Emilia: assessing the WHO Mental Global Action Programme intervention guide for use on digital devices

The aim of the Emilia project is to assess if it is possible to produce an e-version of the World Health Organization (WHO) Mental Health Global Action Programme Intervention Guide (e-mhGAP IG) that is easily usable on smartphones and tablet devices by primary care staff in Nepal and Nigeria. The project will assess if this electronic form of guidance is suitable for use in low and middle income countries (LMICs), where over 85% of the world’s population live. The development of the e-mhGAP IG will offer significant improvements over the printed paper version by surpassing limitations such as slow and irregular updating, and will create new opportunities for remote supervision. To evaluate fidelity, the researchers will interview practice managers and service users who have attended the clinics to assess their knowledge and their experience of how the e-mhGAP intervention guides is applied in practice by primary healthcare staff, and collect service user/patient service satisfaction data through a brief structured form. In each clinic the research team plan to gather patient service satisfaction data from all attending service users over three separate one-week periods. This strategy will allow the researchers to evaluate implementation fidelity and its change over time. The study is led by Professor Sir Graham Thornicroft, working with colleagues in the Centre of Implementation Science and researchers from Nepal, Nigeria, Ethiopia and the WHO.

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ASPIRES: reduction of surgical site infection rates and improved antibiotic prescription and utilisation in perioperative care globally

Researchers from the Centre for Implementation Science lead on one of four work-packages of the global ASPIRES project (Antibiotic use across Surgical Pathways - Investigating, Redesigning and Evaluating Systems). Funded by the ESRC, the project asks how can antibiotic use be optimised along the entire surgical pathway such that surgical outcomes improve. The approaches taken to address this question involve developing behavioural, structural and technological interventions which are context specific – and applied in hospital settings in India, Rwanda, South Africa and the UK.

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Indigo: Develop and test new methods to reduce mental-health-related stigma in China, Ethiopia, India, Tunisia, and Nepal

Researchers in the Centre for Implementation Science are part of an international research programme (Indigo) which aims to develop and test new methods to reduce mental health related stigma in China, Ethiopia, India, Tunisian and Nepal. Specifically, the research within the Indigo Partnership is aimed at establishing a research collaboration that enables the development of effective, contextually adapted stigma reduction interventions. It also aims to carry out activities to strengthen the scientific understanding of how people with mental illness are affected by stigma.

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The Friendship Bench: Optimizing implementation strategies of the first scale-up of a primary care psychological intervention for common mental disorders in Sub-Saharan Africa

This research is funded by the Medical Research Council (MRC) and is being jointly led by Professor Ricardo Araya (Centre for Global Mental Health, KCL) and Professor Dixon Chibanda (University of Zimbabwe). CIS are providing health economic expertise. The project is evaluating the comparative performance of health clinics in Zimbabwe in terms of their success in implementing the Friendship Bench, a lay-worker delivered psychological therapy for improving symptoms of depression and anxiety. This will be used as a basis for testing promising implementation strategies to maximize the reach, effectiveness, adoption, implementation, and maintenance of the Friendship Bench into the future.

ASSET: HeAlth System StrEngThening in Sub Saharan Africa: A five-year programme funded by the NIHR to address the “how to” component of bringing to scale complex interventions to achieve high-quality care for Universal Health Coverage

Centre scientists lead on one of several work packages that constitute the ASSET global health research programme. Funded by the National Institute for Health Research (NIHR), ASSET is a Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa. We are working in four countries; Ethiopia, South Africa, Sierra Leone and Zimbabwe; and across three healthcare platforms: integrated primary health care; maternal care and surgical care. Part of the Government’s wider Official Developmental Assistance (ODA) budget, the aim of this research is to improve the health of patients and public in low and middle-income countries. CIS scientists lead on the Improvement and Implementation cross-cutting work-group, aiming to strengthen and harmonise implementation strategies across ASSET countries and platforms.

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Evaluating the HARPdoc trial – aimed at helping people with type 1 diabetes avoid hypoglycaemia

Researchers in the Centre of Implementation Science are working closely with researchers in CLAHRC South London’s diabetes theme to help them evaluate two new educational programmes aimed at helping people with type 1 diabetes to avoid hypoglycaemia. This work is part of the ‘HARPdoc’ randomised controlled trial, which was designed to address the motivations and barriers to hypoglycaemia avoidance. It uses educational and psychological techniques, such as motivational interviewing and cognitive behaviour theory delivered by specially trained diabetes educators to small groups of patients. The trial will be comparing two interventions designed to help change patients’ thoughts and behaviours around hypoglycaemia to improve detection, treatment and prevention. Postdoctoral research associate Dr Tayana Soukup is leading a process evaluation of the HARPdoc trial, in collaboration with other implementation scientists in the Centre. ‘While the trial is concerned with understanding which intervention is more effective, the process evaluation is focused on understanding the way in which the programmes are implemented and assessing their impact at study sites. Ultimately the aim is to inform the scale-up of the effective programme after the trial is complete,’ says Dr Soukup.

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NIHR Applied Research Collaboration South London – Implementation Research Theme

This theme offers a hub of expertise in implementation research, methodologies and metrics – ultimately aimed at accelerating translation of evidenced practices into routine health and social care across the newly established NIHR ARC South London (2019-24). Centre researchers are leading on two implementation methodology studies: (i) ImpRes study: this is an international Delphi Validation of the recently Implementation Science Research Development tool (ImpRes) developed by our Centre. The aim is to enhance the design and execution of high-quality implementation research by further advancing the validation of the ImpRes tool. The study will produce a refined, validated ImpRes tool, and its associated guide – with a view to apply it across NIHR ARC South London applied health studies. (ii) INSPECT study: for the Implementation Science Outcomes Project (INSPECT), Centre scientists will appraise the scientific quality and usability of standardised quantitative measures of implementation effectiveness, typically called ‘implementation outcomes’ and consolidate these outcome measures across physical, mental, and social care settings. The study will involve review of health and care implementation metrics and stakeholder user panels (incl. scientists, patients/service users, and commissioners). The study will produce an online consolidated compendium of implementation outcome measures presented with their psychometric properties and usability commentary for use in health and care settings.

IMPHS: Integrating Mental & Physical Healthcare Systems

Centre researchers, in collaboration with the KCL IoPPN Department for Psychosis Studies and the universities of East Anglia and Southampton, are leading on the evaluation of the implementation and scale up of a large scale improvement programme within the South London and Maudsley NHS Trust aimed at ‘Integrating Mental and Physical Healthcare System’ (IMPHS). Funded by the Maudsley Charity from 2019, this 3-year project aims to apply implementation and scale-up frameworks, methodologies and outcomes in order to understand, optimise and evaluate the implementation and scale up processes of a number of initiatives launched within the Trust – including the development and utilisation of a cadre of health champions; the implementation of IT-driven physical health initiatives; in- and out-reach initiatives focused on physical health; and finally initiatives in the area of staff training and upskilling in addressing the physical health needs of mental health patients.

SHAPER: Scaling-up Health-Arts Programmes: Implementation and Effectiveness Research

Centre scientists are leading on the implementation evaluation arm of the SHAPER programme. A collaborative programme between King’s College London, King’s Health Partners, and University College London (UCL), SHAPER aims to translate arts in health research into sustainable, standardised and scalable health interventions that make both clinical and economic sense. The primary aim is to upscale three known effective arts interventions (Melodies for Mums for Postnatal Depression, Dance for Parkinson’s, and Stroke Odysseys) and embed them in clinical pathways, thereby strengthening the economic case for funding such interventions in the long-term. We will seek to establish defined, clinical referral pathways, from either primary or secondary care settings. In addition, by examining larger cohorts than has hitherto been possible, we will gather further evidence of (i) the clinical effectiveness of our chosen interventions, and of the mechanisms underpinning it, (ii) the implementation effectiveness (i.e., uptake, acceptability, feasibility and appropriateness), and (iii) their economic effectiveness. The programme involves three award-winning arts organisations, Breathe Arts Health Research, the English National Ballet and Rosetta Life and applies an innovative ‘hybrid: effectiveness-implementation’ evaluation approach.

Evaluation of the Time to Change anti-stigma programme delivered by Mind and Rethink Mental Illness

Time to Change is a population and target group level programme to reduce mental health related stigma and discrimination in England currently in its third phase of delivery, 2016-21. The evaluation comprises: Social Marketing Campaign evaluation: analysis of market research data collected from the target demographic group and using validated measures of stigma related knowledge, attitudes to mental illness, and desire for social distance. Analysis of press coverage of mental health related topics. Analysis of a biennial Attitudes to Mental Illness survey of the population in England aged 16 and over, using measures of knowledge attitudes and reported, observed and intended behaviour, including those used to evaluate the social marketing campaign. The press coverage and Attitudes to Mental Illness survey continue work started in 2008 to create a baseline before the start of the first phase of Time to Change. The social marketing campaign evaluation has used the same measures throughout for the different demographic target groups for phases 1 and 2 versus phase 3. NOTE about how to access the measures used: (i) Original 40 item scale: Taylor SM, Dear MJ. Scaling community attitudes toward the mentally ill. Schizophr.Bull 1981;7(2):225-240. (ii) 27 item version: Rüsch N, Evans-Lacko S, Henderson C Leese M, Flach C Thornicroft G. Public knowledge and attitudes as predictors of help-seeking and disclosure in mental illness. Psychiatric Services, 62:675-678, 2011. (iii) 12 item version: Ilic N, Henderson H, Henderson C, Evans-Lacko S, Thornicroft G. Attitudes towards mental illness, in Craig R, Fuller E, Mindell J (eds). Health Survey for England 2014: Health, social care and lifestyles. London: Health and Social Care Information Centre. (iv) Sampogna G, Bakolis I, Evans-Lacko S, Robinson E, Thornicroft G, Henderson C. The impact of social marketing campaigns on reducing mental health stigma: Results from the 2009-2014 Time to Change programme. European Psychiatry, 2016 Dec 16;40:116-122. doi: 10.1016/j.eurpsy.2016.08.008.

Evaluation of the Every Mind Matters campaign delivered by Public Health England, on behalf of the Mental Health Policy Research Unit

The Every Mind Matters (EMM) campaign is a government initiative which aims to improve adult population mental health literacy in England. It is a multi-platform, social marketing campaign created and developed by Public Health England that will has been funded for three years and launched nationally in October 2019. The primary outcome of MHL is defined as: knowledge of how to obtain and maintain positive mental health; knowledge of the four problem areas covered in the campaign (stress, poor sleep, anxiety and low mood); mental health related self- efficacy; decreased stigma related to mental disorders. Secondary objectives are to assess: population level mental distress, mental wellbeing before, during and after the campaign; whether there are variations in campaign effects across groups of the population; whether use/awareness of EMM moderates the relationships between wellbeing and each of help-seeking and costs of primary care use; how the campaign is experienced and how this may explain the quantitative results. The evaluation uses: serial population surveys recruited from a market research panel; the use of existing and additional questions in the annual Health Survey for England; qualitative interviews of users of the EMM online content.

CAFI trial: site for the HTA trial of culturally adapted family therapy for African and African Caribbean people with psychosis

Black people in the UK are diagnosed with schizophrenia more than other ethnic groups and experience a ‘negative care pathway’ more than others. NICE recommends Family Intervention therapies for families affected by schizophrenia. Some people, especially Black service users, do not have regular contact with their families. In previous research, the PI (Edge) worked with Caribbean service users, carers and health professionals to develop Culturally-adapted FI (CaFI). The current trial will adapt this to extend its use for Sub-Saharan African service users. AIMS: i) Evaluate CaFI’s clinical and cost-effectiveness in African and Caribbean populations; ii) Determine how to maximise facilitators/overcome barriers to successful implementation. DESIGN: Blind-rated RCT with internal Stop/Go pilot and process evaluation. SETTING: 6 NHS Mental Health Trusts: 3 Northwest, 1 Midlands, 1 London, 1 South West. POPULATION: African and Caribbean origin service users (including ‘Black British’ and ‘Mixed’) in inpatient, rehabilitation, community, and forensic settings. HEALTH TECHNOLOGY: 10 x1 hour sessions of Culturally-adapted Family Intervention (CaFI) delivered within a 20 week ‘therapy window’. PRIMARY OUTCOME: Reduction in relapse (as defined by an exacerbation of symptoms lasting over two weeks). SECONDARY OUTCOMES: Number of psychiatric and compulsory admissions, length of inpatient stays, service use, Perceived Coercion, Positive and Negative Syndrome Scale (PANSS), Personal and Social Performance Scale (PSP)(10), Brief Illness Perception Questionnaire (Brief-IPQ), Knowledge about Psychosis Interview (KAPI), General Health Questionnaire (GHQ), EQ-5D-5L(14), Working Alliance Inventory (WAI), Service Engagement Scale (SES).

Working with BME faith communities to improve mental health care

Researchers at King’s College London are working on a project with clinicians at South London and Maudsley NHS Foundation Trust to address the stark healthcare inequalities for the Black community in relation to mental health care in Southwark and Lambeth. The incidence of psychosis among black and minority ethnic (BME) groups is up to 14 times higher than for white people, while the prevalence rate is 2.7 times higher in inner city London boroughs (Quassem et al, 2015). In their pathways to care, people in BME communities with a first episode of psychosis are 2.1 times more likely to access care via the police than are their white counterparts (Anderson et al, 2014)(1). Service satisfaction locally is significantly lower among BME groups (NIMHE, 2003; Parkman et al 1999). This project aims to create a mental health awareness training package for local Black majority or led churches which is accredited by King’s College London. The research team also hope to train mental health staff at South London and Maudsley to become more aware of different faith communities in their local area and the importance of working alongside faith communities to help people on their journey to recovery. They will offer opportunities for interested members of faith communities to be trained to co-facilitate mental health awareness groups, to become mental health champions for their faith community or to become faith consultants for South London and Maudsley. These roles will involve offering consultation to staff around any faith-based queries they may have when working with clients. The project is funded by Guy's and St Thomas' Charity Health Innovation Fund.

King’s Improvement Science research programme

King's Improvement Science (KIS) is a King’s Health Partners-supported research programme aimed at enhancing how quality improvement activity is carried out across major south London health care providers. Initially established in 2013, KIS comprises an interdisciplinary team of researchers and quality improvement experts. In the first phase of its work (2013-19), KIS supported five quality improvement projects at Guy's and St Thomas' NHS Foundation Trust, King's College London NHS Foundation Trust and South London and Maudsley NHS Foundation Trust, working in collaboration with health professionals, managers, patients and service users. KIS also hosted a number of postdoctoral improvement science research fellows, aiming to develop a cadre of interdisciplinary improvement science specialists who would then further advance the science of improvement but also develop and evaluate scalable improvement projects within the NHS. A major deliverable of this work was the launch in 2018 of the KIS ‘Resources about Improvement and Implementation’ – which can be used to design scientific or practical improvement projects. In the second phase of its work (2019-24), the KIS programme is aligned to the NIHR Applied Research Collaboration South London as co-funded research infrastructure. The KIS programme will continue to support scalable improvement projects across the host NHS Trusts and King’s Health Partners, as well as develop methodological research to further advance the science of improvement.

Resources about Improvement and Implementation

EQUIP: Developing capacity and capability for perioperative improvement within UK urology training

Researchers from the Centre, the University of East Anglia and Barts Health, jointly with patients, medical education and improvement experts, trainees and the charitable Urology Foundation have set up a new training programme, aiming to provide urology trainees across the UK with the skills and expertise they need to carry out successful and impactful quality improvement projects as part of their training rotations. Launched in 2017, the ‘Education in Quality Improvement Programme’ (EQUIP) is a research project supported by the Urology Foundation at the interface of improvement and implementation sciences and surgical education. The programme aims to develop an evidence-based, user-informed, practical and scalable quality improvement skills training curriculum for urology trainees surgical residents in the UK. To-date, EQUIP has: (i) delivered a review of published evidence regarding how best to teach improvement skills to healthcare personnel; (ii) designed a pragmatic core improvement skills curriculum for urology trainees, deliverable within half a day of face to face teaching. The curriculum has been evaluated and found feasible and offering positive immediate educational impact; (iii) carried out a national needs assessment across urology training programmes in the UK. In the coming two years, EQUIP researchers will: (i) develop a train-the-trainers approach to facilitate the scale-up of the EQUIP curriculum nationally in the UK; (ii) establish national consensus regarding the requirements of trainee improvement projects, in terms of project scope and quality assurance criteria; (iii) develop a national web portal for the sharing of trainees’ improvement projects at national level; (iv) explore the potential for EQUIP to reach out to surgical specialities outside urology.

A summary of the work completed to-date

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Using smartphone technology to enhance patient safety in surgical care

Research suggests that around one in ten patients entering NHS hospitals will experience an unintended error (termed an ‘adverse event’) in their care. These events can result in harm and have catastrophic implications, not only for the patient and their family, but for the healthcare staff involved and for the NHS organisation as a whole (at both areputational and financial level). Adverse event rates are higher for surgery than other healthcare specialties. This may be a reflection of the risk profile of the patients receiving surgery; the complexity of the procedure and/or the operating theatre environment; or simply higher rates of reporting errors by surgical staff. Either way, improving surgical safety is a priority for NHS England. This research project aims to explore how we can effectively translate what the evidence tells us about the causes of error in surgery into a format that patients can use to improve their safety. Specifically, the project looks at the use of smartphone apps to address this problem. An app, called MySurgery, has been designed to help patients and their carers understand the risks associated with having surgery and inform them of the specific actions they can take to improve their safety and recovery.

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Improving safety and quality in mental healthcare

A team of Centre for Implementation Science experts is involved in this doctoral project, which is aimed at the interface of patient safety and improvement sciences. Funded by the Healthcare Improvement Studies Institute (THIS) for three years (2019-22), the project will (i) study the nature of safety and quality of care problems that mental health patients face, (ii) shortlist potential interventions to address these, and (iii) conduct a proof-of-concept investigation of at least one of these interventions. The project will utilise arrange of methods – including evidence review to identify the nature and scale of the problem within mental health services; rapid ethnography and further qualitative methods to establish the views of providers, patients and their carers and families; and a multi-stakeholder approach to intervention development, implementation and evaluation, to evaluate interventions that are potentially effective in improving patient safety in this patient population. The project will be carried out in close collaboration with the South London and Maudsley NHS Trust.

The concept and determinants of return on investment for quality improvement in mental health NHS Foundation Trusts

Researchers in the Centre for Implementation Science will develop a measurement system for evaluating return on investment (ROI) of quality improvement projects in mental health services of the South London and Maudsley (SLaM) NHS Foundation Trust. Quality improvement in healthcare has seen a surge of investment amidst times of austerity in the UK. Very little guidance exists for evaluating return on investment, particularly in mental health NHS Foundation Trusts. This impedes communication with healthcare leaders and boards regarding the extent to which quality improvement is achieving its full potential within the organisation. A robust ROI measure will make it possible to generate regular reports for healthcare leaders which can be used to give them strategic insights and inform their decisions about investment strategies for capacity building, training and support. The research is supported through a London Interdisciplinary Social Science Doctoral Training Partnership (LISS DTP).

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