Investigating 'treat culture' in a secure care service: a study of inpatient NHS staff on their views and opinions on weight gain and treat giving for patients in a forensic secure care service.

BACKGROUND: Obesity is a significant health inequality within forensic secure care mental health/learning disability inpatient settings. Patients may be at increased risk of developing preventable long-term conditions/premature death. This study investigated staff views on patient weight gain, how it affects patients and how to better manage patient weight in this setting. Furthermore, the research explored the culture of food being used as a 'treat' and the perceived impact of 'treats' on weight. METHODS: A two-phase mixed methods approach was taken to explore staff views on patient weight gain and the 'treat' culture on adult forensic secure care inpatient wards in one NHS Mental Health Trust in the north-east of England. Phase one was an online survey, and phase two consisted of semi-structured qualitative interviews. The quantitative survey data were analysed using descriptive statistics. Thematic analysis was used for the open-ended survey questions and interview data. RESULTS: The survey had 49 responses out of a possible 380 (13%). Ninety-two per cent of staff participants viewed patient weight gain as an area for concern, citing a range of reasons for weight gain. Weight gain was considered a risk to developing long-term health conditions and poor mental health. Nine participants were interviewed. Six themes were identified suggesting why patients might gain weight in forensic secure care, for example, patient history, staff behaviours, the surrounding 'treat' culture in this environment, along with suggestions of what could be improved to manage patient weight. CONCLUSIONS: People detained in forensic secure care may be more at risk of weight gain due to their history, the secure care environment and the 'treat' culture adopted in these environments.

Soil-derived Nature's Contributions to People and their contribution to the UN Sustainable Development Goals.

This special issue provides an assessment of the contribution of soils to Nature's Contributions to People (NCP). Here, we combine this assessment and previously published relationships between NCP and delivery on the UN Sustainable Development Goals (SDGs) to infer contributions of soils to the SDGs. We show that in addition to contributing positively to the delivery of all NCP, soils also have a role in underpinning all SDGs. While highlighting the great potential of soils to contribute to sustainable development, it is recognized that poorly managed, degraded or polluted soils may contribute negatively to both NCP and SDGs. The positive contribution, however, cannot be taken for granted, and soils must be managed carefully to keep them healthy and capable of playing this vital role. A priority for soil management must include: (i) for healthy soils in natural ecosystems, protect them from conversion and degradation; (ii) for managed soils, manage in a way to protect and enhance soil biodiversity, health and sustainability and to prevent degradation; and (iii) for degraded soils, restore to full soil health. We have enough knowledge now to move forward with the implementation of best management practices to maintain and improve soil health. This analysis shows that this is not just desirable, it is essential if we are to meet the SDG targets by 2030 and achieve sustainable development more broadly in the decades to come. This article is part of the theme issue 'The role of soils in delivering Nature's Contributions to People'.

Psychological intervention, antipsychotic medication or a combined treatment for adolescents with a first episode of psychosis: the MAPS feasibility three-arm RCT.

BACKGROUND: When psychosis emerges in young people there is a risk of poorer outcomes, and access to evidence-based treatments is paramount. The current evidence base is limited. Antipsychotic medications show only a small benefit over placebo, but young people experience more side effects than adults. There is sparse evidence for psychological intervention. Research is needed to determine the clinical effectiveness and cost-effectiveness of psychological intervention versus antipsychotic medication versus a combined treatment for adolescents with psychosis. OBJECTIVES: The objective of Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) was to determine the feasibility of conducting a definitive trial to answer the question of clinical effectiveness and cost-effectiveness of these three treatment options. DESIGN: This was a prospective, randomised, open-blinded, evaluation feasibility trial with a single blind. Participants were allocated 1 : 1 : 1 to receive antipsychotic medication, psychological intervention or a combination of both. A thematic qualitative study explored the acceptability and feasibility of the trial. SETTING: Early intervention in psychosis services and child and adolescent mental health services in Manchester, Oxford, Lancashire, Sussex, Birmingham, Norfolk and Suffolk, and Northumberland, Tyne and Wear. PARTICIPANTS: People aged 14-18 years experiencing a first episode of psychosis either with an International Classification of Diseases, Tenth Revision, schizophrenia spectrum diagnosis or meeting the entry criteria for early intervention in psychosis who had not received antipsychotic medication or psychological intervention within the last 3 months. INTERVENTIONS: Psychological intervention involved up to 26 hours of cognitive-behavioural therapy and six family intervention sessions over 6 months, with up to four booster sessions. Antipsychotic medication was prescribed by the participant's psychiatrist in line with usual practice. Combined treatment was a combination of psychological intervention and antipsychotic medication. MAIN OUTCOME MEASURES: The primary outcome was feasibility (recruitment, treatment adherence and retention). We used a three-stage progression criterion to determine feasibility. Secondary outcomes were psychosis symptoms, recovery, anxiety and depression, social and educational/occupational functioning, drug and alcohol use, health economics, adverse/metabolic side effects and adverse/serious adverse events. RESULTS: We recruited 61 out of 90 (67.8%; amber zone) potential participants (psychological intervention, n = 18; antipsychotic medication, n = 22; combined treatment, n = 21). Retention to follow-up was 51 out of 61 participants (83.6%; green zone). In the psychological intervention arm and the combined treatment arm, 32 out of 39 (82.1%) participants received six or more sessions of cognitive-behavioural therapy (green zone). In the combined treatment arm and the antipsychotic medication arm, 28 out of 43 (65.1%) participants received antipsychotic medication for 6 consecutive weeks (amber zone). There were no serious adverse events related to the trial and one related adverse event. Overall, the number of completed secondary outcome measures, including health economics, was small. LIMITATIONS: Medication adherence was determined by clinician report, which can be biased. The response to secondary outcomes was low, including health economics. The small sample size obtained means that the study lacked statistical power and there will be considerable uncertainty regarding estimates of treatment effects. CONCLUSIONS: It is feasible to conduct a trial comparing psychological intervention with antipsychotic medication and a combination treatment in young people with psychosis with some adaptations to the design, including adaptations to collection of health economic data to determine cost-effectiveness. FUTURE WORK: An adequately powered definitive trial is required to provide robust evidence. TRIAL REGISTRATION: Current Controlled Trials ISRCTN80567433. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 4. See the NIHR Journals Library website for further project information.

Psychosis is a mental health problem that can involve hearing, seeing or believing things that others do not. Although many young people who experience psychosis recover well from their first episode of psychosis, others can have more serious, longer-lasting problems. There has not been a large amount of research into the treatment of psychosis in young people; therefore, it is important to test different treatments against each other in clinical trials. 'Feasibility' trials, such as the one we carried out [Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS)], test whether or not it is possible to run larger trials. MAPS was a small trial that was run in seven locations in the UK. People who were aged 14­18 years and experiencing psychosis were able to take part. Each participant was randomly assigned to receive psychological treatment (cognitive­behavioural therapy and optional family therapy), antipsychotic medication or a combination of both. All of the participants met with a trial research assistant three times for assessments about well-being and symptoms. Some clinicians, participants and family members were interviewed about their opinions of the trial and treatments. The trial also had patient and public involvement; service user researchers were involved in design, interview data collection, analysis and report writing. Sixty-one young people took part in MAPS, which was around 68% of our target number. In total, 84% completed the assessments with research assistants. The results showed that, overall, all treatments were acceptable to young people and their family members. However, a higher percentage of young people actually received the 'minimum dose' of psychological treatment than the 'minimum dose' of antipsychotic medication (82% vs. 65%). Results showed that it was possible to run a larger trial such as this. However, some changes would be required to run a larger trial, such as location (focusing on urban areas with well established early intervention in psychosis teams), increasing involvement of psychiatrists and increasing the age limit for participation to 25 years.

Seasonal variability of resources: The unexplored adversary of biogas use in rural Ethiopia.

Biogas digester programmes have been rolled out across many countries in sub-Saharan Africa over the past decade with varying levels of success. In Ethiopia, reported success rates have been low, despite high levels of interaction between non-governmental organisations and various levels of government, plus the establishment of practical eligibility criteria. In Halaba, Ethiopia, we investigated physical and social factors affecting feedstock and water availability using a face-to-face questionnaire-based survey (n = 112) in four kebeles (local administration areas). We found that practices of fuel use and water collection were markedly different between seasons. Fuel use was almost entirely dependent on season, with wood being burned in the wet season and crop residues and cow dung being used instead in the dry season. A matched pair t-test found a significant difference between seasons in terms of water collection times (p = 7.4 × 10-16), with households spending more time and money obtaining clean drinking water in the dry season. Results indicate that seasonal differences in resource availability may reduce the proportion of households that meet the physical characteristics for maintaining a biogas digester by approximately 62% from wet season to dry season. Conversely, the greatest benefits of digester use would be gained in the dry season, when dung could be returned to the soil as a nutrient-rich bioslurry, instead of being combusted as a dirty and inefficient fuel. Seasonality is rarely considered in feasibility studies, so we recommend that these factors should be built into future analyses.

Accuracy of urine dipstick tests and urine glucose-to-creatinine ratios for assessment of glucosuria in dogs and cats.

OBJECTIVE: To assess the accuracy of automated readings of urine dipstick results for assessment of glucosuria in dogs and cats, compare visual versus automated readings of urine glucose concentration, and determine the utility of the urine glucose-to-creatinine ratio (UGCR) for quantification of glucosuria. SAMPLE: 310 canine and 279 feline urine samples. PROCEDURES: Glucose concentration was estimated in 271 canine and 254 feline urine samples by visual assessment of urine dipstick results and with an automated dipstick reader. Absolute urine glucose and creatinine concentrations were measured in 39 canine and 25 feline urine samples by colorimetric assay with a clinical chemistry analyzer (reference standard for detection of glucosuria), and UGCRs were determined. RESULTS: Automated assessment of the urine dipsticks yielded accurate results for 163 (60.1%) canine urine samples and 234 (92.1%) feline urine samples. Sensitivity of the automated dipstick reader for detection of glucosuria was 23% for canine samples and 68% for feline samples; specificity was 99% and 98%, respectively. Visual readings were more accurate than automated readings for both canine and feline urine. The UGCR was significantly correlated with absolute urine glucose concentration for both dogs and cats, yet there was incomplete distinction between dipstick categories for glucose concentration and UGCR. CONCLUSIONS AND CLINICAL RELEVANCE: Urine dipstick readings for dogs and cats were useful for ruling glucosuria in when the result was positive but not for ruling it out when the result was negative. The evaluated dipsticks were more accurate for detection of glucosuria in cats than in dogs. Visual dipstick readings were more accurate than automated readings. The UGCR did not appear to provide additional useful information.

Bridging barriers to advance multisector approaches to improve food security, nutrition and population health in Nepal: transdisciplinary perspectives.

BACKGROUND: Understanding stakeholders' perceptions is crucial to the development and implementation of any intervention. However, a structured approach to eliciting stakeholder insights into complex, multisector issues of food security, household environment and health is lacking in many low and middle-income countries. This qualitative, workshop-based participatory study explores stakeholders' experiences of developing and implementing multisector interventions to provide transdisciplinary lessons for future developments in low and middle-income countries. METHODS: Participants were purposely selected based on their involvement in, or exposure to, the multisector intervention. Participants with interests in agriculture, nutrition, household air-quality, drinking water-quality and health from academic institutes, government and developmental organisations were brought together at a one-day workshop to participate in a series of discussions on issues relating to food security, nutrition, household environment and health in Nepal. All group discussions were audio-recorded and transcribed, and a thematic qualitative analysis performed to identify relevant themes. RESULTS: The government's ongoing Multisector Nutrition Plan, stakeholders' willingness to work together, availability of local infrastructure for cross-institutional inputs and increasing global movement towards transdisciplinary approaches were identified by the 33 workshop participants, representing 23 organisations as key factors determining success of transdisciplinary work. Fragmentation, lack of research-based and practice-based evidence, limited transdisciplinary knowledge amongst sectoral stakeholders, short-term funding and lack of knowledge-sharing mechanisms were identified as barriers, often creating systematic problems for successful implementation. Stakeholders suggested methods to bring about success included: improved knowledge, both amongst policy-makers and implementers, of food security and its linkage with nutrition, household environments, health and hygiene; investment in collaborative practice-based research and evidence-based practice; and strengthened transdisciplinary collaboration between multi-stakeholders, such as researchers, implementers and beneficiaries, throughout the intervention development and implementation process. CONCLUSIONS: This study suggests that multisector approach needs to adapt to take into account the experiences and views of the stakeholders concerned. The paper offers recommendations for successful development and implementation of future multisector interventions in Nepal that can be extrapolated to other low and middle-income countries, and lays foundations for future transdisciplinary working to support realisation of the recommendations.

'I didn't think you were allowed that, they didn't mention that.' A qualitative study exploring women's perceptions of home birth.

BACKGROUND: Evidence suggests that home birth is as safe as hospital birth for low risk multiparous women, and is associated with reduced intervention rates and increased rates of normal birth. However the home birth rate in the UK is low, and few women choose this option. The aims of this study were to identify what influences multiparous women's choice of birth place, and to explore their views of home birth. METHODS: Five focus groups were conducted with multiparous women (n = 28) attending mother and baby groups in a city in the UK with a diverse multi-ethnic population. Data were analysed thematically using the Framework Method, combining deductive and inductive approaches to the data. RESULTS: Several themes were developed from the data, these were: the expectation that birth would take place in an Obstetric Unit; perceptions of birth as a 'natural' event; lack of knowledge of what home birth looked like; and a lack of confidence in the reliability of the maternity service. Two themes emerged regarding the influences on women's choices: clear information provision, particularly for those from ethnic minority groups, and the role of health care professionals. A final theme concerned women's responses to the offer of choice. CONCLUSIONS: There are gaps in women's knowledge about the reality and practicalities of giving birth at home that have not been previously identified. Other findings are consistent with existing evidence, suggesting that many women still do not receive consistent, comprehensive information about home birth. The findings from this research can be used to develop approaches to meet women's information and support needs, and facilitate genuine choice of place of birth.

Early intervention in psychosis: From clinical intervention to health system implementation.

AIM: Early intervention in psychosis (EIP) is a well-established approach with the intention of early detection and treatment of psychotic disorders. Its clinical and economic benefits are well documented. This paper presents basic aspects of EIP services, discusses challenges to their implementation and presents ideas and strategies to overcome some of these obstacles. METHODS: This paper is a narrative review about the evidence supporting EIP, with examples of successful implementation of EIP and of cases where major obstacles still need to be overcome. RESULTS: Experience from successfully implemented EIP services into the mental healthcare system have generated evidence, concepts and specific strategies that might serve as guidance or inspiration in other countries or systems where EIP is less well developed or not developed at all. Previous experience has made clear that evidence of clinical benefits alone is not enough to promote implementation, as economic arguments and political and social pressure have shown to be important elements in efforts to achieve implementation. CONCLUSIONS: Users' narratives, close collaboration with community organizations and support from policy-makers and known people within the community championing early intervention (EI) services are just a few of the approaches that should be considered in campaigns for implementation of EI services. Fast progress in implementation is possible.

The economic impact of early intervention in psychosis services for children and adolescents.

AIMS: To develop and populate a plausible model of the impact of early intervention (EI) for children and adolescents with psychosis to estimate potential short-term health-related cost savings compared to generic Child and Adolescent Mental Health Services (CAMHS). METHOD: A decision-tree-based model for EI in CAMHS was developed. The model was populated using data relating to the use of inpatient care and EI service activity for people aged under 18 from an area of North East England. Data were abstracted from the National Health Service clinical reporting systems for 2001-2008. Sensitivity analyses were performed to examine costs associated with the model under differing assumptions. RESULTS: EI delivered cost savings of £4814 per patient compared to care provided by generic CAMHS. Cost savings were predominantly a consequence of reduced length of hospital admissions for patients served by the EI team. The findings were robust to sensitivity analyses. CONCLUSIONS: These findings suggest that EI services for children and adolescents with psychosis provide potential direct health cost savings comparable to those observed for working-age adults.

Importance of effective collaboration between health professionals for the facilitation of optimal community diabetes care.

Diabetes places a significant burden on the individuals concerned, their families and society as a whole. The debilitating sequelae of diabetes can be limited or prevented altogether through strict glycaemic control. Despite the seemingly uncomplicated nature of the disorder, effective management can be elusive, as the impact of having to deal with diabetes on a daily basis can be profound and appropriate professional support is not always readily available. As the roles of general practitioners (GPs) and allied health professionals have evolved, a major issue now facing all is that of developing and maintaining effective collaborative relationships for the facilitation of optimal community diabetes care. Using a simple survey methodology, the present exploratory study investigated the referral patterns of GPs to diabetic educators (DEs) working for a community health service in an Australian town, and reasons for referral and non-referral in order to identify factors that contribute to a sound and sustainable collaborative relationship. The results provide some evidence that GPs and DEs in this town do work collaboratively towards achieving client-centred goals and highlight the need to inform GPs who are new to communities, such as this one, of the available DE services. Most importantly, the study identified that there are many opportunities to strengthen collaboration so as to facilitate optimal community diabetes care. This information is valuable, because there is limited empirical evidence either nationally or internationally about the process of collaboration between health professionals in the management of chronic diseases, such as diabetes.

First episode psychosis and employment: a review.

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.

Greenhouse gas mitigation in agriculture.

Agricultural lands occupy 37% of the earth's land surface. Agriculture accounts for 52 and 84% of global anthropogenic methane and nitrous oxide emissions. Agricultural soils may also act as a sink or source for CO2, but the net flux is small. Many agricultural practices can potentially mitigate greenhouse gas (GHG) emissions, the most prominent of which are improved cropland and grazing land management and restoration of degraded lands and cultivated organic soils. Lower, but still significant mitigation potential is provided by water and rice management, set-aside, land use change and agroforestry, livestock management and manure management. The global technical mitigation potential from agriculture (excluding fossil fuel offsets from biomass) by 2030, considering all gases, is estimated to be approximately 5500-6000Mt CO2-eq.yr-1, with economic potentials of approximately 1500-1600, 2500-2700 and 4000-4300Mt CO2-eq.yr-1 at carbon prices of up to 20, up to 50 and up to 100 US$ t CO2-eq.-1, respectively. In addition, GHG emissions could be reduced by substitution of fossil fuels for energy production by agricultural feedstocks (e.g. crop residues, dung and dedicated energy crops). The economic mitigation potential of biomass energy from agriculture is estimated to be 640, 2240 and 16 000Mt CO2-eq.yr-1 at 0-20, 0-50 and 0-100 US$ t CO2-eq.-1, respectively.

Ecosystem service supply and vulnerability to global change in Europe.

Global change will alter the supply of ecosystem services that are vital for human well-being. To investigate ecosystem service supply during the 21st century, we used a range of ecosystem models and scenarios of climate and land-use change to conduct a Europe-wide assessment. Large changes in climate and land use typically resulted in large changes in ecosystem service supply. Some of these trends may be positive (for example, increases in forest area and productivity) or offer opportunities (for example, "surplus land" for agricultural extensification and bioenergy production). However, many changes increase vulnerability as a result of a decreasing supply of ecosystem services (for example, declining soil fertility, declining water availability, increasing risk of forest fires), especially in the Mediterranean and mountain regions.