS: We included 19 RCTs with a total of 3489 randomised participants, aged eight to 95 years. Three studies examined only people with ulcerative colitis (UC), two studies examined only people with Crohn's disease (CD), and the remaining studies examined a mix of IBD patients. Studies considered a range of disease activity states. The length of the interventions ranged from six months to two years. The telehealth interventions were web-based and telephone-based. Web-based monitoring versus usual care Twelve studies compared web-based disease monitoring to usual care. Three studies, all in adults, provided data on disease activity. Web-based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI -0.11 to 0.29). The certainty of the evidence is moderate. Five studies on adults provided dichotomous data that we could use for a meta-analysis on flare-ups. Web-based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare-ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web-based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare-ups or relapses in adults with CD (MD 0.00 events, 95% CI -0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare-ups in a paediatric population. Web-based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare-ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low. Four studies, all in adults, provided data on quality of life. Web-based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI -0.04 to 0.20). The certainty of the evidence is moderate. Based on continuous data from one study in adults, we found that web-based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI -0.63 to 0.63), although the evidence is very uncertain. When we meta-analysed dichotomous data from two studies on adults, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain. We were unable to draw any conclusions on the effects of web-based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost- or time-effectiveness. The certainty of the evidence is very low. AUTHORS' CONCLUSIONS: The evidence in this review suggests that web-based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare-ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web-based monitoring probably increases medication adherence slightly compared to usual care. We are uncertain about the effects of web-based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited. Further studies comparing web-based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow-up or investigate under-reported outcomes or populations. Studies with a clearer definition of web-based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.

Dietary interventions for induction and maintenance of remission in inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD), comprised of Crohn's disease (CD) and ulcerative colitis (UC), is characterized by chronic mucosal inflammation, frequent hospitalizations, adverse health economics, and compromised quality of life. Diet has been hypothesised to influence IBD activity. OBJECTIVES: To evaluate the efficacy and safety of dietary interventions on IBD outcomes. SEARCH METHODS: We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, Embase, Web of Science, Clinicaltrials.gov and the WHO ICTRP from inception to 31 January 2019. We also scanned reference lists of included studies, relevant reviews and guidelines. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared the effects of dietary manipulations to other diets in participants with IBD. Studies that exclusively focused on enteral nutrition, oral nutrient supplementation, medical foods, probiotics, and parenteral nutrition were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, extracted data and assessed bias using the risk of bias tool. We conducted meta-analyses where possible using a random-effects model and calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We assessed the certainty of evidence using GRADE. MAIN RESULTS: The review included 18 RCTs with 1878 participants. The studies assessed different dietary interventions for active CD (six studies), inactive CD (seven studies), active UC (one study) and inactive UC (four studies). Dietary interventions involved either the consumption of low amounts or complete exclusion of one or more food groups known to trigger IBD symptoms. There was limited scope for data pooling as the interventions and control diets were diverse. The studies were mostly inadequately powered. Fourteen studies were rated as high risk of bias. The other studies were rated as unclear risk of bias.The effect of high fiber, low refined carbohydrates, low microparticle diet, low calcium diet, symptoms-guided diet and highly restricted organic diet on clinical remission in active CD is uncertain. At 4 weeks, remission was induced in: 100% (4/4) of participants in the low refined carbohydrates diet group compared to 0% (0/3) of participants in the control group (RR 7.20, 95% CI 0.53 to 97.83; 7 participants; 1 study; very low certainty evidence). At 16 weeks, 44% (23/52) of participants in the low microparticle diet achieved clinical remission compared to 25% (13/51) of control-group participants (RR 3.13, 95% CI 0.22 to 43.84; 103 participants; 2 studies; I² = 73%; very low certainty evidence). Fifty per cent (16/32) of participants in the symptoms-guided diet group achieved clinical remission compared to 0% (0/19) of control group participants (RR 20.00, 95% CI 1.27 to 315.40; 51 participants ; 1 study; very low certainty evidence) (follow-up unclear). At 24 weeks, 50% (4/8) of participants in the highly restricted organic diet achieved clinical remission compared to 50% (5/10) of participants in the control group (RR 1.00, 95% CI 0.39 to 2.53; 18 participants; 1 study; very low certainty evidence). At 16 weeks, 37% (16/43) participants following a low calcium diet achieved clinical remission compared to 30% (12/40) in the control group (RR 1.24, 95% CI 0.67 to 2.29; 83 participants; 1 study; very low certainty evidence).The effect of low refined carbohydrate diets, symptoms-guided diets and low red processed meat diets on relapse in inactive CD is uncertain. At 12 to 24 months, 67% (176/264) of participants in low refined carbohydrate diet relapsed compared to 64% (193/303) in the control group (RR 1.04, 95% CI 0.87 to 1.25; 567 participants; 3 studies; I² = 35%; low certainty evidence). At 6 to 24 months, 48% (24/50) of participants in the symptoms-guided diet group relapsed compared to 83% (40/48) participants in the control diet (RR 0.53, 95% CI 0.28 to 1.01; 98 participants ; 2 studies; I² = 54%; low certainty evidence). At 48 weeks, 66% (63/96) of participants in the low red and processed meat diet group relapsed compared to 63% (75/118) of the control group (RR 1.03, 95% CI 0.85 to 1.26; 214 participants; 1 study; low certainty evidence). At 12 months, 0% (0/16) of participants on an exclusion diet comprised of low disaccharides / grains / saturated fats / red and processed meat experienced clinical relapse compared to 26% (10/38) of participants on a control group (RR 0.11, 95% CI 0.01 to 1.76; 54 participants; 1 study; very low certainty evidence).The effect of a symptoms-guided diet on clinical remission in active UC is uncertain. At six weeks, 36% (4/11) of symptoms-guided diet participants achieved remission compared to 0% (0/10) of usual diet participants (RR 8.25, 95% CI 0.50 to 136.33; 21 participants; 1 study; very low certainty evidence).The effect of the Alberta-based anti-inflammatory diet, the Carrageenan-free diet or milk-free diet on relapse rates in inactive UC is uncertain. At 6 months, 36% (5/14) of participants in the Alberta-based anti-inflammatory diet group relapsed compared to 29% (4/14) of participants in the control group (RR 1.25, 95% CI 0.42 to 3.70; 28 participants; 1 study; very low certainty evidence). Thirty per cent (3/10) of participants following the carrageenan-free diet for 12 months relapsed compared to 60% (3/5) of the participants in the control group (RR 0.50, 95% CI 0.15 to 1.64; 15 participants; 1 study; very low certainty evidence). At 12 months, 59% (23/39) of milk free diet participants relapsed compared to 68% (26/38) of control diet participants (RR 0.83, 95% CI 0.60 to 1.15; 77 participants; 2 studies; I² = 0%; low certainty evidence).None of the included studies reported on diet-related adverse events. AUTHORS' CONCLUSIONS: The effects of dietary interventions on CD and UC are uncertain. Thus no firm conclusions regarding the benefits and harms of dietary interventions in CD and UC can be drawn. There is need for consensus on the composition of dietary interventions in IBD and more RCTs are required to evaluate these interventions. Currently, there are at least five ongoing studies (estimated enrollment of 498 participants). This review will be updated when the results of these studies are available.

Negotiating organisational blame to foster learning: Professionals' perspectives about Domestic Homicide Reviews.

Domestic Homicide Reviews (DHRs) are a statutory requirement in England and Wales, conducted when somebody aged 16 and over dies from violence, abuse or neglect by a relative, intimate partner or member of the same household. While key aims of DHRs are to identify recommendations and lessons learned to eventually prevent further domestic homicides, there is limited evidence globally regarding the extent to which these are followed up or make a difference. This paper explores the barriers and facilitators to the conduct and impact of DHRs to enhance their learning potential. It is based on nineteen qualitative interviews with professionals involved in the DHR process across five Safeguarding Boards in Wales and fourteen Community Safety Partnerships in the North-West of England, UK. Findings are presented thematically under four section headings: upskilling and democratising the review process; family and friends' involvement; negotiating organisational blame to foster learning; and actioning and auditing recommendations. It is suggested that organisational learning cannot be achieved without accepting organisational responsibility, which could be interpreted as blame. The role and skills of the Chair are perceived as key to ensure a safe, evidence-based, transparent and learning-focused DHR process. Developing and actioning recommendations may challenge longstanding prejudices. Promoting the role of families/survivor networks and professionals on an equal footing would support a more democratic process. Learning could be enhanced by thematising recommendations and proactively using lessons from one area to inform another. Participants called for appropriate central regulation and accountability to support the action of recommendations.

The Consequences of the COVID-19 Lockdown on Stalking Victimisation.

Stalking involves repeated unwanted communication, harassment, and intrusive behaviour. This brief report draws on a service evaluation undertaken immediately prior to and during the 2020 COVID-19 crisis. The pandemic creates a paradox when considering safety in the home, but it is important to recognise the dangers this presents to many victims of stalking. The information presented in this report is based on existing literature and early evidence from semi-structured interviews and discussions with 15 victims and six practitioners. Whilst lockdown measures might appear to be a time when victims are less accessible to their stalkers, early evidence from this study suggests that their vulnerability is increased. Technology has helped to facilitate stalking behaviours by providing stalkers with new approaches to control, humiliate, threaten and isolate their victims. Some lockdown restrictions have provided increased opportunities for stalkers to monitor their victims and the professional uncertainty and recognition around stalking has continued, coupled with delays in the criminal justice system. The COVID-19 crisis has reversed gains made by stalking victims and has imprisoned some victims in their homes making their whereabouts easier to monitor. Stalking behaviour has not ceased as a result of the COVID-19 restrictions and the risk of harm to victims remains significant. Effective practice, policy and legal responses are required for both the victims and perpetrators of stalking during the pandemic and afterwards.