Health Behavior Theories and Research: Implications for Suicidal Individuals' Treatment Linkage and Adherence

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

An infodemiology study on exploring the quality and reliability of colorectal cancer immunotherapy information

Background

Immunotherapy is a new treatment modality which promises hope for advanced colorectal cancer patients. To our knowledge, no previous studies have evaluated the quality of patient information available on this topic online.

Objective

This study will explore the quality and reliability of colorectal cancer immunotherapy information using the Journal of the American Medical Association (JAMA) and DISCERN tools.

Methods

Design thinking methodology was integrated with systematic scoping reviews framework to inform our descriptive observational media analysis study. Google Chrome was used to run four searches using prespecified search terms selected according to the top patient concerns about immunotherapy. The first 20 relevant results were identified (n = 80) and then duplicates were removed. Descriptive narrative univariate and bivariate analysis was done for the relevant variables.

Results

The total of included websites was 17. Most websites score <3 points on JAMA and fair/poor on DISCERN. Most of the websites that score ≥3 points on JAMA and excellent/good on DISCERN have a charity affiliation. A total of 58.8% of the websites present the date, 41.2% demonstrate authorship, and sources are mentioned in 29.4% of the websites. Lack of content was noticed in providing the prognosis of patients if no treatment is given, clear aim and the effect of treatments on patient's quality of life.

Conclusion

Assessing the reliability of information about cancer treatments online remains a challenge. Further research is required to understand the patient perceptions and use of online information and whether it has an impact on their behavioural health outcomes.

COVID-19 self-protective practices and associated factors among secondary school students in Jimma town, Jimma, Oromia, Southwest Ethiopia

Background

Since there is limited evidence regarding COVID-19 self-protective practices among school students, this study assessed COVID-19 self-protective practices and associated factors among secondary school students.

Methods

A school-based cross-sectional study was conducted in Jimma town, Oromia regional state, Southwest Ethiopia from 25 May 2021 to 10 June 2021. The total sample size was 634, and students were randomly selected from public and private secondary schools. A self-administered questionnaire was used for data collection. The data were entered into Epidata 3.1 and analyzed using SPSS 21.0 software. Descriptive statistics, such as proportion and mean, were computed to describe the findings. The composite index was computed for each dimension. A linear regression analysis was used to identify the predictors of self-protective practice. A local polynomial smoothing graph was done using Stata 12 software to visualize the relationship between a significant variable and an outcome variable.

Results

A total of 576 respondents participated in this study, which made a response rate of 90.85%. The mean score for overall knowledge was 31.40 (SD ±8.65). Knowledge about COVID-19 symptoms and preventive practices had a mean score of 23.93 and 45.96, respectively. The mean scores for perceived vulnerability, severity, benefits, barriers, self-efficacy, and school support were 26.37, 33.21, 43.13, 16.15, 33.38, and 25.45, respectively. The mean score for self-protective practice was 28.38 (SD ±11.04). As perceived benefit (AOR = 0.199, p = 0.000, 95% CI: 0.094-0.304), perceived school support (AOR = 0.125, p = 0.009, 95% CI: 0.032-0.218), and self-efficacy (AOR = 0.186, p = 0.000, 95% CI: 0.102-0.270) increased, COVID-19 self-protective practices also increased and vice versa. However, age (AOR = -0.873, p = 0.006, 95% CI = -1.495, -0.251), perceived vulnerability (AOR = -0.107, p = 0.021; 95% CI = -0.199, -0.016), and maternal educational status (no formal education) (AOR = -5.395, p = 0.000, 95% CI = -7.712 to 3.077) had negatively associated with self-protective practices.

Conclusion

COVID-19 self-protective practice is unsatisfactory. Perceived benefit, perceived school support, and self-efficacy are positively associated with it. However, students' age, perceived vulnerability, and maternal educational status (no formal education) were negatively associated with COVID-19 self-protective measures among secondary school students. The findings underscore that there is a need to conduct risk communications among students. Similarly, awareness creation intervention should target mothers with no formal education.

Development and validation of Health Belief Model based instrument to assess secondary school student's adherence to COVID-19 self-protective practices in Jimma, Oromia, Ethiopia

BACKGROUND

The study aimed in developing and validating a Health Belief Model (HBM) based instrument used for cross-sectional studies among secondary school students in Jimma town, Oromia, Ethiopia.

METHODS

A school-based cross-sectional study was conducted from May 25 to June 10, 2021. The sample size was 634, and students were randomly selected from public and private secondary schools. The 81 items were developed reviewing different literatures based on the constructs of HBM. The constructs were perceived severity, perceived vulnerability, perceived benefit, perceived barrier, self-efficacy, cues to action, perceived school support and self-protective practice. Data were collected using a self-administered questionnaire. The data were cleaned, entered into and analyzed using SPSS 23.0. A principal axis factoring with varimax rotation was carried out to extract items. Items with no loading factor or cross-loaded items were deleted. Items having factor loading coefficient of ≥0.4 were retained. An internal reliability was ensured at Cronbach's alpha >0.70. All items with corrected item-total correlation coefficient below 0.30 were deleted from reliability analysis.

RESULTS

In this study, 576 respondents were participated making a response rate of 90.8%. A total of thirty items were extracted and loaded in to eleven factors with cumulative variance of 56.719%. Percieved social support, percieved benefit, percieved school responsibility, self-efficacy, and practice items were internally consistent. Percieved vurnerability was neither valid nor reliable construct. Similarly, from the extracted factors, attitude towards face mask use and percieved peer influence were not internally consistent. Lastly, percieved benefit, self-efficacy and percieved school responsibility significantly predicted student's adherence to COVID-19 self-protective practices.

CONCLUSIONS

The study found that perceived benefit, perceived school support, social support, self-efficacy, perceived school environment cleanness, perceived school responsibility, perceived school health education, attitude to use face mask, perceived severity, cues to action and perceived peer influence were valid. Finally, perceived benefit, self-efficacy and perceived school responsibility significantly predicted student's adherence to COVID-19 self-protective practices.

Process-based functional analysis can help behavioral science step up to novel challenges: COVID - 19 as an example

Historically speaking, the behavioral tradition advanced functional analysis as a method of applying existing principles to novel situations. In the more than half a century since that idea was advanced, functional analysis has either fallen into disuse, as in most of applied psychology, or has been used but modified to a point that is virtually inapplicable elsewhere, as in applied behavior analysis work with severe developmental disabilities. In this paper we argue that the current challenges with COVID-19 present an ideal time to reinvigorate functional analysis by combining it with the growing body of evidence on processes of change, organized under an extended evolutionary meta-model. This new form of process-based functional analysis takes advantage of the strengths of contextual behavioral science, while opening avenues of fruitful interaction with other wings of intervention and evolutionary science more generally. Using the psychological flexibility model as an example, we show how this approach solves the key problems of classical functional analysis and helps professionals deal with novel challenges such as those posed by COVID-19. Humanity is now facing an extraordinary and unexpected situation. Behavioral science needs to rise to that challenge in a way that provides both immediate practical value and greater assurance of long-term benefits for our understanding of human complexity more generally. Process-based functional analysis can be a vehicle to do just that.

Role of Treatment Theory and Enablement Theory for Restoring Health and Rehabilitation in Saudi Arabia

Several challenges are involved in providing the appropriate treatment during the process of a patient's rehabilitation. Studies conducted in relation to the rehabilitation issues are ineffective in providing useful developments in the provided treatments. Most of the studies lack the utilization of theoretical framework which ultimately proposed weak findings. This study aimed to provide a theoretical framework in relation to the treatment theory as well as the enablement theory along with their effectiveness in improving rehabilitation treatments. The study involves a thorough review undertaking of published articles from 2014 to 2019 that were based on the rehabilitation and other health restoration measures through PubMed and Medline databases. Findings of the study were proposed in the form of a theoretical framework of treatment and the enablement theory. For rehabilitation and clinical researches, it is recommended to use treatment theory and enablement theory to propose unique results that may contribute to the improved healthcare treatment.

Pilot randomized clinical trial of the Teachable Moment Brief Intervention for hospitalized suicide attempt survivors

OBJECTIVE

The aim of this study was to further evaluate the acceptability and feasibility of the Teachable Moment Brief Intervention (TMBI).

METHOD

A single blind, pilot randomized controlled trial of the TMBI + care as usual (CAU) compared to CAU was conducted for patients who survived a recent suicide attempt that required medical inpatient hospitalization. The intervention was delivered on medical/surgical and inpatient psychiatry units in the medical center. Interviews were completed at baseline, 1, 3, and 12 months.

RESULTS

Patients reported high ratings of satisfaction with the TMBI. Interventionists representing fields of Psychiatry, Social Work, and Counseling were able to deliver the intervention with fidelity to the treatment manual with equal adherence ratings. The TMBI patients were more likely to maintain a positive recovery trajectory on motivation and engagement in mental health services at 3 months.

CONCLUSION

The TMBI provides an option for targeted intervention to health care providers as they engage patients admitted to an acute medical setting after a serious suicide attempt. This is the second pilot study demonstrating enhanced motivation in the post-hospitalization period.

Exploring Psychiatric Inpatients' Beliefs About the Role of Post-discharge Follow-up Care in Suicide Prevention

Introduction:

Patients are at increased risk for death by suicide following a psychiatric hospitalization. There has been limited study of the association between patient engagement in follow-up care after psychiatric hospitalization and suicide risk. Understanding why psychiatric inpatients choose to engage in post-discharge care is important in developing effective suicide prevention strategies.

Materials and Methods:

The theory of planned behavior (TPB) has been widely used to understand many health behaviors including healthcare utilization. Using the TPB, we developed an interview guide that assessed psychiatric inpatients’ attitudes and beliefs about the role of post-discharge care in addressing suicide risk. We also inquired about perception of future risk for suicide after discharge. We conducted semi-structured interviews prior to discharge and administered the Columbia-Suicide Severity Rating Scale (C-SSRS). We assessed healthcare utilization at 1 and 3 mo after discharge. We coded and grouped the transcribed data according to the three domains of the TPB model: attitudes, subjective norms, and perceived behavioral control.

Results:

Sixteen individuals consented to enrollment. More than half (N = 10) believed that they were at no or low future suicide risk after discharge. Participants who felt that their future risk for suicide was low or none were significantly older (mean 59.3 yr, SD: 8.3) and reported significantly less severe suicidal ideation in the past month (mean CSSR-S 2.5, SD 2.1) compared to those participants who believed that their future risk was high (mean age 47.5, SD: 8.6; mean CSSR-S 4.7, SD 0.5, p < 0.05). However, all participants had a lifetime history of severe suicidal ideation (mean CSSR-S > 4.7). Many participants felt that peers facilitated treatment engagement. However, participants expressed a tendency to avoid treatment if they experienced unwanted side effects, encountered stigma, or experienced poor-therapeutic alliance. Five participants experienced poor continuity of care after discharge. Of these participants, four reported at the time of discharge no or low perceived future risk of suicide and three were readmitted within 90 d after discharge.

Conclusions:

Individuals may not appreciate that they are at heightened risk for suicide after hospitalization and this may negatively impact treatment engagement.

Concept analysis of adherence

Objective

To explore the concept of adherence in the context of rehabilitation of patients with chronic illnesses. This concept analysis is helpful in predicting health behaviors and intentions including physical activity and dietary behaviors in patients with chronic illnesses.

Methods

The framework of Walker and Avant was used to analyze the concept of adherence.

Results

Adherence is defined as the extent to which a person’s behavior, such as taking medication, following a diet, and/or executing lifestyle changes, corresponds to agreed recommendations from a health-care provider. The antecedents of adherence are the biomedical status of the individual, social support, self-efficacy, and education. Self-report questionnaires and patient self-reporting are the most common measurement tools of adherence. Thus, the reliable and valid instrument of monitoring adherence in the clinical settings is challenging.

Conclusions

Analyzing the concept of adherence is necessary to help understand how best to promote adherence to improve health-related outcomes.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths

BACKGROUND

Suicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention.

METHODS

Thematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment.

RESULTS

Two main themes were identified. The first, 'A therapy that works', revealed inpatients' views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, 'Concerns about in-patient suicide-focused therapy', depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients' whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians.

CONCLUSIONS

We conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting.

TRIAL REGISTRATION NUMBER

ISRCTN 17890126 , Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

Health attitudes and suicidal ideation among university students

OBJECTIVE

The purpose of this study was to examine whether positive health attitudes are associated with suicidal ideation among university students after accounting for other health risk factors linked to suicidal ideation.

PARTICIPANTS

Participants were 690 undergraduates from a large midwestern university during fall semester 2011.

METHODS

Participants reported demographics and health characteristics. Regression models compared individuals who reported suicidal ideation and those who did not.

RESULTS

In unadjusted models, suicidal ideation was significantly negatively associated with positive health attitudes, and positively associated with depression, drug use problems, sleep problems, and being overweight. In adjusted models, more positive health attitudes continued to be significantly negatively associated with suicidal ideation.

CONCLUSIONS

This study suggests a link between positive health attitudes and lower probability of suicidal ideation. Additional research is needed to assess enhancing general health attitudes as a suicide prevention effort.

Suicide acceptability among U.S. Veterans with active duty experience: results from the 2010 General Social Survey

The objective of this study was to examine whether U.S. Veterans more frequently indicate suicide acceptability than non-Veterans. The 2010 General Social Survey, which employed a probability-based sample of U.S. adults, was analyzed by self-reported Veteran status on suicide acceptability in four, separate hypothetical situations regarding ending one's life (i.e., incurable illness, bankruptcy, bringing dishonor/shame upon family, tired of living and ready to die). Veterans were no more likely to endorse suicide as acceptable than their non-Veteran counterparts. Results suggest that attitudes approving of suicide are not different among Veterans in general and non-Veterans. However, future research may need to examine whether subpopulations of Veterans with elevated risk for suicide may report differential attitudes about suicide.