Virtual Multidisciplinary Stroke Care Clinic for Community-Dwelling Stroke Survivors: A Randomized Controlled Trial.

BACKGROUND: Stroke survivors constantly feel helpless and unprepared after discharge from hospitals. More flexible and pragmatic support are needed for their optimized recovery. We examined the effects of a virtual multidisciplinary stroke care clinic on survivors' health and self-management outcomes. METHODS: A randomized controlled trial was conducted. Survivors were recruited from 10 hospitals and randomized at 1:1 ratio into the intervention or the control groups. Intervention group participants received the Virtual Multidisciplinary Stroke Care Clinic service (monthly online consultations with a nurse, follow-up phone calls, and access to an online platform). Control group participants received the usual care. Outcomes of self-efficacy (stroke self-efficacy questionnaire; primary), self-management behaviors (Stroke Self-Management Behaviors Performance Scale), social participation (reintegration to normal living index), and depression (Geriatric Depression Scale; secondary) were measured at baseline, and 3 and 6 months after commencing the intervention (post-randomization). A generalized estimating equations model was used to compare the differential changes in outcomes at 3 and 6 months with respect to baseline between 2 groups. RESULTS: Between July 2019 and June 2022, 335 eligible participants were enrolled in the study. Participants (intervention group; n=166) showed significantly greater improvements in outcomes of self-efficacy (group-by-time interaction regression coefficient, B=4.60 [95% CI, 0.16 to 9.05]), social participation (B=5.07 [95% CI, 0.61 to 9.53]), and depression (B=-2.33 [95% CI, -4.06 to -0.61]), and no significant improvement in performance of self-management behaviors (B=3.45, [95% CI, -0.87 to 7.77]), compared with the control group (n=169) right after the intervention (6 months after its commencement). Hedges' g effect sizes of the intervention on outcomes: 0.19 to 0.36. CONCLUSIONS: The results provide some positive evidence on the usefulness of the Virtual Multidisciplinary Stroke Care Clinic service. The effect sizes are regarded as small to medium, which may not be of clinical relevance. The baseline levels in outcomes were in favor of the control group, the intervention effects might be overestimated. The service must be tested further to determine its effectiveness. REGISTRATION: URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1800016101.

Health Professional- and Volunteer-partnered Self-management Support (COMBO-KEY) to Promote Self-efficacy and Self-management Behaviors in People with Stroke: A Randomized Controlled Trial.

BACKGROUND: Multiple systematic reviews have reported that self-management interventions are associated with positive impacts on self-efficacy and health-related quality of life (HRQoL) of people with stroke. PURPOSE: This article reports the effects of an enhanced stroke self-management program. METHODS: Eligible adults with stroke were recruited from community-based organizations and a support group for a two-arm, assessor-blinded randomized controlled trial. Participants in the control group received usual care, while those in the intervention group also received the 8-week self-management program, Coaching Ongoing Momentum Building On stroKe rEcovery journeY (COMBO-KEY), consisting of four individual home visits and five follow-up phone calls, delivered by healthcare professionals and trained volunteers. Assessments were conducted at baseline and after the intervention, for outcomes of self-efficacy, satisfaction with the performance of self-management behaviors, HRQoL, and community reintegration, which were analyzed using generalized estimating equations (GEEs). RESULTS: 134 Participants were recruited [mean age = 64.1 years, standard deviation (SD) = 12.7]. Over 80% of the participants had a first-ever stroke [mean years after first stroke: 4.2 (SD = 5.1)]. The GEE analysis revealed that the intervention group participants showed significantly greater improvements in self-efficacy, satisfaction with their performance of self-management behaviors, HRQoL, and community reintegration at 8-week follow-up with respect to their baseline levels. CONCLUSIONS: The COMBO-KEY program showed effective improvements in recovery outcomes of people with stroke. Future research should explore the inclusion of virtual/hybrid sessions, strategies to assess health conditions of people with stroke via online modes, and assessment of goal attainment and actual performance of self-management behaviors.

Self-management is the active involvement of a person in managing their overall needs for being able to live well with a chronic condition. Self-management interventions have shown to improve the recovery outcomes of people with stroke. We developed an 8-week long enhanced self-management program "COMBO-KEY" delivered by healthcare professionals and trained volunteers, consisting of individual home visits, follow-up phone calls, peer sharing videos, and enriched resources sharing through a website and a reference guide, aimed at promoting self-efficacy, and self-management behaviors of people with stroke. In this study, 134 adults with stroke were recruited and randomized to either receive the COMBO-KEY program or continue to receiving usual care only. Participants receiving the program showed greater improvements in self-efficacy and self-management behaviors with increased quality of life and reintegrating back to the community after eight weeks compared to the participants receiving usual care. The results highlighted the positive role of a health coaching approach, whereby healthcare professionals, and trained volunteers provide self-management support, to improve the recovery of people with stroke.

Acupuncture for post-stroke depression: a systematic review and network meta-analysis.

BACKGROUND: Patients with post-stroke depression (PSD) usually experience anxiety, hopelessness, and insomnia, which have a negative impact on their daily activities and post-stroke rehabilitation. Acupuncture (AC), as a minimally invasive technique, has become a popular choice for improving depression symptoms. However, it is still unclear which therapy is associated with the best outcomes for PSD. In this review, we aimed to explore the impact of AC in alleviating symptoms of PSD and to evaluate the difference in effectiveness between AC combined with pharmacotherapies and various non-pharmacotherapies. METHODS: Six databases and three clinical trials registration platforms were searched from inception to March 2023. Randomized clinical trial comparing needle-based AC with pharmacotherapy, and other non-pharmacotherapy or invalid group were included. Two independent reviewers identified eligible studies, and collected data using a pre-made form. A Bayesian network meta-analysis was conducted to assess and compare different techniques using RStudio 3.6.0 with the package 'GEMTC' V.0.8.1. The primary outcome was the efficacy for PSD assessed by scales measuring depressive symptoms. The secondary outcomes were effectiveness for neurological function and the quality of life. The ranking probabilities for all treatment interventions was performed using the Surface Under the Cumulative Ranking curve (SUCRA). The risk of bias was assessed by using the Revised Cochrane Risk of Bias tool 2. RESULTS: Sixty-two studies, involving 5308 participants published from 2003 to 2022, were included. The results showed that compared with western medicine (WM) (defined as pharmacotherapy for PSD), AC alone or with repetitive transcranial magnetic stimulation (RTMS), Traditional Chinese medicine (TCM) alone or with WM, were superior for alleviating depression symptoms. Compared to Usual Care, AC alone or plus other therapies could significantly decrease scores on the Hamilton Depression Rating scale. According to result of SUCRA, AC plus RTMS had the highest probability of improving depressive symptoms with a probability of 49.43%. CONCLUSIONS: The results of this study indicate that AC alone or combined with other therapies appears to be effective in improving depression symptoms of stroke survivors. Moreover, in comparison to WM, AC alone or plus RTMS, TCM, TCM with WM, or WM, were more effective in improving depression symptoms of PSD. Also, AC with RTMS seems to be the most effective with the highest probability. REGISTRATION: This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database in November 2020 and updated in July 2021. The registration number is CRD42020218752.

Experiences of participating in group-based rehabilitation programmes: A qualitative study of community-dwelling adults with post-stroke aphasia.

BACKGROUND: People with post-stroke aphasia tend to have smaller social networks, a higher risk of depression and poorer health-related quality of life than those who do not have aphasia after stroke. Stroke-specific or general rehabilitation programmes offered by community-based organizations are commonly group-based and involve discussions among group members with or without stroke. Research has shown that people with post-stroke aphasia may be unable to participate fully in verbal sharing of experiences and exchange of thoughts. AIMS: To explore the experiences of people with post-stroke aphasia in relation to participating in group-based rehabilitation programmes organized by community-based organizations. METHODS & PROCEDURES: A qualitative design was adopted, including individual, semi-structured interviews with 20 adults with post-stroke aphasia recruited from community-based rehabilitation centres and support groups. The participants had a mean age of 68.86 ± 13.54 years and a mean post-stroke duration of 9.24 ± 7.72 years. They had participated in at least one group-based rehabilitation programme organized by community-based organizations in the past year. The participants were asked about their experiences of attending group-based programme(s), thoughts and feelings while interacting with the facilitators and group members, and satisfaction with their participation. The interview data were thematically analysed. OUTCOMES & RESULTS: Three themes were identified: (1) hurdles to active and fulfilling participation including the dominance of verbal sharing, short duration of the programme, being a minority in the group and accumulated negative experiences; (2) strategies adopted to improve participation including accepting a reduced speaking ability, having support from caregivers, and trying mobile apps to vocalize and supplement meanings; and (3) a preference for certain group conditions including receiving invitations by staff with whom they were familiar, groups that are led by experienced facilitators, a large or small group, the dominance of non-verbal activities, and inclusion of only people with post-stroke aphasia. CONCLUSIONS & IMPLICATIONS: The findings showed that people with post-stroke aphasia experience difficulties participating more actively in group-based rehabilitation programmes due to hurdles in terms of the structure and format of the programmes and accumulation of negative experiences. Facilitating positive group experiences for these people with innovative methods, such as using technology and providing professional and standby support, would be helpful. Longer sessions with smaller groups, exclusively including people with post-stroke aphasia and involving more non-verbal activities to help them express feelings, are suggested to optimize the benefits they derive from these group-based programmes. WHAT THIS PAPER ADDS: What is already known on the subject Stroke-specific or general group-based rehabilitation programmes are commonly offered by community-based organizations to support the recovery of people with or without stroke. However, some people with post-stroke aphasia may be unable to participate fully in verbal sharing of experiences and exchange of thoughts during these group-based programmes, which can limit the benefits they derive from these programmes. What this paper adds to existing knowledge This study explored the experiences of people with post-stroke aphasia in relation to participating in group-based rehabilitation programmes not specifically designed for people with stroke-induced aphasia organized by community-based organizations. The findings provide an insight into how these people participate in groups, their thoughts and feelings during interactions with the facilitators and group members, their satisfaction with their level of participation, and the characteristics of the groups they prefer to join. What are the potential or actual clinical implications of this work? People with post-stroke aphasia experience difficulties participating more actively in group-based programmes due to hurdles in terms of the structure and format of the group-based programmes and accumulation of negative experiences contributing to decreased motivation to participating in groups. More positive group experiences can be fostered by adopting longer sessions with smaller groups that exclusively include people with post-stroke aphasia and involve more non-verbal activities to help them express their feelings. Communication partner training for facilitators and the use of technology to support communication are suggested to promote active and fulfilling participation of the people with aphasia in group-based programmes.

Understanding the priorities in life beyond the first year after stroke: Qualitative findings and non-participant observations of stroke survivors and service providers.

ABSTRACTLong-term unmet health needs are associated with a lower quality of life in stroke survivors. Survivors' priorities in living their lives and health professionals' recognition influence survivors' perceptions of their needs. From the perspectives of survivors and service providers, this study investigated survivors' long-term priorities for continuing their lives after stroke. A qualitative study was conducted with a convenience sample of 40 stroke survivors and a purposive sample of 11 providers who had worked with survivors for more than five years and were currently managers of community-based stroke care services or leaders of volunteer groups. Following the survivors' interviews, non-participant observations of a random day's activities were conducted. Data were transcribed verbatim. Survivors' and providers' data were analyzed separately and then together thematically. Five themes emerged: healing the mind in order to move forward, optimizing adaptations and maintaining physical function, living a safe and cost-effective life, returning to work, and giving back to society. Community-based services can be improved to offer more at-home, technology-supported psychological and self-management interventions, barrier-free and one-stop services, and opportunities for employment and volunteering. It would be worthwhile to invest in conducting public education to promote social inclusion and strengthening collaboration between academic and community organizations.

User Engagement on a Novel Educational Health Intervention Aimed at Increasing HPV Vaccine Uptake in Hong Kong: a Qualitative Study.

HPV vaccine uptake rates are suboptimal in Hong Kong. A multi-disciplinary school-based HPV health-promotion programme (MDL-SHPVP) aimed at raising HPV knowledge levels and increasing vaccine uptake has therefore been developed to address vaccine hesitancy. This qualitative study was conducted to collect user feedback and identify the strengths and limitations of the educational resources developed for the programme among key vaccination stakeholders including adolescent girls and their mothers. Twenty-six participants including eight mother-daughter dyads, four teachers, three social workers, two school principals and one school nurse were recruited. To cater to the diverse audience, ten educational videos, three animations, a digital game and one booklet were developed for the programme and distributed to the participants for viewing. Semi-structured interviews were then conducted to collect feedback on the acceptability and effectiveness of the resources. Interviews were audio-recorded, transcribed verbatim, and resulting data were thematically analysed. Three themes and six sub-themes emerged. The educational materials were well-received and effective in raising HPV-knowledge levels, generating confidence in vaccine safety and effectiveness, and boosting vaccination intention. Some doubts regarding vaccine necessity remained, and recommendations for improving resource presentation and accessibility were provided. Our findings suggest that the MDL-SHPVP has the potential to boost HPV vaccine uptake. Future studies may explore educational interventions which target to increase not only HPV vaccination intention but also the sense of urgency so as to encourage timely vaccination for adolescents at the ideal age. Study findings may also provide directions for the development of future health education interventions.

The effects of a sensory stimulation intervention for preventing delirium in a surgical intensive care unit: A randomized controlled trial.

BACKGROUND: Despite extensive efforts and advances in developing and fostering evidence-based delirium prevention interventions, the incidence of delirium remains high in hospitalized patients. Evidence suggests that sensory stimulation is a core component in interventions to prevent delirium among critically ill patients. However, its impact on the occurrence and outcomes of delirium is poorly understood. AIM: To evaluate the effects of a sensory stimulation intervention on preventing delirium in a surgical intensive care unit (ICU). STUDY DESIGN: A prospective, assessor-blind, parallel-group randomized controlled trial. Adult patients were recruited from a surgical ICU of one tertiary hospital in Guangzhou, China. Participants in the intervention group received a daily 30-min auditory and visual stimulation session for a week, taking into consideration the participants' predefined condition and intervention protocol. The primary outcomes were delirium incidence and delirium-free days, and the secondary outcomes were delirium duration, severity and the first occurrence of delirium. Demographic and clinical data were collected at recruitment, and delirium was assessed three times a day for seven consecutive days using Confusion Assessment-ICU. RESULTS: One hundred and fifty-two participants were randomly assigned to intervention or control groups. For primary outcomes, there were fewer patients with delirium in the intervention group than in the control group (10 vs. 19, risk ratio = 0.53), although statistical significance was not reached. The result showed that there were longer delirium-free days among participants in the intervention group than in the control group (3.66 vs. 2.84, p = .019). For secondary outcomes, the intervention could significantly reduce delirium duration (1.70 ± 0.82 vs. 4.53 ± 2.74 days, p = .004) and delirium severity (3.70 ± 1.25 vs. 5.68 ± 1.57, p = .002). The Kaplan-Meier curve showed the intervention group had a significantly delayed first occurrence of delirium compared with the control group (p = .043). CONCLUSIONS: The study did not provide significant evidence to support that sensory stimulation could reduce the incidence of delirium, but significant difference on delirium-free days. RELEVANCE TO CLINICAL PRACTICE: This study provides evidence-based practice for clinical healthcare providers to adopt the sensory stimulation protocol to prevent delirium, significantly reducing delirium duration and severity.

Association between participation self-efficacy and participation in stroke survivors.

BACKGROUND: Most stroke survivors face restrictions in functional disability and social participation, which can impede their recovery and community reintegration. Participation self-efficacy refers to survivors' confidence in using strategies to manage participation in areas including community living and work engagement. This study aimed to assess the association between participation self-efficacy and participation among stroke survivors. METHODS: This study adopted a cross-sectional correlational design with a convenience sample of 336 stroke survivors recruited from five hospitals in China. Participation self-efficacy was measured using the Chinese version of the Participation Strategies Self-Efficacy Scale (PS-SES-C) and participation measured using the Chinese version of the Reintegration to Normal Living Index (RNLI-C). The association between participation self-efficacy and participation was examined using multiple regression analysis with adjustment for potential confounders. RESULTS: Participants had a mean age of 69.9 ± 11.5 years, with most (81.6%) having an ischaemic stroke, and more than half (61.6%) a first-ever stroke. After adjustment for potential confounders, every 10-point increase in the PS-SES-C total score was significantly associated with an average 1.3-point increase in the RNLI-C total score (B = 1.313, SE = 0.196, p < 0.001). CONCLUSIONS: This study demonstrates that participation self-efficacy is significantly associated with participation among Chinese community-dwelling survivors of a mild or moderate stroke. This suggests that rehabilitation programmes for stroke survivors may be more effective if they incorporate participation-focused strategies designed to enhance self-efficacy. (229 words).

Perioperative enhanced recovery programmes for women with gynaecological cancers.

BACKGROUND: Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015. OBJECTIVES: To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes. SEARCH METHODS: We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty. MAIN RESULTS: We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants). AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.

Development and psychometric evaluation of a questionnaire for assessing self-management behaviors in stroke survivors.

OBJECTIVES: To develop and examine the psychometric properties of the Stroke Self-management Behaviors Performance Scale (SSBPS). MATERIALS AND METHODS: This is a cross-sectional descriptive correlational study. An 11-item SSBPS was developed. Its content validity was reviewed by an expert panel, and it was piloted among six stroke survivors. Participants completed the SSBPS and four additional measures, namely Stroke Self-Efficacy Questionnaire, Stroke Specific Quality of Life Scale, Geriatric Depression Scale and Reintegration to Normal Living Index, at baseline and the SSBPS again after four weeks. Principal component factor analysis was performed to examine the factor structure. Internal consistency, convergent validity and test-test reliability were evaluated. RESULTS: 128 stroke survivors completed the SSBPS and additional measures. Thirty-four of them completed the SSBPS again after four weeks. A two-factor structure of "Psychosocial management" and "Medical management" consisting of nine items was identified and accounted for 62% of the total variance. The SSBPS had acceptable internal consistency (Cronbach's alpha=0.65-0.88) and test-retest reliability (Intra-class correlation coefficient=0.57-0.73). The SSBPS total score was significantly correlated with the Stroke Self-Efficacy Questionnaire total (r=0.63, p<0.01), Reintegration to Normal Living Index total and subscales (r=0.60-0.69, p<0.01), Stroke Specific Quality of Life Scale total and all domains (r=0.19-0.61, p<0.05), and Geriatric Depression Scale total (r=-0.50, p<0.01) scores. CONCLUSIONS: The desirable psychometric properties of the SSBPS provide evidence that the scale may be reliable and valid for assessing stroke survivors' performance of self-management behaviors. It would inform the development of effective strategies to promote positive self-management behavioral performance for optimal recovery.

Critical elements in nursing graduates' transition to advanced practice roles and their perceived impact on patient care: an exploratory, descriptive study of graduates' and their managers' perceptions.

BACKGROUND: While there is a growth in the number of advanced practice nurses, there is a dearth of research examining their role transition from registered nurses. This study aimed to identify critical elements in the career path of nursing graduates who have taken up advanced practice roles and examine their perceived impact on patient care. METHODS: An exploratory descriptive study was performed. Individual semi-structured interviews were conducted face-to-face with 10 nursing graduates now in advanced practice roles, and their ten respective managers. All interviews were audio-recorded and transcribed verbatim for latent and manifest content analyses. RESULTS: The nursing graduates, six of whom were male, had a mean age of 35 years. All possessed a master's degree and formal post-registration education and/or training. Six had at least three years' experience as an advanced practice nurse. The managers, all female, had a mean age of 49 years. Eight had at least one year's experience in their current position. Six key themes emerged: prior enhancement of personal and professional knowledge and skills; active participation in clinical roles and knowledge translation in preparation for advanced practice; adapting to new and diverse advanced practice nursing responsibilities; role of advanced practice nurses in leadership; personal qualities crucial for success in advanced practice; and provision of evidence-based patient-centered care. CONCLUSIONS: Postgraduate education, management knowledge and leadership skills, and active participation in clinical roles and knowledge translation appear crucial ingredients for promotion of nursing graduates to advanced practice roles. Other ingredients include a positive outlook, flexibility and adaptability, and good interpersonal, communication and problem-solving skills.

Non-pharmacological delirium prevention practices among critical care nurses: a qualitative study.

BACKGROUND: Delirium is common among critically ill patients, leading to increased mortality, physical dependence, and cognitive impairment. Evidence suggests non-pharmacological delirium prevention practices are effective in preventing delirium. However, only a few studies explore the actual implementation and its associated challenges among critical care nurses. AIM: To explore critical care nurses' perceptions of current non-pharmacological delirium prevention practices in adult intensive care settings, including delirium screening, early mobilisation, sleep promotion, family engagement, and sensory stimulation. METHODS: A qualitative design adopting a thematic analysis approach. Semi-structured interviews with 20 critical care nurses were conducted in ten acute hospitals in mainland China. RESULTS: Three themes emerged: (a) importance of family engagement; (b) influence of organisational factors, and (c) suggestions on implementation. The implementation of non-pharmacological delirium prevention practices was limited by a strict ICU visitation policy, lack of routine delirium screening and delirium training, light and noise disturbances during nighttime hours, frequent resuscitation and new admissions and strict visitation policy. Case-based training, adopting a sensory stimulation protocol, and family engagement may be enablers. CONCLUSION: ICU care routine that lacks delirium assessment and the strict family visitation policy made it challenging to implement the complete bundle of non-pharmacological practices. Resource deficiency (understaffing, lack of training) and ICU environment (frequent resuscitation) also limited the implementation of non-pharmacological practices. Clinicians could implement case-based training and sensory-stimulation programs and improve communication with family caregivers by instructing family caregivers to recognise delirium symptoms and delirium prevention strategies.

Effects of a self-efficacy theory-based parental education program on eczema control and parental outcomes.

BACKGROUND: Eczema is the most common childhood skin problem worldwide. Education that enhances parental self-efficacy in carrying out appropriate eczema management is crucial to controlling eczema symptoms of their children. However, the lack of such a structured education program hinders everyday lives of eczematous children and their families. This study evaluated the effects of a self-efficacy theory-based parental eczema education program in controlling eczema of Chinese children at three months after commencement of intervention. METHODS: An assessor-blind, 2-arm, randomized controlled trial was conducted at an outpatient clinic of a regional hospital. One hundred and thirty-six Chinese children aged 3 months to 12 years with physician-diagnosed eczema, and their parents were recruited. The intervention was underpinned by the Social Cognitive Theory. Children's disease severity, parental self-efficacy, treatment adherence, and quality of life of family members were assessed by validated tools. Generalized estimating equation model was employed to compare differential change in each outcome across time between different groups. RESULTS: Eczema severity of children and parental self-efficacy in the intervention group were found to show greater improvement at 3-month follow-up with regression coefficient (ß) -16.98 (95% CI, -21.04 to -12.92; P < .001) and ß 29.39 (95% CI, 22.64-36.14; P < .001), respectively. Nearly all parents (97%) receiving the intervention rated this program as useful and helpful. CONCLUSIONS: This program is effective in enhancing parents' self-efficacy in managing their children's eczema and improving their adherence to eczema treatment and quality of life.

Promoting community reintegration using narratives and skills building for young adults with stroke: a protocol for a randomised controlled trial.

BACKGROUND: Stroke in adults aged between 18 and 64 years old is increasing significantly worldwide. Studies have reported that this group of young stroke survivors encounters enormous difficulties reintegrating into their social roles. Individualised discussions with healthcare professionals and learning from other survivors are imperative for them to reconstruct their identities after stroke. There is also great demand for community support during their chronic stage of recovery to help them rebuild life skills to promote reintegration. METHODS/DESIGN: This is a randomised controlled trial to investigate the effects of a 24-week Narrative and Skills-building Intervention (NSI) on young stroke survivors' community reintegration and psychosocial outcomes. A total of 208 adults aged 18-64 years old with a first-ever or recurrent ischaemic or haemorrhagic stroke and have been discharged home will be recruited and randomly assigned to receive usual care or usual care with NSI. The NSI is grounded in Narrative Theory and Bandura's principles of Self-efficacy and Outcome Expectation, consisting of successive eight individual sessions over six months delivered by a trained facilitator (a registered nurse). Participants will be facilitated to narrate their survival experiences and rebuild core life skills. Videos of peer young stroke survivors' experiences of recovery will be provided. Outcomes including community reintegration, depressive symptoms, health-related quality of life, self-efficacy, outcome expectation and satisfaction with performance of self-management behaviours will be measured before (T0) and immediately after NSI (T1), then six (T2) and 12 months after NSI (T3). Generalised estimating equations models will be used to compare the differential changes in outcomes across time between the two groups. Focus group interviews will be conducted with the facilitator at T1 and with the participants in the intervention group at T1 and T3. DISCUSSION: This study will evaluate the short and long-term effects of a theory-based NSI on young stroke survivors' community reintegration and establish a new model of community reintegration after stroke to inform future research. The results will also provide valuable evidence to develop clinical guidelines for young stroke survivors' community reintegration. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04560140 , registered on 23 September, 2020.

The effectiveness of self-management programmes for people with type 2 diabetes receiving insulin injection: A systematic review and meta-analysis.

BACKGROUND: People with type 2 diabetes (T2D) receiving insulin injection are reported to encounter challenges to achieve optimal glycaemic control. The evidence on effectiveness of self-management programmes for T2D people receiving insulin injection is far from conclusive. AIM: To examine the effectiveness of self-management programmes for people with T2D receiving insulin injection. METHODS: Twelve databases were searched from dates of inception to June 2021. All randomised controlled trials (RCTs) and controlled clinical trials examining the effectiveness of self-management programmes were included. The methodological quality was appraised using the Joanna Briggs Institute critical appraisal tools by two independent researchers. Data were summarised narratively or pooled statistically where appropriate. RESULTS: Nine RCTs involving 2613 participants were included. At post-intervention, meta-analysis results showed that self-management programmes significantly improved glycated haemoglobin A1c (HbA1c) (mean difference [MD]: -0.21, 95% confidence interval [CI] -0.29 to -0.12, P < .001), self-management behaviours (standardised MD [SMD]: 0.23, 95% CI: 0.12 to 0.33, P < .001) and self-efficacy (SMD: 0.20, 95% CI: 0.09 to 0.31, P = .0002). Only one intensive lifestyle intervention reported significant improvements in body weight and waist circumference. Three RCTs demonstrated significant improvements in body mass index compared with the control group. Only one study demonstrated significant improvements in total cholesterol and triglycerides in favour of the intervention group. At six months post-intervention, pooled results of two studies revealed decreased diabetes-related distress (MD: -2.98, 95% CI: -5.15 to -0.82, P = .007). No significant changes in blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, depression and anxiety were found. CONCLUSIONS: Self-management programmes have the potential to improve glycaemic control, weight management, blood lipids, self-management behaviours, self-efficacy and diabetes-related distress of people with T2D receiving insulin injection. More rigorous experimental trials are warranted to examine the effectiveness of self-management programme and its maintenance.

Multistakeholder knowledge levels and perspectives of human papillomavirus and its vaccination: An exploratory qualitative study.

OBJECTIVE: This qualitative study was an integral part in the development of a multidisciplinary team-led school-based human papillomavirus vaccination health-promotion programme (MDL-SHPVP) aiming to increase HPV vaccine uptake in Hong Kong. Study findings will inform the design of the MDL-SHPVP by drawing on interview data regarding the expectations and needs of key stakeholders and potential programme users. METHODS: Eight mother-daughter dyads, four secondary school teachers, two school principals, three social workers and one school nurse were interviewed. All interviews were audio-recorded and transcribed verbatim for thematic analysis. RESULTS: Most participants had misconceptions about HPV and the vaccine. Alhough there was no immediate perceived need for the vaccination, most participants had favourable attitudes towards HPV inoculation and vaccines in general. Factors affecting vaccine uptake included perceptions about risk of infection, vaccine availability, and cost. Participants were largely open to suggested MDL-SHPVP components (videos, digital game, and group discussions). CONCLUSION: Findings have highlighted knowledge gaps among potential users and key stakeholders and will be used to inform the design of the MDL-SHPVP to ensure that their needs and expectations are addressed. Study findings may also aid future HPV vaccine promotion efforts and boost HPV vaccine uptake among youth in the city.

Factors Associated with Post-Stroke Depression in Chinese Stroke Survivors.

OBJECTIVES: To explore the relationship between participation self-efficacy, sociodemographic and clinical characteristics, and post-stroke depression in stroke survivors and provide insights into the development of rehabilitation programmes. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted with 336 participants recruited from five hospitals in Kunming, China. Measures included the Chinese version of the Participation Strategies Self-Efficacy Scale (PS-SES-C), Geriatric Depression Scale (GDS), modified Barthel Index, Rivermead Mobility Index (RMI), Reintegration to Normal Living Index (RNLI), and the Social Support Questionnaire (SSQ6). Logistic regression analyses were performed using SPSS 25.0. RESULTS: Nearly half (44.6%) of the sample was found to have depression. The mean participation self-efficacy score of stroke survivors with depression was significantly lower than that of those without depression. Logistic regression analyses suggested that participation self-efficacy is a constant and major factor negatively associated with depression, with every 10-pt increase in the PS-SES-C score associated with decreased odds of depression (p<0.001). Other features associated with depression prevalence to varying degrees included education level, marital status, pre-morbid financial role in family, stroke symptom severity, history of heart disease, frequency of stroke, lesion side, stroke type, and use of assistive aids. CONCLUSIONS: Participation self-efficacy is negatively associated with depression in stroke survivors. Rehabilitation programmes might consider incorporating interventions aimed at boosting participation self-efficacy in order to promote positive recovery outcomes among survivors.

Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey.

BACKGROUND: Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China. AIMS AND OBJECTIVES: To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China. DESIGN: A cross-sectional study was conducted. METHODS: A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China. RESULTS: Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families. CONCLUSIONS: Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged. RELEVANCE TO CLINICAL PRACTICE: Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.

Validation of PREdiction of DELIRium in ICu patients (PRE-DELIRIC) among patients in intensive care units: A retrospective cohort study.

BACKGROUND: An intensive care unit (ICU) delirium prediction tool, PREdiction of DELIRium in ICu patients (PRE-DELIRIC), has been developed and calibrated in a multinational project. However, there is a lack of evidence regarding the predictive ability of the PRE-DELIRIC among Chinese ICU patients. AIM: To evaluate the predictive validity (discrimination and calibration) of PRE-DELIRIC. DESIGN: This is a retrospective cohort study. METHODS: A retrospective cohort study was conducted. Consecutive participants (a) admitted to the ICU for ≥24 hours, (b) aged ≥18 years, and (c) admitted to the ICU for the first time were included. Ten predictors (age, APACHE-II, urgent and admission category, urea level, metabolic acidosis, infection, coma, sedation, and morphine use) assessed within 24 hours upon ICU admission were assessed. Delirium was assessed using the Confusion Assessment Method for ICU. Outcomes included ICU length of stay and mortality. Discrimination and calibration were determined by the areas under the receiver operating characteristic curve (AUROC), box plot, and calibration plot. RESULTS: A total of 375 ICU patients were included, with 44.0% of patients being delirious. Delirium was significantly associated with age, PRE-DELIRIC score, ICU length of stay, and mortality. The AUROC was 0.81 (95% confidence interval, 0.77-0.86). The optimal cut-off point identified by max Youden index was 49%. The calibration plot of pooled data demonstrated a calibration slope of 0.894 and an intercept of -0.178. CONCLUSIONS: The PRE-DELIRIC has high predictive value and is suggested to be adopted in ICUs for early initiation of preventive interventions against delirium among high-risk patients. RELEVANCE TO CLINICAL PRACTICE: Clinicians can adopt the PRE-DELIRIC among ICU patients to screen patients at high risk of developing delirium. Early initiative interventions could be implemented to reduce the negative impacts of ICU delirium.

Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: A systematic review and meta-analysis.

BACKGROUND: Delirium is common in critically ill patients and may lead to severe complications, such as falls and injuries. Nonpharmacological interventions have been widely suggested to prevent delirium, yet the effects remain uncertain. OBJECTIVES: The aim of the study was to determine the effects of nonpharmacological interventions on preventing delirium and improving critically ill patients' clinical, psychological, and family outcomes. METHODS: Ten databases were searched from their inception to September 2020. Two reviewers assessed the methodological quality and extracted details of the included studies. The data were narratively or statistically pooled where appropriate. Dichotomous variables are presented as odds ratio (OR), and continuous variables are presented as mean difference (MD). The Grading of Recommendations Assessment, Development, and Evaluation criteria were used to assess the quality of evidence for each review outcome. RESULTS: Thirty-four studies (10 randomised controlled trials, eight controlled clinical trials, and 16 before-and-after studies) were included in the analysis. Low-certainty evidence indicated that nonpharmacological interventions reduced delirium incidence (OR = 0.43, 95% confidence interval [CI] [0.33, 0.55]), delirium duration (MD = -1.43 days, 95% CI [-1.94, 0.92]), and length of stay in the intensive care unit (MD = -1.24 days, 95% CI [-2.05, -0.43]). Moderate-certainty evidence demonstrated no effect on mortality. Narrative synthesis further implied improvements in patients' psychological recovery (two studies, very low-certainty evidence) and families' satisfaction with care (two studies, very low-certainty evidence) through nonpharmacological interventions. As for effective intervention types, moderate-certainty evidence demonstrates that early mobilisation (OR = 0.33, 95% CI [0.24, 0.46], five studies, 859 participants, I2 = 24%), family participation (OR = 0.25, 95% CI [0.18, 0.34], four studies, 997 participants, I2 = 21%), and use of multicomponent interventions (OR = 0.48, 95% CI [0.34, 0.69], 13 studies, 3172 participants, I2 = 77%) are associated with reduced incidence of delirium. CONCLUSIONS: Healthcare professionals are recommended to apply early mobilisation, family participation, or multicomponent interventions in clinical practice to prevent delirium. Further studies investigating the effects of nonpharmacological interventions on patients' psychological and family outcomes are warranted.