Randomised pilot and feasibility trial of a group intervention for men who perpetrate intimate partner violence against women.

BACKGROUND: There is a need for robust evidence on the effectiveness and cost-effectiveness of domestic abuse perpetrator programmes in reducing abusive behaviour and improving wellbeing for victim/survivors. While any randomised controlled trial can present difficulties in terms of recruitment and retention, conducting such a trial with domestic abuse perpetrators is particularly challenging. This paper reports the pilot and feasibility trial of a voluntary domestic abuse perpetrator group programme in the United Kingdom. METHODS: This was a pragmatic individually randomised pilot and feasibility trial with an integrated qualitative study in one site (covering three local-authority areas) in England. Male perpetrators were randomised to either the intervention or usual care. The intervention was a 23-week group programme for male perpetrators in heterosexual relationships, with an average of three one-to-one sessions, and one-to-one support for female current- or ex-partners delivered by third sector organisations. There was no active control treatment for men, and partners of control men were signposted towards domestic abuse support services. Data were collected at three-monthly intervals for nine months from male and female participants. The main objectives assessed were recruitment, randomisation, retention, data completeness, fidelity to the intervention model, and acceptability of the trial design. RESULTS: This study recruited 36 men (22 randomly allocated to attend the intervention group programme, 14 to usual care), and 15 current- or ex-partners (39% of eligible partners). Retention and completeness of data were high: 67% of male (24/36), and 80% (12/15) of female participants completed the self-reported questionnaire at nine months. A framework for assessing fidelity to the intervention was developed. In interviews, men who completed all or most of the intervention gave positive feedback and reported changes in their own behaviour. Partners were also largely supportive of the trial and were positive about the intervention. Participants who were not allocated to the intervention group reported feeling disappointed but understood the rationale for the trial. CONCLUSIONS: It was feasible to recruit, randomise and retain male perpetrators and female victim/survivors of abuse and collect self-reported outcome data. Participants were engaged in the intervention and reported positive benefits. The trial design was seen as acceptable. TRIAL REGISTRATION: ISRCTN71797549, submitted 03/08/2017, retrospectively registered 27/05/2022.

Trauma-informed co-production: Collaborating and combining expertise to improve access to primary care with women with complex needs.

INTRODUCTION: Health, social care, charitable and justice sectors are increasingly recognising the need for trauma-informed services that seek to recognise signs of trauma, provide appropriate paths to recovery and ensure that services enable people rather than retraumatise. Foundational to the development of trauma-informed services is collaboration with people with lived experience of trauma. Co-production principles may provide a useful framework for this collaboration, due to their emphasis on lived experience, and intent to address power imbalances and promote equity. This article aims to examine trauma-informed and co-production principles to consider the extent to which they overlap and explore how to tailor co-production approaches to support people who have experienced trauma. METHODS: Bridging Gaps is a collaboration between women who have experienced complex trauma, a charity that supports them, primary care clinicians and health researchers to improve access to trauma-informed primary care. Using co-production principles, we aimed to ensure that women who have experienced trauma were key decision-makers throughout the project. Through reflective notes (n = 19), observations of meetings (n = 3), interviews with people involved in the project (n = 9) and reflective group discussions on our experiences, we share learning, successes and failures. Data analysis followed a framework approach, using trauma-informed principles. RESULTS: Co-production processes can require adaptation when working with people who have experienced trauma. We emphasise the need for close partnership working, flexibility and transparency around power dynamics, paying particular attention to aspects of power that are less readily visible. Sharing experiences can retrigger trauma. People conducting co-production work need to understand trauma and how this may impact upon an individual's sense of psychological safety. Long-term funding is vital to enable projects to have enough time for the establishment of trust and delivery of tangible results. CONCLUSIONS: Co-production principles are highly suitable when developing trauma-informed services. Greater consideration needs to be given as to whether and how people share lived experiences, the need for safe spaces, honesty and humility, difficult dynamics between empowerment and safety and whether and when blurring boundaries may be helpful. Our findings have applicability to policy-making, funding and service provision to enable co-production processes to become more trauma-informed. PUBLIC CONTRIBUTION: Bridging Gaps was started by a group of women who have experienced complex trauma, including addiction, homelessness, mental health problems, sexual exploitation, domestic and sexual violence and poverty, with a general practitioner (GP) who provides healthcare to this population, alongside a support worker from the charity One25, a charity that supports some of the most marginalised women in Bristol to heal and thrive. More GPs and healthcare researchers joined the group and they have been meeting fortnightly for a period of 4 years with the aim of improving access to trauma-informed primary care. The group uses co-production principles to work together, and we aim to ensure that women who have experienced trauma are key decision-makers throughout our work together. This article is a summary of our learning, informed by discussion, observations and interviews with members of the group.

Domestic violence and injuries: prevalence and patterns-a pilot database study to identify suspected cases in a UK major trauma centre.

BACKGROUND: Victim-survivors of domestic violence and abuse (DVA) present to secondary care with isolated injuries to the head, limb or face. In the UK, there are no published studies looking at the relationship of significant traumatic injuries in adults and the relationship to DVA.The primary objective was to assess the feasibility of using a tailored search method to identify cases of suspected DVA in the national audit database for trauma. The secondary objective was to assess the association of DVA with clinical characteristics. METHODS: We undertook a single-centre retrospective observational cohort pilot study. Data were analysed from the local Trauma and Audit Research Network (TARN) database. The 'Scene Description' field in the database was searched using a tailored search strategy. Feasibility was evaluated with notes review and assessed by the PPV and prevalence. Secondary objectives used a logistic regression in Excel. RESULTS: This method of identifying suspected cases of DVA from the TARN database is feasible. The PPV was 100%, and the prevalence of suspected DVA in the study period was 3.6 per 1000 trauma discharges. Of those who had experienced DVA, 52.7% were male, median age 43 (IQR: 33-52) and mortality 5.5%. Subgroup analysis of older people demonstrated longer hospital stay (p=0.17) and greater likelihood of admission to intensive care (OR 2.60, 95% CI 0.48 to 14.24). CONCLUSION: We have created a feasible methodology to identify suspected DVA-related injuries within the TARN database. Future work is needed to further understand this relationship on a national level.

Shared decision making in consultations for hypertension: Qualitative study in general practice.

BACKGROUND: Hypertension is mainly managed in primary care. Shared decision making is widely recommended as an approach to treatment decision making. However, no studies have investigated; in detail, what happens during primary care consultations for hypertension. AIM: To understand patients' and clinicians' experience of shared decision making for hypertension in primary care, in order to propose how it might be better supported. DESIGN: Longitudinal qualitative study. SETTING: Five general practices in south-west England. METHOD: Interviews with a purposive sample of patients with hypertension, and with the health-care practitioners they consulted, along with observations of clinical consultations, for up to 6 appointments. Interviews and consultations were audio-recorded and observational field notes taken. Data were analysed thematically. RESULTS: Forty-six interviews and 18 consultations were observed, with 11 patients and nine health-care practitioners (five GPs, one pharmacist and three nurses). Little shared decision making was described by participants or observed. Often patients' understanding of their hypertension was limited, and they were not aware there were treatment choices. Consultations provided few opportunities for patients and clinicians to reach a shared understanding of their treatment choices. Opportunities for patients to engage in choices were limited by structured consultations and the distribution of decisions across consultations. CONCLUSION: For shared decision making to be better supported, consultations need to provide opportunities for patients to learn about their condition, to understand that there are treatment choices, and to discuss these choices with clinicians. PATIENT OR PUBLIC CONTRIBUTION: A patient group contributed to the design of this study.

Acceptability of the BATHE technique amongst GPs and frequently attending patients in primary care: a nested qualitative study.

BACKGROUND: BATHE is a brief psychosocial intervention designed for physician use in patient consultations. The technique has gained some international recognition, but there is currently limited research evidence to demonstrate its acceptability and benefits to patient care. We conducted a pilot cluster randomised controlled trial and feasibility study to explore the use of BATHE as a key component of a person-focused intervention to improve the care of frequent attending patients in UK primary care. METHODS: A nested qualitative interview study conducted within a pilot trial. The trial took place in six general practices in the South West of England. Eligible patients had been identified as being in the top 3% of attenders in the previous 12 months. General practitioners (GPs) were trained to use BATHE during a one-hour initial training session, and two top-up trainings which included feedback on implementation fidelity. GPs were asked to use BATHE with their study patients for a period of 12 months. 34 GPs were trained and documented using BATHE in a total of 577 consultations with eligible patients during the intervention period. At the end of the intervention period, GPs and study patients from the intervention practices were invited to take part in an interview. Interviews were semi-structured, audio-recorded and transcribed. Thematic analysis was used. RESULTS: Eleven GPs and 16 patients took part in post-intervention interviews. Benefits of using BATHE included making consultations more person-centred, challenging assumptions that the GP knew what was going on for the patient and their main concerns, and supporting self-management. Difficulties reported included changing existing consultation habits, identifying appropriate consultations in which to use BATHE, and organisational constraints. CONCLUSIONS: The study suggests that using BATHE is both acceptable and beneficial but also highlighted some of the difficulties GPs had incorporating BATHE into routine practice. Strategies to reduce these difficulties are needed before the extent of the potential benefits of BATHE can be fully assessed. TRIAL REGISTRATION: ISRCTN62939408 Prospectively registered on 24/06/2015.

Interventions to support shared decision making for hypertension: A systematic review of controlled studies.

BACKGROUND: Hypertension (high blood pressure) is a common long-term health condition. Patient involvement in treating and monitoring hypertension is essential. Control of hypertension improves population cardiovascular outcomes. However, for an individual, potential benefits and harms of treatment are finely balanced. Shared decision making has the potential to align decisions with the preferences and values of patients. OBJECTIVE: Determine the effectiveness of interventions to support shared decision making in hypertension. SEARCH STRATEGY: Searches in MEDLINE, EMBASE, CINAHL, Web of Science and PsycINFO up to 30 September 2017. ELIGIBILITY CRITERIA: Controlled studies evaluating the effects of shared decision-making interventions for adults with hypertension compared with any comparator in any setting and reporting any outcome measures. RESULTS: Six studies (five randomized controlled trials) in European primary care were included. Main intervention components were as follows: training for health-care professionals, decision aids, patient coaching and a patient leaflet. Four studies, none at low risk of bias, reported a measure of shared decision making; the intervention increased shared decision making in one study. Four studies reported blood pressure between 6 months and 3 years after the intervention; there was no difference in blood pressure between intervention and control groups in any study. Lack of comparability between studies prevented meta-analysis. CONCLUSIONS: Despite widespread calls for shared decision making to be embedded in health care, there is little evidence to inform shared decision making for hypertension, one of the most common conditions managed in primary care.

'Who does this patient belong to?' boundary work and the re/making of (NSTEMI) heart attack patients.

This ethnography within ten English and Welsh hospitals explores the significance of boundary work and the impacts of this work on the quality of care experienced by heart attack patients who have suspected non-ST segment elevation myocardial infarction (NSTEMI) /non-ST elevation acute coronary syndrome. Beginning with the initial identification and prioritisation of patients, boundary work informed negotiations over responsibility for patients, their transfer and admission to different wards, and their access to specific domains in order to receive diagnostic tests and treatment. In order to navigate boundaries successfully and for their clinical needs to be more easily recognised by staff, a patient needed to become a stable boundary object. Ongoing uncertainty in fixing their clinical classification, was a key reason why many NSTEMI patients faltered as boundary objects. Viewing NSTEMI patients as boundary objects helps to articulate the critical and ongoing process of classification and categorisation in the creation and maintenance of boundary objects. We show the essential, but hidden, role of boundary actors in making and re-making patients into boundary objects. Physical location was critical and the parallel processes of exclusion and restriction of boundary object status can lead to marginalisation of some patients and inequalities of care (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Community case management and unplanned hospital admissions in patients with heart failure: A systematic review and qualitative evidence synthesis.

AIMS: The aim of this study was to describe case management as experienced by patients with heart failure and their health professionals with the aim of understanding why case management might contribute in reducing hospital admissions. BACKGROUND: Heart failure is a common cause of unplanned hospital admission. The evidence for case management in patients with heart failure for reducing admissions is promising. DESIGN: Systematic review and qualitative evidence synthesis. DATA SOURCE: Searches were conducted in Medline, Psychinfo, Kings Fund database and Cinahl from inception of each database to 16 February 2017. REVIEW METHODS: Robust systematic review methodology was used to identify qualitative studies describing the experiences of patients with heart failure and healthcare providers of case management. Data were synthesized thematically, and analytic themes were developed. FINDINGS: Five studies (six papers) from which nine descriptive themes were used to determine three analytic themes. This synthesis showed that case management provides positive quality of care for patients, increases perceived access to services and creates more time to ask questions and develop trusted relationships. For health professionals, case management enhanced care by improved relationships with both patients and colleagues although concerns remained around resources, training and inter-professional conflict. CONCLUSIONS: This synthesis emphasizes the importance of the quality of being cared for as a patient and caring as a health professional. Case management enhances communication between patients and health professionals, supports patient self-care and self-management and can be an important contributing factor in reducing unplanned admissions for patients with heart failure.

"Sometimes we can't fix things": a qualitative study of health care professionals' perceptions of end of life care for patients with heart failure.

BACKGROUND: Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care. METHODS: A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK - the Midlands, South Central and South West. RESULTS: The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients' lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished. CONCLUSIONS: The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included.

Managing patients with heart failure: a qualitative study of multidisciplinary teams with specialist heart failure nurses.

PURPOSE: The purpose of this study was to explore the perceptions and experiences of health care clinicians working in multidisciplinary teams that include specialist heart failure nurses when caring for the management of heart failure patients. METHODS: We used a qualitative in-depth interview study nested in a broader ethnographic study of unplanned admissions in heart failure patients (HoldFAST). We interviewed 24 clinicians across primary, secondary, and community care in 3 locations in the Midlands, South Central, and South West of England. RESULTS: Within a framework of the role and contribution of the heart failure specialist nurse, our study identified 2 thematic areas that the clinicians agreed still represent particular challenges when working with heart failure patients. The first was communication with patients, in particular explaining the diagnosis and helping patients to understand the condition. The participants recognized that such communication was most effective when they had a long-term relationship with patients and families and that the specialist nurse played an important part in achieving this relationship. The second was communication within the team. Multidisciplinary input was especially needed because of the complexity of many patients and issues around medications, and the participants believed the specialist nurse may facilitate team communication. CONCLUSIONS: The study highlights the role of specialist heart failure nurses in delivering education tailored to patients and facilitating better liaison among all clinicians, particularly when dealing with the management of comorbidities and drug regimens. The way in which specialist nurses were able to be caseworkers for their patients was perceived as a method of ensuring coordination and continuity of care.

Feasibility and impact of a computerised clinical decision support system on investigation and initial management of new onset chest pain: a mixed methods study.

BACKGROUND: Clinical decision support systems (CDSS) can modify clinician behaviour, yet the factors influencing their effect remain poorly understood. This study assesses the feasibility and acceptability of a CDSS supporting diagnostic and treatment decisions for patients with suspected stable angina. METHODS: Intervention The Optimising Management of Angina (OMA) programme includes a CDSS guiding investigation and medication decisions for clinicians managing patients with new onset stable angina, based on English national guidelines, introduced through an educational intervention. Design and participants A mixed methods study i. A study of outcomes among patients presenting with suspected angina in three chest pain clinics in England before and after introduction of the OMA programme. ii. Observations of clinic processes, interviews and a focus group with health professionals at two chest pain clinics after delivery of the OMA programme. OUTCOMES: Medication and cardiovascular imaging investigations undertaken within six months of presentation, and concordance of these with the recommendations of the CDSS. Thematic analysis of qualitative data to understand how the CDSS was used. RESULTS: Data were analysed for 285 patients attending chest pain clinics: 106 before and 179 after delivery of the OMA programme. 40 consultations were observed, 5 clinicians interviewed, and a focus group held after the intervention. The proportion of patients appropriate for diagnostic investigation who received one was 50 % (95 CI 34-66 %) of those before OMA and 59 % (95 CI 48-70 %) of those after OMA. Despite high use of the CDSS (84 % of consultations), observations and interviews revealed difficulty with data entry into the CDSS, and structural and practical barriers to its use. In the majority of cases the CDSS was not used to guide real-time decision making, only being consulted after the patient had left the room. CONCLUSIONS: The OMA CDSS for the management of chest pain is not feasible in its current form. The CDSS was not used to support decisions about the care of individual patients. A range of barriers to the use of the CDSS were identified, some are easily removed, such as insufficient capture of cardiovascular risk, while others are more deeply embedded in current practice, such as unavailability of some investigations or no prescribing privileges for nurses.

"I Am Not Taking Sides as a Female At All": Co-Facilitation and Gendered Positioning in a Domestic Abuse Perpetrator Program.

The facilitation of domestic abuse perpetrator programs (DAPPs) by mixed gender co-facilitation pairs brings different facilitator perspectives and enables the modeling of egalitarian and respectful male-female relationships. This study analyzed 22 video and audio recordings of community-based DAPP groups featuring male participants, and male and female facilitators. Using thematic analysis, we aimed to understand how facilitators engaged participants and whether the facilitator's gender affected this. We found an asymmetry in the positioning of the facilitators. Group participants challenged both facilitators, but especially the female facilitators. Facilitator strategies toward behavior change included softening direct challenges (female facilitators) and mobilizing the shared category of men (male facilitators). Implications from this study are for reflective practice in facilitator management and supervision specifically focused on gendered power dynamics. Skilled facilitation is key to behavior change and the gendered interplay within groups may be a crucial element in the reduction of interpersonal violence and abuse.

Moving beyond the 'PPG': co-production and inclusion health.

BACKGROUND: We frequently fail to meaningfully incorporate patient voice in the development of health services, in particular the voices of those who are most disadvantaged. AIM: To share learning from a co-production project to improve primary care experience for those with multiple disadvantage and lived experience of trauma. METHOD: We formed a collective of women (Bridging Gaps). Group members had lived experience of poverty, mental health challenges, addictions, homelessness, and sexual exploitation. Other members were researchers, GPs, and members of a third-sector organisation. We worked alongside local GPs to change how services were delivered. We collected interviews (n = 9), ethnographic data from group meetings (n = 3), and reflective notes from group members (n = 19). Data on our process were analysed using a framework approach drawn from the principles of trauma-informed care. RESULTS: We highlight the challenges for those with multiple disadvantages and trauma experience to meaningfully and safely engage in traditional Patient Participation Group (PPG) models. True co-production of services requires adequate resources and close collaborative working with local community organisations. Groups must be facilitated by those with relevant experience and the ability to both notice and manage power dynamics within the room. With sufficient support, co-production models have potential to empower group participants and improve health services. CONCLUSION: Partnership working between GPs, the third sector, and other organisations is vital. This can allow GPs to benefit from the expertise of those with relevant lived experience in tackling health inequalities.

Improving access to general practice for and with people with severe and multiple disadvantage: a qualitative study.

BACKGROUND: People with severe and multiple disadvantage (SMD) who experience combinations of homelessness, substance misuse, violence, abuse, and poor mental health have high health needs and poor access to primary care. AIM: To improve access to general practice for people with SMD by facilitating collaborative service improvement meetings between healthcare staff, people with lived experience of SMD, and those who support them; participants were then interviewed about this work. DESIGN AND SETTING: The Bridging Gaps group is a collaboration between healthcare staff, researchers, women with lived experience of SMD, and a charity that supports them in a UK city. A project was co-produced by the Bridging Gaps group to improve access to general practice for people with SMD, which was further developed with three inner-city general practices. METHOD: Nine service improvement meetings were facilitated at three general practices, and six of these were formally observed. Nine practice staff and four women with lived experience of SMD were interviewed. Three women with lived experience of SMD and one staff member who supports them participated in a focus group. Data were analysed inductively and deductively using thematic analysis. RESULTS: By providing time and funding opportunities to motivated general practice staff and involving participants with lived experience of SMD, service changes were made in an effort to improve access for people with SMD. These included prioritising patients on an inclusion patient list with more flexible access, providing continuity for patients via a care coordinator and micro-team of clinicians, and developing an information-sharing document. The process and outcomes improved connections within and between general practices, support organisations, and people with SMD. CONCLUSION: The co-designed strategies described in this study could be adapted locally and evaluated in other areas. Investing in this focused way of working may improve accessibility to health care, health equity, and staff wellbeing.

Methodological Challenges in Group-based Randomised Controlled Trials for Intimate Partner Violence Perpetrators: A Meta-summary.

Evidence for treatment effects of group-based Intimate Partner Violence (IPV) perpetrators programmes remains, at best, inconclusive. In the present review, systematic/meta-analytic reviews were used to identify randomised controlled trials and a meta-summary approach was employed to identify methodological challenges in the design and conduct of these trials. Of the fifteen studies identified, seven were comparative effectiveness trials. A range of methodological challenges were also identified by the trialists; source of outcome data, treatment modality, attrition and sample characteristics were the most frequently mentioned. Although there are only a few randomised controlled trials compared to non randomised studies, the findings of both highlight the need to invest in the development of innovative and/or combined IPV treatment programmes to address co-occurring issues such as substance use and trauma. The summary of methodological challenges will provide the first step in the development of methods guidance for researchers working in this area.

La evidencia del efecto del tratamiento de los programas de intervención grupal para agresores de pareja (IPV) siguen siendo, en el mejor de los casos, no concluyentes. En la presente revisión se emplearon revisiones sistemáticas/meta-analíticas para identificar ensayos controlados aleatorizados y se empleó un enfoque de meta-resumen para identificar los desafíos metodológicos en el diseño y la realización de estos ensayos. De los quince estudios identificados, siete fueron ensayos de comparación de la efectividad. Los autores de los ensayos también identificaron una serie de desafíos metodológicos: la fuente de la que se obtienen los datos relativos a los resultados, la modalidad de tratamiento, la mortalidad de la muestra y sus características fueron los mencionados con más frecuencia. Aunque son todavía escasos los ensayos controlados aleatorizados en comparación con los estudios no aleatorizados, los resultados de ambos tipos de estudios han destacado la importancia de invertir en el desarrollo de programas de tratamiento de IPV innovadores y/o combinados para tratar problemáticas conjuntas tales como consumo de substancias y trauma. El resumen de los desafíos metodológicos proporcionará el primer paso para el desarrollo de guías metodológicas para los investigadores que trabajan en este área.

The effectiveness and cost-effectiveness of a group domestic abuse perpetrator programme: protocol for a randomised controlled trial.

BACKGROUND: In contrast to evidence for interventions supporting victim/survivors of domestic violence and abuse (DVA), the effectiveness of perpetrator programmes for reduction of abuse is uncertain. This study aims to estimate the effectiveness and cost-effectiveness of a perpetrator programme for men. METHODS: Pragmatic two-group individually randomised controlled trial (RCT) with embedded process and economic evaluation. Five centres in southwest England and South Wales aim to recruit 316 (reduced from original target of 366) male domestic abuse perpetrators. These will be randomised 2:1 to a community-based domestic abuse perpetrator programme (DAPP) or usual care comparator with 12-month follow-up. Female partners/ex-partners will be invited to join the study. The intervention for men comprises 23 weekly sessions of a group programme delivered in voluntary sector domestic abuse services. The intervention for female partners/ex-partners is one-to-one support from a safety worker. Men allocated to usual care receive no intervention; however, they are free to access other services. Their partners/ex-partners will be signposted to support services. Data is collected at baseline, and 4, 8 and 12 months' follow-up. The primary outcome is men's self-reported abusive behaviour measured by the Abusive Behaviour Inventory (ABI-29) at 12 months. Secondary measures include physical and mental health status and resource use alongside the abuse measure ABI (ABI-R) for partners/ex-partners and criminal justice contact for men. A mixed methods process evaluation and qualitative study will explore mechanisms of effectiveness, judge fidelity to the intervention model using interviews and group observations. The economic evaluation, over a 1-year time horizon from three perspectives (health and social care, public sector and society), will employ a cost-consequences framework reporting costs alongside economic outcomes (Quality-Adjusted Life Years derived from EQ-5D-5L, SF-12 and CHU-9D, and ICECAP-A) as well as the primary and other secondary outcomes. DISCUSSION: This trial will provide evidence of the (cost)effectiveness of a DAPP. The embedded process evaluation will further insights in the experiences and contexts of participants and their journey through a perpetrator programme, and the study will seek to address the omission in other studies of economic evaluations. TRIAL REGISTRATION: ISRCTN15804282, April 1, 2019.

Researching Men's Violence Against Women as Feminist Women Researchers: The Tensions We Face.

Qualitative and feminist researchers aim to build rapport, show empathy, be non-judgemental, and equalise power imbalances. A crucial challenge researchers face is how to navigate and balance competing aims and values when interacting with and interviewing participants who have perpetrated intimate partner violence and abuse towards women. In this article, four female researchers evaluating perpetrator programmes for abusive men use reflexive analysis to identify the tensions encountered in such research. We outline how these tensions affected us and the data produced, and end with recommendations, which we hope will help prepare researchers, particularly women, for conducting interviews with violent/abusive men.

Group cognitive behavioural therapy for women with depression: pilot and feasibility study for a randomised controlled trial using mixed methods.

BACKGROUND: Group Cognitive Behavioural Therapy (CBT) may provide a means of improving mental health among people with depression but few studies have explored its effectiveness. Our aim was to examine the feasibility and acceptability of a randomised controlled trial of a group intervention based on CBT principles for women with depression in primary care. METHODS: Women aged 30 to 55 years were recruited and randomly assigned to either 12 weeks of the group intervention or usual care (control). The group intervention was based on a manual and used CBT and problem solving principles with weekly topics including raising activity levels, spotting and catching negative thoughts, problem solving and relaxation. Women were recruited from deprived areas of Bristol. The groups were run by facilitators with some experience and background in group work and one weeks training in use of the course manual. Assessments of mental health were made using measures including the PHQ-9. Follow-up was at 3 and 6 months after the intervention. Qualitative methods were used to support the design of the intervention and to help understand issues of acceptability and feasibility. Interviews were conducted with all participants at baseline and at 3 and 6 months although detailed qualitative analysis was based on a purposive sample of 20 participants at the 3 time points. RESULTS: Of the 86 participants assessed for eligibility, 52 were allocated to the intervention arm and 21 to the control group. The intervention was delivered according to the manual despite the limited training of the facilitators. The intervention was received favourably by participants and facilitators, with good attendance at sessions for those who engaged with the intervention. Follow up rates at 3 and 6 months for women in both the intervention and control arms were also good. The trial methodology used was appropriate and feasible. CONCLUSIONS: This study showed that a randomised controlled trial of group CBT for women with depression is feasible and the intervention is acceptable, and may possibly prove to be effective in a larger trial. The cost effectiveness of group CBT for depression should be explored further in a full trial. TRIAL REGISTRATION: NCT00663078.

Continuity of care as a predictor of ongoing frequent attendance in primary care: a retrospective cohort study.

BACKGROUND: Frequent attenders (FAs) in primary care receive considerable resources with uncertain benefit. Only some FAs attend persistently. Modestly successful models have been built to predict persistent attendance. Nevertheless, an association between relational continuity of care and persistent frequent attendance remains unclear, and could be important considering both the UK government and Royal College of General Practitioner's (RCGP) aim of improving continuity. AIM: To identify predictive measures (including continuity) for persistent frequent attendance that may be modified in future interventions. DESIGN & SETTING: This is a retrospective cohort study sampling 35 926 adult patients registered in seven Bristol practices. METHOD: The top 3% (1227) of patients by frequency of GP consultations over 6 months were classed as FAs. Individual relational continuity was measured over the same period using the Usual Provider Continuity (UPC) index. Attendance change was calculated for the following 6 months. Multivariable logistic regression analysis was used to determine variables that predicted attendance change. RESULTS: FAs were on average 8.41 years older (difference 95% confidence interval [CI] = 7.33 to 9.50, P<0.001) and more likely to be female (65.36% versus 57.88%) than non-FAs. In total, 79.30% of FAs decreased attendance over the subsequent 6 months. No association was found between continuity and subsequent attendance. Increasing age was associated with maintained frequent attendance. CONCLUSION: Continuity does not predict change in frequent attendance. In addition to improving continuity, recent government policy is focused on increasing primary care access. If both aims are achieved it will be interesting to observe any effect on frequent attendance.

Addressing the challenges of knowledge co-production in quality improvement: learning from the implementation of the researcher-in-residence model.

The concept of knowledge co-production is used in health services research to describe partnerships (which can involve researchers, practitioners, managers, commissioners or service users) with the purpose of creating, sharing and negotiating different knowledge types used to make improvements in health services. Several knowledge co-production models have been proposed to date, some involving intermediary roles. This paper explores one such model, researchers-in-residence (also known as 'embedded researchers').In this model, researchers work inside healthcare organisations, operating as staff members while also maintaining an affiliation with academic institutions. As part of the local team, researchers negotiate the meaning and use of research-based knowledge to co-produce knowledge, which is sensitive to the local context. Even though this model is spreading and appears to have potential for using co-produced knowledge to make changes in practice, a number of challenges with its use are emerging. These include challenges experienced by the researchers in embedding themselves within the practice environment, preserving a clear focus within their host organisations and maintaining academic professional identity.In this paper, we provide an exploration of these challenges by examining three independent case studies implemented in the UK, each of which attempted to co-produce relevant research projects to improve the quality of care. We explore how these played out in practice and the strategies used by the researchers-in-residence to address them. In describing and analysing these strategies, we hope that participatory approaches to knowledge co-production can be used more effectively in the future.