The mental wellbeing of prison staff in England during the COVID-19 pandemic: A cross-sectional study.

Background: COVID-19 is likely to have had an impact on the mental wellbeing of prison staff because of the high risk for infectious disease outbreaks in prisons and the pre-existing high burden of mental health issues among staff. Methods: A cross-sectional study of staff within 26 prisons in England was carried out between 20th July 2020 and 2nd October 2020. Mental wellbeing was measured using the Short-version of Warwick-Edinburgh Wellbeing Scale (SWEMWBS). Staff wellbeing was compared to that of the English population using indirectly standardised data from the Health Survey for England 2010-13 and a one-sample t-test. Multivariate linear regression modelling explored associations with mental wellbeing score. Results: Two thousand five hundred and thirty-four individuals were included (response rate 22.2%). The mean age was 44 years, 53% were female, and 93% were white. The sample mean SWEMWBS score was 23.84 and the standardised population mean score was 23.57. The difference in means was statistically significant (95% CI 0.09-0.46), but not of a clinically meaningful level. The multivariate linear regression model was adjusted for age category, sex, ethnicity, smoking status, occupation, and prison service region. Higher wellbeing was significantly associated with older age, male sex, Black/Black British ethnicity, never having smoked, working within the health staff team, and working in certain prison regions. Interpretation: Unexpectedly, prison staff wellbeing as measured by SWEMWBS was similar to that of the general population. Reasons for this are unclear but could include the reduction in violence within prisons since the start of the pandemic. Qualitative research across a diverse sample of prison settings would enrich understanding of staff wellbeing within the pandemic.

A systematic review and mixed-methods synthesis of the experiences, perceptions and attitudes of prison staff regarding adult prisoners who self-harm.

BACKGROUND: Self-harm, including suicide, is common among prisoners. Staff attitudes and perceptions regarding self-harm may affect quality of care and patient safety. AIMS: To systematically review the experiences, perceptions and attitudes of staff in adult prisons regarding self-harm. METHOD: Systematic searches of EMBASE, Medline, PsycINFO and CINAHL databases were conducted, and supplemented by hand-searching and grey literature review, to identify relevant English-language articles published since the year 2000. Articles were screened by two authors and evaluated with standardised quality appraisal tools. Qualitative data were analysed thematically, whereas quantitative data were narratively synthesised because of high study heterogeneity. RESULTS: Two thousand articles were identified, of which 32 were included, involving 6389 participants from five countries. Most studies were moderate (n = 15) or poor (n = 10) quality, and seven were rated as good quality. Staff frequently witnessed self-harm and described multiple perceived risk factors and causes of this. Perceptions that self-harm is 'manipulative' or 'attention-seeking' were associated with hostility toward prisoners and lower quality of care. Perceived barriers to preventing and managing self-harm included low staffing levels, prison environments and culture, poor staff confidence and insufficient training. The importance of multidisciplinary teamwork and building staff-prisoner relationships were highlighted. Staff occasionally experienced intense psychological reactions to self-harm, which resulted in adaptive or maladaptive coping that influenced their capacity to care. CONCLUSIONS: There are mixed attitudes and perceptions toward self-harm among prison staff. Further training, support and resources are required to protect staff's well-being and improve self-harm prevention and management in prisons.

Determining the Prevalence and Incidence of SARS-CoV-2 Infection in Prisons in England: Protocol for a Repeated Panel Survey and Enhanced Outbreak Study.

BACKGROUND: There are over 80,000 people imprisoned in England and Wales in 117 prisons. The management of the COVID-19 pandemic presents particular challenges in this setting where confined, crowded, and poorly ventilated conditions facilitate the rapid spread of infectious diseases. OBJECTIVE: The COVID-19 in Prison Study aims to examine the epidemiology of SARS-CoV-2 in prisons in England in order to inform public health policy and practice during the pandemic and recovery. The primary objective is to estimate the proportion of positive tests of SARS-CoV-2 infection among residents and staff within selected prisons. The secondary objectives include estimating the incidence rate of SARS-CoV-2 infection and examining how the proportion of positive tests and the incidence rate vary among individual, institutional, and system level factors. METHODS: Phase 1 comprises a repeated panel survey of prison residents and staff in a representative sample of 28 prisons across England. All residents and staff in the study prisons are eligible for inclusion. Participants will be tested for SARS-CoV-2 using a nasopharyngeal swab twice (6 weeks apart). Staff will also be tested for antibodies to SARS-CoV-2. Phase 2 focuses on SARS-CoV-2 infection in prisons with recognized COVID-19 outbreaks. Any prison in England will be eligible to participate if an outbreak is declared. In 3 outbreak prisons, all participating staff and residents will be tested for SARS-CoV-2 antigens at the following 3 timepoints: as soon as possible after the outbreak is declared (day 0), 7 days later (day 7), and at day 28. They will be swabbed twice (a nasal swab for lateral flow device testing and a nasopharyngeal swab for polymerase chain reaction testing). Testing will be done by external contractors. Data will also be collected on individual, prison level, and community factors. Data will be stored and handled at the University of Southampton and Public Health England. Summary statistics will summarize the prison and participant characteristics. For the primary objective, simple proportions of individuals testing positive for SARS-CoV-2 and incidence rates will be calculated. Linear regression will examine the individual, institutional, system, and community factors associated with SARS-CoV-2 infection within prisons. RESULTS: The UK Government's Department for Health and Social Care funds the study. Data collection started on July 20, 2020, and will end on May 31, 2021. As of May 2021, we had enrolled 4192 staff members and 6496 imprisoned people in the study. Data analysis has started, and we expect to publish the initial findings in summer/autumn 2021. The main ethical consideration is the inclusion of prisoners, who are vulnerable participants. CONCLUSIONS: This study will provide unique data to inform the public health management of SARS-CoV-2 in prisons. Its findings will be of relevance to health policy makers and practitioners working in prisons. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30749.

Preventive Digital Mental Health for Children in Primary Schools: Acceptability and Feasibility Study.

BACKGROUND: The incidence of mental health problems in children and adolescents in the United Kingdom has significantly increased in recent years, and more people are in contact with mental health services in Greater Manchester than in other parts of the country. Children and young people spend most of their time at school and with teachers. Therefore, schools and other educational settings may be ideal environments in which to identify those experiencing or those at the risk of developing psychological symptoms and provide timely support for children most at risk of mental health or related problems. OBJECTIVE: This study aims to test the feasibility of embedding a low-cost, scalable, and innovative digital mental health intervention in schools in the Greater Manchester area. METHODS: Two components of a 6-week digital intervention were implemented in a primary school in Greater Manchester: Lexplore, a reading assessment using eye-tracking technology to assess reading ability and detect early atypicality, and Lincus, a digital support and well-being monitoring platform. RESULTS: Of the 115 children approached, 34 (29.6%) consented and took part; of these 34 children, all 34 (100%) completed the baseline Lexplore assessment, and 30 (88%) completed the follow-up. In addition, most children were classified by Lincus as regular (≥1 per week) survey users. Overall, the teaching staff and children found both components of the digital intervention engaging, usable, feasible, and acceptable. Despite the widespread enthusiasm and recognition of the potential added value from staff, we met significant implementation barriers. CONCLUSIONS: This study explored the acceptability and feasibility of a digital mental health intervention for schoolchildren. Further work is needed to evaluate the effectiveness of the digital intervention and to understand whether the assessment of reading atypicality using Lexplore can identify those who require additional help and whether they can also be supported by Lincus. This study provides high-quality pilot data and highlights the potential benefits of implementing digital assessment and mental health support tools in a primary school setting.

Scoping review of mental health in prisons through the COVID-19 pandemic.

OBJECTIVE: To examine the extent, nature and quality of literature on the impact of the COVID-19 pandemic on the mental health of imprisoned people and prison staff. DESIGN: Scoping review. DATA SOURCES: PubMed, Embase, CINAHL, Global Health, Cochrane, PsycINFO, PsychExtra, Web of Science and Scopus were searched for any paper from 2019 onwards that focused on the mental health impact of COVID-19 on imprisoned people and prison staff. A grey literature search focused on international and government sources and professional bodies representing healthcare, public health and prison staff was also performed. We also performed hand searching of the reference lists of included studies. ELIGIBILITY CRITERIA FOR SELECTION OF STUDIES: All papers, regardless of study design, were included if they examined the mental health of imprisoned people or prison staff specifically during the COVID-19 pandemic. Imprisoned people could be of any age and from any countries. All languages were included. Two independent reviewers quality assessed appropriate papers. RESULTS: Of 647 articles found, 83 were eligible for inclusion, the majority (58%) of which were opinion pieces. The articles focused on the challenges to prisoner mental health. Fear of COVID-19, the impact of isolation, discontinuation of prison visits and reduced mental health services were all likely to have an adverse effect on the mental well-being of imprisoned people. The limited research and poor quality of articles included mean that the findings are not conclusive. However, they suggest a significant adverse impact on the mental health and well-being of those who live and work in prisons. CONCLUSIONS: It is key to address the mental health impacts of the pandemic on people who live and work in prisons. These findings are discussed in terms of implications for getting the balance between infection control imperatives and the fundamental human rights of prison populations.

Lessons Learnt From the Narratives of Women Who Self-Harm in Prison.

Background: In England and Wales, women in prison make up a minority (<5%) of the total custodial population, yet acts of self-harm are around five times more common among incarcerated women. While there has been a multiagency effort to improve how acts of self-harm are documented across prisons, the patterns and functions of self-harm for women in prison have not yet been fully addressed. Aims: We aimed to determine the patterns, prevalence, and functions of self-harm among women in prison through a mixed-methods study. Method: A total of 108 women with a history of self-harm were interviewed across three female prisons. Participants completed a structured questionnaire detailing their experiences of self-harm across prison and community settings. Results: We found that women in prison who frequently self-harmed disclosed high levels of trauma: past experiences of domestic violence (81.5%), childhood sexual abuse (66.7%), and adult sexual abuse (60.2%). Prevalent methods of recent in-prison acts of self-harm involved cutting, followed by ligaturing. Limitations: The study used a cross-sectional design, self-reported data, and featured a subset of women identified as being at high-risk of self-harm. Conclusion: Motivations behind acts of self-harm by women in prison are complex. Triggers appear to be past trauma, deteriorating mental health, and separation from children or family.

Acceptability and feasibility pilot randomised controlled trial of medical skin camouflage for recovery of women prisoners with self-harm scarring (COVER): the study protocol.

INTRODUCTION: Self-harm in prison is a major public health concern. Less than 5% of UK prisoners are women, but they carry out more than a fifth of prison self-harm. Scars resulting from self-harm can be traumatising and stigmatising, yet there has been little focus on recovery of women prisoners with self-harm scarring. Medical skin camouflage (MSC) clinics treat individuals with disfiguring skin conditions, with evidence of improved well-being, self-esteem and social interactions. Only one community study has piloted the use of MSC for self-harm scarring. METHODS AND ANALYSIS: We describe an acceptability and feasibility pilot randomised controlled trial; the first to examine MSC for women prisoners who self-harm. We aim to randomise 20-25 women prisoners to a 6-week MSC intervention and 20-25 to a waitlist control (to receive the MSC after the study period). We aim to train at least 6-10 long-term prisoners with personal experience of self-harm to deliver the intervention. Before and after intervention, we will pilot collection of women-centred outcomes, including quality of life, well-being and self-esteem. We will pilot collection of self-harm incidents during the intervention, resources used to manage/treat self-harm and follow-up of women at 12 weeks from baseline. Data on recruitment, retention and dropout will be recorded. We aim for the acceptability of the intervention to prison staff and women prisoners to be explored in qualitative interviews and focus groups. ETHICS AND DISSEMINATION: Ethical approval for COVER has been granted by the North East-York Research Ethics Committee (REC) for phases 1 and 2 (reference: 16/NE/0030) and West of Scotland REC 3 for phases 3 and 4 (reference: 16/WS/0155). Informed consent will be the primary consideration; it will be made clear that participation will have no effect on life in prison or eligibility for parole. Due to the nature of the study, disclosures of serious self-harm may need to be reported to prison officials. We aim for findings to be disseminated via events at the study prison, presentations at national/international conferences, journal publications, prison governor meetings and university/National Health Service trust communications. TRIAL REGISTRATION NUMBER: NCT02638974; Pre-results.

Patient and general practitioner attitudes to taking medication to prevent cardiovascular disease after receiving detailed information on risks and benefits of treatment: a qualitative study.

BACKGROUND: There are now effective drugs to prevent cardiovascular disease and guidelines recommend their use. Patients do not always choose to accept preventive medication at levels of risk reduction recommended in guidelines. The purpose of the study was to identify and explore the attitudes of patients and general practitioners towards preventative medication for cardiovascular disease (CVD) after they have received information about it; to identify implications for practice and prescribing. METHODS: Qualitative interviews with GPs and patients following presentation of in depth information about CVD risks and the absolute effects of medication. SETTING: GP practices in Birmingham, United Kingdom. RESULTS: In both populations: wide variation on attitudes to preventative medication; concerns about unnecessary drug taking & side effects; preferring to consider lifestyle changes first. In patient population: whatever their attitudes to medication were, the vast majority explained that they would ultimately do what their GP recommended; there was some misunderstanding of the distinction between curative and preventative medication. A common theme was the degree of trust in their doctors' judgement and recommendations, which contrasted with scepticism of the role of pharmaceutical companies and academics. Scepticism in guidelines was also common among doctors although many nevertheless recommended treatment for their patients CONCLUSIONS: A guideline approach to prescribing preventative medication could be against the interests and preferences of the patient. GPs must take extra care to explain what preventative medication is and why it is recommended, attempt to discern preferences and make recommendations balancing these potentially conflicting concerns.

Safer self-injury or assisted self-harm?

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who use harm-minimisation can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered.

The myth of agency and patient choice in health care? The case of drug treatments to prevent coronary disease.

Patient choice is at the heart of health-care reform programmes in the UK and in many other countries. The success of patient choice initiatives is dependent on a well-functioning agency relationship in health care. We interviewed 197 patients from 13 general practices in the West Midlands, UK, both before and after coronary screening. Our study suggests that, for patients presenting for coronary risk screening in primary care, the agency relationship is not working well--patients' expressed preferences relating to decisions to commence drug treatments were largely over-ridden in the clinical consultation. Therefore, if choice is to be a real driver of change in health care it needs to encompass patient empowerment and be based on a more collaborative approach to decision making between patients and professionals.

HUMAN TISSUE LEGISLATION AND MEDICAL PRACTICE: A BENEFIT OR A BURDEN?

The scandals surrounding organ removal and retention throughout the United Kingdom provoked several Inquiries and ultimately led to law reform. Although the medical professions were well represented at the Inquiries, little was heard of the voices of those at the 'coal face'. In this scoping study, funded by the Wellcome Trust, we interviewed a number of doctors and others engaged in the uses of human tissue and organs to explore their hopes, concerns and fears about the role of the law in their practices. We found that those involved in transplantation were more aware of, and more actively involve with, the law, whereas others, such as pathologists, had less direct engagement with the law. Most of those we interviewed expressed the hope that law reform would provide much-needed clarity. Although some expressed concern that the law might be over-intrusive, most felt that the placing of authority firmly in the hands of the person him or her self to decide what should happen to their bodies was to be welcomed.