Associations with sub-optimal clinic attendance and reasons for missed appointments among heterosexual women and men living with HIV in London

Poor engagement in HIV care is associated with poorer health outcomes and increased mortality. Our survey examined experiential and circumstantial factors associated with clinic attendance among women (n = 250) and men (n = 106) in London with heterosexually-acquired HIV. While no associations were found for women, among men, sub-optimal attendance was associated with insecure immigration status (25.6% vs. 1.8%), unstable housing (32.6% vs. 10.2%) and reported effect of HIV on daily activities (58.7% vs. 40.0%). Among women and men on ART, it was associated with missing doses of ART (OR = 2.96, 95% CI:1.74-5.02), less belief in the necessity of ART (OR = 0.56, 95% CI:0.35-0.90) and more concern about ART (OR = 3.63, 95% CI:1.45-9.09). Not wanting to think about being HIV positive was the top reason for ever missing clinic appointments. It is important to tackle stigma and the underlying social determinants of health to improve HIV prevention, and the health and well-being of people living with HIV.

Do members of the public think they should use lateral flow tests (LFT) or polymerase chain reaction (PCR) tests when they have COVID-19-like symptoms? The COVID-19 Rapid Survey of Adherence to Interventions and Responses study

Objectives

This study aimed to investigate public use of lateral flow tests (LFT) and polymerase chain reaction (PCR) tests when experiencing key COVID-19 symptoms.

Study design

In this study, data from two waves of a cross-sectional nationally representative online survey (data collected 1 and 2 June, and 14 and 15 June 2021; n = 3665 adults aged ≥18 years living in England or Scotland) were used.

Methods

We report data investigating which type of test, if any, the public think Government guidance asks people to use if they have COVID-19 symptoms. In people with key COVID-19 symptoms (high temperature / fever; new, continuous cough; loss of sense of smell; loss of taste), we also describe the uptake of testing, if any.

Results

Ten percent of respondents thought Government guidance stated that they should take an LFT if symptomatic, whereas 18% of people thought that they should take a PCR test; 60% of people thought they should take both types of test (12% did not select either option). In people who were symptomatic, 32% reported taking a test to confirm whether they had COVID-19. Of these, 53% reported taking a PCR test and 44% reported taking an LFT.

Conclusions

Despite Government guidance stating that anyone with key COVID-19 symptoms should complete a PCR test, a significant percentage of the population use LFT tests when symptomatic. Communications should emphasise the superiority of, and need for, PCR tests in people with symptoms.

Factors associated with non-essential workplace attendance during the COVID-19 pandemic in the UK in early 2021: evidence from cross-sectional surveys

Objectives

Working from home where possible is important in reducing the spread of COVID-19. In early 2021, a quarter of people in England who believed they could work entirely from home reported attending their workplace. To inform interventions to reduce this, this study examined associated factors.

Study design

Data from the ongoing COVID-19 Rapid Survey of Adherence to Interventions and Responses survey series of nationally representative samples of people in the UK aged 16+ years in January–February 2021 were used.

Methods

The study sample was 1422 respondents who reported that they could work completely from home. The outcome measure was self-reported workplace attendance at least once during the preceding week. Factors of interest were analysed in three blocks: 1) sociodemographic variables, 2) variables relating to respondents’ circumstances and 3) psychological variables.

Results

26.8% (95% confidence interval [CI] = 24.5%–29.1%) of respondents reported having attended their workplace at least once in the preceding week. Sociodemographic variables and living circumstances significantly independently predicted non-essential workplace attendance: male gender (odds ratio [OR] = 1.85, 95% CI = 1.33–2.58); dependent children in the household (OR = 1.65, 95% CI = 1.17–2.32); financial hardship (OR = 1.14, 95% CI = 1.08–1.21); lower socio-economic grade (C2DE; OR = 1.65, 95% CI = 1.19–2.53); working in sectors such as health or social care (OR = 4.18, 95% CI = 2.56–6.81), education and childcare (OR = 2.45, 95% CI = 1.45–4.14) and key public service (OR = 3.78, 95% CI = 1.83–7.81) and having been vaccinated (OR = 2.08, 95% CI = 1.33–3.24).

Conclusions

Non-essential workplace attendance in the UK in early 2021 during the COVID-19 pandemic was significantly independently associated with a range of sociodemographic variables and personal circumstances. Having been vaccinated, financial hardship, socio-economic grade C2DE, having a dependent child at home and working in certain key sectors were associated with higher likelihood of workplace attendance.

A system dynamics-based scenario analysis of residential solid waste management in Kisumu, Kenya

The problem of solid waste management presents an issue of increasing importance in many low-income settings, including the progressively urbanised context of Kenya. Kisumu County is one such setting with an estimated 500 t of waste generated per day and with less than half of it regularly collected. The open burning and natural decay of solid waste is an important source of greenhouse gas (GHG) emissions and atmospheric pollutants with adverse health consequences. In this paper, we use system dynamics modelling to investigate the expected impact on GHG and PM_2.5 emissions of (i) a waste-to-biogas initiative and (ii) a regulatory ban on the open burning of waste in landfill. We use life tables to estimate the impact on mortality of the reduction in PM_2.5 exposure. Our results indicate that combining these two interventions can generate over 1.1 million tonnes of cumulative savings in GHG emissions by 2035, of which the largest contribution (42%) results from the biogas produced replacing unclean fuels in household cooking. Combining the two interventions is expected to reduce PM_2.5 emissions from the waste and residential sectors by over 30% compared to our baseline scenario by 2035, resulting in at least around 1150 cumulative life years saved over 2021–2035. The contribution and novelty of this study lies in the quantification of a potential waste-to-biogas scenario and its environmental and health impact in Kisumu for the first time.

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We present a system dynamics study of solid waste management in Kisumu, Kenya.

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Scenarios involve a waste-to-biogas initiative and a ban on open burning in landfill.

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Combined scenario generates 1.1m tonnes cumulative GHG savings by 2035.

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Largest contribution (42%) is from biogas substituting traditional cooking fuels.

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Combined scenario may save 1,150 cumulative life years by 2035, plus ~220 more p.a.

Behavioral Intervention Components Associated With Cost-effectiveness: A Comparison of Six Domains

Background

To help implement behavior change interventions (BCIs) it is important to be able to characterize their key components and determine their effectiveness.

Purpose

This study assessed and compared the components of BCIs in terms of intervention functions identified using the Behaviour Change Wheel Framework (BCW) and in terms of their specific behavior change techniques (BCTs) identified using the BCT TaxonomyV1, across six behavioral domains and the association of these with cost-effectiveness.

Methods

BCIs in 251 studies targeting smoking, diet, exercise, sexual health, alcohol and multiple health behaviors, were specified in terms of their intervention functions and their BCTs, grouped into 16 categories. Associations with cost-effectiveness measured in terms of incremental cost-effectiveness ratio (ICER) upper and lower estimates were determined using regression analysis.

Results

The most prevalent functions were increasing knowledge through education (72.1%) and imparting skills through training (74.9%). The most prevalent BCT groupings were shaping knowledge (86.5%), changing behavioral antecedents (53.0%), supporting self-regulation (47.7%), and providing social support (44.6%). Intervention functions associated with better cost-effectiveness were those based on training (β_low = −15044.3; p = .002), persuasion (β_low = −19384.9; p = .001; β_upp = −25947.6; p < .001) and restriction (β_upp = −32286.1; p = .019), and with lower cost-effectiveness were those based on environmental restructuring (β = 15023.9_low; p = .033). BCT groupings associated with better cost-effectiveness were goals and planning (β_low = −8537.3; p = .019 and β_upp = −12416.9; p = .037) and comparison of behavior (β_low = −13561.9, p = .047 and β_upp = −30650.2; p = .006). Those associated with lower cost-effectiveness were natural consequences (β_low = 7729.4; p = .033) and reward and threat (β_low = 20106.7; p = .004).

Conclusions

BCIs that focused on training, persuasion and restriction may be more cost-effective, as may those that encourage goal setting and comparison of behaviors with others.

The association between use of chemsex drugs and HIV clinic attendance among gay and bisexual men living with HIV in London

OBJECTIVES

To investigate the association between chemsex drug use and HIV clinic attendance among gay and bisexual men in London.

METHODS

A cross-sectional survey of adults (> 18 years) diagnosed with HIV for > 4 months, attending seven London HIV clinics (May 2014 to August 2015). Participants self-completed an anonymous questionnaire linked to clinical data. Sub-optimal clinic attenders had missed one or more HIV clinic appointments in the past year, or had a history of non-attendance for > 1 year.

RESULTS

Over half (56%) of the 570 men who identified as gay or bisexual reported taking recreational drugs in the past 5 years and 71.5% of these men had used chemsex drugs in the past year. Among men reporting chemsex drug use (past year), 32.1% had injected any drugs in the past year. Sub-optimal clinic attenders were more likely than regular attenders to report chemsex drug use (past year; 46.9% vs. 33.2%, P = 0.001), injecting any drugs (past year; 17.1% vs. 8.9%, P = 0.011) and recreational drug use (past 5 years; 65.5% vs. 48.8%, P < 0.001). One in five sub-optimal attenders had missed an HIV clinic appointment because of taking recreational drugs (17.4% vs. 1.8%, P < 0.001). In multivariable logistic regression, chemsex drug use was significantly associated with sub-optimal clinic attendance (adjusted odds ratio = 1.71, 95% confidence interval: 1.10-2.65, P = 0.02).

CONCLUSIONS

Our findings highlight the importance of systematic assessment of drug use and development of tools to aid routine assessment. We suggest that chemsex drug use should be addressed when developing interventions to improve engagement in HIV care among gay and bisexual men.

Sustained type 1 diabetes self-management: Specifying the behaviours involved and their influences

AIMS

Sustained engagement in type 1 diabetes self-management behaviours is a critical element in achieving improvements in glycated haemoglobin (HbA1c) and minimising risk of complications. Evaluations of self-management programmes, such as Dose Adjustment for Normal Eating (DAFNE), typically find that initial improvements are rarely sustained beyond 12 months. This study identified behaviours involved in sustained type 1 diabetes self-management, their influences and relationships to each other.

METHODS

A mixed-methods study was conducted following the first two steps of the Behaviour Change Wheel framework. First, an expert stakeholder consultation identified behaviours involved in self-management of type 1 diabetes. Second, three evidence sources (systematic review, healthcare provider-generated 'red flags' and participant-generated 'frequently asked questions') were analysed to identify and synthesise modifiable barriers and enablers to sustained self-management. These were characterised according to the Capability-Opportunity-Motivation-Behaviour (COM-B) model.

RESULTS

150 distinct behaviours were identified and organised into three self-regulatory behavioural cycles, reflecting different temporal and situational aspects of diabetes self-management: Routine (e.g. checking blood glucose), Reactive (e.g. treating hypoglycaemia) and Reflective (e.g. reviewing blood glucose data to identify patterns). Thirty-four barriers and five enablers were identified: 10 relating to Capability, 20 to Opportunity and nine to Motivation.

CONCLUSIONS

Multiple behaviours within three self-management cycles are involved in sustained type 1 diabetes self-management. There are a wide range of barriers and enablers that should be addressed to support self-management behaviours and improve clinical outcomes. The present study provides an evidence base for refining and developing type 1 diabetes self-management programmes.

Evidence-based medicine meets democracy: the role of evidence-based public health guidelines in local government

Background

In 2013, many public health functions transferred from the National Health Service to local government in England. From 2006 NICE had produced public health guidelines based on the principles of evidence-based medicine. This study explores how the guidelines were received in the new environment in local government and related issues raised relating to the use of evidence in local authoritites.

Methods

In depth, interviews with 31 elected members and officers, including Directors of Public Health, from four very different local government organizations (‘local authorities’).

Results

Participants reported that (i) there were tensions between evidence-based, and political decision-making; (ii) there were differences in views about what constituted ‘good’ evidence and (iii) that organizational life is an important mediator in the way evidence is used.

Conclusions

Democratic political decision-making does not necessarily naturally align with decision-making based on evidence from the international scientific literature, and local knowledge and local evidence are very important in the ways that public health decisions are made.

Protocol of a two arm randomised, multi-centre, 12-month controlled trial: evaluating the impact of a Cognitive Behavioural Therapy (CBT)-based intervention Supporting UPtake and Adherence to antiretrovirals (SUPA) in adults with HIV

Background

Delay to start antiretroviral therapy (ART) and nonadherence compromise the health and wellbeing of people living with HIV (PLWH), raise the cost of care and increase risk of transmission to sexual partners. To date, interventions to improve adherence to ART have had limited success, perhaps because they have failed to systematically elicit and address both perceptual and practical barriers to adherence. The primary aim of this study is to determine the efficacy of the Supporting UPtake and Adherence (SUPA) intervention.

Methods

This study comprises 2 phases. Phase 1 is an observational cohort study, in which PLWH who are ART naïve and recommended to take ART by their clinician complete a questionnaire assessing their beliefs about ART over 12 months. Phase 2 is a randomised controlled trial (RCT) nested within the observational cohort study to investigate the effectiveness of the SUPA intervention on adherence to ART. PLWH at risk of nonadherence (based on their beliefs about ART) will be recruited and randomised 1:1 to the intervention (SUPA intervention + usual care) and control (usual care) arms. The SUPA intervention involves 4 tailored treatment support sessions delivered by a Research Nurse utilising a collaborative Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) approach. Sessions are tailored to individual needs and preferences based on the individual patient’s perceptions and practical barriers to ART. An animation series and intervention manual have been developed to communicate a rationale for the personal necessity for ART and illustrate concerns and potential solutions. The primary outcome is adherence to ART measured using Medication Event Monitoring System (MEMS). Three hundred seventy-two patients will be sufficient to detect a 15% difference in adherence with 80% power and an alpha of 0.05. Costs will be compared between intervention and control groups. Costs will be combined with the primary outcome in cost-effectiveness analyses. Quality adjusted life-years (QALYs) will also be estimated over the follow-up period and used in the analyses.

Discussion

The findings will enable patients, healthcare providers and policy makers to make informed decisions about the value of the SUPA intervention.

Trial registration

The trial was retrospectively registered 21/02/2014, ISRCTN35514212.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6893-z) contains supplementary material, which is available to authorized users.

From the National Health Service to local government: perceptions of public health transition in England

OBJECTIVES

In England, in 2013, responsibility for some public health (PH) functions transferred from the National Health Service (NHS) to local government. This moved PH from a health-focussed into a broader and more politically oriented context. This article reports on the perceptions of those involved in this transition about how the PH function was changing as it transited to local government.

STUDY DESIGN

This is a cross-sectional interview study.

METHODS

The study included semi-structured interviews with 31 local government councillors, directors and deputy directors of PH, PH team members and members of clinical commissioning groups. Interviews and data analysis were informed by a theoretical framework, COM-B and an inductive and deductive approach was taken to identify relevant themes.

RESULTS

There was a mixed picture of perceived gains and losses for PH. The transition from NHS to local government was seen by some as a 'homecoming', providing the opportunity for PH to have further reach through influence and collaboration with departments like housing, transport and planning. The opportunity to promote evidence-based practice across local government was also seen as a positive aspect of the transition. However, professional roles of PH and individual PH practitioners were perceived to have less influence and autonomy than in the NHS, with some uncertainty about roles within local government. PH practitioners perceived the need to develop other skills to fulfil their roles in local government. Shorter timescales for action and pressure for faster responses were reported to be the reason for less emphasis on using PH evidence to inform policy and decision-making than hitherto in the NHS.

CONCLUSION

This study illustrates a variety of consequences of transitioning from NHS to local government. There were perceived benefits afforded by proximity to related local government departments but at the costs of reduction in status for PH practitioners and working to a timescale which in some cases reduced drawing on scientific evidence.

Increasing condom use in heterosexual men: development of a theory-based interactive digital intervention

Increasing condom use to prevent sexually transmitted infections is a key public health goal. Interventions are more likely to be effective if they are theory- and evidence-based. The Behaviour Change Wheel (BCW) provides a framework for intervention development. To provide an example of how the BCW was used to develop an intervention to increase condom use in heterosexual men (the MenSS website), the steps of the BCW intervention development process were followed, incorporating evidence from the research literature and views of experts and the target population. Capability (e.g. knowledge) and motivation (e.g. beliefs about pleasure) were identified as important targets of the intervention. We devised ways to address each intervention target, including selecting interactive features and behaviour change techniques. The BCW provides a useful framework for integrating sources of evidence to inform intervention content and deciding which influences on behaviour to target.

Development and application of a new measure of engagement in out-patient HIV care

OBJECTIVES

Commonly used measures of engagement in HIV care do not take into account that the frequency of attendance is related to changes in treatment and health status. This study developed a new measure of engagement in care (EIC) incorporating clinical factors.

METHODS

We conducted semi-structured interviews with eight HIV physicians to identify factors associated with the timing of patients' next scheduled appointments. These factors informed the development of an algorithm to classify each month of follow-up as "in care" (on or before the time of the next expected attendance) or "out of care" (after the time of the next expected attendance). The EIC algorithm was applied to data from the UK Collaborative HIV Cohort (UK CHIC) study, a large clinical cohort study.

RESULTS

The interviews indicated that time to next appointment varied depending on psychosocial and physical comorbidities, and clinical factors (time since diagnosis, AIDS diagnosis, treatment status, CD4 count and viral load). The resulting EIC algorithm was applied to 44 432 patients; 83.9% of the 3 021 224 person-months were "in care". Greater EIC was independently associated with older age, white ethnicity, HIV acquisition through sex between men, current use of antiretroviral therapy (ART), a higher nadir CD4 count, later calendar year and being seen at the clinic for the first time within the last year.

CONCLUSIONS

This algorithm describing engagement in HIV care incorporates a time-updated measure of patients' treatment and health status. It adds to the options available for measuring this key performance indicator.

Factors associated with study attrition in a pilot randomised controlled trial to explore the role of exercise-assisted reduction to stop (EARS) smoking in disadvantaged groups

Background

Study attrition has the potential to compromise a trial’s internal and external validity. The aim of the present study was to identify factors associated with participant attrition in a pilot trial of the effectiveness of a novel behavioural support intervention focused on increasing physical activity to reduce smoking, to inform the methods to reduce attrition in a definitive trial.

Methods

Disadvantaged smokers who wanted to reduce but not quit were randomised (N = 99), of whom 61 (62 %) completed follow-up assessments at 16 weeks. Univariable logistic regression was conducted to determine the effects of intervention arm, method of recruitment, and participant characteristics (sociodemographic factors, and lifestyle, behavioural and attitudinal characteristics) on attrition, followed by multivariable logistic regression on those factors found to be related to attrition.

Results

Participants with low confidence to quit, and who were undertaking less than 150 mins of moderate and vigorous physical activity per week at baseline were less likely to complete the 16-week follow-up assessment. Exploratory analysis revealed that those who were lost to follow-up early in the trial (i.e., by 4 weeks), compared with those completing the study, were younger, had smoked for fewer years and had lower confidence to quit in the next 6 months. Participants who recorded a higher expired air carbon monoxide reading at baseline were more likely to drop out late in the study, as were those recruited via follow-up telephone calls. Multivariable analyses showed that only completing less than 150 mins of physical activity retained any confidence in predicting attrition in the presence of other variables.

Conclusions

The findings indicate that those who take more effort to be recruited, are younger, are heavier smokers, have less confidence to quit, and are less physically active are more likely to withdraw or be lost to follow-up.

[Better Reporting of Interventions: Template for Intervention Description and Replication (TIDieR) Checklist and Guide]

Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face-to-face panel meeting. The resultant 12-item TIDieR checklist (brief name, why, what (materials), what (procedure), who intervened, how, where, when and how much, tailoring, modifications, how well (planned), how well (actually carried out)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with a detailed explanation of each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure the accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.

Who is sceptical about emerging public health threats? Results from 39 national surveys in the United Kingdom

Objectives

Members of the public are often sceptical about warnings of an impending public health crisis. Breaking through this scepticism is important if we are to convince people to take urgent protective action. In this paper we explored correlates of perceiving that ‘too much fuss’ was being made about the 2009/10 influenza A H1N1v (‘swine flu’) pandemic.

Study design

A secondary analysis of data from 39 nationally representative telephone surveys conducted in the UK during the pandemic.

Methods

Each cross-sectional survey (combined n = 42,420) collected data over a three day period and asked participants to state whether they agreed or disagreed that ‘too much fuss is being made about the risk of swine flu.’

Results

Overall, 55.1% of people agreed or strongly agreed with this sentiment. Perceiving that too much fuss was being made was associated with: being male, being white, being generally healthy, trusting most in a primary care physician to provide advice, not knowing someone who had contracted the illness, believing you know a lot about the outbreak, not wishing to receive additional information about the outbreak and possessing worse factual knowledge about the outbreak than other people.

Conclusions

In future disease outbreaks merely providing factual information is unlikely to engage people who are sceptical about the need to take action. Instead, messages which challenge their perceived knowledge and which present case studies of people who have been affected may prove more effective, especially when delivered through trusted channels.

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Data from 39 UK telephone surveys conducted during the ‘swine flu’ pandemic were analysed (n = 42,420).

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Scepticism was assessed by asking whether participants agreed that ‘too much fuss is being made about the risk of swine flu.’

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Around half of respondents were sceptical about the risk of swine flu (55.1%).

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Scepticism was associated with being white, healthy and male, and having high subjective knowledge about the outbreak.

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Challenging perceived knowledge may improve communication with sceptical groups in future.

Using realist review to inform intervention development: methodological illustration and conceptual platform for collaborative care in offender mental health

BACKGROUND

This paper reports how we used a realist review, as part of a wider project to improve collaborative mental health care for prisoners with common mental health problems, to develop a conceptual platform. The importance of offenders gaining support for their mental health, and the need for practitioners across the health service, the criminal justice system, and the third sector to work together to achieve this is recognised internationally. However, the literature does not provide coherent analyses of how these ambitions can be achieved. This paper demonstrates how a realist review can be applied to inform complex intervention development that spans different locations, organisations, professions, and care sectors.

METHODS

We applied and developed a realist review for the purposes of intervention development, using a three-stage process. (1) An iterative database search strategy (extending beyond criminal justice and offender health) and groups of academics, practitioners, and people with lived experience were used to identify explanatory accounts (n = 347). (2) From these accounts, we developed consolidated explanatory accounts (n = 75). (3) The identified interactions between practitioners and offenders (within their organisational, social, and cultural contexts) were specified in a conceptual platform. We also specify, step by step, how these explanatory accounts were documented, consolidated, and built into a conceptual platform. This addresses an important methodological gap for social scientists and intervention developers about how to develop and articulate programme and implementation theory underpinning complex interventions.

RESULTS

An integrated person-centred system is proposed to improve collaborative mental health care for offenders with common mental health problems (near to and after release) by achieving consistency between the goals of different sectors and practitioners, enabling practitioners to apply scientific and experiential knowledge in working judiciously and reflectively, and building systems and aligning resources that are centred on offenders' health and social care needs.

CONCLUSIONS

As part of a broader programme of work, a realist review can make an important contribution to the specification of theoretically informed interventions that have the potential to improve health outcomes. Our conceptual platform has potential application in related systems of health and social care where integrated, and person-centred care is a goal.

Genetic Counselors' Judgments of Patient Concerns: Concordance and Consequences

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60-84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.

Mediation analysis of the association between use of NRT for smoking reduction and attempts to stop smoking

OBJECTIVES

Use of nicotine replacement therapy (NRT) for smoking reduction (SR) is linked to higher quit attempt rates than SR without NRT. This study aimed to assess the possible mediating roles of confidence in ability to quit, enjoyment of smoking and motivation to quit in this association.

DESIGN

Cross-sectional survey.

MAIN OUTCOME MEASURES

Smokers were asked if they were currently attempting SR, and if they were, whether they were using NRT. Motivation to stop, enjoyment of smoking, confidence in ability to stop, and previous quit attempts, were also assessed.

RESULTS

There was no evidence that confidence in ability to quit or enjoyment of smoking mediated the association between the use of NRT for SR and attempts to quit. Only motivation to stop partially mediated between the use of NRT for SR and attempts to stop (indirect effect: odds ratio 1.08, p < 0.001).

CONCLUSION

Although this study is limited by its cross-sectional design, the findings point towards the possibility that the use of NRT to aid SR may promote attempts to stop through increasing motivation to quit but not by increasing confidence or by reducing enjoyment of smoking. Longitudinal studies are required to draw firmer conclusions about the possible mediating effects of motivation to quit.

Adaptive e-learning to improve dietary behaviour: a systematic review and cost-effectiveness analysis

BACKGROUND

UK public health policy strongly advocates dietary change for the improvement of population health and emphasises the importance of individual empowerment to improve health. A new and evolving area in the promotion of dietary behavioural change is 'e-learning', the use of interactive electronic media to facilitate teaching and learning on a range of issues including health. The high level of accessibility, combined with emerging advances in computer processing power, data transmission and data storage, makes interactive e-learning a potentially powerful and cost-effective medium for improving dietary behaviour.

OBJECTIVE

This review aims to assess the effectiveness and cost-effectiveness of adaptive e-learning interventions for dietary behaviour change, and also to explore potential psychological mechanisms of action and components of effective interventions.

DATA SOURCES

Electronic bibliographic databases (Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Dissertation Abstracts, EMBASE, Education Resources Information Center, Global Health, Health Economic Evaluations Database, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science) were searched for the period January 1990 to November 2009. Reference lists of included studies and previous reviews were also screened; authors were contacted and trial registers were searched.

REVIEW METHODS

Studies were included if they were randomised controlled trials, involving participants aged ≥ 13 years, which evaluated the effectiveness of interactive software programs for improving dietary behaviour. Primary outcomes were measures of dietary behaviours, including estimated intakes or changes in intake of energy, nutrients, dietary fibre, foods or food groups. Secondary outcome measures were clinical outcomes such as anthropometry or blood biochemistry. Psychological mediators of dietary behaviour change were also investigated. Two review authors independently screened results and extracted data from included studies, with any discrepancies settled by a third author. Where studies reported the same outcome, the results were pooled using a random-effects model, with weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated. Cost-effectiveness was assessed in two ways: through a systematic literature review and by building a de novo decision model to assess the cost-effectiveness of a 'generic' e-learning device compared with dietary advice delivered by a health-care professional.

RESULTS

A total of 36,379 titles were initially identified by the electronic searches, of which 43 studies were eligible for inclusion in the review. All e-learning interventions were delivered in high-income countries. The most commonly used behavioural change techniques reported to have been used were goal setting; feedback on performance; information on consequences of behaviour in general; barrier identification/problem solving; prompting self-monitoring of behaviour; and instruction on how to perform the behaviour. There was substantial heterogeneity in the estimates of effect. E-learning interventions were associated with a WMD of +0.24 (95% CI 0.04 to 0.44) servings of fruit and vegetables per day; -0.78 g (95% CI -2.5 g to 0.95 g) total fat consumed per day; -0.24 g (95% CI -1.44 g to 0.96 g) saturated fat intake per day; -1.4% (95% CI -2.5% to -0.3%) of total energy consumed from fat per day; +1.45 g (95% CI -0.02 g to 2.92 g) dietary fibre per day; +4 kcal (95% CI -85 kcal to 93 kcal) daily energy intake; -0.1 kg/m2 (95% CI -0.7 kg/m2 to 0.4 kg/m2) change in body mass index. The base-case results from the E-Learning Economic Evaluation Model suggested that the incremental cost-effectiveness ratio was approximately £102,112 per quality-adjusted life-year (QALY). Expected value of perfect information (EVPI) analysis showed that although the individual-level EVPI was arguably negligible, the population-level value was between £37M and £170M at a willingness to pay of £20,000-30,000 per additional QALY.

LIMITATIONS

The limitations of this review include potential reporting bias, incomplete retrieval of completed research studies and data extraction errors.

CONCLUSION

The current clinical and economic evidence base suggests that e-learning devices designed to promote dietary behaviour change will not produce clinically significant changes in dietary behaviour and are at least as expensive as other individual behaviour change interventions.

FUTURE WORK RECOMMENDATIONS

Despite the relatively high EVPI results from the cost-effectiveness modelling, further clinical trials of individual e-learning interventions should not be undertaken until theoretically informed work that addresses the question of which characteristics of the target population, target behaviour, content and delivery of the intervention are likely to lead to positive results, is completed.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health

BACKGROUND

There is a need to identify and analyse the range of models developed to date for delivering health-related lifestyle advice (HRLA), or training, for effectiveness and cost-effectiveness in improving the health and well-being of individuals and communities in the UK, with particular reference to the reduction of inequalities.

OBJECTIVES

To identify the component intervention techniques of lifestyle advisors (LAs) in the UK and similar contexts, and the outcomes of HRLA interventions.

DATA SOURCES

Stakeholder views, secondary analysis of the National Survey of Health Trainer Activity, telephone survey of health trainer leads/coordinators. A search of a range of electronic databases was undertaken [including the Applied Social Sciences Index and Abstracts (ASSIA), EMBASE, NHS Economic Evaluation Database (NHS EED), MEDLINE, Psyc INFO, etc.], as well searching relevant journals and reference lists, conducted from inception to September 2008.

REVIEW METHODS

Identified studies were scanned by two reviewers and those meeting the following criteria were included: studies carrying out an evaluation of HRLA; those taking place in developed countries similar to the UK context; those looking at adult groups; interventions with the explicit aim of health improvement; interventions that involved paid or voluntary work with an individual or group of peers acting in an advisory role; advice delivered by post, online or electronically; training, support or counselling delivered to patients, communities or members of the public. After quality assessment, studies were selected for inclusion in the review. Data were abstracted from each study according to an agreed procedure and narrative, and realist and economic approaches were used to synthesise the data. Cost-effectiveness analysis of interventions was undertaken.

RESULTS

In total, 269 studies were identified but 243 were excluded. The 26 included studies addressing chronic care, mental health, breastfeeding, smoking, diet and physical activity, screening and human immunodeficiency virus (HIV) infection prevention. Overall, there was insufficient evidence to either support or refute the use of LAs to promote health and improve quality of life (QoL), and thus uncertainty about the interventions' cost-effectiveness. However, the economic analysis showed that LA interventions were cost-effective in chronic care and smoking cessation, inconclusive for breastfeeding and mental health and not cost-effective for screening uptake and diet/physical activity. LA interventions for HIV prevention were cost-effective, but not in a UK context.

LIMITATIONS

The wide variety of LA models, delivery settings and target populations prevented the reviewers from establishing firm causal relationships between intervention mode and study outcomes.

CONCLUSIONS

Evidence was variable, giving only limited support to LAs having a positive impact on health knowledge, behaviours and outcomes. Levels of acceptability appeared to be high. LAs acted as translational agents, sometimes removing barriers to prescribed behaviour or helping to create facilitative social environments. Reporting of processes of accessing or capitalising on indigenous knowledge was limited. Ambiguity was apparent with respect to the role and impact of lay and peer characteristics of the interventions. A future programme of research on HRLA could benefit from further emphasis on identification of needs, the broadening of population focus and intervention aims, the measurement of outcomes and the reviewing of evidence.

FUNDING

This study was funded by the Health Technology Assessment programme of the National Institute for Health Research.

Use of nicotine replacement therapy for smoking reduction and during enforced temporary abstinence: a national survey of English smokers

AIMS

To assess the prevalence of nicotine replacement therapy (NRT) use for smoking reduction (SR) and temporary abstinence (TA), the association between the two and the strength of the association between NRT use for SR or TA and socio-demographic characteristics, cigarette consumption and past quit attempts.

DESIGN

Cross-sectional monthly surveys.

SETTING

England.

PARTICIPANTS

A total of 11, 414 smokers.

MEASUREMENTS

Participants were asked (i) whether they were reducing the amount they smoked: if so, whether they used NRT; and (ii) whether they used NRT for TA. Demographic characteristics, daily cigarette consumption and whether a quit attempt had been made in the past 12 months were also assessed.

FINDINGS

Of the participants, 56% were attempting SR, 14% were using NRT for SR and 14% were using NRT for TA. Use of NRT for SR and TA were highly correlated. The nicotine patch was the most commonly used form of NRT. The use of NRT for SR, compared with unassisted SR, was more common among older smokers, while the use of NRT for TA was more common among women. Cigarette consumption was higher in those using NRT for SR than those attempting SR without NRT. The use of NRT for SR and TA was associated positively with past quit attempts.

CONCLUSIONS

Nicotine replacement therapy use for smoking reduction and temporary abstinence is common in England. The use of NRT for SR and TA does not appear to be associated with lower cigarette consumption relative to SR or TA without NRT, but is associated with a higher rate of past quit attempts.

The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK

OBJECTIVES

To assess the association between levels of worry about the possibility of catching swine flu and the volume of media reporting about it; the role of psychological factors in predicting likely uptake of the swine flu vaccine; and the role of media coverage and advertising in predicting other swine flu-related behaviours.

DESIGN

Data from a series of random-digit-dial telephone surveys were analysed. A time series analysis tested the association between levels of worry and the volume of media reporting on the start day of each survey. Cross-sectional regression analyses assessed the relationships between likely vaccine uptake or behaviour and predictor variables.

SETTING

Thirty-six surveys were run at, on average, weekly intervals across the UK between 1 May 2009 and 10 January 2010. Five surveys (run between 14 August and 13 September) were used to assess likely vaccine uptake. Five surveys (1-17 May) provided data relating to other behaviours.

PARTICIPANTS

Between 1047 and 1173 people aged 16 years or over took part in each survey: 5175 participants provided data about their likely uptake of the swine flu vaccine; 5419 participants provided data relating to other behaviours.

MAIN OUTCOME MEASURES

All participants were asked to state how worried they were about the possibility of personally catching swine flu. Subsets were asked how likely they were to take up a swine flu vaccination if offered it and whether they had recently carried tissues with them, bought sanitising hand gel, avoided using public transport or had been to see a general practitioner, visited a hospital or called NHS Direct for a flu-related reason.

RESULTS

The percentage of 'very' or 'fairly' worried participants fluctuated between 9.6% and 32.9%. This figure was associated with the volume of media reporting, even after adjusting for the changing severity of the outbreak [chi2(1) = 6.6, p = 0.010, coefficient for log-transformed data = 2.6]. However, this effect only occurred during the UK's first summer wave of swine flu. In total, 56.1% of respondents were very or fairly likely to accept the swine flu vaccine. The strongest predictors were being very worried about the possibility of oneself [adjusted odds ratio (aOR) 4.7, 95% confidence interval (CI) 3.2 to 7.0] or one's child (aOR 8.0, 95% CI 4.6 to 13.9) catching swine flu. Overall, 33.1% of participants reporting carrying tissues with them, 9.5% had bought sanitising gel, 2.0% had avoided public transport and 1.6% had sought medical advice. Exposure to media coverage or advertising about swine flu increased tissue carrying or buying of sanitising hand gel, and reduced avoidance of public transport or consultation with health services during early May 2009. Path analyses showed that media coverage and advertising had these differential effects because they raised the perceived efficacy of hygiene behaviours but decreased the perceived efficacy of avoidance behaviours.

CONCLUSIONS

During the swine flu outbreak, uptake rates for protective behaviours and likely acceptance rates for vaccination were low. One reason for this may in part be explained by was the low level of public worry about the possibility of catching swine flu. When levels of worry are generally low, acting to increase the volume of mass media and advertising coverage is likely to increase the perceived efficacy of recommended behaviours, which, in turn, is likely to increase their uptake.

Low-income groups and behaviour change interventions: a review of intervention content, effectiveness and theoretical frameworks

BACKGROUND

Interventions to change health-related behaviours have potential to increase health inequalities.

METHODS

This review investigated the effectiveness of interventions targeting low-income groups to reduce smoking or increase physical activity and/or healthy eating. Of 9766 papers identified by the search strategy, 13 met the inclusion criteria. Intervention content was coded into component technique and theoretical basis, and examined as a potential source of effect heterogeneity.

RESULTS

Interventions were heterogeneous, comprising 4-19 techniques. Nine interventions had positive effects, seven resulted in no change and one had an adverse effect. Effective interventions had a tendency to have fewer techniques than ineffective interventions, with no evidence for any technique being generally effective or ineffective. Only six studies cited theory relative to intervention development, with little information about how theory was used and no obvious association with intervention content or effect.

CONCLUSION

This review shows that behaviour change interventions, particularly those with fewer techniques, can be effective in low-income groups, but highlights the lack of evidence to draw on in informing the design of interventions for disadvantaged groups.

Genetic testing for heart disease susceptibility: potential impact on motivation to quit smoking

As genetic tests for common gene variants and multifactorial, lifestyle-related conditions become available, it will be increasingly important to determine the psychological and behavioral impact of this emerging class of genetic tests. Our aim was to examine the potential impact of genetic testing for heart disease susceptibility on psychological predictors of smoking cessation. Two hundred and sixty-one smokers were asked to imagine that they had undergone a test for heart disease risk. They were randomly assigned to a genetic test scenario (low- or high-risk result) or an oxidative test scenario (high-risk result). Smokers in the genetic test-high risk group reported greater intention to quit smoking than smokers in the oxidative test-high risk group (p = 0.009); 30% of this was mediated by their holding stronger beliefs that quitting would reduce their heart disease risk (outcome expectations) (p = 0.011). The effect of genetic test-high risk feedback on outcome expectations was greatest amongst smokers with no heart disease family history (p = 0.038). The results suggest that genetic testing for heart disease risk may enhance interventions designed to improve health via increasing smoking cessation rates. Whether the findings hold true in studies that use real rather than hypothetical genetic tests remains to be seen.

Words matter: increasing the implementation of clinical guidelines

OBJECTIVES

To determine whether writing clinical guideline recommendations in behaviourally specified "plain English" language increases the likelihood of their implementation by service users (patients).

DESIGN

Randomised controlled trial in which participants received either the original text of the National Institute for Clinical Excellence (NICE) public guidelines for the management of schizophrenia or a behaviourally specified text with the same content.

SETTING

Mental health service user networks and voluntary sector organisations within two inner London boroughs.

PARTICIPANTS

Eighty four mental health service users recruited by post or face to face contact at service user meetings.

INTERVENTION

The section of the NICE public guidelines for schizophrenia concerning psychological and pharmacological treatments was rewritten to improve style and behavioural specificity by applying evidence-based and psychologically informed principles of good written communication.

OUTCOME MEASURES

Cognitive predictors of behaviour, as specified by the evidence based theory of planned behaviour, constituted the primary outcome as it was not possible to measure the actual behaviour of guideline implementation. The predictors were behavioural intentions to implement the guidelines, attitudes towards implementation, and perceived behavioural control over implementation. Satisfaction with the guidelines and perceived comprehension were also measured.

RESULTS

Behaviourally specified "plain English" guidelines led to stronger intentions to implement the guidelines, more positive attitudes towards them, and greater perceived behavioural control over using them. There was no difference in satisfaction or perceived comprehension.

CONCLUSIONS

Writing guidelines with high behavioural specificity in conjunction with the use of "plain English" may be a simple and effective method of increasing their implementation. Evaluation with a behavioural outcome is now needed.

Making psychological theory useful for implementing evidence based practice: a consensus approach

BACKGROUND

Evidence-based guidelines are often not implemented effectively with the result that best health outcomes are not achieved. This may be due to a lack of theoretical understanding of the processes involved in changing the behaviour of healthcare professionals. This paper reports the development of a consensus on a theoretical framework that could be used in implementation research. The objectives were to identify an agreed set of key theoretical constructs for use in (1) studying the implementation of evidence based practice and (2) developing strategies for effective implementation, and to communicate these constructs to an interdisciplinary audience.

METHODS

Six phases of work were conducted to develop a consensus: (1) identifying theoretical constructs; (2) simplifying into construct domains; (3) evaluating the importance of the construct domains; (4) interdisciplinary evaluation; (5) validating the domain list; and (6) piloting interview questions. The contributors were a "psychological theory" group (n = 18), a "health services research" group (n = 13), and a "health psychology" group (n = 30).

RESULTS

Twelve domains were identified to explain behaviour change: (1) knowledge, (2) skills, (3) social/professional role and identity, (4) beliefs about capabilities, (5) beliefs about consequences, (6) motivation and goals, (7) memory, attention and decision processes, (8) environmental context and resources, (9) social influences, (10) emotion regulation, (11) behavioural regulation, and (12) nature of the behaviour.

CONCLUSIONS

A set of behaviour change domains agreed by a consensus of experts is available for use in implementation research. Applications of this domain list will enhance understanding of the behaviour change processes inherent in implementation of evidence-based practice and will also test the validity of these proposed domains.

Reducing absenteeism in hospital cleaning staff: pilot of a theory based intervention

AIMS

To develop, pilot, and evaluate a workplace intervention to reduce sickness absence, based on a demand-control-support model of job strain.

METHODS

Changes in the working arrangements of hospital cleaning staff were introduced with the aim of increasing their control over work and the support received at work. The study design was quasi-experimental, with 221 cleaning staff in the intervention group and 91 catering staff in the control group. The dependent variable was the difference in percentage monthly sickness absence between the 12 months preceding and following the intervention. Differences in sickness absence between staff groups for each month after the intervention were compared with differences between staff groups for the equivalent month one year prior to it.

RESULTS

There was a significant reduction in the difference in sickness absence rates between the intervention and control group of 2.3% in the six months after the intervention, compared to the six months before. The difference was not maintained at 12 months.

CONCLUSIONS

These results suggest that a workplace intervention aimed at increasing control and support at work has a small effect on reducing sickness absence among hospital cleaning staff in the short term. Future research should seek to replicate this effect in larger, experimental studies, analyse postulated mediators of such theory based interventions, and develop interventions that maintain improvement.

Certainty and uncertainty in genetic counselling: a qualitative case study

This study examines the communication that occurs during routine genetic counselling sessions. It involves the qualitative analysis of nine consultations with one member of a clinical genetics team. The consultations were characterised by a contrast between the sense of certainty apparent in how the clinicians talked about the power and promise of the new genetics and the uncertainty communicated regarding the actual information produced by genetic tests and their limitations in solving people's problems. There was also a contrast between how the clinician seemed to control the format and agenda of the consultation and the apparently uncontrollable personal and social implications of the topics discussed. We speculate that this may be explained in terms of the clinician giving some order and certainty in an area of inherent uncertainty, and where great promises are as yet unrealised.

Informed choice to undergo prenatal screening: a comparison of two hospitals conducting testing either as part of a routine visit or requiring a separate visit

BACKGROUND

It is not known which of two common methods of conducting prenatal screening best facilitate women making informed choices.

OBJECTIVE

To describe rates of informed choice in two hospitals: one where screening for Down's syndrome was conducted at a routine visit; the other where screening was conducted as part of a separate visit.

DESIGN

Prospective descriptive study.

SETTING

Two hospitals in England.

PARTICIPANTS

1499 pregnant women offered screening for Down's syndrome.

OUTCOME MEASURE

A multidimensional measure of informed choice derived from measures of (a) consistency between attitudes towards undergoing the test and uptake and (b) knowledge about the screening test.

RESULTS

The proportion of women making an informed choice to accept the test was higher at the routine visit hospital than at the separate visit hospital (41% v 21%, 95% confidence interval (95% CI) of the difference 16% to 25%). The proportions of women making an informed choice to decline the test were similar at the two hospitals (23% at both, 95% CI of the difference -5% to 4%). These results reflect the finding that women with negative attitudes were equally likely to decline the test at each of the two hospitals, whereas women with positive attitudes were more likely to accept the test at the routine visit hospital than at the separate visit hospital. This finding held after adjusting for parity, socioeconomic status, age, and ethnicity. At both hospitals, women with good knowledge were slightly more likely to undergo the test than were women with poor knowledge. This difference disappeared after a similar adjustment.

CONCLUSION

Screening conducted as part of a routine visit may be associated with higher levels of informed choice than screening conducted at a separate visit. This finding constitutes a hypothesis for experimental investigation.

Reducing work related psychological ill health and sickness absence: a systematic literature review

A literature review revealed the following: key work factors associated with psychological ill health and sickness absence in staff were long hours worked, work overload and pressure, and the effects of these on personal lives; lack of control over work; lack of participation in decision making; poor social support; and unclear management and work role. There was some evidence that sickness absence was associated with poor management style. Successful interventions that improved psychological health and levels of sickness absence used training and organisational approaches to increase participation in decision making and problem solving, increase support and feedback, and improve communication. It is concluded that many of the work related variables associated with high levels of psychological ill health are potentially amenable to change. This is shown in intervention studies that have successfully improved psychological health and reduced sickness absence.