Approaches to co-production of research in care homes: a scoping review

BACKGROUND

Using the technique of co-production to develop research is considered good practice. Co-production involves the public, practitioners and academics working together as equals throughout a research project. Co-production may help develop alternative ways of delivering care for older adults that are acceptable to those who live and work in care homes. However, guidance about applying co-production approaches in this context is lacking. This scoping review aims to map co-production approaches used in care homes for older adults in previous research to support the inclusion of residents and care staff as equal collaborators in future studies.

METHODS

A scoping review was conducted using the Joanna Briggs Institute scoping review methodology. Seven electronic databases were searched for peer-reviewed primary studies using co-production approaches in care home settings for older adults. Studies were independently screened against eligibility criteria by two reviewers. Citation searching was completed. Data relating to study characteristics, co-production approaches used, including any barriers and facilitators, was charted by one reviewer and checked by another. Data was summarised using tables and diagrams with an accompanying narrative description. A collaborator group of care home and health service representatives were involved in the interpretation of the findings from their perspectives.

RESULTS

19 studies were selected for inclusion. A diverse range of approaches to co-production and engaging key stakeholders in care home settings were identified. 11 studies reported barriers and 13 reported facilitators affecting the co-production process. Barriers and facilitators to building relationships and achieving inclusive, equitable and reciprocal co-production were identified in alignment with the five NIHR principles. Practical considerations were also identified as potential barriers and facilitators.

CONCLUSION

The components of co-production approaches, barriers and facilitators identified should inform the design of future research using co-production approaches in care homes. Future studies should be explicit in reporting what is meant by co-production, the methods used to support co-production, and steps taken to enact the principles of co-production. Sharing of key learning is required to support this field to develop. Evaluation of co-production approaches, including participants' experiences of taking part in co-production processes, are areas for future research in care home settings.

496 NON-RANDOMISED FEASIBILITY STUDY OF THE REHABILITATION POTENTIAL ASSESSMENT TOOL (REPAT) IN FRAIL OLDER PEOPLE IN ACUTE SETTING

Introduction

Clinicians are often required to decide about patients’ potential to respond to rehabilitation. ‘Rehabilitation potential’ can determine what services patients can access. In acute hospitals clinicians have limited time to assess and deliver rehabilitation which takes into account the complexities of frailty and ageing. We set out to evaluate whether the Rehabilitation Potential Assessment Tool (RePAT)—a 15 item assessment tool and training package which emphasises person-centred approaches—was feasible and could aid rehabilitation decisions.

Method

A non-randomised feasibility study with nested semi-structured interviews, set in the acute hospital, explored whether RePAT was deliverable and acceptable to staff, patient and carers. A maximum variation sample of physiotherapists and occupational therapists was recruited. Patient and carer participants were recruited from Healthcare of Older People wards. Staff and patient characteristics were summarised using descriptive statistics. Interview data were analysed thematically. Fidelity of completed RePAT items was assessed on how closely they matched tool guidance by two reviewers. Mean values of the two scores were calculated.

Results

Six staff participants were recruited and trained, and assessed a total of 26 patient participants using RePAT. Mean patient age was 86.16 (±6.39) years. 32% were vulnerable or mildly frail, 42% moderately frail and 26% severely or very severely frail using the Clinical Frailty Scale. Mean time to complete RePAT was 32.7 (±9.6) minutes. 13 out of 15 RePAT items achieved fidelity. RePAT was acceptable and tolerated by staff and patients. Staff participants reported RePAT enabled them to consider the complex and dynamic nature of rehabilitation decisions in a more structured and consistent way.

Conclusion

RePAT was found to be acceptable and tolerated by staff, carers and patients. It allowed clinicians to make explicit their reasoning behind rehabilitation potential decision-making and encouraged them to become more cognisant of ethical dilemmas and biases.

Contamination in complex healthcare trials: the falls in care homes (FinCH) study experience

Background

Trials are at risk of contamination bias which can occur when participants in the control group are inadvertently exposed to the intervention. This is a particular risk in rehabilitation studies where it is easy for trial interventions to be either intentionally or inadvertently adopted in control settings. The Falls in Care Homes (FinCH) trial is used in this paper as an example of a large randomised controlled trial of a complex intervention to explore the potential risks of contamination bias. We outline the FinCH trial design, present the potential risks from contamination bias, and the strategies used in the design of the trial to minimise or mitigate against this. The FinCH trial was a multi-centre randomised controlled trial, with embedded process evaluation, which evaluated whether systematic training in the use of the Guide to Action Tool for Care Homes reduced falls in care home residents.

Data were collected from a number of sources to explore contamination in the FinCH trial. Where specific procedures were adopted to reduce risk of, or mitigate against, contamination, this was recorded. Data were collected from study e-mails, meetings with clinicians, research assistant and clinician network communications, and an embedded process evaluation in six intervention care homes.

During the FinCH trial, there were six new falls prevention initiatives implemented outside the study which could have contaminated our intervention and findings. Methods used to minimise contamination were: cluster randomisation at the level of care home; engagement with the clinical community to highlight the risks of early adoption; establishing local collaborators in each site familiar with the local context; signing agreements with NHS falls specialists that they would maintain confidentiality regarding details of the intervention; opening additional research sites; and by raising awareness about the importance of contamination in research among participants.

Conclusion

Complex rehabilitation trials are at risk of contamination bias. The potential for contamination bias in studies can be minimized by strengthening collaboration and dialogue with the clinical community. Researchers should recognise that clinicians may contaminate a study through lack of research expertise.

Description of an Occupational Therapy Intervention Aimed at Improving Outdoor Mobility

After a stroke people can find outdoor mobility difficult, but a targeted occupational therapy intervention has been shown to help people to get out of the house more often. This study describes the intervention.

The occupational therapists who provided the intervention kept records of the number and duration of therapy sessions, the goal of therapy and the activities undertaken. As part of the trial, functional and mobility outcome assessments were completed by the participants 4 and 10 months after recruitment and were used to compare the goals set with the goals achieved and the mobility performance.

Eighty-six participants were randomised to, and 78 received, the intervention. They received a median of 6 (mean 4.7, SD 1.9) sessions, with an average of 40 minutes per session. Sixty (77%) of the participants achieved their primary goal. Those who did not had greater functional limitations at the start of the study than those who did. Walking was the most common goal (17/78, 22%) and the most performed activity (135 times, 33%). Thirteen participants achieved walking and 12 of these were still walking outside at the 10-month assessment.

Three-quarters of people with stroke were therefore able to achieve their outdoor mobility goals after an occupational therapy intervention.

The Use of Transport by Stroke Patients

The objectives of this research were to survey the use of transport by stroke patients in the community and study its relationship to their activities of daily living and mood.

The records of 90 consecutive stroke patients receiving community occupational therapy in a rehabilitation trial were surveyed for entries of therapy related to transport. A further 50 stroke patients in the same study were surveyed about their use of transport one year after discharge from hospital.

In the survey of occupational therapy notes, a transport assessment had been recorded for all 90 patients. Of these, 22 patients had been given leaflets describing the range of transport options locally but had been unable to use these options.

In the survey of transport use, 42/50 (84%) patients surveyed at one year responded. Twenty-one (50%) had used transport on their own, six of whom scored <26/66 on the Extended Activities of Daily Living scale (indicating that they needed help in most activities of daily living). Twenty-one (50%) patients had not travelled alone, four of whom scored >48/66 on the Extended Activities of Daily Living scale (very able in activities of daily living). Only 1 (2%) patient had used specialist transport and 22 (52%) reported that they did not get out as much as they wished.

Despite receiving advice, these patients did not use specialist transport options, yet many still wanted to get out more. The reason for this is unclear but it is not due simply to physical disability.

Using an interview study of transport use by people who have had a stroke to inform rehabilitation

Introduction: Many people who have had a stroke want to get out of their house more often. This study explored attitudes and barriers to the use of transport with the aim of informing rehabilitation.

Method: Semi-structured interview study of 24 community-dwelling people who had had a stroke, purposively sampled to find people with a variety of recent experiences of transport. Interviews were taped and transcribed. Analysis was by constant comparative methodology, to develop emerging themes and concepts.

Results: Interviewees wanted to travel for specific purposes but also for its own sake. Many could no longer use their car. This gave them less flexibility to travel and reduced their autonomy. Barriers to using alternative forms of transport were fear of injury or embarrassment from falling, an associated lack of confidence, inadequate information about transport services, perceptions about the cost of taxis and pavement vehicles (scooters) and environmental factors such as the weather. Those who could drive, or who lived with someone who did, gave the most positive descriptions of transport use. Those reliant on family or friends felt they could ask only for help getting to health-related appointments and those who used specialist transport services provided the most negative descriptions of transport.

Conclusions: Many of the barriers to transport use after stroke may be amenable to intervention. An intervention package capable of re-enabling people to drive or be driven, to use a pavement scooter safely, to provide information about the alternatives and to encourage best use of public transport is worth developing.

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

OBJECTIVE

To evaluate an occupational therapy intervention to improve outdoor mobility after stroke.

DESIGN

Randomised controlled trial.

SETTING

General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital.

PARTICIPANTS

168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group.

INTERVENTIONS

Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group).

MAIN OUTCOME MEASURES

Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire.

RESULTS

Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months.

CONCLUSION

A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

A study of interventions and related outcomes in a randomized controlled trial of occupational therapy and leisure therapy for community stroke patients

OBJECTIVE

To undertake a detailed analysis of therapy provided in a multicentred randomized controlled trial of activities of daily living (ADL) and leisure (TOTAL), testing the hypothesis that specific interventions given in the trial affected specific aspects of outcome.

SUBJECTS

Three hundred and nine stroke patients who had been randomly allocated to receive either occupational therapy aimed at ADL activities (n = 156) or leisure (n = 153).

MEASURES

Number, duration and type of activity undertaken per patient. Barthel Index, Extended Activities of Daily Living Scale (EADL) and Nottingham Leisure Questionnaire (NLQ) six months after entry to the study.

METHOD

Activities that had been used in treatment were coded and categorized. Frequently used activities identified. These activities were matched to items from the six-month outcome measures. Patient independence in these outcome items was compared between the leisure and ADL groups.

RESULTS

Three hundred and nine therapy record forms were returned. Patients received a median of ten sessions with a median duration of 55 minutes. The ADL group received significantly more, mobility training, transfer training, cleaning, dressing, cooking and bathing training (chi-squared, p < 0.05). Sport, creative activities, games, hobbies, gardening, entertainment and shopping were used significantly more in the leisure group (chi-squared, p < 0.05) than the ADL group. Fifteen items from the outcome measures were identified as specific to these interventions. There were no statistically significant differences in outcome on these 15 items between the ADL and leisure groups (chi-squared, p > 0.05).

CONCLUSIONS

We found no evidence that specific ADL or leisure interventions led to improvements in specific relevant outcomes. We believe that these findings should prompt a review of the relationship between process and outcome of occupational therapy.

Development and validation of the Nottingham Leisure Questionnaire (NLQ)

OBJECTIVES

To reduce the length of the Nottingham Leisure Questionnaire (NLQ) in order to make it more suitable for postal use, and to evaluate its test-retest reliability, sensitivity, stability and validity in relation to other measures of activities of daily living (ADL), mood and handicap.

METHOD

The NLQ was shortened and the response categories collapsed. Results from a previous trial which had used the NLQ were reanalysed to establish if significant group differences were maintained. The new version of the NLQ was subsequently tested for test-retest reliability on a new group of patients from the Nottingham stroke register who were asked to complete it twice. The new NLQ and other measures were sent to patients in a multicentre rehabilitation trial (TOTAL) six and twelve months after recruitment for postal completion.

SUBJECTS

One hundred and thirty-seven consecutive patients from the Nottingham stroke register and 466 patients with a stroke in a multicentre rehabilitation trial.

RESULTS

The original NLQ was reduced from 37 to 30 items and from five to three response categories. Data from an earlier study were reanalysed and differences between treatment groups remained. The results of a test-retest analysis using kappa showed that six items had excellent agreement, 15 good and nine fair, suggesting acceptable test-retest reliability. Results from the rehabilitation trial showed that the subjects performed all items and few additional activities were suggested. Higher NLQ scores were associated with higher subscores on the Nottingham Extended Activities of Daily Living Scale (NEADL) and lower NLQ scores with living alone and worse emotional health.

CONCLUSION

The NLQ has been successfully modified for postal self-administration but there is potential for further development.

An evaluation of the concept of living at moderate altitude and training at sea level

Despite equivocal findings about the benefit of altitude training, current theory dictates that the best approach is to spend several weeks living at > or =2500 m but training near sea level. This paper summarizes six studies in which we used simulated altitude (normobaric hypoxia) to examine: (i) the assumption that moderate hypoxia compromises training intensity (two studies); and (ii) the nature of physiological adaptations to sleeping in moderate hypoxia (four studies). When submaximal exercise was >55% of sea level maximum oxygen uptake (VO2max), 1800 m simulated altitude significantly increased heart rate, blood lactate and perceived exertion of skiers. In addition, cyclists self-selected lower workloads during high-intensity exercise in hypoxia (2100 m) than in normoxia. Consequently, our findings partially confirm the rationale for 'living high, training low'. In the remaining four studies, serum erythropoietin increased 80% in the early stages of hypoxic exposure, but the reticulocyte response did not significantly exceed that of control subjects. There was no significant increase in haemoglobin mass (Hb(mass)) and VO2max tended to decrease. Performance in exercise tasks lasting approximately 4 min showed a non-significant trend toward improvement (1.0+/-0.4% vs. 0.1+/-0.4% for a control group; P=0.13 for group x time interaction). We conclude that sleeping in moderate hypoxia (2650-3000 m) for up to 23 days may offer practical benefit to elite athletes, but that any effect is not likely due to increased Hb(mass) or VO2max.

A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. TOTAL Study Group. Trial of Occupational Therapy and Leisure

OBJECTIVE

To evaluate the effects of leisure therapy and conventional occupational therapy (OT) on the mood, leisure participation and independence in activities of daily living (ADL) of stroke patients 6 and 12 months after hospital discharge.

DESIGN

Multicentre randomized controlled trial.

SETTING AND PARTICIPANTS

Four hundred and sixty-six stroke patients from five UK centres.

MAIN OUTCOME MEASURES

The General Health Questionnaire (12 item), the Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire, assessed by post, with telephone clarification.

RESULTS

Four hundred and forty (94%) and 426 (91%) subjects were alive at 6 and 12 months, respectively. Three hundred and seventy-four (85% of survivors) and 311 (78% of survivors) responded at 6 and 12 month follow-up respectively. At six months and compared to the control group, those allocated to leisure therapy had nonsignificantly better GHQ scores (-1.2: 95% CI -2.9, +0.5), leisure scores (+0.7, 95% CI -1.1, +2.5) and Extended ADL scores (+0.4: 95% CI -3.8, +4.5): the ADL group had nonsignificantly better GHQ scores (-0.1: 95% CI -1.8, +1.7) and Extended ADL scores (+1.4: 95% CI -2.9, +5.6) and nonsignificantly worse leisure scores (-0.3: 95% CI -2.1, +1.6). The results at 12 months were similar.

CONCLUSION

In contrast to the findings of previous smaller trials, neither of the additional OT treatments showed a clear beneficial effect on mood, leisure activity or independence in ADL measured at 6 or 12 months.

Beta-hydroxy beta-methylbutyrate (HMB) supplementation does not influence the urinary testosterone: epitestosterone ratio in healthy males

Six healthy, recreationally active, males undertook two weeks supplementation with beta-Hydroxy beta-Methylbutyrate (HMB). Supplementation was in capsule form with 3 g consumed each day in three even doses of 1 g at main meals. Mid stream urine samples were collected prior to, as well as, after one and two weeks of supplementation and subsequently analysed for testosterone and epitestosterone. The testosterone: epitestosterone ratio was not affected by 2 weeks of HMB supplementation (mean +/- SD baseline 1.02 +/- 0.68; week one 0.98 +/- 0.61; week two 0.92 +/- 0.62). Our results support the claim that supplementation with HMB at the doses recommended will not influence the urinary testosterone: epitestosterone ratio and thus not breach doping policies of the International Olympic Committee for exogenous testosterone or precursor administration.

Concurrent strength and endurance training. A review

Concurrent strength and endurance training appears to inhibit strength development when compared with strength training alone. Our understanding of the nature of this inhibition and the mechanisms responsible for it is limited at present. This is due to the difficulties associated with comparing results of studies which differ markedly in a number of design factors, including the mode, frequency, duration and intensity of training, training history of participants, scheduling of training sessions and dependent variable selection. Despite these difficulties, both chronic and acute hypotheses have been proposed to explain the phenomenon of strength inhibition during concurrent training. The chronic hypothesis contends that skeletal muscle cannot adapt metabolically or morphologically to both strength and endurance training simultaneously. This is because many adaptations at the muscle level observed in response to strength training are different from those observed after endurance training. The observation that changes in muscle fibre type and size after concurrent training are different from those observed after strength training provide some support for the chronic hypothesis. The acute hypothesis contends that residual fatigue from the endurance component of concurrent training compromises the ability to develop tension during the strength element of concurrent training. It is proposed that repeated acute reductions in the quality of strength training sessions then lead to a reduction in strength development over time. Peripheral fatigue factors such as muscle damage and glycogen depletion have been implicated as possible fatigue mechanisms associated with the acute hypothesis. Further systematic research is necessary to quantify the inhibitory effects of concurrent training on strength development and to identify different training approaches that may overcome any negative effects of concurrent training.

Resistance training frequency: strength and myosin heavy chain responses to two and three bouts per week

Seventeen subjects performed resistance training of the leg extensor and flexor muscle groups two (2/wk) or three (3/wk) times per week. Changes in the relative myosin heavy chain (MHC) isoform contents (I, IIa and IIx) of the vastus lateralis and isometric, isokinetic and squat-lift one-repetition maximum (1 RM) strength were compared between conditions after both a common training period (6 weeks) and number of training sessions (18). After 6 weeks and 18 sessions (9 weeks for the 2/wk group), increments in 1RM strength for the 3/wk and 2/wk groups were similar [effect size (ES) differences approximately 0.3, 3/wk > 2/wk], whereas the 2/wk group presented greater isokinetic (ES differences = 0.3-1.2) and isometric (ES differences approximately 0.7) strength increases than the 3/wk condition. A significant (P < 0.05) increase in MHC IIa percentage was evident for the 2/wk group after 18 sessions. Both training groups exhibited a trend towards a reduction in the relative MHC IIx and an increase in MHC IIa contents (ES range = 0.5-1.24). However, correlations between changes in the strength and MHC profiles were weak (r2: 0.0-0.5). Thus, isometric and isokinetic strength responses to variations in training frequency differed from 1RM strength responses, and changes in strength were not strongly related to alterations in relative MHC content.

A randomized controlled trial of enhanced Social Service occupational therapy for stroke patients

OBJECTIVE

To determine whether stroke patients referred to the Social Service occupational therapy service would benefit from an enhanced service compared to the usual service.

DESIGN

Randomized controlled study allocating patients to the enhanced service or the usual service.

SUBJECTS

Stroke patients discharged home from hospital and referred to Social Service occupational therapy department.

OUTCOME MEASURES

The sections and total score from the Nottingham Extended Activities of Daily Living Scale (EADL), the Barthel Index, the General Health Questionnaire (GHQ) and the number of pieces of equipment provided were analysed.

RESULTS

One hundred and eleven stroke patients were recruited to this study. Fifty-three were randomly allocated to the enhanced service and 58 to the usual service. Patients receiving the enhanced service were seen more quickly after referral, for longer, and received significantly more visits (p < 0.01) than those receiving the usual service. Three months after entry to the study the enhanced service group had better EADL (p < 0.01) than the usual service group. This benefit remained significant in only the mobility section of the EADL at six months. Careers of the stroke patients in the enhanced group had lower GHQ scores (p < 0.05) than those in the usual group at six months.

CONCLUSIONS

This trial supports the use of domiciliary occupational therapy for stroke patients after discharge from hospital in terms of improvements in functional outcomes in the short term, but the long-term benefits remain unclear.

A Study of the Housing Needs of Disabled Applicants to the Nottingham City Council Housing Department and the Problems Faced by Local Housing Providers in Meeting These Needs

This study of the housing needs of disabled people and the problems faced by housing providers in Nottingham was carried out with a view to establishing a data base of adapted properties and disabled people. A small survey of 47 disabled people, with 22 respondents, reported problems when trying to find a new home. Less than a quarter of those who replied had been assessed prior to looking for a new home by an occupational therapist, while over half said that they would like help from an occupational therapist when choosing a new home. A survey of 42 housing providers found that, of the 26 respondents, over half had disabled people waiting for a property and a third had adapted properties that they were unable to let.

These findings supported local concern about housing problems for disabled people and led to the development of the Disabled People and Adapted Properties Register (DPAPR). This register holds a computerised list of disabled people looking for a new home and of the adapted properties in Nottingham, for sale or for rent.

Acute and chronic response of skeletal muscle to resistance exercise

Skeletal muscle tissue is sensitive to the acute and chronic stresses associated with resistance training. These responses are influenced by the structure of resistance activity (i.e. frequency, load and recovery) as well as the training history of the individuals involved. There are histochemical and biochemical data which suggest that resistance training alters the expression of myosin heavy chains (MHCs). Specifically, chronic exposure to bodybuilding and power lifting type activity produces shifts towards the MHC I and IIb isoforms, respectively. However, it is not yet clear which training parameters trigger these differential expressions of MHC isoforms. Interestingly, many programmes undertaken by athletes appear to cause a shift towards the MHC I isoform. Increments in the cross-sectional area of muscle after resistance training can be primarily attributed to fibre hypertrophy. However, there may be an upper limit to this hypertrophy. Furthermore, significant fibre hypertrophy appears to follow the sequence of fast twitch fibre hypertrophy preceding slow twitch fibre hypertrophy. Whilst some indirect measures of fibre number in living humans suggest that there is no interindividual variation, postmortem evidence suggests that there is. There are also animal data arising from investigations using resistance training protocols which suggest that chronic exercise can increase fibre number. Furthermore, satellite cell activity has been linked to myotube formation in the human. However, other animal models (i.e. compensatory hypertrophy) do not support the notion of fibre hyperplasia. Even if hyperplasia does occur, its effect on the cross-sectional area of muscle appears to be small. Phosphagen and glycogen metabolism, whilst important during resistance activity appear not to normally limit the performance of resistance activity. Phosphagen and related enzyme adaptations are affected by the type, structure and duration of resistance training. Whilst endogenous glycogen reserves may be increased with prolonged training, typical isotonic training for less than 6 months does not seem to increase glycolytic enzyme activity. Lipid metabolism may be of some significance in bodybuilding type activity. Thus, not surprisingly, oxidative enzyme adaptations appear to be affected by the structure and perhaps the modality of resistance training. The dilution of mitochondrial volume and endogenous lipid densities appears mainly because of fibre hypertrophy.