Measuring refugees' capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda.

BACKGROUND: Forcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda. We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done. RESULTS: The Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences. CONCLUSIONS: In this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

A pilot study of an integrated mental health, social and medical model for diabetes care in an inner-city setting: Three Dimensions for Diabetes (3DFD).

AIMS: We examined the effectiveness of a service innovation, Three Dimensions for Diabetes (3DFD), that consisted of a referral to an integrated mental health, social care and diabetes treatment model, compared with usual care in improving biomedical and health economic outcomes. METHODS: Using a non-randomized control design, the 3DFD model was offered in two inner-city boroughs in London, UK, where diabetes health professionals could refer adult residents with diabetes, suboptimal glycaemic control [HbA1c ≥ 75 mmol/mol (≥ 9.0%)] and mental health and/or social problems. In the usual care group, there was no referral pathway and anonymized data on individuals with HbA1c ≥ 75 mmol/mol (≥ 9.0%) were collected from primary care records. Change in HbA1c from baseline to 12 months was the primary outcome, and change in healthcare costs and biomedical variables were secondary outcomes. RESULTS: 3DFD participants had worse glycaemic control and higher healthcare costs than control participants at baseline. 3DFD participants had greater improvement in glycaemic control compared with control participants [-14 mmol/mol (-1.3%) vs. -6 mmol/mol (-0.6%) respectively, P < 0.001], adjusted for confounding. Total follow-up healthcare costs remained higher in the 3DFD group compared with the control group (mean difference £1715, 95% confidence intervals 591 to 2811), adjusted for confounding. The incremental cost-effectiveness ratio was £398 per mmol/mol unit decrease in HbA1c , indicating the 3DFD intervention was more effective and costed more than usual care. CONCLUSIONS: A biomedical, psychological and social criteria-based referral system for identifying and managing high-cost and high-risk individuals with poor glycaemic control can lead to improved health in all three dimensions.

Patient explanations for non-attendance at structured diabetes education sessions for newly diagnosed Type 2 diabetes: a qualitative study.

AIM: To determine the reasons for non-attendance at structured education sessions among people with a recent diagnosis of Type 2 diabetes. METHODS: This was a qualitative study using semi-structured interviews to elicit the main themes explaining non-attendance. A thematic framework method was applied to analyse the data. People who had not attended structured education were recruited from a population cohort of newly diagnosed Type 2 diabetes from South London (the South London Diabetes cohort study), UK. RESULTS: A sample of 30 people was interviewed. Three main themes emerged from the qualitative data explaining non-attendance at structured education: (1) lack of information/perceived benefit of the programme (e.g. not being informed about the course by their health professional); (2) unmet personal preferences (e.g. parking, timing); and (3) shame and stigma of diabetes (e.g. not wishing to tell others of diabetes diagnosis). CONCLUSION: This is the first time that reasons for non-attendance have been explored in depth among people who have newly diagnosed Type 2 diabetes. Novel reasons identified included non-attendance because of shame and stigma of diabetes. To improve uptake at structured education we need to: consider how health professionals in primary care communicate with their patients on the subject of structured diabetes education; offer alternatives to the traditional group education format; and understand that diabetes is associated with health-related stigma, which may affect participation.

Provision of health promotion programmes to people with serious mental illness: a mapping exercise of four South London boroughs.

BACKGROUND: People with serious mental illness (SMI) are at increased risk of developing various physical health diseases, contributing to significantly reduced life expectancies compared with the general population. In light of this, the Department of Health have set the physical health of people with mental health problems as a priority for improvement. Additionally, the UK government encourages the NHS and local authorities to develop health promotion programmes (HPPs) for people with SMI. AIMS: To document how many and what types of HPPs were available to people with SMI across four South London boroughs, UK. RESULTS: We found 145 HPPs were available to people with SMI across the four boroughs, but with an inequitable distribution. We also found that certain HPPs set admission criteria that were likely to act as a barrier to improving health. CONCLUSIONS: A more integrated approach of documenting and providing information regarding the provision of HPPs for or inclusive of people with SMI is needed. ABSTRACT: People with serious mental illness (SMI) such as schizophrenia, schizoaffective disorders and bipolar disorder are at increased risk of developing diabetes, cardiovascular disease and respiratory disease, contributing to significantly reduced life expectancies. As a result, emphasis has been placed on developing Health Promotion Programmes (HPPs) to modify the risk of poor physical health in SMI. We examined how many and what types of HPPs are available for or inclusive of people with SMI across four borough in South London, UK. A cross-sectional mapping study was carried out to identify the number of HPPs available to people with SMI. We found 145 HPPs available to people with SMI existed across the four boroughs but with an inequitable distribution, which in some boroughs we anticipate may not meet need. In some cases, HPPs set admission conditions which were likely to further impede access. We recommend that accurate and readily available information on the provision of HPPs for or inclusive of people with SMI is needed.

Motivational enhancement therapy with and without cognitive behaviour therapy for Type 1 diabetes: economic evaluation from a randomized controlled trial.

AIMS: To assess the cost-effectiveness of motivational enhancement therapy and cognitive behaviour therapy for poorly controlled Type 1 diabetes. METHODS: Within-trial prospective economic evaluation from (i) health and social care and (ii) societal perspectives. Three hundred and forty-four adults with Type 1 diabetes for at least 2 years and persistent, suboptimal glycaemic control were recruited to a three-arm multi-centre randomized controlled trial in London and Manchester, UK. They were randomized to (i) usual care plus four sessions of motivational enhancement therapy (ii) usual care plus four sessions of motivational enhancement therapy and eight sessions of cognitive behaviour therapy or (iii) usual care alone. Outcomes were (i) costs, (ii) Quality-Adjusted Life Year gains measured by the EuroQol 5-dimensional health state index and the 36-item Short Form and (iii) diabetes control measured by change in HbA(1c) level at 1 year. RESULTS: Both intervention groups had significantly higher mean health and social care costs (+ £535 for motivational enhancement therapy and + £790 for combined motivational enhancement and cognitive behavioural therapy), but not societal costs compared with the usual-care group. There were no differences in Quality Adjusted Life Years. There was a significantly greater HbA(1c) improvement in the combined motivational enhancement and cognitive behavioural therapy group (+ 0.45%; incremental cost-effectiveness ratio = £1756), but the not in the motivational enhancement therapy group. Cost-effectiveness acceptability curves suggested that both interventions had low probabilities of cost-effectiveness based on Quality Adjusted Life Years (but high based on HbA(1c) improvements). Imputing missing costs and outcomes confirmed these findings. CONCLUSIONS: Neither therapy was undisputedly cost-effective compared with usual care alone, but conclusions vary depending on the relative importance of clinical and quality-of-life outcomes.

A randomised controlled trial of cognitive behaviour therapy and motivational interviewing for people with Type 1 diabetes mellitus with persistent sub-optimal glycaemic control: a Diabetes and Psychological Therapies (ADaPT) study.

OBJECTIVES: To determine whether (i) motivational enhancement therapy (MET) + cognitive behaviour therapy (CBT) compared with usual care, (ii) MET compared with usual care, (iii) or MET + CBT compared with MET was more effective in improving glycaemic control when delivered by general nurses with additional training in these techniques. DESIGN: A three-arm parallel randomised controlled trial as the gold standard design to test the effectiveness of psychological treatments. SETTING: The recruiting centres were diabetes clinics in seven acute trusts in south-east London and Greater Manchester. PARTICIPANTS: Adults (18-65 years) with a confirmed diagnosis of type 1 diabetes for a minimum duration of 2 years and a current glycated (or glycosylated) haemoglobin (HbA1c) value between 8.2% and 15.0%. INTERVENTIONS: The control arm consisted of usual diabetes care which varied between the hospitals, but constituted at least three monthly appointments to diabetes clinic. The two treatments arms consisted of usual care with MET and usual care with MET + CBT. MAIN OUTCOME MEASURES: The primary outcome was HbA1c at 12 months from randomisation. Secondary outcome measures were 1-year costs measured by the Client Service Receipt Inventory at baseline, 6 months and 12 months; quality of life-years [quality-adjusted life-years (QALYs)] measured by the SF-36 (Short Form-36 Health Survey Questionnaire) and EQ-5D (European Quality of Life-5 Dimensions) at baseline and 12 months. RESULTS: One thousand six hundred and fifty-nine people with type 1 diabetes were screened and 344 were randomised to MET + CBT (n = 106), MET (n = 117) and to usual care (n = 121). The 12-month follow-up rate for HbA1c was 88% (n = 305). The adjusted mean 12-month HbA1c was 0.45% lower in those treated with MET + CBT [95% confidence interval (CI) 0.16% to 0.79%, p = 0.008] than for usual care; 0.16% lower in those treated with MET (95% CI 0.20% to 0.51%, p = 0.38) than for usual care; and 0.30% lower with MET + CBT than with MET (95% CI -0.07% to 0.66%, p = 0.11). The higher the HbA1c, and the younger the participant at baseline, the greater was the reduction in HbA1c. The interventions had no effect on secondary outcomes such as depression and quality of life. The economic evaluation was inconclusive. Both interventions were associated with increased health care costs than for usual care alone. There was no significant difference in social costs. Cost effectiveness ratios, up to one year, varied considerably according to whether QALY estimates were based on EQ-5D or SF-36 and whether imputed or complete data were used in the analyses. CONCLUSIONS: A combination of MET and CBT may be useful for patients with persistent sub-optimal diabetic control. MET alone appears less effective than usual care. Economic evaluation was inconclusive. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77044517.

National guidelines for psychological care in diabetes: how mindful have we been?

AIMS: To assess the availability and types of psychological services for people with diabetes in the UK, compliance with national guidelines and skills of the diabetes team in, and attitudes towards, psychological aspects of diabetes management. METHODS: Postal questionnaires to team leads (doctor and nurse) of all UK diabetes centres (n = 464) followed by semi-structured telephone interviews of expert providers of psychological services identified by team leads. RESULTS: Two hundred and sixty-seven centres (58%) returned postal questionnaires; 66 (25%) identified a named expert provider of psychological services, of whom 53 (80%) were interviewed by telephone. Less than one-third (n = 84) of responding centres had access to specialist psychological services and availability varied across the four UK nations (P = 0.02). Over two-thirds (n = 182) of centres had not implemented the majority of national guidelines and only 2.6% met all guidelines. Psychological input into teams was associated with improved training in psychological issues for team members (P < 0.001), perception of better skills in managing more complex psychological issues (P < or = 0.01) and increased likelihood of having psychological care pathways (P < or = 0.05). Most (81%) expert providers interviewed by telephone were under-resourced to meet the psychological needs of their population. CONCLUSIONS: Expert psychological support is not available to the majority of diabetes centres and significant geographical variation indicates inequity of service provision. Only a minority of centres meet national guidelines. Skills and services within diabetes teams vary widely and are positively influenced by the presence of expert providers of psychological care. Lack of resources are a barrier to service provision.

Seasonal variation in energy expenditure, water flux and food consumption of Arabian oryx Oryx leucoryx.

We report on the energy expenditure and water flux, measured in the laboratory and in the field, of the Arabian oryx Oryx leucoryx, the largest desert ruminant for which measurements of the field metabolic rate of free-living individuals have been made using doubly labeled water. Prior to extirpation of this species in the wild in 1972, conservationists sequestered a number of individuals for captive breeding; in 1989, oryx were reintroduced in Saudi Arabia into Mahazat as-Sayd (2244 km(2)). Apart from small pools of water available after rains, oryx do not have free-standing water available for drinking and therefore rely on grasses that they eat for preformed water intake as well as their energy needs. We tested whether oryx have a reduced fasting metabolic rate and total evaporative water loss (TEWL) in the laboratory, as do some other arid-adapted mammals, and whether oryx have high field metabolic rates (FMRs) and water influx rates (WIRs), as predicted by allometric equations for large arid-zone mammals. We measured FMR and WIR during the hot summer, when plant moisture content was low and ambient temperatures were high, and after winter rains, when the water content of grasses was high. For captive oryx that weighed 84.1 kg, fasting metabolic rate averaged 8980 kJ day(-1), 16.7% lower than predictions for Artiodactyla. Our own re-analysis of minimal metabolic rates among Artiodactyla yielded the equation: logV(O2)=-0.153+0.758logM, where V(O2) is the rate of oxygen uptake in lh(-1) and M is body mass in kg. Fasting metabolic rate of oryx was only 9.1% lower than predicted, suggesting that they do not have an unusually low metabolic rate. TEWL averaged 870.0 ml day(-1), 63.9% lower than predicted, a remarkably low value even compared with the camel, but the mechanisms that contribute to such low rates of water loss remain unresolved. For free-living oryx, FMR was 11076 kJ day(-1) for animals with a mean body mass of 81.5 kg during summer, whereas it was 22081 kJ day(-1) for oryx in spring with a mean body mass of 89.0 kg, values that were 48.6% and 90.4% of allometric predictions, respectively. During summer, WIR averaged 1310 ml H(2)O day(-1), whereas in spring it was 3438 ml H(2)O day(-1). Compared with allometric predictions, WIR was 76.9% lower than expected in summer and 43.6% lower in spring. We found no evidence to support the view that the WIR of large desert ungulates is higher than that of their mesic counterparts. On the basis of the WIR of the oryx averaged over the year and the water contents of plants in their diet, we estimated that an oryx consumes 858 kg of dry matter per year.