Experiences of Non-Pharmaceutical Primary Care Interventions for Common Mental Health Disorders in Socioeconomically Disadvantaged Groups: A Systematic Review of Qualitative Studies.

Common mental health disorders (CMDs) disproportionately affect people experiencing socioeconomic disadvantage. Non-pharmaceutical interventions, such as 'social prescribing' and new models of care and clinical practice, are becoming increasingly prevalent in primary care. However, little is known about how these interventions work and their impact on socioeconomic inequalities in health. Focusing on people experiencing socioeconomic disadvantage, this systematic review aims to: (1) explore the mechanisms by which non-pharmaceutical primary care interventions impact CMD-related health outcomes and inequalities; (2) identify the barriers to, and facilitators of, their implementation in primary care. This study is a systematic review of qualitative studies. Six bibliographic databases were searched (Medline, ASSIA, CINAHL, Embase, PsycInfo and Scopus) and additional grey literature sources were screened. The included studies were thematically analysed. Twenty-two studies were included, and three themes were identified: (1) agency; (2) social connections; (3) socioeconomic environment. The interventions were experienced as being positive for mental health when people felt a sense of agency and social connection. The barriers to effectiveness and engagement included socioeconomic deprivation and underfunding of community sector organisations. If non-pharmaceutical primary care interventions for CMDs are to avoid widening health inequalities, key socioeconomic barriers to their accessibility and implementation must be addressed.

Non-pharmaceutical primary care interventions to improve mental health in deprived populations: a systematic review.

BACKGROUND: Common mental health disorders are especially prevalent among people from socioeconomically disadvantaged backgrounds. Non-pharmaceutical primary care interventions, such as social prescribing and collaborative care, provide alternatives to pharmaceutical treatments for common mental health disorders, but little is known about the impact of these interventions for patients who are socioeconomically disadvantaged. AIM: To synthesise evidence for the effects of non-pharmaceutical primary care interventions on common mental health disorders and associated socioeconomic inequalities. DESIGN AND SETTING: Systematic review of quantitative primary studies published in English and undertaken in high-income countries. METHOD: Six bibliographic databases were searched and additional grey literature sources screened. Data were extracted onto a standardised proforma and quality assessed using the Effective Public Health Practice Project tool. Data were synthesised narratively and effect direction plots were produced for each outcome. RESULTS: Thirteen studies were included. Social-prescribing interventions were evaluated in 10 studies, collaborative care in two studies, and a new model of care in one study. Positive results (based on effect direction) were reported for the impact of the interventions on wellbeing in groups that were socioeconomically deprived. Inconsistent (mainly positive) results were reported for anxiety and depression. One study reported that people from the group with least deprivation, compared with the group with greatest deprivation, benefitted most from these interventions. Overall, study quality was weak. CONCLUSION: Targeting non-pharmaceutical primary care interventions at areas of socioeconomic deprivation may help to reduce inequalities in mental health outcomes. However, only tentative conclusions can be drawn from the evidence in this review and more-robust research is required.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review.

BACKGROUND: Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients. OBJECTIVE: To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021. REVIEW METHODS: A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements. RESULTS: Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer. LIMITATIONS: The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered. CONCLUSIONS: Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults. FUTURE WORK: Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness. STUDY REGISTRATION: This study is registered as PROSPERO CRD42020170906. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

WHAT WAS THE QUESTION?: Malnutrition, in the form of undernutrition, is very common in frail older people. Dietary advice is recommended (e.g. adding nutrients to meals) for older adults who are malnourished, while powdered or liquid supplements (oral nutritional supplements) can be prescribed to those who are malnourished or at risk of becoming malnourished. In this study, we reviewed previous studies to see if oral nutritional supplements (as a form of dietary support) work at reducing malnutrition in frail older adults and whether or not they are value for money. WHAT DID WE DO?: We searched for studies up to September 2021 on frail older people who were at risk of malnutrition or were malnourished in care homes, hospitals or the community in any country. We included studies that measured malnutrition and the consequences of malnutrition, quality of life, survival, costs and hospitalisations. We assessed the difference in malnutrition between those receiving oral nutritional supplements and those receiving usual care or other dietary (or nutritional) interventions. We also looked at the value for money of oral nutritional supplements. WHAT DID WE FIND?: We found 12 studies (11 studies looking at whether the supplements worked and one study looking at value for money). Most of which were of low quality, and many were funded by industry. Studies often did not report on longer-term effects, or how older people felt about the supplements. There was no clear or strong evidence that oral nutritional supplements worked or were value for money in reducing malnutrition or its consequences (such as the ability to perform everyday tasks). WHAT DOES THIS MEAN?: There is weak evidence for oral nutritional supplements in frail older adults. Future high-quality studies should be independent, assess longer-term effects, and have better reporting on factors that influence the impacts of oral nutritional supplements.

Effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk of malnutrition: a systematic review and meta-analysis.

BACKGROUND: Current management of malnutrition can include prescribed oral nutritional supplements (ONS); however, there is uncertainty whether these supplements are effective in people who are older (≥65 years) and frail. We assessed the effectiveness, cost-effectiveness, and adherence and acceptability of ONS in frail older people who are malnourished or at risk of malnutrition. METHODS: In this systematic review and meta-analysis, five bibliographic databases (MEDLINE, EMBASE, Cochrane Library, Scopus, and CINAHL) and grey literature sources were searched from inception to Sept 13, 2021, to identify studies assessing the effectiveness and cost-effectiveness of ONS (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. Multiple reviewers independently did study screening, data extraction, and risk of bias assessment. Quality was assessed using version 1.0 of the Cochrane risk of bias tool for randomised controlled trials (RCTs), and the BMJ Drummond checklist was used to assess the quality of the included cost-effectiveness study. A meta-analysis was done for the effectiveness review; for the other reviews, a narrative synthesis approach was used. This systematic review and meta-analysis was registered on PROSPERO, CRD42020170906. FINDINGS: Of 8492 records retrieved and screened, we included 11 RCTs involving 822 participants, six of which were fully or partly funded by industry. For the majority of the outcomes for which meta-analyses were possible (11/12), Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessments suggested that the evidence was of very low certainty. Results suggested that ONS might have a slightly positive effect on energy (kcal) intake (standardised mean difference 1·02 [95% CI 0·15 to 1·88]; I2=87%; four studies), protein intake (standardised mean difference 1·67 [-0·03 to 3·37; I2=97%; four studies), and mobility (mean difference 0·03 [0·02 to 0·04]; I2=0%; four studies), compared with standard care. Narrative syntheses suggested that the effect of ONS on quality of life, compared with standard care, was mixed. In the identified studies, there was very little information related to active components, determinants, or acceptability of interventions. One economic evaluation, done in a care home setting, showed that ONS could be cost-effective. INTERPRETATION: We found little evidence of ONS reducing malnutrition or its associated adverse outcomes in older people who are frail. High-quality, non-industry-funded, adequately powered studies reporting on short-term and long-term health outcomes, determinants, and participant characteristics are needed. FUNDING: UK National Institute of Health and Care Research (NIHR) Health Technology Assessment (NIHR128729).

Which Non-Pharmaceutical Primary Care Interventions Reduce Inequalities in Common Mental Health Disorders? A Protocol for a Systematic Review of Quantitative and Qualitative Studies.

Common mental health disorders (CMDs) represent a major public health concern and are particularly prevalent in people experiencing disadvantage or marginalisation. Primary care is the first point of contact for people with CMDs. Pharmaceutical interventions, such as antidepressants, are commonly used in the treatment of CMDs; however, there is concern that these treatments are over-prescribed and ineffective for treating mental distress related to social conditions. Non-pharmaceutical primary care interventions, such as psychological therapies and "social prescribing", provide alternatives for CMDs. Little is known, however, about which such interventions reduce social inequalities in CMD-related outcomes, and which may, unintentionally, increase them. The aim of this protocol (PROSPERO registration number CRD42021281166) is to describe how we will undertake a systematic review to assess the effects of non-pharmaceutical primary care interventions on CMD-related outcomes and social inequalities. A systematic review of quantitative, qualitative and mixed-methods primary studies will be undertaken and reported according to the PRISMA-Equity guidance. The following databases will be searched: Assia, CINAHL, Embase, Medline, PsycInfo and Scopus. Retrieved records will be screened according to pre-defined eligibility criteria and synthesised using a narrative approach, with meta-analysis if feasible. The findings of this review will guide efforts to commission more equitable mental health services.

Powered mobility interventions for very young children with mobility limitations to aid participation and positive development: the EMPoWER evidence synthesis.

BACKGROUND: One-fifth of all disabled children have mobility limitations. Early provision of powered mobility for very young children (aged < 5 years) is hypothesised to trigger positive developmental changes. However, the optimum age at which to introduce powered mobility is unknown. OBJECTIVE: The aim of this project was to synthesise existing evidence regarding the effectiveness and cost-effectiveness of powered mobility for very young children, compared with the more common practice of powered mobility provision from the age of 5 years. REVIEW METHODS: The study was planned as a mixed-methods evidence synthesis and economic modelling study. First, evidence relating to the effectiveness, cost-effectiveness, acceptability, feasibility and anticipated outcomes of paediatric powered mobility interventions was reviewed. A convergent mixed-methods evidence synthesis was undertaken using framework synthesis, and a separate qualitative evidence synthesis was undertaken using thematic synthesis. The two syntheses were subsequently compared and contrasted to develop a logic model for evaluating the outcomes of powered mobility interventions for children. Because there were insufficient published data, it was not possible to develop a robust economic model. Instead, a budget impact analysis was conducted to estimate the cost of increased powered mobility provision for very young children, using cost data from publicly available sources. DATA SOURCES: A range of bibliographic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence (OTseeker), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO, Science Citation Index (SCI; Clarivate Analytics, Philadelphia, PA, USA), Social Sciences Citation Index™ (SSCI; Clarivate Analytics), Conference Proceedings Citation Index - Science (CPCI-S; Clarivate Analytics), Conference Proceedings Citation Index - Social Science & Humanities (CPCI-SSH; Clarivate Analytics), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database and OpenGrey] was systematically searched and the included studies were quality appraised. Searches were carried out in June 2018 and updated in October 2019. The date ranges searched covered from 1946 to September 2019. RESULTS: In total, 89 studies were included in the review. Only two randomised controlled trials were identified. The overall quality of the evidence was low. No conclusive evidence was found about the effectiveness or cost-effectiveness of powered mobility in children aged either < 5 or ≥ 5 years. However, strong support was found that powered mobility interventions have a positive impact on children's movement and mobility, and moderate support was found for the impact on children's participation, play and social interactions and on the safety outcome of accidents and pain. 'Fit' between the child, the equipment and the environment was found to be important, as were the outcomes related to a child's independence, freedom and self-expression. The evidence supported two distinct conceptualisations of the primary powered mobility outcome, movement and mobility: the former is 'movement for movement's sake' and the latter destination-focused mobility. Powered mobility should be focused on 'movement for movement's sake' in the first instance. From the budget impact analysis, it was estimated that, annually, the NHS spends £1.89M on the provision of powered mobility for very young children, which is < 2% of total wheelchair service expenditure. LIMITATIONS: The original research question could not be answered because there was a lack of appropriately powered published research. CONCLUSIONS: Early powered mobility is likely to have multiple benefits for very young children, despite the lack of robust evidence to demonstrate this. Age is not the key factor; instead, the focus should be on providing developmentally appropriate interventions and focusing on 'movement for movement's sake'. FUTURE WORK: Future research should focus on developing, implementing, evaluating and comparing different approaches to early powered mobility. STUDY REGISTRATION: This study is registered as PROSPERO CRD42018096449. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 50. See the NIHR Journals Library website for further project information.

The aim of this study was to find out the benefits and costs of providing very young children, aged < 5 years, with powered mobility devices. Examples of powered mobility devices are electrically powered wheelchairs and modified ride-on toys. We looked at many research papers about children and powered mobility. We found many benefits of powered mobility. We then combined all of the information to see if using powered mobility before the age of 5 years had any specific benefits for children. The evidence tells us that powered mobility has a positive effect on children's movement, and it can boost children's social interactions with other people, and their independence. Children using powered mobility were able to go to their friends by themselves, move around a play space as they wanted and take part in physical activities and games. We found that the fit between the child, the powered mobility device and the child's everyday environment was important. When the fit was not good, children experienced a lot of problems. Some children and families felt that powered mobility did not suit their needs, leading to children using a manual wheelchair instead and thereby missing out on education, social opportunities and play. Barriers to powered mobility were found in the physical environment (e.g. inaccessible buildings) and the social environment (e.g. adults supervising children too closely) and often affected children's independence. We found that the advantages and disadvantages of powered mobility were similar in younger and older children, even though the activities they took part in were different. We also found that each year the NHS spends < 2% of its wheelchair service budget on powered mobility for very young children. In conclusion, powered mobility can benefit very young children, but it requires a good fit with the child's environment.

Socioeconomic and behavioural risk factors for adverse winter health and social outcomes in economically developed countries: a systematic review of quantitative observational studies.

BACKGROUND: Mortality and morbidity rates are often highest during the winter period, particularly in countries with milder climates. A growing body of research has identified potential socioeconomic, housing and behavioural mediators of cold weather-related adverse health and social outcomes, but an inclusive systematic review of this literature has yet to be performed. METHODS: A systematic review, with narrative synthesis, of observational research published in English between 2001 and 2011, which quantified associations between socioeconomic, housing or behavioural factors and cold weather-related adverse health or social outcomes. RESULTS: Thirty-three studies met the inclusion criteria. Average study quality was not high. Most studies failed to control for all relevant confounding factors, or to conduct research over a long enough period to ascertain causality. Low income, housing conditions and composite fuel poverty measures were most consistently associated with cold weather-related adverse health or social outcomes. CONCLUSIONS: This review identified socioeconomic, housing and behavioural factors associated with a range of cold weather-related adverse health or social outcomes. Only tentative conclusions can be drawn due to the limitations of existing research. More robust studies are needed to address the methodological issues identified and uncover causal associations. A review of qualitative and intervention studies would help to inform policies to reduce the adverse health and social impacts of cold weather.