Nikolina Jovanović

Background: The IMPULSE trial investigated the effectiveness and implementation of a digital psychosocial intervention (DIALOG+) for people with psychosis in five Southeast European countries. DIALOG+ significantly improved patients’ quality of life after four treatment sessions. The process evaluation reported here aimed to assess contextual influences on intervention delivery during the trial, to explain the trial findings and generate hypotheses about mechanisms of action by exploring acceptability from the perspectives of clinicians who delivered it and trial participants who received it, and fidelity (was the intervention delivered and received as planned?). Method: A mixed-methods process evaluation was conducted in accordance with the published protocol, guided by theoretical frameworks and the Medical Research Council’s guidance for complex interventions. To explore the role of context, data were analysed about the participating services, policy documents, and from focus groups with key stakeholders. Semi-structured interviews with clinicians and patients were conducted to explore acceptability. Process data (format and content of sessions) were analysed to assess intervention fidelity. Data analysis included descriptive methods, framework and content analysis, and triangulation. Results: Several attributes of context related to health services, including resource limitations, funding priorities, reliance on paper records and lack of community support, potentially negatively impacted DIALOG+ acceptability, fidelity and outcomes. Contextual enablers were also identified, including an appetite for change among key stakeholders that can help overcome contextual barriers. Acceptability of the psychosocial intervention was moderate to high and fidelity was high. Conclusions: Intervention acceptability is likely to have played a key role in ensuring high fidelity, which in turn likely contributed to the intervention’s positive impact on patients’ quality of life. The high fidelity confirms that the IMPULSE trial findings provide a valid assessment of the intervention as designed. While the identified contextual barriers appear not to have impaired intervention fidelity, acceptability and outcomes, they could pose challenges to the long-term sustainability of the intervention. Trial registration: Retrospectively registered on 29 March 2021, ISRCTN11913964

Background: Ethnic minority women face worse maternity outcomes and increased risk of perinatal mental health issues, yet research on the accessibility and acceptability of perinatal mental health services for these groups is limited. Objectives: (1) To explore access to and utilisation of mental health services during the perinatal period among ethnic minority women; (2) to explore care pathways to community and inpatient perinatal mental health services; (3) to explore the attitudes, experiences and service improvement suggestions of ethnic minority women with perinatal mental health problems, as well as those of their partners, family members and healthcare professionals and (4) to produce recommendations for improving clinical practice. Methods: Mixed-methods study was conducted during 2018–23, encompassing four studies aligned with specific aims: (1) a population-based study of 615,092 women who gave birth in National Health Services hospitals in England, using data from the National Commissioning Data Repository; (2) a retrospective evaluation of patients accessing community perinatal mental health services in Birmingham and London (n = 228) and inpatient services in Birmingham, London and Nottingham (n = 198) using an adapted World Health Organization care pathways questionnaire; (3) a qualitative study with four cohorts across England: service users (n = 37), non-users or those who disengaged (n = 23), partners/family (n = 15) and healthcare professionals (n = 24); (4) findings informed recommendations for practice improvements, coproduced with individuals with lived experience of perinatal mental illness and of being in a minoritised ethnic group. Data were analysed using quantitative and qualitative approaches. Results: Access issues to mental health services were evident for Black African, Asian and White other women compared to White British women. Variability in patient journeys to community perinatal mental health services seem to stem from service-level factors rather than patient needs. Asian patients had more emergency admissions to Mother and Baby Units, while Black patients were less likely to experience multiple services before Mother and Baby Unit admission. Barriers to access included limited service awareness, fear of child removal, stigma, remote clinical appointments and unresponsive services. Despite these challenges, many women found services helpful. Family members noted gaps in family-focused care. Recommendations for improvement include raising awareness, monitoring access for different ethnic groups and addressing concerns about child removal, with a focus on consistent care, family involvement and cultural sensitivity. Conclusion: These findings shed light on health inequalities in perinatal mental health care for ethnic minority women. The results can be utilised to address existing barriers and improve outcomes for mothers, infants and families. Limitations: Diversity within merged ethnic groups; limited sample of non-English-speaking women; reliance on self-reported measures; use of pre-COVID-19 data; under-representation of Black women who did not engage with services, and over-representation of Black and Asian patients in Birmingham and London samples in the study exploring patient pathways to Mother and Baby Units (compared to maternity population). Future work: Implementation of good practices in perinatal mental health care, targeted interventions to address the fear of child removal, innovative strategies to recruit Black and non-English-speaking women and exploring the experiences of ‘White other’ women. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14.

Background: Mother and Baby Units are specialised psychiatric facilities for women during and after pregnancy. In the United Kingdom, efforts have been made to expand the Mother and Baby Unit availability and establish care guidelines. However, the accessibility of these services for ethnic minority women remains relatively unexplored despite well-documented disparities. Aims: To explore patient pathways to Mother and Baby Units in three UK localities, with a focus on variations in pathways between services and among ethnic groups. Methods: This is a three-site, longitudinal retrospective service evaluation conducted in Birmingham, London and Nottingham during a 12-month period (1 January–31 December 2019). Electronic records were accessed to extract data on the type of admission, the referral process and the type of pathway (simple or complex). The simple pathway entailed contact with one clinician/service prior to admission to the Mother and Baby Unit, while the complex pathway involved interactions with two or more clinicians/services before Mother and Baby Unit admission. Data were collected using the adapted World Health Organization Encounter form and were analysed using uni- and multivariable analyses. Results: Electronic records from 198 patients were analysed, with participants distributed proportionally across three sites: Birmingham (n = 70, 35.4%), London (n = 62, 31.3%) and Nottingham (n = 66, 33.3%). All Mother and Baby Units were nationally commissioned and received referrals from across England. Most patients were in the post partum period, admitted for the first time through emergency, informal and complex pathways. The average length of admission was 6 weeks. Significant differences in admission characteristics were observed between services. Patients of Asian ethnicity had more emergency admissions compared to those of Black and White ethnicities. Ethnicity was the only significant factor associated with the simple/complex care pathway. After controlling for pathway-level and patient-level factors, Black patients were 6.24 times less likely to experience a complex care pathway than White patients. No evidence was found that patients from the Black ethnic background are detained more often than White patients. Limitations: The heterogeneity among categorised ethnic groups, data extracted solely from electronic records without validation through patients’ personal accounts of their care pathways, unanalysed declined referrals and the utilisation of pre-COVID-19 pandemic data. The ethnic composition of the study sample matched that of the UK maternity population in the Nottingham subsample, but Black and Asian populations were over-represented in the Birmingham and London subsamples. Conclusion: The study provides valuable insights into patient journeys to Mother and Baby Units, highlighting significant differences between services. It also emphasises the role of ethnicity in care pathways. For example, Black patients were less likely to encounter more than two services before Mother and Baby Unit admission, suggesting either more direct access to specialist care or insufficient community-based interventions. This dual interpretation calls for future research to explore whether pathway differences among ethnic groups result from optimal clinical decision-making or gaps in care provision. Future work: Should further examine the role of ethnicity in shaping care pathways; explore the link between care pathway types and treatment outcomes; investigate if simple or complex pathways result from optimal clinical decisions or gaps in the healthcare system and explore admissions to general wards versus Mother and Baby Units and transitions between these units. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14.

Women from Black and South Asian backgrounds with perinatal mental health difficulties face significant barriers to accessing healthcare. Clinical guidelines recommend that services collaborate with families, as they not only influence women’s decisions to seek help and engage with care but also serve as a vital source of support. However, family members’ experiences in providing this support remain poorly understood. This study aims to address this evidence gap. Individual semi-structured qualitative interviews were conducted with family members of Black and South Asian women who had experienced moderate to severe perinatal mental illness. The interviews explored the family members’ experiences, the personal impact of their relative’s condition, and their perspectives on accessing help and support. Interview transcripts were analysed using framework analysis, by a multidisciplinary team including psychiatrists, psychologists, methodologists, and people with a lived experience of perinatal mental illness. Fifteen family members of women with perinatal mental illness were interviewed; twelve husbands and/or partners, and three Mothers and/or Mothers-in-Law. Three themes were identified: (1) Recognising and understanding their relative’s perinatal mental illness was important to make sense of the situation (2) High emotional cost of supporting a relative with perinatal mental illness and (3) Varied experiences and expectations of services, with opportunities for improvement. Family members described how their relative’s illness had a pronounced negative impact on their own physical and mental health and wellbeing, and on relationships within their families. Whilst many family members felt listened to and well supported by services, several barriers that prevented or delayed getting professional support were identified. Families would value improved communication, more information and proactive care from perinatal mental health services. This paper offers valuable insights into perinatal mental illness for Black and South Asian women from a family perspective. Despite individual experiences being varied and wide-ranging, the suggestions for service improvement were congruent and often repeated, indicating a widespread need for a greater awareness and wider support for the family members of women in perinatal services, who are often struggling themselves.

Background: Maternity outcomes for women from certain ethnic groups are notably poor, partly owing to their not receiving treatment from services.Aims: To explore barriers to access among Black and south Asian women with perinatal mental health problems who did not access perinatal mental health services and suggestions for improvements, and to map findings on to the perinatal care pathway.Method: Semi-structured interviews were conducted in 2020 and 2021 in the UK. Data were analysed using the framework method.Results: Twenty-three women were interviewed, and various barriers were identified, including limited awareness of services, fear of child removal, stigma and unresponsiveness of perinatal mental health services. Whereas most barriers were related to access, fear of child removal, remote appointments and mask-wearing during COVID-19 affected the whole pathway. Recommendations include service promotion, screening and enhanced cultural understanding.Conclusions: Women in this study, an underrepresented population in published literature, face societal, cultural, organisational and individual barriers that affect different aspects of the perinatal pathway.

Background: During pregnancy and the postpartum period, women’s mental health can deteriorate quickly. Timely and easy access to services is critically important; however, little is known about the pathways women take to access services. Previous research has shown that women from ethnic minority groups in the United Kingdom experience more access issues compared to the White British women. Aim: To describe pathways taken to specialist community perinatal mental health services and explore how they vary across services and ethnic groups. Methods: This is a two-site, longitudinal retrospective service evaluation conducted in Birmingham and London during 6 months (1 July–31 December 2019). Electronic records of 228 women were accessed and data were extracted on help-seeking behaviour, referral process and the type of pathway (i.e. simple or complex). Data were collected using the adapted World Health Organization encounter form and analysed using uni- and multivariable analyses. Results: The median time from the start of perinatal mental illness to contact with perinatal mental health services was 20 weeks. The majority of patients accessed perinatal mental health services through primary care (69%) and their pathway was simple, that is they saw one service before perinatal mental health services (63%). The simple pathway was used as a proxy for accessible services. In Birmingham, compared to London, more referrals came from secondary care, more women were experiencing current deterioration in mental health, and more women followed a complex pathway. Despite differences between ethnic groups regarding type of pathway and duration of patient journey, there was no evidence of difference when models controlled for confounders such as clinical presentation, general characteristics and location. The service’s location was the strongest predictor of the type of pathway and duration of patient journey. Limitations: The heterogeneity among categorised ethnic groups; data extracted from available electronic records and not validated with patient’s own accounts of their pathways to care; unanalysed declined referrals; the study was conducted before the COVID-19 pandemic and pathways may be different in the post-COVID-19 period. Conclusion: The study provides important insights into how patients find their way to community perinatal mental health services. It shows that there is a great degree of variability in the time taken to get into these services, and the pathway taken. This variation does not come from different needs of patients or different clinical presentations but rather from service-level factors. Future work: The studied community perinatal mental health services in the United Kingdom operate with a significant degree of variability in the types and characteristics of patient pathways. Future research should explore these issues on the national and international levels. Additionally, future research should explore the reasons for the different pathways taken and the outcomes and risks associated with them. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14.

In times of crisis, such as public health emergency, military conflict or natural disaster, health systems face immense pressures. Large-scale crises continue to appear at irregular intervals and healthcare facilities should be prepared to react quickly and flexibly to the increased need for treatment and care. This paper aims to outline key concepts related to healthcare architecture during a mass-scale crisis, discuss challenges, and suggest solutions. Although the field lacks robust research evidence, lessons learned from past and ongoing events clearly indicate that advance planning is essential for effective crisis response. The crisis response has three guiding principles -adaptability, flexibility, and creativity. The interventions can focus on adapting existing healthcare facilities, building new units, and repurposing civil facilities for hospitals. A wide range of building typologies can be utilised, including modular containers, tents, lightweight structures, and repurposing civil buildings and public spaces. These interventions must be quick, economic, durable, and easily deployable. Temporary facilities must ensure an effective spatial platform for patients and staff, establish links with existing services, and consider post-crisis life of interventions. While these principles can be considered for any type of healthcare facility and any type of crisis, end-results will depend on baseline infrastructure and available resources.

People with psychosis have poorer physical health than the general population and this aspect of care delivery has largely been neglected. The IMPULSE trial (ISRCTN 11913964) investigated a psychosocial intervention prompting people with psychosis to discuss their physical health concerns with mental health clinicians. This mixed-method study explored a series of clinical meetings over 6 months to understand how physical health is discussed, what actions are taken, and if these translated into benefits for the participating individuals with psychosis. 221 individuals with psychosis were included, attending 847 clinical meetings over 6 months. Results show that, when prompted, most participants (54%) took up the opportunity to discuss their physical health at least once. These individuals were keen to make changes such as adopt healthy diet, stop smoking, lose weight, etc. Despite taking steps to achieve these goals, after 6 months no improvement was detected in subjective satisfaction with physical health, severity of physical health problems or satisfaction with services. Adopting healthier lifestyle behaviours is difficult even in motivated individuals. Future research is needed to determine innovative approaches to promote lifestyle change in individuals with psychosis.

Background: DIALOG+ is an evidence-based, generic, cost-saving and easily deliverable psychosocial intervention, adaptable to clinicians’ personal manner of interaction with patients. It was implemented in mental health services in five low- and middle-income countries in South-Eastern Europe during a 12-month randomised-controlled trial (IMPULSE) to improve the effectiveness of out-patient treatment for people with psychotic disorders. Aims: To investigate barriers and facilitators to the perceived sustainability of DIALOG+ that has been successfully implemented as a part of the IMPULSE project. Method: Three months after the IMPULSE trial's end, perceived sustainability of the DIALOG+ intervention was assessed via a short survey of clinicians and patients who took part in the trial. Quantitative data collected from the survey were analysed using descriptive statistics; content analysis assessed qualitative survey data. The views and experiences of key informants (patients, clinicians and healthcare policy influencers) regarding the sustainability and scale-up of DIALOG+ were further explored through semi-structured interviews. These data were explored using framework analysis. Results: Clinicians mostly appreciated the comprehensiveness of DIALOG+, and patients described DIALOG+ meetings as empowering and motivating. The barrier most commonly identified by key informants was availability of financial resources; the most important facilitators were the clinically relevant structure and comprehensiveness of the DIALOG+ intervention. Conclusions: Participants showed a willingness to sustain the implementation of DIALOG+. It is important to maintain collaboration with healthcare policy influencers to improve implementation of DIALOG+ across different levels of healthcare systems and ensure availability of resources for implementing psychosocial interventions such as DIALOG+.

Background: In Southeast Europe (SEE) standard treatment of patients with psychosis is largely based on pharmacotherapy with psychosocial interventions rarely available. DIALOG+ is a digital psychosocial intervention designed to make routine care therapeutically effective. This trial simultaneously examined effectiveness of DIALOG+ versus standard care on clinical and social outcomes (Aim 1) and explored intervention fidelity (Aim 2). Methods: A hybrid type II effectiveness–implementation, cluster-randomized trial was conducted in five SEE countries: Bosnia and Herzegovina, Kosovo*, Montenegro, North Macedonia, and Serbia. The intervention was offered to patients six times across 12 months instead of routine care. The outcomes were subjective quality of life (primary), clinical symptoms, satisfaction with services, and economic costs. Intervention fidelity was operationalized as adherence to the protocol in terms of frequency, duration, content, and coverage. Data were analyzed using multilevel regression. Results: A total of 81 clinicians and 468 patients with psychosis were randomized to DIALOG+ or standard care. The intervention was delivered with high fidelity. The average number of delivered sessions was 5.5 (SD = 2.3) across 12 months. Patients in the intervention arm had better quality of life (MANSA) at 6 months (p = 0.03). No difference was found for other outcomes at 6 months. Due to disruptions caused by the COVID-19 pandemic, 12-month data were not interpretable. Conclusions: DIALOG+ improved subjective quality of life of individuals with psychosis at 6 months (after four sessions), albeit with small effect size. The intervention has the potential to contribute to holistic care of patients with psychosis.