Assessing deprescribing tools for implementation in care homes: A qualitative study of the views of care home staff.

BACKGROUND: Care home residents often experience polypharmacy (defined as taking five or more regular medicines). Therefore, we need to ensure that residents only take the medications that are appropriate or provide value (also known as medicines optimisation). To achieve this, deprescribing, or the reduction or stopping of prescription medicines that may no longer be providing benefit, can help manage polypharmacy and improve outcomes. Various tools, guides, and approaches have been developed to help support health professionals to deprescribe in regular practice. Little evaluation of these tools has been conducted and no work has been done in the care home setting. OBJECTIVE: This qualitative study aimed to assess distinct types of deprescribing tools for acceptability, feasibility, and suitability for the care home setting. METHODS: Cognitive (think-aloud) interviews with care home staff in England were conducted (from December 2021 to June 2022) to assess five different deprescribing tools. The tools included a general deprescribing guidance, a generic (non-drug specific) deprescribing framework, a drug-specific deprescribing guideline/guide, a tool for identifying potentially inappropriate medications, and an electronic clinical decision support tool. Participants were recruited via their participation in another deprescribing study. The Consolidated Framework for Implementation Research informed the data collection and analysis. RESULTS: Eight care home staff from 7 different care homes were interviewed. The five deprescribing tools were reviewed and assessed as not acceptable, feasible, or suitable for the care home setting. All would require significant modifications for use in the care home setting (e.g., language, design, and its function or use with different stakeholders). CONCLUSIONS: As none of the tools were deemed acceptable, feasible, and suitable, future work is warranted to develop and tailor deprescribing tools for the care home setting, considering its specific context and users. Deprescribing implemented safely and successfully in care homes can benefit residents and the wider health economy.

Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study.

OBJECTIVES: To explore the factors that may help or hinder deprescribing practice for older people within care homes. DESIGN: Qualitative semistructured interviews using framework analysis informed by the Consolidated Framework for Implementation Research (CFIR). SETTING: Participants were recruited from two care home provider organisations (a smaller independently owned organisation and a large organisation) in England. PARTICIPANTS: A sample of 23 care home staff, 8 residents, 4 family members and 1 general practitioner were associated with 15 care homes. RESULTS: Participants discussed their experiences and perceptions of implementing deprescribing within care homes. Major themes of (1) deprescribing as a complex process and (2) internal and external contextual factors influencing deprescribing practice (such as beliefs, abilities and relationships) were interrelated and spanned several CFIR constructs and domains. The quality of local relationships with and support from healthcare professionals were considered more crucial factors than the type of care home management structure. CONCLUSIONS: Several influencing social and contextual factors need to be considered for implementing deprescribing for older adults in care homes. Additional training, tools, support and opportunities need to be made available to care home staff, so they can feel confident and able to question or raise concerns about medicines with prescribers. Further work is warranted to design and adopt a deprescribing approach which addresses these determinants to ensure successful implementation.

Models of Care and Relationships with Care Homes: Cross-Sectional Survey of English General Practices.

The Enhanced Health in Care Homes framework for England sets out standards for how primary care should work with care homes. How care home staff and General Practitioners work together and the quality of their working relationships are core to resident healthcare. This study explored the current models of care and relationships between General Practitioners' practices and care homes. Sixty-seven respondents from 35 practices were recruited in the East of England and completed a semi-structured online survey. Responses were analysed using descriptive statistics. Free text responses were interpreted thematically. The number of care homes that practices supported ranged from 0-15. Most reported having designated General Practitioners working with care homes and a good working relationship. Despite the national rollout of the Enhanced Health in Care Homes framework, two-thirds reported no recent changes in how they worked with care homes. There is a shift towards practices working with fewer care homes and fewer accounts of fractured working relationships, suggesting that residents' access to primary care is improving. The continuing variability suggests further work is needed to ensure it is driven by context, not inequitable provision. Future work needs to address how policy changes are changing work practices and residents' health outcomes.

Reflections on a personalized cognitive rehabilitation intervention: Experiences of people living with dementia and their carers participating in the GREAT trial.

Cognitive rehabilitation for people living with early-stage dementia improves functional ability in areas targeted in the therapy, but little is known about how participants experience this intervention. This qualitative paper investigates participants' views about a cognitive rehabilitation intervention in a randomized controlled trial (the GREAT trial) and aims to help explain and interpret the findings and to inform further intervention development. Using in-depth thematic analysis, 43 semi-structured interviews (35 individual and 8 dyadic) were conducted with 25 people living with dementia and 26 family carers from three sites. The person-centred, individualized approach was valued. Some participants' views about dementia were questioned as a consequence of taking part in the therapy; they considered the effectiveness of the intervention in the context of the progressive nature of the condition. Certain participants continued to be doubtful, focussing on the inevitability of decline, rather than the possibility of reablement. Such views may have influenced engagement. The therapeutic relationship played a vital role as it was how personalized care was provided and participants' views had changed positively. Therapists engendered greater confidence and reduced anxiety and social isolation. Positive responses support personalized rehabilitative care to address the specific needs of people living with dementia.

Behaviour change interventions to increase physical activity in hospitalised patients: a systematic review, meta-analysis and meta-regression.

BACKGROUND: Low physical activity levels are a major problem for people in hospital and are associated with adverse outcomes. OBJECTIVE: This systematic review, meta-analysis and meta-regression aimed to determine the effect of behaviour change interventions on physical activity levels in hospitalised patients. METHODS: Randomised controlled trials of behaviour change interventions to increase physical activity in hospitalised patients were selected from a database search, supplemented by reference list checking and citation tracking. Data were synthesised with random-effects meta-analyses and meta-regression analyses, applying Grades of Recommendation, Assessment, Development and Evaluation criteria. The primary outcome was objectively measured physical activity. Secondary measures were patient-related outcomes (e.g. mobility), service level outcomes (e.g. length of stay), adverse events and patient satisfaction. RESULTS: Twenty randomised controlled trials of behaviour change interventions involving 2,568 participants (weighted mean age 67 years) included six trials with a high risk of bias. There was moderate-certainty evidence that behaviour change interventions increased physical activity levels (SMD 0.34, 95% CI 0.14-0.55). Findings in relation to mobility and length of stay were inconclusive. Adverse events were poorly reported. Meta-regression found behaviour change techniques of goal setting (SMD 0.29, 95% CI 0.05-0.53) and feedback (excluding high risk of bias trials) (SMD 0.35, 95% CI 0.11-0.60) were independently associated with increased physical activity. CONCLUSIONS: Targeted behaviour change interventions were associated with increases in physical activity in hospitalised patients. The trials in this review were inconclusive in relation to the patient-related or health service benefits of increasing physical activity in hospital.

Assessing the fidelity of the independently getting up off the floor (IGO) technique as part of the ReTrain pilot feasibility randomised controlled trial for stroke survivors.

PURPOSE: Hemiparesis and physical deconditioning following stroke lead to an increase in falls, which many individuals cannot get up from. Teaching stroke survivors to independently get off the floor (IGO) might mitigate long-lie complications. IGO was taught as part of a community-based, functional rehabilitation training programme (ReTrain). We explore the feasibility of teaching IGO and assess participant's level of mastery, adherence, and injury risk. MATERIALS AND METHODS: Videos of participants (n = 17) performing IGO at early, middle, and late stages of the ReTrain programme were compared to a manualised standard. A visual, qualitative analysis was used to assess technique mastery, adherence, and injury risk. RESULTS: Most participants (64%) achieved independent, safe practice of IGO. A good (73%) level of adherence to IGO and low incidence of risk of injury (6.8%) were observed. Deviations were made to accommodate for non-stroke related comorbidities. CONCLUSIONS: IGO was successfully and safely practised by stroke survivors including those with hemiparesis. Trainers should be aware of comorbidities that may impede completion of IGO and modify teaching to accommodate individual need. Further research should assess if IGO can be utilised by individuals who have other disabilities with unilateral impairments and whether IGO has physical, functional and economic benefit.Implications for rehabilitationFalls are common in stroke survivors, and many are unable to get up despite being uninjured, leading to long-lie complications or ambulance call-outs but non-conveyance to hospital.Teaching the independently getting up off the floor (IGO) technique to stroke survivors was possible for those with or without hemiparesis, and remained safe despite modifications to accommodate an individual's needs.Individual assessment is needed to check if a stroke survivor is suitable for learning IGO including, but not limited to, their ability to safely get to the floor and to temporarily stand (without support) at the end of the technique.

Implementation processes in a cognitive rehabilitation intervention for people with dementia: a complexity-informed qualitative analysis.

OBJECTIVES: Healthcare is often delivered through complex interventions. Understanding how to implement these successfully is important for optimising services. This article demonstrates how the complexity theory concept of 'self-organisation' can inform implementation, drawing on a process evaluation within a randomised controlled trial of the GREAT (Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer's and related dementias: a multi-centre single-blind randomised controlled Trial) intervention which compared a cognitive rehabilitation intervention for people with dementia with usual treatment. DESIGN: A process evaluation examined experiences of GREAT therapists and participants receiving the intervention, through thematic analysis of a focus group with therapists and interviews with participants and their carers. Therapy records of participants receiving the intervention were also analysed using adapted framework analysis. Analysis adopted a critical realist perspective and a deductive-inductive approach to identify patterns in how the intervention operated. SETTING: The GREAT intervention was delivered through home visits by therapists, in eight regions in the UK. PARTICIPANTS: Six therapists took part in a focus group, interviews were conducted with 25 participants and 26 carers, and therapy logs for 50 participants were analysed. INTERVENTION: A 16-week cognitive rehabilitation programme for people with mild-to-moderate dementia. RESULTS: 'Self-organisation' of the intervention occurred through adaptations made by therapists. Adaptations included simplifying the intervention for people with greater cognitive impairment, and extending it to meet additional needs. Relational work by therapists produced an emergent outcome of 'social support'. Self-organised aspects of the intervention were less visible than formal components, but were important aspects of how it operated during the trial. This understanding can help to inform future implementation. CONCLUSIONS: Researchers are increasingly adopting complexity theory to understand interventions. This study extends the application of complexity theory by demonstrating how 'self-organisation' was a useful concept for understanding aspects of the intervention that would have been missed by focusing on formal intervention components. Analysis of self-organisation could enhance future process evaluations and implementation studies. TRIAL REGISTRATION NUMBER: ISRCTN21027481.

A Culturally Sensitive Social Support Intervention for Chinese American Breast Cancer Survivors (Joy Luck Academy): Protocol for a Randomized Controlled Trial.

BACKGROUND: Breast cancer is the most prevalent type of cancer among Asian American women. Chinese American immigrant breast cancer survivors face unique challenges because of cultural and socioecological factors. They report emotional distress and the need for social, emotional, and spiritual support. However, culturally and linguistically appropriate information for managing survivorship health care is often unavailable. OBJECTIVE: To improve the health outcomes for this underserved and understudied population, we developed, designed, and launched a randomized controlled trial to test the health benefits of a culturally sensitive social support intervention (Joy Luck Academy). In this paper, we describe the research protocol. METHODS: This randomized controlled trial will enroll Chinese-speaking, stage 0 to 3 breast cancer survivors who have completed treatment within the previous 36 months using a community-based participatory research approach. We will randomly assign 168 participants to the intervention or control group. The intervention arm will attend 7 weekly 3.5-hour peer mentor and educational sessions. The control group will receive the educational information. We will assess health outcomes at baseline, immediately after the Joy Luck Academy, and at 1- and 4-month follow-ups. The primary outcome is quality of life, as measured by the Functional Assessment of Cancer Therapy scale. Secondary outcomes include depressive symptoms, positive affect, fatigue, and perceived stress. We will also explore how the intervention influences cortisol levels. To identify how and to whom the program is effective, we will measure social and personal resources and theorized mechanisms and perform qualitative interviews with a subsample of participants to enhance the interpretation of quantitative data. RESULTS: Recruitment began in February 2015, and data collection was completed in February 2019. We expect to complete data management by August 2021 and publish results in 2022. CONCLUSIONS: If the Joy Luck Academy is demonstrated to be effective, it may be easily disseminated as an intervention for other groups of Asian American immigrant breast cancer survivors. Furthermore, similar programs could be integrated into other diverse communities. TRIAL REGISTRATION: ClinicalTrials.gov NCT02946697; http://clinicaltrials.gov/ct2/show/NCT02946697. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30950.

A multi-stakeholder approach to the co-production of the research agenda for medicines optimisation.

BACKGROUND: Up to 50% of medicines are not used as intended, resulting in poor health and economic outcomes. Medicines optimisation is 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. The purpose of this exercise was to co-produce a prioritised research agenda for medicines optimisation using a multi-stakeholder (patient, researcher, public and health professionals) approach. METHODS: A three-stage, multiple method process was used including: generation of preliminary research questions (Stage 1) using a modified Nominal Group Technique; electronic consultation and ranking with a wider multi-stakeholder group (Stage 2); a face-to-face, one-day consensus meeting involving representatives from all stakeholder groups (Stage 3). RESULTS: In total, 92 research questions were identified during Stages 1 and 2 and ranked in order of priority during stage 3. Questions were categorised into four areas: 'Patient Concerns' [e.g. is there a shared decision (with patients) about using each medicine?], 'Polypharmacy' [e.g. how to design health services to cope with the challenge of multiple medicines use?], 'Non-Medical Prescribing' [e.g. how can the contribution of non-medical prescribers be optimised in primary care?], and 'Deprescribing' [e.g. what support is needed by prescribers to deprescribe?]. A significant number of the 92 questions were generated by Patient and Public Involvement representatives, which demonstrates the importance of including this stakeholder group when identifying research priorities. CONCLUSIONS: A wide range of research questions was generated reflecting concerns which affect patients, practitioners, the health service, as well the ethical and philosophical aspects of the prescribing and deprescribing of medicines. These questions should be used to set future research agendas and funding commissions.

The role of acculturation in the relationship between self-stigma and psychological distress among Chinese American breast cancer survivors.

Attitudes about breast cancer have improved in the USA, yet stigma is still present in some ethnic and immigrant populations and affecting survivors' experiences. Chinese American breast cancer survivors report negative beliefs and stigma to be a major stressor; this could result in mental health consequences. We hypothesized that greater self-stigma will be related to greater psychological distress (namely, depressive symptoms, and perceived stress). Furthermore, we expected that the association between self-stigma and psychological distress will be stronger among Chinese American breast cancer survivors who are less acculturated to the USA than those who are highly acculturated. One hundred and thirty-six Chinese American breast cancer survivors completed questionnaires that measured self-stigma, acculturation, depressive symptoms, perceived stress, and demographic information. Hierarchical linear regressions were conducted to examine the main effect of stigma on depressive symptoms and perceived stress, and the moderating effect of acculturation. As predicted, self-stigma was associated with greater depressive symptoms and perceived stress among Chinese American breast cancer survivors, especially those who are less acculturated. Self-stigma may play a part in psychological adjustment among Chinese American breast cancer survivors. Interventions that incorporate techniques to reduce self-stigma could be beneficial for Chinese American breast cancer survivors, especially for those who are less acculturated to American society.

Benefits of a Psychosocial Intervention on Positive Affect and Posttraumatic Growth for Chinese American Breast Cancer Survivors: A Pilot Study.

Breast cancer survivors report persistent psychological and physical symptoms, which affect their quality of life and may challenge the recovery process. Due to social, cultural, and linguistic barriers, culturally sensitive care is largely unavailable for Chinese Americans, and their psychological needs are not often addressed. We aimed to investigate whether the Joy Luck Academy (JLA), a psychosocial intervention providing both information and peer support, was associated with positive adjustment among Chinese American breast cancer survivors. Thirty-nine Chinese American breast cancer survivors participated in a pilot psychosocial intervention. The educational materials and lectures were delivered in the participants' native language of Chinese. All of the educators and mentors shared the same linguistic and cultural background with the participants. The program utilized a community-based participatory research (CBPR) approach to further enhance the cultural sensitivity of the intervention. Participants' post-traumatic growth and positive affect were assessed before and after the intervention. The JLA showed an improvement in positive affect, and they had a greater appreciation for life. The intervention was found to be feasible, well-accepted, and beneficial for this population. Chinese American breast cancer survivors reported improved psychological health after attending the intervention. These findings encourage the development and implementation of psychosocial interventions for Chinese breast cancer survivors. Similar programs could be integrated into other ethnic or cultural communities.

Successful Strategies for Engaging Chinese Breast Cancer Survivors in a Randomized Controlled Trial.

Chinese immigrant breast cancer survivors face various challenges due to cultural and socioecological factors. Research efforts to develop culturally sensitive interventions have been limited by lack of knowledge regarding successful recruitment and implementation practices among Chinese immigrant populations. This paper documents strategies utilized during the development and implementation of a randomized controlled trial of a culturally sensitive psychosocial intervention for Chinese immigrant breast cancer survivors. In partnership with a community agency, we developed culturally and linguistically appropriate research materials, recruited participants from community channels, and conducted longitudinal data collection. Key strategies include building equitable research partnerships with community agencies to engage participants; being responsive to the needs of community agencies and participants; considering within-group diversity of the research population; utilizing recruitment as an opportunity for relationship-building with participants; and developing key strategies to promote retention. Successful participant engagement in cancer intervention research is the result of collaboration among breast cancer survivors, community leaders and agencies, and academic researchers. The engagement process for this study is novel because we have emphasized cultural factors in the process and taken a relational approach to recruitment and retention.

Relationship between perceptions of ageing and frailty in English older adults.

Older adults' negative beliefs about ageing are related to their health and functioning, but little is known about how perceptions of ageing (POA) relate to frailty status. This study aimed to explore the relationship between POA and frailty. Secondary analysis of data used were from the English Longitudinal Study of Ageing Waves 2 and 5. A POA score was based on participants' responses to 12 statements using a five-point Likert scale at baseline, and a Frailty Index (FI) score was calculated for each participant for both waves. Multiple linear regression models were conducted to assess the relationship between POA and frailty cross-sectionally and longitudinally in models controlled for age, gender, depression symptoms, and socioeconomic status. Older adults with more negative POA had greater frailty (ß = .12, p < .001). Negative POA predicted greater frailty 6 years later (ß = .03, p < .05). Future work regarding the mechanisms of this relationship is needed to identify ways of intervening to improve health.

Relation of social constraints on disclosure to adjustment among Chinese American cancer survivors: A multiprocesses approach.

PURPOSE: The present study examines the association between social constraints and depressive symptoms among Chinese American breast cancer survivors, and the mechanism underling this association. A multiprocesses model is tested to examine the mediating roles of ambivalence over emotional expression (AEE), avoidance, intrusive thoughts, and social support in the association between social constraints and depressive symptoms among Chinese American breast cancer survivors. METHODS: Ninety-six Chinese American breast cancer survivors were recruited from Chinese community organizations. They were asked to complete a questionnaire package that assessed social constraints, AEE, avoidance, intrusive thoughts, social support, depressive symptoms, and demographic information. Path analysis was conducted to test the hypothesized model. RESULTS: The overall and specific indirect effects of social constraints on depressive symptoms through AEE, avoidance, intrusive thoughts, and social support are significant. When the mediators are controlled for, the direct effect of social constraints on depressive symptoms is no longer significant. CONCLUSIONS: A multiprocesses model of social constraints and depressive symptoms is tested in a sample of Chinese American breast cancer survivors. The findings suggest that the existence of multiple pathways through which social constraints may associate with depressive symptoms among Chinese American breast cancer survivors.

Exploring the Social Needs and Challenges of Chinese American Immigrant Breast Cancer Survivors: a Qualitative Study Using an Expressive Writing Approach.

PURPOSE: Little is known about the psychological well-being and social barriers among immigrant Chinese American breast cancer survivors. The aim of the present study was to explore the social needs and challenges of Chinese American immigrant breast cancer survivors. METHOD: This study used the expressive writing approach to explore the experiences among 27 Chinese American breast cancer survivors. The participants were recruited through community-based organizations in Southern California, most of whom were diagnosed at stages I and II (33 and 48%, respectively). Participants, on average, had been living in the USA for 19 years. Participants were asked to write three 20-min essays related to their experience with breast cancer (in 3 weeks). Participants' writings were coded with line-by-line analysis, and categories and themes were generated. RESULTS: Emotion suppression, self-stigma, and perceived stigma about being a breast cancer survivor were reflected in the writings. Interpersonally, participants indicated their reluctance to disclose cancer diagnosis to family and friends and concerns about fulfilling multiple roles. Some of them also mentioned barriers of communicating with their husbands. Related to life in the USA, participants felt unfamiliar with the healthcare system and encountered language barriers. CONCLUSION: Counseling services addressing concerns about stigma and communication among family members may benefit patients' adjustments. Tailor-made information in Chinese about diagnosis and treatment for breast cancer and health insurance in the USA may also help patients go through the course of recovery.

Fear of cancer recurrence and physical well-being among Chinese cancer survivors: the role of conscientiousness, positive reappraisal and hopelessness.

PURPOSE: The degree to which conscientiousness contributes to well-being in Chinese cancer survivors and the mechanisms through which conscientiousness is associated with well-being remain unclear. Based on Lent's restorative well-being model [1], the current study tested a mediation model of the contribution of conscientiousness, positive reappraisal, and hopelessness to fear of cancer recurrence (FCR), and physical well-being in a sample of 238 Chinese cancer survivors. METHOD: Participants completed self-report questionnaires. Path analysis was used to analyze the linear relationships between the variables. RESULTS: The empirical model supported the mediator roles of positive reappraisal and hopelessness. Specifically, the results indicated that conscientiousness was first associated with positive reappraisal, which in turn was associated with decreased hopelessness, resulting in decreased FCR and improved physical well-being. In addition, the results showed that conscientiousness was associated with decreased hopelessness, which was then associated with decreased FCR and greater physical well-being. CONCLUSION: Conscientiousness confers benefits on FCR and physical well-being through the mechanisms of positive reappraisal and decreased hopelessness.

Differences in quality of life between American and Chinese breast cancer survivors.

OBJECTIVE: It has been speculated that cancer survivors in Asia may have lower quality of life (QOL) compared with their Western counterparts. However, no studies have made international comparisons in QOL using a comprehensive measure. This study aimed to compare Chinese breast cancer survivors' QOL with US counterparts and examine if demographic and medical factors were associated with QOL across groups. METHOD: The sample consisted of 159 breast cancer patients (97 Chinese and 62 American) who completed the Functional Assessment for Cancer Therapy Breast Cancer (FACT-B) scale before the start of radiotherapy in Shanghai, China and Houston, USA. RESULTS: Higher income was associated with higher QOL total scores in both Chinese and American cancer patients, but QOL was not significantly associated with other factors including age, education, disease stage, mastectomy, and chemotherapy. Consistent with hypotheses, compared to their US counterparts, Chinese breast cancer survivors reported lower QOL and all four subdimensions including functional well-being (FWB), physical well-being (PWB), emotional well-being (EWB), and social well-being (SWB); they also reported more breast cancer-specific concerns (BCS). Differences were also clinically significant for Functional Assessment for Cancer Therapy General (FACT-G) scale total scores and the FWB subscale. After controlling for demographic and medical covariates, these differences remained except for the SWB and BCS. Furthermore, Chinese breast cancer survivors receiving chemotherapy reported significantly lower FACT-G scores than those who did not, but this difference did not emerge among US breast cancer survivors. DISCUSSION: Chinese breast cancer survivors reported poorer QOL on multiple domains compared to US women. Findings indicate that better strategies are needed to help improve the QOL of Chinese breast cancer survivors, especially those who underwent chemotherapy.

Creating psychological connections between intervention recipients: development and focus group evaluation of a group singing session for people with aphasia.

OBJECTIVES: The study sought to identify key design features that could be used to create a new framework for group-based health interventions. We designed and tested the first session of a group intervention for stroke survivors with aphasia which was aimed at nurturing new psychological connections between group members. SETTING: The intervention session, a participant focus group and interviews with intervention facilitators were held in a local community music centre in the South West of England. PARTICIPANTS: A convenience sample of 10 community-dwelling people with poststroke aphasia participated in the session. Severity of aphasia was not considered for inclusion. INTERVENTION: Participants took part in a 90-min group singing session which involved singing songs from a specially prepared song book. Musical accompaniment was provided by the facilitators. PRIMARY AND SECONDARY OUTCOME MEASURES: Participants and group facilitators reported their experiences of participating in the session, with a focus on activities within the session related to the intervention aims. Researcher observations of the session were also made. RESULTS: Two themes emerged from the analysis, concerning experiences of the session ('developing a sense of group belonging') and perceptions of its design and delivery ('creating the conditions for engagement'). Participants described an emerging sense of shared social identity as a member of the intervention group and identified fixed (eg, group size, session breaks) and flexible (eg, facilitator responsiveness) features of the session which contributed to this emergence. Facilitator interviews and researcher observations corroborated and expanded participant reports. CONCLUSIONS: Engagement with health intervention content may be enhanced in group settings when intervention participants begin to establish positive and meaningful psychological connections with other group members. Understanding and actively nurturing these connections should be a core feature of a general framework for the design and delivery of group interventions.

Older adults' perceptions of ageing and their health and functioning: a systematic review of observational studies.

Many older people perceive ageing negatively, describing it in terms of poor or declining health and functioning. These perceptions may be related to older adults' health. The aim of this review was to synthesise existing research on the relationship between older adults' perceptions of ageing and their health and functioning. A systematic search was conducted of five electronic databases (ASSIA, CINAHL, IBSS, MEDLINE and PsycINFO). Citations within identified reports were also searched. Observational studies were included if they included perceptions of ageing and health-related measures involving participants aged 60 years and older. Study selection, data extraction and quality appraisal were conducted using predefined criteria. Twenty-eight reports met the criteria for inclusion. Older adults' perceptions of ageing were assessed with a variety of measures. Perceptions were related to health and functioning across seven health domains: memory and cognitive performance, physical and physiological performance, medical conditions and outcomes, disability, care-seeking, self-rated health, quality of life and death. How ageing is perceived by older adults is related to their health and functioning in multiple domains. However, higher quality and longitudinal studies are needed to further investigate this relationship.