We Can Quit2 (WCQ2): a community-based intervention on smoking cessation for women living in disadvantaged areas of Ireland-study protocol for a pilot cluster randomised controlled trial

BACKGROUND

Tobacco use is the leading cause of preventable death in Ireland with almost 6000 smokers dying each year from smoking-related diseases. The 'We Can Quit2' (WCQ2) study is a pilot pragmatic two-arm, parallel-group, cluster randomised trial that aims to explore the feasibility and acceptability of trial processes including recruitment and to estimate parameters to inform sample size estimates needed for an effectiveness trial. This future trial will assess the effectiveness of a community-based smoking cessation intervention for women living in disadvantaged areas on short- and medium-term cessation rates.

METHODS/DESIGN

Four matched pairs of districts (eight clusters) selected by area level of deprivation, geographical proximity, and eligibility for free medical services will be randomised to receive either WCQ (behavioural support + access to Nicotine Replacement Therapy (NRT)) delivered over 12 weeks by trained Community Facilitators (CFs) or to a form of usual care, a one-to-one smoking cessation service delivered by Smoking Cessation Officers from Ireland's national health service, the Health Service Executive (HSE). Within each cluster, 24-25 women will be recruited (97 per arm; 194 in total) in 4 phases with consent obtained prior to cluster randomisation. The outcome measures will assess feasibility and acceptability of trial processes, including randomisation. Outcome data for a future definitive intervention (biochemically validated smoking abstinence) will be collected at end of programme (12 weeks) and at 6 months. WCQ2 has an embedded process evaluation using both qualitative and quantitative methods. This will be conducted (semi-structured client and CF interviews, intervention delivery checklist, and diary) to explore acceptability of trial processes, intervention fidelity, trial context, and implementation. Trial processes will be assessed against domains of the PRECIS-2 wheel to inform a future definitive trial design.

DISCUSSION

Data from this pilot trial will inform the design and sample size for a full cluster randomised trial to determine the effectiveness of an intervention tailored to disadvantaged women in improving smoking cessation rates. It will provide transferable learning on the systems and implementation strategies needed to support effective design of future pragmatic community-based trials which address health promotion interventions for women in disadvantaged communities.

TRIAL REGISTRATION

Concurrent to publication. Controlled trials ISRCTN74721694.

Smoking cessation programmes for women living in disadvantaged communities, “We Can Quit 2”: A systematic review protocol

Tobacco use is the leading cause of preventable death in Ireland with almost 6,000 smokers dying each year from smoking-related diseases. Amongst younger Irish women, smoking rates are considerably higher in those from socially disadvantaged areas compared to women from affluent areas. Women from poorer areas also experience higher rates of lung cancer. To our knowledge, there are no peer reviewed published systematic reviews on the effectiveness of interventions tailored to reduce smoking rates in women from disadvantaged areas. This systematic review protocol will aim to examine the effectiveness of such interventions and to describe trial processes such as recruitment, follow-up and dropout prevention strategies, as well as barriers and enablers of successful implementation.    A systematic review will be conducted of peer-reviewed randomised controlled trials and associated process evaluations of smoking cessation interventions designed for women living in socially disadvantaged areas. If the search returns, less than five studies are review criteria will expand to include quasi-experimental studies. A number of databases of scholarly literature will be searched from inception using a detailed search strategy. Two independent reviewers will screen titles, abstracts and full-text articles to identify relevant studies using a pre-defined checklist based on PICOS. In the case of disagreement, a third reviewer will be consulted. The quality of included studies will be assessed using the ‘Grading of Recommendations Assessment, Development and Evaluation’ (GRADE) criteria. Quantitative data will be extracted and, if comparable, will be assessed using meta-analysis. A narrative meta-synthesis of qualitative data will be conducted.   This review aims to synthesise information from relevant studies on smoking cessation interventions tailored for women from socially disadvantaged areas. The evidence obtained from studies and presented in this review will help guide future research in this area. Registration: This review will be registered with International Prospective Register of Systematic Reviews (PROSPERO).

Implementation of a peer-led school based smoking prevention programme: a mixed methods process evaluation

BACKGROUND

Smoking prevention programmes that reach adolescents before they experiment with tobacco may reduce the prevalence of tobacco use. ASSIST is a school-based, peer-led smoking prevention programme that encourages the diffusion of non-smoking norms among secondary school students (aged 12-13), and was shown in a randomised control trial (conducted 2001-2004) to reduce the prevalence of weekly smoking. This paper presents findings from a process evaluation of the implementation of ASSIST in Scotland in 2014-2017. It examines acceptability and fidelity of implementation and explores the context of message diffusion between peers.

METHODS

Mixed method implementation study with students (n = 61), school staff (n = 41), trainers (n = 31) and policy and commissioning leads (n = 17), structured observations (n = 42) and student surveys (n = 2130).

RESULTS

ASSIST was delivered with a high degree of fidelity to the licensed manual with all elements of the programme implemented. Student survey findings indicated that the frequency of conversations about smoking increased over the ASSIST delivery period (18% at baseline, 26% at follow-up), but student recollection of conversations about smoking with peer supporters was low (9%). The delivery context of ASSIST was important when considering perceptions of message diffusion. In the study schools, survey findings showed that 0.9% (n = 19) of participants were regular smokers (at least once a week), with nine out of ten (89.9%, n = 1880) saying they had never smoked. This very low prevalence may have affected when and with whom conversations took place. Study participants indicated that there were wider benefits of taking part in ASSIST for: peer supporters (i.e. personal and communication skills); schools (an externally delivered health promotion programme that required minimal resource from schools); and communities (via communication about the risks of smoking to wider social networks).

CONCLUSIONS

ASSIST in Scotland was delivered with a high degree of fidelity to the licensed programme and was acceptable from the perspective of schools, students and trainers. Targeting ASSIST in deprived areas with higher youth smoking prevalence or in other countries where youth smoking rates are rising or higher than in Scotland may be particularly relevant for the future delivery.

Smoking cessation programmes for women living in disadvantaged communities, "We Can Quit 2": A systematic review protocol

Tobacco use is the leading cause of preventable death in Ireland with almost 6,000 smokers dying each year from smoking-related diseases. Amongst younger Irish women, smoking rates are considerably higher in those from socially disadvantaged areas compared to women from affluent areas. Women from poorer areas also experience higher rates of lung cancer. To our knowledge, there are no peer reviewed published systematic reviews on the effectiveness of interventions tailored to reduce smoking rates in women from disadvantaged areas. This systematic review protocol will aim to examine the effectiveness of such interventions and to describe trial processes such as recruitment, follow-up and dropout prevention strategies, as well as barriers and enablers of successful implementation.    A systematic review will be conducted of peer-reviewed randomised controlled trials and associated process evaluations of smoking cessation interventions designed for women living in socially disadvantaged areas. If the search returns, less than five studies are review criteria will expand to include quasi-experimental studies. A number of databases of scholarly literature will be searched from inception using a detailed search strategy. Two independent reviewers will screen titles, abstracts and full-text articles to identify relevant studies using a pre-defined checklist based on PICOS. In the case of disagreement, a third reviewer will be consulted. The quality of included studies will be assessed using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) criteria. Quantitative data will be extracted and, if comparable, will be assessed using meta-analysis. A narrative meta-synthesis of qualitative data will be conducted.   This review aims to synthesise information from relevant studies on smoking cessation interventions tailored for women from socially disadvantaged areas. The evidence obtained from studies and presented in this review will help guide future research in this area. Registration: This review will be registered with International Prospective Register of Systematic Reviews (PROSPERO).

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study

Introduction

Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.

Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk.

Methods

This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother’s linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour.

Results

ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. ‘Clinical Classifications Software’ ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported.

Conclusion

There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners.

Key words

Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol

Epidemiology of emergency ambulance service calls related to mental health problems and self harm: a national record linkage study

BACKGROUND

People experiencing a mental health crisis receive variable and poorer quality care than those experiencing a physical health crisis. Little is known about the epidemiology, subsequent care pathways of mental health and self-harm emergencies attended by ambulance services, and subsequent all-cause mortality, including deaths by suicide. This is the first national epidemiological analysis of the processes and outcomes of people attended by an ambulance due to a mental health or self-harm emergency. The study aimed to describe patient characteristics, volume, case-mix, outcomes and care pathways following ambulance attendance in this patient population.

METHODS

A linked data study of Scottish ambulance service, emergency department, acute inpatient and death records for adults aged ≥16 for one full year following index ambulance attendance in 2011.

RESULTS

The ambulance service attended 6802 mental health or self harm coded patients on 9014 occasions. This represents 11% of all calls attended that year. Various pathways resulted from these attendances. Most frequent were those that resulted in transportation to and discharge from the emergency department (n = 4566/9014; 51%). Some patients were left at home (n = 1003/9014 attendances, 11%). Others were admitted to hospital (n = 2043/9014, 23%). Within 12 months of initial attendance, 279 (4%) patients had died, 97 of these were recorded as suicide.

CONCLUSIONS

This unique study finds that ambulance service and emergency departments are missing opportunities to provide better care to this population and in potentially avoidable mortality, morbidity and service burden. Developing and testing interventions for this patient group in pre-hospital and emergency department settings could lead to reductions in suicide, patient distress, and service usage.

Defining and assessing vulnerability within law enforcement and public health organisations: a scoping review

BACKGROUND

Historically, police departments focused solely on criminal justice issues. Recently, there has been a dynamic shift in focus, with Law Enforcement professional groups assuming more responsibility for tackling mental health and distress-related issues (that may arise because of mental health related problems and learning disabilities) alongside Public Health departments. While Law Enforcement has become a 'last line of support' and an increasing partner in mental health support, there is partnership working between law enforcement, psychology, and health professions in training and mental health service delivery. The term vulnerability is frequently used across Law Enforcement and Public Health (LEPH) to identify those in need of these services. Effective vulnerability assessment is therefore expected to prevent unintentional harmful health and criminal justice consequences and manage the negative impact of such in cases where prevention is not possible. This scoping review aimed to identify how vulnerability is defined and assessed across LEPH organisations.

RESULTS

Vulnerability is context-specific from a Law Enforcement perspective, and person-specific from a Public Health perspective. Definitions of vulnerability are at best fragmented, while models for assessing vulnerability lack uniformity across LEPH. The implications are two-fold. For "vulnerable groups", the lack of an evidence-based definition and assessment model could prevent access to relevant LEPH services, exacerbating issues of multiple vulnerabilities, co-morbidity, and/or dual diagnosis. All could inadvertently enable social exclusion of vulnerable groups from political discourse and policy interventions. The lack of consistency regarding vulnerability may result in reactive crisis responses as opposed to proactive preventative measures.

CONCLUSIONS

This scoping review exposes the complexities associated with defining and assessing vulnerability from a LEPH perspective, which are perceived and prioritised differently across the organizations. Future research must bridge this gap. Building on the establishment of a definition of vulnerability within the empirical literature, researchers ought to engage with service users, LEPH staff, and those engaged in policy making to craft effective vulnerability definitions and assessment models. Only through evidence based, co-produced definitions and assessment models for vulnerability can we ensure that best-practice, but also meaningful and feasible practice, in vulnerability assessment can be achieved.

Mode of birth after caesarean section: individual prediction scores using Scottish population data

Background

Rising caesarean section (CS) rates are a global health concern. Contemporary data indicates that almost 50% of CS are electively performed, with a high proportion of these being a repeat procedure. Vaginal birth after caesarean (VBAC) is recognised as a safe way to give birth in developed countries. UK national maternity policy and worldwide professional guidance supports shared decision-making about mode of birth with women following CS. Evidence suggests that women want individualised information, particularly about their likeilihood of successful VBAC, to enable them to participate in the decision making process. This study aimed to identify characteristics that could inform a predictive model which would allow women to receive personalised and clinically specific information about their likelihood of achieving a successful VBAC in subsequent pregnancies.

Methods

An observational study using anonymised clinical data extracted from a detailed, comprehensive socio-demographic and clinical dataset. All women who attempted a singleton term VBAC between 2000 and 2012 were included. Data were analysed using both logistic regression and Bayesian statistical techniques to identify clinical and demographic variables predictive of successful VBAC.

Results

Variables significantly associated with VBAC were: ethnicity (p = 0.011), maternal obstetric complications (p < 0.001), previous vaginal birth (p = < 0.001), antepartum haemorrhage (p = 0.005), pre-pregnancy BMI (p < 0.001) and a previous second stage CS (p < 0.001).

Conclusions

By using current literature, expert clinical opinion and having access to clinically detailed variables, this study has identified a new significant characteristic. Women who had a previous CS in the second stage of labour are more likely to have a successful VBAC. This predictor may have international significance for women and clinicians in shared VBAC decision-making. Further research is planned to validate this model on a larger national sample leading to further development of the nomogram tool developed in this study for use in clinical practice to assist women and clinicians in the decision-making process about mode of birth after CS.

Reducing delay in patients with acute coronary syndrome and other time-critical conditions: a systematic review to identify the behaviour change techniques associated with effective interventions

Background

Time to treatment in many conditions, particularly acute coronary syndrome, is critical to reducing mortality. Delay between onset of symptoms and treatment remains a worldwide problem. Reducing patient delay has been particularly challenging. Embedding behaviour change techniques (BCTs) within interventions might lead to shorter delay.

Objective

To identify which BCTs are associated with reductions in patient delay among people with symptoms or conditions where time to treatment is critical.

Methods

The data sources were Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO. Study eligibility criteria include intervention evaluations (randomised controlled trials, controlled clinical trials and cohort studies) involving adults (aged >18 years) and including an outcome measure of patient delay up to August 2016. Study appraisal and synthesis methods include screening potential studies using a transparent, replicable process. Study characteristics, outcomes and BCTs were extracted from eligible studies.

Results

From 39 studies (200 538 participants), just over half (n=20) reported a significant reduction in delay. 19 BCTs were identified, plus 5 additional techniques, with a mean of 2 (SD=2.3) BCTs and 2 (SD=0.7) per intervention. No clear pattern between BCTs and effectiveness was found. In studies examining patient delay specifically, three of four studies that included two or more BCTs, in addition to the two most commonly used additional techniques, reported a significant reduction in delay.

Conclusions

Around half of the interventions to reduce prehospital delay with time-critical symptoms report a significant reduction in delay time. It is not clear what differentiates effective from non-effective interventions, although in relation to patient delay particularly additional use of BCTs might be helpful.

Trial registration number

CRD42014013106.

Health Inequalities in British Nurses using Census derived databases linked to an adjusted UK Index of Multiple Deprivation

IntroductionScottish health outcomes are worse than in England and Wales. This variation remains after controlling for deprivation, which explains less excess mortality now than previously. Alternative cross-national deprivation measures have limitations which may explain some of this trend. Recent policy interventions to reduce inequalities have not been effective. Objectives and ApproachThis study aims to test a recently developed measure of area deprivation, the UK adjusted Index of Multiple Deprivation which has been linked to National Census derived Longitudinal Studies in England, Wales and Scotland. This adjusted measure is consistent across UK countries and addresses some limitations of previously utilised area measures of deprivation. This study also aims to test whether characteristics of Nurses are protective against inequalities in health. This study will test whether Nurses are more socio-economically homogenous and whether higher health literacy is protective against the social gradient in health outcomes. Results(1) Comparing Nurses to Non-Nurses in Scotland we found that they have systematically different demographic characteristics. Nurses are; older on average, more likely to be female, more likely to own their home, more likely to live in less deprived areas and they report better self-rated health. (1a) Correlation tests will examine the strength of relationship between health and Deprivation quintile for these groups. (2) Comparing Self-Rated Health of Scottish Nurses with English and Welsh Nurses will determine whether any ‘excess’ in worse health outcomes exists and (2a) if an excess does exist, whether the UK consistent deprivation measure can account for this. Analysis is currently ongoing and will be completed, with full results cleared for dissemination through disclosure control, prior to conference. Conclusion/ImplicationsThis study implements methods which provide a basis for cross-national comparison of inequalities using individual-level data and a consistent measure of area deprivation. Results from this study may also permit recommendations to improve the effectiveness of policy aimed at improving population health and reducing socio-economic inequalities in health.

Health Inequalities in the British Nursing Workforce

BackgroundAverage health in the UK is improving, yet geographical inequalities in health persist. The relative difference between the least and most deprived is also growing. Recent policy interventions to reduce these inequalities have not been effective. MethodsThis work compares Self-Rated Health using the ONS LS and SLS linked to an adjusted UK-consistent small-area Deprivation measure. This study aims to compare Nurses to the general population to assess whether they also exhibit a social gradient in health. Using a single occupational group adjusts for potential confounders and tests whether characteristics of Nurses, such a good health literacy, degree education and above average income, are protective against inequalities. ResultsIn Scotland, Nurses are more likely to be older, female, homeowners who live in less deprived areas with better Self-Rated Health than Non-Nurses. We will test whether the social gradient in health is observed for this occupational group.Forthcoming results from cross-national analysis will be presented at conference following disclosure checks. ConclusionThe relationship between area deprivation and health may remain even in relatively privileged groups. Results from this study may inform recommendations to improve the effectiveness of policy aimed at improving population health and reducing socio-economic inequalities in health

Psychological therapy for inpatients receiving acute mental health care: A systematic review and meta-analysis of controlled trials

OBJECTIVES

The effectiveness of psychological therapies for those receiving acute adult mental health inpatient care remains unclear, partly because of the difficulty in conducting randomized controlled trials (RCTs) in this setting. The aim of this meta-analysis was to synthesize evidence from all controlled trials of psychological therapy carried out with this group, to estimate its effects on a number of important outcomes and examine whether the presence of randomization and rater blinding moderated these estimates.

METHOD

A systematic review and meta-analysis of all controlled trials of psychological therapy delivered in acute inpatient settings was conducted, with a focus on psychotic symptoms, readmissions or emotional distress (anxiety and depression). Studies were identified through ASSIA, EMBASE, CINAHL, Cochrane, MEDLINE, and PsycINFO using a combination of the key terms 'inpatient', 'psychological therapy', and 'acute'. No restriction was placed on diagnosis. The moderating effect of the use of assessor-blind RCT methodology was examined via subgroup and sensitivity analyses.

RESULTS

Overall, psychological therapy was associated with small-to-moderate improvements in psychotic symptoms at end of therapy but the effect was smaller and not significant at follow-up. Psychological therapy was also associated with reduced readmissions, depression, and anxiety. The use of single-blind randomized controlled trial methodology was associated with significantly reduced benefits on psychotic symptoms and was also associated with reduced benefits on readmission and depression; however, these reductions were not statistically significant.

CONCLUSIONS

The provision of psychological therapy to acute psychiatric inpatients is associated with improvements; however, the use of single-blind RCT methodology was associated with reduced therapy-attributable improvements. Whether this is a consequence of increased internal validity or reduced external validity is unclear. Trials with both high internal and external validity are now required to establish what type, format, and intensity of brief psychological therapy is required to achieve sustained benefits.

PRACTITIONER POINTS

Clinical implications: This review provides the first meta-analytical synthesis of brief psychological therapy delivered in acute psychiatric inpatient settings. This review suggests that brief psychological therapy may be associated with reduced emotional distress and readmissions.

LIMITATIONS

The evidence in this review is of limited quality. The type, format, and intensity of brief psychological therapy required to achieve sustained benefits are yet to be established.

A Position Statement on Population Data Science: The Science of Data about People

Information is increasingly digital, creating opportunities to respond to pressing issues about human populations using linked datasets that are large, complex, and diverse. The potential social and individual benefits that can come from data-intensive science are large, but raise challenges of balancing individual privacy and the public good, building appropriate socio-technical systems to support data-intensive science, and determining whether defining a new field of inquiry might help move those collective interests and activities forward. A combination of expert engagement, literature review, and iterative conversations led to our conclusion that defining the field of Population Data Science (challenge 3) will help address the other two challenges as well. We define Population Data Science succinctly as the science of data about people and note that it is related to but distinct from the fields of data science and informatics. A broader definition names four characteristics of: data use for positive impact on citizens and society; bringing together and analyzing data from multiple sources; finding population-level insights; and developing safe, privacy-sensitive and ethical infrastructure to support research. One implication of these characteristics is that few people possess all of the requisite knowledge and skills of Population Data Science, so this is by nature a multi-disciplinary field. Other implications include the need to advance various aspects of science, such as data linkage technology, various forms of analytics, and methods of public engagement. These implications are the beginnings of a research agenda for Population Data Science, which if approached as a collective field, can catalyze significant advances in our understanding of trends in society, health, and human behavior.

The Patient Centred Assessment Method for improving nurse-led biopsychosocial assessment of patients with long-term conditions: a feasibility RCT

Background

Annual reviews of people living with long-term conditions (LTCs) are mostly conducted by practice nurses (PNs), who focus on the physical needs of patients. The broader mental well-being and social needs of patients are also important if they are to live well. The Patient Centred Assessment Method (PCAM) is a new tool to help PNs conduct biopsychosocial assessments of patients’ needs.

Research questions

Is it feasible and acceptable to use the PCAM in primary care nurse-led reviews for those with LTCs? Is it feasible and acceptable to run a cluster randomised trial of the PCAM in primary care?

Methods

Four practitioner and two patient focus groups explored the acceptability and implementation requirements of the PCAM, which was then tested in a feasibility cluster randomised controlled trial aiming to recruit eight general practitioner (GP) practices and 16 nurses. Baseline data collection was conducted with nurses prior to randomisation, with a cohort of 10 patients per nurse, including patient demographics, patient evaluation of consultation, patient-completed outcomes (measured via the Consultation and Relational Empathy, Patient Enablement Instrument, Warwick–Edinburgh Mental Well-Being Scale, General Health Questionnaire and the Short Form questionnaire-12 items) and nurse referrals/signposting to services. Patient follow-up questionnaires were completed at 8 weeks. Practices were then randomised to the PCAM intervention or care as usual (CAU). Data collection was repeated for a second cohort of patients. Fidelity was tested by comparing a sample of recorded consultations before and after PCAM training. Qualitative interviews were conducted with PCAM nurses and a sample of patients.

Results

Approaches to 159 eligible practices resulted in the recruitment of six practices (10 nurses), with five practices (seven nurses) completing both data collection phases. Nurses collected baseline data on 113 patients, 71 of whom (62.8%) completed follow-up questionnaires. Five practices were randomised: three practices (six nurses) to the PCAM arm and two practices (four nurses) to the CAU arm. In phase 2, seven nurses collected data on 77 patients, of whom 40 (52%) completed follow-up. Only four PCAM nurses agreed to recording consultations, with five pre- and four post-PCAM recordings obtained. Post PCAM training, there was evidence of more attention being given to patients’ mental well-being and social issues. The PCAM was fairly easily integrated into consultation, although some nurses reflected that this benefited from early support. Patients were not always aware of its use, but most were happy to have their needs assessed.

Limitations

Recruitment of GP practices, and nurse recruitment and retention.

Conclusions

The PCAM is feasible and acceptable for use by primary care nurses and may have potential for encouraging biopsychosocial assessment of patients. Efforts required to recruit and retain staff indicate that a full trial is not feasible or cost-effective at this time.

Future work

The PCAM intervention warrants further exploration as an effective mechanism for improving care for people with LTCs; this could be conducted within an implementation study.

Trial registration

Current Controlled Trials ISRCTN98973169.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

An analysis of suicide trends in Scotland 1950-2014: comparison with England & Wales

BACKGROUND

Scotland has disproportionately high rates of suicide compared with England. An analysis of trends may help reveal whether rates appear driven more by birth cohort, period or age. A 'birth cohort effect' for England & Wales has been previously reported by Gunnell et al. (B J Psych 182:164-70, 2003). This study replicates this analysis for Scotland, makes comparisons between the countries, and provides information on 'vulnerable' cohorts.

METHODS

Suicide and corresponding general population data were obtained from the National Records of Scotland, 1950 to 2014. Age and gender specific mortality rates were estimated. Age, period and cohort patterns were explored graphically by trend analysis.

RESULTS

A pattern was found whereby successive male birth cohorts born after 1940 experienced higher suicide rates, in increasingly younger age groups, echoing findings reported for England & Wales. Young men (aged 20-39) were found to have a marked and statistically significant increase in suicide between those in the 1960 and 1965 birth cohorts. The 1965 cohort peaked in suicide rate aged 35-39, and the subsequent 1970 cohort peaked even younger, aged 25-29; it is possible that these 1965 and 1970 cohorts are at greater mass vulnerability to suicide than earlier cohorts. This was reflected in data for England & Wales, but to a lesser extent. Suicide rates associated with male birth cohorts subsequent to 1975 were less severe, and not statistically significantly different from earlier cohorts, suggestive of an amelioration of any possible influential 'cohort' effect. Scottish female suicide rates for all age groups converged and stabilised over time. Women have not been as affected as men, with less variation in patterns by different birth cohorts and with a much less convincing corresponding pattern suggestive of a 'cohort' effect.

CONCLUSIONS

Trend analysis is useful in identifying 'vulnerable' cohorts, providing opportunities to develop suicide prevention strategies addressing these cohorts as they age.

Reducing patient delay in Acute Coronary Syndrome (RAPiD): research protocol for a web-based randomized controlled trial examining the effect of a behaviour change intervention

AIMS

To evaluate the efficacy of a behaviour change technique-based intervention and compare two possible modes of delivery (text + visual and text-only) with usual care.

BACKGROUND

Patient delay prevents many people from achieving optimal benefit of time-dependent treatments for acute coronary syndrome. Reducing delay would reduce mortality and morbidity, but interventions to change behaviour have had mixed results. Systematic inclusion of behaviour change techniques or a visual mode of delivery might improve the efficacy of interventions.

DESIGN

A three-arm web-based, parallel randomized controlled trial of a theory-based intervention.

METHODS

The intervention comprises 12 behaviour change techniques systematically identified following systematic review and a consensus exercise undertaken with behaviour change experts. We aim to recruit n = 177 participants who have experienced acute coronary syndrome in the previous 6 months from a National Health Service Hospital. Consenting participants will be randomly allocated in equal numbers to one of three study groups: i) usual care, ii) usual care plus text-only behaviour change technique-based intervention or iii) usual care plus text + visual behaviour change technique-based intervention. The primary outcome will be the change in intention to phone an ambulance immediately with symptoms of acute coronary syndrome ≥15-minute duration, assessed using two randomized series of eight scenarios representing varied symptoms before and after delivery of the interventions or control condition (usual care). Funding granted January 2014.

DISCUSSION

Positive results changing intentions would lead to a randomized controlled trial of the behaviour change intervention in clinical practice, assessing patient delay in the event of actual symptoms.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov: NCT02820103.

Measuring patient activation: The utility of the Patient Activation Measure within a UK context-Results from four exemplar studies and potential future applications

OBJECTIVE

Patient activation can be measured using the Patient Activation Measure (PAM) developed by Hibbard et al., however, little is known about the uses of the PAM in research and in practice. This study aims to explore its differing utility in four UK exemplar sites.

METHODS

Data from four exemplars in a range of health settings with people living with long-term conditions (i.e. stroke or COPD) were evaluated. PAM scores were described and explored in relation to clinical and sociodemographic variables and outcome measures.

RESULTS

PAM scores illustrated that most with COPD or stroke reported PAM levels of 3 or 4, indicating that they are engaging, but may need help to sustain their scores. The exemplars illustrate the utility of, and potential issues involved in, using PAM as a process/outcome measure to predict activation and the effectiveness of interventions, and as a tool to inform tailoring of targeted interventions.

CONCLUSIONS

The PAM tool has been shown to be useful as an outcome measure, a screening tool to tailor education, or a quality indicator for delivery of care.

PRACTICE IMPLICATIONS

However good demographic and patient history are needed to substantiate PAM scores. Further work is needed to monitor PAM prospectively.

Development and feasibility of a Swallowing intervention Package (SiP) for patients receiving radiotherapy treatment for head and neck cancer-the SiP study protocol

Background

Head and neck cancer (HNC) is the sixth most common cancer worldwide, and the functional, psychological and social consequences of HNC cancer and its treatment can be severe and chronic. Dysphagia (swallowing problems) affects up to two thirds of patients undergoing combined chemoradiotherapy. Recent reviews suggest that prophylactic swallowing exercises may improve a range of short- and long-term outcomes; however, the importance of psychological and behavioural factors on adherence to swallowing exercises has not been adequately studied. This study aims to develop and test the feasibility of a Swallowing intervention Package (SiP) designed in partnership with patients, speech and language therapists (SLTs) and other members of the head and neck multi-disciplinary team (MDT), for patients undergoing chemoradiotherapy (CRT) or radiotherapy (RT) for head and neck cancer.

Methods/design

This feasibility study uses quantitative and qualitative research methods, within a quasi-experimental design, to assess whether patients will tolerate and adhere to the SiP intervention, which aspects of the intervention can be implemented and which cannot, whether treatment fidelity can be achieved across different contexts, whether study processes and outcome measures will be feasible and acceptable and to what extent the intervention is likely to have an impact on swallowing dysfunction and quality of life. Patients are being recruited from five sites in Scotland and England (three interventions and two usual care). The SLT based in the relevant intervention centre teaches the exercise programme and provides supporting materials. A combination of patient-reported outcome measures (PROMs), adherence measures and clinical swallowing assessments are used prior to intervention (baseline), at the end of treatment, 3 and 6 months post-treatment.

Discussion

This collaborative study has taken a unique approach to the development of a patient-centred and evidence-based swallowing intervention. The introduction of an e-SiP app provides an exploration of the use of technology in delivering this intervention. The study provides an opportunity to examine the feasibility of delivering and participating in a supported swallowing intervention across several different NHS sites and will provide the evidence needed to refine intervention and study processes for a future trial.

Trial registration

NCRI portfolio, 18192 & 20259

Optimisation of complex health interventions prior to a randomised controlled trial: a scoping review of strategies used

BACKGROUND

Many complex intervention trials fail to show an intervention effect. Although this may be due to genuine ineffectiveness, it may also be the result of sub-optimal intervention design, implementation failure or a combination of these. Given current financial constraints and the pressure to reduce waste and increase value in health services research, pre-trial strategies are needed to reduce the likelihood of design or implementation failure and to maximise the intervention's potential for effectiveness. In this scoping review, we aimed to identify and synthesise the available evidence relating to the strategies and methods used to 'optimise' complex interventions at the pre-trial stage.

METHODS

We searched MEDLINE, CINAHL, AMED, PsycINFO and ProQuest Nursing & Allied Health Source for papers published between January 2000 and March 2015. We included intervention development and optimisation studies that explored potential intervention weaknesses and limitations before moving to a definitive randomised controlled trial (RCT). Two reviewers independently applied selection criteria and systematically extracted information relating to the following: study characteristics; intervention under development; framework used to guide the development process; areas of focus of the optimisation process, methods used and outcomes of the optimisation process. Data were tabulated and summarised in a narrative format.

RESULTS

We screened 3968 titles and 231 abstracts for eligibility. Eighty-nine full-text papers were retrieved; 27 studies met our selection criteria. Optimisation strategies were used for a range of reasons: to explore the feasibility and acceptability of the intervention to patients and healthcare professionals; to estimate the effectiveness and cost-effectiveness of different combinations of intervention components; and to identify potential barriers to implementation. Methods varied widely across studies, from interviews and focus groups to economic modelling and probability analysis.

CONCLUSIONS

The review identifies a range of optimisation strategies currently used. Although a preliminary classification of these strategies can be proposed, a series of questions remain as to which methods to use for different interventions and how to determine when the intervention is ready or 'optimised enough' to be tested in a RCT. Future research should explore potential answers to the questions raised, to guide researchers in the development and evaluation of more effective interventions.

Evidence of perceived psychosocial stress as a risk factor for stroke in adults: a meta-analysis

BACKGROUND

Several studies suggest that perceived psychosocial stress is associated with increased risk of stroke; however results are inconsistent with regard to definitions and measurement of perceived stress, features of individual study design, study conduct and conclusions drawn and no meta-analysis has yet been published. We performed a systematic review and meta-analysis of studies assessing association between perceived psychosocial stress and risk of stroke in adults.The results of the meta-analysis are presented.

METHODS

Systematic searches of MEDLINE, EMBASE, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews were undertaken between 1980 and June 2014. Data extraction and quality appraisal was performed by two independent reviewers. Hazard ratios (HR) and odds ratios (OR) were pooled where appropriate.

RESULTS

14 studies were included in the meta-analysis, 10 prospective cohort, 4 case-control design. Overall pooled adjusted effect estimate for risk of total stroke in subjects exposed to general or work stress or to stressful life events was 1.33 (95 % confidence interval [CI], 1.17, 1.50; P < 0.00001). Sub-group analyses showed perceived psychosocial stress to be associated with increased risk of fatal stroke (HR 1.45 95 % CI, 1.19,1.78; P = 0.0002), total ischaemic stroke (HR 1.40 95 % CI, 1.00,1.97; P = 0.05) and total haemorrhagic stroke (HR 1.73 95 % CI, 1.33,2.25; P > 0.0001).A sex difference was noted with higher stroke risk identified for women (HR 1.90 95 % CI, 1.4, 2.56: P < 0.0001) compared to men (HR 1.24 95 % CI, 1.12, 1.36; P < 0.0001).

CONCLUSIONS

Current evidence indicates that perceived psychosocial stress is independently associated with increased risk of stroke.

Transcranial Magnetic Stimulation for Schizophrenia

People with schizophrenia typically experience auditory hallucinations or delusions during acute episodes. Although effective drug treatments are available, many have intractable symptoms that do not recover between acute episodes. One proposed alternative to drug treatments is transcranial magnetic stimulation (TMS). To date, many research trials to assess effectiveness of TMS for people with symptoms of schizophrenia have been conducted worldwide. However, there is a lack of consensus on whether TMS should be recommended to be adopted in routine clinical practice. We conducted a systematic review of the literature for all relevant randomized controlled trials (RCTs) comparing TMS with sham or standard treatment. Forty-one trials (1473 participants) survived eligibility criteria and had extractable data. We found significant differences in favor of temporoparietal TMS compared with sham TMS for global state (7 RCTs, n = 224, MD: -0.5, 95% CI: -0.76 to -0.23) and for positive symptoms measured on the Positive and Negative Syndrome Scale (5 RCTs, n = 127, MD: -6.09, 95% CI: -10.95 to -1.22). However, we also found that the quality of trial reporting was frequently suboptimal and the risks of bias were strong or unascertainable for many trial aspects; this led to many results being graded as very low-quality evidence. On that basis, we were unable to definitively support or refute the routine use of TMS in clinical practice. Future definitive trials of TMS with rigorous processes and high-quality reporting are needed.

Transcranial magnetic stimulation (TMS) for schizophrenia

BACKGROUND

People with schizophrenia often experience symptoms which fail to fully respond to antipsychotic medication. Transcranial magnetic stimulation (TMS) has been proposed as a new treatment for people with schizophrenia, especially those who experience persistent auditory hallucinations.

OBJECTIVES

To estimate the effects of TMS alone, compared with sham TMS or with 'standard management' and any other comparison interventions in reducing psychotic symptoms associated with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (June 2006, June 2008, April 2013). This register is compiled by methodical searches of MEDLINE, EMBASE, BIOSIS, CINAHL, Dissertation abstracts, LILACS, PSYNDEX, PsycINFO, RUSSMED, and Sociofile, and is supplemented with handsearching of relevant journals and numerous conference proceedings.

SELECTION CRITERIA

We included all randomised controlled trials recruiting at least five participants and comparing TMS with sham TMS or any other treatment for people with schizophrenia.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RRs) and their 95% confidence intervals (CIs). For continuous data, we calculated mean differences (MD) and 95% CI. We used a fixed-effect model. We assessed overall quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 41 studies with 1473 participants in the review. We found significant differences in favour of temporoparietal TMS compared to sham TMS for global state measured on the CGI scale (7 RCTs, n = 224, MD -0.5, 95% CI -0.76 to -0.23, very low-quality evidence) and positive symptoms measured on the PANSS scale (5 RCTs, n = 127, MD -6.09, 95% CI -10.95 to -1.22, very low-quality evidence). Participants experienced significantly more headaches in the temporoparietal TMS group (10 RCTs, n = 392, RR 2.65, 95% CI 1.56 to 4.50, very low-quality evidence). However, no more participants left the study early from the TMS group than from the sham group (very low-quality evidence). Cognitive state was assessed using 39 different measures, and all were equivocal (very low-quality evidence).We included only two trials which compared temporoparietal TMS with standard treatment. In both trials the participants received first- and second-generation antipsychotic medication in both treatment groups, therefore TMS was used an adjunctive therapy to medication. We found no significant differences in the number of participants that showed clinical improvement in global state (1 RCT, n = 100, RR 1.19, 95% CI 0.91 to 1.57) or left the study early (2 RCTs, n = 140, RR 0.33, 95% CI 0.08 to 1.46) (both very low-quality evidence). No studies reported on global state score, mental state, cognitive state and adverse effects.For prefrontal TMS compared to sham TMS, global state was measured on three different scales, all of which presented equivocal results (very low quality evidence). We could not pool data for mental state on the PANSS scale due to high heterogeneity. Cognitive state was assessed using 19 different measures, with 15/19 being equivocal (very low-quality evidence). Prefrontal TMS caused more headaches (6 RCTs, n = 164, RR 2.77, 95% CI 1.22 to 6.26, very low-quality evidence) but there was no difference in the number of participants leaving the study early (very low-quality evidence). No studies reported data for clinical improvement.We found a significant difference in favour of prefrontal theta burst stimulation TMS compared to sham TMS for mental state on the PANNS scale (3 RCTs, n = 108, MD -5.71, 95% CI -9.32 to -2.10, very low evidence). We found no difference for clinical improvement, cognitive state, number of headaches, and leaving the study early (very low-quality evidence).None of the included studies reported satisfaction with care.

AUTHORS' CONCLUSIONS

Based on this review, there is insufficient evidence to support or refute the use of TMS to treat symptoms of schizophrenia. Although some evidence suggests that TMS, and in particular temporoparietal TMS, may improve certain symptoms (such as auditory hallucinations and positive symptoms of schizophrenia) compared to sham TMS, the results were not robust enough to be unequivocal across the assessment measures used. There was insufficient evidence to suggest any added benefit with TMS used as an adjunctive therapy to antipsychotic medication.The overall quality of evidence was graded as very low due to risk of bias, and this was accompanied by an imprecision in estimates due to the relatively small number of participants in the studies. Thus, consideration is required in improving the quality of trial processes, as well as the quality of reporting of ongoing and future TMS trials, so as to facilitate accurate future judgements in assessing risk of bias. Differences in TMS techniques in relation to stimulation intensity, stimulation length, brain areas stimulated and variations in the design of sham TMS all contributed to the heterogeneity of study findings and limited the interpretation and applicability of the results. In addition, the trials assessed their outcomes with a variety of scales, and usable data were limited. Therefore, to better evaluate the treatment effects of TMS in people with schizophrenia, we favour the use of standardised treatment protocols and outcome measures.