Experiences of implementing the 'Making Every Contact Count' initiative into a UK integrated care system: an interview study.

BACKGROUND: The 'Making Every Contact Count' (MECC) approach is in line with the current National Health Service (NHS) strategy to improve and prevent health conditions in England. Despite its importance and value for preventative healthcare, implementation of MECC varies. The aim of this study was to explore the barriers and facilitators of implementing MECC and MECC training into an integrated care system (ICS). METHODS: Remote semi-structured interviews were conducted with staff across an ICS in the North West of England who were involved in implementing and delivering MECC across the region. Data were analysed initially using an inductive thematic analysis approach and then interpreted using the 'Capability, Opportunity, Motivation = Behaviour' (COM-B) model of behaviour change. RESULTS: We interviewed nine stakeholders and identified three superordinate themes: (1) macro-level barriers and facilitators, e.g. funding; (2) organizational level barriers and facilitators, e.g. time and resource; and (3) individual-level barriers/facilitators for both MECC trainers and MECC agents. CONCLUSIONS: MECC has potential to meet the needs of the public's health, but barriers to its implementation exist. MECC must be successfully embedded into organizations and regions in which it is implemented, which relies on further development of an appropriate infrastructure including sustainable funding and a shift in culture to value preventative healthcare.

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.

Enhancing community weight loss groups in a low socioeconomic status area: Application of the COM-B model and Behaviour Change Wheel.

BACKGROUND: Obesity rates are higher among people of lower socioeconomic status. While numerous health behaviour interventions targeting obesity exist, they are more successful at engaging higher socioeconomic status populations, leaving those in less affluent circumstances with poorer outcomes. This highlights a need for more tailored interventions. The aim of this study was to enhance an existing weight loss course for adults living in low socioeconomic communities. METHODS: The Behaviour Change Wheel approach was followed to design an add-on intervention to an existing local authority-run weight loss group, informed by mixed-methods research and stakeholder engagement. RESULTS: The COM-B analysis of qualitative data revealed that changes were required to psychological capability, physical and social opportunity and reflective motivation to enable dietary goal-setting behaviours. The resulting SMART-C booklet included 6 weeks of dietary goal setting, with weekly behavioural contract and review. CONCLUSION: This paper details the development of the theory- and evidence-informed SMART-C intervention. This is the first report of the Behaviour Change Wheel being used to design an add-on tool to enhance existing weight loss services. The process benefitted from a further checking stage with stakeholders.

Patient and public involvement in doctoral research: Impact, resources and recommendations.

BACKGROUND AND AIM: Patient and public involvement (PPI) has potential to enhance health-care research and is increasingly an expectation, particularly for many funding bodies. However, PPI can be tokenistic, which may limit this potential. Furthermore, few studies report PPI processes and impact, particularly in doctoral research studies, which are seldom reported in peer-reviewed papers. The aim of this paper was to explore the impact of PPI on two health-related doctoral research studies and identify how PPI could be used meaningfully at this level. METHOD: The PPI processes included (a) involvement of two 'Research Buddies' who informed the research design and ensured implementation of a booklet intervention was feasible for family carers, (b) data analysis workshops with 'Research Buddies' to identify emerging themes from practitioner interviews, (c) public and stakeholder involvement who informed data collection tool design, and the design of an intervention to help people with obesity who attend weight loss groups. FINDINGS: The application of PPI enhanced both doctoral studies by assisting data analysis; problem solving and improving recruitment rates; improving the usability and appeal of data collection tools and interventions; and developing implementation strategies. Patient and public involvement was considered a rewarding experience for both researchers and PPI contributors. CONCLUSION: This paper demonstrates the value of PPI in doctoral research in relation to its impact on research processes, researchers and contributors. We also present recommendations on how PPI could be incorporated into future doctoral research, including resources required, planning PPI processes and involving PPI contributors in all stages of research.

An evaluation of the implementation of cascade training for suicide prevention during the 'Choose Life' initiative in Scotland - utilizing Normalization Process Theory.

BACKGROUND: 'Cascade training' or 'train-the-trainers' has been widely utilised in the dissemination of information and expertise in health and social care, but with little examination of the work required for optimal delivery. National suicide prevention strategies commonly include such training initiatives. METHODS: A qualitative study to characterise the work, according to the concepts of Normalization Process Theory, required to disseminate STORM, a model of suicide prevention training across Scotland, and then implement it within organisations. This utilised a cascade style 'train-the trainers' intervention delivered as part of the Choose Life suicide prevention strategy in Scotland during 2008-11. Semi-structured interviews were carried out with 19 training facilitators, 30 of their group participants within organisations and 11 local managers within health boards in Scotland. RESULTS: Crucial to the process of a cascade training approach to implementing suicide prevention within an organisation was the multi-layered activity of constructing coherence of the intervention at every level in order to prevent dilution of the training. This necessitated collaborative work within and between groups of actors- managers, facilitators and participants. Where facilitators were effectively engaged in their role, confident in their ability to train, supported by supervision and possessed the leadership skills to engage both with participants and their local context to deliver training, there was evidence of both successful delivery and embedding within the organisation. However, there was little systematic evidence of institutional level appraisal- crucial to truly implementing a novel intervention within the system - despite efforts at local managerial engagement. CONCLUSIONS: Successful cascade or train-the-trainer implementation of an intervention requires extensive collaborative work to take place between and within groups of actors at all levels of an organization from those working at policy level to the 'coalface'. A priori application of Normalization Process Theory, to specify aims and goals for the necessary work to be carried out between different groups of actors, would assist in embedding a novel working practice at all levels. Future national training strategies for suicide prevention should address what is required to establish a flourishing culture of high-quality skills acquisition and development within healthcare organisations.

The effect of commitment-making on weight loss and behaviour change in adults with obesity/overweight; a systematic review.

BACKGROUND: Adherence to weight loss interventions is crucial to successful outcomes, yet little is known about how best to improve it. This suggests a need for developing and improving adherence strategies, such as formal commitments. This review aims to identify the effect of including a commitment device alongside lifestyle interventions on weight loss, and identify the most appropriate delivery mechanisms and target behaviours. METHODS: We searched five databases and hand-searched reference lists for trials of behavioural interventions to achieve weight loss among adults with excess weight or obesity. Interventions incorporating commitment devices were included in a narrative review and meta-analysis where appropriate. Commitment devices with financial incentives were excluded. RESULTS: Of 2675 unique studies, ten met the inclusion criteria. Data from three randomised trials including 409 participants suggests that commitment interventions increases short-term weight loss by a mean of 1.5 kg (95% CI: 0.7, 2.4). Data from two randomised trials including 302 patients suggests that benefits were sustained at 12 months (mean difference 1.7 kg; 95% CI: 0.0, 3.4). Commitment devices appeared most successful when made publicly, and targeting diet rather than physical activity. CONCLUSIONS: Using commitment devices, such as behavioural contracts, as part of a weight loss intervention may be useful in improving weight loss outcomes and dietary changes, at least in the short-term. However, evidence is limited and of variable quality so results must be interpreted with caution. Poor reporting of intervention details may have limited the number of identified studies. More rigorous methodology and longer term follow-ups are required to determine the effectiveness of behavioural contracts given their potential for use in public health interventions.

Referral of patients to diabetes prevention programmes from community campaigns and general practices: mixed-method evaluation using the RE-AIM framework and Normalisation Process Theory.

BACKGROUND: Each year around 5-10% of people with non-diabetic hyperglycaemia will develop type 2 diabetes mellitus. Diabetes prevention is a national and global public health concern. Diabetes Prevention Programmes, which seek to identify at-risk individuals and support entry to health improvement initiatives, recognise that enhanced identification and referral of at-risk individuals is required within primary care and beyond, through community-focused prevention approaches. We report an evaluation of a demonstrator site for the NHS Diabetes Prevention Programme in the UK, which piloted an enhanced Primary Care referral programme (sampling from patients identified as at-risk from general practice databases) and a Community identification programme (sampling from the general population through opportunistic identification in community locations) in an effort to maximise participation in prevention services. METHODS: We used mixed-methods evaluation to assess the impact of the two referral routes on participation in the Diabetes Prevention Programmes in line with the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation and Maintenance). Individual level patient data was descriptively analysed to assess identifications and eligible referrals made in each route. Semi-structured interviews conducted with referral staff and key stakeholders were analysed using thematic analysis and informed by Normalisation Process Theory. RESULTS: The nurse facilitated primary care referral route provided 88% of all referrals to the telephone DPP, compared to the community referral route which provided 5%, and the proportion joining the programme was higher among primary care referrals (45%) than community referrals (22%), and retention rates were higher (73% compared to 50%). The nurse-facilitated route integrated more easily into existing clinical processes. The community programme was impeded by a lack of collaborative inter-agency working which obscured the intended focus on high-risk populations despite conversion rates (numbers identified at risk who entered prevention programmes) being highest in areas of high deprivation. CONCLUSIONS: The study demonstrates the interaction of components, with effective Adoption and Implementation necessary to support Reach. The NPT analysis demonstrated the importance of consensus around not only the need for such programmes but agreement on how they can be delivered. Future programmes should support inter-agency communication and collaboration, and focus identification efforts on areas of high-risk.

Correction to: Tailoring lifestyle interventions to low socio-economic populations: a qualitative study.

In the original publication of this article [1] there is an error in the citations of Tables 2 and 3. In this correction article the incorrect and correct citations are shown for clarity.

Tailoring lifestyle interventions to low socio-economic populations: a qualitative study.

BACKGROUND: People living in deprived areas are more likely to be overweight or obese, have poorer health outcomes, and tend to benefit less from interventions than those from more affluent backgrounds. One approach to address such health inequalities is to tailor existing interventions to low socio-economic populations, yet there is limited evidence to inform their design. This study aims to identify how best to tailor lifestyle interventions to low socio-economic populations to improve outcomes. METHODS: Following direct observations of community-run weight loss groups, we interviewed 11 group facilitators and 14 service users from a health improvement service in a low socio-economic area in the North West of England. Audio-recorded interviews were transcribed verbatim and analysed thematically. RESULTS: We identified two overarching themes within the data. The first theme, managing diversity, included challenges faced in delivering a generic intervention to a diverse population in terms of knowledge, language and literacy skills, and cultural diversity. The second theme incorporated all issues relating to the environment, such as cost, access and availability of food and leisure facilities, and 'life gets in the way'. CONCLUSIONS: Tailoring interventions for this population is necessary, and more attention is needed to develop ways to ensure service providers and users engage with behaviour change techniques such as goal setting, rather than focusing on information provision alone. Interventions should also be mindful of cost, cultural diversity, and language and literacy barriers, as well as potential for disengaging this hard to reach population.

Getting messier with TIDieR: embracing context and complexity in intervention reporting.

BACKGROUND: The Template for Intervention Description and Replication (TIDieR) checklist and guide was developed by an international team of experts to promote full and accurate description of trial interventions. It is now widely used in health research. The aim of this paper is to describe the experience of using TIDieR outside of trials, in a range of applied health research contexts, and make recommendations on its usefulness in such settings. MAIN BODY: We used the TIDieR template for intervention description in six applied health research projects. The six cases comprise a diverse sample in terms of clinical problems, population, settings, stage of intervention development and whether the intervention was led by researchers or the service deliverers. There was also variation in how the TIDieR description was produced in terms of contributors and time point in the project. Researchers involved in the six cases met in two workshops to identify issues and themes arising from their experience of using TIDieR. We identified four themes which capture the difficulties or complexities of using TIDieR in applied health research: (i) fidelity and adaptation: all aspects of an intervention can change over time; (ii) voice: the importance of clarity on whose voice the TIDieR description represents; (iii) communication beyond the immediate context: the usefulness of TIDieR for wider dissemination and sharing; (iv) the use of TIDieR as a research tool. CONCLUSION: We found TIDieR to be a useful tool for applied research outside the context of clinical trials and we suggest four revisions or additions to the original TIDieR which would enable it to better capture these complexities in applied health research: An additional item, 'voice' conveys who was involved in preparing the TIDieR template, such as researchers, service users or service deliverers. An additional item, 'stage of implementation' conveys what stage the intervention has reached, using a continuum of implementation research suggested by the World Health Organisation. A new column, 'modification' reminds authors to describe modifications to any item in the checklist. An extension of the 'how well' item encourages researchers to describe how contextual factors affected intervention delivery.

Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model.

BACKGROUND: Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals. METHODS: Nested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews. RESULTS: Based on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients' health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems. CONCLUSION: The COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC.

Facilitating professional liaison in collaborative care for depression in UK primary care; a qualitative study utilising normalisation process theory.

BACKGROUND: Collaborative care (CC) is an organisational framework which facilitates the delivery of a mental health intervention to patients by case managers in collaboration with more senior health professionals (supervisors and GPs), and is effective for the management of depression in primary care. However, there remains limited evidence on how to successfully implement this collaborative approach in UK primary care. This study aimed to explore to what extent CC impacts on professional working relationships, and if CC for depression could be implemented as routine in the primary care setting. METHODS: This qualitative study explored perspectives of the 6 case managers (CMs), 5 supervisors (trial research team members) and 15 general practitioners (GPs) from practices participating in a randomised controlled trial of CC for depression. Interviews were transcribed verbatim and data was analysed using a two-step approach using an initial thematic analysis, and a secondary analysis using the Normalisation Process Theory concepts of coherence, cognitive participation, collective action and reflexive monitoring with respect to the implementation of CC in primary care. RESULTS: Supervisors and CMs demonstrated coherence in their understanding of CC, and consequently reported good levels of cognitive participation and collective action regarding delivering and supervising the intervention. GPs interviewed showed limited understanding of the CC framework, and reported limited collaboration with CMs: barriers to collaboration were identified. All participants identified the potential or experienced benefits of a collaborative approach to depression management and were able to discuss ways in which collaboration can be facilitated. CONCLUSION: Primary care professionals in this study valued the potential for collaboration, but GPs' understanding of CC and organisational barriers hindered opportunities for communication. Further work is needed to address these organisational barriers in order to facilitate collaboration around individual patients with depression, including shared IT systems, facilitating opportunities for informal discussion and building in formal collaboration into the CC framework. TRIAL REGISTRATION: ISRCTN32829227 30/9/2008.

Psychotic symptoms, self-harm and violence in individuals with schizophrenia and substance misuse problems.

When schizophrenia is combined with substance misuse, rates are consistently higher. However research findings on the relationship between violence, self-harm and schizophrenia are inconclusive. This study aimed to examine links between specific psychotic symptoms, substance misuse and violence in people dually diagnosed with schizophrenia and substance misuse. Presence and frequency of violence to self and others were examined in relation to the type and severity of psychotic symptoms and level of substance use over a 24 month period in 327 people with schizophrenia and substance misuse problems. 32.3% had an incident of violence to others during the study period and 28.6% had a self-harm/suicide incident. 39 (11.9%) participants reported command hallucinations (CH) and 157 (48.0%) had threat control override symptoms (TCOS). Presence of TCOS and presence of CH were not associated with violence to others but were both associated with self-harm. Different command hallucination sub-types were associated with different types of violence. Delusional and hallucination severity and distress were mainly associated with self-harm. These findings suggest that specific symptoms are related to different outcomes, particularly in relation to self-harm, and these effects remain even after substance use is controlled for. This has important implications for assessment and treatment of this group.

Better together? a naturalistic qualitative study of inter-professional working in collaborative care for co-morbid depression and physical health problems.

BACKGROUND: Mental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases. Collaborative care models encourage inter-professional working to deliver better care for patients with multiple chronic conditions, such as depression and long-term physical health problems. Successive trials from the United States have shown that collaborative care effectively improves depression outcomes, even in people with long-term conditions (LTCs), but little is known about how to implement collaborative care in the United Kingdom. The aim of the study was to explore the extent to which collaborative care was implemented in a naturalistic National Health Service setting. METHODS: A naturalistic pilot study of collaborative care was undertaken in North West England. Primary care mental health professionals from IAPT (Increasing Access to Psychological Therapies) services and general practice nurses were trained to collaboratively identify and manage patients with co-morbid depression and long-term conditions. Qualitative interviews were performed with health professionals at the beginning and end of the pilot phase. Normalization Process Theory guided analysis. RESULTS: Health professionals adopted limited elements of the collaborative care model in practice. Although benefits of co-location in primary care practices were reported, including reduced stigma of accessing mental health treatment and greater ease of disposal for identified patients, existing norms around the division of mental and physical health work in primary care were maintained, limiting integration of the mental health practitioners into the practice setting. Neither the mental health practitioners nor the practice nurses perceived benefits to joint management of patients. CONCLUSIONS: Established divisions between mental and physical health may pose particular challenges for multi-morbidity service delivery models such as collaborative care. Future work should explore patient perspectives about whether greater inter-professional working enhances experiences of care. The study demonstrates that research into implementation of novel treatments must consider how the introduction of innovation can be balanced with the need for integration into existing practice.