Evidence-based long term interventions targeting acute mental health presentations for children and adolescents: systematic review

Background

Long term intervention services have proven to be effective in improving mental health (MH) outcomes and the quality of life for children and young people (CYP).

Aim

To synthesize evidence on the effectiveness of long-term interventions in improving MH outcomes for CYP, 0-17 years, presenting with MH conditions.

Methods

A systematic search was carried out and the methodological quality of included long term MH intervention studies were assessed. Six databases were searched for peer-reviewed articles between January 2000 and September 2022.

Results

We found 30 studies that reported on the effectiveness of a range of long-term MH interventions in the form of (i) group therapy, (ii) multisystemic behavior therapy, (iii) general services, (iv) integrated services, (v) psychotherapy, (vi) intensive intervention services, (vii) comprehensive collaborative care, (viii) parent training, and (ix) home outreach service. Among the included studies, seven were rated as high level of evidence based on the National Health and Medical Research Council (NHMRC) levels of evidence hierarchy scale and seven were of moderate quality evidence. Others were rated as lower-quality evidence. Among the studies providing high quality evidence, most were reported for group therapy, general services, and psychotherapy studies demonstrating beneficial effects.

Conclusion

This systematic review provides evidence to demonstrate the benefits of a range of long-term interventions, in a range of settings, can be effective in improving MH outcomes for CYP and their families.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022323324.

Real world evidence for public health decision-making on vaccination policies: perspectives from an expert roundtable

INTRODUCTION

Influenza causes significant morbidity and mortality, but influenza vaccine uptake remains below most countries' targets. Vaccine policy recommendations vary, as do procedures for reviewing and appraising the evidence.

AREAS COVERED

During a series of roundtable discussions, we reviewed procedures and methodologies used by health ministries in four European countries to inform vaccine recommendations. We review the type of evidence currently recommended by each health ministry and the range of approaches toward considering randomized controlled trials (RCTs) and real-world evidence (RWE) studies when setting influenza vaccine recommendations.

EXPERT OPINION

Influenza vaccine recommendations should be based on data from both RCTs and RWE studies of efficacy, effectiveness, and safety. Such data should be considered alongside health-economic, cost-effectiveness, and budgetary factors. Although RCT data are more robust and less prone to bias, well-designed RWE studies permit timely evaluation of vaccine benefits, effectiveness comparisons over multiple seasons in large populations, and detection of rare adverse events, under real-world conditions. Given the variability of vaccine effectiveness due to influenza virus mutations and increasing diversification of influenza vaccines, we argue that consideration of both RWE and RCT evidence is the best approach to more nuanced and timely updates of influenza vaccine recommendations.

A reanalysis of the Institute for Research and Evaluation report that challenges non-US, school-based comprehensive sexuality education evidence base

Comprehensive sexuality education (CSE) prepares young people to make informed decisions about their sexuality. A review by the Institute of Research and Evaluation that analysed 43 CSE studies in non-US settings found the majority to be ineffective and concluded that there was little evidence of the effectiveness of CSE. We reanalysed the review to investigate its validity. We found several weaknesses with the review's methodology and analysis: (1) there was an absence of a clearly articulated search strategy and specific eligibility criteria; (2) the authors put forth criteria for programme effectiveness but included studies that did not collect the data needed to show programme effectiveness and thus several studies were determined to be ineffective by default; (3) the analytical framework minimised positive intervention effects and privileged negative intervention effects; and (4) there were errors in the data extracted, with 74% of studies containing one or more discrepancies. Overall, our reanalysis reveals that the IRE review suffers from significant methodological flaws and contains many errors which compromise its conclusions about CSE. Our reanalysis is a tool for the international community to refute CSE opposition campaigns based on poor science.

Multidisciplinary development of guidelines for ketamine treatment for treatment-resistant major depression disorder for use by adult specialist mental health services in New Zealand

BACKGROUND

The evidence base for racemic ketamine treatment for treatment-resistant major depressive disorder (TRD) continues to expand, but there are major challenges translating this evidence base into routine clinical care.

AIM

To prepare guidelines for ketamine treatment of TRD that are suitable for routine use by publicly funded specialist mental health services.

METHOD

We consulted with senior leadership, clinical pharmacy, psychiatrists, nursing, service users and Māori mental health workers on issues relating to ketamine treatment. We prepared treatment guidelines taking the evidence base for ketamine treatment and the consultation into account.

RESULTS

Ketamine treatment guidance is reported. This offers two treatment pathways, including a test of ketamine responsiveness with intramuscular ketamine and the dominant use of oral ketamine for a 3-month course to maximise the opportunity for the short-term benefits of ketamine to accumulate.

CONCLUSIONS

We have responded to the challenges of translating the evidence base for ketamine treatment into a form suitable for routine care.

Stress Management Apps: Systematic Search and Multidimensional Assessment of Quality and Characteristics

BACKGROUND

Chronic stress poses risks for physical and mental well-being. Stress management interventions have been shown to be effective, and stress management apps (SMAs) might help to transfer strategies into everyday life.

OBJECTIVE

This review aims to provide a comprehensive overview of the quality and characteristics of SMAs to give potential users or health professionals a guideline when searching for SMAs in common app stores.

METHODS

SMAs were identified with a systematic search in the European Google Play Store and Apple App Store. SMAs were screened and checked according to the inclusion criteria. General characteristics and quality were assessed by 2 independent raters using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality (range 1 to 5) on the following four dimensions: (1) engagement, (2) functionality, (3) esthetics, and (4) information. In addition, the theory-based stress management strategies, evidence base, long-term availability, and common characteristics of the 5 top-rated SMAs were assessed and derived.

RESULTS

Of 2044 identified apps, 121 SMAs were included. Frequently implemented strategies (also in the 5 top-rated SMAs) were psychoeducation, breathing, and mindfulness, as well as the use of monitoring and reminder functions. Of the 121 SMAs, 111 (91.7%) provided a privacy policy, but only 44 (36.4%) required an active confirmation of informed consent. Data sharing with third parties was disclosed in only 14.0% (17/121) of the SMAs. The average quality of the included apps was above the cutoff score of 3.5 (mean 3.59, SD 0.50). The MARS-G dimensions yielded values above this cutoff score (functionality: mean 4.14, SD 0.47; esthetics: mean 3.76, SD 0.73) and below this score (information: mean 3.42, SD 0.46; engagement: mean 3.05, SD 0.78). Most theory-based stress management strategies were regenerative stress management strategies. The evidence base for 9.1% (11/121) of the SMAs could be identified, indicating significant group differences in several variables (eg, stress or depressive symptoms) in favor of SMAs. Moreover, 38.0% (46/121) of the SMAs were no longer available after a 2-year period.

CONCLUSIONS

The moderate information quality, scarce evidence base, constraints in data privacy and security features, and high volatility of SMAs pose challenges for users, health professionals, and researchers. However, owing to the scalability of SMAs and the few but promising results regarding their effectiveness, they have a high potential to reach and help a broad audience. For a holistic stress management approach, SMAs could benefit from a broader repertoire of strategies, such as more instrumental and mental stress management strategies. The common characteristics of SMAs with top-rated quality can be used as guidance for potential users and health professionals, but owing to the high volatility of SMAs, enhanced evaluation frameworks are needed.

Valuing the Diversity of Research Methods to Advance Nutrition Science

The ASN Board of Directors appointed the Nutrition Research Task Force to develop a report on scientific methods used in nutrition science to advance discovery, interpretation, and application of knowledge in the field. The genesis of this report was growing concern about the tone of discourse among nutrition professionals and the implications of acrimony on the productive study and translation of nutrition science. Too often, honest differences of opinion are cast as conflicts instead of areas of needed collaboration. Recognition of the value (and limitations) of contributions from well-executed nutrition science derived from the various approaches used in the discipline, as well as appreciation of how their layering will yield the strongest evidence base, will provide a basis for greater productivity and impact. Greater collaborative efforts within the field of nutrition science will require an understanding that each method or approach has a place and function that should be valued and used together to create the nutrition evidence base. Precision nutrition was identified as an important emerging nutrition topic by the preponderance of task force members, and this theme was adopted for the report because it lent itself to integration of many approaches in nutrition science. Although the primary audience for this report is nutrition researchers and other nutrition professionals, a secondary aim is to develop a document useful for the various audiences that translate nutrition research, including journalists, clinicians, and policymakers. The intent is to promote accurate, transparent, verifiable evidence-based communication about nutrition science. This will facilitate reasoned interpretation and application of emerging findings and, thereby, improve understanding and trust in nutrition science and appropriate characterization, development, and adoption of recommendations.

Expanding the Reach of an Evidence-Based, System-Level, Racial Equity Intervention: Translating ACCURE to the Maternal Healthcare and Education Systems

The abundance of literature documenting the impact of racism on health disparities requires additional theoretical, statistical, and conceptual contributions to illustrate how anti-racist interventions can be an important strategy to reduce racial inequities and improve population health. Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) was an NIH-funded intervention that utilized an antiracism lens and community-based participatory research (CBPR) approaches to address Black-White disparities in cancer treatment completion. ACCURE emphasized change at the institutional level of healthcare systems through two primary principles of antiracism organizing: transparency and accountability. ACCURE was successful in eliminating the treatment completion disparity and improved completion rates for breast and lung cancer for all participants in the study. The structural nature of the ACCURE intervention creates an opportunity for applications in other health outcomes, as well as within educational institutions that represent social determinants of health. We are focusing on the maternal healthcare and K-12 education systems in particular because of the dire racial inequities faced by pregnant people and school-aged children. In this article, we hypothesize cross-systems translation of a system-level intervention exploring how key characteristics of ACCURE can be implemented in different institutions. Using core elements of ACCURE (i.e., community partners, milestone tracker, navigator, champion, and racial equity training), we present a framework that extends ACCURE's approach to the maternal healthcare and K-12 school systems. This framework provides practical, evidence-based antiracism strategies that can be applied and evaluated in other systems to address widespread structural inequities.

Site-specific risk assessment enables trade-off analysis of non-native tree species in European forests

Non-native tree species (NNT) are used in European forestry for many purposes including their growth performance, valuable timber, and resistance to drought and pest or pathogen damage. Yet, cultivating NNT may pose risks to biodiversity, ecosystem functioning, and the provisioning of ecosystem services, and several NNT have been classified as invasive in Europe. Typically, such classifications are based on risk assessments, which do not adequately consider site-specific variations in impacts of the NNT or the extent of affected areas. Here, we present a new methodological framework that facilitates both mitigating risks associated with NNT and taking advantage of their ecosystem services. The framework is based on a stratified assessment of risks posed by NNT which distinguishes between different sites and considers effectiveness of available management strategies to control negative effects. The method can be applied to NNT that already occur in a given area or those NNT that may establish in future. The framework consists of eight steps and is partly based on existing knowledge. If adequate site-specific knowledge on NNT does not yet exist, new evidence on the risks should be obtained, for example, by collecting and analyzing monitoring data or modeling the potential distribution of NNT. However, limitations remain in the application of this method, and we propose several policy and management recommendations which are required to improve the responsible use of NNT.

Value Assessment, Real World Evidence and Fundamental Measurement: Version 3.0 of the Minnesota Formulary Submission Guidelines

This latest version of the Minnesota guidelines is intended to reassert the application of the standards of normal science in formulary submissions for new and existing pharmaceutical products and devices. This represents a paradigm shift from the existing value assessment standards which are focused on imaginary or I-QALY modeling of lifetime claims. The proposed new paradigm rejects this as pseudoscience; a failure to recognize the standards of normal science, in particular a failure to recognize the constraints of fundamental measurement. As a result, current health technology assessment is dominated by value assessments that create claims that are neither credible, nor empirically evaluable or replicable. The fatal flaw is the failure to recognize that QALYS are an impossible mathematical construct (hence the term I-QALY). The proposed paradigm recognizes that if there are claims for product value then, regardless of whether the claim is for clinical impact, quality of life or resource utilization, all claims must be empirically evaluable. If not, then they should be rejected. The Minnesota guidelines propose a new evidence based approach to formulary assessment, together with ongoing disease area and therapeutic class reviews. The focus is on claims that are specific to target patient populations that are claims for specific attributes and are consistent with the axioms of fundamental measurement. Manufacturers are asked to support claims assessment through protocols detailing the evidence base for claims assessment, the timelines for those assessments and the process by which claims assessments are reported back to formulary committees. Value assessment leads naturally to value contracting, revisiting provisional prices as new information is discovered and delivered to the formulary committee.

Do interventions to prevent or stop abuse and neglect among older adults work? A systematic review of reviews

Abuse and neglect among older adults impact everyone and are recognized internationally as significant and growing public health issues. A systematic review of reviews was conducted to identify effective strategies and approaches for preventing abuse and neglect among older adults. Eligible reviews were systematic or meta-analyses; focused on the older population as reported in the publications; reviewed prevention interventions; included relevant violence and abuse outcomes; written in English; and published in a peer-reviewed journal between January 2000 and May 2020. Eleven unique reviews (12 publications) met the eligibility criteria, including one meta-analysis. Included reviews mainly focused on general abuse directed toward older adults; and educational interventions for professional and paraprofessional caregivers, multidisciplinary teams of health care and legal professionals, and families. Interventions were implemented in a variety of community and institutional settings and addressed primary, secondary, and tertiary prevention. The reviews indicated weak or insufficient evidence of effectiveness in preventing or reducing abuse, yet several promising practices were identified. Future research is needed to evaluate emerging and promising strategies and approaches to prevent abuse among older adults. Effective interventions are also needed to prevent or reduce abuse and neglect among older adults.

Assessing and Expanding the Evidence Base for Project ECHO and ECHO-Like Models: Findings of a Technical Expert Panel

BACKGROUND

In 2003, Project ECHO (Extension for Community Healthcare Outcomes) began using technology-enabled collaborative models of care to help general practitioners in rural settings manage hepatitis C. Today, ECHO and ECHO-like models (EELM) have been applied to a variety of settings and health conditions, but the evidence base underlying EELM is thin, despite widespread enthusiasm for the model.

METHODS

In April 2018, a technical expert panel (TEP) meeting was convened to assess the current evidence base for EELM and identify ways to strengthen it.

RESULTS

TEP members identified four strategies for future implementors and evaluators of EELM to address key challenges to conducting rigorous evaluations: (1) develop a clear understanding of EELM and what they are intended to accomplish; (2) emphasize rigorous reporting of EELM program characteristics; (3) use a wider variety of study designs to fill key knowledge gaps about EELM; (4) address structural barriers through capacity building and stakeholder engagement.

CONCLUSIONS

Building a strong evidence base will help leverage the innovative aspects of EELM by better understanding how, why, and in what contexts EELM improve care access, quality, and delivery, while also improving provider satisfaction and capacity.

Driving Precision Policy Responses to Child Health and Developmental Inequities

The growing evidence base on the extent of and opportunities to reduce inequities in children's health and development still lacks the specificity to inform clear policy decisions. A new phase of research is needed that builds on contemporary directions in precision medicine to develop precision policy making; with the aim to redress child inequities. This would include identifying effective interventions and their ideal time point(s), duration, and intensity to maximize impact. Drawing on existing data sources and innovations in epidemiology and biostatistics would be key. The economic and social gains that could be achieved from reducing child inequities are immense.

[The prevention of drug substances abuse among schoolchildren]

The drug abuse is one of the most important medical and social problems of the youth. The problems with illegal and dangerous using of psychoactive drugs of different chemical categories by schoolchildren are caused by common social and psychological risk factors. Thus, in many research studies, all drugs and solvent substances are covered by general concept of "narcotic substances". The study purpose is to develop an evidence database related to efficiency of common prevention measures and to development of sound recommendations of its management. The study included sociological survey of representative sampling of 445 schoolchildren aged from 14 to 17 years. The relationship between participation in preventive activities (factorial sign) and development of objective concepts about harm of drug abuse and possibilities of narcology (resulting sign) are studied using calculation of relative risk and its confidence interval. The study proves the positive effect of lecturing of specialists, psychological lessons and trainings, review of thematic video materials. The involvement of schoolchildren into development of agitation materials concerning healthy life-style and into reading of special literature is considered as effective in case of their implementation after target group received initial knowledge about problems of drug abuse and toxicomania. The study proved the negative effect of independent search of information about drugs in Internet, fabrication agitation materials about harm of drugs by adolescents, discussions based on opposite opinions and all forms of communication with patients with drug addiction. The necessity of widespread implementation of target advanced training of managers of preventive measures application.

Campus Sexual Assault: Future Directions for Research

Campus sexual assault (CSA) has received unprecedented attention over recent years, resulting in an abundance of federal guidance and mandates. In response, efforts to address and prevent CSA at Institutions of Higher Education (IHE) across the country have grown quickly, including the development and implementation of programs and policies. Because the changes on campuses have occurred at such a rapid pace, a number of gaps exist within the field of CSA research. To ensure that changes on IHE are evidence-based, there is a need to review the existing research available and the inquiry still needed, based on key areas outlined in federal guidance, the expressed needs of campus community members, survivors, and students who commit sexual offenses on college campuses. The purpose of this review is to summarize the empirical research related to CSA gained from the past two decades and identify areas in which further work is needed, specifically related to key areas identified in recent guidance provided to IHE. This article concludes with guidance for research moving forward to help strengthen response and prevention efforts.

Enhancing diversity to reduce health information disparities and build an evidence base for genomic medicine

Advances in genomic medicine are arising from efforts to build a national learning healthcare system (LHS) and large-scale precision medicine studies. However, the underlying evidence base lacks sufficient data from populations historically underrepresented in biomedical research. Although the literature on health and healthcare disparities is extensive, disparities in the availability and quality of health information about diverse and underrepresented populations are less well characterized. This Perspective describes scientific and ethical benefits to incorporating health information from diverse and underrepresented populations in the LHS, resulting in a more robust and generalizable LHS. Near-term recommendations for incorporating diversity into the evidence base for genomic medicine are proposed, even as the groundwork for national and international efforts is underway.

The Road Map for National Health Service Proton Beam Therapy

Proton Beam Therapy is one of the key elements in a major improvement in access to advanced radiotherapy in the UK. An overseas programme has treated significant numbers of children and young adults and skull base tumours since 2008. A major government investment has resulted in building two proton centres in England sited in academic major cancer centres. A weak evidence base for most adult indications means that the NHS will use clinical trials and studies to explore the future role of Protons.

Patterns and Gaps Identified in a Systematic Review of the Hepatitis C Virus Care Continuum in Studies among People Who Use Drugs

Introduction

Systematic reviews are useful for synthesizing data on various health conditions and for identifying gaps in available data. In the US, the main risk group for hepatitis C virus (HCV) infection is people who use drugs (PWUD); as a group, PWUD have the highest prevalence of chronic HCV. While the care continuum construct has been increasingly applied to studies of HCV care among PWUD, what constitutes the steps in an HCV care continuum is not standardized. We sought to examine the range of HCV care continuum outcomes that studies reported on, to identify gaps in the literature, and to develop strategies that allowed for valuable syntheses of care continuum data.

Methods

We conducted searches of electronic databases for published literature. Reports were eligible if they provided original data from 1990 to 2016 from the US, presented data on one or more HCV care continuum outcomes, and provided outcome data on PWUD as a distinct group.

Results

A total of 313 full-text reports were assessed for eligibility. Of 212 potentially eligible reports, 32 (15.1%) did not present outcomes for PWUD separately from those who were non-PWUD. Among 101 eligible reports, a total of 166 care continuum outcomes were extracted; outcomes could be grouped into three categories that represent the HCV care continuum: testing (39.8%, n = 66/166); linkage to care (16.9%, n = 28/166); and treatment (43.4%, n = 72/166). Seventy-four reports (73.3%, n = 74/101) presented data on only one step. Linkage to care occurred variably after only antibody, or after antibody and viral load (VL) testing. Six (5.9%, n = 6/101) reports presented data on all three steps.

Conclusion

Reports examined a variety of HCV care continuum outcomes that could be grouped into the three steps of testing, linkage to care, and treatment. The application of this care continuum model would facilitate subsequent data synthesis for program comparison and public health evaluation. Given the two-step nature of HCV testing, analyses also need to account for variation in whether linkage to care occurred after antibody testing or after sequential antibody and VL testing. Additional data are needed on the progression of PWUD through the entire care continuum.

Primary care evidence in clinical guidelines: a mixed methods study of practitioners' views

BACKGROUND

Clinical practice guidelines are widely used in primary care, yet are not always based on applicable research.

AIM

To explore primary care practitioners' views on the applicability to primary care patients of evidence underpinning National Institute for Health and Care Excellence (NICE) guideline recommendations.

DESIGN AND SETTING

Delphi survey and focus groups in primary care, England, UK.

METHOD

Delphi survey of the perceived applicability of 14 guideline recommendations rated before and after a description of their evidence base, followed by two focus groups.

RESULTS

GPs significantly reduced scores for their perceived likelihood of pursuing recommendations after finding these were based on studies with low applicability to primary care, but maintained their scores for recommendations based on highly applicable research. GPs reported they were more likely to use guidelines where evidence was applicable to primary care, and less likely if the evidence base came from a secondary care population. Practitioners in the focus groups accepted that guideline developers would use the most relevant evidence available, but wanted clearer signposting of those recommendations particularly relevant for primary care patients. Their main need was for brief, clear, and accessible guidelines.

CONCLUSION

Guidelines should specify the extent to which the research evidence underpinning each recommendation is applicable to primary care. The relevance of guideline recommendations to primary care populations could be more explicitly considered at all three stages of guideline development: scoping and evidence synthesis, recommendation development, and publication. The relevant evidence base needs to be presented clearly and concisely, and in an easy to identify way.

Understanding scoping reviews: Definition, purpose, and process

BACKGROUND/PURPOSE

Scoping review design represents a methodology that allows assessment of emerging evidence, as well as a first step in research development. Despite its increasing use, to date no article reflecting use of scoping review methodology has been submitted for review at JAANP. The purpose of this article is to provide detailed information on scoping reviews, including definition, related processes, and uses, and discuss the relationship to nurse practitioner (NP) practice, policy, education, and research. The longer-term goal is that NPs will understand the related techniques, consider the methodology as a viable one for NP scholarship, and bring related reports to the forefront of NP publications.

METHODS

This manuscript represents a brief report. Processes to develop the brief include detailed search and review of scoping review literature in CINAHL and PubMed. Both methodologic reports and reviews were included. Definitions and uses of scoping reviews were reviewed.

CONCLUSION

The definition and process of scoping review are evolving. Although there is controversy regarding the methodology, there is increasing visibility of scoping review methodology in the published literature since the year 2000, with over 500 published reviews currently available.

IMPLICATIONS FOR PRACTICE

A well-executed scoping review has potential to inform NP practice, policy, education, and research.

A systematic review and meta-analysis of interventions designed to prevent or stop elder maltreatment

BACKGROUND

elder maltreatment is a major risk for older adults' mental health, quality of life, health, institutionalisation and even mortality.

OBJECTIVES

to perform a systematic review and meta-analysis of interventions designed to prevent or stop elder abuse.

METHODS

Studies that were posted between January 2000 and December 2014, written in English, specifically designed to prevent or stop elder maltreatment were included.

RESULTS

overall, 24 studies (and four records reporting on the same participants) were kept for the systematic review and the meta-analysis. Studies were broadly grouped into three main categories: (i) interventions designed to improve the ability of professionals to detect or stop elder maltreatment (n = 2), (ii) interventions that target older adults who experience elder maltreatment (n = 3) and (iii) interventions that target caregivers who maltreat older adults (n = 19). Of the latter category, one study targeted family caregivers, five targeted psychological abuse among paid carers and the remaining studies targeted restraint use. The pooled effect of randomised controlled trials (RCTs)/cluster-RCTs that targeted restraint use was significant, supporting the effectiveness of these interventions in reducing restraint use: standardised mean difference: -0.24, 95% confidence interval = -0.38 to -0.09.

INTERPRETATION

the most effective place to intervene at the present time is by directly targeting physical restraint by long-term care paid carers. Specific areas that are still lacking evidence at the present time are interventions that target (i) elder neglect, (ii) public awareness, (iii) older adults who experience maltreatment, (iv) professionals responsible for preventing maltreatment, (v) family caregivers who abuse and (vi) carers who abuse.

Exploring the ambivalent evidence base of mobile health (mHealth): A systematic literature review on the use of mobile phones for the improvement of community health in Africa

BACKGROUND

Africa is labelled the world's fastest-growing 'mobile region'. Considering such growth and the fragility of the continent's healthcare, mHealth has flourished. This review explores mHealth for community health in Africa in order to assess its still ambivalent evidence base.

METHODS

Using PubMed, Web of Science, OvidSP and Google Scholar, a systematic review was conducted of one decade (2005-2015) of peer-reviewed literature on mHealth in Africa. Data analysis focused on qualifications of success and failure. Impact evaluations of project assessments (n = 65) were complemented with general analyses/overviews of mHealth's effectiveness (n = 35).

RESULTS

Review of these texts reveals ambivalence in the appraisal of mHealth; essentially, the critical stance in general analyses/overviews is absent from project assessments. Especially weak evidence concerning sustainability and scalability is stressed in overviews. Project assessments are more optimistic. Their analysis suggests a causal connection between simplicity and success. Effective interventions are thus characterized by straightforward design and modest objectives. Greatest impediments of impact are general technology-related issues and intervention inappropriateness due to insufficient understanding of beneficiaries and specific context of use (circumstantial complications).

CONCLUSION

Distinguishing between these two categories of complications helps to break the deadlock that marks the mHealth debate and add nuance to claims that mHealth's evidence base is weak. Constructive realism - rather than unfounded optimism or pessimism without nuance - should guide the design of interventions. Besides anticipative of technology-related complications, such realism must lead to either basic interventions or to smart mHealth shaped by deep understanding of the context of implementation.

"Violence. Enough already": findings from a global participatory survey among women living with HIV

INTRODUCTION

Women living with HIV are vulnerable to gender-based violence (GBV) before and after diagnosis, in multiple settings. This study's aim was to explore how GBV is experienced by women living with HIV, how this affects women's sexual and reproductive health (SRH) and human rights (HR), and the implications for policymakers.

METHODS

A community-based, participatory, user-led, mixed-methods study was conducted, with women living with HIV from key affected populations. Simple descriptive frequencies were used for quantitative data. Thematic coding of open qualitative responses was performed and validated with key respondents.

RESULTS

In total, 945 women living with HIV from 94 countries participated in the study. Eighty-nine percent of 480 respondents to an optional section on GBV reported having experienced or feared violence, either before, since and/or because of their HIV diagnosis. GBV reporting was higher after HIV diagnosis (intimate partner, family/neighbours, community and health settings). Women described a complex and iterative relationship between GBV and HIV occurring throughout their lives, including breaches of confidentiality and lack of SRH choice in healthcare settings, forced/coerced treatments, HR abuses, moralistic and judgemental attitudes (including towards women from key populations), and fear of losing child custody. Respondents recommended healthcare practitioners and policymakers address stigma and discrimination, training, awareness-raising, and HR abuses in healthcare settings.

CONCLUSIONS

Respondents reported increased GBV with partners and in families, communities and healthcare settings after their HIV diagnosis and across the life-cycle. Measures of GBV must be sought and monitored, particularly within healthcare settings that should be safe. Respondents offered policymakers a comprehensive range of recommendations to achieve their SRH and HR goals. Global guidance documents and policies are more likely to succeed for the end-users if lived experiences are used.

How does living with HIV impact on women's mental health? Voices from a global survey

INTRODUCTION

Women living with HIV experience a disproportionate burden of mental health issues. To date, global guidelines contain insufficient guidance on mental health support, particularly regarding perinatal care. The aim of this article is to describe the extent and impact of mental health issues as experienced by women living with HIV on their sexual and reproductive health and human rights (SRH&HR).

METHODS

A global, mixed-methods, user-led and designed survey on SRH&HR of women living with HIV was conducted using snowball sampling, containing an optional section exploring mental health issues. Statistical quantitative data analysis included descriptive statistics, correlation and multiple linear regression analysis for the mental health responses. Thematic analysis of open free-text responses was performed for qualitative data.

RESULTS

A total of 832 respondents from 94 countries participated in the online survey with 489 responses to the optional mental health section. Of the respondents, 82% reported depression symptoms and 78% rejection. One-fifth reported mental health issues before HIV diagnosis. Respondents reported experiencing a 3.5-fold higher number of mental health issues after diagnosis (8.71 vs 2.48, t[488]=23.00, p<0.001). Nearly half (n=224; 45.8%) had multiple socially disadvantaged identities (SDIs). The number of SDIs was positively correlated with experiencing mental health issues (p<0.05). Women described how mental health issues affected their ability to enjoy their right to sexual and reproductive health and to access services. These included depression, rejection and social exclusion, sleep problems, intersectional stigma, challenges with sexual and intimate relationships, substance use and sexual risk, reproductive health barriers and human rights (HR) violations. Respondents recommended that policymakers and clinicians provide psychological support and counselling, funding for peer support and interventions to challenge gender-based violence and to promote HR.

CONCLUSIONS

Interventions addressing intersecting stigmas and any especial impacts of diagnosis during pregnancy are required to ensure women's SRH&HR. Global policy guidelines regarding women living with HIV must incorporate mental health considerations.

How did policy actors use mass media to influence the Scottish alcohol minimum unit pricing debate? Comparative analysis of newspapers, evidence submissions and interviews

Aims: To explore how policy actors attempted to deliberately frame public debate around alcohol minimum unit pricing (MUP) in the UK by comparing and contrasting their constructions of the policy in public (newspapers), semi-public (evidence submissions) and private (interviews). Methods: Content analysis was conducted on articles published in ten national newspapers between 1 January 2005 and 30 June 2012. Newsprint data were contrasted with alcohol policy documents, evidence submissions to the Scottish Parliament's Health and Sport Committee and 36 confidential interviews with policy stakeholders (academics, advocates, industry representatives, politicians and civil servants). Findings: A range of policy actors exerted influence both directly (through Parliamentary institutions and political representatives) and indirectly through the mass media. Policy actors were acutely aware of mass media's importance in shaping public opinion and used it tactically to influence policy. They often framed messages in subtly different ways, depending on target audiences. In general, newspapers presented the policy debate in a "balanced" way, but this arguably over-represented hostile perspective and suggested greater disagreement around the evidence base than is the case. Conclusions: The roles of policy actors vary between public and policy spheres, and how messages are communicated in policy debates depends on perceived strategic advantage.

What works for obesity prevention and treatment in black Americans? Research directions

Obesity prevalence in black/African American children and adults of both sexes is high overall and compared with US whites. What we know, and do not know, about how to enhance the effectiveness of obesity prevention and treatment interventions in African Americans is the focus of the 10 articles in this special issue of Obesity Reviews. The evidence base is limited in quantity and quality and insufficient to provide clear guidance. With respect to children, there is relatively consistent, but not definitive support for prioritizing the systematic implementation and evaluation of child-focused interventions in pre-school and school settings and outside of school time. For adults or all ages, developing and refining e-health approaches and faith-based or other culturally and contextually relevant approaches, including translation of the Diabetes Prevention Program intervention to community settings is indicated. Major evidence gaps were identified with respect to interventions with black men and boys, ways to increase participation and retention of black adults in lifestyle behaviour change programmes, and studies of the impact of environmental and policy changes on eating and physical activity in black communities. Bold steps related to research funding priorities, research infrastructure and methodological guidelines are recommended to improve the quantity and quality of research in this domain.

Lingual orthodontic treatment: what is the current evidence base?

As the number of adults that seek orthodontic treatment continues to grow, so too is the popularity of lingual fixed appliances. Although the aesthetic advantages associated with these systems are obvious, for some orthodontists, there has been a reluctance to offer lingual-based treatment to their patients. This is often based upon the perceived problems associated with lingual braces, relating to discomfort and difficulties with speech for the patient, and problems in using these appliances for the orthodontist. Although some of these factors have been investigated, the current evidence base is weak, possibly due to the fact that these are evolving appliance systems. Among the studies that have been carried out to date, pain and discomfort for the patient appears to be similar following the placement of labial or lingual appliances, although the onset can be earlier with lingual brackets and the location different, with the tongue more frequently being involved. Customized lingual brackets may be associated with less pain than pre-fabricated. In addition, patients do seem to be more likely to experience difficulties with speech and mastication when fitted with a lingual appliance. However, there is some evidence that the lingual surfaces of the teeth are more resistant to early demineralization and caries. Little data exist regarding treatment outcome and ease of use for the orthodontist, either between lingual or labial appliances or between different lingual systems. Further research is required to investigate the efficiency of lingual appliance systems, both for the patient and orthodontist.

Reputation and science: examining the effectiveness of DBT in the treatment of borderline personality disorder

OBJECTIVE

This paper examines the evidence base for dialectical behaviour therapy (DBT) in the treatment of patients with borderline personality disorder (BPD).

CONCLUSION

DBT has built an impressive reputation within psychology and psychiatry as an effective treatment for deliberate self harm and chronic suicidal behaviours in patients with BPD. However, when each of the randomised controlled trials that comprise this evidence base is examined carefully, the actual results are less convincing about DBT's positive reputation.

Everything should be as simple as possible, but no simpler: towards a protocol for accumulating evidence regarding the active content of health behaviour change interventions

There is a need to consolidate the evidence base underlying our toolbox of methods of behaviour change. Recent efforts to this effect have conducted meta-regressions on evaluations of behaviour change interventions, deriving each method's effectiveness from its association to intervention effect size. However, there are a range of issues that raise concern about whether this approach is actually furthering or instead obstructing the advancement of health psychology theories and the quality of health behaviour change interventions. Using examples from theory, the literature and data from previous meta-analyses, these concerns and their implications are explained and illustrated. An iterative protocol for evidence base accumulation is proposed that integrates evidence derived from both experimental and applied behaviour change research, and combines theory development in experimental settings with theory testing in applied real-life settings. As evidence gathered in this manner accumulates, a cumulative science of behaviour change can develop.

Dental therapists/hygienists working in remote-rural primary care: a structured review of effectiveness, efficiency, sustainability, acceptability and affordability

AIM

To examine the use of dental therapist/hygienists to provide primary dental treatment in remote-rural areas with regard to their effectiveness, efficiency, sustainability, acceptability and costs (affordability).

METHOD

The structured literature review of studies indexed in Medline, Embase and CinAHL was conducted using search terms relevant to 'dental therapists' and 'remote-rural'. Remote-rural was defined as 'those (individuals) with a greater than 30-minute drive time to the nearest settlement with a population of greater than 10,000'.

RESULTS

From 1,175 publications screened, 21 studies from 19 publications were initially included. Only seven studies were included that explicitly focused on remote-rural areas. Four were surveys and three were qualitative studies. All of the included studies were reported within the last 7 years. The methodological quality of the surveys varied, particularly with regard to their response rates. All three of the qualitative studies were assessed as potentially weak methodologies. Regarding the research question, none of the studies included provided data relevant to understanding efficiency, cost issues or the acceptability of dental therapists. The available empirical evidence contained only indirect indicators about the sustainability of dental therapy in rural areas.

CONCLUSIONS

The available data indicates that dental therapist/hygienists have suitable skills and could constitute a valuable asset to meet the dental demands in remote-rural areas. However, the evidence base is limited and of a poor quality. There is a need to put in place 'well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce'.

The role of assistive technology in supporting medication adherence in practice: what are the outcomes and is there evidence for efficacy?

Medication adherence has a cumulative effect on people’s health and wellbeing and reduces the reliance on health and social care services. This paper reviews the London Borough of Lambeth’s assistive technology service, which is occupational therapy led and includes the use of electronic medication dispensers as part of innovative intervention in support of medication adherence.

The paper gives an appraisal of the key-factors in the successful implementation of medication adherence aids in social care settings and is supported by observational records that originate in practice and by a review of the current evidence base for the use of assistive technologies in medicines management. Key factors include interdisciplinary working as well as having needs-led and outcome focussed services.

In the current economic climate there is increased pressure on local government to deliver services more efficiently and cost-effectively. The paper examines several case studies, which demonstrate how the use of assistive technology can support medication adherence, resulting in cost savings and cost avoidances. A guiding framework with practical recommendations for best practice in implementing medication compliance aids in social care settings is then offered.

There is a need for health and social care workers and others to engage with medication adherence more widely. There is a large and growing new variety of strategies, interventions, technologies and services available which have the potential to aid, facilitate and motivate clients to adhere to their prescribed medications. The paper gives an overview of their practical application and outcomes.

Integrated care at the crossroads-defining the way forward

INTRODUCTION AND BACKGROUND

The non-existence of a common terminology or standards in Integrated Care makes it difficult to compare experiences and results, whether on a national or international level, while the interdisciplinarity of the concept, both in theory and practice, proves to be a curse when it should be a blessing. Thus, we found it high time to bridge the gap, bring practice to theory and discuss the pressing issues of future Integrated Care research. WORKSHOP REPORT: DURING THE EXPERT WORKSHOP, DISCUSSIONS WERE HELD CONCERNING FOUR OVERARCHING TOPICS: (1) defining the common base for integrated care, evaluation and quality; (2) discussion on methods and tools, healthy environs; (3) governing and managerial prerequisites for integrated care and the future of integrated care; and (4) research questions arising from the workshop. The results were formulated into actions and research questions for the future.

DISCUSSION

The workshop proved the necessity of consolidation in the area in order to foment the concept. Researchers should improve coordination and cooperation among themselves and draw from the various fields which deal with similar questions.

CONCLUSION

It remains to be seen whether integrated care manages to grow out of its baby shoes and establish itself as an independent and interdisciplinary field of research.

Initial development of an evidence base for personalized medicine's translation to clinical practice and health policy

A major challenge to adoption of personalized medicine approaches, such as pharmacogenomics, is that data to address many critical questions relevant to clinical application, economics, policy and regulation are typically unavailable or widely dispersed. The evidence base we tentatively call Evaluation Data for Assessing Personalized Medicine Translation (EDAPT) would generate the foundation for a database of information. This article begins with a description of the rationale and conceptual framework for this effort.

Patterns of antihypertensive therapy among patients with diabetes

BACKGROUND

Hypertension is extremely prevalent in patients with diabetes. Limited data exist on whether patterns of antihypertensive use in this population are consistent with evidence-based practice guidelines.

OBJECTIVE

To evaluate utilization patterns of antihypertensive agents and blood pressure (BP) control among diabetic patients with hypertension.

DESIGN

Retrospective cohort study.

PATIENTS/PARTICIPANTS

In all, 9,975 patients with diabetes and hypertension as of March 2001 from an outpatient medical center of the Department of Veterans Affairs.

MEASURES

Proportions of use of 6 different antihypertensive drug classes were compared for all patients receiving 1, 2, 3, or 4 or more drugs, and separately among patients with and without coronary artery disease (CAD). Blood pressure control (<130/85 mmHg) was compared for untreated patients, those on monotherapy, and patients on multi-drug regimens.

RESULTS

Over 60% of patients were receiving angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB), followed by diuretics (38.1%), calcium channel blockers (35.3%) and beta-blockers (28.5%) with 19.1% of patients untreated. Patients on monotherapy were mostly receiving ACEI/ARB (59.5%). The majority (70.7%) of treated patients were on multidrug regimens. In patients with CAD, beta-blocker and ACEI/ARB use was higher, and 70.5% of patients on single-drug regimens received either ACEI/ARB or beta-blockers. The proportions of patients not on medications, on monotherapy, or multidrug regimens achieving BP control were 23.4%, 27.4%, and 24.9%, respectively.

CONCLUSIONS

Patterns of anti-hypertensive therapy were generally consistent with evidence-based practice guidelines. Areas of improvement include increasing ACEI/ARB and diuretic use, decreasing the number of untreated patients, and increasing the proportion of patients with controlled BP in this population.

acp Best Practice No 169. Evidence based pathology: squamous carcinoma of the hypopharynx

This best practice article reviews the published evidence on the pathology and patterns of spread of carcinomas of the hypopharynx, and the relevance of pathological features to prognosis. Medline (1966-2001) was searched using a combination of head and neck neoplasms and prognosis, focusing on hypopharynx and pathology. Other relevant publications were identified from the bibliographies of these papers, and from those obtained opportunistically. There is relatively little pathological literature devoted specifically to squamous carcinomas of the hypopharynx and most information comes from large series of patients with head and neck cancers at a range at sites. Lack of consistency in reporting and shifts in terminology make comparisons between series difficult. The most important features determining prognosis are size and extent of local spread of the primary carcinoma and extent of involvement of regional lymph nodes. There is evidence to support the use of the minimum dataset criteria for head and neck carcinomas at this site. Within the hypopharynx, subsite related differences in aetiology and biology may become important.