Achieving integrated self-directed Cancer aftercare (ASICA) for melanoma: how a digital intervention to support total skin self-examination was used by people treated for cutaneous melanoma.

BACKGROUND: Melanoma incidence has quadrupled since 1970 and melanoma is now the second most common cancer in individuals under 50. Targeted immunotherapies for melanoma now potentially enable long-term remission even in advanced melanoma, but these melanoma survivors require ongoing surveillance, with implications for NHS resources and significant social and psychological consequences for patients. Total skin self-examination (TSSE) can detect recurrence earlier and improve clinical outcomes but is underperformed in the UK. To support survivors, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) intervention was developed to prompt and improve TSSE performance, with subsequent reporting of concerns and submission of skin photos to a Dermatology Nurse Practitioner (DNP). ASICA was delivered as a randomized pilot trial. METHODS: This paper reports on process evaluation. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using Microsoft Excel and SPSS. We explored which participants used ASICA, and how frequently, to report any skin concerns. We also determined how the interactions had worked in terms of quality of skin photographs submitted, clinical assessments made by the DNP, and the assessments and decisions made for each concern. Finally, we explored significant events occurring during the trial. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using SPSS. A semi-structured interview was undertaken with the DNP to gain perspective on the range of concerns presented and how they were resolved. RESULTS: Of 121 recruited melanoma patients receiving ASICA for 12 months, 69 participants submitted a total of 123 reports detailing 189 separate skin-related concerns and including 188 skin photographs. Where participants fully complied with follow-up by the DNP, concerns were usually resolved remotely, but 19 (10.1%) were seen at a secondary care clinic and 14 (7.4%) referred to their GP. 49 (25.9%) of concerns were not completely resolved due to partial non-compliance with DNP follow-up. CONCLUSION: Melanoma patients randomized to the ASICA intervention were able to report skin-related concerns that could be resolved remotely through interaction with a DNP. Feasibility issues highlighted by ASICA will support further development and optimization of this digital tool. TRIAL REGISTRATION: Clinical Trials.gov , NCT03328247 . Registered on 1 November 2017.

How can we better prepare new doctors for the tasks and challenges of ward rounds?: An observational study of junior doctors' experiences.

PURPOSE: Ward rounds play a crucial role in the delivery of patient care in inpatient settings, but involve a complex mix of tasks, skills and challenges for junior doctors to negotiate. This study informs the development of high-quality training by identifying the activities that junior doctors perform, and those associated with stress during real-life ward rounds. MATERIALS AND METHODS: All activities performed by FY1 doctors (n = 60) over 2 ward rounds were coded in real-time by a trained observer using the work observation method by activity timing (WOMBAT). Doctors' heart rate was continuously recorded and non-metabolic peaks in heart rate used as a physiological indicator of stress. RESULTS: During ward rounds, FY1 doctors commonly engaged in indirect patient care, professional communication, documentation and observation. Very little time was spent on direct patient care (6%) or explicit supervision/education (0.01%). Heart rate data indicated that stress was highest during administrative tasks while interacting directly with patients while stepping out of rounds to complete personal tasks, when answering bleeps and while multi-tasking. CONCLUSIONS: Training that specifically covers the activities involved, skills required, and challenges inherent in real-life ward rounds may better prepare FY doctors for this complex area of practice.

Why does work cause fatigue? A real-time investigation of fatigue, and determinants of fatigue in nurses working 12-hour shifts.

BACKGROUND: One of the striking regularities of human behavior is that a prolonged physical, cognitive, or emotional activity leads to feelings of fatigue. Fatigue could be due to (1) depletion of a finite resource of physical and/or psychological energy or (2) changes in motivation, attention, and goal-directed effort (e.g. motivational control theory). PURPOSE: To contrast predictions from these two views in a real-time study of subjective fatigue in nurses while working. METHODS: One hundred nurses provided 1,453 assessments over two 12-hr shifts. Nurses rated fatigue, demand, control, and reward every 90 min. Physical energy expenditure was measured objectively using Actiheart. Hypotheses were tested using multilevel models to predict fatigue from (a) the accumulated values of physical energy expended, demand, control, and reward over the shift and (b) from distributed lag models of the same variables over the previous 90 min. RESULTS: Virtually all participants showed increasing fatigue over the work period. This increase was slightly greater when working overnight. Fatigue was not dependent on physical energy expended nor perceived work demands. However, it was related to perceived control over work and perceived reward associated with work. CONCLUSIONS: Findings provide little support for a resource depletion model; however, the finding that control and reward both predicted fatigue is consistent with a motivational account of fatigue.

What Is Behavioural Medicine? Commentary on Definition Proposed by Dekker, Stauder and Penedo.

PURPOSE: Dekker et al. (2016) propose an updated definition of behavioural medicine. METHOD: In this commentary, we discuss how the field and the disciplines involved have changed over time before suggesting small amendments to the proposed definition. RESULTS: We suggest that the range of medicine which might be considered 'behavioural' is increasing to encompass virtually all medical practice. In addition, the role of behaviour and the potential for behaviour change as a means of improving health have become increasingly important. A defining characteristic of behavioural medicine is the involvement of multiple disciplines, working together or in parallel and, as the extent of the field expands, more disciplines are likely to be involved. CONCLUSION: We therefore propose that the definition should represent the full width of the research, practice and disciplines involved in behavioural medicine.

Stressors, Appraisal of Stressors, Experienced Stress and Cardiac Response: A Real-Time, Real-Life Investigation of Work Stress in Nurses.

BACKGROUND: Stress in health care professionals may reflect both the work and appraisal of work and impacts on the individuals, their patients, colleagues and managers. PURPOSE: The purpose of the present study is to examine physiological and psychological effects of stressors (tasks) and theory-based perceptions of work stressors within and between nurses in real time. METHODS: During two work shifts, 100 nurses rated experienced stress, affect, fatigue, theory-based measures of work stress and nursing tasks on electronic diaries every 90 min, whereas heart rate and activity were measured continuously. RESULTS: Heart rate was associated with both demand and effort. Experienced stress was related to demand, control, effort and reward. Effort and reward interacted as predicted (but only within people). Results were unchanged when allowance was made for work tasks. CONCLUSIONS: Real-time appraisals were more important than actual tasks in predicting both psychological and physiological correlates of stress. At times when effort was high, perceived reward reduced stress.

Understanding usage of a hybrid website and smartphone app for weight management: a mixed-methods study.

BACKGROUND: Advancements in mobile phone technology offer huge potential for enhancing the timely delivery of health behavior change interventions. The development of smartphone-based health interventions (apps) is a rapidly growing field of research, yet there have been few longitudinal examinations of how people experience and use these apps within their day-to-day routines, particularly within the context of a hybrid Web- and app-based intervention. OBJECTIVE: This study used an in-depth mixed-methods design to examine individual variation in (1) impact on self-reported goal engagement (ie, motivation, self-efficacy, awareness, effort, achievement) of access to a weight management app (POWeR Tracker) when provided alongside a Web-based weight management intervention (POWeR) and (2) usage and views of POWeR Tracker. METHODS: Thirteen adults were provided access to POWeR and were monitored over a 4-week period. Access to POWeR Tracker was provided in 2 alternate weeks (ie, weeks 1 and 3 or weeks 2 and 4). Participants' goal engagement was measured daily via self-report. Mixed effects models were used to examine change in goal engagement between the weeks when POWeR Tracker was and was not available and whether the extent of change in goal engagement varied between individual participants. Usage of POWeR and POWeR Tracker was automatically recorded for each participant. Telephone interviews were conducted and analyzed using inductive thematic analysis to further explore participants' experiences using POWeR and POWeR Tracker. RESULTS: Access to POWeR Tracker was associated with a significant increase in participants' awareness of their eating (ß1=0.31, P=.04) and physical activity goals (ß1=0.28, P=.03). The level of increase varied between individual participants. Usage data showed that participants used the POWeR website for similar amounts of time during the weeks when POWeR Tracker was (mean 29 minutes, SD 31 minutes) and was not available (mean 27 minutes, SD 33 minutes). POWeR Tracker was mostly accessed in short bursts (mean 3 minutes, SD 2 minutes) during convenient moments or moments when participants deemed the intervention content most relevant. The qualitative data indicated that nearly all participants agreed that it was more convenient to access information on-the-go via their mobiles compared to a computer. However, participants varied in their views and usage of the Web- versus app-based components and the informational versus tracking tools provided by POWeR Tracker. CONCLUSIONS: This study provides evidence that smartphones have the potential to improve individuals' engagement with their health-related goals when used as a supplement to an existing online intervention. The perceived convenience of mobile access to information does not appear to deter use of Web-based interventions or strengthen the impact of app access on goal engagement. A mixed-methods design enabled exploration of individual variation in daily usage of the app-based tools.

Stress in nurses: stress-related affect and its determinants examined over the nursing day.

BACKGROUND: Nurses are a stressed group and this may affect their health and work performance. The determinants of occupational stress in nurses and other occupational groups have almost invariably been examined in between subject studies. PURPOSE: This study aimed to determine if the main determinants of occupation stress, i.e. demand, control, effort and reward, operate within nurses. METHODS: A real time study using personal digital-assistant-based ecological momentary assessment to measure affect and its hypothesised determinants every 90 min in 254 nurses over three nursing shifts. The measures were negative affect, positive affect, demand/effort, control and reward. RESULTS: While the effects varied in magnitude between people, in general increased negative affect was predicted by high demand/effort, low control and low reward. Control and reward moderated the effects of demand/effort. High positive affect was predicted by high demand/effort, control and reward. CONCLUSIONS: The same factors are associated with variations in stress-related affect within nurses as between.

Nursing stress and patient care: real-time investigation of the effect of nursing tasks and demands on psychological stress, physiological stress, and job performance: study protocol.

AIM: To examine the effects of nursing tasks (including their physiological and psychological demands, and the moderating effects of reward and control) on distress and job performance in real time. BACKGROUND: Nurses working in hospital settings report high levels of occupational stress. Stress in nurses has been linked to reduced physical and psychological health, reduced job satisfaction, increased sickness absence, increased staff turnover, and poorer job performance. In this study, we will investigate theoretical models of stress and use multiple methods, including real-time data collection, to assess the relationship between stress and different nursing tasks in general medical and surgical ward nurses. DESIGN: A real-time, repeated measures design. METHODS: During 2011/2012, 100 nurses from a large general teaching hospital in Scotland will: (a) complete self-reports of mood; (b) have their heart rate and activity monitored over two shifts to obtain physiological indices of stress and energy expenditure; (c) provide perceptions of the determinants of stress in complex ward environments; and (d) describe their main activities. All measures will be taken repeatedly in real time over two working shifts. DISCUSSION: Data obtained in this study will be analysed to examine the relationships between nursing tasks, self-reported and physiological measures of stress and to assess the effect of occupational stress on multiple work outcomes. The results will inform theoretical understanding of nurse stress and its determinants and suggest possible targets for intervention to reduce stress and associated harmful consequences.

Do mood and the receipt of work-based support influence nurse perceived quality of care delivery? A behavioural diary study.

AIMS AND OBJECTIVES: To examine the effect of nurse mood in the worst event of shift (negative affect, positive affect), receipt of work-based support from managers and colleagues, colleague and patient involvement on perceived quality of care delivery. BACKGROUND: While the effect of the work environment on nurse mood is well documented, little is known about the effects of the worst event of shift on the quality of care delivered by nurses. DESIGN: This behavioural diary study employed a within-subject and between-subject designs incorporating both cross-sectional and longitudinal elements. METHODS: One hundred and seventy-one nurses in four large district general hospitals in England completed end-of-shift computerised behavioural diaries over three shifts to explore the effects of the worst clinical incident of shift. Diaries measured negative affect, positive affect, colleague involvement, receipt of work-based support and perceived quality of care delivery. Analysis used multilevel modelling (MLWIN 2.19; Centre for Multi-level Modelling, University of Bristol, Bristol, UK). RESULTS: High levels of negative affect and low levels of positive affect reported in the worst clinical incident of shift were associated with reduced perceived quality of care delivery. Receipt of managerial support and its interaction with negative affect had no relationship with perceived quality of care delivery. Perceived quality of care delivery deteriorated the most when the nurse reported a combination of high negative affect and no receipt of colleague support in the worst clinical incident of shift. Perceived quality of care delivery was also particularly influenced when the nurse reported low positive affect and colleague actions contributed to the problem. CONCLUSIONS: Receipt of colleague support is particularly salient in protecting perceived quality of care delivery, especially if the nurse also reports high levels of negative affect in the worst event of shift. RELEVANCE TO CLINICAL PRACTICE: The effect of work-based support on care delivery is complex and requires further investigation.

Frequency of nursing tasks in medical and surgical wards.

AIM: To explore the frequency of different nursing tasks in medical and surgical wards. BACKGROUND: The time nurses spend on direct patient care is important for both patients and nurses. However, little is known about the time nurses spend on various nursing tasks. METHODS: A real-time, repeated measures design conducted amongst 67 (n = 39 medical, n = 28 surgical) UK hospital nurses. Between September 2011 and August 2012 participants completed an electronic diary version of a classification of nursing tasks (WOMBAT) during shifts. RESULTS: A total of 961 real-time measures of nursing task were obtained. Direct patient care [median = 37.5%, interquartile range = 27.8], indirect care (median = 11.1%, interquartile range = 19.4) and medication (median = 11.1%, interquartile range = 18.8) were most commonly reported. Participants were interrupted in 62% of entries (interquartile range = 35), reported adequate time in 78% (interquartile range = 31) and adequate resources in 89% (interquartile range = 36). Ward-related tasks were significantly more frequent on medical wards than surgical wards but otherwise there were no significant differences. CONCLUSIONS: Nurses spend the highest proportion of time in direct patient care and majority of this on core nursing activities. Interruptions to tasks are common. Nurses tend to report adequate time/resources. The frequency of nursing tasks is similar in medical and surgical wards. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should review the level of interruptions to nurses' work and ensure appropriate levels of supervision.

The use of pedometers in stroke survivors: are they feasible and how well do they detect steps?

OBJECTIVES: To determine (1) the feasibility of pedometers for stroke patients and (2) the level of agreement between pedometers and actual step count. DESIGN: Observational agreement study. SETTING: Six stroke units. PARTICIPANTS: Independently mobile stroke patients (N=50) ready for hospital discharge. INTERVENTIONS: Patients were asked to apply 3 pedometers: 1 around the neck and 1 above each hip. Patients performed a short walk lasting 20 seconds, then a 6-minute walk test 6MWT. Video recordings determined the criterion standard step count. MAIN OUTCOME MEASURE: Agreement between the step count recorded by pedometers and the step count recorded by viewing the criterion standard video recordings of the 2 walks. RESULTS: Five patients (10%) needed assistance to put on the pedometers, and 5 (10%) could not read the step count. Thirty-nine (78%) would use pedometers again. Below a gait speed of about 0.5 m/s, pedometers did not generally detect steps. Agreement analyses showed that even above 0.5 m/s, pedometers undercounted steps for both the short walk and 6MWT; for example, the mean difference between the video recorder and pedometer around the neck was 5.93 steps during the short walk and 32.4 steps during the 6MWT. CONCLUSIONS: Pedometers are feasible but generally do not detect steps at gait speeds below about 0.5 m/s, and they undercount steps at gait speeds above 0.5 m/s.

Assessing acute coronary syndrome patients' cardiac-related beliefs, motivation and mood over time to predict non-attendance at cardiac rehabilitation.

AIM: This research protocol describes and justifies a study to assess patients' cardiac-related beliefs (i.e. illness representations, knowledge/misconceptions, cardiac treatment beliefs), motivation and mood over time to predict non-attendance at a cardiac rehabilitation programme by measuring weekly/monthly changes in these key variables. BACKGROUND: Heart disease is the UK's leading cause of death. Evidence from meta-analyses suggests that cardiac rehabilitation facilitates recovery following acute cardiac events. However, 30-60% of patients do not attend cardiac rehabilitation. There is some evidence from questionnaire studies that a range of potentially modifiable psychological variables including patients' cardiac-related beliefs, motivation and mood may influence attendance. DESIGN: Mixed-methods. METHODS: In this study, during 2012-2013, electronic diary data will be gathered weekly/monthly from 240 patients with acute coronary syndrome from discharge from hospital until completion of the cardiac rehabilitation programme. This will identify changes and interactions between key variables over time and their power to predict non-attendance at cardiac rehabilitation. Data will be analysed to examine the relationship between patients' illness perceptions, cardiac treatment beliefs, knowledge/misconceptions, mood and non-attendance of the cardiac rehabilitation programme. The qualitative component (face-to-face interviews) seeks to explore why patients decide not to attend, not complete or complete the cardiac rehabilitation programme. DISCUSSION: The identification of robust predictors of (non-)attendance is important for the design and delivery of interventions aimed at optimizing cardiac rehabilitation uptake. Funding for the study was granted in February 2011 by the Scottish Government Chief Scientist Office (CZH/4/650).

Stress amongst nurses working in a healthcare telephone-advice service: relationship with job satisfaction, intention to leave, sickness absence, and performance.

AIMS: This paper is a report of a study, which assessed levels of stress amongst nurses working in a healthcare telephone-advice service. We explored whether stress related to performance, sickness absence, and intention to leave. BACKGROUND: Nurses report high levels of stress, as do call-centre workers. The emergence of telephone health advice services means many nurses now work in call-centres, doing work that differs markedly from traditional nursing roles. Stress associated with these roles could have implications for nurses, patients, and service provision. DESIGN: This paper reports cross-sectional survey results. The design of the overall study included longitudinal elements. METHOD: A comprehensive study of stress was conducted amongst nurses working for a telephone-advice service in Scotland (2008-2010). All nurse-advisors were approached by letter and invited to participate. A total of 152 participants (33%) completed a questionnaire including General Health Questionnaire-12, Work Family Conflict Questionnaire, Job Satisfaction Scale and a measure of intention to leave the telephone-advice service and rated the perceived stress of 2 working shifts. Nurses' employers provided data on sickness absence and performance. RESULTS: Overall levels of psychological distress were similar to those found amongst Scottish women generally. In multiple regression, work-family conflict was identified as a significant predictor of job satisfaction and intention to leave, and significantly related to sickness absence. There were significant correlations between General Health Questionnaire scores and perceived stress of shifts and some performance measures. CONCLUSIONS: Work-family conflict is a significant predictor of job satisfaction, intention to leave, and sickness absence amongst telephone helpline nurses. Minimizing the impact of nurses' work on their home lives might reduce turnover and sickness absence.

Describing, predicting and explaining adherence to total skin self-examination (TSSE) in people with melanoma: a 12-month longitudinal study.

OBJECTIVES: To describe trajectories in melanoma survivors' adherence to monthly total skin self-examination (TSSE) over 12 months, and to investigate whether adherence trajectories can be predicted from demographic, cognitive or emotional factors at baseline. DESIGN: A longitudinal observational study nested within the intervention arm of the ASICA (Achieving Self-Directed Integrated Cancer Aftercare) randomised controlled trial. SETTING: Follow-up secondary care in Aberdeen and Cambridge UK. PARTICIPANTS: n=104 adults (48 men/56 women; mean age 58.83 years, SD 13.47, range 28-85 years; mean Scottish Index of Multiple Deprivation score 8.03, SD 1.73, range 2-10) who had been treated for stage 0-IIC primary cutaneous melanoma in the preceding 60 months and were actively participating in the intervention arm of the ASICA trial. INTERVENTIONS: All participants were using the ASICA intervention-a tablet-based intervention designed to support monthly TSSE. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was adherence to guideline recommended (monthly) TSSE over 12 months. This was determined from time-stamped TSSE data recorded by the ASICA intervention app. RESULTS: Latent growth mixture models identified three TSSE adherence trajectories (adherent -41%; drop-off -35%; non-adherent -24%). People who were non-adherent were less likely to intend to perform TSSE as recommended, intending to do it more frequently (OR=0.21, 95% CI 0.06 to 0.81, p=0.023) and were more depressed (OR=1.31, 95% CI 1.06 to 1.61, p=0.011) than people who were adherent. People whose adherence dropped off over time had less well-developed action plans (OR=0.78, 95% CI 0.63 to 0.96, p=0.016) and lower self-efficacy about TSSE (OR=0.92, 95% CI 0.86 to 0.99, p=0.028) than people who were adherent. CONCLUSIONS: Adherence to monthly TSSE in people treated for melanoma can be differentiated into adherent, drop-off and non-adherent trajectories. Collecting information about intentions to engage in TSSE, depression, self-efficacy and/or action planning at outset may help to identify those who would benefit from additional intervention. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03328247).

Changing healthcare professionals' non-reflective processes to improve the quality of care.

RATIONALE: Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. OBJECTIVES: To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. METHODS: Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. RESULTS: From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. CONCLUSION: Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

N-Acylhydrazones as inhibitors of PDE10A.

Cyclic nucleotide phosphodiesterases (PDEs) are represented by a large superfamily of enzymes. A series of hydrazone-based inhibitors was synthesized and shown to be novel, potent, and selective against PDE10A. Optimized compounds of this class were efficacious in animal models of schizophrenia and may be useful for the treatment of this disease.

Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus.

Researchers, practitioners, and policymakers develop interventions to change behavior based on their understanding of how behavior change techniques (BCTs) impact the determinants of behavior. A transparent, systematic, and accessible method of linking BCTs with the processes through which they change behavior (i.e., their mechanisms of action [MoAs]) would advance the understanding of intervention effects and improve theory and intervention development. The purpose of this study is to triangulate evidence for hypothesized BCT-MoA links obtained in two previous studies and present the results in an interactive, online tool. Two previous studies generated evidence on links between 56 BCTs and 26 MoAs based on their frequency in literature synthesis and on expert consensus. Concordance between the findings of the two studies was examined using multilevel modeling. Uncertainties and differences between the two studies were reconciled by 16 behavior change experts using consensus development methods. The resulting evidence was used to generate an online tool. The two studies showed concordance for 25 of the 26 MoAs and agreement for 37 links and for 460 "nonlinks." A further 55 links were resolved by consensus (total of 92 [37 + 55] hypothesized BCT-MoA links). Full data on 1,456 possible links was incorporated into the online interactive Theory and Technique Tool (https://theoryandtechniquetool.humanbehaviourchange.org/). This triangulation of two distinct sources of evidence provides guidance on how BCTs may affect the mechanisms that change behavior and is available as a resource for behavior change intervention designers, researchers and theorists, supporting intervention design, research synthesis, and collaborative research.

Analysing N-of-1 observational data in health psychology and behavioural medicine: a 10-step SPSS tutorial for beginners.

Background: N-of-1 observational studies can be used to describe natural intra-individual changes in health-related behaviours or symptoms over time, to test behavioural theories and to develop highly personalised health interventions. To date, N-of-1 observational methods have been under-used in health psychology and behavioural medicine. One reason for this may be the perceived complexity of statistical analysis of N-of-1 data. Objective: This tutorial paper describes a 10-step procedure for the analysis of N-of-1 observational data using dynamic regression modelling in SPSS for researchers, students and clinicians who are new to this area. The 10-step procedure is illustrated using real data from an N-of-1 observational study exploring the relationship between pain and physical activity. Conclusion: The availability of a user-friendly and robust statistical technique for the analysis of N-of-1 data using SPSS may foster increased awareness, knowledge and skills and establish N-of-1 designs as a useful methodological tool in health psychology and behavioural medicine.

A taxometric analysis of type-D personality.

OBJECTIVE: To test the dimensionality of Type-D personality, using taxometric procedures, to assess if Type-D personality is taxonic or dimensional. Type-D personality is treated as a categorical variable and caseness has been shown to be a risk factor for poor prognosis in coronary heart disease. However, at present, there is no direct evidence to support the assumption that Type D is categorical and able to differentiate true cases from noncases. METHODS: In total, 1012 healthy young adults from across the United Kingdom and Ireland completed the DS14, the standard index of Type D, and scores were submitted to two taxometric procedures MAMBAC and MAXCOV. RESULTS: Graphical representations (comparing actual with simulated data) and fit indices indicated that Type D is more accurately represented as a dimensional rather than categorical construct. CONCLUSION: Type D is better represented as a dimensional construct. Implications for theory development and clinical practice with respect to Type D are examined as well as the wider use of taxometrics within psychosomatic medicine (e.g., to investigate if there are medically unexplained syndrome taxons, such as a Gulf War Syndrome taxon).

Adherence to angiotensin-converting-enzyme inhibitors and illness beliefs in older heart failure patients.

AIMS: Patient beliefs about heart failure (HF) may be important determinants of adherence. This study assessed levels of adherence to angiotensin-converting-enzyme inhibitors (ACEI) and examined whether beliefs about HF were associated with adherence to ACEI. METHODS AND RESULTS: Fifty-eight patients with chronic stable HF (mean age 80.2 years SD +/- 4.6, 43% female) were recruited from two outpatient clinics in Dundee, UK. The Illness Perception Questionnaire-Revised was used to assess beliefs about HF. Adherence to ACEI was assessed by measuring serum levels of angiotensin-converting enzyme (sACE). Adherence to ACEI (defined as sACE <5 U/L) was 72%. Beliefs about the time-line of HF and the consequences of HF accounted for 19% of the variability in adherence to ACEI in this sample. Heart failure patients who believed that their illness had a more chronic (longer term) time frame and had beliefs about the greater consequences of HF on their lives were less likely to adhere to ACEI. CONCLUSION: Adherence to ACEI is sub-optimal. Beliefs about HF appear to be associated with objectively measured adherence to ACEI. Future studies should attempt to identify beliefs that consistently predict adherence and examine whether modifying these beliefs can increase adherence to HF medications.