Mini-AFTERc: a controlled pilot trial of a nurse-led psychological intervention for fear of breast cancer recurrence.

OBJECTIVES: To determine the feasibility and acceptability of implementing the Mini-AFTERc intervention. DESIGN: Non-randomised cluster-controlled pilot trial. SETTING: Four NHS out-patient breast cancer centres in Scotland. PARTICIPANTS: Ninety-two women who had successfully completed primary treatment for breast cancer were screened for moderate levels of fear of cancer recurrence (FCR). Forty-five were eligible (17 intervention and 28 control) and 34 completed 3-month follow-up (15 intervention and 21 control). INTERVENTION: Mini-AFTERc, a single brief (30 min) structured telephone discussion with a specialist breast cancer nurse (SBCN) trained to target the antecedents of FCR. OUTCOMES: Feasibility and acceptability of Mini-AFTERc and the study design were assessed via recruitment, consent, retention rates, patient outcomes (measured at baseline, 2, 4, and 12 weeks), and post-study interviews with participants and SBCNs, which were guided by Normalisation Process Theory. RESULTS: Mini-AFTERc was acceptable to patients and SBCNs. SBCNs believe the implementation of Mini-AFTERc to be feasible and an extension of discussions that already happen routinely. SBCNs believe delivery, however, at the scale required would be challenging given current competing demands for their time. Recruitment was impacted by variability in the follow-up practices of cancer centres and COVID-19 lockdown. Consent and follow-up procedures worked well, and retention rates were high. CONCLUSIONS: The study provided invaluable information about the potential challenges and solutions for testing the Mini-AFTERc intervention more widely where limiting high FCR levels is an important goal following recovery from primary breast cancer treatment. TRIAL REGISTRATION: ClinicalTrials.gov, NCT0376382 . Registered on 4 December 2018.

Concerns raised by people treated for head and neck cancer: a secondary analysis of audiotaped consultations in a health services follow-up clinic.

PURPOSE: People treated for head and neck cancer (HNC) face various barriers in communicating concerns with consultants. Our aim was to investigate the number of concerns raised between patients using the Patient Concerns Inventory (PCI) and those who did not. The PCI is a 57-item prompt list used in routine HNC follow-up clinics. Additionally, we aimed to examine whether who initiated the concerns differed between groups and the factors that may predict this initiation. METHODS: Secondary data analysis included 67 participants across 15 HNC consultants from specialist cancer centres in Liverpool and Leeds. Seven consultants utilised the PCI and eight did not, assigned by preferential and random assignment. RESULTS: Patients in the PCI group raised on average 2.5 more concerns than patients in the non-PCI group (p < .001). There was no significant relationship between group and who initiated the first concern (p = .28). A mixed-effects logistic regression was found to significantly predict who initiated the first concern in consultations (p < .05). DISCUSSION: The number of concerns raised by patients increased when the PCI was introduced pre-HNC consultation. A number of factors were shown to predict the number of concerns raised in consultations by both patient and consultant. As concerns may not be raised further following the concern mentioned, we propose that the discussion of concerns needs to be maintained by the clinician throughout the consultation and not solely at the start. CONCLUSION: The PCI promoted the sharing of concerns in follow-up consultations between patient and consultant.

Predictors of weight discussion in primary care consultations: A multilevel modeling approach.

OBJECTIVE: To understand how primary care weight-related communication processes are influenced by individual differences in primary care practitioner (PCP) and patient characteristics and communication use. METHODS: Two multilevel logistic regression models were calculated to predict the occurrence of 1) weight-related discussion and 2) weight-related consultation outcomes. Coded communication data (Roter Interaction Analysis System) from 218 video-recorded consultations between PCPs and patients with overweight and obesity in Scottish primary care practices were combined with their demographic data to develop the multilevel models. RESULTS: Weight-related discussions were more likely to occur when a greater proportion of PCP's total communication was partnership building and activating communication. More discrete weight discussions during a consultation predicted weight-related consultation outcomes. Patient BMI positively predicted both weight-related discussion and consultation outcomes. CONCLUSION: This work demonstrates that multilevel modeling is a viable approach to investigating coded primary care weight-related communication data and that it can provide insight into the impact that various patient and PCP factors have on these communication processes. PRACTICE IMPLICATIONS: Through the increased use of partnership building and activating communications, and by engaging in shorter, but more frequent, discussions about patient weight, PCPs may better facilitate weight-related discussion and weight-related consultation outcomes for their patients.

Studying trajectories of multimorbidity: a systematic scoping review of longitudinal approaches and evidence.

OBJECTIVES: Multimorbidity-the co-occurrence of at least two chronic diseases in an individual-is an important public health challenge in ageing societies. The vast majority of multimorbidity research takes a cross-sectional approach, but longitudinal approaches to understanding multimorbidity are an emerging research area, being encouraged by multiple funders. To support development in this research area, the aim of this study is to scope the methodological approaches and substantive findings of studies that have investigated longitudinal multimorbidity trajectories. DESIGN: We conducted a systematic search for relevant studies in four online databases (Medline, Scopus, Web of Science and Embase) in May 2020 using predefined search terms and inclusion and exclusion criteria. The search was complemented by searching reference lists of relevant papers. From the selected studies, we systematically extracted data on study methodology and findings and summarised them in a narrative synthesis. RESULTS: We identified 35 studies investigating multimorbidity longitudinally, all published in the last decade, and predominantly in high-income countries from the Global North. Longitudinal approaches employed included constructing change variables, multilevel regression analysis (eg, growth curve modelling), longitudinal group-based methodologies (eg, latent class modelling), analysing disease transitions and visualisation techniques. Commonly identified risk factors for multimorbidity onset and progression were older age, higher socioeconomic and area-level deprivation, overweight and poorer health behaviours. CONCLUSION: The nascent research area employs a diverse range of longitudinal approaches that characterise accumulation and disease combinations and to a lesser extent disease sequencing and progression. Gaps include understanding the long-term, life course determinants of different multimorbidity trajectories, and doing so across diverse populations, including those from low-income and middle-income countries. This can provide a detailed picture of morbidity development, with important implications from a clinical and intervention perspective.

Development and Testing of a Novel Measure to Assess Fidelity of Implementation: Example of the Mini-AFTERc Intervention.

BACKGROUND: Fidelity of implementation (FOI) reflects whether an intervention was implemented in clinical practice according to the originally developed manual and is a key aspect in understanding intervention effectiveness. To illustrate this process of developing a fidelity measure, this study uses the Mini-AFTERc, a brief psychological intervention aimed at managing breast cancer patients' fear of cancer recurrence, as an example. OBJECTIVES: To illustrate the development of an FOI measure through (1) applying this process to the Mini-AFTERc intervention, by including the design of a scoring system and rating criteria; (2) content validating the FOI measure using thematic framework analysis as a qualitative approach; (3) testing consistency of the FOI measure using interrater reliability. METHODS: The FOI measure was developed, its scoring system modified and the rating criteria defined. Thematic framework analysis was conducted to content validate the FOI measure using nine intervention discussions between four specialist cancer nurses and four breast cancer patients, and one simulated breast cancer patient. Intraclass-correlation was conducted to assess interrater reliability. RESULTS: The qualitative findings suggested that the Mini-AFTERc FOI measure has content validity as it was able to measure all five components of the Mini-AFTERc intervention. The interrater reliability suggested a moderate to excellent degree of reliability among three raters, r ICC = 0.84, 95% CI [0.51, 0.96]. CONCLUSION: The study has illustrated the steps that an FOI measure can be developed through a systematic approach applied to the Mini-AFTERc intervention. The FOI measure was found to have content validity and was consistently applied, independently, by three researchers familiar with the Mini-AFTERc intervention. Future studies should determine whether similar levels of interrater reliability can be obtained by distributing written and/or video instructions to researchers who are unfamiliar with the FOI measure, using a larger sample. Employing developed and validated FOI measures such as the one presented for the Mini-AFTERc would facilitate implementation of interventions in the FCR field in clinical practice as intended. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier: NCT03763825.

A controlled pilot trial of a nurse-led intervention (Mini-AFTERc) to manage fear of cancer recurrence in patients affected by breast cancer.

BACKGROUND: Fear of cancer recurrence (FCR) is common in people affected by breast cancer. FCR is associated with increased health service and medication use, anxiety, depression and reduced quality of life. Existing interventions for FCR are time and resource intensive, making implementation in a National Health Service (NHS) setting challenging. To effectively manage FCR in current clinical practice, less intensive FCR interventions are required. Mini-AFTERc is a structured 30-min counselling intervention delivered over the telephone and is designed to normalise moderate FCR levels by targeting unhelpful behaviours and misconceptions about cancer recurrence.This multi-centre non-randomised controlled pilot trial will investigate the feasibility of delivering the Mini-AFTERc intervention, its acceptability and usefulness, in relation to specialist breast cancer nurses (SBCNs) and patients. This protocol describes the rationale, methods and analysis plan for this pilot trial of the Mini-AFTERc intervention in everyday practice. METHODS: This study will run in four breast cancer centres in NHS Scotland, two intervention and two control centres. SBCNs at intervention centres will be trained to deliver the Mini-AFTERc intervention. Female patients who have completed primary breast cancer treatment in the previous 6 months will be screened for moderate FCR (FCR4 score: 10­14). Participants at intervention centres will receive the Mini-AFTERc intervention within 2 weeks of recruitment. SBCNs will audio record the intervention telephone discussions with participants. Fidelity of intervention implementation will be assessed from audio recordings. All participants will complete three separate follow-up questionnaires assessing changes in FCR, anxiety, depression and quality of life over 3 months. Normalisation process theory (NPT) will form the framework for semi-structured interviews with 20% of patients and all SBCNs. Interviews will explore participants' experience of the study, acceptability and usefulness of the intervention and factors influencing implementation within clinical practice. The ADePT process will be adopted to systematically problem solve and refine the trial design. DISCUSSION: Findings will provide evidence for the potential effectiveness, fidelity, acceptability and practicality of the Mini-AFTERc intervention, and will inform the design and development of a large randomised controlled trial (RCT). TRIAL REGISTRATION: ClinicalTrials.gov: NCT0376382. Registered 4th December 2018, https://clinicaltrials.gov/ct2/show/NCT03763825.

Primary care patient and practitioner views of weight and weight-related discussion: a mixed-methods study.

OBJECTIVE: To understand the beliefs that primary care practitioners (PCPs) and patients with overweight and obesity have about obesity and primary care weight management in Scotland. SETTING: Seven National Health Service (NHS) Scotland primary care centres. PARTICIPANTS: A total of 305 patients and 14 PCPs (12 general practitioners; two practice nurses) participated. DESIGN AND METHODOLOGY: A cross-sectional mixed-methods study. PCPs and patients completed questionnaires assessing beliefs about obesity and primary care weight communication and management. Semi-structured interviews were conducted with PCPs to elaborate on questionnaire topics. Quantitative and qualitative data were synthesised to address study objectives. RESULTS: (1) Many patients with overweight and obesity did not accurately perceive their weight or risk of developing weight-related health issues; (2) PCPs and patients reported behavioural factors as the most important cause of obesity, and medical factors as the most important consequence; (3) PCPs perceive their role in weight management as awareness raising and signposting, not prevention or weight monitoring; (4) PCPs identify structural and patient-related factors as barriers to weight communication and management, but not PCP factors. CONCLUSIONS: Incongruent and/or inaccurate beliefs held by PCPs and patient may present barriers to effective weight discussion and management in primary care. There is a need to review, standardise and clarify primary care weight management processes in Scotland. Acknowledging a shared responsibility for obesity as a disease may improve outcomes for patients with overweight and obesity.

An analysis of directly observed weight communication processes between primary care practitioners and overweight patients.

OBJECTIVE: To analyse weight-related communication prevalence and processes (content/context) between primary care practitioners (PCPs) and overweight patients within routine primary healthcare consultations. METHODS: Consultations between 14 PCPs and 218 overweight patients (BMI ≥ 25 kg/m2) were video recorded. Weight communication was coded using the Roter Interaction Analysis System (RIAS) and the novel St Andrews Issue Response Analysis System (SAIRAS). Communication code frequencies were analysed. RESULTS: Weight discussion occurred in 25% of consultations with overweight patients; 26% of these had weight-related consultation outcomes (e.g. weight-related counselling and referrals, stated weight-related intention from patients). Weight discussions were more likely to occur if PCPs provided space to patient attempts to discuss weight (p = 0.013). Longer weight discussions (p < 0.001) and contextualising weight as problematic when PCP/patient-initiated weight discussion (p < 0.001) were associated with weight-related consultation outcomes. CONCLUSION: Weight was rarely discussed with overweight patients, however PCP space provision to patient weight-discussion initiation attempts increased weight discussion. When weight was discussed, increased time and/or contextualising weight as a problem increased the likelihood of weight-related consultation outcomes. PRACTICAL IMPLICATION: PCP use of specific communication approaches when discussing, contextualising and responding to patient weight may facilitate weight-related discussion and consultation outcomes and could lead to more effective patient weight management.

Direct observation of weight-related communication in primary care: a systematic review.

BACKGROUND: Primary care is ideally placed to play an effective role in patient weight management; however, patient weight is seldom discussed in this context. A synthesis of studies that directly observe weight discussion in primary care is required to more comprehensively understand and improve primary care weight-related communication. OBJECTIVE: To systematically identify and examine primary care observational research that investigates weight-related communication and its relationship to patient weight outcomes. METHODS: A systematic review of literature published up to August 2015, using seven electronic databases (including MEDLINE, Scopus and PsycINFO), was conducted using search terms such as overweight, obese and/or doctor-patient communication. RESULTS: Twenty papers were included in the final review. Communication analysis focused predominantly on 'practitioner' use of specific patient-centred communication. Practitioner use of motivational interviewing was associated with improved patient weight-related outcomes, including patient weight loss and increased patient readiness to lose weight; however, few studies measured patient weight-related outcomes. CONCLUSION: Studies directly observing weight-related communication in primary care are scarce and limited by a lack of focus on patient communication and patient weight-related outcomes. Future research should measure practitioner and patient communications during weight discussion and their impact on patient weight-related outcomes. This knowledge may inform the development of a communication intervention to assist practitioners to more effectively discuss weight with their overweight and/or obese patients.

Talk weight: an observational study of communication about patient weight in primary care consultations.

BACKGROUND: Obesity is a major public health issue and primary care practitioners are well placed to opportunistically raise the issue of overweight or obesity with their patients. AIM AND METHODS: This study investigated the prevalence of weight discussion in primary care consultations with overweight and obese patients, in a practice in Fife, Scotland, and described weight-related communication using video analysis. FINDINGS: Weight was raised in 25% of consultations with overweight and obese patients. GPs initiated weight discussion more often than patients; however, these attempts were often blocked by patients. Weight-related outcomes were more common when patients initiated the weight discussion. This study confirms the potential of video analysis for understanding primary care weight discussion. It also suggests that GPs may benefit from a communication-based intervention to tackle patient blocking behaviours and contributes to the evidence suggesting that interventions targeted to increase the prevalence of weight-related discussions with their patients are needed.

Behaviour and burnout in medical students.

BACKGROUND: Burnout is prevalent in doctors and can impact on job dissatisfaction and patient care. In medical students, burnout is associated with poorer self-rated health; however, it is unclear what factors influence its development. This study investigated whether health behaviours predict burnout in medical students. METHODS: Medical students (n=356) at the Universities of St Andrews and Manchester completed an online questionnaire assessing: emotional exhaustion (EE), depersonalisation (DP), personal accomplishment (PA), alcohol use, physical activity, diet, and smoking. RESULTS: Approximately 55% (54.8%) of students reported high levels of EE, 34% reported high levels of DP, and 46.6% reported low levels of PA. Linear regression analysis revealed that year of study, physical activity, and smoking status significantly predicted EE whilst gender, year of study, and institution significantly predicted DP. PA was significantly predicted by alcohol binge score, year of study, gender, and physical activity. CONCLUSIONS: Burnout is present in undergraduate medical students in the United Kingdom, and health behaviours, particularly physical activity, predict components of burnout. Gender, year of study, and institution also appear to influence the prevalence of burnout. Encouraging medical students to make healthier lifestyle choices early in their medical training may reduce the likelihood of the development of burnout.