Alcohol use during pregnancy and motherhood: Attitudes and experiences of pregnant women, mothers, and healthcare professionals

Alcohol is the most used substance by women of childbearing age. Alcohol exposed pregnancies can have serious consequences to the fetus, and the UK has one of the highest rates of drinking during pregnancy. Alcohol use during motherhood is also a public health concern, linked with potential harms to the woman and child. This qualitative study investigated the attitudes and experiences of pregnant/parenting women and healthcare professionals regarding maternal drinking. A semi-structured focus group and interviews were conducted in the North West of England with pregnant women, mothers, and healthcare professionals. Quantitative measures captured demographics, alcohol use, and screened for mental ill-health for pregnant women and mothers. Reflexive thematic analysis was used to analyse narratives. Findings revealed that most participants believed avoiding alcohol during pregnancy is the safest option. However, some pregnant women and mothers stated that there was insufficient evidence to demonstrate the harms of low-level drinking and that abstinence guidelines were patronising. All participants reported that low-level drinking during motherhood was acceptable. Heavy drinking was believed to pose serious harm during pregnancy and motherhood to the baby and mother, in addition to damaging relationships. Strong motives were revealed for choosing and avoiding to drink, such as coping with the difficulties of motherhood and parental responsibilities, respectively. Contradictions were found across quantitative and qualitative self-reports of consumption, reflecting potential underreporting of alcohol use. Additionally, drinking levels were discussed in extremes only (low/heavy) without considering 'grey area' drinking. Clear, consistent advice and guidelines are needed to support women in reducing their alcohol use during pregnancy and motherhood. These should include the unique potential risks regarding maternal drinking, and the harm attributable to non-clinically dependent alcohol use. The maternal participants in this study were middle-class, therefore, research is needed to capture the views and experiences of women of all socioeconomic backgrounds.

Exploring primary school years interactions around child weight: A qualitative meta-synthesis of school staff, parent, and child views and experiences

Interactions about children's weight and weight-related behaviors occur from an early stage in school settings between various stakeholders and are often intended to facilitate weight-related behavioral change in children and/or families. This meta-synthesis (PROSPERO - CRD42019133231) aimed to investigate stakeholder reported experiences and challenges of these encounters. Studies were eligible if they included school stakeholders (teaching or nonteaching staff, parents, caregivers, or children), explored communication topics related to child obesity (weight, diet or activity), were conducted within an early school setting (primary school stage or international equivalent), and used qualitative methods. Database searches conducted March-July 2019 (updated November 2020) identified 40 studies (2324 participants) from seven countries. Included studies were assessed for quality using the Critical Appraisal Skills Programme. Using inductive thematic analysis, we identified four core themes across this database: (1) "conversation characteristics and consequences," (2) "missing components," (3) "avoiding stigma," and (4) "school responsibilities." Overall, stakeholders recognized that schools are well-positioned to provide positive influential messages about childhood obesity and reported that discussions on this topic do occur in early school settings but that stakeholders find them difficult, complex, and lack the necessary skills to deliver the nonjudgmental, consistent, and tailored support that they desire.

Educators' experiences and perspectives of child weight discussions with parents in primary school settings

Background

The role of schools in addressing rising childhood obesity levels has been acknowledged, and numerous diet- and physical activity-related interventions exist. Aside from formal interventions, opportunistic parent-educator conversations about child weight can arise, particularly in primary school settings, yet little is known about how useful these are. This study aimed to understand the utility of child weight related conversations with parents through exploring educators’ experiences and perspectives.

Methods

This qualitative study consisted of semi-structured interviews conducted with primary school teaching staff in the United Kingdom (N = 23), recruited through purposive and subsequent snowball sampling. Interviews were audio-recorded, transcribed, and analysed using thematic analysis.

Results

Participants identified opportunities and need for child weight discussions in schools. However, conversations were prevented by the indirect and sensitive nature of conversations, and educators’ professional identity beliefs. Using pre-existing face-to-face opportunities, good parent-teacher relationships and holistic approaches to child health and wellbeing were reported as important in optimising these conversations.

Conclusions

Whilst educator-parent child weight discussions are necessary, discussions are highly challenging, with contradictory views on responsibility sometimes resulting in avoidance. Educators’ roles should be clarified, and communication training tailored to increase teacher confidence and skills. Current social distancing will likely reduce opportunistic encounters, highlighting a need to further improve communication routes.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Use of motivational interviewing in behavioural interventions among adults with obesity: A systematic review and meta-analysis

This review aimed to identify whether motivational interviewing (MI) (a counselling approach for supporting behaviour change [BC]) helps to reduce bodyweight and BMI in an adult obesity context. This included evaluating effectiveness of MI interventions within this population and reporting the methodology used, including theoretical underpinnings and identification of BC and MI techniques. Eight databases were searched using controlled vocabulary. Eligible studies included adults with obesity (BMI ≥30 kg/m² ), author-reported interventions using MI aiming to reduce body weight or BMI, and comparator groups not receiving an MI intervention. Data extraction and quality appraisal tools were used to identify study characteristics, intervention content was coded for techniques, and random-effects meta-analysis were conducted to investigate effects. Meta-analysis of 12 studies indicated no overall pooled effect on bodyweight and BMI outcomes between intervention and control groups (SMD = -0.01 [95%CI -0.13 to 0.12, P = .93]). Findings were limited by multiple sources accounting for risk of bias, and poor reporting of intervention fidelity and content. Intervention and control content descriptions indicated similar techniques, with social support, goal setting (behaviour) and self-monitoring of behaviour occurring most frequently across both. Findings do not contribute additional evidence for MI use in this context, however methodological limitations were identified which must be resolved to better identify the intervention effects on obesity-related outcomes.

Are psychosocial interventions effective in reducing alcohol consumption during pregnancy and motherhood? A systematic review and meta-analysis

BACKGROUND AND AIMS

Alcohol use by pregnant and parenting women can have serious and long-lasting consequences for both the mother and offspring. We reviewed the evidence for psychosocial interventions to reduce maternal drinking.

DESIGN

Literature searches of PsycINFO, PubMed and Scopus identified randomised controlled trials of interventions with an aim of reduced drinking or abstinence in mothers or pregnant women.

SETTING

Interventions were delivered in healthcare settings and homes.

PARTICIPANTS

Pregnant women and mothers with dependent children.

INTERVENTIONS

Psychosocial interventions were compared with usual care or no intervention.

MEASUREMENTS

The revised Cochrane risk-of-bias tool for randomised trials was used for quality assessments. Narrative synthesis summarised the findings of the studies with a subset of trials eligible for random-effects meta-analysis. General and alcohol-specific behaviour change techniques (BCTs) were identified to investigate potential mechanism of change.

RESULTS

Twenty-four studies were included (20 pregnancy, four motherhood). Because of quality of reporting, data from only six pregnancy and four motherhood studies could be pooled. A significant treatment effect was revealed by the meta-analyses of pregnancy studies regarding abstinence (OR = 2.31, 95% CI = 1.61, 3.32; P < 0.001) and motherhood studies regarding a reduction in drinking (standardised mean difference [SMD] = -0.20, 95% CI = -0.38, -0.02; P = 0.03). Narrative synthesis of the remaining trials yielded inconsistent results regarding intervention effectiveness. A wide range of BCTs were used, present in both effective and ineffective interventions. The most commonly used general and alcohol-specific BCTs included information about consequences, social support, goal setting and action planning.

CONCLUSIONS

In pregnant women identified as consuming alcohol, psychosocial interventions appear to increase abstinence rates compared with usual care or no intervention. Similarly, such interventions appear to lead to a reduction in alcohol consumption in mothers with dependent children. It is unclear that behaviour change techniques are contributing to these effects. Conclusions from randomised controlled trials are only meaningful if the behavioural outcome, population, setting, intervention and comparator are clearly reported. An important barrier when it comes to identifying effective behaviour change techniques is a widespread failure to provide enough information in study reports.

Translation and application of an obesity behavior change technique training in a Spanish nursing undergraduate setting

BACKGROUND

The TEnT PEGS framework is a behavior change communication toolkit which has been shown to be useful in increasing health professional trainees' skills and knowledge about obesity-related behavior change techniques. There is no version of the behavioral change intervention toolkit in Spanish. Therefore, the objectives of this study were 1) to translate the TEnT PEGS framework into Spanish and apply it to a Spanish nursing student population; 2) To analyze whether training with the Spanish toolkit (DEPREMIO) had a positive impact on students' skills in encouraging obesi-ty-related behavioral change.

METHODS

First year nursing students (n=95) attended two face-to-face (2 hours per session) obesity management training sessions. A specifically designed pre-post test was carried out. Data were collected using an ad-hoc questionnaire of fourteen items, ten of them evaluated the student's knowledge and attitude about behavior change techniques, and four evaluated the student's perception of their skills in developing different strategies.

RESULTS

Training significantly increased most students' knowledge and attitudes with a 0.05 level of significance and effect sizes were between 0.36 and 0.77. It also increased students' skills, although not to any significant extent.

CONCLUSION

The DEPREMIO toolkit helped nursing students to acquire more knowledge, attitudes and skills in obesity management. It therefore seems that this adaptation is an acceptable and feasible training tool for the Spanish nursing student population.

A feasibility and acceptability study of an e-training intervention to facilitate health behaviour change conversations in dental care settings

Introduction Health behaviours result in oral health problems. Behaviour change techniques, informed by behaviour science, are rarely utilised by dental care professionals (DCPs) within routine care.Aim To develop a theory-informed intervention to support DCPs' behaviour change conversations and evaluate its feasibility and acceptability.Intervention A behaviour change toolkit (Toothpicks) comprising 33 behaviour change techniques relevant to dentistry, delivered within an interactive online course.Design Development and mixed-methods evaluation of the intervention.Materials and methods Participants' motivation to discuss behaviour change with patients was measured before and after training using a validated questionnaire. Acceptability was assessed through semi-structured interviews.Results DCPs' (N = 32) motivation increased significantly post-training. Participants found the training acceptable and reported subsequently implementing techniques into their practice. Potential barriers preventing implementation to clinical practice include perceived lack of opportunities to effect change within the constraints of the clinical context.Conclusions Acceptable theory-informed training that is acceptable and accessible can be developed that increases DCPs' motivation to discuss behaviour change with patients. Further research is necessary to establish the longer-term impact of brief behaviour change training on DCPs' clinical practice and patient health behaviours.

Obesity, eating behavior and physical activity during COVID-19 lockdown: A study of UK adults

Eating, physical activity and other weight-related lifestyle behaviors may have been impacted by the COVID-19 crisis and people with obesity may be disproportionately affected. We examined weight-related behaviors and weight management barriers among UK adults during the COVID-19 social lockdown. During April-May of the 2020 COVID-19 social lockdown, UK adults (N = 2002) completed an online survey including measures relating to physical activity, diet quality, overeating and how mental/physical health had been affected by lockdown. Participants also reported on perceived changes in weight-related behaviors and whether they had experienced barriers to weight management, compared to before the lockdown. A large number of participants reported negative changes in eating and physical activity behavior (e.g. 56% reported snacking more frequently) and experiencing barriers to weight management (e.g. problems with motivation and control around food) compared to before lockdown. These trends were particularly pronounced among participants with higher BMI. During lockdown, higher BMI was associated with lower levels of physical activity and diet quality, and a greater reported frequency of overeating. Reporting a decline in mental health because of the COVID-19 crisis was not associated with higher BMI, but was predictive of greater overeating and lower physical activity in lockdown. The COVID-19 crisis may have had a disproportionately large and negative influence on weight-related behaviors among adults with higher BMI.

The relationship between sleep disturbance, symptoms and daytime functioning in psoriasis: a prospective study integrating actigraphy and experience sampling methodology

OBJECTIVE/BACKGROUND

Sleep disturbance is common in individuals with psoriasis and appears to be related to both physical and psychological factors. We sought to examine whether psoriasis symptoms, night-time arousal and low mood predicted subsequent objective and self-reported sleep; and whether objective and self-reported sleep predicted next-day psoriasis symptoms and day-time functioning.

PARTICIPANTS/METHODS

A total of 19 individuals (Female: 11 [57.9%], median age: 39 years) with chronic plaque psoriasis and poor sleep quality (mean Pittsburgh Sleep Quality Index, PSQI = 9.11) participated. Momentary assessments of psoriasis symptoms, mood and daytime functioning were completed at five pseudo-random intervals each day for 15 days using time-stamped digital diary entry. Objective sleep was estimated using wrist-worn actigraphy. Self-reported sleep and night-time arousal were assessed each morning using validated measures.

RESULTS AND CONCLUSIONS

Two-level random intercept models showed that increased night-time arousal was associated with poorer diary-reported sleep. Neither self-reported nor objective sleep parameters were associated with daytime psoriasis symptoms in bi-directional analyses. Diary-reported sleep predicted next-day functioning, specifically sleepiness, concentration, and fatigue. Actigraphy-defined total sleep time predicted next-day fatigue. Night-time arousal is associated with poorer self-reported sleep in people with psoriasis, and sleep predicts next-day functioning. Contrary to our hypothesis, sleep disturbance does not appear to be associated with momentary assessments of psoriasis symptoms.

Online behaviour change technique training to support healthcare staff 'Make Every Contact Count'

Background

National Health Service (NHS) staff support service users to change health-related behaviours such as smoking, alcohol consumption, diet and physical activity. It can be challenging to discuss behaviour changes with service users hence training is needed to equip staff with up-to-date, evidence-based behaviour change skills. In order to identify how training may help to improve health professional skills in this area, this study evaluated change in professionals’ behavioural determinants following an online behaviour change skills module as part of Making Every Contact Count (MECC) training.

Methods

This evaluation comprised a within-subject design in which staff from one Northwest England NHS Trust completed a 9-item survey immediately before and after training. This prospective survey identified behavioural determinants regarding adhering to MECC recommendations to hold health conversations with service users and provided written comments about their training experiences. Individuals working within the Trust in clinical or non-clinical roles were eligible to take part and were invited to contribute to the evaluation upon uptake of their usual NHS staff online training programmes.

Results

Of participants completing the evaluation (n=206), 12 professional cadres accessed the module, most being female (91%), nurses/midwives (43%), working in children and family services (48%), aged 22 - 62 years. Eight behavioural determinants increased significantly following training, with effect sizes ranging from sizes ranging from 0.27 to 0.51; ‘identity’ did not change. Content analysis of written feedback (n=256) indicates that training enhanced staff behaviour change skills, modelled a productive and specific method of adopting a patient-led approach to behaviour change conversations, and identified that staff may require further support with embedding skills in practice.

Conclusions

Behaviour change science can be translated into useful learning for NHS staff. Online training can engage staff in learning about behaviour change skills and increase their behavioural determinants to adopt these skills in practice.

The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed-methods systematic review

Global evidence demonstrates that adherence to the Baby Friendly Initiative (BFI) has a positive impact on multiple child health outcomes, including breastfeeding initiation and duration up to 1 year post-partum. However, it is currently unclear whether these findings extend to specific countries with resource-rich environments. This mixed-methods systematic review aims to (a) examine the impact of BFI implementation (hospital and community) on maternal and infant health outcomes in the United Kingdom (UK) and (b) explore the experiences and views of women receiving BFI-compliant care in the UK. Two authors independently extracted data including study design, participants, and results. There is no UK data available relating to wider maternal or infant health outcomes. Two quantitative studies indicate that Baby Friendly Hospital Initiative implementation has a positive impact on breastfeeding outcomes up to 1 week post-partum but this is not sustained. There was also some evidence for the positive impact of individual steps of Baby Friendly Community Initiative (n = 3) on breastfeeding up to 8 weeks post-partum. Future work is needed to confirm whether BFI (hospital and community) is effective in supporting longer term breastfeeding and wider maternal and infant health outcomes in the UK. A meta-synthesis of five qualitative studies found that support from health professionals is highly influential to women's experiences of BFI-compliant care, but current delivery of BFI may promote unrealistic expectations of breastfeeding, not meet women's individual needs, and foster negative emotional experiences. These findings reinforce conclusions that the current approach to BFI needs to be situationally modified in resource-rich settings.

Understanding the experience of sleep disturbance in psoriasis: a qualitative exploration using the Common-Sense Model of Self-Regulation

BACKGROUND

Psoriasis is associated with significant morbidity, which negatively impacts upon quality of life. Sleep disturbance is reported to be common in patients with psoriasis and is associated with physical and psychological variables, although there is little published work in this area. Understanding sleep and the factors involved in its disturbance in psoriasis is a potentially important clinical area given the role of sleep in health and disease processes.

OBJECTIVES

To explore the experience of sleep and sleep disturbance in psoriasis using the Common-Sense Model of Self-Regulation (CS-SRM).

METHODS

Semistructured interviews were conducted with adults diagnosed with psoriasis. Interview questions were informed by the CS-SRM and previous research. Framework analysis was applied, including coding data into the CS-SRM dimensions and allowing additional inductive themes to emerge.

RESULTS

Seventeen people with psoriasis (nine women, eight men; aged 19-86 years) were interviewed about sleep and sleep disturbance. Seven themes emerged, with six accounted for by the CS-SRM: characteristics of sleep disturbance, change in sleep patterns, thoughts about and symptoms of disease disturbing sleep, impact of poor sleep on daily life, attempts to improve sleep, a daily battle for control and a seventh relating to metacognitive processes. A reciprocal relationship between sleep and psoriasis was evident across themes with interactions between key sleep-related thoughts, emotions and behaviours.

CONCLUSIONS

This study showed that sleep disturbance is a persistent concern for people with psoriasis; it has a 24-h impact, and interacts with the psychological and physical aspects of psoriasis. The distress and frustration felt when managing sleep disturbance perpetuated problematic sleep. Addressing this with currently available sleep treatments may therefore confer sleep and psoriasis-related benefits for people living with this condition.

Barriers and facilitators to health care professionals discussing child weight with parents: A meta-synthesis of qualitative studies

INTRODUCTION

Childhood obesity is one of the most serious global public health challenges. However, obesity and its consequences are largely preventable. As parents play an important role in their children's weight-related behaviours, good communication between parents and health care professionals (HCPs) is essential. This systematic review provides a meta-synthesis of qualitative studies exploring the barriers and facilitators experienced by HCPs when discussing child weight with parents.

METHODS

Searches were conducted using the following databases: MEDLINE (OVID), Psych INFO (OVID), EMBASE (OVID), Web of Knowledge and CINAHL. Thirteen full-text qualitative studies published in English language journals since 1985 were included. Included studies collected data from HCPs (e.g., nurses, doctors, dieticians, psychologists, and clinical managers) concerning their experiences of discussing child weight-related issues with parents. An inductive thematic analysis was employed to synthesize findings.

FINDINGS

Emerging subthemes were categorized using a socio-ecological framework into intra/interpersonal factors, organizational factors, and societal factors. Perceived barriers and facilitators most commonly related to intra/interpersonal level factors, that is, relating to staff factors, parental factors, or professional-parent interactions. HCPs also attributed a number of barriers, but not facilitators, at the organizational and societal levels.

CONCLUSION

The findings of this review may help to inform the development of future weight-related communication interventions. Whilst intra/interpersonal interventions may go some way to improving health care practice, it is crucial that all stakeholders consider the wider organizational and societal context in which these interactions take place. Statement of contribution What is already known on the subject? Childhood obesity is one of the United Kingdom's most serious current public health challenges. Health care professionals are in a prime position to identify child weight issues during routine consultations. However, they often feel unable or unequipped to raise the topic and provide information on child weight management. What does this study add? To our knowledge, this is the first review to synthesize barriers and facilitators to discussing child weight. This review interprets key barriers and facilitators in the context of the socio-ecological model. Supports the development of interventions matched to the appropriate level of the socio-economic model.

A mixed methods investigation of an online intervention to facilitate student midwives' engagement in effective conversations about weight-related behaviour change with pregnant women

OBJECTIVE

(1) To identify whether an online training intervention could increase midwifery students' knowledge of behaviour change techniques (BCTs) and intentions to use them in practice. (2) To identify students' views and current experiences of talking to women about weight-related behaviour change.

DESIGN

Mixed methods study involving pre- and post-training assessments, and qualitative interviews with midwifery students.

SETTING

Online training course delivered at a University in the North of England, UK.

PARTICIPANTS

Midwifery students in the third year of their undergraduate degree during 2015-2016.

INTERVENTION

Online training focused on equipping students with knowledge of theoretically-informed BCTs, and the skills to use them opportunistically in existing practice settings.

MEASUREMENTS

Likelihood of discussing obesity with women was assessed via a 12-item, 7-point Likert scale assessing students' attitudes, subjective norms, perceived behavioural control, and intentions. A 14-item checklist was used to assess BCT knowledge whereby students selected recognised BCTs (of 7 correct, 7 false). Students' views and experiences of current practice was explored through in-depth, semi-structured one-on-one interviews with a member of the research team.

FINDINGS

Students' subjective norms, perceived behavioural control, and knowledge of BCTs increased post-training but intention and attitudes did not. Interviews revealed three themes accounting for students experiences and views of behaviour change practice: (1) 'How training fits with current encounters with maternal obesity in midwifery training' (2) 'TEnT PEGS prepares students for practice', and (3) 'Value of tailored training'.

KEY CONCLUSIONS

Online BCT training can improve the midwifery students' confidence, knowledge and beliefs that this is part of their role. They also reported finding the training helpful in better preparing them for this challenging element of their routine practice.

IMPLICATIONS FOR PRACTICE

Online BCT training can be used to prepare undergraduate midwifery students for practice.

Impact of Disease Severity, Illness Beliefs, and Coping Strategies on Outcomes in Psoriatic Arthritis

OBJECTIVE

Little is known about how people with psoriatic arthritis (PsA) cope with and manage their condition, but data show that psychological problems are underrecognized and undertreated. The Common Sense Self-Regulatory Model (CS-SRM) suggests illness beliefs, mediated by coping, may influence health outcomes. The study aimed to investigate the roles of disease severity, illness beliefs, and coping strategies in predicting depression, anxiety, and quality of life (QoL) in people with PsA. Additionally, we aimed to assess the role of depression and anxiety in predicting QoL.

METHODS

We conducted a cross-sectional observational study, where adults with PsA (n = 179) completed validated measures of predictor (illness beliefs, coping strategies, disease severity) and outcome variables (depression, anxiety, QoL) using an online survey distributed via social media.

RESULTS

The participants were a community sample of 179 adults with PsA, ages 20 to 72 years (77.1% female). After controlling for disease severity, hierarchical multiple regression models indicated that more negative beliefs about consequences and behavioral disengagement as a coping method predicted levels of depression, and self-blame predicted anxiety. Beliefs about consequences and the presence of depression predicted quality of life scores after controlling for disease severity.

CONCLUSION

This study offers support for the use of the CS-SRM in explaining variation on psychological outcomes in individuals with PsA. The illness beliefs and coping strategies identified as predictors in this article are potential targets for interventions addressing PsA-related distress and QoL.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617

A cross-sectional survey of the nature and correlates of sleep disturbance in people with psoriasis

BACKGROUND

Research suggests that sleep disturbance is common in psoriasis. While several sleep investigations have been conducted in psoriasis populations, many have methodological shortcomings, and no study has examined multiple dimensions of sleep-wake functioning. Moreover, research has yet to be performed comprehensively examining the range of physical and psychological factors that may affect sleep in people with psoriasis.

OBJECTIVES

To characterize sleep disturbance using validated measures and to identify physical and psychological predictors of sleep quality in people with psoriasis.

METHODS

An online survey was conducted (186 respondents; mean age 39·2 years) comprising validated measures assessing sleep [Pittsburgh Sleep; Quality Index (PSQI), Berlin Questionnaire, Pre-Sleep Arousal Scale]; chronotype (Morningness-Eveningness Questionnaire); mood (Hospital Anxiety and Depression Scale); itch (5-D Itch Scale); and psoriasis severity (Simplified Psoriasis Index). Group comparisons and regression analyses were used to examine predictors of poor sleep.

RESULTS

The mean PSQI score was 9·2 ± 4·3, with 76·3% scoring above the threshold for poor sleep (≥ 6 on the PSQI) and 32·5% scoring 'positive' for probable obstructive sleep apnoea (OSA). Poor sleep and high likelihood of OSA were associated with more severe psoriasis (P < 0·05; η = 0·07; η² = 0·005). Cognitive arousal (β = 0·26, P = 0·001), itch (β = 0·26, P < 0·001) and depression (β = 0·24, P = 0·001) were the most robust predictors of poor sleep quality, which, together with somatic arousal (β = 0·17, P = 0·022), accounted for 43% of variance in PSQI scores.

CONCLUSIONS

Poor sleep is common in psoriasis and associated with psychological and physical factors. Rates of probable OSA are also high. Given the importance of restorative sleep for health, sleep complaints should receive greater clinical attention in the management of psoriasis.

Measurement, Classification and Evaluation of Sleep Disturbance in Psoriasis: A Systematic Review

BACKGROUND

Psoriasis is a long-term immune-mediated inflammatory disorder mainly, but not only, affecting skin, and is associated with significant medical and psychological morbidity. Evidence suggests that sleep is disrupted in psoriasis, however high quality empirical evidence is lacking. Given the importance of sleep for health, characterisation of sleep disruption in psoriasis is an important goal. We therefore conducted a systematic review of the sleep-psoriasis literature.

METHODS

Searches were conducted in Pubmed, SCOPUS and Web of Science from inception to May 2016. Studies were compared against inclusion/exclusion criteria and underwent a quality evaluation. Given the heterogeneity of studies, we conducted a narrative synthesis of the findings.

RESULTS

Searches revealed 32 studies which met our predetermined inclusion/exclusion criteria. Whilst 93.7% of studies reported sleep disruption in this population, ranging from 0.05% to 85.4%, many had important methodological shortcomings. Over half of all quantitative studies (54.8%; 17/31) relied on non-validated measures, contributing to heterogeneity in study findings. In those that employed valid measures, assessing sleep was often not the primary objective. We frequently found the absence of adequate sample size calculations and poor statistical reporting.

CONCLUSION

This review showed that in psoriasis, reported sleep rates of sleep disturbance varied substantially. Most studies lacked a hypothesis driven research question and/or failed to use validated measures of sleep. We were unable to draw firm conclusions about the precise prevalence and nature of sleep disturbance within the psoriasis population. We offer suggestions to help advance understanding of sleep disturbance in psoriasis.

Which behaviour change techniques are most effective at increasing older adults' self-efficacy and physical activity behaviour? A systematic review

BACKGROUND

Increasing self-efficacy is an effective mechanism for increasing physical activity, especially for older people.

PURPOSE

The aim of this review was to identify behaviour change techniques (BCTs) that increase self-efficacy and physical activity behaviour in non-clinical community-dwelling adults 60 years or over.

METHODS

A systematic search identified 24 eligible studies reporting change in self-efficacy for physical activity following an intervention. Moderator analyses examined whether the inclusion of specific BCTs (as defined by CALO-RE taxonomy) was associated with changes in self-efficacy and physical activity behaviour.

RESULTS

Overall, interventions increased self-efficacy (d = 0.37) and physical activity (d = 0.14). Self-regulatory techniques such as setting behavioural goals, prompting self-monitoring of behaviour, planning for relapses, providing normative information and providing feedback on performance were associated with lower levels of both self-efficacy and physical activity.

CONCLUSIONS

Many commonly used self-regulation intervention techniques that are effective for younger adults may not be effective for older adults.

'I should have taken that further' - missed opportunities during cardiovascular risk assessment in patients with psoriasis in UK primary care settings: a mixed-methods study

Background

Unhealthy lifestyle is common in psoriasis, contributing to worsening disease and increased cardiovascular disease (CVD) risk. CVD risk communication should improve patients’ understanding of risk and risk‐reducing behaviours; however, the effectiveness of risk screening is debated and evaluation currently limited.

Objective

To examine the process of assessing for and communicating about CVD risk in the context of psoriasis.

Design

Mixed‐methods study in English general practices to (i) determine proportions of CVD risk factors among patients with psoriasis at risk assessment and (ii) examine patient and practitioner experiences of risk communication to identify salient ‘process’ issues. Audio recordings of consultations informed in‐depth interviews with patients and practitioners using tape‐assisted recall, analysed with framework analysis.

Participants

Patients with psoriasis (n = 287) undergoing CVD risk assessment; 29 patients and 12 practitioners interviewed.

Results

A high proportion of patients had risk factor levels apparent at risk assessment above NICE recommendations: very high waist circumference (52%), obesity (35%), raised blood pressure (29%), smoking (18%) and excess alcohol consumption (18%). There was little evidence of personalized discussion about CVD risk and behaviour change support in consultations. Professionals reported a lack of training in behaviour change, while patients wanted to discuss CVD risk/risk reduction and believed practitioners to be influential in supporting lifestyle management.

Conclusions

Despite high levels of risk factors identified, opportunities may be missed in consultations to support patients with psoriasis to understand CVD risk/risk reduction. Practitioners need training in behaviour change techniques to capitalize on ‘teachable moments’ and increase the effectiveness of risk screening.

The role of personal models in clinical management: Exploring health care providers' beliefs about psoriasis

OBJECTIVES

Individuals' illness representations, including beliefs about psoriasis (a complex immune-mediated condition), and their emotional responses to the condition guide self-management behaviour. It is also plausible that health care providers' illness representations guide their own management of psoriasis. Patients commonly report poor health care experiences related to psoriasis, and the role of health care providers' beliefs, emotions, as well as their knowledge, experiences and behaviours ('personal models') in this is unexplored. This study aimed explore health care providers' personal models of psoriasis.

DESIGN AND METHODS

Qualitative analysis of 23 semi-structured interviews with health care professionals providing care for psoriasis patients was performed. Purposive sampling achieved maximum variation regarding participant discipline, level of experience, gender and age. The self-regulatory/common sense model informed data collection and initial data analysis. Principles of framework analysis were used to generate predetermined and emergent key issues related to practitioners' personal models.

RESULTS

Three types of personal model emerged. Sophisticated-Linear Model: 70% of practitioners recognized psoriasis as a complex condition but managed it as a skin condition. Mixed Model: 17% of practitioners recognized/managed some elements of psoriasis as complex and some as a skin condition. Sophisticated-Sophisticated Model: 13% recognized and managed psoriasis as a complex condition. Across the data set, five themes emerged illustrating key patterns underpinning these different models including (1) Recognising complexity, (2) Putting skin first, (3) Taking on the complexities of psoriasis with the patient, (4) Aiming for clearance, and (5) Affective experiences within psoriasis consultations.

CONCLUSIONS

Health care providers recognized psoriasis as a complex condition but commonly reported managing psoriasis as a simple skin condition. Providers' beliefs and management approaches varied in the extent to which they were consistent with one another; and their emotional experiences during consultations may vary depending upon their personal model. Findings could inform future dermatology training programmes by highlighting the role of health care providers' illness representations in clinical management of the condition.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Health behaviour is predicted by underlying beliefs and emotions associated with an illness and its treatment. Few studies have examined health care providers' beliefs and emotions about the illnesses they manage in clinical practice. Many patients are dissatisfied with dermatology consultations and wish to be treated holistically. What does this study add? Qualitative exploration of health care providers' beliefs/emotions revealed their personal models of psoriasis. Providers' personal models of psoriasis vary in coherence and are often skin rather than whole person focused. Further investigation of health care providers' models of psoriasis and their impact on health outcomes is needed.

Investigating the feasibility and acceptability of health psychology-informed obesity training for medical students

Health psychologists have succeeded in identifying theory-congruent behaviour change techniques (BCTs) to prevent and reduce lifestyle-related illnesses, such as cardiovascular disease, cancers and diabetes. Obesity management discussions between doctors and patients can be challenging and are often avoided. Despite a clear training need, it is unknown how best to tailor BCT research findings to inform obesity-management training for future healthcare professionals. The primary objective of this descriptive study was to gather information on the feasibility and acceptability of delivering and evaluating health psychology-informed obesity training to UK medical students. Medical students (n = 41) attended an obesity management session delivered by GP tutors. Sessions were audio-recorded to enable fidelity checks. Acceptability of training was explored qualitatively. Tutors consistently delivered training according to the intervention protocol; and students and tutors found the training highly acceptable. This psychology-informed training can be delivered successfully by GP tutors and further research is warranted to explore its efficacy.

Providing lifestyle behaviour change support for patients with psoriasis: an assessment of the existing training competencies across medical and nursing health professionals

BACKGROUND

Psoriasis is associated with unhealthy lifestyle behaviours which contribute to psoriasis onset and severity. Health professionals who manage patients with psoriasis are well placed to support lifestyle change but few feel confident to do so. Little is known about the extent to which health promotion and lifestyle behaviour change (LBC) skills are included within post-qualification training curricula.

OBJECTIVES

This study aimed to systematically examine the content of post-qualification U.K. training curricula for health professionals across General Practice and Dermatology for evidence of behaviour change skills relating to the promotion of healthy lifestyles.

METHODS

Core curricula documents from professional organizations were analysed for content to examine the extent to which curricula: (1) mentioned health promotion and LBC as part of the professional role; and/or (2) included health promotion and LBC as explicit training competencies or requirements for qualification.

RESULTS

Of the 11 core curricula documents analysed, we found 67 occurrences of terms related to LBC and health promotion. Most were in the General Practitioner curriculum (n = 42; 62·7%), followed by the Dermatology Specialist Nurse curriculum (n = 14; 20·9%) and Dermatologist curriculum (n = 11; 16·4%). No occurrences were found in the General Practitioner with a Special Interest in Dermatology curriculum. LBC knowledge, skills and attitudes were not clearly specified and only basic level LBC competencies were included.

CONCLUSIONS

Development of post-qualification curricula would ensure health professionals are equipped with the necessary knowledge, skills and attitudes to support LBC for patients with psoriasis. This is of particular relevance, given the evidence linking unhealthy lifestyles with psoriasis outcomes.

Overcoming the barriers to the diagnosis and management of chronic fatigue syndrome/ME in primary care: a meta synthesis of qualitative studies

BACKGROUND

The NICE guideline for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) emphasises the need for an early diagnosis in primary care with management tailored to patient needs. However, GPs can be reluctant to make a diagnosis and are unsure how to manage people with the condition.

METHODS

A meta synthesis of published qualitative studies was conducted, producing a multi-perspective description of barriers to the diagnosis and management of CFS/ME, and the ways that some health professionals have been able to overcome them. Analysis provided second-order interpretation of the original findings and developed third-order constructs to provide recommendations for the medical curriculum.

RESULTS

Twenty one qualitative studies were identified. The literature shows that for over 20 years health professionals have reported a limited understanding of CFS/ME. Working within the framework of the biomedical model has also led some GPs to be sceptical about the existence of the condition. GPs who provide a diagnosis tend to have a broader, multifactorial, model of the condition and more positive attitudes towards CFS/ME. These GPs collaborate with patients to reach agreement on symptom management, and use their therapeutic skills to promote self care.

CONCLUSIONS

In order to address barriers to the diagnosis and management of CFS/ME in primary care, the limitations of the biomedical model needs to be recognised. A more flexible bio-psychosocial approach is recommended where medical school training aims to equip practitioners with the skills needed to understand, support and manage patients and provide a pathway to refer for specialist input.

Early training in tackling patient obesity: a systematic review of nurse education

OBJECTIVES

This systematic review aims to identify studies that have assessed educational interventions in undergraduate nurse training regarding obesity, and to investigate the interventions' effectiveness.

BACKGROUND

Obesity is a prominent global issue and nurses have an increased role in weight management with patients. The literature has identified various theory-based behaviour change techniques that successfully assist weight management in patients. Thus, training nurses in obesity-related behaviour change techniques is appropriate in preparing them for their future professional role. However, effectiveness of these educational interventions has not yet been assessed.

METHODS

The Centre for Reviews and Dissemination guidelines informed this systematic review. Four databases were systematically searched and articles were assessed against inclusion criteria. Data extraction and quality appraisal forms were developed and completed to identify salient features within the articles.

RESULTS

Eight studies met inclusion criteria. Only two included both baseline and outcome measures, one of which was a randomised controlled trial. Additionally, only one study included an explicitly identified behaviour change technique. Interventions were delivered through a range of methods, however, quality appraisal indicated that all of the studies had poor methodologies and had high risks of bias.

CONCLUSIONS

Studies in this area of research are sparse and are not methodologically robust. Therefore, it is not possible to identify effective educational interventions for nursing students on weight management.

IMPLICATIONS

More robust research is needed to investigate how nurses can be trained to facilitate weight management. Greater transparency of intervention descriptions, particularly around what behaviour change techniques were taught, would allow for replication and appropriate evaluation. Until then, it is not known if current teaching adequately equips nurses to manage obese and overweight patients.

Development of a behaviour change communication tool for medical students: the 'Tent Pegs' booklet

OBJECTIVE

To describe the development and validation of a behaviour change communication tool for medical students.

METHODS

Behaviour change techniques (BCTs) were identified within the literature and used to inform a communication tool to support medical students in discussing health-related behaviour change with patients. BCTs were organized into an accessible format for medical students (the 'Tent Pegs' booklet) and validated using discriminant content validity methods with 11 expert judges.

RESULTS

One-sample t-tests showed that judges reliably mapped BCTs onto six of the seven Tent Pegs domains (confidence rating means ranged from 4.0 to 5.1 out of 10, all p≤0.002). Only BCTs within the 'empowering people to change' domain were not significantly different from the value zero (mean confidence rating=1.2, p>0.05); these BCTs were most frequently allocated to the 'addressing thoughts and emotions' domain instead.

CONCLUSION

BCTs within the Tent Pegs booklet are reliably allocated to corresponding behaviour change domains with the exception of those within the 'empowering people to change' domain.

PRACTICE IMPLICATIONS

The existing evidence-base on BCTs can be used to directly inform development of a communication tool to support medical students facilitate health behaviour change with patients.

Nursing students' perceptions of obesity and behaviour change: implications for undergraduate nurse education

BACKGROUND

Rates of obesity are rising and previous research suggests this is not effectively dealt with in healthcare settings. Nurses are increasingly involved in lifestyle management of patients, and understanding the barriers to discussing weight with patients is likely to increase successful weight management. Obesity management is a role that nursing students will need to be equipped with and more likely to be targeted for future training developments in tackling the increasing rates of obesity.

OBJECTIVES

To explore the perceptions of obesity, potential barriers to successful patient weight management and training needs of nursing students.

METHODS

Qualitative, semi-structured interviews were conducted with 20 nursing students. Audiotaped interviews were transcribed verbatim and analysed using an inductive thematic approach informed by principles of grounded theory.

RESULTS

Participants reported the challenge of managing obesity in healthcare practice, such as the impact of negative attitudes in healthcare practice on patient care. Although perceived as core to their training, nursing students lacked the confidence and techniques to discuss weight management with patients. Participants also perceived the nursing curriculum as lacking a focus on obesity, and reported a need for advanced communication skills training.

CONCLUSION

Although seen as important, nurses lack the skills to facilitate weight management, leading to nurses failing to broach the issue.

PRACTICE IMPLICATIONS

Nurse educators should consider the perceptions of current students when making curriculum developments in this area.

Are medical educators following General Medical Council guidelines on obesity education: if not why not?

BACKGROUND

Although the United Kingdom's (UK's) General Medical Council (GMC) recommends that graduating medical students are competent to discuss obesity and behaviour change with patients, it is difficult to integrate this education into existing curricula, and clinicians report being unprepared to support patients needing obesity management in practice. We therefore aimed to identify factors influencing the integration of obesity management education within medical schools.

METHODS

Twenty-seven UK and Irish medical school educators participated in semi-structured interviews. Grounded theory principles informed data collection and analysis. Themes emerging directly from the dataset illustrated key challenges for educators and informed several suggested solutions.

RESULTS

Factors influencing obesity management education included: 1) Diverse and opportunistic learning and teaching, 2) Variable support for including obesity education within undergraduate medical programmes, and 3) Student engagement in obesity management education. Findings suggest several practical solutions to identified challenges including clarifying recommended educational agendas; improving access to content-specific guidelines; and implementing student engagement strategies.

CONCLUSIONS

Students' educational experiences differ due to diverse interpretations of GMC guidelines, educators' perceptions of available support for, and student interest in obesity management education. Findings inform the development of potential solutions to these challenges which may be tested further empirically.

Preparing medical students to facilitate lifestyle changes with obese patients: a systematic review of the literature

PURPOSE

Doctors will increasingly encounter opportunities to support obese patients in lifestyle change efforts, but the extent to which medical schools prepare their students for this challenge is unknown. Further, despite evidence indicating theory-based techniques are effective in facilitating patients' behavioral changes, the methods taught to medical students and the means of content delivery are unclear. The authors reviewed the literature to investigate how effective educational interventions are in preparing medical students to facilitate lifestyle changes with obese patients.

METHOD

The authors systematically searched Excerpta Medica (EMBASE), PsycINFO, MEDLINE, and Scopus for educational interventions on obesity management for medical students published in English between January 1990 and November 2010 and matching PICOS (Population, Interventions, Comparators, Outcomes, Study design) inclusion criteria.

RESULTS

Results of a narrative synthesis are presented. Of 1,680 studies initially identified, 36 (2%) full-text articles were reviewed, and 12 (1%) were included in the final dataset. Eleven (92%) of these studies had quantitative designs; of these, 7 (64%) did not include control groups. Nine (75%) of the 12 studies were atheoretical, and 4 (33%) described behavior management strategies. Despite positive reported outcomes regarding intervention evaluations, procedures to control for bias were infrequently reported, and conclusions were often unsupported by evidence.

CONCLUSIONS

Evidence from this systematic review revealed data highly susceptible to bias; thus, intervention efficacy could not be determined. Additionally, evidence-based strategies to support patients' obesity-related behavior changes were not applied to these studies, and thus it remains unknown how best to equip medical students for this task.

Current challenges of behavior change talk for medical professionals and trainees

OBJECTIVE

To explore medical professionals' and trainees' experiences and views of behavior change talk in various health care settings to develop current understanding of the challenges that underlie this phenomenon.

METHODS

Qualitative, semi-structured interviews were conducted with medical professionals and trainees (n=29). Grounded theory principles informed sampling, data collection and analysis. To achieve maximum variance, participants with different levels of experience were purposively sampled from a range of primary and secondary care settings. Analysis was iterative, involving a constant comparative approach allowing emergent ideas to be tested in subsequent interviews until thematic saturation was reached.

RESULTS

Three emergent themes described reasons for not engaging in behavior change talk with patients: (1) 'personal challenges'; (2) 'somebody else's responsibility' and (3) 'prioritizing the doctor-patient relationship'.

CONCLUSION

Despite increasingly being recognized as a core aspect of medical practice and education, medical professionals and trainees remain unprepared to discuss health-related behavior change with patients and unclear of their roles within contemporary health care.

PRACTICE IMPLICATIONS

Formal training in theory-based behavior change techniques is likely to help empower doctors and mitigate many of the barriers found, particularly in relation to socially and emotionally uncomfortable topics that are perceived to threaten the doctor-patient relationship.

Impulsivity in restrained eaters: emotional and external eating are associated with attentional and motor impulsivity

The current study examined the relationships of motor, nonplanning, and attentional impulsivity to external and emotional eating among restrained eaters. Data were collected from a female college sample of restrained eaters (N=90). Aspects of impulsivity and disordered eating were assessed using the Barratt Impulsiveness Scale, Version 11, the Attentional Control Scale and the Dutch Eating Behavior Questionnaire. Significant correlations emerged between eating disturbances and different types of impulsivity. The results indicated that restrained eating is associated with motor and attentional forms of impulsivity. Emotional eating appears to be linked to both attentional and motor impulsivity whereas external eating seems to be linked only to motor impulsivity. Future studies should explore which aspects of disinhibited eating among restrained eaters are best predicted by a tendency to act impulsively.

Challenges to nurse prescribers of a no-antibiotic prescribing strategy for managing self-limiting respiratory tract infections

AIMS

To report a qualitative study of the experiences of nurse prescribers in managing patients with self-limiting respiratory tract infections.

BACKGROUND

Patients frequently attend primary care with respiratory tract infections. Although a no-prescribing strategy is recommended for these consultations, general practitioners frequently prescribe antibiotics, citing non-clinical reasons such as patient pressure. Nurses increasingly manage people with respiratory tract infections, but research has not yet explored their experiences within such consultations.

DESIGN

Semi-structured interviews and focus groups.

METHODS

Fifteen semi-structured interviews and three focus groups (n=5, n=4, and n=12) with a purposive sample of nurse prescribers (n=34) and other non-medical prescribers (n=2) were conducted between November 2009-November 2010. A qualitative approach was used to develop conceptual categories from the dataset, and emerging themes were explored in subsequent interviews/focus groups.

FINDINGS

Although participants reported experiencing numerous challenges within these consultations, they believed that they possessed some of the communication skills to deal effectively with patients without prescribing antibiotics. Participants reported that protocols supported their decision-making and welcomed the benefits of peer support in dealing with 'demanding' patients. However, the newness of nurses and other non-medical prescribers to the prescribing role meant that some were cautious in dealing with patients with respiratory tract infections.

CONCLUSION

Training for nurses and other non-medical prescribers should focus on building their confidence and skills to manage people with respiratory tract infections without recourse to antibiotics. Further work should seek to explore which strategies are most effective in managing respiratory tract infections while maintaining patient satisfaction with care.

Managing self-limiting respiratory tract infections: a qualitative study of the usefulness of the delayed prescribing strategy

BACKGROUND

Despite respiratory tract infections usually being viral and self-limiting, most primary care consultations still result in an antibiotic prescription. The National Institute for Health and Clinical Excellence (NICE) introduced the 'delayed prescribing' (DP) strategy. It remains unknown how useful UK clinicians find this approach.

AIM

To investigate how DP is used within UK primary care, and the benefits and challenges associated with this strategy.

DESIGN AND SETTING

Qualitative interview and focus group study in UK scheduled and unscheduled care primary care settings.

METHOD

Data were gathered through semi-structured interviews (n = 49) and six focus groups with GPs, trainee GPs, and nurse prescribers (NPs). An iterative analysis approach, using grounded theory principles, was used to generate themes from the dataset.

RESULTS

Prescribers were familiar with DP but used it infrequently. DP was often used to manage diagnostic uncertainty, although NPs, trainee GPs, and GPs working in unscheduled care services preferred patients to reconsult under these circumstances. Prescribers used DP to avoid conflict, although some had found more effective strategies to achieve this. Prescribers were generally uncomfortable giving clinical responsibility to patients, and DP was perceived to communicate a conflicting message to patients about antibiotic efficacy.

CONCLUSION

DP was not considered to be a helpful strategy for managing patients with self-limiting respiratory tract infections within primary care and the findings do not support the centrality of DP in NICE guidelines as a primary means of reducing antibiotic prescribing. Future training and guidelines should encourage alternative ways of communicating empathy, addressing patient beliefs, and encouraging self-management.

Asthma control with extrafine-particle hydrofluoroalkane-beclometasone vs. large-particle chlorofluorocarbon-beclometasone: a real-world observational study

BACKGROUND

The extrafine-particle formulation of hydrofluoroalkane-beclometasone (EF HFA-BDP; Qvar®) demonstrates improved total and small airway deposition compared with large-particle chlorofluorocarbon (CFC)-BDP. In some short-term studies, EF HFA-BDP provides greater effects on lung function than CFC-BDP, and hence is recommended to be prescribed at a lower dose, but whether there are differences in asthma outcomes during long-term treatment is unknown.

OBJECTIVE

To compare the effectiveness of EF HFA-BDP vs. CFC-BDP over 1 year.

METHODS

This retrospective matched cohort study examined outcomes in a large primary care database for patients aged 5-60 years with asthma receiving their first inhaled corticosteroid (ICS) prescription (initiation population) or first ICS dose increase (step-up population) by a pressurized metered-dose inhaler (pMDI) as EF HFA-BDP or CFC-BDP. Patients were matched on baseline demographic and asthma severity measures in EF HFA-BDP:CFC-BDP ratios of 1:3 and 1:2 for initiation and step-up populations, respectively. Step-up patients were matched also on ICS dose during a baseline year. Co-primary endpoints were asthma control (composite measure comprising no recorded hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and exacerbation rate during the outcome year.

RESULTS

For the initiation population (EF HFA-BDP n=2882; CFC-BDP n=8646), adjusted odds of achieving asthma control with EF HFA-BDP vs. CFC-BDP was 1.15 (95% CI 1.02-1.28). For the step-up population (n=258 and 516), adjusted odds of asthma control with EF HFA-BDP was 1.72 (95% CI 1.14-2.56). EF HFA-BDP was prescribed at a median dose half that of CFC-BDP.

CONCLUSION AND CLINICAL RELEVANCE

During 1 year after initiating or stepping up ICS therapy by pMDI, patients who received EF HFA-BDP were more likely to achieve asthma control than those receiving CFC-BDP. These findings suggest that ICS formulation, particle size, and deposition characteristics play important roles in real-life effectiveness of asthma therapy. This study shows that an EF-particle formulation of beclometasone can be used at half the dose of the large-particle formulation with at least as good clinical outcomes.

Cholesterol lowering effects of nuts compared with a Canola oil enriched cereal of similar fat composition

BACKGROUND AND AIM

Small quantities of nuts protect against subsequent cardiovascular risk. There is speculation that the cholesterol lowering effect associated with nut consumption arises primarily from the fatty acid composition of nuts but may be caused by some other component. To evaluate this possibility we compared the effect of various nuts, against a Canola oil based cereal with a comparable fatty acid profile, on lipids, lipoproteins and fatty acids to determine whether the fatty acid profile of nuts explains their cholesterol lowering effects.

METHODS AND RESULTS

Twenty-eight men and women with mean (s.d.) levels of total and low density lipoprotein cholesterol of 6.0 (1.1) mmol/L, and 4.1 (1.0) mmol/L, respectively and a mean body mass index (BMI) of 26.9 (3.2) kg/m2 took part in a randomised cross over trial. For two periods of six weeks, separated by a four-week washout, participants were asked to consume a low saturated fat diet, which included either 30 g/d nuts (nut diet) or one serving of a cereal containing Canola oil (cereal diet). There were no significant differences in the lipids, lipoproteins, plasma fatty acids or other variables between the two diets at the end of the study. Total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) were lower on both experimental diets than at baseline, 0.51 mmol/L and 0.40 mmol/L (p<0.001, p<0.01), respectively on the nut diet and 0.42 mmol/L and 0.37 mmol/L (p<0.001, p<0.01), respectively on the cereal diet.

CONCLUSION

A 30 g serving of nuts, or a serving of a Canola oil enriched cereal with a similar fatty acid composition reduced total and LDL cholesterol to a similar extent when consumed as part of a lipid lowering diet. Results suggest that foods with a similar fatty acid composition to nuts can produce comparable decreases in lipoprotein mediated cardiovascular risk.

Replacing cows' with sheep's dairy fat lowers plasma cholesterol concentration in participants consuming dairy fat-rich diets

OBJECTIVE

To determine the effects on plasma cholesterol concentration of replacing cows' dairy fat with sheep's dairy fat.

DESIGN

Randomised crossover dietary intervention.

SETTING

General community, Dunedin, New Zealand.

SUBJECTS

Volunteer sample of 41 healthy adults with initial plasma cholesterol concentration between 4.8 and 7.8 mmol/l.

INTERVENTIONS

Participants were asked to follow a self-selected low-fat background diet throughout the study to which, during each of the 2, 3-week dairy diets, they were asked to add sheep's or cows' dairy products.

MAIN OUTCOME MEASURES

Energy and nutrient intakes, plasma triacylglycerol fatty acids, and plasma cholesterol.

RESULTS

Energy and nutrient intakes on the sheep-dairy and cow-dairy diets were very similar, with total, saturated, monounsaturated and polyunsaturated fat contributing 34, 18-19, 9, and 3% of total energy intake, respectively. Participants consumed approximately 50 g/day of dairy fat on each diet. Replacing cows' with sheep's dairy fat led to a 0.33 (0.11-0.56, 95% CI) mmol/l decrease (6%) in plasma total cholesterol concentration, from 5.53 (0.90, s.d.) to 5.20 (0.90) mmol/l. Plasma low-density lipoprotein (LDL) cholesterol was 0.18 (0.02-0.33) mmol/l lower on the sheep-dairy diet as was the concentration of plasma high-density lipoprotein (HDL) cholesterol, 0.11 (0.02-0.20) mmol/l. The LDL to HDL cholesterol ratio at the end of the sheep-dairy diet, 2.91 (1.10), was not significantly different (P>0.05) from the cow-dairy diet, 2.73 (0.83).

CONCLUSIONS

Within the context of a diet high in dairy fat (50 g/day), replacing cows' milk fat with sheep's milk fat leads to a small reduction in plasma cholesterol concentration, but no change in the ratio of LDL to HDL cholesterol.

Plant sterol-enriched spread enhances the cholesterol-lowering potential of a fat-reduced diet

OBJECTIVE

To determine the effect of a plant sterol-enriched spread on plasma cholesterol concentrations when replacing butter or a standard polyunsaturated spread in a diet containing 30% of energy fat.

DESIGN

Parallel butter phase followed by double-blind, randomized, cross-over polyunsaturated spread phases.

SETTING

General community.

SUBJECTS

Volunteer sample of 50 free-living men and women with mean age (s.d.) 46.7 y (10.5), moderately elevated plasma total cholesterol 5.95 mmol/l (0.78), and body mass index 26.0 (3.9) kg/m(2).

INTERVENTION

Participants ate a moderately low-fat diet (30% of energy) for the 11-week intervention. During the first 3 weeks the diet included 20 g per day of butter. Participants were then randomized to replace the butter with 25 g of polyunsaturated spread with or without 2 g of plant sterols for 4 weeks, crossing over in the last 4 weeks to the alternate spread.

MAIN OUTCOME MEASURES

Plasma cholesterol and fatty acids.

RESULTS

Replacing butter with a standard polyunsaturated fat spread reduced mean plasma total cholesterol concentrations by 4.6% (from 6.09 (0.82) to 5.81 (0.77) mmol/l, P<0.01) and low-density lipoprotein cholesterol by 5.5% (from 3.98 (0.76) to 3.76 (0.74) mmol/l, P<0.05). Replacing butter with a polyunsaturated spread containing plant sterols reduced plasma total cholesterol by 8.9% (from 6.09 (0.82) to 5.55 (0.76) mmol/l, P<0.01) and low density lipoprotein cholesterol by 12.3% (from 3.98 (0.76) to 3.49 (0.72) mmol/l, P<0.01). Plasma high density lipoprotein cholesterol concentration was the same on the three diets.

CONCLUSION

In people with moderately raised plasma cholesterol concentrations consuming reduced-fat diets the reduction in plasma total and low-density lipoprotein cholesterol concentrations achieved by replacing butter with a polyunsaturated spread is enhanced by addition of plant sterols.

Assessment of three levels of folic acid on serum folate and plasma homocysteine: a randomised placebo-controlled double-blind dietary intervention trial

OBJECTIVE

To determine the minimum effective dose of folic acid required to appreciably increase serum folate and to produce a significant reduction in plasma total homocysteine (tHcy).

DESIGN

Double-blind, randomised placebo-controlled intervention trial.

SETTING

Community-based project in a New Zealand city.

SUBJECTS

Seventy free living men and women with tHcy> or =10 micromol/l. Mean age (range) was 58 (29-90) y.

INTERVENTIONS

Daily consumption over 4 weeks of 20 g breakfast cereal either unfortified (placebo) or fortified with 100, 200 or 300 microg folic acid. Dietary intake was determined by weighed diet records and consumption of commercially fortified products was avoided.

MAIN OUTCOME MEASURES

Plasma tHcy and serum folate concentrations.

RESULTS

Average serum folate concentrations (95% CI) increased significantly in the treatment groups relative to the control group by 28(9-51)%, 60(37-87)% and 79(51-114)% for supplementation with 100, 200 and 300 microg folic acid, respectively. A reduction in tHcy was observed, being 16(8-22)%, 12(4-18)% and 17(9-24)% in the three treatment groups, respectively.

CONCLUSIONS

A regular intake of as little as 100 microg folic acid per day was sufficient to lower tHcy in persons at the upper end of the normal range for tHcy. Low-level fortification may also be appropriate for lowering the risk of neural tube defects given that, when aggregated from all sources, the total intake of folic acid may be sufficiently high to adequately improve the folate status of young women.

Comparison of a vitamin E-rich diet and supplemental vitamin E on measures of vitamin E status and lipoprotein profile

OBJECTIVE

To determine whether dietary modification rather than use of supplements can raise indices of vitamin E status to potentially cardioprotective levels.

DESIGN

Eight week randomised controlled trial with parallel treatments to compare increased use of vitamin E-rich foods, supplementation with 200 IU of vitamin E, and a placebo.

SETTING

Dunedin, New Zealand.

SUBJECTS

Ninety subjects were recruited, of whom 82 non-smoking, free-living individuals aged 22-72 y with plasma cholesterol <7.5 mmol/l completed the trial.

MAIN OUTCOME MEASURES

Dietary intakes, plasma alpha tocopherol, plasma alpha tocopherol/cholesterol ratio and lipoprotein cholesterol.

RESULTS

Consumption of an additional 12 mg of vitamin E (alpha tocopherol equivalents) from dietary sources was primarily achieved through the replacement of saturated fat-rich foods with unsaturated fats rich in vitamin E, nuts and vegetables. This resulted in a 3.4 micromol/l increase in plasma alpha tocopherol at week 6 (95% CI 1.6-5.3), and 0.9 micromol/mmol in plasma alpha tocopherol/cholesterol at weeks 4 and 6 (95% CI 0.3-1.4 and 0.4-1.4, respectively) when compared with the placebo group. In the supplement group, plasma alpha tocopherol and plasma alpha tocopherol/cholesterol were significantly increased within 2 weeks and remained so throughout the 8 week intervention.

CONCLUSION

Increasing dietary vitamin E intake can increase plasma alpha tocopherol levels, although factors other than dietary intake are also important determinants. The extent of dietary modification required to achieve potentially cardioprotective levels of plasma alpha tocopherol is difficult in practice.

SPONSORSHIP

The study was supported through the Otago Medical Research Foundation Laurenson Award.

Variants in the cholesterol ester transfer protein and lipoprotein lipase genes are predictors of plasma cholesterol response to dietary change

There are no definitive explanations as to why individuals with hypercholesterolemia, a major cardiovascular risk factor, respond differently to dietary change. Fifty five free-living individuals completed a double crossover trial with two dietary regimens, a high saturated fat diet (providing 21% energy from saturated fat and 3% energy from polyunsaturated fat) and a high polyunsaturated fat diet (providing 11% energy as saturated fat and 10% energy as polyunsaturated fat), each phase continuing for 4 weeks. Extensive genotyping and several measures of dietary compliance have provided further insights regarding the determinants of extent of cholesterol response to changes in the nature of dietary fat. Individuals with the CETP B1B1 genotype and the LPL X447+ allele showed an average 0. 44 (95% CI: 0.22, 0.66) and 0.45 (95% CI: 0.18, 0.72) mmol/l greater change in total cholesterol, respectively, than those with one or more CETP B2 allele or homozygous for the LPL S447 allele when comparing diets high and low in saturated fat. Indices of dietary compliance including changes in reported saturated and polyunsaturated fat intake and change in triglyceride linoleate were not significantly different between the CETP genotypes. Change in reported saturated (r=0.36, P=0.04) and polyunsaturated (r=0.22, P=0. 05) fat intake and change in triglyceride linoleate (reflecting polyunsaturated fat intake) (r=0.21, P=0.07), also predicted total cholesterol response to dietary fat changes. In multivariate analyses, variation in the cholesterol ester transfer protein and lipoprotein lipase genes predicted response independent of measures of dietary compliance, suggesting that these two genes are important determinants of variation in cholesterol response to dietary change in free-living individuals.