How might secondary dementia prevention programs work in practice: a pre-implementation study of the APPLE-Tree program.

BACKGROUND: Over 850,000 people in the UK currently have dementia, and that number is expected to grow rapidly. One approach that may help slow or prevent this growth is personalized dementia prevention. For most people, this will involve targeted lifestyle changes. These approaches have shown promise in trials, but as of yet, the evidence for how to scale them to a population level is lacking. In this pre-implementation study, we aimed to explore stakeholder perspectives on developing system-readiness for dementia prevention programs. We focused on the APPLE-Tree program, one of several low-intensity, lifestyle-based dementia prevention interventions currently in clinical trials. METHODS: We conducted semi-structured interviews with health and social care professionals without previous experience with the APPLE-Tree program, who had direct care or managerial experience in services for older adults with memory concerns, without a dementia diagnosis. We used the Consolidated Framework for Implementation Research to guide interviews and thematic analysis. RESULTS: We interviewed 26 stakeholders: commissioners and service managers (n = 15) and frontline workers (n = 11) from eight NHS and 11 third sector organizations throughout England. We identified three main themes: (1) favorable beliefs in the effectiveness of dementia prevention programs in enhancing cognition and wellbeing and their potential to fill a service gap for people with memory concerns, (2) challenges related to funding and capacity to deliver such programs at organizations without staff capacity or higher prioritization of dementia services, and (3) modifications to delivery and guidance required for compatibility with organizations and patients. CONCLUSION: This study highlights likely challenges in scale-up if we are to make personalized dementia prevention widely available. This will only be possible with increased funding of dementia prevention activities; integrated care systems, with their focus on prevention, may enable this. Scale-up of dementia prevention programs will also require clear outlines of their core and adaptable components to fit funding, patient, and facilitator needs.

Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention.

BACKGROUND: Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a new HPV-based screen-and-treat approach for cervical cancer prevention in Iquitos, Peru. METHODS: We conducted semi-structured interviews with "obstetras" (i.e., midwives) (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analyses. We utilized manifest content analysis to describe barriers to follow-up according to the obstetras and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women. RESULTS: We found an incomplete and fragmented patient monitoring system. This incomplete system, in conjunction with challenges in contacting some of the women, led to structural barriers for the obstetras when attempting to deliver positive results. Women in this study expressed a desire to receive treatment, however, faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier and reported frequently using natural medicine. Reported financial barriers were minimal. CONCLUSION: This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not as prominently observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.

"I wanted information": navigating breast Cancer and its treatment in Lima, Peru.

BACKGROUND: Breast cancer impacts millions of people worldwide, and in Peru, breast cancer is the most common cause of cancer related death among women. Breast cancer treatment is physically and emotionally burdensome and challenging for patients. METHODS: In-depth interviews were conducted with 14 female breast cancer patients and survivors in Lima, Peru. The interviews explored four main themes: the women's emotional experiences, coping mechanisms, resources available or needed, and advice for newly diagnosed breast cancer patients. RESULTS: Respondents described a tremendous lack of informational support during and after diagnosis and treatment and requested more of this support from health professionals. Social support groups were helpful to participants; however, these forms of support were not available to all participants. Emotional and esteem support seemed amply received from family and friends, faith organizations, and fellow cancer patients. Participants experienced a range of emotions upon diagnosis and during treatment including fear, anxiety, difficulty accepting bodily changes, loneliness, and denial. CONCLUSION: Breast cancer and its treatment can be a long, emotional journey; more extensive forms of informational support could help patients cope with this process.

"Day or night, no matter what, I will go": Women's perspectives on challenges with follow-up care after cervical cancer screening in Iquitos, Peru: a qualitative study.

BACKGROUND: The study's objective was to explore the factors associated with loss to follow-up among women with abnormal cervical cancer screening results in Iquitos, Peru from women's perspectives. METHODS: In-depth interviews were conducted with 20 screen-positive women who were referred for follow-up care but for whom evidence of follow-up was not found. Interview transcripts were thematically analyzed inductively, and the codes were then categorized using the Health Care Access Barriers Model for presentation of results. RESULTS: All interviewed women were highly motivated to complete the continuum of care but faced numerous barriers along the way, including cognitive barriers such as a lack of knowledge about cervical cancer and poor communication from health professionals regarding the process, structural barriers such as challenges with scheduling appointments and unavailability of providers, and financial barriers including out-of-pocket payments and costs related to travel or missing days of work. With no information system tracking the continuum of care, we found fragmentation between primary and hospital-level care, and often, registration of women's follow-up care was missing altogether, preventing women from being able to receive proper care and providers from ensuring that women receive care and treatment as needed. CONCLUSIONS: The challenges elucidated demonstrate the complexity of implementing a successful cervical cancer prevention program and indicate a need for any such program to consider the perspectives of women to improve follow-up after a positive screening test.

"Easy women get it": pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program.

BACKGROUND: Cervical cancer is preventable with vaccination and early detection and treatment programs. However, for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system and community of a low-resource setting prior to implementation of an HPV screen-and-treat program. METHODS: This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis. RESULTS: We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism. CONCLUSIONS: Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system and community in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.

Women's perspectives on the acceptability and feasibility of an HPV screen-and-treat approach to cervical cancer prevention in Iquitos, Peru: a qualitative study.

BACKGROUND: The objective of this study was to explore women's experiences of a screen-and-treat approach with ablative therapy (referred to by the Spanish acronym TVT-TA) as a method of treatment following a positive HPV test in Iquitos, Peru. METHODS: A total of 111 in-depth interviews were conducted with 47 HPV positive women who attended the TVT-TA procedure at a primary-level healthcare facility. Interviews were conducted immediately before, immediately after, and six-weeks after TVT-TA. RESULTS: Most interviewed women reported experiencing moderate pain during ablative therapy and minimal pain immediately after and six weeks after ablative therapy. Women also stated that the pain was less intense than they had expected. The most common physical after-effects of treatment were bleeding and vaginal odor. Women experienced oscillating emotions with fear upon receiving a positive HPV result, calming after hearing about ablative therapy treatment, worry about pain from the treatment itself, relaxation with counseling about the procedure, and relief following treatment. CONCLUSIONS: Nearly all participants emphasized that they were pleased with the TVT-TA process even if they had experienced pain during TVT-TA, recommended that TVT-TA be expanded and available to more women, and stated that TVT-TA was faster and easier than expected. This study found that TVT-TA is a feasible and acceptable means of treating HPV according to the women receiving the treatment.

Beyond "Meat Free Monday": A mixed method study of giving up eating meat.

Increasing numbers of people are vegan, vegetarian, or reducing meat consumption. There has also been growth in campaigns such as Meat Free Monday (MFM) that encourage and support reduced meat consumption. We conducted a mixed-method exploration of the behaviour and beliefs associated with reducing or eliminating meat consumption. An online questionnaire was completed by an opportunistic sample of 655 people aged 18-82 who were registered on the MFM website, and were meat eaters at the time of registering. The key focus of quantitative analyses was comparisons between three groups: those who described themselves as "omnivores" who ate all meat at the time of completing the survey, those who ate only some meat, and those who had stopped eating meat since registering for MFM. The qualitative component entailed Interpretative Phenomenological Analysis of in-depth interviews with 18 people who had completed the questionnaire. The quantitative data revealed that people who had stopped eating meat since engaging with the MFM campaign had more positive attitudes toward being vegetarian or vegan, had been engaged with MFM for a longer time, and had used more elements of the MFM website. The qualitative data illustrated that individuals understood and appreciated MFM's aim of supporting people to make an initial change and then considering expanding on this. Interviewees highlighted the value and importance of campaign materials that helped them to turn their beliefs and motivation into enduring behaviour change. The observed associations between longer engagement with the campaign and greater behaviour change suggest that MFM and similar campaigns will maximise their impact if they can maintain people's active engagement: that this will necessitate deeper understanding of the forms of support and advice are most wanted and most effective.

Worry and ruminative brooding: associations with cognitive and physical health in older adults.

Introduction: Mental health conditions are associated with cognition and physical function in older adults. We examined whether worry and ruminative brooding, key symptoms of certain mental health conditions, are related to subjective and/or objective measures of cognitive and physical (cardiovascular) health. Methods: We used baseline data from 282 participants from the SCD-Well and Age-Well trials (178 female; agemean = 71.1 years). We measured worry and ruminative brooding using the Penn State Worry Questionnaire and the Ruminative Response Scale-brooding subscale. We assessed subjective physical health using the WHOQOL-Bref physical subscale, and objective physical health via blood pressure and modified versions of the Framingham Risk Score and Charlson Comorbidity Index. With subjective and objective cognition, we utilized the Cognitive Difficulties Scale and a global composite (modified Preclinical Alzheimer's Cognitive Composite, PACC5, with the Wechsler Adult Intelligence Scale-IV, category fluency, Mattis Dementia Rating Scale-2, and either the California Verbal Learning Test or the Rey Auditory Verbal Learning Test). We conducted linear regressions, adjusted for education, age, sex and cohort. Results: Worry and ruminative brooding were negatively associated with subjective physical health (worry: ß = -0.245, 95%CI -0.357 to -0.133, p < 0.001; ruminative brooding: ß = -0.224, 95%CI -0.334 to -0.113, p < 0.001) and subjective cognitive difficulties (worry: ß = 0.196, 95%CI 0.091 to 0.302, p < 0.001; ruminative brooding: ß = 0.239, 95%CI 0.133 to 0.346, p < 0.001). We did not observe associations between worry or ruminative brooding and any measure of objective health. Discussion: Worry and ruminative brooding may be common mechanisms associated with subjective but not objective health. Alternatively, cognitively unimpaired older adults may become aware of subtle changes not captured by objective measures used in this study. Interventions reducing worry and ruminative brooding may promote subjective physical and cognitive health; however, more research is needed to determine causality of the relationships.

Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention in Iquitos, Peru: a mixed methods study.

Background: Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a screen-and-treat approach with visual triage and ablative therapy for cervical cancer prevention in Iquitos, Peru. Methods: We conducted semi-structured interviews with nurse-midwives (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analysis. We utilize manifest content analysis to describe barriers to follow-up according to the nurse-midwives and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women and report discrepancies and concordances between nurse-midwives and women regarding reasons for loss to follow-up. Results: Women in this study expressed a desire to receive treatment. Barriers, including fragmented and incomplete registry systems, made receiving follow-up care more challenging. Nurse-midwives faced structural barriers in attempting to deliver positive results to women who were challenging to contact, and women did not have clear knowledge of how to receive their HPV results. Women faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier. Reported financial barriers were minimal. There was agreement between women's and nurse-midwives' reported barriers to follow-up in slightly over half of the cases. Conclusion: This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.

"Easy women get it": Pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program.

Background: Cervical cancer is preventable with vaccination and early detection and treatment programs. However, in order for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system of a low-resource setting prior to implementation of an HPV screen-and-treat program. Methods: This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis. Results: We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism. Conclusions: Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.

Association of Self-reflection With Cognition and Brain Health in Cognitively Unimpaired Older Adults.

BACKGROUND AND OBJECTIVES: Self-reflection (the active evaluation of ones thoughts, feelings, and behaviors) can confer protection against adverse health outcomes. Its effect on markers sensitive to Alzheimer disease (AD), however, is unknown. The primary objective of this cross-sectional study was to examine the association between self-reflection and AD-sensitive markers. METHODS: This study used baseline data from cognitively unimpaired older adults enrolled in the Age-Well clinical trial and older adults with subjective cognitive decline from the SCD-Well clinical trial. In both cohorts, self-reflection was measured via the reflective pondering subscale of the Rumination Response Scale, global cognition assessed via the Preclinical Alzheimer's Cognitive Composite 5, and a modified late-life Lifestyle-for-Brain-Health (LIBRA) index computed to assess health and lifestyle factors. In Age-Well, glucose metabolism and amyloid deposition were quantified in AD-sensitive gray matter regions via fluorodeoxyglucose- and AV45-PET scans, respectively. Associations between self-reflection and AD-sensitive markers (global cognition, glucose metabolism, and amyloid deposition) were assessed via unadjusted and adjusted regressions. Furthermore, we explored whether associations were independent of health and lifestyle factors. To control for multiple comparisons in Age-Well, false discovery rate-corrected p values (p FDR) are reported. RESULTS: A total of 134 (mean age 69.3 ± 3.8 years, 61.9% women) Age-Well and 125 (mean age 72.6 ± 6.9 years, 65.6% women) SCD-Well participants were included. Across unadjusted and adjusted analyses, self-reflection was associated with better global cognition in both cohorts (Age-Well: adjusted-ß = 0.22, 95% CI 0.05-0.40, p FDR = 0.041; SCD-Well: adjusted-ß = 0.18, 95% CI 0.03-0.33, p = 0.023) and with higher glucose metabolism in Age-Well after adjustment for all covariates (adjusted-ß = 0.29, 95% CI 0.03-0.55, p FDR = 0.041). Associations remained following additional adjustment for LIBRA but did not survive false discovery rate (FDR) correction. Self-reflection was not associated with amyloid deposition (adjusted-ß = 0.13, 95% CI -0.07 to 0.34, p FDR = 0.189). DISCUSSION: Self-reflection was associated with better global cognition in 2 independent cohorts and with higher glucose metabolism after adjustment for covariates. There was weak evidence that relationships were independent from health and lifestyle behaviors. Longitudinal and experimental studies are warranted to elucidate whether self-reflection helps preserve cognition and glucose metabolism or whether reduced capacity to self-reflect is a harbinger of cognitive decline and glucose hypometabolism. TRIAL REGISTRATION INFORMATION: Age-Well: NCT02977819; SCD-Well: NCT03005652.

The science and art of asking questions in cognitive therapy.

BACKGROUND: Questions underpin all aspects of therapeutic assessment and intervention and are a vital component of the clinical process. Over recent years frameworks have started to be applied to obtain a greater understanding of questioning formats and processes. METHOD: This paper examines the use of questions in cognitive therapy (CT). An overview of the main types of questions identified in the literature is presented. In addition, we examine a range of client and therapist characteristics that may impact on the questioning process. CONCLUSIONS: Asking questions in therapy is a complex, yet under-taught, skill. This paper provides a set of frameworks to assist in identifying helpful and unhelpful questioning skills. Thus the article has implications for further training and research.

Opportunities for Mobile App-Based Adherence Support for Children With Tuberculosis in South Africa.

Tuberculosis is the number one infectious cause of death globally. Young children, generally those younger than 5 years, are at the highest risk of progressing from tuberculosis infection to tuberculosis disease and of developing the most severe forms of tuberculosis. Most current tuberculosis drug formulations have poor acceptability among children and require consistent adherence for prolonged periods of time. These challenges complicate children's adherence to treatment and caregivers' daily administration of the drugs. Rapid developments in mobile technologies and apps present opportunities for using widely available technology to support national tuberculosis programs and patient treatment adherence. Pilot studies have demonstrated that mobile apps are a feasible and acceptable means of enhancing children's treatment adherence for other chronic conditions. Despite this, no mobile apps that aim to promote adherence to tuberculosis treatment have been developed for children. In this paper, we draw on our experiences carrying out research in clinical pediatric tuberculosis studies in South Africa. We present hypothetical scenarios of children's adherence to tuberculosis medication to suggest priorities for behavioral and educational strategies that a mobile app could incorporate to address some of the adherence support gaps faced by children diagnosed with tuberculosis. We argue that a mobile app has the potential to lessen some of the negative experiences that children associate with taking tuberculosis treatment and to facilitate a more positive treatment adherence experience for children and their caregivers.

The prevalence of wholly attributable alcohol conditions in the United Kingdom hospital system: a systematic review, meta-analysis and meta-regression.

BACKGROUND AND AIMS: The prevalence of alcohol-related conditions is often reported as higher in hospital in-patients compared with the general population. However, formal prevalence estimates are commonly derived from small studies which report highly varied results. This systematic review and meta-analysis, within the UK hospital system, aimed to estimate the pooled prevalence of the 26 ICD-10 conditions that are wholly attributable to alcohol in in-patient settings. METHODS: We searched Medline, Embase, PsychINFO and CENTRAL from database inception until 1 May 2018. We included studies of any design that reported the prevalence of one of 26 wholly attributable alcohol conditions defined by the ICD-10. Studies were required to be conducted in one or more of the constituent nations of the United Kingdom and in an in-patient setting (general wards, intensive care units, accident and emergency departments or mental health in-patient units). Estimates were pooled using random-effects meta-analysis, and meta-regression tested study and patient factors contributing to variation. Quality was assessed using the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework. RESULTS: A total of 124 studies were included, reporting on a total of 1 657 614 patients. The majority of studies reported on harmful use of alcohol and alcohol dependence, for which the pooled prevalence was 19.76% [95% confidence interval (CI) = 15.61-24.26%] and 10.25% (95% CI = 7.06-13.96%), respectively. Mean patient age and type of in-patient setting were identified as the main sources of variation in prevalence estimates, but not date of data collection. Both estimates were deemed very low quality according to GRADE. CONCLUSIONS: An estimated one in five patients in the UK hospital system use alcohol harmfully, and one in 10 are alcohol-dependent.

An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in patients with breast cancer.

BACKGROUND: To determine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in patients with breast cancer and determine the suitability of the instrument for use with this clinical group. METHODS: A cross-sectional design was used. The study used a pooled data set from three breast cancer clinical groups. The dependent variables were HADS anxiety and depression sub-scale scores. Exploratory and confirmatory factor analyses were conducted on the HADS to determine its psychometric properties in 110 patients with breast cancer. Seven models were tested to determine model fit to the data. RESULTS: Both factor analysis methods indicated that three-factor models provided a better fit to the data compared to two-factor (anxiety and depression) models for breast cancer patients. Clark and Watson's three factor tripartite and three factor hierarchical models provided the best fit. CONCLUSION: The underlying factor structure of the HADS in breast cancer patients comprises three distinct, but correlated factors, negative affectivity, autonomic anxiety and anhedonic depression. The clinical utility of the HADS in screening for anxiety and depression in breast cancer patients may be enhanced by using a modified scoring procedure based on a three-factor model of psychological distress. This proposed alternate scoring method involving regressing autonomic anxiety and anhedonic depression factors onto the third factor (negative affectivity) requires further investigation in order to establish its efficacy.