A qualitative study exploring the barriers and facilitators of implementing a cardiovascular disease risk reducing intervention for people with severe mental illness into primary care contexts across England: the 'PRIMROSE' trial.

BACKGROUND: People with severe mental illness (SMI) are at greater risk of earlier mortality due to physical health problems including cardiovascular disease (CVD). There is limited work exploring whether physical health interventions for people with SMI can be embedded and/or adopted within specific healthcare settings. This information is necessary to optimise the development of services and interventions within healthcare settings. This study explores the barriers and facilitators of implementing a nurse-delivered intervention ('PRIMROSE') designed to reduce CVD risk in people with SMI in primary care, using Normalisation Process Theory (NPT), a theory that explains the dynamics of embedding or 'normalising' a complex intervention within healthcare settings. METHODS: Semi-structured interviews were conducted between April-December 2016 with patients with SMI at risk of CVD who received the PRIMROSE intervention, and practice nurses and healthcare assistants who delivered it in primary care in England. Interviews were audio recorded, transcribed and analysed using thematic analysis. Emergent themes were then mapped on to constructs of NPT. RESULTS: Fifteen patients and 15 staff participated. The implementation of PRIMROSE was affected by the following as categorised by the NPT domains: 1) Coherence, where both staff and patients expressed an understanding of the purpose and value of the intervention, 2) Cognitive participation, including mental health stigma and staff perceptions of the compatibility of the intervention to primary care contexts, 3) Collective action, including 3.1. Interactional workability in terms of lack of patient engagement despite flexible appointment scheduling. The structured nature of the intervention and the need for additional nurse time were considered barriers, 3.2. Relational integration i.e. whereby positive relationships between staff and patients facilitated implementation, and access to 'in-house' staff support was considered important, 3.3. Skill-set workability in terms of staff skills, knowledge and training facilitated implementation, 3.4. Contextual integration regarding the accessibility of resources sometimes prevented collective action. 4) Reflexive monitoring, where the staff commonly appraised the intervention by suggesting designated timeslots and technology may improve the intervention. CONCLUSIONS: Future interventions for physical health in people with SMI could consider the following items to improve implementation: 1) training for practitioners in CVD risk prevention to increase practitioners knowledge of physical interventions 2) training in SMI to increase practitioner confidence to engage with people with SMI and reduce mental health stigma and 3) access to resources including specialist services, additional staff and time. Access to specialist behaviour change services may be beneficial for patients with specific health goals. Additional staff to support workload and share knowledge may also be valuable. More time for appointments with people with SMI may allow practitioners to better meet patient needs.

Delivering cognitive behavioural therapy to advanced cancer patients: A qualitative exploration into therapists' experiences within a UK psychological service.

BACKGROUND: Cognitive behavioural therapy (CBT) is commonly used to treat cancer patients with psychological disorders such as depression. There has been little qualitative research exploring the experience of therapists delivering CBT to patients with advanced cancer and long-term health conditions generally. Therapists' views may help identify difficulties in delivering therapy and how these may be overcome. The aim of this study was to inform practice by qualitatively exploring the experiences of therapists delivering CBT to patients with advanced cancer. DESIGN: Sixteen semi-structured interviews were conducted with therapists from Increasing Access to Psychological Therapy (IAPT) services in London, UK, who had delivered CBT to patients enrolled on the CanTalk trial. Interviews were recorded, transcribed, and analysed using framework analysis. RESULTS: Therapists reported positive experiences when working with the target population. Flexibility, adaptability, and a consideration of individual needs were identified as important when delivering CBT, but the rigidity of IAPT policies and demand for services were perceived as problematic. Although therapists reported adequate training, specialist supervision was desired when delivering therapy to this complex population. CONCLUSION: IAPT therapists can deliver CBT to advanced cancer patients, given therapists positive experiences evident in the present study. However, it was concluded that additional service and modifications of therapy may be needed before positive outcomes for both therapists and patients can be achieved.

Changes in the number and outcome of takeaway food outlet planning applications in response to adoption of management zones around schools in England: A time series analysis.

Physical exposure to takeaway food outlets ("takeaways") is associated with poor diet and excess weight, which are leading causes of excess morbidity and mortality. At the end of 2017, 35 local authorities (LAs) in England had adopted takeaway management zones (or "exclusion zones"), which is an urban planning intervention designed to reduce physical exposure to takeaways around schools. In this nationwide, natural experimental study, we used interrupted time series analyses to estimate the impact of this intervention on changes in the total number of takeaway planning applications received by LAs and the percentage rejected, at both first decision and after any appeal, within management zones, per quarter of calendar year. Changes in these proximal process measures would precede downstream retail and health impacts. We observed an overall decrease in the number of applications received by intervention LAs at 12 months post-intervention (6.3 fewer, 95% CI -0.1, -12.5), and an increase in the percentage of applications that were rejected at first (additional 18.8%, 95% CI 3.7, 33.9) and final (additional 19.6%, 95% CI 4.7, 34.6) decision, the latter taking into account any appeal outcomes. This effect size for the number of planning applications was maintained at 24 months, although it was not statistically significant. We also identified three distinct sub-types of management zone regulations (full, town centre exempt, and time management zones). The changes observed in rejections were most prominent for full management zones (where the regulations are applied irrespective of overlap with town centres), where the percentage of applications rejected was increased by an additional 46.1% at 24 months. Our findings suggest that takeaway management zone policies may have the potential to curb the proliferation of new takeaways near schools and subsequently impact on population health.

Changes in the number of new takeaway food outlets associated with adoption of management zones around schools: A natural experimental evaluation in England.

By the end of 2017, 35 local authorities (LAs) across England had adopted takeaway management zones (or "exclusion zones") around schools as a means to curb proliferation of new takeaways. In this nationwide, natural experimental study, we evaluated the impact of management zones on takeaway retail, including unintended displacement of takeaways to areas immediately beyond management zones, and impacts on chain fast-food outlets. We used uncontrolled interrupted time series analyses to estimate changes from up to six years pre- and post-adoption of takeaway management zones around schools. We evaluated three outcomes: mean number of new takeaways within management zones (and by three identified sub-types: full management, town centre exempt and time management zones); mean number on the periphery of management zones (i.e. within an additional 100 m of the edge of zones); and presence of new chain fast-food outlets within management zones. For 26 LAs, we observed an overall decrease in the number of new takeaways opening within management zones. Six years post-intervention, we observed 0.83 (95% CI -0.30, -1.03) fewer new outlets opening per LA than would have been expected in absence of the intervention, equivalent to an 81.0% (95% CI -29.1, -100) reduction in the number of new outlets. Cumulatively, 12 (54%) fewer new takeaways opened than would have been expected over the six-year post-intervention period. When stratified by policy type, effects were most prominent for full management zones and town centre exempt zones. Estimates of intervention effects on numbers of new takeaways on the periphery of management zones, and on the presence of new chain fast-food outlets within management zones, did not meet statistical significance. Our findings suggest that management zone policies were able to demonstrably curb the proliferation of new takeaways. Modelling studies are required to measure the possible population health impacts associated with this change.

Exploring how health behaviours are supported and changed in people with severe mental illness: A qualitative study of a cardiovascular risk reducing intervention in Primary Care in England.

Objectives This study explored how health behaviours were supported and changed in people with severe mental illness by primary health care professionals trained in delivering behaviour change techniques (BCTs) within a cardiovascular disease risk reducing intervention. Design Secondary qualitative analysis of 30 staff and patient interviews. Methods We mapped coded data to the BCT Taxonomy (version 1) to identify BCT application. Thematic analysis was conducted to explore the barriers and facilitators of supporting and changing health behaviours. Themes were then interpreted using the Capability, Opportunity, Motivation, and Behaviour model to gain greater explanation behind the processes. Results Twenty BCTs were identified. Staff and patients perceived that health behaviours were commonly affected by both automatic and reflective motivation, sometimes in turn affected by psychological capability, social, and physical opportunity. Staff and patients suggested that motivation was enhanced by both patient and staff ability to observe health benefits, in some cases patients' health knowledge, mental health status, and social support networks. It was suggested that engaging in/sustaining healthy behaviours was influenced by physical opportunities to engrain behaviours into routine. Conclusions According to staff and patients, health behaviour change in this population was driven by complex processes. It was suggested that capability, opportunity, and motivation were in some cases enhanced by BCTs, but variable. Behaviour change may be optimized by individualized behavioural assessments, identifying drivers of behaviour and applying a range of BCTs may help to target individual needs. Patient peer-led approaches, techniques to encourage awareness of visible success, and normalizing health behaviours may increase behaviour change. Statement of contribution What is already known on this subject? Poorer health behaviours may contribute to early mortality rates in people with severe mental illness. Health care professionals are encouraged to target the uptake of healthy behaviours, but there is limited guidance on how. The processes that cause or inhibit health behaviour change within interventions that use behaviour change techniques by health care practitioners are unclear. What does the study add? Staff and patients suggested that behaviour change techniques (BCTs) in some cases increased capability, opportunity, and motivation to engage in healthy behaviours, but in other cases had variable success. Staff and patients reported that in some cases, motivation impacted health behaviour change and was in turn affected by psychological capability, social, and physical opportunity. Individualized behavioural assessments, flexible approaches to BCT application, involvement from patient peer support and different ways of targeting patient motivation may help to increase healthy behaviour changes in this population.

Factors prospectively associated with physical activity and dietary related outcomes in people with severe mental illness: A systematic review of longitudinal studies.

Understanding factors that contribute towards physical activity and diet outcomes are important for health improvement in people with severe mental illness. Cross-sectional findings on factors associated with diet and physical activity outcomes provide limited information on what predicts changes or long-term outcomes in lifestyle behaviours in people with severe mental illness. A systematic review was therefore conducted to identify prospective studies with quantitative data on baseline factors associated with follow-up diet or physical activity related outcomes. MEDLINE, EMBASE, PsycINFO, CINAHL Plus and grey literature databases were searched from inception to March 2018. From 6921 studies, 5 were eligible for physical activity related outcomes and 2 for diet related outcomes. The follow-up duration was 4 weeks to 24 months and participants were mostly diagnosed with schizophrenia. Older age was commonly related to better physical activity related outcomes, whilst higher negative symptoms were related to poorer-related outcomes. Physical activity intentions and gender were unrelated to physical activity outcomes. There was a lack of data on factors influencing dietary outcomes. Although there were some common factors predictive of physical activity including older age and negative symptoms, more high-quality research is needed to determine the effect of sociodemographic, mental health, social, clinical, lifestyle and other factors on both physical activity and dietary outcomes.

The efficacy of different regimens of chlorhexidine as an antimicrobial agent for a group of egyptians.

UNLABELLED: This study was conducted to evaluate different regimens of 0.12% chlohexidine (CHX) rinse on the salivary parameters and Mutans Streptococci (MS) for a group of Egyptians. Twenty one females were recruited based on inclusive exclusive criteria. They were assigned to three different groups according to the CHX regimen specified. Salivary parameters (unstimulated salivary flow rate, stimulated salivary flow rate, pH and buffering capacity) and salivary mutans streptococci were evaluated at base line for all participants. Diet recording was done for 4 days in a supplied chart. DMFS and DS scores were also determined. This was followed by the use of 0.12% CHX mouth rinse once daily for 60 seconds before bedtime for either 3,7 or 14 days. Salivary parameters were re-evaluated in the early morning after the use of the mouth rinse, after 1 month and 3months. Mutans Streptococci (MS) were also evaluated at the same intervals. The salivary parameters did not show any difference throughout the study. The majority of the participants belonged to the moderate low fermentable CHO diet content category and they consumed five meals of cariogenic intake per day. Their DMFS scores ranged between 2 and 50 whereas the DS scores ranged between 2 and 10. The 3 day regimen was not statistically significantly different from the 7 and 14 days regimens and the maximum efficacy of CHX was obtained immediately after its use and lasted throughout the first week after stopping it. The effect of the CHX disappeared after 1 month and gradually reached the base line and surpassed this level sometimes. CONCLUSION AND RECOMMENDATIONS: A regimen of once daily use of 15 ml of 0.12% CHX mouth rinse for 3 days is effective in reducing MS below critical values. It is recommended to reuse the CHX rinse after 1 month owing to the cessation of its effect. Patients who start using CHX should not discontinue it.