Cost-utility and cost consequence of a telehealth intervention targeting improvement in addictive eating for Australian adults (the TRACE program).

BACKGROUND: The TRACE (Targeted Research for Addictive and Compulsive Eating) intervention was evaluated in a 3-month randomized controlled trial which demonstrated significant improvement in Yale Food Addiction Scale scores favoring dietitian-led telehealth (active intervention) compared with passive and control groups. This study aimed to determine intervention costs and cost-utility. METHODS: Costs of each intervention (2021$AUD) and incremental net monetary benefit (iNMB; incremental benefit, defined as Quality-Adjusted Life Years (QALY) gained, multiplied by willingness to pay threshold minus incremental cost) were calculated to estimate differences between groups. RESULTS: The active intervention (n = 38) cost $294 (95% UI: $266, $316) per person compared to $47 (95% UI: $40, $54) in the passive intervention (n = 24), and $26 in the control group (n = 37). At a cost-effectiveness threshold of $50 000 per QALY score gained, the active intervention iNMB was -$186 (95% UI: -$1137, $834) and the passive group $127 (95% UI: -$1137, $834). Compared to the control group, estimates indicate a 30% chance of the active intervention, and a 60% chance of the passive intervention being cost effective. CONCLUSION: Although the overall cost of the active intervention was low, this was not considered cost-effective in comparison to the passive intervention, given small QALY score gains. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ACTRN12621001079831.

QuitNic: A Pilot Randomized Controlled Trial Comparing Nicotine Vaping Products With Nicotine Replacement Therapy for Smoking Cessation Following Residential Detoxification.

INTRODUCTION: The QuitNic pilot trial aimed to test the feasibility of providing a nicotine vaping product (NVP) compared with combination nicotine replacement therapy (NRT) to smokers upon discharge from a smoke-free residential substance use disorder (SUD) treatment service. METHODS: QuitNic was a pragmatic two-arm randomized controlled trial. At discharge from residential withdrawal, 100 clients received telephone Quitline behavioral support and either 12-week supply of NRT or an NVP. Treatment adherence and acceptability, self-reported abstinence, cigarettes smoked per day (CPD), frequency of cravings, and severity of withdrawal symptoms were assessed at 6 and 12 weeks. Results are reported for complete cases and for abstinence outcomes, penalized imputation results are reported where missing is assumed smoking. RESULTS: Retention on was 63% at 6 weeks and 50% at 12 weeks. At 12 weeks, 68% of the NRT group reported using combination NRT while 96% of the NVP group used the device. Acceptability ratings for the products were high in both groups. At 12 weeks, 14% of the NVP group and 18% of the NRT group reported not smoking at all in the last 7 days. Mean CPD among continued smokers decreased significantly between baseline to 12 weeks in both groups; from 19.91 to 4.72 for the NVP group (p < .001) and from 20.88 to 5.52 in the NRT group (p < .001). Cravings and withdrawal symptoms significantly decreased for both groups. CONCLUSIONS: Clients completing residential withdrawal readily engaged with smoking cessation post-treatment when given the opportunity. Further research is required to identify the most effective treatments postwithdrawal for this population at elevated risk of tobacco-related harm. TRIAL REGISTRATION NUMBER: ACTRN12617000849392. IMPLICATIONS: This pilot study showed that smoking cessation support involving options for nicotine replacement and Quitline-delivered cognitive behavioral counseling is attractive to people after they have been discharged from SUD treatment. Both nicotine vaping products and nicotine replacement therapies were highly acceptable and used by participants who reported reductions in cravings for cigarettes and perceptions of withdrawal symptoms and reductions in number of cigarettes smoked. Some participants self-reported abstinence from cigarettes-around one in five reported having quit smoking cigarettes at 12 weeks postdischarge. The results have significant public health implications for providing quit support following discharge from SUD treatment.

Self-reported suboptimal sleep and receipt of sleep assessment and treatment among persons with and without a mental health condition in Australia: a cross sectional study.

BACKGROUND: Poor sleep and poor mental health go hand in hand and, together, can have an adverse impact on physical health. Given the already disproportionate physical health inequities experienced by people with a mental health condition worldwide, the need to consider and optimise sleep has been highlighted as a means of improving both physical and mental health status. Sleep recommendations recently developed by the United States' National Sleep Foundation incorporate a range of sleep parameters and enable the identification of 'suboptimal' sleep. Among community-dwelling persons with and without a 12-month mental health condition in Australia, this study reports: [1] the prevalence of 'suboptimal' sleep and [2] rates of sleep assessment by a health care clinician/service and receipt of and desire for sleep treatment. METHODS: A descriptive study (N = 1265) was undertaken using self-report data derived from a cross-sectional telephone survey of Australian adults, undertaken in 2017. RESULTS: Fifteen per cent (n = 184) of participants identified as having a mental health condition in the past 12 months. Across most (7 of 8) sleep parameters, the prevalence of suboptimal sleep was higher among people with a mental health condition, compared to those without (all p < 0.05). The highest prevalence of suboptimal sleep for both groups was seen on measures of sleep duration (36-39% and 17-20% for people with and without a mental health condition, respectively). In terms of sleep assessment and treatment, people with a mental health condition were significantly more likely to: desire treatment (37% versus 16%), have been assessed (38% versus 12%) and have received treatment (30% versus 7%). CONCLUSIONS: The prevalence of suboptimal sleep among persons with a mental health condition in Australia is significantly higher than those without such a condition, and rates of assessment and treatment are low for both groups, but higher for people with a mental health condition. Population health interventions, including those delivered as part of routine health care, addressing suboptimal sleep are needed.

Systematic review and meta-analysis of the prevalence of smokeless tobacco consumption among adults in Bangladesh, India and Myanmar.

OBJECTIVE: To estimate the pooled prevalence of smokeless tobacco consumption (STC) by gender and location in Bangladesh, India and Myanmar and to identify periodic changes in STC prevalence using data extracted from published studies. METHODS: We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. We undertook a meta-analysis to estimate pooled prevalence and confidence intervals within these countries. To compare periodic changes in STC prevalence, we grouped studies into five-year periods (2000-2004, 2005-2009, 2010-2014 and 2015-2019). RESULTS: The pooled estimates of STC prevalence were 25% (95% CI: 22-28%), 22% (95% CI: 15-28%) and 21% (95% CI: 14-28%) for Bangladesh, India and Myanmar, respectively. In pooled estimates across these countries, we found higher STC prevalence for men (30%; 95% CI: 24-35%) than women (16%; 95% CI: 10-23%) and for rural dwellings (24%; 95% CI: 18-31%) than urban dwellings (17%; 95% CI: 10-24%). We found significant decrease in STC in Bangladesh and India in the period 2010-2014 and 2015-2019, respectively. In Myanmar, STC prevalence increased significantly and substantially in 2010-2014, to levels higher than in Bangladesh and India. CONCLUSIONS: The prevalence of STC in Bangladesh, India and Myanmar is highest in rural areas and among men. Public health prevention strategies are needed to maintain decrease in STC in Bangladesh and India, and to reverse the increased use in Myanmar.

OBJECTIF: Estimer la prévalence poolée de la consommation de tabac sans fumée (CTSF) par sexe et lieu au Bangladesh, en Inde et au Myanmar et identifier les changements périodiques de la prévalence des CTSF à l'aide de données extraites d'études publiées. MÉTHODES: Nous avons recherché une combinaison de mots-clés dans les bases de données électroniques et utilisé un formulaire standard pour extraire les données de chaque article. Nous avons entrepris une méta-analyse pour estimer la prévalence poolée et les intervalles de confiance dans ces pays. Pour comparer les changements périodiques de la prévalence des CTSF, nous avons regroupé les études en périodes de cinq ans (2000-2004, 2005-2009, 2010-2014, 2015-2019). RÉSULTATS: Les estimations poolées de la prévalence des CTSF étaient de 25% (IC95%: 22-28%), 22% (IC95%: 15-28%) et 21% (IC95%: 14-28%) pour le Bangladesh, l'Inde et le Myanmar, respectivement. Dans les estimations poolées de ces pays, nous avons constaté une prévalence des CTSF plus élevée pour les hommes (30%; IC95%: 24-35%) que pour les femmes (16%; IC95%: 10-23%) et pour les habitations rurales (24%; IC95%: 18-31%) que les habitations urbaines (17%; IC95%: 10-24%). Nous avons constaté une diminution significative des CTSF au Bangladesh et en Inde au cours de la période 2010-2014 et 2015-2019 respectivement. Au Myanmar, la prévalence des CTSF a augmenté de manière significative et substantielle en 2010-2014, à des niveaux plus élevés qu'au Bangladesh et en Inde. CONCLUSIONS: La prévalence des CTSF au Bangladesh, en Inde et au Myanmar est la plus élevée dans les zones rurales et chez les hommes. Des stratégies de prévention de la santé publique sont nécessaires pour maintenir la diminution des CTSF au Bangladesh et en Inde et pour inverser l'augmentation de la consommation au Myanmar.

Impact of Perinatal Depression and Anxiety on Birth Outcomes: A Retrospective Data Analysis.

OBJECTIVES: During the perinatal period, 10-20% of women experience anxiety and/or depression. Untreated perinatal depression has the potential for adverse effects on the family and infant resulting in long-term deleterious consequences. This study measured the association between self-reported depression using the Edinburgh Postnatal Depression Scale scores, self-reported anxiety and neonatal birth outcomes. METHODS: A retrospective design was used with ObstetriX™ data retrieved from 16 metropolitan and rural hospitals in NSW, Australia during 2009-2014. Data were available for 53,646 singleton births. The Edinburgh Postnatal Depression Scale was used to identify self-reported depression while women self-reported pregnancy related anxiety. Regression modelling measured the effects of self-reported depression and self-reported pregnancy related anxiety on neonatal birth outcomes. Linear regression and logistic regression were used to model the effect on birth weight, gestational age, admission to NICU or the SCN, outcome (stillborn vs livebirth), and Apgar scores. Cox proportional hazards regression was used to estimate the effect on neonatal length of stay. RESULTS: Babies born to women self-reporting anxiety were more likely to have birth complications, be admitted to the nursery, had lower Apgar scores and longer hospital stays. Babies born to women self-identifying as experiencing a level of depression were more likely to have a lower birth weight, shorter gestational age, and, lower Apgar score. These babies were more likely to be admitted to the nursery with an increased length of stay. CONCLUSIONS: Perinatal anxiety and depression contribute to poor birth outcomes. Early detection of maternal perinatal anxiety and depression is an important step towards treatment interventions. More research is needed to identify models of care that are effective in identifying and managing perinatal depression and anxiety to improve birth outcomes for women and their babies.

An online cross-sectional survey of the health risk behaviours among informal caregivers.

ISSUE ADDRESSED: Informal caregivers may experience unique barriers to engaging in healthy lifestyles, consequently increasing their risk of chronic disease. Among a convenience sample of informal caregivers, this study aimed to: (a) assess the self-reported health risk behaviours of low fruit and vegetable consumption, low physical activity, current smoking and hazardous alcohol consumption; (b) examine the demographic, caree condition and country of residence variables associated with each health risk behaviour; and (c) report the engagement in multiple health risk behaviours. METHODS: An online cross-sectional survey among caregivers in Australia, Canada, New Zealand, the United Kingdom and the United States was conducted. Self-reported health risk behaviours were assessed and compared to key Australian healthy living guidelines. Logistic regression modelling identified participant factors associated with each health risk behaviour. RESULTS: Overall, 384 caregivers were included in the analysis. Hazardous alcohol consumption was the only self-reported health risk behaviour which was much higher than in the general population (60.0%). Caregiver age (P = .018) and country of residence (P = .015) were associated with hazardous alcohol consumption. A majority of caregivers reported engaging in three health risk behaviours (55.0%). CONCLUSIONS: Caregivers are engaging in a range of health risk behaviours; however, rates of hazardous alcohol consumption among the sample were high. Health promotion interventions targeted to address alcohol consumption should consider caregiver age and country of residence. SO WHAT?: This study highlights the health risk behaviours caregivers engage in across a number of countries, and suggests that caregivers require further support to manage alcohol consumption in particular.

The Support for New Mums Project: A protocol for a pilot randomized controlled trial designed to test a postnatal psychoeducation smartphone application.

AIM: To report a pilot trial protocol for testing the effectiveness of the Support for New Mums smartphone application in a cohort of first-time mothers. DESIGN: A pilot/feasibility randomized controlled trial using a two-group pre-test and repeated post-test design. METHOD: This protocol follows the Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT) guidelines. The Intervention group will receive access to the smartphone application for 6 weeks post birth. Both Intervention and control groups will receive standardized institutional postnatal care services. Trial funding was gained from respective grant sponsors in May and November 2016. DISCUSSION: The Support for New Mums smartphone application could be a novel method for addressing the gap in provision of postpartum care services providing psychoeducation and improving maternal parental self-efficacy for Australian childbearing women. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001580268.

ß-Endorphin neuronal transplantation into the hypothalamus alters anxiety-like behaviors in prenatal alcohol-exposed rats and alcohol-non-preferring and alcohol-preferring rats.

BACKGROUND: Alcohol exposure has adverse effects on stress physiology and behavioral reactivity. This is suggested to be due, in part, to the effect of alcohol on ß-endorphin (ß-EP)-producing neurons in the hypothalamus. In response to stress, ß-EP normally provides negative feedback to the hypothalamic-pituitary-adrenal axis and interacts with other neurotransmitter systems in the amygdala to regulate behavior. We examined whether ß-EP neuronal function in the hypothalamus reduces the corticosterone response to acute stress, attenuates anxiety-like behaviors, and modulates alcohol drinking in rats. METHODS: To determine whether ß-EP neuronal transplants modulate the stress response, anxiety behavior, and alcohol drinking, we implanted differentiated ß-EP neurons into the paraventricular nucleus (PVN) of the hypothalamus of normal, prenatal alcohol-exposed, and alcohol-preferring (P) and alcohol-non-preferring (NP) rats. We then assessed corticosterone levels in response to acute restraint stress and other markers of stress response in the brain and anxiety-like behaviors in the elevated plus maze and open-field assays. RESULTS: We showed that ß-EP neuronal transplants into the PVN reduced the peripheral corticosterone response to acute stress and attenuated anxiety-like behaviors. Similar transplants completely reduced the hypercorticosterone response and elevated anxiety behaviors in prenatal alcohol-exposed adult rats. Moreover, we showed that ß-EP reduced anxiety behavior in P rats with minimal effects on alcohol drinking during and following restraint stress. CONCLUSIONS: These data further establish a role of ß-EP neurons in the hypothalamus for regulating physiological stress response and anxiety behavior and resemble a potential novel therapy for treating stress-related psychiatric disorders in prenatal alcohol-exposed children and those genetically predisposed to increased alcohol consumption.

Barriers and enablers to addressing smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) as part of antenatal care: A mixed methods systematic review.

BACKGROUND: International clinical guidelines recommend that smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) be addressed as part of routine antenatal care throughout pregnancy. However, guideline recommendations are poorly implemented, and few antenatal care recipients routinely receive the recommended care. There is a need to establish the determinants (barriers and enablers) to care delivery to inform strategies to improve implementation. This systematic review aimed to synthesize qualitative and quantitative evidence of the barriers and enablers to the routine delivery of antenatal care targeting SNAP-W health risks. METHODS: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seven databases were searched for relevant studies published between January 2001 and November 2023. Study findings were coded and analysed according to the domains of the Theoretical Domains Framework (TDF). RESULTS: Forty-nine studies were included in the review, 27 qualitative studies and 22 quantitative studies. The studies were conducted in 14 countries. Data were collected from 7146 antenatal care providers (midwives, Aboriginal health workers, obstetricians, medical officers, general practitioners) and 352 barriers and enablers were identified. Across all SNAP-W health risk and antenatal care provider groups, the predominant TDF domain was 'environmental context and resources', identified in 96% of studies. Barriers within this domain included insufficient time, limited access to and quality of resources, and limited organisational supports. 'Beliefs about consequences' was the second most common TDF domain, reported in 67% of studies, particularly studies of care related to alcohol use, nutrition/ physical activity/ gestational weight gain and those involving midwives, multidisciplinary practitioners and general practitioners. 'Optimism' was the second most common TDF domain for studies of smoking-related care and involving obstetricians, gynaecologists, and other mixed medical professions. CONCLUSIONS: It is critical that determinants related to environmental context and resources including time, resources and organisational supports are considered in the development of strategies to support the implementation of recommended antenatal care related to SNAP-W risks. Strategies addressing clinician beliefs about consequences and optimism may also be needed to support the implementation of care related to specific health behaviours and by specific antenatal care provider groups. REGISTRATION: The review protocol was prospectively registered with Prospero: CRD42022353084; 22 October 2022.

Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys.

INTRODUCTION: Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts. METHODS: Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group. RESULTS: In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015. DISCUSSION AND CONCLUSIONS: The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

Study protocol for an economic evaluation and budget impact of implementation strategies to support routine provision of antenatal care for gestational weight gain: a stepped-wedge cluster trial.

BACKGROUND: Antenatal clinical practice guidelines recommend routine assessment of weight and provision of advice on recommended weight gain during pregnancy and referral to additional services when appropriate. However, there are barriers to clinicians adopting such best-practice guidelines. Effective, cost-effective, and affordable implementation strategies are needed to ensure the intended benefits of guidelines are realised. This paper describes the protocol for evaluating the efficiency and affordability of implementation strategies compared to the usual practice in public antenatal services. METHOD: The prospective trial-based economic evaluation will identify, measure, and value key resource and outcome impacts arising from the implementation strategies compared with usual practice. The evaluation will comprise of (i) costing, (ii) cost-consequence analyses, where a scorecard approach will be used to show the costs and benefits given the multiple primary outcomes included in the trial, and (iii) cost-effectiveness analysis, where the primary outcome will be incremental cost per percent increase in participants reporting receipt of antenatal care for gestational weight gain consistent with the guideline recommendations. Affordability will be evaluated using (iv) budget impact assessment and will estimate the financial implications of adoption and diffusion of this implementation strategy from the perspective of relevant fund-holders. DISCUSSION: Together with the findings from the effectiveness trial, the outcomes of this economic evaluation will inform future healthcare policy, investment allocation, and research regarding the implementation of antenatal care to support healthy gestational weight gain. TRIAL REGISTRATION: Trial Registration: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 (22/01/2021) http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380680&isReview=true .

Barriers and facilitators to using vaporised nicotine products as smoking cessation aids among people receiving treatment for substance use disorder.

INTRODUCTION: Vaporised nicotine products (VNPs) may be useful smoking cessation aids for people in alcohol and other drug (AOD) treatment, a population with high tobacco-related morbidity and mortality rates. This qualitative study aimed to examine the barriers and facilitators of using VNPs as part of a clinical trial to reduce or quit smoking among people in AOD treatment. METHODS: Thirteen people in AOD treatment who were participating in a trial of VNPs for smoking cessation (QuitENDs) completed a brief semi-structured interview examining experiences of using VNPs to reduce or quit smoking. Transcribed data was analysed using the iterative categorisation framework. RESULTS: Many participants expressed the benefit of having a smoking cessation aid that addressed nicotine cravings and the behavioural hand-to-mouth action to help them reduce or quit smoking. Although many participants reported that VNPs were easy to use, some found maintaining the device to be challenging. Some participants described Australian regulations limiting use of VNPs as reducing their desire to use the device as a cessation aid. Many participants attempting to reduce or quit tobacco and cannabis simultaneously stated that VNPs alone were insufficient to help them reduce or quit tobacco. CONCLUSIONS: VNPs hold significant promise as smoking cessation aids among people in AOD treatment because of their unique ability to satisfy both nicotine cravings and behavioural habits. However, multiple barriers, such as accessibility, maintenance, and the challenges of reducing other substance use simultaneously also need to be addressed for optimal engagement in clinical trials with VNPs to quit smoking.

Exploring Support Provided by Community Managed Organisations to Address Health Risk Behaviours Associated with Chronic Disease among People with Mental Health Conditions: A Qualitative Study with Organisational Leaders.

People living with mental health conditions experience a significantly reduced life expectancy compared to people without, largely linked to health risk behaviours and associated chronic disease. Community managed organisations (CMOs) represent an important setting in which to address health risk behaviours among people with mental health conditions. However, little is known about how these behaviours (smoking, poor nutrition, alcohol consumption, inadequate physical activity, poor sleep: SNAPS) are being addressed in this setting. One-on-one, semi-structured telephone interviews were conducted with a sample of 12 senior staff, representing 12 CMOs in New South Wales, Australia to: (1) explore types of support provided by CMOs to address the SNAPS behaviours of consumers living with a mental health condition; and (2) assess perceived organisational and staff level barriers and facilitators to providing such support. Transcribed interviews were analysed using inductive thematic analysis. This study found there was a range of supports offered by CMOs, and these differed by health risk behaviour. Findings suggest CMOs are well-placed to embed SNAPS supports as a part of their service provision; however, available funding, consistency of supports, workplace policies and culture, collaboration with other available supports, staff training and education, all impacted capacity.

The long-term unmet needs of informal carers of stroke survivors at home: a systematic review of qualitative and quantitative studies.

AIM: To synthesise research describing the long-term unmet needs of carers who are providing care to a stroke survivor at home who is at least 3 months post-discharge. METHODS: A systematic review with a narrative synthesis of the English-language qualitative and quantitative studies identified from MEDLINE, CINAHL, PsycINFO, EMBASE, AMED, and Scopus was undertaken. RESULTS: Five quantitative studies, seven qualitative studies, and one mixed-method study were included in the review. Five themes of unmet needs were identified from the synthesis: (1) Obtaining adequate information, (2) Taking care of oneself, (3) Service accessibility, (4) Emotional and psychological, and (5) Relationship. Commonly reported needs across the 13 final studies included the need for support from health care and/or service providers, help with self-care, and help with coping and managing emotions. Variables associated with unmet needs included the severity of the stroke that the stroke survivor experienced and the length of hospital stay. CONCLUSIONS: Evidence from this review suggests that carers are experiencing a range of long-term unmet needs, particularly in education and training, coping and managing their own emotions, and accessing much-needed services. Recommendations to support carers at home include continuing engagement, assessment, and support from health care providers and services to meet the needs of carers throughout the stroke recovery process.IMPLICATIONS FOR REHABILITATIONCarers of stroke survivors experience complex long-term unmet needs around managing the recovery process of the stroke survivor when they have been discharged from hospital and returned home.Evidence suggests that continuing engagement and support from health care providers and services may assist carers in meeting their unmet needs.Healthcare professionals should provide help in accessing training and services.Support is required to help carers cope and to manage their emotions.

Systematic review of lifestyle interventions to improve weight, physical activity and diet among people with a mental health condition.

BACKGROUND: People with a mental health condition experience an elevated risk of chronic disease and greater prevalence of health and behaviours. Lifestyle interventions aim to reduce this risk by modifying health behaviours such as physical activity and diet. Previous reviews exploring the efficacy of such interventions for this group have typically limited inclusion to individuals with severe mental illness (SMI), with a focus of impact on weight. This review assessed the efficacy of lifestyle interventions delivered in community or outpatient settings to people with any mental health condition, on weight, physical activity and diet. METHODS: Eligible studies were randomised or cluster-randomised controlled trials published between January 1999 and February 2019 aiming to improve weight, physical activity or diet, for people with any mental health condition. Two reviewers independently completed study screening, data extraction and assessment of methodological quality. Primary outcome measures were weight, physical activity and diet. Secondary outcome measures were body mass index (BMI), waist circumference, sedentary behaviour and mental health. Where possible, meta-analyses were conducted. Narrative synthesis using vote counting based on direction of effect was used where studies were not amenable to meta-analysis. RESULTS: Fifty-seven studies were included (49 SMI only), with 46 contributing to meta-analyses. Meta-analyses revealed significant (< 0.05) effect of interventions on mean weight loss (-1.42 kg), achieving 5% weight loss (OR 2.48), weight maintenance (-2.05 kg), physical activity (IPAQ MET minutes: 226.82) and daily vegetable serves (0.51), but not on fruit serves (0.01). Significant effects were also seen for secondary outcomes of BMI (-0.48 units) and waist circumference (-0.87cm), but not mental health (depression: SMD -0.03; anxiety: SMD -0.49; severity of psychological symptoms: SMD 0.72). Studies reporting sedentary behaviour were not able to be meta-analysed. Most trials had high risk of bias, quality of evidence for weight and physical activity were moderate, while quality of evidence for diet was low. CONCLUSION: Lifestyle interventions delivered to people with a mental health condition made statistically significant improvements to weight, BMI, waist circumference, vegetable serves and physical activity. Further high-quality trials with greater consistency in measurement and reporting of outcomes are needed to better understand the impact of lifestyle interventions on physical activity, diet, sedentary behaviour and mental health and to understand impact on subgroups. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019137197.

Iterative delivery of an implementation support package to increase and sustain the routine provision of antenatal care addressing alcohol consumption during pregnancy: study protocol for a stepped-wedge cluster trial.

INTRODUCTION: Antenatal care addressing alcohol consumption during pregnancy is not routinely delivered in maternity services. Although a number of implementation trials have reported significant increases in such care, the majority of women still did not receive all recommended care elements, and improvements dissipated over time. This study aims to assess the effectiveness of an iteratively developed and delivered implementation support package in: (1) increasing the proportion of pregnant women who receive antenatal care addressing alcohol consumption and (2) sustaining the rate of care over time. METHODS AND ANALYSIS: A stepped-wedge cluster trial will be conducted as a second phase of a previous trial. All public maternity services within three sectors of a local health district in Australia will receive an implementation support package that was developed based on an assessment of outcomes and learnings following the initial trial. The package will consist of evidence-based strategies to support increases in care provision (remind clinicians; facilitation; conduct educational meetings) and sustainment (develop a formal implementation blueprint; purposely re-examine the implementation; conduct ongoing training). Measurement of outcomes will occur via surveys with women who attend antenatal appointments each week. Primary outcomes will be the proportion of women who report being asked about alcohol consumption at subsequent antenatal appointments; and receiving complete care (advice and referral) relative to alcohol risk at initial and subsequent antenatal appointments. Economic and process evaluation measures will also be reported. ETHICS AND DISSEMINATION: Ethical approval was obtained through the Hunter New England (16/11/16/4.07, 16/10/19/5.15) and University of Newcastle Human Research Ethics Committees (H-2017-0032, H-2016-0422) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health service decision makers to inform the feasibility of conducting additional cycles to further improve antenatal care addressing alcohol consumption as well as at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry (ACTRN12622000295741).

The effectiveness of implementation strategies in improving preconception and antenatal preventive care: a systematic review.

BACKGROUND: Clinical guideline recommendations for addressing modifiable risk factors are not routinely implemented into preconception and antenatal care. This review assessed the effectiveness of implementation strategies in improving health professional provision of preconception and antenatal care addressing tobacco smoking, weight management and alcohol consumption. METHODS: A systematic review of randomised and non-randomised studies with a parallel comparison group was conducted. Eligible studies used implementation strategy/ies targeted at health professionals to improve at least one element of preconception and/or antenatal care (smoking: ask, advise, assess, assist, arrange; weight/alcohol: assess, advise, refer) compared to usual practice/control or alternative strategies. Eligible studies were identified via CENTRAL, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL and other sources. Random-effects meta-analyses were conducted where appropriate, with other findings summarised using the direction of effect. The certainty of the pooled evidence was assessed using the GRADE approach. RESULTS: Fourteen studies were included in the review. Thirteen were in the antenatal period and 12 tested multiple implementation strategies (median: three). Meta-analyses of RCTs found that implementation strategies compared to usual practice/control probably increase asking (OR: 2.52; 95% CI: 1.13, 5.59; 3 studies; moderate-certainty evidence) and advising (OR: 4.32; 95% CI: 3.06, 6.11; 4 studies; moderate-certainty evidence) about smoking and assessing weight gain (OR: 57.56; 95% CI: 41.78, 79.29; 2 studies; moderate-certainty evidence), and may increase assessing (OR: 2.55; 95% CI: 0.24, 27.06; 2 studies; low-certainty evidence), assisting (OR: 6.34; 95% CI: 1.51, 26.63; 3 studies; low-certainty evidence) and arranging support (OR: 3.55; 95% CI: 0.50, 25.34; 2 studies; low-certainty evidence) for smoking. The true effect of implementation strategies in increasing advice about weight gain (OR: 3.37; 95% CI: 2.34, 4.84; 2 non-randomised studies; very low-certainty evidence) and alcohol consumption (OR: 10.36; 95% CI: 2.37, 41.20; 2 non-randomised studies; very low-certainty evidence) is uncertain due to the quality of evidence to date. CONCLUSIONS: Review findings provide some evidence to support the effectiveness of implementation strategies in improving health professional delivery of antenatal care addressing smoking and weight management. Rigorous research is needed to build certainty in the evidence for improving alcohol and weight gain advice, and in preconception care. TRIAL REGISTRATION: PROSPERO-CRD42019131691.

Smokeless tobacco policy in Bangladesh: A stakeholder study of compatibility with the World Health Organization's Framework Convention on Tobacco Control.

INTRODUCTION: Smokeless tobacco (ST) is the predominant form of tobacco used in Bangladesh and is associated with adverse health outcomes. Bangladesh ratified the World Health Organization's Framework Convention on Tobacco Control (FCTC) in 2004. There are concerns that FCTC legislation and implementation of ST control policy is insufficient in Bangladesh. The aim of this study was to investigate the achievements and challenges of ST policy in Bangladesh and its alignment with the FCTC. METHODS: We conducted semi-structured key informant interviews with 20 stakeholders from government and non-government offices and international funding agencies, including tobacco control advocates, policy makers and non-governmental organisation workers. We used NVivo software to create key themes and the framework method for thematic analysis. RESULTS: Our findings revealed a lack of national policy in terms of disclosure of harmful contents, illicit trade and standardised packaging of ST. Legislation remains ineffective in relation to graphical health warnings and tax measures. Challenges to ST control identified included inadequate law enforcement; paucity of research, surveillance, and evidence generation; and supply chain control. We identified lack of congruence of ST policies with FCTC due to slow progress in implementation of FCTC measures, lack of a country-specific policy and industry interference. To comply with FCTC, participants recommended strong leadership and political commitment, co-ordination between public and private sectors and proper use of tobacco control resources. DISCUSSION AND CONCLUSIONS: Bangladesh has adopted several important FCTC measures, but further strengthening of ST policy is needed to enable full implementation of FCTC.

The unmet needs of carers of stroke survivors: An evaluation of Google search results.

Google is the most used search engine in the world, and likely to be used by caregivers of stroke survivors to find online forums and online communities to connect with other caregivers. This study aims to identify the types of websites accessed by caregivers of stroke survivors to connect with other caregivers, and analyse the online content produced by caregivers to identify their unmet needs. The first 20 websites from eight search strings entered into Google were systematically reviewed. Unmet needs on included websites were identified using a pre-determined coding schedule. Six websites were analysed. Most were discussion boards (n = 5, 83%) developed by organisations in the United States (n = 4, 66.6%). Overall, 2124 unmet needs appeared in 896 posts from caregivers. 'Emotional and psychological' were the most reported needs across posts (n = 765, 36%). Content produced on websites may address social isolation and provide insight into delivering and developing services to meet the needs of caregivers of stroke survivors.