Effectiveness of embedding a specialist preventive care clinician in a community mental health service in increasing preventive care provision: A randomised controlled trial.

OBJECTIVE: Clinical practice guidelines recommend that community mental health services provide preventive care for clients' chronic disease risk behaviours; however, such care is often not routinely provided. This study aimed to assess the effectiveness of offering clients an additional consultation with a specialist clinician embedded within a community mental health service, in increasing client-reported receipt of, and satisfaction with, preventive care. METHOD: A randomised controlled trial was undertaken in one Australian community mental health service. Participants (N = 811) were randomised to receive usual care (preventive care in routine consultations; n = 405) or usual care plus the offer of an additional consultation with a specialist preventive care clinician (n = 406). Blinded interviewers assessed at baseline and 1-month follow-up the client-reported receipt of preventive care (assessment, advice and referral) for four key risk behaviours individually (smoking, poor nutrition, alcohol overconsumption and physical inactivity) and all applicable risks combined, acceptance of referrals and satisfaction with preventive care received. RESULTS: Analyses indicated significantly greater increases in 12 of the 18 preventive care delivery outcomes in the intervention compared to the usual care condition from baseline to follow-up, including assessment for all risks combined (risk ratio = 4.00; 95% confidence interval = [1.57, 10.22]), advice for all applicable risks combined (risk ratio = 2.40; 95% confidence interval = [1.89, 6.47]) and offer of referral to applicable telephone services combined (risk ratio = 20.13; 95% confidence interval = [2.56, 158.04]). For each component of care, there was a significant intervention effect for at least one of the individual risk behaviours. Participants reported high levels of satisfaction with preventive care received, ranging from 77% (assessment) to 87% (referral), with no significant differences between conditions. CONCLUSION: The intervention had a significant effect on the provision of the majority of recommended elements of preventive care. Further research is needed to maximise its impact, including identifying strategies to increase client uptake.

Preventive care for physical activity and fruit and vegetable consumption: a survey of family carer expectations of health service delivery for people with a mental health condition.

BACKGROUND: Chronic disease is a leading cause of death globally, where inadequate fruit and vegetable consumption and inadequate physical activity are consistently implicated as key contributing risk factors for such diseases. People with a mental health condition are reported to experience a higher prevalence of such risks and experience an increased morbidity and mortality from resultant chronic disease. Despite guidelines identifying a need for services accessed by people with a mental health condition to provide care to address such health risk behaviours, sub-optimal care is frequently reported suggesting a need for innovative strategies to increase the provision of physical health care. An exploratory study was conducted to examine: 1) family carers' expectations of care provision regarding fruit and vegetable consumption and physical activity by health and community services for people with a mental health condition; 2) carer's own health risk behaviour status and perceptions of the influence of the health risk behaviours on mental health; and 3) possible associations of socio-demographic, clinical and attitudinal factors with carer expectations of care provision for fruit and vegetable consumption and physical activity. METHODS: Family carers (n = 144) of a person with a mental health condition completed a cross-sectional survey. Participants were members of a mental health carer support organisation operating in New South Wales, Australia. RESULTS: A high proportion of participants considered care for fruit and vegetable consumption and physical activity respectively should be provided by: mental health hospitals (78.5, 82.7%); community mental health services (76.7, 85.9%); general practice (81.1, 79.2%); and non-government organisations (56.2, 65.4%). Most participants perceived adequate fruit and vegetable consumption (55.9%), and physical activity (71.3%) would have a very positive impact on mental health. Carers who perceived adequate fruit and vegetable consumption and physical activity would have a positive impact on mental health were more likely to expect care for such behaviours from some services. CONCLUSIONS: The majority of participants expected care for fruit and vegetable consumption and physical activity be provided by all services catering for people with a mental health condition, reinforcing the appropriateness for such services to provide physical health care for clients in a systematic manner.

A survey of the prevalence of modifiable health risk behaviours among carers of people with a mental illness.

BACKGROUND: Family carers provide significant support to people with a mental illness; yet may experience poor mental and physical health themselves. Among limited research addressing the physical health of carers, studies of carers of people with dementia and young people with psychosis suggest increased risk of chronic diseases in conjunction with higher levels of potentially modifiable lifestyle risk behaviours. This exploratory study, conducted with carers of people with various mental illnesses, aimed to determine: carer prevalence of health risk behaviours (inadequate fruit and vegetable consumption, inadequate physical activity, harmful alcohol consumption, and tobacco smoking); interest in changing 'at risk' behaviours; and potential associations of socio-demographic characteristics with risk status and interest in change. METHODS: A cross-sectional survey was conducted among family carers of people with a mental illness (N = 144) residing in New South Wales, Australia. Analyses explored risk behaviour prevalence and interest in change, and associations with socio-demographic variables. RESULTS: Inadequate fruit and vegetable consumption was most prevalent (74.8%), followed by engaging in inadequate amounts of physical activity (57.6%); harmful alcohol consumption (36.3%) and smoking (11.8%). The majority of carers were interested in improving 'at risk' behaviours (56.3-89.2%), with the exception of alcohol consumption (41.5%). Previously or never married participants were more likely to consume inadequate amounts of fruits and/or vegetables compared to those married or cohabiting (Odds Ratio [OR]: 4.1, 95% Confidence Interval [CI]: 1.3-12.9, p = .02). Carers in the workforce were more likely to be engaging in inadequate physical activity (OR: 2.6, 95% CI: 1.2-5.7, p = .02); and male participants were more likely to engage in harmful alcohol consumption (OR: 2.9, 95% CI: 1.1-7.9, p = .03). Working carers were approximately five times more likely to report interest in improving their alcohol consumption (OR: 5.1, 95% CI: 1.3-20.5, p = .02) compared to those not currently in the workforce. CONCLUSIONS: Results suggest high engagement in health risk behaviours among carers of people with a mental illness, particularly with regards to harmful alcohol consumption. Findings suggest a need to develop and implement chronic disease prevention strategies. Further research with larger representative samples is needed to confirm findings.

Supporting change in chronic disease risk behaviours for people with a mental illness: a qualitative study of the experiences of family carers.

BACKGROUND: People with a mental illness experience greater chronic disease morbidity and mortality, and associated reduced life expectancy, compared to those without such an illness. A higher prevalence of chronic disease risk behaviours (inadequate nutrition, inadequate physical activity, tobacco smoking, and harmful alcohol consumption) is experienced by this population. Family carers have the potential to support change in such behaviours among those they care for with a mental illness. This study aimed to explore family carers': 1) experiences in addressing the chronic disease risk behaviours of their family members; 2) existing barriers to addressing such behaviours; and 3) perceptions of potential strategies to assist them to provide risk behaviour change support. METHODS: A qualitative study of four focus groups (n = 31), using a semi-structured interview schedule, was conducted with carers of people with a mental illness in New South Wales, Australia from January 2015 to February 2016. An inductive thematic analysis was employed to explore the experience of carers in addressing the chronic disease risk behaviours. RESULTS: Two main themes were identified in family carers' report of their experiences: firstly, that health behaviours were salient concerns for carers and that they were engaged in providing support, and secondly that they perceived a bidirectional relationship between health behaviours and mental well-being. Key barriers to addressing behaviours were: a need to attend to carers' own well-being; defensiveness on behalf of the family member; and not residing with their family member; with other behaviour-specific barriers also identified. Discussion around strategies which would assist carers in providing support for health risk behaviours identified a need for improved communication and collaboration between carers and health services accessed by their family members. CONCLUSIONS: Additional support from general and mental health services accessed by family members is desired to assist carers to address the barriers to providing behaviour change support. Carers have the potential to support and extend health service interventions aimed at improving the chronic disease risk behaviours of people with a mental illness but may require additional information, and collaboration from services. Further research is needed to explore these constructs in a large representative sample.

Smoking and Mental Illness: A Bibliometric Analysis of Research Output Over Time.

INTRODUCTION: The prevalence of smoking among persons with a mental illness has remained unchanged, being 2-3 times higher than the general population in high-income countries. Assessment of the volume and characteristics of research output over time can assist in identifying research priorities to promote progress within a field. The aim of this study was to undertake such an assessment in the field of smoking and mental illness. METHODS: A descriptive repeat cross-sectional study was conducted of peer-reviewed publications in Medline and PsycINFO for the periods 1993-1995, 2003-2005, and 2013-2015. Publications were classified as data- or non-data-based; data-based publications were further categorized by study type, population, setting, and for intervention-focused publications by level of evidence and research translation phase. RESULTS: Included were 547 articles published in 1993-1995 (n = 65), 2003-2005 (n = 153), and 2013-2015 (n = 329). The number and proportion of data-based publications significantly increased over time, although their focus remained predominantly descriptive (≥83%); less than 14% of publications in any period had an intervention focus. The proportion of publications reporting on study populations with multiple diagnostic categories and recruiting from nonmental health settings, significantly increased from 1993-1995 to 2003-2005, however then plateaued by 2013-2015. The level of evidence provided by intervention-focused publications was suggested to increase over time, however there was no evident variation in translation phase. CONCLUSIONS: Research has increased over time to characterize smoking among those with a mental illness; however more is needed to inform the development and implementation of effective cessation interventions for this group. IMPLICATIONS: This is the first study to examine the volume and characteristics of research publications in the field of smoking and mental illness over time. The number of publications increased fivefold between 1993-1995 and 2013-2015. Between 1993-1995 and 2003-2005, progression was also indicated by increased: data-based publications, diagnostic diversity of samples, and variation in study settings; however further increases in such measures were not evident in 2013-2015. Notably, it continues to be the case that few intervention studies are undertaken. To achieve meaningful changes in the smoking prevalence of this group, a greater focus on research that assesses the effectiveness and implementation of tailored cessation interventions is required.

Effectiveness of a clinical practice change intervention in increasing the provision of nicotine dependence treatment in inpatient psychiatric facilities: an implementation trial.

BACKGROUND: Despite clinical practice guidelines recommending the routine provision of nicotine dependence treatment to smokers in inpatient psychiatric facilities, the prevalence of such treatment provision is low. The aim of this study was to examine the effectiveness of a clinical practice change intervention in increasing clinician recorded provision of nicotine dependence treatment to patients in inpatient psychiatric facilities. METHODS: We undertook an interrupted time series analysis of nicotine dependence treatment provision before, during and after a clinical practice change intervention to increase clinician recorded provision of nicotine dependence treatment for all hospital discharges (aged >18 years, N = 4175) over a 19 month period in two inpatient adult psychiatric facilities in New South Wales, Australia. The clinical practice change intervention comprised six key strategies: leadership and consensus, enabling systems and procedures, training and education, information and resources, audit and feedback and an on-site practice change support officer. Systematic medical record audit and segmented logistic regression was used to determine differences in proportions for each nicotine dependence treatment outcome measure between the 'pre', 'during' and 'post-intervention' periods. RESULTS: The prevalence of all five outcome measures increased significantly between the pre and post-intervention periods, including clinician recorded: assessment of patient smoking status (36.43 to 51.95%; adjusted odds ratio [AOR] = 2.39, 99% Confidence Interval [CI]: 1.23 to 4.66); assessment of patient nicotine dependence status (4.74 to 11.04%; AOR = 109.67, 99% CI: 35.35 to 340.22); provision of brief advice to quit (0.85 to 8.81%; AOR = 97.43, 99% CI: 31.03 to 306.30); provision of nicotine replacement therapy (8.06 to 26.25%; AOR = 19.59, 99% CI: 8.17 to 46.94); and provision of nicotine dependence treatment on discharge (8.82 to 13.45%, AOR = 12.36; 99% CI: 6.08 to 25.14). CONCLUSIONS: This is the first study to provide evidence that a clinical practice change intervention may increase clinician recorded provision of nicotine dependence treatment in inpatient psychiatric settings. The intervention offers a mechanism for psychiatric facilities to increase the provision of nicotine dependence treatment in accordance with clinical guidelines.

Chronic disease health risk behaviours amongst people with a mental illness.

OBJECTIVE: Amongst people with a mental illness, modifiable health risk behaviours contribute substantially to increased chronic disease morbidity and mortality. This study examined the prevalence of and interest in changing such behaviours amongst community mental health service clients in Australia. METHOD: A telephone interview was undertaken with Australian community mental health service clients. Participants reported engagement in four health risk behaviours: tobacco smoking, fruit and vegetable consumption, alcohol consumption, and physical activity. Participants were classified as at risk based upon Australian national guidelines. At-risk participants were asked whether they were considering improving their health risk behaviour within the next month. The association between psychiatric diagnosis and risk, and interest in improving health risk behaviours was examined. RESULTS: Risk prevalence was highest for inadequate vegetable consumption (78.3%), followed by inadequate fruit consumption (60%), smoking (50.7%), physical inactivity (46.8%), short-term alcohol risk (40.3%) and chronic alcohol risk (35.3%). A majority of at-risk participants were considering improving their health risk behaviour for smoking, physical inactivity and inadequate fruit and vegetable consumption (65.1%, 71.1%, and 53.3%, respectively). After adjusting for demographic factors, no diagnostic categories were associated with risk for any behaviour. Those with a diagnosis of depression were more likely to be interested in quitting smoking and increasing physical activity. CONCLUSIONS: Regardless of diagnosis, a high prevalence of chronic disease health risk behaviours was identified, with many participants expressing an interest in improving these behaviours. Such findings reinforce recommendations that preventive care addressing the chronic disease risks of clients be provided routinely by mental health clinicians. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000693729. URL: www.anzctr.org.au/.

Impact of a postdischarge smoking cessation intervention for smokers admitted to an inpatient psychiatric facility: a randomized controlled trial.

INTRODUCTION: Persons with a mental disorder smoke at higher rates and suffer disproportionate tobacco-related burden compared with the general population. The aim of this study was to determine if a smoking cessation intervention initiated during a psychiatric hospitalization and continued postdischarge was effective in reducing smoking behaviors among persons with a mental disorder. METHODS: A randomized controlled trial was conducted at an Australian inpatient psychiatric facility. Participants were 205 patient smokers allocated to a treatment as usual control (n = 101) or a smoking cessation intervention (n = 104) incorporating psychosocial and pharmacological support for 4 months postdischarge. Follow-up assessments were conducted at 1 week, 2, 4, and 6 months postdischarge and included abstinence from cigarettes, quit attempts, daily cigarette consumption, and nicotine dependence. RESULTS: Rates of continuous and 7-day point prevalence abstinence did not differ between treatment conditions at the 6-month follow-up; however, point prevalence abstinence was significantly higher for intervention (11.5%) compared with control (2%) participants at 4 months (OR = 6.46, p = .01). Participants in the intervention condition reported significantly more quit attempts (F[1, 202.5] = 15.23, p = .0001), lower daily cigarette consumption (F[4, 586] = 6.5, p < .001), and lower levels of nicotine dependence (F[3, 406] = 8.5, p < .0001) compared with controls at all follow-up assessments. CONCLUSIONS: Postdischarge cessation support was effective in encouraging quit attempts and reducing cigarette consumption up to 6 months postdischarge. Additional support strategies are required to facilitate longer-term cessation benefits for smokers with a mental disorder.

The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review.

OBJECTIVE: Smoke-free policies have been introduced in inpatient psychiatric facilities in most developed nations. Such a period of supported abstinence during hospitalization may impact smoking behaviours post discharge, yet little quantitative evidence exists. The aim of this review was to provide the first synthesis of the research evidence examining the impact of a smoke-free psychiatric hospitalization on patients' smoking-related behaviours, motivation, and beliefs. METHODS: We conducted a systematic review of electronic databases PubMed, MEDLINE, PsycINFO, and EMBASE from inception to June 2013. Studies were included if they were conducted in an inpatient psychiatric facility with a smoke-free policy and if they examined any change in patients' smoking-related behaviours, motivation, or beliefs either during admission, post discharge, or both. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool. RESULTS: Fourteen studies were included in the review. Of the four studies that assessed change in smoking from admission to post discharge, two indicated a significant decline in cigarette consumption up to 3 months post discharge. Positive changes in motivation to quit and beliefs about quitting ability were identified in two studies. One study reported an increase in the rate of quit attempts and one reported a decline in nicotine dependence levels. CONCLUSIONS: A smoke-free psychiatric hospitalization may have a positive impact on patients' smoking-related behaviours, motivation, and beliefs, both during admission and up to 3 months post discharge. Further controlled studies with more rigorous designs are required to confirm this potential.

The delivery of preventive care to clients of community health services.

BACKGROUND: Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients. METHODS: In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care. RESULTS: Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%). CONCLUSIONS: Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

A randomised controlled trial linking mental health inpatients to community smoking cessation supports: a study protocol.

BACKGROUND: Mental health inpatients smoke at higher rates than the general population and are disproportionately affected by tobacco dependence. Despite the advent of smoke free policies within mental health hospitals, limited systems are in place to support a cessation attempt post hospitalisation, and international evidence suggests that most smokers return to pre-admission smoking levels following discharge. This protocol describes a randomised controlled trial that will test the feasibility, acceptability and efficacy of linking inpatient smoking care with ongoing community cessation support for smokers with a mental illness. METHODS/DESIGN: This study will be conducted as a randomised controlled trial. 200 smokers with an acute mental illness will be recruited from a large inpatient mental health facility. Participants will complete a baseline survey and will be randomised to either a multimodal smoking cessation intervention or provided with hospital smoking care only. Randomisation will be stratified by diagnosis (psychotic, non-psychotic). Intervention participants will be provided with a brief motivational interview in the inpatient setting and options of ongoing smoking cessation support post discharge: nicotine replacement therapy (NRT); referral to Quitline; smoking cessation groups; and fortnightly telephone support. Outcome data, including cigarettes smoked per day, quit attempts, and self-reported 7-day point prevalence abstinence (validated by exhaled carbon monoxide), will be collected via blind interview at one week, two months, four months and six months post discharge. Process information will also be collected, including the use of cessation supports and cost of the intervention. DISCUSSION: This study will provide comprehensive data on the potential of an integrated, multimodal smoking cessation intervention for persons with an acute mental illness, linking inpatient with community cessation support.

The effectiveness of an intervention in increasing community health clinician provision of preventive care: a study protocol of a non-randomised, multiple-baseline trial.

BACKGROUND: The primary behavioural risks for the most common causes of mortality and morbidity in developed countries are tobacco smoking, poor nutrition, risky alcohol use, and physical inactivity. Evidence, guidelines and policies support routine clinician delivery of care to prevent these risks within primary care settings. Despite the potential afforded by community health services for the delivery of such preventive care, the limited evidence available suggests it is provided at suboptimal levels. This study aims to assess the effectiveness of a multi-strategic practice change intervention in increasing clinician's routine provision of preventive care across a network of community health services. METHODS/DESIGN: A multiple baseline study will be conducted involving all 56 community health facilities in a single health district in New South Wales, Australia. The facilities will be allocated to one of three administratively-defined groups. A 12 month practice change intervention will be implemented in all facilities in each group to facilitate clinician risk assessment of eligible clients, and clinician provision of brief advice and referral to those identified as being 'at risk'. The intervention will be implemented in a non-random sequence across the three facility groups. Repeated, cross-sectional measurement of clinician provision of preventive care for four individual risks (smoking, poor nutrition, risky alcohol use, and physical inactivity) will occur continuously for all three facility groups for 54 months via telephone interviews. The interviews will be conducted with randomly selected clients who have visited a community health facility in the last two weeks. Data collection will commence 12 months prior to the implementation of the intervention in the first group, and continue for six months following the completion of the intervention in the last group. As a secondary source of data, telephone interviews will be undertaken prior to and following the intervention with randomly selected samples of clinicians from each facility group to assess the reported provision of preventive care, and the acceptability of the practice change intervention and implementation. DISCUSSION: The study will provide novel evidence regarding the ability to increase clinician's routine provision of preventive care across a network of community health facilities. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12611001284954 UNIVERSAL TRIAL NUMBER (UTN): U1111-1126-3465.

Systematic review and meta-analysis of the provision of preventive care for modifiable chronic disease risk behaviours by mental health services.

People with mental illness experience increased chronic disease burden, contributed to by a greater prevalence of modifiable chronic disease risk behaviours. Policies recommend mental health services provide preventive care for such risk behaviours. Provision of such care has not previously been synthesised. This review assessed the provision of preventive care for modifiable chronic disease risk behaviours by mental health services. Four databases were searched from 2006 to 2017. Eligible studies were observational quantitative study designs conducted in mental health services, where preventive care was provided to clients for tobacco smoking, harmful alcohol consumption, inadequate nutrition, or inadequate physical activity. Two reviewers independently screened studies, conducted data extraction and critical appraisal. Results were pooled as proportions of clients receiving or clinicians providing preventive care using random effects meta-analyses, by risk behaviour and preventive care element (ask/assess, advise, assist, arrange). Subgroup analyses were conducted by mental health service type (inpatient, outpatient, other/multiple). Narrative synthesis was used where meta-analysis was not possible. Thirty-eight studies were included with 26 amenable to meta-analyses. Analyses revealed that rates of assessment were highest for smoking (78%, 95% confidence interval [CI]:59%-96%) and lowest for nutrition (17%, 95% CI:1%-35%); with variable rates of care provision for all behaviours, care elements, and across service types, with substantial heterogeneity across analyses. Findings indicated suboptimal and variable provision of preventive care for modifiable chronic disease risk behaviours in mental health services, but should be considered with caution due to the very low quality of cumulative evidence. PROSPERO registration: CRD42016049889.

Family carers: A role in addressing chronic disease risk behaviours for people with a mental illness?

People with a mental illness experience greater chronic disease morbidity and mortality compared to those without mental illness. Family carers have the potential to promote the health behaviours of those they care for however factors which may influence the extent to which they do so have not been reported. An exploratory study was conducted to investigate carers': 1) promotion of fruit and vegetable consumption, physical activity, quitting smoking, and reducing alcohol consumption; 2) perceptions of their role and ability to promote such behaviours; 3) and the association between carer perceptions and the promotion of such behaviours. A cross-sectional survey was conducted with mental health carers (N = 144, 37.6% response rate) in New South Wales, Australia in 2013. Associations between current promotion of health behaviours and carer perceptions were explored through multivariate regression analysis in 2016. A majority of respondents promoted fruit and vegetable consumption (63.8%), physical activity (60.3%), quitting smoking (56.3%), and reducing alcohol consumption (56.2%) to the person they cared for. A perception that it was 'very important' to have a positive influence on these behaviours was positively related with promotion of each of the four behaviours, with those holding such a view being more likely to promote such behaviours, than those who did not (odds ratio: 9.47-24.13, p < 0.001). The majority (56.2%-63.8%) of carers reported promoting the health behaviours of those they cared for, demonstrating a need and opportunity to build the capacity of carers to contribute to reducing the health risk behaviours among people with a mental illness.

Systematic review of interventions to increase the delivery of preventive care by primary care nurses and allied health clinicians.

BACKGROUND: Primary care nurses and allied health clinicians are potential providers of opportunistic preventive care. This systematic review aimed to summarise evidence for the effectiveness of practice change interventions in increasing nurse or allied health professional provision of any of five preventive care elements (ask, assess, advise, assist, and/or arrange) for any of four behavioural risks (smoking, inadequate nutrition, alcohol overconsumption, physical inactivity) within a primary care setting. METHODS: A search of Medline, Embase, PsycInfo, and CINAHL databases was undertaken to locate controlled intervention trials published between 1992 and May 2014 that provided practice change interventions to primary care nurses and/or allied health professionals to increase preventive care. The effect of interventions aimed at increasing the provision of any of the five care elements for any of the four behavioural risks was examined. A narrative synthesis was utilised. RESULTS: From 8109 articles, seven trials met the inclusion criteria. All trials bar one, assessed multi-strategic practice change interventions (three to five strategies) focused on care by nurses (six trials) or mixed nursing/allied health clinicians. One trial examined care provision for all four risks, five trials examined care for smoking only, and one trial examined care for alcohol consumption only. For the six trials reporting significance testing (excludes one smoking care trial), significant effects favouring the intervention group were reported in at least one trial for smoking risk assessment (2/4 trials reported an effect for at least one analysis of an assessment outcome), brief advice (2/3), assistance (2/2), and arranging referral (2/3); alcohol risk assessment (1/2) and brief advice (1/2); inadequate nutrition risk assessment (1/1); and physical inactivity risk assessment and brief advice (1/1). When the number of analyses undertaken within trials focusing on smoking care was considered, the results were less promising (e.g. of the 15 analyses conducted on brief advice variables across three trials, four showed a positive effect). CONCLUSIONS: Evidence for the effect of practice change interventions on preventive care by primary care nurses or allied health providers is inconclusive given the small number of trials and inconsistency of results between and within trials. SYSTEMATIC REVIEW REGISTRATION NUMBER: None.

Effectiveness of an intervention in increasing the provision of preventive care by community mental health services: a non-randomized, multiple baseline implementation trial.

BACKGROUND: Relative to the general population, people with a mental illness are more likely to have modifiable chronic disease health risk behaviours. Care to reduce such risks is not routinely provided by community mental health clinicians. This study aimed to determine the effectiveness of an intervention in increasing the provision of preventive care by such clinicians addressing four chronic disease risk behaviours. METHODS: A multiple baseline trial was undertaken in two groups of community mental health services in New South Wales, Australia (2011-2014). A 12-month practice change intervention was sequentially implemented in each group. Outcome data were collected continuously via telephone interviews with a random sample of clients over a 3-year period, from 6 months pre-intervention in the first group, to 6 months post intervention in the second group. Outcomes were client-reported receipt of assessment, advice and referral for tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption and inadequate physical activity and for the four behaviours combined. Logistic regression analyses examined change in client-reported receipt of care. RESULTS: There was an increase in assessment for all risks combined following the intervention (18 to 29 %; OR 3.55, p = 0.002: n = 805 at baseline, 982 at follow-up). No significant change in assessment, advice or referral for each individual risk was found. CONCLUSIONS: The intervention had a limited effect on increasing the provision of preventive care. Further research is required to determine how to increase the provision of preventive care in community mental health services. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12613000693729.

Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment.

The implementation of smoke-free policies in inpatient psychiatric facilities, including patient adherence, mental health nursing staff support, and provision of nicotine-dependence treatment to patients, has been reported to be poor. The extent to which the quality of smoke-free policy implementation is associated with patient views of a policy is unknown. We conducted a cross-sectional survey of 181 patients (53.6%, n = 97 smokers; and 46.4%, n = 84 non-smokers) in an Australian inpatient psychiatric facility with a total smoke-free policy. Smokers' adherence to the policy was poor (83.5% smoked). Only half (53.6%) perceived staff to be supportive of the policy. Most smokers used nicotine-replacement therapy (75.3%); although few received optimal nicotine-dependence treatment (19.6%). Overall, 45.9% of patients viewed the smoke-free policy in the unit as positive (29.9% smokers; 64.3% non-smokers). For smokers, adhering to the ban, perceiving staff to be supportive, and reporting that the nicotine-replacement therapy reduced cravings to smoke were associated with a more positive view towards the smoke-free policy. These findings support the importance of patient adherence, mental health nursing staff support, and adequate provision of nicotine-dependence treatment in strengthening smoke-free policy implementation in inpatient psychiatric settings.

Care provision to prevent chronic disease by community mental health clinicians.

BACKGROUND: People with a mental illness have higher prevalence of behavioral risks for chronic disease than the general population. Despite recommendations regarding the provision of preventive care by mental health services, limited research has examined the extent to which such care is provided. PURPOSE: To examine mental health clinician provision of care for preventable chronic disease risks, and whether such care was associated with the availability of practice support strategies. METHODS: A cross-sectional survey was undertaken of 151 community mental health clinicians in New South Wales, Australia regarding the provision of three elements of preventive care (i.e., assessment, brief advice, and referral/follow-up) for four health risk behaviors (i.e., tobacco smoking, inadequate fruit and vegetable consumption, harmful alcohol consumption, and inadequate physical activity). Clinicians reported the availability of 16 strategies to support such care delivery. Data were collected in 2010 and analyzed in 2012-2013. RESULTS: Preventive care provision varied by both care element and risk behavior. Optimal care (each care element provided to at least 80% of clients for all health behaviors) was provided by few clinicians: assessment (8.6%), brief advice (24.5%), and referral/follow-up (9.9%). Less than half of clinicians reported more than four support strategies were available (44.4%). The availability of five or more strategies was associated with increased optimal preventive care. CONCLUSIONS: The provision of preventive care focused on chronic disease prevention in community mental health services is suboptimal. Interventions to increase the routine provision of such care should involve increasing the availability of evidence-based strategies to support care provision.

Clinician assessment, advice and referral for multiple health risk behaviors: prevalence and predictors of delivery by primary health care nurses and allied health professionals.

OBJECTIVE: Primary care clinicians have considerable potential to provide preventive care. This study describes their preventive care delivery. METHODS: A survey of 384 community health nurses and allied health clinicians from in New South Wales, Australia was undertaken (2010-11) to examine the assessment of client risk, provision of brief advice and referral/follow-up regarding smoking inadequate fruit and vegetable consumption, alcohol misuse, and physical inactivity; the existence of preventive care support strategies; and the association between supports and preventive care provision. RESULTS: Preventive care to 80% or more clients was least often provided for referral/follow-up (24.7-45.6% of clinicians for individual risks, and 24.2% for all risks) and most often for assessment (34.4-69.3% of clinicians for individual risks, and 24.4% for all risks). Approximately 75% reported having 9 or fewer of 17 supports. Provision of care was associated with: availability of a paper screening tool; training; GP referral letter; and number of supports. CONCLUSION: The delivery of preventive care was limited, and varied according to type of care and risk. Supports were variably associated with elements of preventive care. PRACTICE IMPLICATIONS: Further research is required to increase routine preventive care delivery and the availability of supports.

Smoking cessation care provision and support procedures in Australian community mental health centers.

OBJECTIVE: The study assessed the association of supportive clinical systems and procedures with smoking cessation care at community mental health centers. METHODS: Managers (N=84) of community mental health centers in New South Wales, Australia, were asked to complete a survey during 2009 about smoking cessation care. RESULTS: Of the 79 managers who responded, 56% reported that the centers assessed smoking for over 60% of clients, and 34% reported that more than 60% of clients received minimum acceptable smoking cessation care. They reported the use of guidelines and protocols (34%), the use of forms to record smoking status (65%), and the practice of always enforcing smoking bans (52%). Minimum acceptable smoking cessation care was associated with encouraging nicotine replacement therapy for staff who smoke (odds ratio [OR]=9.42), using forms for recording smoking status (OR=5.80), and always enforcing smoking bans (OR=3.82). CONCLUSIONS: Smoking cessation care was suboptimal, and additional supportive systems and procedures are required to increase its delivery.