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Background Trauma-informed (TI) approach is a framework for a system change intervention that transforms the organizational culture and practices to address the high prevalence and impact of trauma on patients and healthcare professionals, and prevents re-traumatization in healthcare services. Review of TI approaches in primary and community mental healthcare identified limited evidence for its effectiveness in the UK, however it is endorsed in various policies. This study aimed to investigate the UK-specific context through exploring how TI approaches are represented in health policies, and how they are understood and implemented by policy makers and healthcare professionals. Methods A qualitative study comprising of a document analysis of UK health policies followed by semi-structured interviews with key informants with direct experience of developing and implementing TI approaches. We used the Ready Extract Analyse Distil (READ) approach to guide policy document review, and the framework method to analyse data. Results We analysed 24 documents and interviewed 11 professionals from healthcare organizations and local authorities. TI approach was included in national, regional and local policies, however, there was no UK- or NHS-wide strategy or legislation, nor funding commitment. Although documents and interviews provided differing interpretations of TI care, they were aligned in describing the integration of TI principles at the system level, contextual tailoring to each organization, and addressing varied challenges within health systems. TI care in the UK has had piecemeal implementation, with a nation-wide strategy and leadership visible in Scotland and Wales and more disjointed implementation in England. Professionals wanted enhanced coordination between organizations and regions. We identified factors affecting implementation of TI approaches at the level of organization (leadership, service user involvement, organizational culture, resource allocation, competing priorities) and wider context (government support, funding). Professionals had conflicting views on the future of TI approaches, however all agreed that government backing is essential for implementing policies into practice. Conclusions A coordinated, more centralized strategy and provision for TI healthcare, increased funding for evaluation, and education through professional networks about evidence-based TI health systems can contribute towards evidence-informed policies and implementation of TI approaches in the UK.

Background The lockdown periods to curb COVID-19 transmission have made it harder for survivors of domestic violence and abuse (DVA) to disclose abuse and access support services. Our study describes the impact of the first COVID-19 wave and the associated national lockdown in England and Wales on the referrals from general practice to the Identification and Referral to Improve Safety (IRIS) DVA programme. We compare this to the change in referrals in the same months in the previous year, during the school holidays in the 3 years preceding the pandemic and the period just after the first COVID-19 wave. School holiday periods were chosen as a comparator, since families, including the perpetrator, are together, affecting access to services. Methods We used anonymised data on daily referrals received by the IRIS DVA service in 33 areas from general practices over the period April 2017–September 2020. Interrupted-time series and non-linear regression were used to quantify the impact of the first national lockdown in March–June 2020 comparing analogous months the year before, and the impact of school holidays (01/04/2017–30/09/2020) on number of referrals, reporting Incidence Rate Ratio (IRR), 95% confidence intervals and p -values. Results The first national lockdown in 2020 led to reduced number of referrals to DVA services (27%, 95%CI = (21,34%)) compared to the period before and after, and 19% fewer referrals compared to the same period in the year before. A reduction in the number of referrals was also evident during the school holidays with the highest reduction in referrals during the winter 2019 pre-pandemic school holiday (44%, 95%CI = (32,54%)) followed by the effect from the summer of 2020 school holidays (20%, 95%CI = (10,30%)). There was also a smaller reduction (13–15%) in referrals during the longer summer holidays 2017–2019; and some reduction (5–16%) during the shorter spring holidays 2017–2019. Conclusions We show that the COVID-19 lockdown in 2020 led to decline in referrals to DVA services. Our findings suggest an association between decline in referrals to DVA services for women experiencing DVA and prolonged periods of systemic closure proxied here by both the first COVID-19 national lockdown or school holidays. This highlights the need for future planning to provide adequate access and support for people experiencing DVA during future national lockdowns and during the school holidays.

ObjectivesThis study aimed to evaluate the prospective cost-effectiveness of the Identification and Referral to Improve Safety plus (IRIS+) intervention compared with usual care using feasibility data derived from seven UK general practice sites.MethodA cost–utility analysis was conducted to assess the potential cost-effectiveness of IRIS+, an enhanced model of the UK’s usual care. IRIS+ assisted primary care staff in identifying, documenting and referring not only women, but also men and children who may have experienced domestic violence/abuse as victims, perpetrators or both. A perpetrator group programme was not part of the intervention per se but was linked to the IRIS+ intervention via a referral pathway and signposting. A Markov model was constructed from a societal perspective to estimate mean incremental costs and quality-adjusted life years (QALYs) of IRIS+ compared with to usual care over a 10-year time horizon.ResultsThe IRIS+ intervention saved £92 per patient and produced QALY gains of 0.003. The incremental net monetary benefit was positive (£145) and the IRIS+ intervention was cost-effective in 55% of simulations at a cost-effectiveness threshold of £20 000 per QALY.ConclusionThe IRIS+ intervention could be cost-effective or even cost saving from a societal perspective in the UK, though there are large uncertainties, reflected in the confidence intervals and simulation results.

Background Identification in UK general practice of women affected by domestic violence and abuse (DVA) is increasing, but men and children/young people (CYP) are rarely identified and referred for specialist support. To address this gap, we collaborated with IRISi (UK social enterprise) to strengthen elements of the IRIS + intervention which included the identification of men, direct engagement with CYP, and improved guidance on responding to information received from other agencies. IRIS + was an adaptation of the national IRIS (Identification and Referral to Improve Safety) model focused on the needs of women victim-survivors of DVA. Without diminishing the responses to women, IRIS + also responded to the needs of men experiencing or perpetrating DVA, and CYP living with DVA and/or experiencing it in their own relationships. Our study tested the feasibility of the adapted IRIS + intervention in England and Wales between 2019–21. Methods We used mixed method analysis to triangulate data from various sources (pre/post intervention questionnaires with primary care clinicians; data extracted from medical records and DVA agencies; semi-structured interviews with clinicians, service providers and referred adults and children) to assess the feasibility and acceptability of the IRIS + intervention. Results The rate of referral for women doubled (21.6/year/practice) from the rate (9.29/year/practice) in the original IRIS trial. The intervention also enabled identification and direct referral of CYP (15% of total referrals) and men (mostly survivors, 10% of total referrals). Despite an increase in self-reported clinician preparedness to respond to all patient groups, the intervention generated a low number of men perpetrator referrals (2% of all referrals). GPs were the principal patient referrers. Over two-thirds of referred women and CYP and almost half of all referred men were directly supported by the service. Many CYP also received IRIS + support indirectly, via the referred parents. Men and CYP supported by IRIS + reported improved physical and mental health, wellbeing, and confidence. Conclusions Although the study showed acceptability and feasibility, there remains uncertainty about the effectiveness, cost-effectiveness, and scalability of IRIS + . Building on the success of this feasibility study, the next step should be trialling the effectiveness of IRIS + implementation to inform service implementation decisions.

Background Reporting of domestic violence and abuse (DVA) increased globally during the pandemic. General Practice has a central role in identifying and supporting those affected by DVA. Pandemic associated changes in UK primary care included remote initial contacts with primary care and predominantly remote consulting. This paper explores general practice’s adaptation to DVA care during the COVID-19 pandemic. Methods Remote semi-structured interviews were conducted by telephone with staff from six localities in England and Wales where the Identification and Referral to Improve Safety (IRIS) primary care DVA programme is commissioned.  We conducted interviews between April 2021 and February 2022 with three practice managers, three reception and administrative staff, eight general practice clinicians and seven specialist DVA staff. Patient and public involvement and engagement (PPI&E) advisers with lived experience of DVA guided the project. Together we developed recommendations for primary care teams based on our findings. Results We present our findings within four themes, representing primary care adaptations in delivering DVA care: 1. Making general practice accessible for DVA care: staff adapted telephone triaging processes for appointments and promoted availability of DVA support online. 2. General practice team-working to identify DVA: practices developed new approaches of collaboration, including whole team adaptations to information processing and communication 3. Adapting to remote consultations about DVA: teams were required to adapt to challenges including concerns about safety, privacy, and developing trust remotely. 4. Experiences of onward referrals for specialist DVA support: support from specialist services was effective and largely unchanged during the pandemic. Conclusions Disruption caused by pandemic restrictions revealed how team dynamics and interactions before, during and after clinical consultations contribute to identifying and supporting patients experiencing DVA. Remote assessment complicates access to and delivery of DVA care. This has implications for all primary and secondary care settings, within the NHS and internationally, which are vital to consider in both practice and policy.

There are known inequalities in vaccine uptake and the distribution of vaccine-preventable diseases. Understanding the best ways to increase vaccine uptake among socially excluded groups is vital to reduce these inequalities. To assess the effectiveness of interventions to increase vaccine uptake among socially excluded groups. Systematic review of randomised controlled trials (RCTs) and non-randomised studies of interventions. Studies were eligible if they evaluated an intervention to increase uptake of any vaccination on the World Health Organization immunisation schedule and focused on socially excluded populations (e.g. people experiencing homelessness, people who use drugs). MEDLINE, Embase and PsycINFO were searched to January 2025. Risk of bias was assessed using Cochrane risk of bias tools. Data were analysed using random-effects meta-analyses and effect direction plots. Of 2673 records, 20 studies were eligible (18 RCTs and two non-randomised studies). Most (13 studies) were conducted among people who use drugs and investigated hepatitis B (HBV) vaccination uptake (16 studies). Various interventions were identified: accelerated HBV vaccination schedules (six studies); financial incentives (four); educational initiatives (two); motivational interviewing (two); post-natal home visits (one); enhanced outreach and on-the-spot vaccination (one), and four varying interventions delivered as part of care co-ordination or nurse-guided case management models. Nine studies were at high risk of bias, six had some concerns and five were at low risk. Meta-analyses indicated a potential beneficial effect of accelerated schedules (odds ratio (OR):1.45, 95%CI:1.10–1.91) and financial incentives (OR:5.36, 95%CI:2.61–11.01). Confidence in the evidence was judged to be ‘moderate’ for both these interventions. Evidence for the effectiveness of other types of interventions was inconclusive. We identify some promising strategies for improving uptake of vaccinations among some socially excluded groups. The conclusions that can be drawn are, however, limited by the lack of high-quality studies on the topic.

Witchdoctor-led violence against people with albinism has left them fearing for their lives and lacking adequate healthcare

We discuss the case of a 49-year-old soldier with a macula-on rhegmatogenous retinal detachment in Sierra Leone. The case highlights the challenge of accessing visually preserving ophthalmic specialist care in sub-Saharan Africa (SSA) for vitreoretinal (VR) disease. It highlights a shortage of VR surgeons in SSA, limited examination facilities, the larger issue of accessing specialist care urgently and the costs associated with accessing surgery out-of-country. It also identifies a shortage in epidemiological data on the issue which limits the assessment of the scale of the problem.

Background: Stroke is a leading cause of seizures and epilepsy, both of which are linked to increased mortality, disability, and hospital readmissions. Early recognition and management of seizures in acute stroke are crucial for improving outcomes. Electroencephalogram (EEG) is not routinely used for post-stroke seizure monitoring and is typically initiated only after clinical suspicion arises, making bedside recognition essential. This scoping review aimed to map the existing literature on clinical methods used for identifying and observing early post-stroke seizures (EPSSs) at the bedside. Methods: We included literature involving adults with acute ischaemic stroke or primary intracerebral haemorrhage who were diagnosed or suspected of having inpatient EPSS. Searches were conducted in Medline, CINAHL, Embase, and the Cochrane Library for English-language publications up to April 2023. Eligible sources included primary research, case reports, systematic reviews, clinical guidelines, consensus statements, and expert opinion. Reference lists of included articles were also reviewed. Data were charted and synthesised to assess the scope, type, and gaps in the evidence. Results: Thirty papers met inclusion criteria: 17 research studies, six expert opinions, four case reports, and three clinical guidelines. Empirical evidence on clinical methods for seizure recognition and monitoring in acute stroke was limited. No studies evaluated the effectiveness of different approaches, and existing recommendations lacked detail and consensus. Conclusions: Accurate EPSS diagnosis is vital due to its impact on outcomes. This review highlights inconsistency in monitoring methods and a clear need for targeted research into effective clinical identification strategies in acute stroke care.