Understanding the lived experience of women before and after fistula repair: a qualitative study in Kenya

OBJECTIVE

To gain understanding of the first-hand experience of women prior to and following repair of a vaginal fistula, to determine the most effective support mechanisms.

DESIGN

Qualitative phenomenological study using a series of in-depth semi-structured interviews at two time points: prior to fistula repair and 6 months post-surgery. Data were analysed thematically.

SETTING

Three fistula clinics in three districts in Kenya.

POPULATION

A purposive sample of 16 women suffering with vaginal fistula who were seeking fistula repair.

METHODS

Thrity-two semi-structured interviews were conducted.

RESULTS

The two main themes represented the women's journeys from social isolation to social reintegration. Women felt euphoric following fistula repair, believing that a 'miracle' had occurred. However, the 'post-miracle phase' demonstrated that the social and psychological impact of fistula leaves scars that are not easily healed, even when fistula repair is successful.

CONCLUSION

Women's experiences of living with fistula have an impact beyond that which can be repaired solely by surgery. The findings from this study support the need for more active psychological assessment in the management of women with fistula, and the role of targeted psychological support in any package of care given in the post repair phase. The format of this support requires further study. Engagement by health professionals with the wider community could raise awareness of the causes of fistula, and provide support for significant others who may also be feeling vulnerable. It is likely that the collaborative efforts from health professionals and community members will provide the most effective support.

TWEETABLE ABSTRACT

Fistula surgery alone is insufficient for women's physical, social and psychological recovery.

Do habits always override intentions? Pitting unhealthy snacking habits against snack-avoidance intentions

Background

Habit is defined as a process whereby an impulse towards behaviour is automatically initiated upon encountering a setting in which the behaviour has been performed in the past. A central tenet of habit theory is that habit overrides intentional tendencies in directing behaviour, such that as habit strength increases, intention becomes less predictive of behaviour. Yet, evidence of this effect has been methodologically limited by modelling the impact of positively-correlated habits and intentions. This study sought to test the effect of habits for unhealthy snacking on the relationship between intentions to avoid unhealthy snacks and snack intake.

Methods

Methods were chosen to match those used in studies that have shown habit-intention interactions. 239 adults completed valid and reliable measures of habitual snacking and intention to avoid snacking at baseline, and a self-report measure of snack intake two weeks later. Data were analysed using multiple regression.

Results

While both habit and intention independently predicted snack intake, no interaction between habit and intention was found.

Conclusions

No support was found for the expected moderating impact of habit on the intention-behaviour relationship, indicating that individuals with intentions can act on those intentions despite having habits. Previous evidence of a habit-intention interaction effect may be unreliable. A growing literature indicates that habitual tendencies can be inhibited, albeit with difficulty. Habits and intentions may vary in the influence they exert over discrete behaviour instances. While the aggregation of behaviours across instances and individuals used in our study reflects the dominant methodology in habit research, it precludes examination of effects of in-situ habits and intentions. More sophisticated data collection and analysis methods may be needed to better understand potential habit-intention interactions.

Electronic supplementary material

The online version of this article (doi:10.1186/s40359-015-0065-4) contains supplementary material, which is available to authorized users.

The Early Mobility Bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay

BACKGROUND

Early mobility facilitated by physiotherapy has been shown to reduce the incidence of hospital-acquired pneumonia (HAP) in patients with hip fractures but its effect on HAP incidence in medical patients has not yet been studied.

AIM

To determine whether early mobility aided by physiotherapy reduces the incidence of HAP and length of stay in patients on medical wards.

METHODS

One respiratory and one elderly care medicine ward in one hospital association in Birmingham, UK, received the 'Early Mobility Bundle'. The bundle consisted of extra targeted physiotherapy and collaboration with ward staff to encourage and promote activity. The incidence of HAP, falls, pressure sores, length of stay (LOS) and activity level were then compared to two matched wards within the same hospital association.

RESULTS

HAP incidence was significantly lower in the intervention group (P < 0.0001) and remained so after adjusting for confounders (P = 0.001). Activity levels were higher (P = 0.04) and patients' LOS was more likely to fall in the lowest quartile (OR: 1.44; P = 0.009) in the intervention group. There was no significant difference in other outcomes.

CONCLUSION

The Early Mobility Bundle demonstrates a promising method to reduce the incidence of HAP and to increase activity in medical inpatients.

Healthy feeding habits: efficacy results from a cluster-randomized, controlled exploratory trial of a novel, habit-based intervention with parents

BACKGROUND

As dietary gatekeepers for young children, parents are often the proximal target of family-based dietary interventions. Habit theory offers a novel approach to modifying parental feeding, based on "context-dependent repetition" to promote automatic responding and to reduce decisional conflict.

OBJECTIVE

This exploratory trial evaluated an intervention promoting habit formation for 3 parental feeding behaviors: serving fruit/vegetables, serving healthy snacks, and serving nonsweetened drinks. The primary outcome was parental habit strength for each behavior. The secondary outcome was children's food intake.

DESIGN

Parents of children aged 2-6 y (n = 126) were recruited from 6 children's centers in London and cluster-randomized to intervention (n = 3) or no-treatment control (n = 3) conditions. Parents in the intervention group (n = 58) received training on habit formation for 3 feeding behaviors; control participants (n = 68) were asked only to complete the measures. At baseline and after treatment, parents completed validated measures of subjective "automaticity" for feeding behaviors and a brief child food-frequency measure. Parents in the intervention group were interviewed about the program. The change between groups, after clustering was controlled for, was analyzed.

RESULTS

For all parental feeding behaviors, automaticity increased more in the intervention group than in the control group (P < 0.01 for all). Significant intervention effects on children's intake of vegetables (P = 0.003), healthy snacks (P = 0.009), and water (P = 0.032) were observed. Changes in children's food intake correlated with changes in parental automaticity of feeding behaviors, and program acceptability was high.

CONCLUSIONS

A habit-based intervention successfully modified parental feeding behaviors, affected children's diets positively, and was well received by parents. Habit theory provides a promising new tool to support family-based obesity prevention. This trial was registered as ISRCTN09910187.

Do mental health professionals enquire about childhood sexual abuse during routine mental health assessment in acute mental health settings? A substantive literature review

This literature review examines the extent to which mental health professionals enquire about childhood sexual abuse during routine mental health assessments in acute mental health settings. Five electronic databases were searched for papers which explored the nature of enquiry about childhood sexual abuse by mental health professionals. The literature was searched between December 2008 and March 2010, with an update in October 2011. Of the 332 papers identified, 54 papers were selected as potentially relevant and data extraction was performed. Eleven studies met the inclusion criteria. Eleven studies were identified that either examined the prevalence of childhood sexual abuse enquiry documented in medical records, or directly asked mental health professionals about their own practice in relation to this subject. The studies found that while many professionals acknowledged the importance of enquiry, there was little evidence of widespread routine enquiry during mental health assessments in acute settings. Mental health professionals do not routinely enquire about childhood sexual abuse during mental health assessment in acute mental health settings. Service providers may have to consider incorporating mandatory enquiry into mental health assessments.

How, when and why do young women use nutrition information on food labels? A qualitative analysis

BACKGROUND

Nutrition information (NI) on food packaging offers a public health tool that could be used to promote informed consumer choice and aid consumption of a healthy diet. Research indicates that the use of NI can lead to reduced energy intake and lower BMI, but little evidence is available regarding how, when or why people use NI when making everyday food choices.

METHODS

This qualitative study explored motivations and contexts surrounding the use of NI among 25 UK-based female NI users aged 23-35 years, using semi-structured individual interviews. Verbatim transcripts were analysed using thematic analysis.

RESULTS

Six themes were identified: (1) understanding and (2) functions of NI, (3) health versus appearance motives, NI use in (4) affective and (5) symbolic food episodes, and (6) competing point-of-purchase influences. Notable observations included a difficulty in understanding and converting NI into personally meaningful terms, and eschewal of NI in settings where food plays an affective or symbolic role (e.g. food consumption after a stressful day, buying food for a dinner party).

CONCLUSIONS

We suggest evidence-based directions for future research and offer policy and practice recommendations, including the adoption of clear and consistent NI formats.

Circulating DBP level and prognosis in operated lung cancer: an exploration of pathophysiology

Vitamin D stimulates transcription of antiangiogenic and apoptotic factors that may suppress tumours, while vitamin D binding protein (DBP) may be a biomarker in murine lung cancer models. We sought to ascertain whether the vitamin D axis is altered in lung cancer or influences prognosis. 148 lung cancer patients, 68 other intrathoracic cancer patients and 33 noncancer controls were studied for up to 5 yrs. Circulating DBP and vitamin D levels were compared between groups and their effect on survival assessed by Cox regression analysis. Expression of DBP and vitamin D receptor (VDR) was examined in lung cancer cell lines and in normal and tumour lung tissue by Western blot and immunohistochemistry. Low serum DBP levels predicted lung cancer-specific death (p=0.04), and DBP was poorly expressed in lung cancer cells on Western blot and immunohistochemistry. Vitamin D did not predict cancer survival and VDR expression was variable in tumours. Preservation of serum DBP is a significant independent factor associated with better cancer outcome in operated lung cancer patients. Given the established role of DBP in macrophage activation and clearance of abnormal cells, further study on its involvement in lung cancer is merited.

Characteristics of family mealtimes affecting children's vegetable consumption and liking

Research has documented an association between family mealtimes and higher dietary quality in school-aged children and adolescents. However, there is little understanding of the specific characteristics of mealtimes that are beneficial and a lack of research with preschool-aged children. This cross-sectional study conducted in the United Kingdom in 2008 examined associations between mealtime characteristics and preschoolers' vegetable consumption and liking. Four hundred and thirty-four primary caregivers of children aged 2 to 5 years reported on children's vegetable intake and liking and completed a questionnaire on frequency of family meals, food preparation, and the social and environmental context of family mealtimes. Univariate and multiple linear regression analyses assessed mealtime variables and children's vegetable intake and liking. Multiple regression analysis revealed children's vegetable consumption was predicted by eating approximately the same food as their parents (β=.14; P ≤ 0.01), using ready-made sauces (β=-.12; P ≤ 0.05), and cooking from scratch (β=.11; P ≤ 0.05), accounting for 21% of the variance (with covariates). Children's liking for vegetables was predicted by eating approximately the same food as their parents (β=.15; P ≤ 0.01) and use of preprepared dishes (β=-.15; P ≤ 0.01), accounting for 8% of the variance (with covariates). Frequency of family mealtimes was unrelated to children's vegetable consumption or liking in this sample. This contrasts with findings in older children and adolescents, where frequency of family mealtimes is related to dietary quality and intake. In preschool-aged children, it seems emphasis should be placed on encouraging parents to provide home-cooked meals that mirror those eaten by the adults in the family to improve vegetable intake.

Towards single embryo transfer? Modelling clinical outcomes of potential treatment choices using multiple data sources: predictive models and patient perspectives

BACKGROUND

In vitro fertilisation (IVF) treatments involve an egg retrieval process, fertilisation and culture of the resultant embryos in the laboratory, and the transfer of embryos back to the mother over one or more transfer cycles. The first transfer is usually of fresh embryos and the remainder may be cryopreserved for future frozen cycles. Most commonly in UK practice two embryos are transferred (double embryo transfer, DET). IVF techniques have led to an increase in the number of multiple births, carrying an increased risk of maternal and infant morbidity. The UK Human Fertilisation and Embryology Authority (HFEA) has adopted a multiple birth minimisation strategy. One way of achieving this would be by increased use of single embryo transfer (SET).

OBJECTIVES

To collate cohort data from treatment centres and the HFEA; to develop predictive models for live birth and twinning probabilities from fresh and frozen embryo transfers and predict outcomes from treatment scenarios; to understand patients' perspectives and use the modelling results to investigate the acceptability of twin reduction policies.

METHODS

A multidisciplinary approach was adopted, combining statistical modelling with qualitative exploration of patients' perspectives: interviews were conducted with 27 couples at various stages of IVF treatment at both UK NHS and private clinics; datasets were collated of over 90,000 patients from the HFEA registry and nearly 9000 patients from five clinics, both over the period 2000-5; models were developed to determine live birth and twin outcomes and predict the outcomes of policies for selecting patients for SET or DET in the fresh cycle following egg retrieval and fertilisation, and the predictions were used in simulations of treatments; two focus groups were convened, one NHS and one web based on a patient organisation's website, to present the results of the statistical analyses and explore potential treatment policies.

RESULTS

The statistical analysis revealed no characteristics that specifically predicted multiple birth outcomes beyond those that predicted treatment success. In the fresh transfer following egg retrieval, SET would lead to a reduction of approximately one-third in the live birth probability compared with DET, a result consistent with the limited data from clinical trials. From the population or clinic perspective, selection of patients based on prognostic indicators might mitigate about half of the loss in live births associated with SET in the initial fresh transfer while achieving a twin rate of 10% or less. Data-based simulations suggested that, if all good-quality embryos are replaced over multiple frozen embryo transfers, repeated SET has the potential to produce more live birth events than repeated DET. However, this would depend on optimising cryopreservation procedures. Universal SET could both reduce the number of twin births and lead to more couples having a child, but at an average cost of one more embryo transfer procedure per egg retrieval. The interview and focus group data suggest that, despite the potential to maintain overall success rates, patients would prefer DET: the potential for twins was seen as positive, while additional transfer procedures can be emotionally, physically and financially draining.

CONCLUSIONS

For any one transfer, SET has about a one-third loss of success rate relative to DET. This can be only partially mitigated by patient and treatment cycle selection, which may be criticised as unfair as all patients receiving SET will have a lower chance of success than they would with DET. However, considering complete cycles (fresh plus frozen transfers), it is possible for repeat SET to produce more live births than repeat DET. Such a strategy would require support from funders and acceptance by patients of both cryopreservation and the burden of additional transfer cycles. Future work should include development of improved clinical and regulatory database systems, surveys to quantify the extent of patients' beliefs and experiences and develop approaches to meet their information needs, and, ideally, randomised controlled trials comparing policies of repeated SET with repeated DET.

Introduction of a child and adolescent mental health link worker: education and health staff focus group findings

Policy guidance suggests that outcomes for adolescents with mental health problems can be improved by secondary education services (SES) and child and adolescent mental health services (CAMHS) working more closely. This study reports on staff experiences of the introduction of a mental health link worker (MHLW). The findings of two focus groups are presented, conducted with staff from CAMHS and SES. These focus groups formed part of the overall wider evaluation of the MHLW role. The groups explored staff perceptions and experiences following the introduction of the MHLW, and elicited their views on the effectiveness of this innovative role. Qualitative methods were employed, and analysis was conducted using the principles of grounded theory and the constant comparative method. The findings revealed that the MHLW was well received by both groups, despite the identification of potential barriers. A number of key themes emerged, which included the ability of the link worker to improve communication and to encourage mutual understanding between services. The issues raised by these themes are discussed and recommendations are made for future practice and research.

A systematic review of motivational interviewing in physical health care settings

PURPOSE

Motivational interviewing (MI), a method of augmenting an individual's motivation to change problematic behaviours, is a patient-centred counselling style that seeks to help patients resolve ambivalence about behaviour change. MI has successfully been used in the field of addictions and has recently received increased interest as a means of promoting treatment adherence in physical health care settings. This systematic review is aimed to evaluate the effectiveness of MI interventions in physical health care settings.

METHODS

Electronic databases were searched for articles specifying the use of 'motivational interviewing' in physical health care settings between 1966 and April 2004. Fifty-one relevant abstracts were yielded and data was extracted from eight relevant selected studies.

RESULTS

Eight studies were identified in the fields of diabetes, asthma, hypertension, hyperlipidaemia, and heart disease. The majority of studies found positive results for effects of MI on psychological, physiological, and life-style change outcomes. Problems with research in this area include: small sample sizes, lack of power, use of disparate multiple outcomes, inadequate validation of questionnaires, poorly-defined therapy and training.

CONCLUSIONS

While MI has high face validity across a number of domains in physical health care settings, the general quality of trials in this area is inadequate and therefore recommendations for its dissemination in this area cannot yet be made. More research into MI applied to health behaviour change is urgently required.

The relationship between restrained eating and poor psychological health is moderated by pleasure normally associated with eating

This study investigated the relationship between restrained eating and poor psychological health, and the importance of pleasure normally associated with eating in this relationship. Pleasure normally associated with eating, restrained eating, and anxiety, depression and satisfaction with life were assessed concurrently by questionnaire. A relationship between restrained eating and poor psychological health was found--greater restrained eating was significantly independently associated with greater anxiety (B=1.099, p<0.01). Furthermore, pleasure associated with eating was an important moderator in this relationship--greater pleasure associated with eating combined with greater restrained eating was also significantly independently associated with greater anxiety (B=1.067, p=0.02). No effects were found for depression or satisfaction with life. These findings suggest that the pleasure normally associated with eating is important in the relationship between restrained eating and poor psychological health. Subsidiary exploratory analyses also suggest that the relationship between restrained eating and poor psychological health, and the importance of pleasure in that relationship, may differ in males and females.

Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction

BACKGROUND

The extent to which depression impairs health-related quality of life (HRQoL) in the physically ill has not been clearly established.

AIMS

To quantify the adverse influence of depression and anxiety, assessed at the time of first myocardial infarction and 6 months later, on the physical aspect of HRQoL 12 months after the infarction.

METHOD

In all, 260 in-patients, admitted following first myocardial infarction, completed the Hospital Anxiety and Depression Scale and the Medical Outcomes Study SF-36 assessment before discharge and at 6- and 12-month follow-up.

RESULTS

Depression and anxiety 6 months after myocardial infarction predicted subsequent impairment in the physical aspects of HRQoL (attributable adjusted R(2)=9%, P<0.0005). These negative effects of depression and anxiety on outcome were mediated by feelings of fatigue. Depression and anxiety present before myocardial infarction did not predict HRQoL 12 months after myocardial infarction.

CONCLUSIONS

Detection and treatment of depression and anxiety following myocardial infarction improve the patient's health-related quality of life.

152 SURVIVAL OF BIOPSIED DAY 15 BOVINE CONCEPTI RE-TRANSFERRED TO SYNCHRONIZED RECIPIENT HEIFERS

In cattle, a significant proportion of in vitro-produced (IVP) blastocysts do not result in viable pregnancies after transfer to recipient surrogates. Betteridge et al. (1980 J. Reprod. Fert. 59, 205–216) showed that it was possible after superovulation to recover elongated bovine embryos up to Day 17, transfer them into synchronized recipient cows, and have them develop further. We investigated the feasibility of recovering cattle embryos at Day 15, taking a sample of the trophoblast and transferring the embryos into recipients afterward for further development. The biopsied material could be used later to evaluate gene expression and correlate the profile retrospectively with developmental potential. With this approach, a larger amount of material is available for study and only embryos surviving to the elongation stage would be examined. In our experience, 30–40% of transferred blastocysts do not develop to the elongation stage. In three separate experiments, IVP embryos were generated using abattoir derived oocytes and cultured in SOF-aa supplemented with BSA (Thompson et al. 2000 J. Reprod. Fert. 118, 47–55). Six graded Day 7 (Day 0 = day of IVF) blastocysts were transferred into synchronized recipient heifers (n = 10 for each experiment). At Day 15 of gestation, concepti were flushed from the uteri after slaughter with EmCare Flush (ICPbio, Ltd., Suckland, New Zealand) containing 25 mg/mL kanamycin sulfate and then put into EmCare Hold. Conceptus lengths were measured and a proportion of those >30 mm long were cut off (5–15 mm) at one end and the trophoblast kept for future analysis. Pairs of cut or uncut (control) concepti were loaded into 0.25-mL embryo transfer straws. Each pair was transferred nonsurgically into recipients synchronized at Days 15 (Expt. 1, n = 17) or 13 (Expts. 2 and 3, n = 16 and 17, respectively) of the estrous cycle. The time between embryo flush and transfer to a recipient was noted. At Day 30, embryo survival was assessed at slaughter and compared using the Fisher's exact and chi-square. Day 15 conceptus lengths varied between 1 and 140 mm. The time between flush and transfer varied between 13 and 126 min and did not affect the ability of the concepti to subsequently establish pregnancies. Transfer to an earlier uterine environment did not significantly improve embryo survival. The proportion of embryos recovered at Day 30 was not affected by the biopsy. Up to 10 mm can be removed from 40–10 mm concepti without effect on subsequent survival. However, the overall survival post-Day 15 transfer is still too low for practical application. Table 1.

The risk factors for depression in first myocardial infarction patients

BACKGROUND

Depression affects outcome following myocardial infarction but the risk factors for such depression have been little studied. This study considered whether the causes of depression occurring before and after myocardial infarction were similar to those of depression in the general population.

METHOD

Consecutive patients admitted to hospital following their first myocardial infarction were interviewed with the Schedule for Clinical Assessment in Neuropsychiatry to detect psychiatric disorders and the Life Events and Difficulties Schedule to assess recent stress. Participants completed the Hospital Anxiety and Depression Scale (HADS) at entry to the study and 1 year later and the risk factors associated with a high score at both times were assessed.

RESULTS

Of 314 (88% of eligible) patients who were recruited, 199 (63%) were male and 63 (20%) had depressive disorders. Logistic regression identified the following as independently associated with depressive disorder that had been present for at least I month before the myocardial infarction: younger age, female sex, past psychiatric history, social isolation, having marked non-health difficulties and lack of a close confidant. At follow-up 269/298 (90%) responded; of 189 participants not depressed at first assessment, 39 (21%) became depressed by the 1 year follow-up. Logistic regression identified frequent angina as the only significant predictor of raised HADS scores at 12 months.

CONCLUSIONS

Depression developing during the year following myocardial infarction does not have the same risk factors as that which precedes myocardial infarction. Further clarification of the mechanisms linking depression to poor outcome may require separation consideration of pre- and post-myocardial infarction depression, and its risk factors.

Lack of a close confidant, but not depression, predicts further cardiac events after myocardial infarction

OBJECTIVE

To assess the role of depression and lack of social support before myocardial infarction (MI) in determining outcome in a large representative sample of patients admitted after MI in the UK.

DESIGN

Prospective cohort design.

PATIENTS

1034 consecutive patients were screened 3-4 days after MI.

MAIN OUTCOME MEASURES

Mortality and further cardiac events over one year after an MI.

RESULTS

At 12 months' follow up mortality and further cardiac events were assessed in 583 of 654 eligible patients (90% response); 140 of 589 for whom baseline data were collected (23.8%) were depressed before their MI. Patients who were depressed before their MI were not more likely to die (mortality 5.2% v 5.0% of non-depressed patients) or suffer further cardiac events (cardiac events rate 20.7% v 20.3% of non-depressed patients). After controlling for demographic factors and severity of MI, the absence of a close confidant predicted further cardiac events (hazard ratio 0.57, p = 0.022).

CONCLUSION

Lack of a close confidant but not depression before MI was associated with adverse outcome after MI in this sample. This association may be mediated by unhealthy behaviours and lack of compliance with medical recommendations, but it is also compatible with difficulties in early life leading to heart disease.