Introducing Quin: The design and development of a prototype chatbot to support smoking cessation.

INTRODUCTION: Chatbots emulate human-like interactions and may usefully provide on-demand access to tailored smoking cessation support. We have developed a prototype smartphone application-based smoking cessation chatbot, named Quin, grounded in real-world, evidence- and theory-based smoking cessation counselling sessions. METHOD: Conversation topics and interactions in Quitline counselling sessions (N=30; 18 hours) were characterised using thematic, content, and proponent analyses of transcripts. Quin was created by programming this content using a chatbot framework which interacts with users via speech-to-text. Reiterative changes and additions were made to the conversation structure and dialogue following regular consultation with a multidisciplinary team from relevant fields, and from evidence-based resources. RESULTS: Chatbot conversations were encoded into initial and scheduled follow-up 'appointments'. Collection of demographic information, and smoking and quit history, informed tailored discussion about pharmacotherapy preferences, behavioural strategies, and social and professional support to form a quit plan. Follow-up appointments were programmed to check in on user progress, review elements of the quit plan, answer questions and solve issues. Quin was programmed to include teachable moments and educational content to enhance health literacy and informed decision-making. Personal agency is encouraged through exploration and self-reflection of users' personal behaviours, experiences, preferences and ideas. CONCLUSION: Quin's successful development represents a movement towards improving access to personalised smoking cessation support. Qualitative foundations of Quin provide greater insight into the smoking cessation counselling relationship and enhances the conversational ability of the technology. The prototype chatbot will be refined through beta-testing with end-users and stakeholders prior to evaluation in a clinical trial. IMPLICATIONS: Our novel study provides transparent description of the translation of qualitative evidence of real-world smoking cessation counselling sessions into the design and development of a prototype smoking cessation chatbot. The successful iterative development of Quin not only embodies the science and art of health promotion, but also a step-forward in expanding the reach of tailored, evidence based, in-pocket support for people who want to quit smoking.

Process-oriented dynamic group psychotherapy for depression as a teaching modality in a family medicine residency program- A pilot study.

Background and Objectives This pilot study provides a description and evaluation of process-oriented dynamic group psychotherapy for depression as a teaching modality for family medicine residents. The main purpose of using this modality was to teach family medicine residents a variety of psychological clinical skills. A secondary benefit of this modality was to provide in-house, primary care treatment to depressed patients, although the efficacy of this was not evaluated in the present study. Methods A 10-item, self-report, Likert-type questionnaire was administered to a convenience sample of family medicine residents who had participated in the program. Results Completed questionnaires were received from 100% of the family medicine resident participants. Responses to the questionnaires indicate that the residents felt they acquired a variety of clinical skills from the training modality, to include developing active listening and interviewing skills; methods to improve the doctor-patient relationship; increased skills in empathy, intuitive processes, and emotional support; a depth understanding of how intra-psychic conflicts and interpersonal problems contribute to depression; how to give effective feedback that promotes behavioral change; and how to place interventions at the appropriate level of change. Eighty-eight percent of residents indicated they would recommend this learning modality to a family medicine physician colleague. Conclusions The family medicine residents' responses to the questionnaires indicate that they perceived process-oriented dynamic group psychotherapy for depression as a constructive and beneficial modality for both patient care and learning a variety of clinical skills.

Variations and value improvement in back pain care in one area of England.

The pursuit of value and equity have been put on a legal footing in the NHS with the arrival of the legal duty for all in the NHS to improve health and well-being of the population served, to provide fair access to high quality healthcare, and to use resources sustainably and efficiently. Recognising this we used analysis of variation to help us understand the degree to which we were fulfilling our new duty for people with back pain in Mid-Nottinghamshire and where there might be opportunities for value improvement.MSK Together is a group of clinical and managerial representatives from providers, purchasers, local government, and patients who work collectively to optimise the use of resources for people with MSK conditions in Mid-Nottinghamshire. Back pain is the third largest burden of disease in the locality, and the largest cause of disability, so it is of strategic importance to MSK Together-we wanted to know about, and act on, opportunities for value improvement across the population of people with back pain.In 2019/20, after adjusting for age and sex, we found a greater than three-fold variation among general practices in age-sex standardised rates of all hospital service usage for back pain conditions. When looking at a four-year period (2016/17-2019/20), the observed variation increased to eight-fold for (with narrow 95% confidence intervals). When looking at procedures (e.g., surgery or injections), the standardised variation among general practices was six-fold in 2019/20. The deprivation score of the general practice (a heterogenous measure given the mixed neighbourhoods many general practices serve) showed little correlation to the rates observed and did not appear to justify the variation.When we looked at the deprivation of the neighbourhood from which the individuals receiving back pain procedures came, there appeared to be a weak correlation in terms of lower rates of intervention in the least-deprived compared with the most-deprived communities. This correlation was not tested statistically. People receiving hospital services for back pain appeared to receive the first episode of care most often in their 40s (working age), compared with people from the least-deprived areas who received care most commonly in their 60s (approaching retirement).When we looked at the interventions provided in Mid-Nottinghamshire for back pain, 29 interventions were provided to 17,225 people. Using a recent NICE evaluation of cost-effectiveness of back pain interventions, we established that, of these 29 interventions, 16 have evidence of improving the quality of life, for nine there was no evidence of benefit or harm, for three there was evidence that they do not provide an improvement in quality of life, and for one there was possible evidence of harm. The total cost of interventions was estimated at £4.5 million and, using the evidence from the NICE review, the total quality adjusted life year (QALY) gain to the treated population of people with back pain was calculated to be 4,571 QALYs.After discussions among the MSK Together group, it was agreed that some interventions could be stopped or scaled down, and new interventions introduced (in particular, in more-deprived neighbourhoods). Within the same estimated cost envelope of £4.5 million, the QALY gain was predicted to increase to 7702 QALYs and, by targeting QALY-related interventions to people from deprived neighbourhoods, reduce inequity (and therefore health inequalities).Using variation helped us identify areas for improvement and generated a momentum for change among the MSK Together group. By examining what we were doing, the associated costs, and the likely QALY benefits (from research evidence), we identified lower value interventions to stop or reduce and new interventions to introduce, achieving greater health gain for people with back pain with no additional resource requirements.

Prevalence of agglutinating antibodies to Toxoplasma gondii in adult and fetal mule deer (Odocoileus hemionus) from Nebraska.

Toxoplasma gondii is an apicomplexan parasite of mammals and birds. Herbivores acquire postnatal infection by ingesting oocysts from contaminated food or water. Toxoplasma gondii infection is common in white-tailed deer, Odocoileus virginianus, but little is known about the prevalence of infection in mule deer, O. hemionus. We examined sera from 89 mule deer from Nebraska for agglutinating antibodies to T. gondii using the modified direct agglutination test (MAT) with formalin-fixed tachyzoites as antigen. Thirty-one (35%) of the samples were positive at dilutions of > or = 1:25. Samples were examined from 29 fetuses from these mule deer and none were positive in the MAT. Sera from 14 white-tailed deer from Nebraska were also examined and 6 (43%) were positive for T. gondii. Samples were examined from 5 fetuses from these white-tailed deer and none was positive in the MAT. Our results in both deer species from Nebraska are similar to studies conducted in white-tailed deer from other regions of the United States. Our findings indicate that mule deer are frequently infected with T. gondii and that mule-deer meat may be a source of human infection.