Factors Associated With Engagement With a Web-Based Lifestyle Intervention Following Provision of Coronary Heart Disease Risk: Mixed Methods Study.

BACKGROUND: Web-based interventions provide the opportunity to combine the tailored approach of face-to-face interventions with the scalability and cost-effectiveness of public health interventions. This potential is often limited by low engagement. A number of studies have described the characteristics of individuals who engage more in Web-based interventions but few have explored the reasons for these variations. OBJECTIVE: We aimed to explore individual-level factors associated with different degrees of engagement with a Web-based behavior change intervention following provision of coronary heart disease (CHD) risk information, and the barriers and facilitators to engagement. METHODS: This study involved the secondary analysis of data from the Information and Risk Modification Trial, a randomized controlled trial of a Web-based lifestyle intervention alone, or alongside information on estimated CHD risk. The intervention consisted of three interactive sessions, each lasting up to 60 minutes, delivered at monthly intervals. Participants were characterized as high engagers if they completed all three sessions. Thematic analysis of qualitative data from interviews with 37 participants was combined with quantitative data on usage of the Web-based intervention using a mixed-methods matrix, and data on the views of the intervention itself were analyzed across all participants. RESULTS: Thirteen participants were characterized as low engagers and 24 as high engagers. There was no difference in age (P=.75), gender (P=.95), or level of risk (P=.65) between the groups. Low engagement was more often associated with: (1) reporting a negative emotional reaction in response to the risk score (P=.029), (2) perceiving that the intervention did not provide any new lifestyle information (P=.011), and (3) being less likely to have reported feeling an obligation to complete the intervention as part of the study (P=.019). The mixed-methods matrix suggested that there was also an association between low engagement and less success with previous behavior change attempts, but the statistical evidence for this association was weak (P=.16). No associations were seen between engagement and barriers or facilitators to health behavior change, or comments about the design of the intervention itself. The most commonly cited barriers related to issues with access to the intervention itself: either difficulties remembering the link to the site or passwords, a perceived lack of flexibility within the website, or lack of time. Facilitators included the nonjudgmental presentation of lifestyle information, the use of simple language, and the personalized nature of the intervention. CONCLUSIONS: This study shows that the level of engagement with a Web-based intervention following provision of CHD risk information is not influenced by the level of risk but by the individual's response to the risk information, their past experiences of behavior change, the extent to which they consider the lifestyle information helpful, and whether they felt obliged to complete the intervention as part of a research study. A number of facilitators and barriers to Web-based interventions were also identified, which should inform future interventions.

The response to receiving phenotypic and genetic coronary heart disease risk scores and lifestyle advice - a qualitative study.

BACKGROUND: Individuals routinely receive information about their risk of coronary heart disease (CHD) based on traditional risk factors as part of their primary care. We are also able to calculate individual's risk of CHD based on their genetic information and at present genetic testing for common diseases is available to the public. Due to the limitations in previous studies further understanding is needed about the impact of the risk information on individual's well-being and health-behaviour. We aimed to explore the short term response to receiving different forms of CHD risk information and lifestyle advice for risk reduction. METHODS: We conducted fourty-one face-to-face interviews and two focus groups across England with participants from the INFORM trial who received a combination of individualised phenotypic and genotypic CHD risk scores and web-based lifestyle advice. Risk scores were presented in different formats, e.g. absolute 10 year risk was presented as a thermometer and expressed as a percentage, natural frequency and 'heart age'. Interviews and focus groups explored participants' understanding and reaction to the risk scores and attempts to change lifestyle during the intervention. We tape-recorded and transcribed the interviews and focus groups and analysed them using thematic analysis. RESULTS: Three main themes were identified: limitations of risk scores to generate concern about CHD risk; the advantages of the 'heart age' format of risk score presentation in communicating a message of sub-optimal lifestyle; and intentions and attempts to make moderate lifestyle changes which were prompted by the web-based lifestyle advice. CONCLUSIONS: There are a number of limitations to the use of risk scores to communicate a message about the need for a lifestyle change. Of the formats used, the 'heart age', if noticed, appears to convey the most powerful message about how far from optimal risk an individual person is. An interactive, user friendly, goal setting based lifestyle website can act as a trigger to initiate moderate lifestyle changes, regardless of concerns about risk scores. TRIAL REGISTRATION: Current Controlled Trials ISRCTN17721237 . Registered 12 January 2015.

Only Making Things Worse: A Qualitative Study of the Impact of Wrongly Removing Disability Benefits from People with Mental Illness.

Many countries belonging to the Organisation for Economic Co-operation and Development (OECD) have seen a considerable increase in the number of disability benefits recipients (DBRs), in addition to an increase in the proportion of people with mental illness. As in other countries, changes to the welfare benefits system in England were made in order to reduce the number of DBRs. Many people lost their benefit payments, although a considerable number had them reinstated after appeal. Our aim was to investigate the impact of the process on DBRs whose disability was related to mental health and who won their appeal. Seventeen DBRs were interviewed. The participants reported three main types of impact. Beyond the practical reduction of income and the related anxiety, interviewees reported considerable stress when coping with the 'never-ending' cycle of bureaucracy. They also expressed anger, frustration and demoralisation at mistrust on the part of the authorities partly due to the 'invisibility' of their disability.

Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour.

BACKGROUND: Cardiovascular disease (CVD) remains the leading cause of death globally. Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions. An integral part of this approach is the use of CVD risk scores. Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies. We aim to evaluate short-term effects of providing different types of information about coronary heart disease (CHD) risk, alongside lifestyle advice, on health-related behaviours. METHODS/DESIGN: In a parallel-group, open randomised trial, we are allocating 932 male and female blood donors with no previous history of CVD aged 40-84 years in England to either no intervention (control group) or to one of three active intervention groups: i) lifestyle advice only; ii) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics; and iii) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics. The primary outcome is change in objectively measured physical activity. Secondary outcomes include: objectively measured dietary behaviours; cardiovascular risk factors; current medication and healthcare usage; perceived risk; cognitive evaluation of provision of CHD risk scores; and psychological outcomes. The follow-up assessment takes place 12 weeks after randomisation. The experiences, attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups. DISCUSSION: The INFORM study has been designed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours. TRIAL REGISTRATION: Current Controlled Trials ISRCTN17721237 . Registered 12 January 2015.

Newspaper coverage of mental illness in England 2008-2011.

BACKGROUND: Better newspaper coverage of mental health-related issues is a target for the Time to Change (TTC) anti-stigma programme in England, whose population impact may be influenced by how far concurrent media coverage perpetuates stigma and discrimination. AIMS: To compare English newspaper coverage of mental health-related topics each year of the TTC social marketing campaign (2009-2011) with baseline coverage in 2008. METHOD: Content analysis was performed on articles in 27 local and national newspapers on two randomly chosen days each month. RESULTS: There was a significant increase in the proportion of anti-stigmatising articles between 2008 and 2011. There was no concomitant proportional decrease in stigmatising articles, and the contribution of mixed or neutral elements decreased. CONCLUSIONS: These findings provide promising results on improvements in press reporting of mental illness during the TTC programme in 2009-2011, and a basis for guidance to newspaper journalists and editors on reporting mental illness.

Lean implementation within healthcare: imaging as fertile ground.

PURPOSE: The purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective. DESIGN/METHODOLOGY/APPROACH: An in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme. FINDINGS: Implementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean. PRACTICAL IMPLICATIONS: When introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean. ORIGINALITY/VALUE: This ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system.

Effect of communicating phenotypic and genetic risk of coronary heart disease alongside web-based lifestyle advice: the INFORM Randomised Controlled Trial.

OBJECTIVE: To determine whether provision of web-based lifestyle advice and coronary heart disease risk information either based on phenotypic characteristics or phenotypic plus genetic characteristics affects changes in objectively measured health behaviours. METHODS: A parallel-group, open randomised trial including 956 male and female blood donors with no history of cardiovascular disease (mean [SD] age=56.7 [8.8] years) randomised to four study groups: control group (no information provided); web-based lifestyle advice only (lifestyle group); lifestyle advice plus information on estimated 10-year coronary heart disease risk based on phenotypic characteristics (phenotypic risk estimate) (phenotypic group) and lifestyle advice plus information on estimated 10-year coronary heart disease risk based on phenotypic (phenotypic risk estimate) and genetic characteristics (genetic risk estimate) (genetic group). The primary outcome was change in physical activity from baseline to 12 weeks assessed by wrist-worn accelerometer. RESULTS: 928 (97.1%) participants completed the trial. There was no evidence of intervention effects on physical activity (difference in adjusted mean change from baseline): lifestyle group vs control group 0.09 milligravity (mg) (95% CI -1.15 to 1.33); genetic group vs phenotypic group -0.33 mg (95% CI -1.55 to 0.90); phenotypic group and genetic group vs control group -0.52 mg (95% CI -1.59 to 0.55) and vs lifestyle group -0.61 mg (95% CI -1.67 to 0.46). There was no evidence of intervention effects on secondary biological, emotional and health-related behavioural outcomes except self-reported fruit and vegetable intake. CONCLUSIONS: Provision of risk information, whether based on phenotypic or genotypic characteristics, alongside web-based lifestyle advice did not importantly affect objectively measured levels of physical activity, other health-related behaviours, biological risk factors or emotional well-being. TRIAL REGISTRATION NUMBER: ISRCTN17721237; Pre-results.

'Keeping your body and mind active': an ethnographic study of aspirations for healthy ageing.

OBJECTIVE: To describe and explore perceptions, practices and motivations for active living in later life. DESIGN: Qualitative study with semistructured interviews and 'semistructured' participant observations of participant-selected activities, such as exercise classes, private or organised walks, shopping and gardening. PARTICIPANTS: 27 participants (65-80 years) from the European Prospective Investigation into Cancer Norfolk study, purposefully selected by gender, age, occupational class, living status and residential location; 19 of the participants agreed to be accompanied for observed activities. SETTING: Participants' homes, neighbourhoods, places of leisure activities and workplaces in Norfolk, England. RESULTS: All participants regarded a positive attitude as important for healthy ageing; this included staying active, both physically and mentally through sedentary activities such as reading and crosswords. 'Getting out of the house', being busy, or following a variety of interests were regarded as both important motivators and descriptions of their 'activeness'. Purposeful activities formed an important part of this, for example, still being engaged in paid or voluntary work, having caring responsibilities, or smaller incidental activities such as helping neighbours or walking for transport. Many also reported adapting previous, often lifelong, activity preferences and habits to their ageing body, or replacing them altogether with lower impact activities such as walking. This included adapting to the physical limitations of partners and friends which dictated the intensity and frequency of shared activities. The social context of activities could thus form a barrier to active living, but could also encourage it through companionship, social responsibilities and social pressures. CONCLUSIONS: Promoting and maintaining physical activity among older people may require more attention to activeness as an attitude and way of life as well as to its social context, and initiatives encouraging broader activity habits rather than discrete activities.

Improving the diagnosis of physical illness in patients with mental illness who present in emergency departments: consensus study.

OBJECTIVE: The aim of this study was to establish consensus among clinicians in order to produce recommendations to optimise the diagnosis of physical illness in patients with mental illness who present in Emergency Departments (EDs). METHOD: A list of recommendations was derived from qualitative interviews conducted with 39 doctors and nurses working in EDs in four general hospitals in England. Using a modified nominal group technique, we then asked a selected group of 15 doctors and nurses to take part in a group discussion with two voting rounds in order to decide which recommendations are most beneficial and feasible. RESULTS: Five recommendations met the a priori criteria to be considered 'strongly supported'. These included: having a psychiatric liaison team staff available 24 hours a day in the vicinity of the ED; developing detailed guidelines regarding intoxicated patients and regarding parallel assessment of patients by both ED and psychiatric staff; and having regular meetings between representatives of both departments. CONCLUSION: In addition to suggesting specific recommendations, the study stresses the advantages in increasing the accessibility of psychiatric staff in the ED but also identifies challenges regarding joint work and division of responsibilities between them and the ED acute team.

Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms--a qualitative study.

We conducted a qualitative study in the Emergency Departments (EDs) of four hospitals in order to investigate the perceived scope and causes of 'diagnostic overshadowing'--the misattribution of physical symptoms to mental illness--and other challenges involved in the diagnostic process of people with mental illness who present in EDs with physical symptoms. Eighteen doctors and twenty-one nurses working in EDs and psychiatric liaisons teams in four general hospitals in the UK were interviewed. Interviewees were asked about cases in which mental illness interfered with diagnosis of physical problems and about other aspects of the diagnostic process. Interviews were transcribed and analysed thematically. Interviewees reported various scenarios in which mental illness or factors related to it led to misdiagnosis or delayed treatment with various degrees of seriousness. Direct factors which may lead to misattribution in this regard are complex presentations or aspects related to poor communication or challenging behaviour of the patient. Background factors are the crowded nature of the ED environment, time pressures and targets and stigmatising attitudes held by a minority of staff. The existence of psychiatric liaison team covering the ED twenty-four hours a day, seven days a week, can help reduce the risk of misdiagnosis of people with mental illness who present with physical symptoms. However, procedures used by emergency and psychiatric liaison staff require fuller operationalization to reduce disagreement over where responsibilities lie.

'Our community is the worst': the influence of cultural beliefs on stigma, relationships with family and help-seeking in three ethnic communities in London.

BACKGROUND: Existing knowledge about the cultural beliefs of black and minority ethnic (BME) communities in the UK regarding stigma and mental illness is limited. MATERIAL: Data were collected in 10 focus groups, five with service users and five with laypersons, from BME communities in London. DISCUSSION: Thematic analysis identified that cultural beliefs regarding mental illness reflect four different voices present within the BME communities. CONCLUSION: The study revealed that cultural beliefs influencing both relationships with family and, consequently, help-seeking for individuals with mental illness must be considered in the development of anti-stigma interventions and when engaging communities around mental health.