Community health workers play an important role in linking communities withformal health service providers, thereby improving access to and utilizationof health care. A novel cadre of community health workers known as villagehealth workers (VHWs) were recruited to create demand for maternal healthservices in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). Inthis study, we investigated the role of contextual factors and underlyingmechanisms motivating VHWs.We used realist evaluation to understand the impact of a multi-interventionmaternal and child health programme on VHW motivation using Anambra State asa case study. Initial working theories and logic maps were developed throughliterature review and stakeholder engagement; programme theories weredeveloped and tested using focus group discussions and in-depth interviewswith various stakeholder groups. Interview transcripts were analysed throughan integrated approach of Context, Mechanism and Outcomes (CMO)categorisation and connecting, and matching of patterns of CMOconfigurations. Motivation theories were used to explain factors thatinfluence VHW motivation. Explanatory configurations are reported in linewith RAMESES reporting standards.The performance of VHWs in the SURE-P maternal and child health programme waslinked to four main mechanisms of motivation: feelings of confidence, senseof identity or feeling of acceptance, feeling of happiness andhopefulness/expectation of valued outcome. These mechanisms were triggeredby interactions of programme-specific contexts and resources such astraining and supervision of VHWs by skilled health workers, provision offirst aid kits and uniforms, and payments of a monthly stipend. The monthlypayment was considered to be the most important motivational factor by VHWs.VHWs used a combination of innovative approaches to create demand formaternity services among pregnant women, and their performance wasinfluenced by health system factors such as organisational capacity andculture, and societal factors such as relationship with the community andcommunity support.This paper highlights important contextual factors and mechanisms for VHWmotivation that can be applied to other interventions that seek tostrengthen community engagement and demand creation in primary health care.Future research on how to sustain VHW motivation is also required. At times also referred to as lay health advisors, village health workers,community health aides and health extension workers, CHW provide basic public healthservices and health care including educating community members about health risks,promoting healthy behaviours or linking community members with providers at formalhealth care facilities. CHWs bridge community and formal health services, therebyincreasing communities’ access to services, especially for those living in rural orunderserved areas. Because CHWs reach community members at relatively low cost, they have beenproposed and deployed to achieve a wide range of disease prevention and healthsystem strengthening objectives, including in areas as diverse as maternal and child health (MCH), familyplanning, malaria control and environmental health.Community health workers (CHWs) are recognised as a promising component of integratedhealth systems and an important part of the frontline primary health care (PHC) team. Education, training, scope of work and employment status of CHWs vary acrosscountries and health programmes but a common characteristic is that CHWs often lacka professional health care certification. CHWs can range from volunteers working without material compensation to paidemployees, with other compensation mechanisms including periodic training stipends,financial incentives or preferential access to health care or microcredit. Irrespective of the potential contribution of CHW to advance universal healthcoverage, little is known about the factors determining their motivation in low- andmiddle-income countries (LMICs).As task-shifting is becoming more widely implemented, CHWs have an increasing numberof tasks added to their list of responsibilities. The maternal and child health (MCH) component (SURE-P/MCH) included therecruitment, training and deployment of midwives and a new cadre of CHWs known asvillage health workers (VHWs) to upgraded PHC centres, along with conditional cashtransfers (CCTs) for mothers completing a series of MCH services including fourantenatal care (ANC) visits, delivery in a PHC centre and postnatal care visit at 6 weeks VHWs were selected from their local communities, trained, supervised and paida monthly stipend of about US$60 per month to mobilise pregnant women, promote ANC,encourage facility delivery by a skilled birth attendant and promote postnatal carefor mothers and babies (family planning and immunisation). VHWs were also trained toprovide a limited set of preventive health services such as birth preparednesscounselling, health education, first aid for minor cuts and injuries, sanitation andhygiene education. VHWs had to be aged over 20 years, have a minimum of primary schooleducation, able to read and write in English (where obtainable), resident in thecommunity (preferably married), willing to serve in the community for at least2 years and, for the northern parts of the country, be female as they were morelikely to be acceptable in this Islam-dominated region. VHWs received an initial 1 week training and bi-annual refresher trainings.Prior to the commencement of VHWs activities, strong multi-level advocacy andsensitization were carried out at all levels, including in the communities.CHWs play a central role in Nigeria’s efforts to reduce maternal mortality. TheSubsidy Reinvestment and Empowerment Programme (SURE-P), launched in 2012, aimed toimprove the lives of vulnerable populations using funds accrued from removal ofpetroleum subsidies. Understanding the factors that motivate CHWs to perform their roles is asimportant to sustainability and this study seeks to contribute to this knowledge byexamining the contextual factors and the mechanisms through which CHWs are motivatedto perform their roles in the SURE-P/MHC programme.The SURE-P programme’s deployment of VHWs aligns with the global drive to use lowercadres of skilled and unskilled workers to optimize access to and efficiency ofuniversal health care provision and accelerate achievement of the SDGs. a theory-driven evaluation approach that builds, tests, validates and refinestheories, with a specific focus on VHW motivation. Realist evaluation provides ameans to understand the resources or opportunities presented by a given interventionthat enable actors  to make it work. The projected effectiveness of an intervention is described inContext-Mechanism-Outcome (C-M-O) configurations, including explanation(s) of (i)why intervention outcomes turned out as they did and (ii) how the intervention/sresponded to underlying mechanisms and in what contexts.The study formed part of a larger project that evaluated the impacts of theSURE-P/MCH programme using realist evaluation,15Motivational factors can be intrinsic or extrinsic to the individual whereasfactors linked to job dissatisfaction (i.e. hygiene factors) are contextual andextrinsic to the individual. The theory stipulates that improving motivationalfactors increases job satisfaction while of hygiene factors decrease jobdissatisfaction. Vroom’s expectancy theory is a process theory which focuses onoutcomes, defined as an action-outcome estimate. People choose their behaviours(effort level) based on their perceptions of whether the behaviour is likely tolead to valued outcomes. Vroom introduced the concepts of expectancy (increased effort will leadto increased results), instrumentality  and valence .We drew on Herzberg’s two-factor theory and Vroom’s expectancy theory tounderstand how VHWs were motivated to carry out their duties, and the (group of)factors acting at macro, meso and micro levels that influenced their motivation.Herzberg’s two-factor theory considers motivational factors that lead to job‘satisfaction’  and hygiene factorsthat cause job ‘dissatisfaction’ when they are absent . We first developed an initial working theory based on a CMOconfiguration: In a context where pregnant women are incentivised  to access MCH care and where VHWsare trained, paid a regular stipend and provided with resources (VHW kits)to enable them to sensitise and mobilise pregnant women and support them toaccess facilities (C), these VHWs will feel more recognised by communitiesand will be motivated to encourage and accompany pregnant women tofacilities for MCH services (M). This will contribute towards increased andsustained utilisation of MCH services by the pregnant women (O). Inthe second step, we used information from 16 in-depth interviews (IDIs) and 32focus group discussions (FGDs) to build an initial programme theory for VHWmotivation. Finally, the initial programme theory on VHWs was tested and refinedalongside the CMO configurations developed in steps 1 and 2 above, usinginformation from nine IDIs.The evaluation was carried out in Anambra State, one of the 36 states in Nigeria,with a population of about 4.1 million and a mix of urban and rural areas.Maternal and child health services are primarily accessed from PHC facilities,each of which covering a given catchment population. The SURE-P intervention wasfirst implemented in 12 PHC facilities, with another 12 facilities included in asecond phase of the intervention. In this paper, we only report on first phasehealth facilities as they had a longer experience of the programme. The realistevaluation comprised three interrelated steps.Focus group discussions were conducted with all VHWs in eight first phasefacilities. FGDs were also conducted with service users, their family membersand representatives of ward development committees (WDC) in eight first phasefacilities.In step 2, we additionally carried out IDIs with six health facility managers andten health facility workers, followed by IDIs with nine VHWs in step 3 to allowfor in-depth exploration of identified themes identified in step 2, in which allthe VHWs participated. The IDIs focused on the factors that motivated the VHWsto carry out their duties, and how and in what combinations (if any) thesefactors worked to trigger mechanisms. We then used this information to develop aC-M-O template which consolidated patterns of explanations.Study participants were provided with a study information sheet and those thatexpressed a willingness to participate were invited to a PHC centre or to thevillage hall, depending of their preference, for the interview. Interviews wereconducted by three pairs of qualitative researchers who had received training inrealist interviewing, with each lasting 45–60 minutes. Data collection tools forthis study are presented in the Online supplement.  Varying explanatory configurations identified from the data are reportedin line with the Realist And Meta‐narrative Evidence Syntheses EvolvingStandards II (RAMESES).Data were analysed using a realist reduction approach consisting of iterations ofinductive and deductive analysis. The analysis was performed by four authors, one of whom is skilled and experienced in realistevaluation. Analysis was guided by our overarching theory which centres on thepresence or absence of resources given (by the programme) and/or existingresources and how the VHWs interacted with these resources to produce behaviourswhich manifested in their actions.Interviews were transcribed verbatim and each transcript was read by tworesearchers to identify themes and sort them into context, mechanisms andoutcomes. Identified themes were compared and synthesised across transcripts,using the CMO categories. This was followed by connecting and matching patternsof CMO configurations across transcripts to determine how the causal mechanismsplayed out and produced similar or distinct outcomes. Step 2 interviews wereused to build and record initial relationships and linkages between contexts(resources), mechanisms and outcomes, and to generate proposed CMOconfigurations. Then, step 3 interviews were used to explore the proposed CMOconfigurations; that is, the effect of context, the proposed enabling mechanismsand the extent to which the outcomes had been achieved or not, and if not,why.Ethical approval was granted by the School of Medicine Research Ethics Committeeat the Faculty of Medicine and Health at the University of Leeds (ref:SoMREC/14/097) and the Health Research Ethics Committee at the University ofNigeria Teaching Hospital (ref: NHREC/05/02/2008B-FWA00002458-1RB00002323).Respondents were informed about the purpose of the study and their roles andrights as participants. Voluntary written consent was obtained from all theparticipants prior to the interviews.Four distinct mechanisms of VHW motivation were identified: (i) feelings ofconfidence and expectation of good performance, (ii) sense of identity or feeling ofacceptance, (iii) feeling of happiness and (iv) hopefulness/expectation of valuedoutcome. The following presents these mechanisms, with illustrative quotes fromparticipants, as well as identified contextual enablers and constraints. VHWs viewed the training and supervision that they had received during SURE-P ina very positive light. All VHWs mentioned that the trainings had equipped themwith the knowledge they required to offer counselling and health education topregnant women and caregivers of children under 5 years, and strengthened theirskills in mobilising these women and their spouses, where necessary.Supervision, provided by health facility staff and the state programmecoordinators, was perceived by many VHWs to have contributed to ensuring thatthey adhered to practice guidelines and standards which they were provided withduring the training. Some VHWs also noted that the kits they were given equippedthem with the necessary materials to provide first aid care to communitymembers. The activities gave VHWs a feeling of confidence and empowerment toperform assigned roles of creating demand for maternal health among pregnantwomen in the communities.In keeping with the expectancy variable of Vroom’s motivation theory, having beenequipped with the right material resources, the right knowledge and skills to dothe job, correct information about the job and supervisor’s support to get thejob done, VHWs were confident that their efforts at mobilising pregnant womenwould lead to increased demand for maternity services from PHC centres. As aconsequence, the VHWs used innovative approaches to create demand such asincorporating activities such as singing and dancing during mobilisationcampaigns.(C2F2VHW_P1)We received some polo (T-shirt) from SURE-P and an apron too thatdignified us such that we were addressed as ‘nurse’ (laughs). They gaveus a kit which we used whenever we were on our way to give a talk…… Whenwe kit-up we were respected in the communities.VHWs were provided with uniforms (crested T-shirts and aprons) whichdistinguished them from the rest of the community and elevated them to a statusof ‘health service provider’. Some VHWs, who had been engaged in deliveringcommunity-based health interventions in the past, did not have a uniform intheir previous role and they did not feel part of the human resource for health.The crested SURE-P uniform made VHWs feel integrated into and accepted as a partof the health workforce. This feeling of acceptance or belonging was furtherstrengthened by the supportive supervision the VHWs received from the formal andskilled health workers. Moreover, their apparel and association with PHCfacility staff earned them the respect of the community:This finding highlights that providing VHWs with a form of identification (e.g. auniform) made them feel accepted by other health workers and gave them a senseof dignity that enabled them perform their roles in the community.(VHW_C2F4)Whenever the alert [bank credit alert of monthly stipend] comes, it usedto give me joy. My husband would even encourage me on the work becausethe money was of high importance to us. (P2C2F1)It [monthly stipend] gave me the assurance that I am working. Becausewhen you are being paid for the job you do, you will be confident doingthe job, but when you are working without seeing the money, you will notbe happy doing the work. But when the money is there, you will put inmore effort doing the job because you are being paid and you are notworking in vain. The assurance of a monthly stipend was emphasised by all VHWs as an incentivethat produced great motivation. They saw this financial reward as a confirmationthat their work was viewed as valuable and this made them feel happy, worthy andwilling to put in the effort. Some VHWs reported that the monthly stipend gavethem some level of financial independence from their spouses, and increasedtheir decision-making ability in the home. For instance, they would not alwaysrequire spousal approval to purchase necessary food items in the home or seekhealth care that required payment of user fees. Some VHWs also reported thatthey were able to make future financial plans because the amount and timing ofpayment of stipend were predictable.(C2F2VHW_P2)We had a record that we document information concerning the number ofpeople that we brought and at the end of the month the record is takento the local government. So, it made us work extra hard and when we dobring people we get praised by the [facility manager]. She makescomments any month we persuaded lots of people and the comment wouldserve as encouragement to us. One of the components of VHW supervision during SURE-P was the use of logbooks inwhich clients’ data were recorded by VHWs, validated by health facility staffand monitored by a state-level supervisor who would provide commendations orcriticisms in the logbook based on number of pregnant women mobilised. VHWsstated that this encouraged them to introduce and use various innovativeapproaches to mobilise pregnant women and as they implemented them and observedpositive results from clients , the VHWs’ commitment to work increased and more pregnant women weremobilised. This motivation mechanism also aligns with the instrumentalityvariable of Vroom’s motivation theory. In addition to the tangible incentivesthat would accompany good performance, VHWs were aware of intangible outcomessuch as commendations/praise or criticisms.VHWs created demand for services among pregnant women, and continued awareness inthe community about free or subsidised maternal health services. They used acombination of approaches including repeated visits at various sites,involvement of male spouses, provision of side attractions during ANC visits,accompaniment of clients during ANC and delivery visits and advocating forclients’ rights. Their work was enabled or constrained by a range of meso-levelcontextual factors within and outside of the organisation, as well asinteractions between VHW incentives and other components of the SURE-P maternaland child health intervention.Meso-level contexts within the organisation includedorganisational capacity; organisational culture of team work, task sharing andcollegial support for colleagues; availability of skilled health facilitymanagers and health workers; and attitude of PHC staff to VHW clients womenreferred by VHWs.Organisational capacity. Working with a team of skilled healthworkers enabled VHWs learn how to identify complications in pregnancy, and howto recognise other health problems.Team work and collegial support. Community outreach was jointly planned and implemented by VHWs and PHCstaff. Some VHWs worked with CHEWs in the health facility and the community.This enabled task sharing and support for colleagues, with facility managersreported to be accommodating and approachable:(P2C1F1)We were divided into four, we had two sets, some went to two villages andwe went to the other two villages, that was how we covered the townthen… It [relationship with colleagues] helped me because when we wereworking with them, … It [referring to the support VHW received from PHCworker] made us to be friendlier. In fact, we were working as mother andchild, we worked well with them. I still have good relationship withthem up till now. Attitude of health facility staff. Facility managers and otherhealth facility staff were receptive and considerate of clients. They took goodcare of clients and this made the work of mobilising and referral easier forVHWs.Meso-level contexts outside the organisation refers to therelationship of VHWs to members of the community; community acceptance of VHWs;availability of resources such as security; means of transportation to remoteparts of the community.Citizenship and residency status in the community. Being anative of the village, or a member of religious and kindred groups facilitatedcontact with people for VHWs. Not being a permanent resident of the communitycould hinder access to people’s homes for another VHW, but this was offset byher being a native of the village.(P2C2F1)It [being a resident of the community] helped me because if I am avisitor, I wouldn’t know the places well, so being an XX person helpedme to know the places well. I know all the places in XX, then the personworking in YY knows about YY, that was how they picked one person eachfrom the six villages we have. Community acceptance of VHWs and community support. Communitiesrecommended trusted members to be selected as VHWs and because VHWs wereselected by their communities, they received the cooperation of communitymembers and were able to gain access to their homes to mobilise pregnant womento utilise maternity services in PHCs.(C1F1WDC_P5)We the WDC [ward development committee] we’re the ones that nominatedthem and we know their capability before nominating them. They are hardworking. They go into the villages and motivate pregnant women to cometo the health centres. Interactions with other components of SURE-P MCHinterventions included resources that enabled VHWs to encouragepregnant women to utilise available maternity services.Availability of midwives and CHEWs round the clock. VHWs foundit easier to encourage their clients to deliver in a PHC if there was assurancethat a skilled health worker would be available at all times. It was seen to beparticularly important to clients that a midwife or senior CHEW was present tomonitor and deliver their babies if they went into labour at night. SURE-Pensured that an adequate number of skilled health workers was present soallowing pregnant women to be confident to plan for PHC-based delivery.Provision of free mama kit to pregnant women. The mama kit was freely given to all pregnant women that attended ANC inSURE-P health facilities and contained essential materials for delivery and newborn care, including sanitary pads, receiving blanket, sanitary cord clips,antiseptic solution and cotton wool. These materials are usually purchased bypregnant women and add to the cost of delivery. The anticipation of receiving afree mama kit encouraged pregnant women to seek maternity care at the PHCs.Free ANC services and subsidised price of delivery. Similarly, as antenatal care services were free of charge and deliverywas highly subsidised, it was easier for VHW to encourage women to use theseservices. Also, women were less dependent on their spouses in deciding where todeliver. VHWs also found it easier to persuade men to permit their wives toutilise maternity services from PHCs because of the free or subsidised cost.Provision of conditional cash transfers (CCTs) to pregnant women. Some pregnant women in selected PHCs received CCTs to utilise maternityservices which also eased the work of VHWs in benefitting communities.Conversely, where CCTs were not provided, VHWs found it more difficult toencourage pregnant women to use PHCs. This was particularly the case where womenwere aware of CCTs being available in another community.This study provides important insights into how and under what circumstances villagehealth workers were motivated to mobilise pregnant women to utilise maternityservices offered in PHC centres in the context of implementing a maternal and childhealth programme in Nigeria. Our observation informed the development of atheoretical framework of CHW motivation, which is illustrated in VHWs in this study were motivated by a range of factors that we broadly refer to asincentives, including training, supervision, materials, crested aprons and a monthlystipend, as well as the outcome of ‘innovative’ approaches they used to mobilisewomen from communities. The interplay of these factors increased their confidence intheir ability to mobilise pregnant women, giving them a sense of identity andbelonging, and making them feel happy.20 Regularity and pattern of payment were important contributorsto CHWs’ decisions to stay or leave the job; the ability to make financial plans wasparticularly valued. Other work has demonstrated that lack of financial compensationfor CHWs led to attrition of CHWs, poor demand for MCH services and a reversal ofgains in MCH outcomes that are attributable to the work of CHWs.21Monetary incentives in the form of monthly stipends were seen as the greatestmotivation to work, creating a sense of achievement and a valued source of income on which they could depend on to support their households.Several studies on CHW motivation in LMICs highlight that monetary incentives arenecessary, and our study supports other work showing that CHWs value the financialindependence (and decision power) they gain from receiving financialcompensation.22 In this study, VHWs developed a sense of identity and feelingof acceptance from having a dedicated uniform, a VHW kit to enable the provision offirst aid, and supervision by skilled health workers. The importance CHWs attach tobeing identified and recognised or accepted in the community as part of healthworkforce is widely documented in literature.25 CHWs desire to contribute tohealth improvements in their communities and require related materials to supportthem in their work, and being able to distinguish them from lay community membersalso serves to reinforce CHW’s roles in community health programmes.25 The interplaybetween motivational factors of confidence, identity and acceptance suggest thatthese mechanisms are mutually reinforcing in improving performance of CHWs.Training and supervision are recognised motivating factors for CHWs because theyfacilitate learning, contribute to improvement in knowledge and skills, and boostconfidence. and receiving the support and encouragement of peers can be seen as adistinct form of recognition, in addition to other incentives.27 Some CHWsjoin community health programmes because they seek the social prestige associatedwith the health profession,24 and providing CHW with the appropriate tools increases theircredibility and value in the community, which could be a source to increasemotivation.20We additionally found that material incentives and supervision by skilled healthworkers made the VHWs feel accepted by formal health workers. Acceptance of thevalue, talents or capabilities and performance of CHWs by the health system is amotivating factor for CHWs,VHWs in our study used a range of innovative approaches to mobilise pregnant womenand so increase demand for formal maternity service. This finding aligns withVroom’s expectancy theory that links a person’s motivation to their efforts andperformance. VHWs were provided with the right resources and skills to mobilisepregnant women, and, with supervision and support from formal health workers, wereled to belief in their ability to perform well, and that if they did a good job,they would receive commendation and praise from their supervisors. This couldexplain their decision to try novel approaches to mobilise pregnant women in theircommunities. and we have identified the importance of teamwork, task sharing and collegialsupport in this context. Our findings also support work that has found that CHWs aremotivated when their peers and supervisors are supportive and encouraging, and that skilled health facility managers and health workers createopportunities for CHWs to acquire new knowledge and skills.We identified a range of additional factors that interacted with the motivatingfactors described above to enhance or, in the case of CCTs, make it more challengingfor VHWs to perform their tasks. Enabling factors included the availability ofskilled health workers in SURE-P, along with material resources (mama kits and CCTs)and free and subsidised maternity services. This highlights that VHWs require asupportive environment to perform well. Our study supports other work that hashighlighted the role of organisational capacity, culture and policies for healthworker motivation,24 In the SURE-P MCHintervention, VHWs recognised the need for their clients to be treated with dignityand respect by health facility staff, and they often accompanied clients to PHCs toensure this was done. We found that a positive attitude of PHC staff contributed toimproving the performance of VHWs and their motivation to refer clients to the PHC.We further show that VHWs’ residency status in the community and membership ofcommunity groups further enhanced their performance, along with community acceptanceand cooperation, which was guaranteed since all VHWs were recommended by theircommunities. Community acceptance, trust and support are critical for the success ofcommunity health worker programmes.Since CHWs interface between the community and the health system, the attitude ofhealth facility staff to clients and the relationship between CHWs and the communityaffect the performance of CHWs.With the withdrawal of funding for the SURE-P intervention, policymakers andprogramme managers must derive other means to sustain payment of CHWs, or else itwill be difficult to retain them in primary health care. Future studies could applychoice experiments to explore the combinations of monetary and non-monetaryincentives that are preferred by VHWs. Economic evaluation studies could be used toalso determine the most cost-effective combinations of monetary and non-monetaryincentives that can produce the expected performance.In this retrospective realist evaluation study, researchers contended with socialdesirability bias. In anticipation that the SURE-P MCH programme could bereactivated and VHWs reinstated, some respondents appeared to share informationthat they believed the research team expected to hear. The effect of this wasreduced by triangulation of data sources, namely by analysing data from VHWs,clients and health facility managers. With respect to external validity,although we achieved urban-rural geographic coverage, our theory was only testedin one state and this must be considered when interpreting our findings; furtherwork is required to understand the applicability of our findings to othersettings.This paper contributes knowledge on motivational factors for CHWs, and it providesnew insight into the patterns of motivational mechanisms of salaried CHWs. We foundthat CHWs are motivated by various combinations of monetary and non-monetaryincentives, and that they particularly value the monetary incentives. Monetarycompensation is necessary for the sustainability of CHW programmes. CHWs’performance was further influenced by health system factors such as organisationalcapacity and culture, and societal factors such as relationship with the communityand community support.


Adolescents of lower socio-economic status initiate smoking earlier and smoke more frequently than those of higher socio-economic status. Tobacco control policies, such as school tobacco policies, aim to reduce adolescent smoking, but their implementation has been found to vary greatly from one school to another. Such differences in the implementation might therefore contribute to social inequalities in smoking. This study examines whether school tobacco policies are implemented where they are most needed, and how this implementation according to needs has changed over time.Student  and staff surveys (n = 438) were conducted in 2013 and 2016 in 38 schools from six European cities in six countries. School tobacco policies were measured as a 10-point score taking into account their multidimensionality, and the perceptions of both students and staff. We used concentration curves and indices to measure the inequality in the implementation of these policies depending on the smoking prevalence and on adolescents’ socio-economic status.A concentration curve below the perfect equity line indicated a concentration of school tobacco policies where smoking prevalence was lower. Moreover, this inequality was larger in 2016 compared to 2013 (concentration indices of .038 in 2013 and .041 in 2016). On the contrary, a concentration curve overlaying the perfect equity line indicated no inequality in the implementation of these policies depending on adolescents’ socio-economic status (concentration indices of .016 in 2013 and -.013 in 2016).School tobacco policies have been developed to reduce adolescent smoking. They, however, seem to be less implemented in schools where they are most needed. This confirms that smoking prevention is still driven by the inverse prevention law. Next to evaluating the impact of such policies on smoking outcomes, research should also focus on their contribution to social inequalities in adolescent smoking.• School tobacco policies, developed to reduce adolescent smoking, might contribute to social inequalities in smoking.• School tobacco policies are less implemented where they are most needed.


This study shows how to improve PRL when using a limited number of personal identifiable information (PIIs) available in HES such as NHS number, DOB, Hospital Number, Gender and Postcode. The focus is on new approaches in categorisation of m-u probabilities for fields related to Postcode. In addition, a brief outline of our procedure to generate an appropriate training dataset will be presented as well as reasons for splitting HES dataset into single and multi-admissions, and proposed techniques to avoid computational cost.PIIs such as DOB and Postcode can be categorised in order to increase the number of potential comparison vectors which is necessary in order to deal with the multi-million size of the HES dataset. We propose a multinomial approach for comparison between postcodes both for agreement and disagreement case scenarios, based on geographical information and a similarity score resulting from a Probit model. In the absence of a `gold-standard' dataset, generating an appropriate training set is possible by combining two-way Deterministic Linkage (DL) and simple random sampling. Splitting HES into single and multi-admissions is recommended for reasons related to computational performance and demographic differences of the underlying population. Selection of the lower and upper thresholds regarding linkage weights can be done in a practical way by using conditional Normal mixture modelling, or more formally by using sampling techniques based on Fellegi-Sunter decision rule. We show how the latter can be further improved avoiding the computational cost by introducing appropriate mapping functions.We show the advantages of PRL over DL between Surveillance Laboratory Flu Data and HES. Preliminary results indicate an additional 10% of matches for < 1% expected false positives. EM convergence problems when treating missing values as separate outcome category will be discussed comparing results with the suggested re-normalisation approach in the bibliography.PRL between Laboratory Surveillance Data and Hospital Episode Statistics (HES) is a common practice and performed in a number of epidemiological studies conducted at Public Health England (PHE). Therefore, improving linkage will subsequently benefit those studies. Furthermore, this study proposes new approaches for Postcode comparison, and the utilisation of mapping functions to avoid the computational cost of the Fellegi-Sunter decision rule. These approaches could be used in a wide range of applications. Finally, we suggest a structural way of handling the HES dataset in order to achieve high efficiency and robustness of linkage.


A new patient safety policy, ‘Learning from Deaths’ (LfD), was implemented in2017 in National Health Service (NHS) organisations in England. This studyexamined how contextual factors influenced the implementation of LfD policyand the ability of the programme to achieve its goals.Semi-structured interviews were undertaken with key policymakers involved inthe development of the policy, along with interviews with managers andsenior clinicians in five NHS organisations responsible for implementing thepolicy at the local level. We also undertook non-participant observation ofrelevant meetings and documentary reviews of key organisation procedures andpolicies pertaining to LfD.The study findings suggest several factors that hinder or support patientsafety policy implementation at a local level. These include: (a) anorganisation’s capacity and capability to support data collation, analysisand synthesis, (b) the dissemination of the resulting information, (c) thelearning culture and hence perceptions of the purpose of LfD within anorganisation, and (d) the extent of engagement in cross-organisationalapproaches to learning.Extra and intra-organisational contextual factors influence all stages of thepolicy implementation process from preparation and tracking toimplementation support and review affecting its chances of success orfailure. Successful adoption of a national patient safety policy withinhealth care organisations can be informed by taking into consideration thosefactors. Factors shaping implementation are multifaceted, and policies created withlinearity in mind are often subject to adaptation.3 As a result,NHS provider organisations find themselves grappling with multiple, often changing,patient safety priorities, which may not always be well aligned with local goals oractivities. This may exacerbate the inherent tensions within policies and increasethe potential for negative impacts when implemented into diverse health careorganisations.4 Such policies are often not evaluated and so less is knownabout local implementation factors that hinder or enable a policy meet its intendedgoals.5 Local context is particularly influential, and aspects such asleadership, staff engagement and the availability of resources  may largely determine the extent of adoption of a policyat a local level.6The complexity of health care systems can impede effective policy design andimplementation. In the United Kingdom, the National Health Service (NHS) and theDepartment of Health and Social Care have often responded to health care crises byintroducing new national policy aimed at improving patient safety.7 A subsequent report publishedby the Care Quality Commission8  highlighted a fragmented approach to learningfrom deaths across the NHS. The concomitant findings from both reports opened a‘policy window’ facilitating the creation of a new policy framework,‘Learning from Deaths’, published by the NHS National Quality Board in early2017.10In 2015, the publication of an independent review into Southern Health  found that Southern Health investigated only 1% of unexpected deathsamongst patients with learning disabilities.9The policy recommended the adoption of systematic case sampling and review of patientdeaths, training of case record reviewers, and mechanisms for capturing andpublicising findings and subsequent actions. The policy also contained an ambitionthat NHS organisations pursue wider investigation and learning across organisationsand that approaches to dealing with families in the aftermath of deaths be improved.All acute, community and mental health NHS Trusts  were required to have these processes in place by September 2017 andthe adoption of the policy at a local level was to be monitored and assessed by theCare Quality Commission.10To increase the speed with which the policy was implemented, it was wrapped aroundseveral initiatives already in place such as the Learning Disabilities MortalityReview Programme (LeDeR), the National Mortality Case Record Review (NMCRR)programme and the Duty of Candour which were developed to increase transparency,accountability and learning in the NHS.In this study, we examine how contextual factors such as patient safety priorities,governance structures, resource allocation and activities at the organisation levelinfluenced the implementation of LfD policy and the ability of the programme toachieve its goals.n = 12) withpolicymakers. Using snowball sampling,11 the policymakersidentified other individuals involved in the development of LfD. Theseinterviews focussed on understanding the key drivers for the development of thepolicy, intended policy outcomes and likely challenges for implementation. Thefindings from these interviews have been published elsewhere.9The study was undertaken in two stages between July 2019 and August 2020. First,we conducted semi-structured interviews (n = 40) in five NHS Trusts. We purposively selected threeacute Trusts and two community/mental health Trusts for participation based ontheir stage of adoption of LfD (early and later adopters). These Trusts covereddistrict general hospitals, a large teaching hospital, and community and mentalhealth providers.The second stage involved semi-structured interviews with managers and clinicians. Each researcher reviewed two to threetranscripts from the Phase 2 data and themes were mapped against each goal.These were compared by the research team to create an initial coding frameworkwhich then progressed through several iterative stages until a final version ofthe framework was agreed upon. Around 50% of transcripts were coded by at leasttwo of the researchers to enhance data validation. Findings from interviews weretriangulated with meeting notes and document content. The research team heldregular meetings to determine the categorisation of data under goals.Our interviews and other data collection also enabled us to determine how the LfDprocess actually takes place at each Trust.12 Where quality of care concerns were raised at the screeningstage, records would be sent for further in-depth reviews by a senior clinicianusually not involved directly in the patient’s care. Other cases were alsoreviewed in depth if the death was judged to be unexpected (unanticipated orsudden) or conformed to LfD selection criteria.The mortality review process varied across the five Trusts, but generally caserecords of all deaths were screened by a senior clinician. In two of the acuteTrusts, screening was undertaken by a Medical Examiner (ME). This is a seniordoctor trained in the legal and clinical elements of death certificationprocesses, who performs ME duties outside of their usual clinicalwork.13 This blends traditional, clinical judgement with astandard format to examine the last episode of care prior to death. Subsequentlearning from reviews was then shared at the Directorate and/or organisationlevel.Further clinical in-depth reviews of records used methods such as StructuredJudgment Review (SJR).supplemental material S2.For more details, see online Across all Trusts, the programme successfully promoted extensive adoption ofsystematic screening and review of deaths. Case notes of each death werescreened for quality-of-care issues by a senior clinician. In the acute Trusts,at least 12% of deaths underwent a further in-depth review using the SJR processundertaken by a consultant not directly involved in the patient’s care. Mostinterviewees mentioned that screening and reviewing deaths was the moststraightforward element of the LfD programme to adopt, acknowledging thewidespread variability in performance in this area that existed previously.It has given structure to a process which had previously been ad hoc. DifferentTrusts did it in different ways. But, even within Trusts, you found thatdifferent departments did things differently…If you want to have a decentgovernance process by which you can learn properly, you have to have peopledoing things the same way, or at least delivering information the same way.(Senior manager)14 also felt the programmewas of less significance for them.Interviewees remarked that the implementation of LfD was rapid and top down,limiting the time and effort taken by Trusts to adapt the programme into theorganisation’s safety infrastructure, which, in some cases, resulted in parallelsystems for delivery. Some interviewees remarked that the CQC, in tracking thepolicy, primarily assessed whether an organisation met the goals of LfD, withless concern about how it was implemented. Community Mental Health Trusts(CMHTs) identified LfD as better suited to acute Trusts. That was because theyfelt the policy has an emphasis on reviewing the last episode of care ratherthan the longer care trajectories typical of patients under their care. AcuteTrusts with better performance on national bench-marking mortality indicators,such as the Hospital Standardised Mortality Ratio,Many interviewees remarked that enthused and engaged programme leaders  were instrumental in driving implementation. Clinical leaders provideda vision for integration of LfD at both strategic and operational levels, andpromoted mainstreaming of the programme. Leaders were able to galvanise Boardsupport and foster LfD alignment with other programmes with similar goals, suchas the ME programme or incident reporting system. This proved important inleveraging internal resources both in terms of new money for extra posts, andfor releasing consultants for SJRs or ME work. As one clinician said of thepeople who championed the programme at their Trust (referred to as ‘leads’):The Learning from Deaths lead is both very capable and enthusiastic and the leadME is again absolutely excellent and very committed to this initiative. You canalways tell when you talk to people whether they believe in something or whetherthey’re going through the motions. When you have people in charge that feel thatway, then that infiltrates the people they work with (Senior Clinician)We’ve worked quite closely with [a neighbouringTrust], in terms of looking at the medical examiner system, and theyshared some ideas about how to align the ME with learning from deaths.It’s been helpful because they were a pilot, they’re a well-oiledmachine…It’s been quite good having them down the road to learn from.(Senior clinician)Interviewees reported that progress in the early stages of implementation wassupported by peer collaboration facilitated by Academic Health Science Networks. This promoted inter-organisational sharing of bestpractice and feedback on different approaches to implementation. One respondentrecalled:I'm so supportive of [LfD]. But the fact [is],it came out of something that was fearful - that people were dying fromneedless deaths. And the focus initially was on what might have gonewrong, as opposed to all of the times that we get it right (Seniorclinician)Trusts were able to articulate clear benefits of the programme in improvingend-of-life care and bereavement services. However, some interviewees believedthat, overall, LfD was too reactive – problems were recognised but subsequentlearning was limited to a single department or clinical team, with lessconsideration for how learning may be relevant across the organisation.Furthermore, measures put in place to prevent an issue from reoccurring wereseldom assessed for impact. LfD also tended to draw more attention to relativelyinfrequent failures in care quality, which was seen as a barrier to stafflearning:Some interviewees suggested that their Trust had endeavoured to strike a balance,with learning from examples of good care, supplementing information from reviewsof deaths with family and carer feedback. For example, one Trust produced‘excellence’ reports from the collation of positive feedback from familymembers, which were shared with the Board resulting in teams being recognisedfor delivering good standards of care.There is a bigger process than Learningfrom Deaths in the organisation. And Learning from Deaths does not feellike it assimilates into the wider process, it feels like it standsalone. Occasionally, we will come up against it and occasionally we’lldovetail in neatly. (Senior manager)A prominent issue participants thought hindered the synthesis of organisationallearning was a lack of integration of information from mortality reviews withother sources of patient safety data, such as serious incident reports orcomplaints. Interviewees identified two key barriers to the integration ofinformation: (a) siloed information collation, analysis and learning and (b)limitations of IT systems to support data management. Trusts often relied onhuman integrators or committees (such as department-level safety committees) tocollate information from different safety databases and sources. However, inmany cases mortality data was siloed away from other sources of safetyinformation. For example, in acute Trusts, findings from mortality reviewstended to be primarily reported to the Mortality Review Group whose primaryfocus was on LfD alone:Without access to broader information inputs, interviewees acknowledged thatreviews of care quality issues remained narrowly scoped and over-focused onclose antecedents to poor care providing restricted analysis of safety issues.This led to a sense amongst some clinicians and managers that there was limitedvalue arising from the large numbers of mortality reviews being undertaken. InCMHTs, findings from mortality reviews were integrated into incident reportingpathways. This approach was one of the factors that supported the undertaking ofbroader thematic reviews or assessments of care pathways, combining data fromLfD with other relevant quality-of-care data and enabling the focus to movebeyond the last episode of care.Trusts reported developing several mechanisms to overcome silos and facilitateLfD across the organisation. These included staff who could cross boundaries,such as Learning Disability Nurses, who were successful in transferringinformation between services (learning disability services and acute care).Furthermore, joint Mortality and Morbidity meetings, which bring togetherdifferent specialities and professionals  to LfD, were seen as an important forum to foster learningacross different departments and clinical teams. The CMHTs’ thematic reviewswere also an important way of engaging the wider multi-disciplinary team inlearning together. Some Trusts had created a range of channels to communicatekey messages from LfD to frontline staff from learning seminars and workshops towritten materials.Some interviewees perceived the main purpose of LfD was assurance, regulation orperformance management, despite assertions within the policy that the goal waslearning and improvement. Participants attributed these views to the framing ofthe policy in the organisation and the nature of Board discussions arounddeaths, which varied across the Trusts. Participants at acute Trusts said thatwhen mortality was discussed at Board meetings, the emphasis tended to be on itsvalue as a bench-marking tool rather than for learning. Moreover, participantsperceived that acute Trust Boards were particularly concerned that unfavourablecomparisons could be made between organisations due to the annual LfDrequirement to publish information from the programme. Participants in Trustswhere the Non-Executive Director was actively engaged in LfD programme oversightsaid that this had resulted in more nuanced Board engagement, opening uppossibilities to discuss safety from a broader perspective.The initial process iswhen the consultants start getting asked all these questions, ‘Did youhave any concerns?’ So, when they start getting the challenges, it’sprobably a system they’ve not been used to. But I think most people knowthat if there’s a death, they will get a call. The team will get askedabout the care of the patient, ‘Were there any concerns? Could anythinghave been done?’ (Middle manager)Interviewees also mentioned the potential for LfD to promote a more open cultureamong senior clinicians in particular. This could happen where senior cliniciansbelieved leveraging combined elements of LfD and ME programmes could support aculture shift within Trusts, both by enhancing assurance, through independentscrutiny of case notes, and by improving transparency through creating morechannels for open dialogue with families and carers. Participants reported thatthe ME had fostered an acceptance amongst consultants of the external scrutinyof their care, particularly when the process was accompanied by reassurance thatthe purpose was learning and improvement:Broadly, many interviewees suggested that the LfD policy had resulted in improvedcommunication and engagement with bereaved relatives. This was via MEscontacting family members and discussing their experience of care, including anyconcerns they may have. Additionally, personalised bereavement support –including the offer of additional conversations about death certification,possible coronial involvement or updates on progress over concerns previouslyraised with the ME – was regarded as an important step in reducing requests forreviews of death and promoting early concern resolution.I think [MEs] actually really felt theconversation with the bereaved, which wasn’t happening previously, andwe have some sort of anecdotes and some attributes back from relativesabout what that conversation felt and looked like, so you know, againsome positivity around that. (Senior clinician)These improvements encouraged Trusts to develop open dialogue with families andto increasingly see families as partners in quality improvement with uniqueinsights to offer:However, participants acknowledged that more work needed to be done to involvefamilies in incident investigation, to improve integration of family feedbackwith other sources of safety data and to provide prompt feedback to familiesonce their concerns have been investigated.Ihave written to the Medical Directors and to the GPs to say Learningfrom Deaths would be much better if it was set within the system ratherthan within an organisation, because these cases are more complex thanactually just meeting once or twice a year…[We could] look at two caseswhere it worked and two cases where it didn’t, and what can we learn asorganisations. I’d find that much more useful than churning a hundredcases, which tell me it’s elderly people on end-of-life pathways.(Senior manager)Interviewees from acute Trusts encountered challenges in engaging withcross-organisational LfD processes. This was because of a lack of time andresources, and difficulty involving key partners, such as GPs:In contrast, CMHTs thought they had made good progress in cross-organisationalLfD. This was due to their experience working with other providers, such aslearning disabilities mortality reviews and vulnerable adult mortality reviews.Participants thought such forums encouraged organisations to share information,focussing on assessing care quality issues across a care pathway rather thanwithin a single organisation.This study has identified the key contextual barriers and enablers to implementationof LfD, providing insights into the contributory factors that may affect adoption ofpatient safety policies and their ability to meet key goals. The study findingssuggest that our sample of NHS Trusts have identified approaches to partiallyaddress these contextual factors in order to promote adoption.15 model of policy implementation recognises that adoption isinfluenced by the ambiguities and conflict in policy goals and their interpretation.Inevitably, LfD demonstrated ambiguity due to its multi-faceted ambition, but therewas less conflict in relation to the focus on reviewing deaths given the broadconsensus that learning from deaths was important and needed standardisation.The design of a policy has implications for the way in which it is implemented. TheLfD policy was rapidly formulated in response to a crisis, wrapped around severalexisting programmes with inherent tensions associated with its purpose , and targeted all types of NHS Trust.Matland’s16 We saw thisin our study, with enthusiastic clinicians often vital to the successful adoption ofLfD. The leaders’ roles included communication of a vision of how the new programmecan be integrated with current safety priorities, securing internal resources,bringing clarity in terms of the roles and responsibilities at different levels inthe organisation, and promoting ownership at the senior management level.Engaged local programme leaders are key to facilitating policy adoption. They act asmediators engaged in knowledge transfer, assessments of readiness, capacitybuilding, engaging senior clinicians and programme monitoring.17 CMHTs were more likely toengage members of the wider multi-disciplinary team in LfD implementation, which hasimplications for both sustainability and wider dissemination of learning. Moreover,an inter-professional approach to learning, reaching beyond specialty boundaries,promotes the potential for transfer of multi-factorial and nuanced information aboutthe quality of care across providers and services.18Internal and external cultural factors are potent influencers of any safetyprogramme’s reception within a health care organisation.19 A focus on comparative performance and reputation in someTrusts orientated their LfD programmes towards predominantly identifying failures ofcare. Participants thought such an approach had a disengaging impact on clinicalstaff, enhancing fears of stigma and blame. There were also examples of learningfrom care that had gone well. Such learning, especially when delivered withincurrent resource constraints is more likely to lead to sustainable change.20In some Trusts, a Non-Executive Director with intimate knowledge of LfD could changethe Board’s orientation and engagement in patient safety. This allowed for deeperunderstanding of safety issues and the opening up of broader perspectives while alsoplacing the Board in a better position to fulfil its key role of providing scrutinyand constructive challenge.21 Yet, wider learning was inhibited by a propensity forreactive, single-loop learning and failure to close feedback loops.22 Broaderapproaches to learning from safety incidents and deaths, through thematic reviews orassessments of care pathways, moving beyond narrowly focused investigations of thelast episode of care are more likely to identify whole-system problems andpriorities for action. Likewise, participants commented that although staff were nowbetter at gathering the perspective of bereaved families on quality of care, moreneeds to be done.Continued staff involvement in quality improvement programmes depends ondemonstration of the benefits of the programme to achieving shared goals such assafer healthcare. This requires an effective means of disseminating learning acrossthe organisation, rather than the data being siloed. LfD has seemingly bolsteredefforts to improve end-of-life care and bereavement services, which had previouslybeen identified as failing to reach key quality standards in manyorganisations.Finally, participants from acute Trusts identified a need for greatercross-institutional cooperation. For CMHTs this was a more natural approach, giventhe longer care trajectories of their service users and well-establishedcross-organisational relationships. Again, we see the role organisational cultureplays in policy implementation.23 The availability ofresources, managerial and clinical leadership, engagement of a range of health carestaff, and the culture within organisations are frequently cited as hindering orenabling implementation of quality and safety initiatives.24 As a consequence, policyimplementation is said to be the product of policy, people and places,25 with thelocal context often the overriding determinant. Indeed, Dixon-Woods et al. suggestthat quality and safety programmes are deemed to be working when a programmeexhibits dynamic properties, such as the development of tailored versions of theprogramme to fit a local context.26Many of the external and internal contextual factors we identified are known keycontributors to the successful implementation of a policy.27Our study provides some useful lessons that may have policy and practice implicationsfor the implementation of patient safety policy in health care organisations. Policypreparation requires a clarity of purpose, with clearly articulated goals andlimited scope for ambiguity and conflict. The elements of patient safety programmesmost likely to survive are those that have become integrated into the localinfrastructure and are seen as integral to delivery of strategic priorities forsafety improvement. Tracking the policy by piloting it first could be used toilluminate potential issues before rollout. Implementation support that strengthensexisting local level capacity and capability may address some of the contextualbarriers identified in this study. Additionally, policy implementation reviewthrough ongoing monitoring and evaluation provides an understanding of programmeevolution and the opportunity for adaption if intended goals are no longer beingmet.28 For example, the introduction of Patient Safety Specialists asstrategic leaders for safety in NHS organisations identifies a Trust individual withthe remit to provide support for programme leads, facilitate Board backing forsafety programme adoption and alignment and promote the shift to an open, learningculture.Furthermore, several current English NHS policy initiatives may contribute toaddressing some of the challenges health care organisations face in implementing andintegrating safety policies. Many of these are detailed in a new national patientsafety strategy.29 An ability to capture familyand carer insights would be valuable. In-depth, broader focused safetyinvestigations would provide greater opportunities for the identification ofeffective actions to improve patient safety. However, such an approach also requireshealth care organisations to prioritise those investigations judged most likely tohave the greatest impact.Intelligent digital systems that allow the management of patient safety data toensure its better use in supporting safety investigations are also required. Theseshould have the capacity to enable user-friendly data entry, the undertaking ofcomplex searches and data collation, and the broadening of access to data for awider range of frontline staff.This study had one major limitation: It involved only a small sample of NHSorganisations in England. Assessing the local level impact of the policy ischallenging given the variation in implementation approaches across the surveyedTrusts and the difficulty in attributing change or improvement in organisationperformance to a single patient safety policy. Nonetheless, some comparisonsacross the Trusts were made in terms of an organisation’s priorities,exemplified by the differing approaches of acute Trusts and CMHTs in theadoption of the policy.Given the complexity of health care systems and competing priorities, health carepolicy implementation is seldom straightforward. The organisations in this studyhave developed a number of approaches to leveraging the enablers and addressing thebarriers that affect implementation. Their experience can inform the development ofnational patient safety agendas, increasing the likelihood of successful adoption ofpolicy at a local level.Click here for additional data file.Supplemental Material for Understanding the factors influencing implementation ofa new national patient safety policy in England: Lessons from ‘learning fromdeaths’ by Mirza Lalani, Sarah Morgan, Anamika Basu, and Helen Hogan in Journalof Health Services Research & Policy


Emerging research on neuroplasticity processes in psychosis spectrum illnesses—from the synaptic to the macrocircuit levels—fill key gaps in our models of pathophysiology and open up important treatment considerations. In this selective narrative review, we focus on three themes, emphasizing alterations in spike-timing dependent and Hebbian plasticity that occur during adolescence, the critical period for prefrontal system development: (1) Experience-dependent dysplasticity in psychosis emerges from activity decorrelation within neuronal ensembles. (2) Plasticity processes operate bidirectionally: deleterious environmental and experiential inputs shape microcircuits. (3) Dysregulated plasticity processes interact across levels of scale and time and include compensatory mechanisms that have pathogenic importance. We present evidence that—given the centrality of progressive dysplastic changes, especially in prefrontal cortex—pharmacologic or neuromodulatory interventions will need to be supplemented by corrective learning experiences for the brain if we are to help people living with these illnesses to fully thrive. Over the years, many investigators have proposed that psychosis spectrum illnesses arise due to progressive changes in neural microcircuits that result in disturbances in experience-dependent plasticity and in the development of maladaptive cortical representational systems  plasticity mechanisms at both the microcircuit and systems level need to be distinguished from spike-timing dependent, homeostatic, and metaplasticity operations, for example Table . At the Experience-dependent dysplasticity in psychosis emerges from activity decorrelation within neuronal ensembles.Plasticity processes operate bidirectionally: Deleterious environmental and experiential inputs shape microcircuits.Dysregulated plasticity processes interact across levels of scale and time and include compensatory mechanisms that have pathogenic importance.In this selective narrative review, we focus on recent research findings related to three themes, emphasizing alterations in spike-timing dependent and Hebbian plasticity that occur during prefrontal system development:The evidence supporting each of these themes is indirect and relies on basic science experiments and computational modeling—we cannot directly assess microcircuit function in humans, while macrocircuit plasticity can only be inferred from neuroimaging evidence and TMS studies. However, each of these themes helps to integrate a disparate range of research findings while broadening our view of what it will take to develop effective restorative, preventive, and perhaps even curative interventions for individuals who are vulnerable to persistent psychosis. We present evidence that—given the centrality of progressive dysplastic changes, especially in prefrontal cortex—pharmacologic or neuromodulatory interventions will need to be supplemented by corrective learning experiences for the brain if we are to support individuals living with these illnesses to fully thrive.Dysplasticity mechanisms are often posited to originate from primary alterations in plasticity-relevant genes and/or gene expression , but theconverged at the neuronal ensemble level, both showing weaker neuronal coactivity patterns (attractor states) in the visual cortex at rest and during visual stimulation. These two different manipulations relevant to schizophrenia showed decorrelated neuronal ensemble firing rate patterns over time, such that fewer and shallower attractor states were visited by the network. Zick and Chafee studied NMDAR blockade in monkeys and a 22q11.2 microdeletion model in mice, and found that both manipulations showed decorrelated activity in prefrontal networks at a finer time scale, on the order of milliseconds, reducing the frequency of synchronous 0-lag spikes observed between pairs of simultaneously recorded prefrontal neurons ).Let us focus for a moment on this social dysfunction. Recent research in rodents indicates unequivocally that adolescence is a “sensitive period” for experience-dependent plasticity in social behavior . For exasocial deafferentation syndrome [Given this, we can view the progressive social and functional impairment that occurs during adolescence and early adulthood in more severe or persistent forms of the illness as a syndrome —a pathogsyndrome . At the Successful treatment in the early phases of psychosis requires not just medications to reduce striatal hyperdopaminergia, but keeping the individual engaged with family, friends, school, and work. A neuroplasticity-based perspective conceptualizes these activities as capitalizing on the critical period for the acquisition of social skills and functional autonomy and as preventing further maladaptive plastic changes in the brain’s cognitive and socio-affective capacities for participating in society. Relationship with peers is especially important and has been found to predict clinical recovery, though it is not always explicitly addressed in treatment programs .Current successful psychotherapies for psychosis spectrum illnesses teach stress-management skills and/or modify the beliefs, behaviors, and sense of self the individual forms around symptoms, especially during the critical developmental period for identity formation. Interventions focused on resilience, positive psychology, and social engagement all have a significant effect on the course of illness, self-stigma, and disability –104. EviFrom a neuroplasticity-based view, these treatments explicitly encourage the development of compensatory strengths-based cognitions, affects, behaviors, and sense of self that reduce stress and fear responses and that create new distributed macrocircuit configurations to competitively interfere with the aberrant perceptual and cognitive representations induced by psychosis. An especially important issue is when an individual’s self-representation becomes fused with the experience of psychosis—what we might call “lack of insight.” In the highly creative AVATAR therapy, patients select virtual avatars to represent their persecutory and derogatory hallucinations, and then engage in a progressive positive dialogue with the avatars via a therapist, to slowly modulate the intensity, negative valence, and significance of the hallucinations and “unfuse” from the aberrant perceptual experience .Animal experiments show unequivocally that enriched environments increase adaptive plasticity and improve neuronal response properties, thus increasing the capacity for ongoing learning. Likewise, psychotherapies that harness corrective environmental and experiential forces induce adaptive systems-level plastic changes that are enduring. CBT for psychosis strengthens the neural connectivity between higher-order cognitive systems and those involved in threat and salience, potentially facilitating reappraisal, and these effects endure at 6 months . CorticaImpaired social cognition is a hallmark feature of many forms of psychosis spectrum illness and is a critical determinant of motivated behavior and functioning , 112. A Impaired basic social cognition capacities—such as emotion recognition, eye-gaze detection, and auditory emotional prosody discrimination—are highly responsive to neuroplasticity-informed targeted cognitive training, as shown in a recent double-blind randomized multi-site trial . In secoThe PRIME app  is another creative approach to improving motivated behavior and social functioning in first episode individuals . Based oNMDAR-enhancing medication to improve microcircuit functioning and create the conditions for optimal learning.Non-invasive neuromodulation to prime prefrontal circuits before or during cognitive training (see ref. ).A course of well-defined cognitive and social cognitive training to drive adaptive plastic changes in brain circuits that support fundamental representational capacities.Evidence-based and user-centered digital tools to support involvement with peers, enhance motivation, and promote engagement with treatment and recovery.Evidence-based psychotherapeutic and psychosocial programs to provide higher-level corrective skills, strategies, and experiences. A special focus on social skills training—which is very effective but not yet systematically implemented—will be important, as will interventions to promote successful peer activities and romantic relationships as part of essential critical period experiences.The field is ready for a systematic neuroscience-informed treatment approach that is delivered as early as possible  anFor a complementary neurophysiologic intervention, Yamamuro et al.—based on their findings of the dysplastic effects in adults of “social deafferentiation” during the critical period in adolescent mice—proposed that chemogenetic or optogenetic stimulation of mPFC→pPVT neurons in adulthood paired with social interaction could rescue the dysplastic social network, restore its function, and reverse the sociability deficits caused by juvenile isolation. Similar macrocircuit targeting could be useful in a clinical population, raising the idea that mPFC might be an important neuromodulation target for people with psychosis spectrum illness, especially in early phases. For instance,  applied TMS activation of mPFC could be useful in enhancing social cognition, mood, motivation and adaptive engagement with treatment. TMS inhibition of mPFC could be useful for addressing the biasing effect of negative memory schemas, which probably play a role in clinical symptoms of defeatist beliefs and possibly also delusions. In a study of individuals with depression, TMS inhibition of mPFC resulted in a lower false recognition of negative critical lures, suggesting that such an approach is feasible [At the very least, one would hypothesize that combining social cognition training with feasible .in their future offspring, a finding with sobering implications for social determinants of psychosis risk [The timescales of the factors which operate on and affect plasticity processes range from milliseconds to hours, days, years, and even intergenerationally. In rat experiments, stressful postnatal experiences, for example, impair memory performance and hippocampal plasticity not just in the animals but sis risk –125. We A common exogenous factor that increases the risk for psychosis and affects the plasticity machinery is cannabis use. Miller et al. have recently shown, in a rat model, that adolescent THC exposure induces premature and irreversible pruning of dendritic spines, protracted atrophy of apical trees, and significant changes in the transcriptional patterns of pyramidal neurons . SpecifiStress, which is also related to the risk for psychosis, alters neuroplasticity operations in multiple complex ways via its effects on noradrenergic and dopaminergic neurotransmission and on the HPA axis  growth is delayed, with the net result being immature cortical circuitry . ChronicMicroglia respond to changes in neural activity by harnessing inflammatory signaling cascades to assemble, remodel, and eliminate synapses across the entire lifespan . IncreasIn sum, the brain retains a lifelong capacity to toggle back and forth between a less-plastic or more-plastic state as a function of PV interneuron function, PNN integrity, synaptic remodeling, and microglial activity—processes which are exquisitely sensitive to not just microcircuit E-I balance and neuronal activity levels, but also to early life events, exposures to substances such as cannabis, and the consequences of psychological stress such as altered neurohormonal activity and redox dysregulation , 141.Prolonged exposure to unstructured stimuli—unreliable or noisy sensory inputs—can have the same effect as deleterious rearing environments in terms of derailing the trajectory of critical period plasticity. For example, exposing juvenile rat pups to temporally modulated white noise produces a shorter than usual critical period for spectral tuning in the auditory cortex, while masking normal auditory inputs with continuous white noise keeps it open indefinitely . As noteWhat are the implications for psychosis spectrum illnesses? If the cortex is exhibiting E-I imbalance, manifesting prediction errors, and functioning as an unreliable or noisy sensory processor, this will result in a subtle degradation over time in the statistical structure and fidelity of sensory inputs and in the predictive machinery that resolves them; indeed, during the height of acute psychosis, such statistical structure and fidelity is entirely disrupted. This may toggle the prefrontal cortex into a state of heightened  plasticity. Abnormally elevated neuromodulatory function may compound this state. Similar to the aging brain, the result is not just cognitive impairment, but can include the development of compensatory neural system reorganization that is not always behaviorally adaptive . In adolConsistent with an abnormal state of immature plasticity, in a recent bioinformatics study of microarray datasets of schizophrenia and bipolar disorder, Smith et al. found a distinct cluster of 60% of psychosis spectrum individuals who showed a “hyperplasticity phenotype” in their functional plasticity transcriptomics. . The reIndividuals with schizophrenia also exhibit transcriptional immaturity of prefrontal cortex-expressed genes, such that the transcriptional patterns more closely resemble those of infants 1–5 years old than healthy adults . The expIn animal experiments, dysplasticity processes can affect discrete subregions/circuits across a cortical sector, depending on the nature of the abnormal sensory inputs . The samIt’s worth noting that dysregulation of critical period plasticity machinery is also likely in autism spectrum disorders (ASD), but earlier in life . Mouse mSmith et al.  also obs, and are associated with the severity of positive symptoms [A large body of work also shows a consistent pattern of differences in cortical connectivity and activity/excitability between very early and chronic phases of illness, moving from abnormally high to abnormally low. In early illness, patterns of brain-wide resting state functional hyperactivity and hyperconnectivity are observed, especially in the prefrontal cortex . Dysregsymptoms , 158; dusymptoms . These fWhat is not at all clear is whether this developmental picture of dysregulated hyperplasticity in adolescence followed by later hypoplasticity is the general rule, or if it reflects just a small piece of a complex picture of genetically-determined hyper/hypo plasticity imbalance that exists in different subgroups of people with psychosis. Certainly, the psychosis biotypes identified by the BSNIP consortium—and the fact that the biotypes hold true in first-degree relatives—suggest this latter model. Biotype 1 individuals manifest cortical hypoexcitability along with significant and widespread reductions in gray matter volume and poorer cognition and functioning , consistIf dysregulated or “hyperplastic” critical period processes are occurring in early phases of illness, they are happening concurrently with dynamic macro-scale structural brain changes that signal a devolving cortex, consistent with over-exuberant synaptic sculpting as the brain attempts to shape its representations to an environment with unreliable statistics and/or is responding to increased stress and inflammation. High-risk individuals who develop psychosis have greater rates of cortical atrophy and reductions in the fractional anisotropy of white matter than those who don’t over the one-year period prior to onset of illness , 162. InAfter the onset of psychosis, accelerated brain aging continues to be observed, particularly in the first few years. Changes include reduced white and gray matter volume  and chanacute symptom onset + elevated inflammatory processes + accelerated gray matter loss may represent a group of individuals who have rapidly entered a period of hyperexcitability-induced dysregulated plasticity and cortical failure, as compared to individuals with an insidious symptom onset with less acutely accelerated gray matter loss, who may be characterized by long-standing hypoplastic processes dating back to childhood or earlier  and on resting state fMRI data from individuals with schizophrenia and found that the experimental data were best accounted for by a single underlying parameter change: greater self-inhibition in excitatory pyramidal cells. However, they also found that this primary loss of synaptic gain on pyramidal cells appeared to be compensated for by a secondary downregulation of inhibitory interneurons, and that psychotic symptoms were the result of this secondary downregulation. performeA receptor availablility, suggesting a role for reduced inhibitory tone in this process [ have pos process .hyperconnectivity between thalamus and sensory cortices [Prefrontal disconnectivity, including prefrontal-thalamic disconnectivity, coexists with cortices , 177. Thcortices . Prefroncortices  employedcortices .Consistent with these ideas, in an MEG study of the encoding of speech sounds in people with schizophrenia, participants with schizophrenia did not show the normal correlation of task performance with task-induced high-gamma power in superior temporal gyrus that was observed in healthy subjects . Insteadincreased even further compared to the control group. Moreover, the increase in thalamo-temporal connectivity was positively associated with post-training gains in cognition. This suggests that training (or other corrective experiences) may sometimes harness a compensatory pathway to drive behavioral improvements, while in other instances, compensations may result in further functional or behavioral impairment.A deeper understanding of compensatory network changes is likely to be important for optimal treatment development.  has showwho do not develop psychosis spectrum illness, then what is protecting them? Can we deliberately harness these protective factors? Finally, the noisy/unreliable cortical dynamics and hypoplasticity seen in persistent psychosis, along with indices of accelerated brain aging, suggest that we may gain useful insights from considering senescence mechanisms in the brain as another window into the illness trajectory and avenue for intervention. For all of these questions, we need a better understanding of the reverberating interactions linking primary and downstream pathogenic processes to each other, to the brain’s plasticity responses, and to clinical symptoms, before we can create a precise map for the nature and timing of optimal interventions. But a few ideas are evident and either have an emerging evidence-base or are ripe for further investigation  anticholinergic burden. Other interventions include a therapeutic focus on adaptive social and cognitive stimulation and a vigorous approach to reducing obesity and improving nutrition; findings are coming to light on the associations among the traditional Western diet, dysbiosis, inflammation, and reduced neuroplasticity .In people with more persistent illness showing features of ongoing hypoplasticity, a wide range of pro-plasticity interventions will be important—to include not just cognitive and social-cognitive training and psychosocial therapies, but also physical exercise, which has a strong evidence-base but is not yet a primary focus of most treatment programs . AdditioThere appears to be a subgroup of individuals with a more acute onset and evidence of abruptly dysregulated plasticity, possibly including significant inflammatory signaling, oxidative stress, and consequent dysfunction in PV cells, devolving PNN integrity, and increased synaptic pruning that leads to progressively worse downstream cognitive effects . For theA number of near-term and long-term research questions and treatment implications emerge from the neuroplasticity lens we have used in this review. They range from actions which clinicians can implement immediately, such as reducing the use of anticholinergic medications as much as possible  and thouHigh-yield insights will come from basic science experiments that delineate: (1) How both exogenous and endogenous factors contribute to the dysregulation of prefrontal plasticity during adolescence; and, (2) How this process drives micro-circuit and macro-circuit changes related to hyperexcitability, impaired interneuron inhibition and PNN maturation, microglial activity, and subsequent hyperplastic/dysplastic changes in brain structure and connectivity. Computational models will need to account for the reverberating nature of aberrant plasticity processes that occur at all levels of the brain’s information processing hierarchy. Experimental work will need to probe the unique nature of plasticity changes that may occur in functionally distinct prefrontal circuits and the compensatory mechanisms that arise as a consequence. Well-designed basic science experiments that study perturbations in plasticity mechanisms at various levels of scale, supported by algorithmic and neurophysiological computational modeling that are applied to longitudinal human data, will help to shed light on these complex interacting processes.


Forensic psychiatry is a specialty of psychiatry primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders(MDOs) are often cared for in secure psychiatric environments or prisons. However, the organisation of these services differs greatly between countries due to different traditions and legal frameworks. Some countries, e. g., require absent or reduced criminal responsibility (at the time of the index offence) in order to enter forensic services while others determine access on the basis of current need for treatment. Numbers detained in forensic services also vary significantly as does length of stay, raising significant economic and ethical challenges. This talk will present different legal concepts determining admission to forensic-psychiatric services, data on length of stay as well as approaches to risk assessment and treatment in Europe.No significant relationships.