Implementing digital mental health interventions at scale: one-year evaluation of a national digital CBT service in Ireland.

BACKGROUND: In recent years, exponential growth in digital innovations and internet access has provided opportunities to deliver health services at a much greater scale than previously possible. Evidence-based technology-enabled interventions can provide cost-effective, accessible, and resource-efficient solutions for addressing mental health issues. This study evaluated the first year of a supported digital cognitive behavioral therapy (CBT) service provided by the national health service in Ireland, which has been accessible to individuals who receive a referral from one of five referring groups: General Practitioners, Primary Care Psychology, Counselling Primary Care, Community Mental Health, and Jigsaw (a nationwide youth mental health service). METHODS: A retrospective, observational study examining data from the service between April 2021 to April 2022 was conducted. Descriptive statistics on referrals, account activations, user demographics, program usage, and user satisfaction were extracted, and pre-to-post clinical outcomes for depression measured by the Patient Health Questionnaire-9 and for anxiety measured by the Generalised Anxiety Disorder-7 were analysed using linear mixed effect models. RESULTS: There were 5,298 referrals and 3,236 (61%) account activations within the year. Most users were female (72.9%) and aged between 18 and 44 years (75.4%). The CBT programs were associated with significant reductions in both depression (ß = 3.34, 95% CI [3.03, 3.65], p < 0.001) and anxiety (ß = 3.64, 95% CI [3.36, 3.93], p < 0.001), with large effect sizes (Cohen's d > 0.8). Time spent using the programs was also found to be a predictor of the variability in these clinical outcomes (p < 0.001), and accounting for this resulted in significantly better model fits (p < 0.001). User satisfaction ratings were also very high, exceeding 94%. CONCLUSIONS: Efforts to improve the representation of male and older adult users are warranted. However, overall, the results demonstrate how digital CBT can be provided at scale and lead to symptom reductions with large effect sizes for patients seeking help for depression and anxiety. The findings substantiate the continued use and expansion of this service in Ireland and the more widespread implementation of similar services in other international public healthcare settings.

Guidelines for treating child and adolescent obesity: A systematic review.

Obesity is a chronic disease that compromises the physical and mental health of an increasing proportion of children globally. In high-income countries, prevalence of paediatric obesity is increasing faster in those from marginalised populations such as low-income households, suggesting the disease as one that is largely systemic. Appropriate treatment should be prioritised in these settings to prevent the development of complications and co-morbidities and manage those that already exist. An array of clinical practice guidelines are available for managing overweight and obesity in children and adolescents, but no systematic review has yet compared their quality or synthesised their recommendations. We aimed to narratively review clinical practice guidelines published in English for treating child and adolescent obesity, to identify the highest quality guidelines, and assess similarities, conflicts, and gaps in recommendations. We systematically searched academic databases and grey literature for guidelines published. We used the AGREE II tool to assess the quality, and identified nine high quality guidelines for inclusion in a narrative review of recommendations. Guidelines predominantly recommended the delivery of multi-component behaviour-change interventions aimed at improving nutrition and physical activity. Treatment outcomes were generally focussed on weight, with less emphasis on managing complications or improving quality-of-life. There was no evidence-based consensus on the best mode of delivery, setting, or treatment format. The guidelines rarely included recommendations for addressing the practical or social barriers to behaviour change, such as cooking skills or supervised physical activity. There is insufficient evidence to evaluate pharmaceutical and surgical interventions in children, and these were generally not recommended. It should be noted that this review addressed documents published in English only, and therefore the included guidelines were applicable predominantly to high-resource settings.

Engaging communities in addressing air quality: a scoping review.

BACKGROUND: Exposure to air pollution has a detrimental effect on health and disproportionately affects people living in socio-economically disadvantaged areas. Engaging with communities to identify concerns and solutions could support organisations responsible for air quality control, improve environmental decision-making, and widen understanding of air quality issues associated with health. This scoping review aimed to provide an overview of approaches used to engage communities in addressing air quality and identify the outcomes that have been achieved. METHODS: Searches for studies that described community engagement in air quality activities were conducted across five databases (Academic Search Complete, CABI, GreenFILE, MEDLINE, Web of Science). Data on study characteristics, community engagement approach, and relevant outcomes were extracted. The review process was informed by a multi-stakeholder group with an interest in and experience of community engagement in air quality. Thirty-nine papers from thirty studies were included in the final synthesis. CONCLUSION: A range of approaches have been used to engage communities in addressing air quality, most notably air quality monitoring. Positive outcomes included increased awareness, capacity building, and changes to organisational policy and practice. Longer-term projects and further exploration of the impact of community engagement on improving air quality and health are needed as reporting on these outcomes was limited.

How did communities in North West England respond to the COVID-19 lockdown? Findings from a diary study.

OBJECTIVES: During the COVID-19 pandemic, the UK government and public health leaders advocated for community level responses to support vulnerable people. This activity could be planned and co-ordinated, however much was informal and developed organically. The effects on the individuals who were involved in providing and receiving informal support and implications for their communities have not been widely explored. The aim of this study was therefore to document and explore the nature, potential effects and longevity of community responses to the COVID-19 pandemic. PARTICIPANTS: We asked 15 individuals in North West England to keep a diary during the first UK COVID-19 lockdown. Over 8 weeks, diaries were completed and supported with weekly calls with researchers. A community capacity building framework was used to explore reported community responses to the COVID-19 pandemic. RESULTS: Diarists described community characteristics that enabled and hindered helpful responses in the lockdown context. Diarists frequently described informal approaches with residents acting alone or with near neighbours, although there were examples of community networks and residents recommencing formal volunteering activities. Diarists reported communities providing practical help and social support to vulnerable people. Participants perceived a greater sense of community, increased contact between residents and new networks during the period covered. CONCLUSION: The diaries provided valuable insights and the framework was a useful tool to explore the COVID-19 lockdown context. The findings indicate that organic capacity building took place, primarily via individual agency, highlighting the risk of communities being 'left behind' if there were not individuals or community networks available with resources to plug gaps in organisational support. Recommendations to sustain helpful responses to the pandemic include further consideration of ongoing community mobilisation, empowerment and community control within the capacity building framework.

A comparison of emotion-focused therapy and cognitive-behavioral therapy in the treatment of generalized anxiety disorder: Results of a feasibility randomized controlled trial.

Generalized anxiety disorder (GAD) is a chronic mental health difficulty typically present in primary care settings. Cognitive-behavioral therapy (CBT) is the psychological intervention with the best evidence for its efficacy for GAD. The development of other psychological interventions can increase client choice. This feasibility trial examined an initial assessment of the efficacy of EFT in comparison to CBT in the treatment of GAD in the context of an Irish public health service. The trial provided information on recruitment, therapist training/adherence, and client retention relevant for a potential noninferiority trial. A randomized controlled trial compared the efficacy of EFT versus CBT for GAD. Both therapies were offered in a 16-20 sessions format. Therapists (n = 8) were trained in both conditions and offered both therapies. Clients were randomly assigned to the two therapies EFT (n = 29) and CBT (n = 29). Outcomes were assessed using several measures, with the Generalized Anxiety Disorder-7 (GAD-7) being the primary outcome. Clients were assessed at baseline, week 16, end of therapy, and at 6-month follow-up. Therapists were able to learn the two models after a short training and showed moderate levels of adherence. Although not statistically significant, the drop out from treatment was 10% for EFT and 27% for CBT. The two therapies showed large pre-post change and similar outcomes across all measures, with these benefits retained at 6-month follow-up. Results suggest that EFT is a potentially promising treatment for GAD. Further investigation is indicated to establish its potential to expand the available psychological therapies for GAD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Public perspectives of social prescribing.

BACKGROUND: There is a strong national drive within the UK government and National Health Service for social prescribing. Previous research studies have mainly focused on service user perspectives and evaluating their experiences. There is limited evidence on how the general public perceive and understand what social prescribing is and how these views could influence service planning and delivery. This paper seeks to understand perceptions of social prescribing within the wider community. METHODS: Semi-structured focus groups were conducted with 37 members of the public in four areas in north-west England. We explored public awareness and understanding of social prescribing. RESULTS: Limited knowledge of the term social prescribing was found amongst participants as well as limited involvement in community discussions of the topic. Concerns were raised about the short-term nature of activities and the need for adequate resourcing to support continuity of service provision. The social prescribing link worker was considered to be important in supporting engagement with services and it was preferred this role was undertaken by people with local knowledge. CONCLUSIONS: The findings provide evidence of public perspectives on social prescribing and highlight how wider community perceptions can supplement service user feedback to support social prescribing service planning, commissioning and delivery.

'A lot of small things make a difference'. Mental health and strategies of coping during the COVID-19 pandemic.

INTRODUCTION: The social and economic consequences of COVID-19 have the potential to affect individuals and populations through different pathways (e.g., bereavement, loss of social interaction). OBJECTIVE: This study adopted a solicited diary method to understand how mental health was affected during England's first lockdown. We also considered the experiences of diary keeping during a pandemic from the perspective of public participants. METHODS: Fifteen adults older than 18 years of age were recruited from northwest England. Diarists completed semistructured online diaries for 8 weeks, which was combined with weekly calls. A focus group captured participants' experiences of diary keeping. FINDINGS: Four key factors influenced mental health, which fluctuated over time and in relation to diarists' situations. These concerned navigating virus risk, loss of social connections and control and constrictions of the domestic space. Diarists also enacted a range of strategies to cope with the pandemic. This included support from social networks, engagement with natural environments, establishing normality, finding meaning and taking affirmative action. CONCLUSION: Use of diary methods provided insights into the lived experiences of the early months of a global pandemic. As well as contributing evidence on its mental health effects, diarists' accounts illuminated considerable resourcefulness and strategies of coping with positive effects for well-being. While diary keeping can also have therapeutic benefits during adversity, ethical and practical issues need to be considered, which include the emotional nature of diary keeping. PUBLIC CONTRIBUTION: Members of the public were involved in interpretation of data as well as critiquing the overall diary method used in the study.

Addressing nutrient shortfalls in 1- to 5-year-old Irish children using diet modeling: development of a protocol for use in country-specific population health.

BACKGROUND: Dietary habits formed in early childhood can track into later life with important impacts on health. Food-based dietary guidelines (FBDGs) may have a role in improving population health but are lacking for young children. OBJECTIVES: We aimed to establish a protocol for addressing nutrient shortfalls in 1- to 5-y-old children (12-60 mo) using diet modeling in a population-based sample. METHODS: Secondary analysis of 2010-2011 Irish National Pre-School Nutrition Survey data (n = 500) was conducted to identify typical food consumption patterns in 1- to 5-y-olds. Nutrient intakes were assessed against dietary reference values [European Food Safety Authority (EFSA) and Institute of Medicine (IOM)]. To address nutrient shortfalls using diet modeling, 4-d food patterns were developed to assess different milk-feeding scenarios (human milk, whole or low-fat cow milk, and fortified milks) within energy requirement ranges aligned with the WHO growth standards. FBDGs to address nutrient shortfalls were established based on 120 food patterns. RESULTS: Current mean dietary intakes for the majority of 1- to 5-y-olds failed to meet reference values (EFSA) for vitamin D (≤100%), vitamin E (≤88%), DHA (22:6n-3) + EPA (20:5n-3) (IOM; ≤82%), and fiber (≤63%), whereas free sugars intakes exceeded recommendations of <10% energy (E) for 48% of 1- to 3-y-olds and 75% of 4- to 5-y-olds. "Human milk + Cow milk" was the only milk-feeding scenario modeled that predicted sufficient DHA + EPA among 1- to 3-y-olds. Vitamin D shortfalls were not correctable in any milk-feeding scenario, even with supplementation (5 µg/d), apart from the "Follow-up Formula + Fortified drink" scenario in 1- to 3-y-olds (albeit free sugars intakes were estimated at 12%E compared with ≤5%E as provided by other scenarios). Iron and vitamin E shortfalls were most prevalent in scenarios for 1- to 3-y-olds at ≤25th growth percentile. CONCLUSIONS: Using WHO growth standards and international reference values, this study provides a protocol for addressing nutrient shortfalls among 1- to 5-y-olds, which could be applied in country-specific population health.

Growth and Nutritional Intake of Infants with Univentricular Circulation.

OBJECTIVES: To evaluate the nutritional status and early nutritional intake of infants with univentricular congenital heart disease. STUDY DESIGN: The included infants underwent a Norwood procedure or hybrid intervention (stage 1) within the first 6 weeks of life, between January 2014 and January 2019, at Children's Health Ireland at Crumlin. Demographic, anthropometric, nutritional intake, and morbidity data were collected. RESULTS: Data were collected on 90 infants and 1886 neonatal admission days. There was a significant drop in mean weight-for-age z-score (WAZ) between measurements at birth, -0.01 and on discharge post stage 1 surgery -1.45 (P < .01). On hospital discharge (median hospital stay, 25 days) 32% of infants had a WAZ <-2 and 11% had a WAZ <-3. Pre-stage 1, 26% received trophic feeds and 39% received parenteral nutrition. Basal metabolic requirements and target caloric intake (120 kcal/kg) were met on 56% and 13% of admission days, respectively. Infants referred to a dietitian had a shorter time to any form of nutrition support, enteral feeds, and target caloric intake (P < .001, P = .016, and P = .048, respectively). At stage 3 (Fontan) surgery, 15% of infants were classified as stunted (length-for-age z-score [LAZ] <-2). CONCLUSIONS: The greatest decline in nutritional status occurs in the neonatal period, followed by significant growth stunting by the time of the Fontan procedure. Early involvement of dietitians is critical in the care of this nutritionally fragile group. With the currently low rate of preoperative nutritional support, there may be opportunities to improve intake at this critical stage.