Preventing Deliberate Self Harm in Prison: Review of Methods

Published Date: 17 Apr 2018

Systematic review of the efficacy of methods of preventing deliberate self harm in prison

In delving into an examination of a ‘Systematic review of the efficacy of methods of preventing deliberate self-harm’ it is important to understand that the scope of the examination takes in a broad range of considerations, views and methodologies that are aligned with the main subject matter. Thus, having a clear understanding of what self-harm is represents a necessary facet in order to be able to determine the context within the scope of this examination. Hawton (1) states that “deliberate self-harm” entails “intentional self-positioning or self injury, irrespective of the apparent purpose of the act”. The most common forms, and or actions usually entail self-poisoning, overdosing on drugs, and the cutting of oneself (2). The preceding, self-harm, in a prison environment represents “a significant problem” that “requires the coordinated input of a number of agencies”, which includes “acute medical and psychiatric care (3)”.

The subject of deliberate self-harm represents a broad subject area that includes alcohol abuse, deliberate self-injury by means of cutting, and other techniques. It also entails drug use, starvation, and other means via which individuals seek to harm, and or damage themselves. Harrison and Sharman (4) advise that self-injury represents a manner in expressing deep distress as represented by the cutting, burning, or other injury to oneself. They continue that frequently individuals do not know, or understand why they inflict harm upon themselves, and add that it is frequently a means to communicate what one cannot put into either words or thoughts (4). Harrison and Sharman (4) indicate that self-harm can be described “as expressing an inner scream”, which after the harm has been inflicted, then individuals are frequently able to cope with life, for a period of time. The preceding is expressed by many studies and articles that self-harm and self-injury represents a broad set of acts that can, and does emanate from one not looking after their own needs from either an emotional and or physical standpoint (4). The infliction if self-injury can include cutting oneself, scratching, burning, hitting oneself, swallowing, and or putting harmful things inside one’s body, as well as the use of drugs to hide, and or mask distress, for escapism, and or relief (4). Self-harm also can include becoming involved in as well as staying in a relationship that is abusive, taking unneeded and unnecessary risks, eating disorders such as anorexia and bulimia, and as mentioned drugs, along with alcohol abuse (4). The preceding are manifestations of excess that almost all individuals exhibit in some limited form or another as also represented by overeating. Overwork is an illustration of the foregoing whereby one attempts and or tries to lose themselves in an activity as opposed to being alone with their thoughts, and or feelings (4).

The foregoing explanation of self-harm, and self-injury spans a broad range of descriptions, and has been utilized to draw attention to the depth of methods that a systematic review of the subject matter entails. In equating a ‘systematic review of the efficacy of methods for preventing deliberate self-harm in prison, it is critical to understand the terms utilized in the preceding title, focusing first on ‘efficacy’ as the core word defining the context. The Merriam-Webster online dictionary (5) defines ‘efficacy’ as “the power to produce an effect”. This definition is mirrored by Houghton Mifflin (6) that states it, efficacy, is the “power or capacity to produce a desired effect; effectiveness”. The foregoing represents a significant contribution to the understanding of the range this examination will cover in terms of its systematic review. The core of the problem represent identification, treatment, and follow up, which is referred to as interventions at varying stages in the process of uncovering and dealing with individuals exhibiting the traits, and or recorded histories of self-harm.

The primary objectives concerning intervention is to identify, and manage self-injurious behaviour, enacting where possible improvement in the individual’s mental state, behaviour patterns, and functioning over the short, medium and long term. The preceding is manifested by less than six weeks, six weeks to six months, and more than six months respectively. The typical manner in which the foregoing is handled in a prison environment is via:

1. the utilization of conventional as well as newer antipsychotic drugs,
2. use of non-pharmacological interventions as represented by dialectical behaviour therapy, and
3. the removal of identified individuals to safe cells whereby they can be placed under close observation.

The secondary objectives represent the determination of the invention(s) that might have a beneficial effect. Such also entails understanding the diagnosis of treatable illnesses as evidenced by:

1. severe depression episodes that include psychotic symptoms, as well as
2. post-schizophrenic depression, and
3. the diagnosis of individuals suffering from emotionally unstable disorders of the personality that are borderline

This examination shall delve into the understanding of self-harm, and self-injury as it relates to individuals that are incarcerated, along with treatments, evaluation of intervention methodologies, common treatments, strategies in treatment and the efficacy of the methods utilized in prevention of the condition of deliberate self-harm. Jackson and Waters (7) inform us that there is no singular method that provides the necessary scope to answer the broad array of questions concerning “… public health, health promotion problems and interventions”. They point to Pettigrew and Roberts (8) who advise that when the problem is known, then the types of studies to answer, and hone in on the problem can be deduced. The preceding thus sets the parameters for this examination concerning a ‘systematic review of the efficacy of methods of preventing deliberates self-harm in prison’.

Garner (9) advises that in general, “people who deliberately hurt themselves do so because they feel that they need to, and that the act itself makes them feel better for a while, and more able to cope”. She adds that “People report overwhelming feelings of misery, emotional distress and hopelessness which lead them to the apparent solution of inflicting pain on their bodies”, and thus harming themselves. For a great many individuals, the preceding, self-harm, represents the solution, but however, it is in the reality a facet of the problem that is unresolved within themselves (9).

Harrsion (10) advises that in the “strictest terms” Deliberate Self-Harm represents the general terminology describing activities that are self-damaging. The foregoing includes activities such as alcohol abuse along with bulimia to add to the other manifestations thus far mentioned. He also advises that Self-Injury makes more specific reference to the activities entailing the utilization of cutting, positioning, bruising, burning, and over-dosing with the intent of suicide as well as other activities directed at self-injury (10). In the preponderance of instances, it has been observed that the infliction of self-injury often means self-protection as opposed to self-destruction, representing a “way of copping … when things get really bad (11).” Bywaters and Rolfe (11) continue that “People deal with things in different ways and, unfortunately or not, this is my way”. The preceding is an important understanding in the issue, which is highly complex.

The phenomenon, deliberate self-harm, represents a subject that has, and is entailing “extensive sociological, epidemiological, psychological, biological and clinical study” along with research as well as speculation as to its causes, reasons and roots (12). Jackson (13) published a set of guidelines which added to the ‘Handbook’ that provide “a working framework to conduct a systematic review of health promotion or public health intervention” to be utilized in conjunction with other source materials in the conducting of reviews concerning health interventions. There are two types of ‘reviews’ referred to by Jackson (13), which consist of:

1. “traditional literature reviews/narrative reviews”, and
2. “systematic reviews (with or without) meta-analysis”

The first, “traditional literature reviews/narrative reviews” is generally conducted as well as interpreted by experts in the field utilizing “informal, unsystematic and subjective methods … which is often summarised subjectively and narratively” (13). Jackson (13) explains that such processes representing “searching, quality appraisal and data synthesis are not usually described and as such, they are prone to bias”. The advantage of the preceding is the participation by said experts “who may have a thorough knowledge of the research field”, however it is also pointed out that the disadvantage is represented by the fact that these individuals and or authors “may have preconceived notions or biases and may overestimate the value of some studies” (13).

In conducting a ‘systematic review’ of an individual with the condition of self-harm and self-injury, Jackson (13) defines the process as one that is “a review that is “very much driven”, in today’s terms, “by the evidence-based medicine movement”. She continues that a systematic review is thus defined as “a review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research” (13). She adds that said systematic review is utilized to “extract and analyse data from the studies that are included in the review”(13). A meta-analysis represents when two or more studies are combined statistically “to produce a single estimate of the effect of the health care intervention under consideration” (13). Jackson (13) cautions us that the preceding, a meta-analysis, represents simply the statistical combination concerning the result from the studies utilized, and that as such the final estimate concerning the effect might not necessarily represent the result found in the systematic review as done via the literature. Accordingly, the preceding should thus “not be considered as a type of review” (13).

The following represents a comparison of the varied types of reviews:

Table 1 – Different Types of Reviews, A Comparison (13)

Review	Characteristics	Uses	Limitations
Traditional Literature Review/ Narrative Review	Describes as well as appraises prior work, but does not describe the specific methods by which the reviewed studies were identified, selected and evaluated.	Overviews, discussions, critiques of prior work, and the current gaps that may exist in knowledge The preceding is often utilized as a rationale for new research. To gather and update on the types of interventions available to include in a review.	The writers assumptions and agenda are often unknown. Biases that occur in selecting and assessing the literature are unknown. Cannot be replicated.
Systematic Review	The scope of the review is identified in advance (eg review question and sub-questions and/or sub- group analysis to be undertaken) Comprehensive search to find all relevant studies. Use of explicit criteria to include / exclude studies. Application of established standards to critically appraise study quality. Explicit methods of extracting and Synthesising study findings.	Identifies, appraises and synthesises all available research that is relevant to a particular review question. Collates all that is known on a given topic and identifies the basis of that knowledge. Comprehensive report using explicit processes so that rationale, assumptions and methods are open to scrutiny by external parties. Can be replicated / updated	Systematic reviews with narrowly defined review questions provide specific answers to specific questions. Alternative questions that have not been answered usually need to be reconstructed by the reader.

The Department of Health, under its “Delivering the Future” guidelines concerning self-harm (14) state that in many instances, acts of self-harm are not connected with attempts to commit an act of suicide. It states that such may represent instead an attempt to either influence, and or secure aid and help from others as well as a means to obtain relief from what is an unpleasant, and or overwhelming emotional state and or situation (14).

Chapter 2 – Clinical Guidelines and Interventions

As advised by Jackson and Waters (7), there is no singular method that provides the scope of information, and or definitions to answer the broad array of questions concerning interventions. As indicated by Pettigrew and Roberts (8), the foregoing requires a determination of what the problem is as a means to select the types of studies and information needed to hone in on the problem so that answers can be deduced. Therefore, in order to reach a determination, and or closer approximation of the potential type, or types of intervention needed, a “preliminary scooping search” (7) represents a means aids in gaining familiarity with the type(s) in interventions. This entails utilizing the questions that are asked, and answered in the interview session as the basis for the preceding. Jackson and Waters (7) in referring to Popay et al (15), as well as Dixson-Woods and Fitzpatrick (16) argue “… qualitative research should have a role in systematic reviews”. Spenser et al (17), as cited in Jackson and Waters (7), advises that the purpose of qualitative research is to provide a deeper understanding of the experience that individuals have, along with their experience factors, histories and importantly, their perspectives within their individual settings, and circumstances in an attempt to glean why people behave in the manner they do. The preceding represents the attempt to understand behavioural patterns, and social actions.

In a study conducted in the United States representing a small group of just 21 adults that were receiving aid for deliberate self-harm, it was found that the most promising intervention methodology entailed ‘problem solving therapy’ (18). The preceding found that the most promising type of intervention entailed short-term problem solving therapy, that was cognitively oriented psychotherapy. The foregoing, as represented in five studies versus that standard aftercare indicated a trend that showed decreasing self-harm, with the treatment time varying among all five participants (18). In another set of interventions conducted that entailed twenty adults in each study group indicated a reduction concerning the repetition of self-harm incidents (18). The methodology utilized represented what is termed ‘dialectical behaviour therapy (DBT), which is a treatment program that is comprehensive, and was developed to see to individuals with severe dysfunctional problems. It also was designed to uncover those who exhibit borderline personality disorder along with recent incidents of deliberate self-harm (18). In addition, the study revealed that the “administration of antipsychotic flupenthixol” was shown to significantly reduce the percentage of repeated incidents of deliberate self-harm among individuals that had a prior history of at least two previous suicide attempts as opposed to testing the preceding on another trial group whereby a placebo was used (18). Hogg and Burke (19) advise that self-harm represents more in the attempt to relieve distress and or tension than anything else.

1. Clinical Guidelines

Nationally, in the United Kingdom, there are ‘clinical practice guidelines’ as represented by what are termed systematically developed statements developed to assist clinicians, and patients in making decisions concerning the appropriate treatment as represented by differing specific conditions (14). And while the aspects of conditions, circumstances, and related criteria differ in a prison environment, it is important to understand that there are national clinical practice guidelines in place that have some applicability. The preceding guidelines have been devised from available research, and evidence that utilized both predetermined as well as systematic methodologies for the identification, and evaluation of evidence concerning the varied specific conditions (14). In those instances whereby sufficient evidence is either lacking, or not compiled in meaningful numbers, and or conclusions, the guidelines incorporate recommendations as well as statements that have been based upon a consensus as arrived at by the development group responsible for the guidelines (14).

The National Institute for Clinical Excellence (20) approach the subject of intervention by stating that the management of self-harm calls for the utilisation of both primary as well as secondary care services in order to provide a complete assessment of the individual’s mental health as well as social needs, along with factors that precipitated the situation, and the factors of risk entailing future and further self-harm incidents. This approach is also supported by Green and Sinclair (21) who add that the appropriate treatment methodologies should be sensitive in terms of the differences that exist between patients exhibiting self-harm characteristics, therefore interventions must be mindful as well as acknowledge the diverse needs as represented by differing circumstances. Thomas and Faulkner (22) add that what is termed as “user led” evidence is increasingly being recognized in both policy making as well as research, and that perspectives of self-harm treatment following incidents should be investigated thoroughly to correlated findings to further establish care pattern guidelines based upon similar lines of historical facets. Such, however has not been the case, as present evidence relies strongly upon patient studies based upon preventing, and managing self-harm based on a medical perspective. The National Institute for Clinical Excellence (20) in its NICE guidelines, recommend that such a study should be implemented whereby qualitative methodology is applied in a rigorous fashion to examine user experiences, and results.

The utilization, and importance of clinical guidelines has been devised as a means via which to improve the outcomes along with processes for the treatment, and intervention of individuals demonstrating a tendency, and or actual history of self-harm and self-injury. It is important to understand that the reasons, and causes for self-harm as well as self-injury are not entirely understood, and that each case and instance represents its own unique set of causes, histories, backgrounds, and rationales. As such, the Department of Health in developing said guidelines has cautioned that the preceding does not represent a substitution for either clinical judgment, or professional knowledge (14). In addition, the guidelines indicate that they are not meant to replace, and or supercede the responsibility of qualified health professionals in their rendering of decisions with respect to their patients.

The purpose of the guidelines are to aid professionals in good practice points as well as recommendations for medical treatment, along with psychosocial ,and interventions, with the aims to (14):

1. reach an evaluation of the specific medical as well as surgical interventions undertaken during the first forty-eight hours following an episode
2. reach an evaluation, where possible, of risk assessment for the individual involved
3. make an evaluation of the utilization, and role concerning the psychological as well as pharmacological interventions utilized in said episode
4. reach an evaluation concerning the role as represented by service delivery systems, along with service-level interventions regarding the treatment and care of individuals who have committed self-harm acts
5. to integrate all of the preceding to reach a determination of best practice representing the care, and treatment of those persons whom have committed an act or acts of self-harm.

The following guidelines are intended to focus upon those individuals that have committed act(s) of self-harm representing an expression that demonstrates personal distress, along with those situations whereby an individual specifically intends to injure themselves (14). It should be noted that the prison systems fall under the guidelines of the NHS, and the guidelines are applicable to these types of situations as such falls under what are termed statutory services (14).

2. Guidelines

The HM Prison Service (23) set forth a “Prison Drug Treatment and Self-Harm” “to introduce new procedures…” devised to “minimize the risk of self-harm” from occurring as a result of “reaction to the stresses” associated with certain drug treatments. It further stated that compliance with the guidelines requires (23):

1. appropriate information sharing to ensure that proper treatments are being conducted as well as to gather database information on treatment effectiveness inventions.
2. That under ‘Mandatory Action’ That the Directors along with Governors ensure:

• That managers and staff in drug treatment positions are informed of the treatment guidance contents, and are following the prescribed outlines,
• That case history information shall be detailed, including prior drug treatment as well as mental state, and such provided to a CARAT team while the assessment is being conducted. The preceding is also to be shared with other intervention treatment programs to further the informational base of how differing case histories, and approaches fair in terms of effectiveness to build the historical base of improved interventions in the future.
• That prisoners under treatment are monitored for emotional as well as mental well being during the drug treatment process.
• That providers administering drug treatment must have familiarity concerning the ‘multi-disciplinary risk management process’, termed ACCT, or F2052SH, as well as invoking these procedures upon the identification of someone found as being at risk concerning self-harm, and or suicide.
• Lastly, drug treatment as administered by providers needs to actively promote as well as facilitate healthcare services access, along with the broad array of support services that are in prisons.

The national guidelines for prison treatment of self-harm and drugs, as set forth in “Prison Drug Treatment and Self-Harm” (23), advises that there are a number of important considerations which must be taken into account during the assessment of the potential utilization of treatment for individuals being treated for self-harm as well as the types of support needed. It advises that the management of the process for self-harm, and suicide represents a multi-disciplinary process that must include CARAT, ACCT, and or F2052SH in the risk management process after the identification of an individual with suicide, and or self-harm tendencies as well as a demonstrated history (23). The treatment of self-harm entails the inclusion of any and all prior treatment, and event histories that should be sought concerning the informational basis for the engagement of intervention (23). The intervention process needs to be cognizant of the individual’s prior treatment along with social, mental, and family problems as the concerns underlying the issue may lie in these areas.

The guidelines, and information as set forth under “Prison Drug Treatment and Self-Harm” (23) specify that the treatment programs as represented by CARATs, clinical services as well as Intensive Rehabilitation I are collectively the responsibility of the UK Prison system. CARAT represents the care coordinators for prisons with drug problems, and this agency maintains contact with each prisoner identified in their database. CARAT also maintains contact those instances whereby prisoners are transferred between institutions as well as treatment intervention transfers. Increased effectiveness under the shared informational context is seen as a result of the availability of prior history on prisoners, thus providing data on the path(s) taken, and the results achieved. The preceding also aids in the implementation of more effective intervention techniques. A mandatory facet of the guideline calls for the opening of an ACCT, and or F2052SH as soon as they are aware of an individual’s suicide, and or self-harm tendencies and or past actions (23).

Under the “Prison Drug Treatment and Self-Harm” (23), the former treatment, medical, and personal histories of individuals represent an important aspect in continuing as well as prescribing new treatment as it aids those in delivering care to build upon past information. Continuity of care is a vital facet in the setting forth of treatment and allied routines, and it also adds that the delivery of treatment, and intervention in isolation is unacceptable (23). Information with respect to the preceding historical aspects can be obtained by those administering treatment from (23):

• Oasys assessments,
• LIDS records that record prior episodes as contained in the ACCT or F2052SH database,
• Healthcare services

The “Prison Drug Treatment and Self-Harm” (23) document states that prisons need to ensure that a written as well as observed policy on the institution’s “substance misuse service” that covers the following (23):

• the clinical services that are provided as a result of healthcare,
• the guidelines for detoxification for opiates, alcohol as well as bebzodiazepines,
• that information representing assessment, the setting for treatment and overdose, along with essential observations are in keeping with the guidelines as set forth by the Department of Health,
• that the health care treatment has been and is being administered in accordance with CARAT drug care plans, as well as
• the fact that an NHS specialist is involved in the guideline preparations.

The foregoing procedural guidelines have been devised to reduce incidences associated with self-harm behaviour.

The use of drugs is also considered as a self-harm behavioural pattern. As such, clinical assessment concerning the misuse of substances represents an area definable through the first reception into the prison system as represented by initial medical examines as well as screening of the individual’s personal medical files, and sentencing records (23). The foregoing also applies to incidents of self-harm. Identified individuals that have self-harm, and drug use problems are thus referred for clinical misuse assessments (23). Under the “Prison Drug Treatment and Self-Harm” (23) guideline, prison systems have the responsibility to provide the appropriate settings for clinical interventions that permit unrestricted observation for patients that exhibit complex needs, with such observation available at all times (23).

The “Prison Drug Treatment and Self-Harm” (23) also provides for healthcare and CARAT teams to work jointly on protocols concerning the referral of individuals that exhibit self-harm risk as well as suicide, and other mental health facets. The preceding, protocols, require in addition to prison referral concerning the aforementioned to CARAT teams, that an ACCT, and or F2052SH must be opened concerning any case that has these symptoms (23). The CARAT assessment framework contains elements that are utilized to provide detailed information concerning individual records of treatment as well as health areas as such relates to self-harm. The following specifies the drug intervention record asks and or records the following under the:

A. Treatment Section (23):

• If the individual is presently receiving drug use treatments, under section 5.12

This aspect represents the opportunity to determine the type(s) of treatment administered to the prisoner, and whether such prior treatment records should be obtained.

• If the individual has had any drug use over the past two years, under section 5.13

Under this segment of questioning the CARAT worker should determine the type(s) of treatment the prisoner received, from the individual themselves as well as the treatment agency. Such data is useful in determining the treatment intervention(s) utilized and how such affected the prisoner, in addition to identifying if the individual had and or has any problems related to coping and related areas.

• Has the individual had any treatment for drug use in prison, under section 5.13

• Details representing prior treatment, help options and other relevant contact details, under section 5.15

B. Health Section (23):

• If the individual has any mental and or physical health issues, under section 6.2

Under this facet, the CARAT worker seeks information from various agencies as well as healthcare concerning if prior treatment has either caused, and or raised any problems that might contribute to the prisoner’s physical, and or mental health areas.

C. Disclosure Form (23):

• Informed Consent

Under the disclosure form, it is indicted clearly that the prisoner’s consent is not a requirement if the CARAT team thinks that the prisoner may be at the risk of committing self-harm. The consent form also permits that information can be shared between agencies, as well as disclosing the treatment the prisoner is receiving.

D. Referral Form (23):

• This form is devised to allow for any other relevant information, such as risk to the prisoner as well as others, access problems, and related areas, to be recorded as part of the assessment, thus resulting treatment formulation.

E. Comprehensive Substance Misuse Assessment (CSMA) (23):

Under the ‘National Treatment Agency Model of Care’, a Comprehensive Substance Misuse Assessment (CSMA), along with the preparation of a corresponding care plan must be concluded before the administration of drug treatment. However, the foregoing is noted as to potentially not being possible for those individuals whose stay inside the prison system is relatively short.

• History of Substance Abuse – Under section 1

Under this segment, the CARAT worker’s responsibility is to seek detailed information concerning the prisoner’s prior treatment through asking direct, and informed questions. In the exploration of the preceding, the CARAT worker needs to be mindful of as well as to take into consideration the processes utilised to achieve said outcomes as discovered through this exploration, and if any difficulties were a part of the process. Under this segment of the ‘National Treatment Agency Model of Care’, the CARAT worker is able to uncover in more detailed terms just how effective, responsive as well as challenging the prisoner finds the treatment process, and the resulting outcomes. This exploration helps to provide the worker with information that can be assessed in either a modification of the treatment process, and or continuation along the prior lines. The utilization of past prisoner files and records should be a part of the foregoing process, and if no prior treatment sessions where engaged, this process thus represents the starting point for the gathering of such data.

• Health, Under section 2

The CARAT worker, under this segment, establishes if there are any mental health, and dual diagnosis aspects. Particularly if there were, or are any circumstances, and or events that triggered feelings in this regard. Exploration should also be utilised to determine if the foregoing has had, or has been any help in aiding the patient once uncovered, and the impact that the preceding has, or may have had. Therefore, the thinking process engaged needs to be broader than simply clinical care. It also provides the worker with the opportunity to explore if a broader approach needs to be taken with regard to self-harm as well as mental health, and that this is followed up and shared with other agencies.

F. Rehabilitation Programmes (23):

• Under this aspect of treatment, no prisoner is to receive this type of referral unless that have had a Comprehensive Substance Misuse Assessment, and the programme providers will only accept prisoner referrals from a CARAT team. Within the Comprehensive Substance Misuse Assessment, the worker is to identify any and all prior difficulties the prisoner has had in engaging treatment. The worker also identifies if there are, or have been any self-harm concerns, and or actions/activities. The full record of the foregoing, along with other files is forwarded to the rehabilitation programme staff who familiarise themselves with this documentation prior to engaging in assessments.

• The programme participants should be provided with a clear guide to the support, and service mechanisms that are available while they are implementing the programme. In the course of the aforementioned it is made clear that no prisoner “should be made to feel” as if they cannot ask for and or seek help elsewhere.

• Each programme within the overall system has its own process for assessment, and represents exclusions that are referred to a separate process; “serious acute psychiatric morbidity” as well as “serious physical morbidly”

• The guidelines indicate that sessions within the programme that might be emotive should not be scheduled for Friday sessions as it is highly likely that the staff will be unavailable to provide support if needed during weekend periods.

• Peer support is an integral aspect of drug treatment programmes, however this facet should not be relied upon as a singular means of the support matrix.

G. Information Sharing and Care Co-ordination

The guidelines state that a co-ordinate CARAT plan is a requirement for drug treatment that should not be administered in isolation (23). One of the more important, and integral facets of the guidelines is how information is collected in relation to the prisoner’s prior drug treatment experience(s) along with self-harm identification, and mental health issues. One of the key aspects of the guidelines, and system in promoting more effective intervention and care is the sharing of case records and results whereby correlations concerning treatment, and outcome methodologies is gathered and thus can be referred to. The following represents guidance under “Prison Drug Treatment and Self-Harm” (23), concerning how the preceding should be achieved:

• Sharing of Information. Under the guidelines treatment services are to have confidentiality policies that are clear, and all prisoners are to be advised that information shall be kept as confidential. The foregoing applies even when information is shared with the other applicable services engaged in their care.

• In addition, all relevant information is required to be shared among other drug treatment providers after consent from the prisoner.

• The failure follow the guidelines on the consent to information disclosure represents a factor that could compromise the treatment assessment process, and the foregoing could lead to exclusion from the treatment modality. As a result of the preceding, the treatment providers thus retain the responsibility in terms of assessing offenders, their suitability, and as a result, the risks concerning inclusion.

The guidelines however, indicate that there are instances whereby information can, and will be shared without the consent of the prisoner, as well as in some instances without the knowledge of the prisoner. Such are represented by the obligation to reinforce care in situations that are life threatening. When a prisoner is at risk as a result of a life-threatening situation, such as self-harm, serious illness, and or injury, staff workers are required to open an ACCT Plan, and or F2052SH.

H. Care Co-ordination

• CARATs and Healthcare

The healthcare system represents a key referral source, especially in local prisons, thus making it important for these institutions to have the correct protocols in place. In addition they are to maintain an effective working relationship between the healthcare system and CARATs. The guidelines representing information sharing, and exchange is stressed throughout all areas of the guidelines, rules and inter agency, and systems procedures.

• CARATs and Intensive Programmes

The preceding information sharing, and exchange is stressed in this aspect of the guidelines, stating if an individual is, and or has been referred to the in prison intensive treatment programme that it is the responsibility of CARAT to see that information is provided to the staff of the facility in charge of treatment and assessment. As stated under information sharing, said information is needed to administer care at the prisoner’s consent, when such condition, and or conditions are life threatening, in which case the consent of the prisoner is not needed.

3. Systematic Reviews

“Systematic Reviews of Health Promotion and Public Health Interventions” (7) represents guidelines concerning the conduct of primary research along with systematic reviews. Jackson in the 2004 “Guidelines for Systematic Reviews of Health Promotion and Public Health Interventions Taskforce: The challenges of systematically reviewing public health interventions” (13) indicate that in the conducting of systematic reviews concerning complex health promotion as well as public health interventions can be challenging” as a result of a number of reasons. In Jackson and Waters work of 2005, “Systematic Reviews of Health Promotion and Public Health Interventions” (7), they state that systematic reviews should seek to address the following two questions:

1. is the intervention effective, meaning, does it work, and
2. the reasons why it works (the intervention), which also includes or should include how it works.

Jackson and Waters work of 2005 has been set forth in the form of guidelines that present recommendations addressing the preceding Systematic Reviews of Health Promotion and Public Health Interventions” (7). The foregoing is broken down into twelve areas that consist of the background segment, and then the recommendations, with the suggestion that each of the recommendations should be considered in a review process.

As the most definitive source concerning this area, the references for this section are provided by Jackson and Waters (7), as their guidelines represent the standard. The following sets forth the aforementioned twelve areas:

1. Planning the Review

There is disagreement between clinical authors and public health authors in terms of the review scope, representing broad versus narrow questions, which Jackson and Waters (7) states is based upon the consideration of “population versus individual” perspectives represented by the two differing disciplines, clinical, versus public health. The recommendations set forth in this segment are intended to enhance the review process, as well as minimise overall concerns.

1. Advisory Groups

The utilization of advice from professionals in the field that bring a broad range of expertise, and experiences to the problem represents a process whereby a higher degree of end user information more often than not results. Jackson and Waters (7) advise that the beginning states of the review process are important as it tends to set the path, and or general direction the process will, and or does take, thus influencing the subsequent review as well as protocol. The advisory group’s focus needs to be cognizant of the priorities of the stakeholders, including relevant interventions, and outcomes along with populations upon which the preceding is drawn. Thus, the individuals drawn upon to form the advisory group should be based upon the consideration of the field, and fields of expertise needed as well as desired, and the relevance of the problem and circumstances.

1). Scope of the Review

In discussing the review process, Jackson and Waters (7) advise that factors such as represented by lumping, and or splitting the review question. Lumping represents when a broad array of interventions is considered, which opens the field to more possibilities. A split review addresses a narrow range of options concerning interventions and is faster than a lumping of the review question in terms of time. The downside of the foregoing is that split reviews provide options that are based upon a narrower field of choices (interventions). Jackson and Waters (7) tell us that the utilization of split reviews are more likely to be conducted in instances such as making immediate decisions regarding the relevance of policy as well as reviews that seek to delve into broad based questions.

2. Recommendations

1). Forming an Advisory Group

One of the first facets in this aspect is to understand the types of interventions to review. The preceding requires knowledge of present policy as well as practice.

• Establishing and Advisory Group

One of the first considerations in the formation of an Advisory Group is to include a broad array of both scientific as well as lay people who are familiar with the topic areas, policy, and stakeholder aspects. Jackson and Waters (7) indicate that the foregoing, Advisory Group, should include methodologists to aid in questions falling into this scope, as well as to broaden the overall view as well as expertise of the Group. The subject of the identification of priority topics represents a function of consultation with health professionals in differing country context to obtain a broad perspective on intervention facets to be considered. Jackson and Waters (7) recommends that the size of the Advisory Group should approximate six members whose expertise covers all areas and represents a manageable size.

• Development of Terms of Reference

This aspect represents ensuring clarity concerning the task(s) at hand, which might include the following:

• the making as well as refining of decisions concerning the scope of the review to be conducted in terms of its population, interventions, examination outcomes, and analysis of sub-group interests,
• formulation of background material(s) whereby the issues are described from differing perspectives,
• interpreting the review findings, and
• the design of a plan to disseminate the information to relevant groups

• Job Descriptions

This area represents clarifying Group areas to strengthen expectations for advisors and consumers as to the assignments and areas of responsibilities for Group members.

3. Key Review Decisions

The Group needs to clarify the types of interventions, settings, outcomes, and populations that the review will address as the foundation of the process.

1). Review Scope

Such entails basing this area on how the review results will be utilized. The review scope also is dependant in the amount of time that is available, and the volume of research to be generated as constraints to the process. After the scope of the review has been identified, the number of citations to be screened is also required as well as overall time estimations concerning the amount and volume of work to be gathered.

2). Populations, interventions and outcomes

Jackson and Waters (7) set forth that there are steps that need to be considered in terms of deciding on the participants, interventions, populations and outcomes for inclusion in a review. The following provides more detail in these areas:

• As a part of the process, consideration concerning the determination of whether or not there is value to be achieved through limiting the variables within the population, as represented by categories. The rationale for the preceding is that certain groups, such as street youths and problem drinkers might be under studied areas, and therefore differ from study populations usually utilized reviews in a number of important regards.

• The Handbook indicates that the use of qualitative research can add to review question framing, such as the selection of interventions as well as outcomes that are of interest to the participants.

• In framing the research, it is important to determine if “proximal/immediate, intermediate or distal outcomes” (7) shall represent measurements. For example, if just intermediate outcomes, such as blood sugar in individuals with diabetes, then the group needs to reach a determination concerning the strength of the linkage to distal outcomes that are more distant, such as cardiovascular disease.

2. Study Designs to Include (7)

Public health as well as health promotion represents areas that can be, and are evaluated via the utilization of a broad array of methodologies, therefore singular methods do not represent a means via which to provide answers concerning these two disciplines. As such, Jackson and Waters (7) indicate that the use of a preliminary scooping search aids in providing familiarity concerning study design types that might have preceded the area(s) of intervention. It is cautioned that the questions that form the review represent the criteria that are utilized to select the studies. Jackson and Waters (7) advise that the study design type(s) has bearing on the subsequent review phases, in particular, they mention “searching, quality assessment and analysis”.

1. Randomised Controlled Trials

Randomised Control Trials (RCT), are stated by Jackson and Waters (7) to represent a source that provides and effectiveness evidence event though the results of theses trials might have only limited applicability in generalised circumstances. A type of RCT termed as a Cluster, are the manner in which some interventions are determined (7).

2. Other Effectiveness Studies

Jackson and Waters (7) indicate that the best effectiveness evidence is provided by non-randomised trials that are controlled at the time the review is conducted. The preceding, via review, can help to provide an approximation concerning the size, as well as nature, and direction of the effects.

3. Role of Qualitative Research in Effectiveness Reviews (7)

Dixon-Woods and Fitzpatrick (24) have argued that qualitative research should have a role in the conduct of systematic reviews as it, qualitative research, provides a detailed understanding of experience factors, an individual’s history and perspectives, all in the context of their individual settings and circumstances (25). Qualitative research attempts to explain and understand why individuals behave and act in the way that they do, which aids in equating behavioural patterns and social action. The following illustrate the manner in which qualitative research makes a contribution:

1). It, qualitative research, helps to provide the context for the review question. For example, it aids in the selection of the intervention types, as well as the outcomes that are of interest to the participants. In the preceding manner, qualitative research is thus utilised to see that reviews do meet the needs of consumers.

2). Qualitative research aids in the uncovering of impeding factors concerning the intervention process, as represented by, for example, human as well as contextual factors.

3). It describes the background experience of the individuals that are participating in the intervention process.

4). It provides the participants in the intervention with outcomes of the evaluation that are subjective.

5). It helps in the understanding of the broad differences in terms of effects that exists across studies, groups and settings.

6). Qualitative research represents a means to determine as well as see the interconnecting linkages that exist between the needs of participants in subjective terms in conjunction with the interventions being evaluated. The foregoing can thus be utilized to aid in the development of modifying existing interventions and or develop new ones.

Jackson and Waters (7), advise that qualitative study methodology can consist of one and or more of the following elements:

• interviews, that are devised based upon the interests of the participants,
• focus groups,
• observations
• conversations, and
• video analysis

4. Recommendations

1). Jackson and Waters (7) Randomised Control Trials, including cluster Randomised Control Trials indicate that the foregoing, when they represent answers to either effectiveness, and or efficacy should thus be a part of the review process.

2). When Randomised Control Trials are not an available component, for whatever reason, political, and or ethical, they should not be utilized.

3). Jackson and Waters Randomised Control Trials advise that ‘Controlled Before and After Studies’ (CBA) measure outcome variables among the respondents that have participated in interventions and those individuals whom have not.

4). Interrupted Time Series (ITS) represent multiple observations that are taken over time that are interrupted by interventions. Jackson & Waters (7) provide the example of mass media campaigns as an example of interventions that ITS designs may evaluate.

5). The recommendations indicate that historical control and national trend comparisons might represent the only available evidence concerning the effectiveness and or effects of certain policies. When the preceding represent the only available sources, they should be considered in terms of inclusion in the review process.

3. Searching for Health Promotion and Public Health Literature

Studies representing interventions are important informational sources that should be considered in the review process through the search of a broad range of databases. Jackson and Waters (7) advise that potential difficulties in this regard, as a result of terminology that is consistently changing. Results in this facet are becoming a complex task of interpretation to correctly analyse the data. In addition to the preceding, Jackson and Waters (7) indicate that the studies and reports on qualitative studies may be dispersed in databases that are not familiar to the medical researchers, and thus indicate that CINAHL represents a good source in that this database use a methodological index system that describes the study design.

Making the overall situation even more complex is the fact that there is not total agreement concerning the best manner in which to identify studies. The ‘theory driven’ approach as the means to identify qualitative studies is presently seen as the preferred methodology over the ‘trials-type search’ as a result of it offering two means to sampling techniques:

• Diversity Approach

A represented by the word, diversity refers to differing population segments and as a part of the review process this aspect should be pre-defined in keeping with the focus.

• Saturation Approach

This means that new studies are included until the addition of another study does not add anything new to the review process. Thus saturation refers to data / information content.

1. Recommendations

Jackson and Waters (7) identify the following as search strategies to be utilised in the identification of both public health and health promotion studies:

• utilize text words as a primary source as the location of subject studies along the title lines of those representing the topic of the review study might represent a difficult search match.
• Allow for sufficient time for the development as well as testing of search strategies to ensure that relevant studies are captured in the technique utilised. Jackson and Waters (7) caution that the initial search strategies might need refinement in order produce the search results that yield studies relevant to the review.
• It is also advised that the utilisation of a librarian skilled in search strategies for database and journals be utilised to increase search effectiveness and completeness, as well as selection of the keywords.

Jackson and Waters (7) advise that additionally, studies can be also located through the application of study design filters, and the utilisation of the following sources and techniques:

• Internet, as represented by sourcing suitable organizations, governmental reports and those offered by health promotion services,
• Hands searching through journals

4. Quality Assessment

The large variety as well as number of studies in the public health and health promotion fields may make the task of assessing study quality a difficult proposition (7). As such, Jackson and Waters (7) indicate through citing Juni et al (26) and Moher et al (27) that the utilisation of methodological research has been utilized in terms of the identification of the quality of Randomised Controlled Trials that are associated bias. In terms of the preceding, there are three attributes that have been identified concerning dimensions of quality:

• concealment of allocation,
• blinding of participants, and
• procedures representing the dealing of individuals that withdraw from the study and in addition the loss of follow up in those participants that remain

Jackson and Waters (7) state that bias due to attrition as well as concealment are important facets, and that the binding of participants through to completion represents a difficult proposition to achieve. They add that binding participants through to completion in Randomised Controlled Trials is very difficult, thus it represents an important bias factor (7). Contamination resulting from contact between participants in a control group also represents another form of bias, and this can be minimised via the utilisation of cluster Randomised Controlled Trials. It is further added that other sources of bias that need to be minimised as well as understood, and thus controlled are data collection methods that suffer from validity and reliability that is substandard, with particular attention paid to outcomes whereby they are subjective (7).

1. Identification of the Strengths and Weaknesses of Studies Included in the Review

Another facet of consideration represents the manner in which the systematic review impacts upon the strengths as well as weaknesses of the studies utilised in the review. The following represents the methods entailing this area (7):

• ‘quality weighting’, which represents the allocation of more weight, or skew to the studies that are of higher methodological quality thereby extending less influence in the results to studies of poorer quality,
• ‘Quality thresholds’ which means that a subset of higher quality studies have a higher weighting in the review results,
• ‘sensitivity analysis’, is when the effects of the elimination of and or addition of lower quality studies are examined regarding their impact on results as well as conclusions.

2. Recommendations (7)

Bias can occur when studies of unequal quality are summarised together. As a result of the preceding, care needs to be taken to access the quality consistency in thus equating the evidence strength. Quality criteria can be examined as a basis for comparison through the Centre for Reviews and Dissemination Report Number 4 (7). That the review might be better served by also equating if the interventions under study meet quality standards as well. At present, there does not exist a singular checklist for the varied types of qualitative studies, thus a guideline for this area represents the following (7):

• methodology that is appropriate to the research question,
• the utilisation of what is termed as an explicit link to theory,
• aims as well as objectives that are clearly stated,
• clear context description,
• clear sample description,
• fieldwork methods clearly described,
• data analysis having some validation, and
• sufficient data included to support the review interpretation

5. Theoretical Framework

Interventions usually are based upon a particular theory, and it is pointed out in Oakley (28) that this factor is not likely to emerge if the review activity does not cross the problem, and outcome areas, thereby permitting interventions to be classified in accordance with their theoretical base. Relevant health promotional theories attempt to explain the following (7):

• individual behaviour
• interpersonal in