Physical health promotion for young people at ultra-high risk for psychosis: An application of the COM-B model and behaviour-change wheel

The Comparison of Lifestyles, Mental Risks, and Physical Indices among Individuals with Ultra-High Risk of Psychosis, Patients with Schizophrenia, and the General Public

(1) Background: Early interventions may effectively reduce the risk of mental disorders in individuals with ultra-high risk. Specifying the health needs of individuals with ultra-high risk is crucial before the implementation of successful early intervention. This study aimed to explore the differences in lifestyles, mental risks, and physical indices among individuals with ultra-high risk, patients with schizophrenia, and healthy subjects. (2) Methods: A cross-section design applying seven questionnaires with physical examinations for 144 participants aged 13-45 years old was conducted in this study. The questionnaires included one about personal data, four on mental risks, and two for lifestyles. (3) Results: The individuals with ultra-high risk scored similarly in many dimensions as the patients with schizophrenia, but they displayed lower positive symptoms, lower negative symptoms, lower prodromal symptoms, higher interpersonal deficits, lower nutrition intake, and higher levels of exercise than the patients with schizophrenia. Female individuals with ultra-high risk had lower self-esteem, higher positive symptoms, lower nutrition intake, and higher exercise levels than male ones. (4) Conclusions: The study pinpointed specific health needs with interpersonal deficits, nutrition intake, and physical activity for the individuals with ultra-high risk. Future interventions targeted on improving social function, dietary pattern, and exercise will be beneficial.

Co-designing an intervention using the COM-B model to change an eating behaviour in people living with achalasia

Background

Achalasia is a rare motility disorder affecting the oesophagus, leading to difficulties with eating and drinking. Participants in previous studies reported that they needed more social, clinical and behavioural support in the long-term management of achalasia. This study, therefore aimed to 1) identify the most challenging eating behaviour for people living with achalasia and 2) co-design a behaviour change intervention to help address the challenges they experience.

Methods

This study used a qualitative approach involving online focus groups. The COM-B model was the theoretical framework, with behaviour change techniques (BCTs) as the active ingredients that target a mixture of capability, opportunity and/or motivation. Three focus groups were undertaken to obtain a range of input from different people living with achalasia. Participants in this study identified the target behaviour, prioritised the different BCTs which most resonated with them to design an intervention and decided on the mode of delivery. The research team analysed the techniques that helped participants with their eating behaviour using the COM-B model as a framework to create the intervention.

Results

The 24 participants in this study identified "eating in a social setting" as the target behaviour for the intervention. A workbook that can be personalised by the individual was the most suitable intervention. The workbook structure aligns with the constructs of the COM-B model. It includes reflection, activities and goal-setting sections based on what was indicated to be useful for the majority of the participants. Key techniques to overcome the challenges with eating in a social setting included social support, regulation to reduce negative emotions, goals and planning.

Conclusion

Using a focus group approach with the COM-B model as the theoretical framework, the participants in this study developed an intervention to support people living with achalasia. In order to achieve long-term behaviour change, engagement with a personalised workbook could facilitate eating in a social setting. Future work will need to pilot the workbook to ensure it can support people to improve their quality of life and complement the ongoing care they receive from health services.

'Who you gonna call?' A qualitative study of psychiatrists accessing mental health services

OBJECTIVE

To identify motivation, capabilities and opportunities that enable psychiatrists and registrars to seek help for mental health problems and to inform design of interventions.

METHOD

Data collected in qualitative semi-structured interviews were analysed using a framework approach with the COM-B model of behaviour as a theoretical frame.

RESULTS

Accounts of the eight participants show help-seeking to be a complex process requiring cognitive and emotional capability to recognise a problem or goal, acceptance of vulnerability, and facilitated by access to professional networks. Help-seeking was enabled by openness about mental health problems in workplace culture.

CONCLUSIONS

Interventions to enable help-seeking should focus on normalising the experience of mental health problems among doctors and challenge the notion that difficulties represent characterological flaws. Greater understanding of the mandatory reporting requirements is also required.

Evaluating the efficacy of the Thai Health Improvement Profile intervention for preventing weight gain in people with early stage psychosis: A randomized controlled trial

OBJECTIVES

To investigate the efficacy of the Thai Health Improvement Profile intervention for preventing clinically significant weight gain in people with early stage psychosis.

METHODS

We undertook a randomised controlled trial from 10/2018 to 05/2021. Participants with early stage psychosis (<5 year duration) were recruited using convenience sampling from the caseloads of community psychiatric nurses in Thailand and randomly allocated to either the Thai Health Improvement Profile intervention or treatment as usual group following baseline assessment. Outcome assessors were blind to group allocation, whereas participants were not. Participants in the intervention group received three monthly (five in total) systematic health checks using the Thai Health Improvement Profile tool, which was used to develop a personal health plan in collaboration with a family member/carer. Nurses supported participants to implement the health plan using behaviour change techniques derived from motivational interviewing. The treatment as usual group consisted of medication and psychosocial support, and no additional intervention was provided. The primary outcome was weight gain (defined as a greater or equal to 7 % increase in weight against baseline) within 1 year.

RESULTS

Fifty-three participants were allocated to the intervention and an equal number to the treatment as usual group. Primary outcome data were available for 30 participants in each group at the 12 month follow-up. We undertook an intention to treat analysis with multiple imputation (to handle the missing data) for the primary outcome. The treatment as usual group was found to have higher odds than the Thai Health Improvement Profile intervention group of gaining ≥7 % of baseline body weight (OR = 6.52; 95 % CI: 1.88-22.65, p = 0.004).

CONCLUSIONS

The Thai Health Improvement Profile intervention was effective at preventing weight gain in people with early stage psychosis at one year, though attrition was relatively high. The results highlight the need for community mental health nurses to adopt a holistic approach, the potential benefits of conducting regular comprehensive health checks and the importance of involving family members when aiming to improve the physical health of people diagnosed with early stage psychosis. A large definitive multi-site randomised controlled trial of the Thai Health Improvement Profile with a longer follow-up is now justified.

TRIAL REGISTRATION

Prospectively registered with the Thai Clinical Trials Registry (reference: TCTR20180305002).

Planning for Change: Co-Designing Implementation Strategies to Improve the Use of Sensory Approaches in an Acute Psychiatric Unit

Implementing sensory approaches in psychiatric units has proven challenging. This multi-staged study involved qualitative interviews (n = 7) with mental health care staff in an acute psychiatric ward to identify the local factors influencing use of sensory approaches, and co-design implementation strategies with key stakeholders to improve their use. Using framework analysis, results revealed that the use of sensory approaches were hindered by: inadequate access to sensory resources/equipment; lack of time; lack of staff knowledge; and belief that sensory approaches are not effective or part of staff's role. To address identified barriers a systematic theory-informed method was used to co-design implementation strategies to improve the use of sensory approaches.

Physical Activity for Cognitive Health: A Model for Intervention Design for People Experiencing Cognitive Concerns and Symptoms of Depression or Anxiety

BACKGROUND

People experiencing cognitive concerns and symptoms of depression or anxiety are at risk for Alzheimer's disease and dementia. We know physical activity can benefit cognition but understanding how to best support engagement is an ongoing challenge. Evidence-based conceptual models of factors underpinning physical activity engagement in target populations can inform intervention tailoring to address this challenge.

OBJECTIVE

This study (part of a pragmatic physical activity implementation trial) aimed to develop a specified model of physical activity engagement in people experiencing depressive or anxiety symptoms and cognitive concerns, to enable optimized dementia risk reduction intervention tailoring.

METHODS

We employed a qualitative design, triangulating data from three sources: semi-structured individual interviews with people experiencing cognitive concerns and mild to moderate depressive or anxiety symptoms; review of published evidence; and the Capability, Opportunity and Motivation system of behavior, an existing behavioral science model. Findings were integrated to develop a contextualized model of mechanisms of action for optimizing engagement.

RESULTS

Twenty-one participants were interviewed, and 24 relevant papers included. Convergent and complementary themes extended understanding of intervention needs. Findings highlighted emotional regulation, capacities to enact intentions despite barriers, and confidence in existing skills as areas of population-specific need that have not previously been emphasized. The final model provides specificity, directionality, and linked approaches for intervention tailoring.

CONCLUSION

This study demonstrated that people experiencing cognitive concerns and symptoms of depression or anxiety require different interventions to improve physical activity engagement. The novel model can enable more precise intervention tailoring, and, ultimately, benefits for a key at-risk population.

Enabling people with severe mental illness to overcome barriers to access dental treatment: a qualitative study applying COM-B framework analysis

BACKGROUND

The oral health of people with severe mental illness is severely compromised. Rates of premature total tooth loss and tooth decay are substantially higher than in the general population. Causation is complex, restricted access to treatment a major contributing factor.

AIMS

To examine factors enabling people with complex problems related to severe mental illness to attend scheduled dental appointments.

METHOD

Qualitative semi-structured interviews were conducted with 15 service users who attended no-cost treatment at a university clinic, following oral health screening at an inner-city community mental health service. Analysis used a framework approach informed by a theoretical model of behaviour (COM-B).

RESULTS

Complex individual motivations, related variously to function, pain and/or self or social appraisal, were also influenced by expectations of treatment. Capabilities included managing "messy" life circumstances; participants overcame various psychological and physical challenges to attend treatment, enabled by opportunities of social and instrumental support.

CONCLUSIONS

Genuine partnerships between agencies to provide access opportunities, in addition to individual support responsive to personal motivators and adapted to capabilities can enable access to services and improve the lives of people with severe mental illness.

The exploration of a screen model for detecting undergraduates at higher risk for developing psychosis: A cross-sectional study in a medical university

PURPOSE

To examine a screen model for detecting undergraduates with higher risk for developing psychosis (HRDP).

DESIGN AND METHODS

A cross-sectional design with convenience sampling was used. The screen model included exploration stage by self-report scales and confirmation stage by face-to-face interviews.

FINDINGS

A total of 273 students were detected from 4744 surveys during 4 years. Of them, 120 students with HRDP were identified and 7 had been diagnosed as schizophrenia or bipolar disorders at 12-month follow-up.

PRACTICE IMPLICATIONS

This screen model can be used in early detection for undergraduates with HRDP from large general samples.

Cardiometabolic health risks, lifestyle behaviours and quality of life in people diagnosed with early psychosis - A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with schizophrenia have poor cardiometabolic health, with elevated 10-year cardiovascular disease risk (CVD-R) scores and low quality of life (QOL). There is a lack of understanding about CVD-R scores in people diagnosed with early psychosis and no studies have quantified CVD-R using the QRISK^® 3 calculator in this client group. Establishing potential relationships between modifiable lifestyle behaviours/treatment characteristics with CVD-R or QOL may identify targets for early intervention. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to quantify the individual 10-year CVD-R of people diagnosed with early psychosis utilising the QRISK^® 3 calculator. This is also the first study to investigate relationships between QOL and CVD-R and lifestyle factors in a cohort of Thai people diagnosed with early psychosis. We observed low levels of physical health-related QOL and high levels of CVR-R despite participants reporting relatively positive lifestyle behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The cardiometabolic health state of this client group warrants as much attention as for those with an enduring severe mental illness; early preventative interventions are warranted. It may be useful to routinely quantify the CVD-R of people diagnosed with early psychosis using the QRISK^® 3 calculator, even in the absence of immediate concerns about lifestyle behaviours. Mental health nurses should utilise evidence-based approaches such as increasing activity levels, dietary counselling and behaviour change interventions to mitigate poor physical health in this client group. ABSTRACT: Introduction People diagnosed with schizophrenia have poor cardiometabolic health, with elevated 10-year cardiovascular disease risk (CVD-R) scores and poor quality of life (QOL). There is lack of understanding of these issues in early psychosis. Aims To quantify CVD-R in people diagnosed with early psychosis and profile their obesity prevalence, lifestyle behaviours and QOL. Secondary aim was to explore associations between lifestyle behaviours/treatment characteristics and CVD-R/QOL. Method Baseline data from 81 RCT participants were used to profile cardiometabolic health risks (QRISK^® 3, BMI and waist circumference). Participants self-reported lifestyle behaviours and QOL. Relationships between modifiable treatment/lifestyle factors and QOL/CVD-R were explored. Results Participants' relative risk for CVD over 10 years was 1.93 times higher than healthy counterparts; 39% also had an obese BMI and physical QOL was poor. No significant associations were observed between CVD-R or QOL with treatment characteristics and lifestyle factors. Discussion Despite positive lifestyle behaviours, participants had elevated CVD-R scores and poor physical health-related QOL. Quantifying CVD-R with QRISK^® 3 may highlight the need for health promotion interventions. Implications for practice Mental health professionals should be aware that elevated CVD-R exists in the context of relatively healthy lifestyle behaviours and utilise evidence-based interventions to address these issues.

'No-one else wears one:' Exploring farmer attitudes towards All-Terrain Vehicle helmets using the COM-B model

INTRODUCTION

All-Terrain Vehicles (ATV) are a popular piece of farming machinery but are linked to many fatalities and injuries every year. Despite evidence that ATV helmets reduce the risk of serious or fatal injury, research suggests that few farmers wear them. The aim of this study was to explore farmer attitudes toward ATV helmets, using the COM-B model as a framework to identify key barriers and enablers of helmet use and suggest potential interventions to increase helmet use in agriculture.

METHODS

A mixed-methods online survey featuring quantitative and qualitative questions was used to explore key attitudinal factors relevant to farmer helmet wearing. A total of 211 UK and Irish farmers were recruited, including farm owners, managers, workers, and contractors.

RESULTS

Personal exemption from risk, emotional benefits, cognitive barriers, and guideline prompts were all found to be significant predictors of farmer helmet wearing. Key categories within the qualitative data indicated that helmet properties, risk perception, farming culture, and the farming environment could all function as barriers to helmet wearing. Suggested enablers of helmet use included increasing helmet availability and enhancing awareness of the consequences of ATV accidents.

CONCLUSIONS

The key barriers and enablers presented within this paper highlight the relevance of capability (helmet design, time pressure), opportunity (social norms), and motivation (perceived control of risk) when considering farmer helmet wearing behaviors. In order to encourage farmers to wear helmets it will be necessary to design specific interventions using the behavior change wheel.

PRACTICAL APPLICATIONS

Key interventions to prompt helmet use include the inclusion of more cues to prompt helmet wearing (e.g., stickers on the ATV), enhanced training and education, and modelling (e.g., key farming figures shown to wear helmets in the media).

Experiences and perceptions on sexuality, risk and STI/HIV prevention campaigns by university students. Designing a digital intervention

This study reports on the qualitative phase of a study that seeks to design a digital intervention for the prevention of STI / HIV and promotion of sexual health in university students. The experience and perception that university students have about sexuality, risk and prevention campaigns are addressed through focus groups. Semi-structured interviews are conducted with key informants. The results reveal that sexual education is limited and restricted to the biological aspect, as well as loaded with prejudices and gender biases, which narrows the information provided to the student population. Wavering prevention strategies that fail to motivate students or offer them opportunities for making informed and independent decisions about their sexual health are apparent. The STI / HIV campaigns assessed are distant, fear-based and not inclusive. Interventions in sexual health do not weigh experiential aspects of youth sexuality, as they are based on models of ideal and stereotyped behavior, discarding first-person narratives and their rich complexity. It is imperative to innovate in the prevention of STI/HIV, formulating interventions based on an integrative, multidisciplinary and contextualized design that values the theory and experience of the target populations.

Overcoming Barriers to Injectable Therapies: Development of the ORBIT Intervention Within a Behavioural Change Framework

It is estimated among individuals with type 2 diabetes (T2D) requiring injectable therapies to achieve optimal glycaemic control, one-third are reluctant to initiate therapies, with approximately 80% choosing to discontinue or interrupt injectable regimens soon after commencement. Initiation of injectables is a complex issue, with effectiveness of such treatments undermined by non-adherence or poor engagement. Poor engagement and adherence are attributed to psychological aspects such as individuals’ negative perceptions of injectables, depression, anxiety, feelings of shame, distress and perceived lack of control over their condition. The aim of this study was to describe the development of a structured diabetes intervention to address psychological barriers to injectable treatments among a cohort of those with T2D; conducted within a behavioural change framework. An evidence base was developed to inform on key psychological barriers to injectable therapies. A systematic review highlighted the need for theory-based, structured diabetes education focussed on associated psychological constructs to inform effective, patient-centric provisions to improve injectable initiation and persistence. Findings from the focus groups with individuals who had recently commenced injectable therapies, identified patient-centric barriers to initiation and persistence with injectables. Findings from the systematic review and focus groups were translated via Behavioural Change Wheel (BCW) framework to develop an intervention for people with T2D transitioning to injectable therapies: Overcoming and Removing Barriers to Injectable Treatment in T2D (ORBIT). This article describes how psychological barriers informed the intervention with these mapped onto relevant components, intervention functions and selected behaviour change techniques, and finally aligned with behaviour change techniques. This article outlines the systematic approach to intervention development within the BCW framework; guiding readers through the practical application of each stage. The use of the BCW framework has ensured the development of the intervention is theory driven, with the research able to be evaluated and validated through replication due to the clarity around processes and tasks completed at each stage.

Exercise training complementary to specialised early intervention in patients with first-episode psychosis: a feasibility randomised trial

Background

The aim of this study was to examine feasibility of trial processes and group-based, structured exercise training in patients with first-episode psychosis.

Methods

Twenty-five patients with first-episode psychosis took part in a two-arm randomised feasibility trial. They were individually randomised (1:1) via a computer-generated randomisation sequence and allocated to either an exercise intervention group (INT) or a control group (CON). Patients allocated to INT completed a physical exercise training programme at moderate-to-vigorous intensity, 1 h three times weekly for 8 weeks. CON patients were encouraged to continue their usual level of activity and were offered the training programme after 8 weeks. Primary outcomes included screening rate, recruitment rate, retention rate, attendance and adverse events. Secondary outcomes included heart rate response during training, cardiovascular health (VO_2max, resting heart rate, blood pressure), body composition (muscle mass, fat percentage), muscle strength (sit-to-stand, grip strength, jump height) and balance.

Results

Recruitment lasted 6 weeks and 86 out of 324 patients (27%) were screened, 71 of whom (83%) were deemed eligible. Twenty-five (35%) accepted inclusion (mean age 25.5; mean body mass index 25.1) and were subsequently randomised (INT = 13, CON = 12). Retention of patients was 76% and 52% at the 8-week and 16-week follow-up, respectively. Attendance was 43% (min. 9%, max. 96%). No significant changes were observed between groups in secondary physiological outcome measures.

Conclusions

Feasibility was challenged by limited recruitment and retention rates, suggesting that modifications are required if a large-scale randomised controlled trial is to be conducted. Recommendations for modifications are presented and discussed.

Trial registration

Clinicaltrials.gov, NCT03409393. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00900-5.

Palm oil: Understanding barriers to sustainable consumption

Palm oil is relatively inexpensive, versatile, and popular, generating great economic value for Southeast Asian countries. However, the growing demand for palm oil is leading to deforestation and biodiversity loss. The current study is the first to employ a capability-opportunity-motivation (COM-B) framework in green consumerism, to determine which capability, opportunity, and motivation factors strongly predict the intentional purchasing of sustainable palm oil products by Australian consumers (N = 781). Exploratory factor analysis revealed four main types of predictors of SPO purchasing–Pro-Green Consumption Attitudes, Demotivating Beliefs, Knowledge and Awareness, and Perceived Product Availability. Multiple regression revealed that these four factors explained 50% of the variability in SPO purchasing behaviour, out of which Knowledge and Awareness accounted for 18% of the unique variance. Perceived Product Availability and Pro-Green Consumption Attitudes were also significant predictors but accounted for only 2% and 1% of unique variance, respectively. These results provide a valuable foundation for designing behaviour change interventions to increase consumer demand for sustainable palm oil products.

Proof-of-Concept Support for the Development and Implementation of a Digital Assessment for Perinatal Mental Health: Mixed Methods Study

Background

Perinatal mental health symptoms commonly remain underdiagnosed and undertreated in maternity care settings in the United Kingdom, with outbreaks of disease, like the COVID-19 pandemic, further disrupting access to adequate mental health support. Digital technologies may offer an innovative way to support the mental health needs of women and their families throughout the perinatal period, as well as assist midwives in the recognition of perinatal mental health concerns. However, little is known about the acceptability and perceived benefits and barriers to using such technologies.

Objective

The aim of this study was to conduct a mixed methods evaluation of the current state of perinatal mental health care provision in the United Kingdom, as well as users’ (women and partners) and midwives’ interest in using a digital mental health assessment throughout the perinatal period.

Methods

Women, partners, and midwives were recruited to participate in the study, which entailed completing an online survey. Quantitative data were explored using descriptive statistics. Open-ended response data were first investigated using thematic analysis. Resultant themes were then mapped onto the components of the Capability, Opportunity, and Motivation Behavior model and summarized using descriptive statistics.

Results

A total of 829 women, 103 partners, and 90 midwives participated in the study. The provision of adequate perinatal mental health care support was limited, with experiences varying significantly across respondents. There was a strong interest in using a digital mental health assessment to screen, diagnose, and triage perinatal mental health concerns, particularly among women and midwives. The majority of respondents (n=781, 76.42%) expressed that they would feel comfortable or very comfortable using or recommending a digital mental health assessment. The majority of women and partners showed a preference for in-person consultations (n=417, 44.74%), followed by a blended care approach (ie, both in-person and online consultations) (n=362, 38.84%), with fewer participants preferring online-only consultations (n=120, 12.88%). Identified benefits and barriers mainly related to physical opportunity (eg, accessibility), psychological capability (eg, cognitive skills), and automatic motivation (eg, emotions).

Conclusions

This study provides proof-of-concept support for the development and implementation of a digital mental health assessment to inform clinical decision making in the assessment of perinatal mental health concerns in the United Kingdom.

Daily Motivational Text Messages to Promote Physical Activity in University Students: Results From a Microrandomized Trial

BACKGROUND

Low physical activity is an important risk factor for common physical and mental disorders. Physical activity interventions delivered via smartphones can help users maintain and increase physical activity, but outcomes have been mixed.

PURPOSE

Here we assessed the effects of sending daily motivational and feedback text messages in a microrandomized clinical trial on changes in physical activity from one day to the next in a student population.

METHODS

We included 93 participants who used a physical activity app, "DIAMANTE" for a period of 6 weeks. Every day, their phone pedometer passively tracked participants' steps. They were microrandomized to receive different types of motivational messages, based on a cognitive-behavioral framework, and feedback on their steps. We used generalized estimation equation models to test the effectiveness of feedback and motivational messages on changes in steps from one day to the next.

RESULTS

Sending any versus no text message initially resulted in an increase in daily steps (729 steps, p = .012), but this effect decreased over time. A multivariate analysis evaluating each text message category separately showed that the initial positive effect was driven by the motivational messages though the effect was small and trend-wise significant (717 steps; p = .083), but not the feedback messages (-276 steps, p = .4).

CONCLUSION

Sending motivational physical activity text messages based on a cognitive-behavioral framework may have a positive effect on increasing steps, but this decreases with time. Further work is needed to examine using personalization and contextualization to improve the efficacy of text-messaging interventions on physical activity outcomes.

CLINICALTRIALS.GOV IDENTIFIER

NCT04440553.

Effects of the Health-Awareness-Strengthening Lifestyle Program in a Randomized Trial of Young Adults with an At-Risk Mental State

Background: Increasing health awareness in health promotion is considered as one of the less stigmatized interventions for improving help-seeking behaviors and total well-being. This study aimed to explore the short-term and long-term effectiveness of the health-awareness-strengthening lifestyle (HASL) program on Taiwanese young adults with at-risk mental state. Methods: A pre- and post-test randomized trial was conducted on 92 young adults with at-risk mental state. The HASL program was provided to the experimental group as intervention, and it was only provided to the control group passively by request after the post-test for ethical reasons. The program was conducted once every six weeks, 60–90 min per session, for a total of three times. Mental health risk, anxiety level, health promotion lifestyles, quality of life, physiological index, and physical exercises were assessed one week before and after the program for both groups and followed up to 6 and 12 months for experimental group only. Results: Compared to the control group, those in the experimental group showed significant improvements regarding anxiety level, health promotion lifestyles, and quality of life one week after participating in the program. Furthermore, the experimental group also showed an additional long-term positive effect on mental risk, physical exercises, and physical health after the follow-ups. Conclusions: The outcomes highlighted the interventions of the HASL program leading to more positive health effects on young adults with at-risk mental state. The implementation of similar clinical service is recommended for young adults with at-risk mental state.

Improving case detection of tuberculosis in hospitalised Kenyan children-employing the behaviour change wheel to aid intervention design and implementation

BACKGROUND

The true burden of tuberculosis in children remains unknown, but approximately 65% go undetected each year. Guidelines for tuberculosis clinical decision-making are in place in Kenya, and the National Tuberculosis programme conducts several trainings on them yearly. By 2018, there were 183 GeneXpert® machines in Kenyan public hospitals. Despite these efforts, diagnostic tests are underused and there is observed under detection of tuberculosis in children. We describe the process of designing a contextually appropriate, theory-informed intervention to improve case detection of TB in children and implementation guided by the Behaviour Change Wheel.

METHODS

We used an iterative process, going back and forth from quantitative and qualitative empiric data to reviewing literature, and applying the Behaviour Change Wheel guide. The key questions reflected on included (i) what is the problem we are trying to solve; (ii) what behaviours are we trying to change and in what way; (iii) what will it take to bring about desired change; (iv) what types of interventions are likely to bring about desired change; (v) what should be the specific intervention content and how should this be implemented?

RESULTS

The following behaviour change intervention functions were identified as follows: (i) training: imparting practical skills; (ii) modelling: providing an example for people to aspire/imitate; (iii) persuasion: using communication to induce positive or negative feelings or stimulate action; (iv) environmental restructuring: changing the physical or social context; and (v) education: increasing knowledge or understanding. The process resulted in a multi-faceted intervention package composed of redesigning of child tuberculosis training; careful selection of champions; use of audit and feedback linked to group problem solving; and workflow restructuring with role specification.

CONCLUSION

The intervention components were selected for their effectiveness (from literature), affordability, acceptability, and practicability and designed so that TB programme officers and hospital managers can be supported to implement them with relative ease, alongside their daily duties. This work contributes to the field of implementation science by utilising clear definitions and descriptions of underlying mechanisms of interventions that will guide others to do likewise in their settings for similar problems.

Barriers and opportunities for cleanliness of shared sanitation facilities in low-income settlements in Kenya

Background

The sharing of sanitation facilities is a common practice in low-income areas in sub-Saharan Africa. However, shared sanitation is currently categorized as a limited sanitation service, and may therefore not count towards meeting the global goals. These shared facilities are often the only option available for most residents in low-income settlements, and improving their cleanliness and overall management is key to reducing open defecation and risk of disease. This study sought to investigate barriers and opportunities for improved cleanliness of shared sanitation facilities in low-income settlements of Kisumu city, Kenya.

Methods

Thirty-nine in-depth interviews and 11 focus group discussions were held with residents – mainly tenants and landlords – of a low-income settlement in Kisumu. Analysis followed a thematic approach to define the problem, specify the target behaviour and identify the changes needed.

Results

Sanitation facilities were mainly pit latrines, typically shared among landlords and tenants. Participants singled out behavioural (poor use of the shared toilets) and social (lack of cooperation in cleaning) challenges that led to unclean shared toilets. Available opportunities for improvement included instituting clear cleaning plans, improving communication among users, and enhanced problem-solving mechanisms between landlords and tenants. These approaches could form the basis for designing intervention strategies for improving the cleanliness of shared sanitation facilities.

Conclusion

The results highlight the need to focus on social aspects for improvement of cleanliness in shared sanitation facilities in low-income settlements. Through a social approach, shared sanitation facilities can be managed appropriately to provide the millions of low-income residents in Kenya an opportunity to access sanitation. This study provides further evidence on approaches for improved management of shared sanitation facilities in line with the World Health Organization’s (WHO) Joint Monitoring Program’s (JMP) recommendation for high quality shared facilities.

Motivational theory-based interventions on health of people with several mental illness: A systematic review and meta-analysis

Motivational theory-based interventions are known to be effective for increasing physical activity (PA) in the general population but their effects in people with severe mental illness are poorly understood. Therefore, we conducted a meta-analysis on the effect of these interventions on PA and cardiometabolic risk factors. A systematic search of randomized controlled trials through 6 databases was carried out from inception to March 2019. Analyses were conducted using random-effect models. Weighted mean difference (WMD) were used as effect size when outcomes had the same units, otherwise Hedge's g was used. Fourteen articles including 2128 participants were identified. Motivational theory-based interventions were effective in increasing PA (g = 0.27, 95%CI[0.03; 0.51], p = .003), reducing weight (WMD = -1.87 kg, 95%CI[-2.98; -0.76], p = .001), body mass index (WMD = -0.82 kg/m², 95%CI[-1.23; -0.41], p = .009), waist circumference (WMD = -1.91 cm, 95%CI[-3.63; -0.18], p = .03) and fasting glucose (g = -0.17, 95%CI[-0.34; -0.001], p = .04). Larger effect sizes were found in interventions based on only one theoretical model of motivation. In conclusion, interventions using motivational theories are effective to improve PA levels and the cardiometabolic health profile of people with severe mental illness. Systematic review registration: CRD42018104445.

Perspectives and practices of health workers around diagnosis of paediatric tuberculosis in hospitals in a resource-poor setting - modern diagnostics meet age-old challenges

BACKGROUND

Detection of tuberculosis (TB) in children in Kenya is sub-optimal. Xpert MTB/RIF® assay (Xpert®) has the potential to improve speed of TB diagnosis due to its sensitivity and fast turnaround for results. Significant effort and resources have been put into making the machines widely available in Kenya, but use remains low, especially in children. We set out to explore the reasons for the under-detection of TB and underuse of Xpert® in children, identifying challenges that may be relevant to other newer diagnostics in similar settings.

METHODS

This was an exploratory qualitative study with an embedded case study approach. Data collection involved semi-structured interviews; small-group discussions; key informant interviews; observations of TB trainings, sensitisation meetings, policy meetings, hospital practices; desk review of guidelines, job aides and policy documents. The Capability, Opportunity and Motivation (COM-B) framework was used to interpret emerging themes.

RESULTS

At individual level, knowledge, skill, competence and experience, as well as beliefs and fears impacted on capability (physical & psychological) as well as motivation (reflective) to diagnose TB in children and use diagnostic tests. Hospital level influencers included hospital norms, processes, patient flows and resources which affected how individual health workers attempted to diagnose TB in children by impacting on their capability (physical & psychological), motivation (reflective & automatic) and opportunity (physical & social). At the wider system level, community practices and beliefs, and implementation of TB programme directives impacted some of the decisions that health workers made through capability (psychological), motivation (reflective & automatic) and opportunity (physical).

CONCLUSION

We used comprehensive approaches to identify influencers of TB case detection and use of TB diagnostic tests in children in Kenya. These results are being used to design a contextually-appropriate intervention to improve TB diagnosis, which may be relevant to similar low-resource, high TB burden countries and can be feasibly implemented by the National TB programme.

Defining healthstyles to plan behavior change interventions in representative samples of children and adults

Based on Michie's COM-B model, we developed a survey methodology and segmentation procedure to identify groups of Hungarian school children and adults with distinctive characteristics, named healthstyles. We aimed to find interventions fitting to each healthstyle to generate behavioural change. For the segmentation of data, the latent class analysis method was applied. The analysis resulted in 8 healthstyles for the school children and 13 for the adults. Each healthstyle possess distinctive 'traits' and, therefore, special behavioural change methods and prevention strategies can be fitted for them. For demonstrating the advantages of using healthstyles, we discuss possible approaches for selecting behavioural change interventions, one for school children and one for adults.

What prevents youth at clinical high risk for psychosis from engaging in physical activity? An examination of the barriers to physical activity

BACKGROUND

Exercise has increasingly been proposed as a healthful intervention prior to and after the onset of psychosis. There is some evidence to suggest that youth at clinical high risk (CHR) for psychosis are less physically active and report more barriers to engaging in exercise; however, there has been relatively limited empirical work documenting this phenomenon, and to date, relationships between physical activity, barriers, and clinical phenomenology have been unclear.

METHODS

CHR (N = 51) and healthy control (N = 37) participants completed a structured clinical interview assessing attenuated psychotic symptoms and substance use, and an exercise survey that assessed current exercise practices, perceived physical fitness, and barriers related to engaging in exercise.

RESULTS

CHR youth engaged in less physical activity, exhibited lower perception of fitness, and endorsed more barriers related to motivation for exercise. The CHR group showed significant negative correlations where lower perceptions of fitness were associated with increased negative, disorganized, and general symptoms. Decreased frequency of activity was related to more barriers of motivation. Interestingly, greater symptomatology in the CHR group was associated with more barriers of self-perception and motivation for engaging in exercise. However, findings suggested a nuanced relationship in this area; for example, increased physical activity was associated with increased substance use.

CONCLUSIONS

The results of the current study support the notion that sedentary behavior is common in CHR youth, and more broadly, provide an impetus to target motivation through supervised exercise and fitness tracking to promote the health and well-being of CHR individuals.

Chinese Health Improvement Profile for people with severe mental illness: A cluster-randomized, controlled trial

The aim of the present study was to establish the feasibility of conducting a full-scale trial and to estimate the preliminary effect of a Chinese Health Improvement Profile (CHIP) intervention on self-reported physical well-being of people with severe mental illness (SMI). The study used a parallel-group, open-label, cluster-randomized, controlled trial (RCT) design. Twelve community psychiatric nurses (CPN) and their corresponding 137 patients with SMI were randomized into the CHIP or treatment-as-usual (TAU) groups. After training, the CPN completed the CHIP at baseline and 12 months, and the findings were used to devise an individualized care plan to promote health behaviour change. Patients were assessed at baseline and 6 and 12 months after starting the intervention. There was an observed positive trend of improvement on the physical component subscale of SF12v2 in the CHIP group compared to the TAU group after 12 months, but the difference did not reach statistical significance (P = 0.138). The mental component subscale showed a similar positive trend (P = 0.077). CHIP participants were more satisfied with their physical health care than TAU patients (P = 0.009), and the CPN were positive about the usefulness/acceptability of the intervention. There were significant within-group improvements in the total numbers of physical health risks, as indicated by the CHIP items (P = 0.005). The findings suggest that it is feasible to conduct a full-scale RCT of the CHIP in future. The CHIP is an intervention that can be used within routine CPN practice, and could result in small-modest improvements in the physical well-being of people with SMI.