Exploring access and engagement with Improving Access to Psychological Therapies (IAPT) services, before, during, and after the COVID-19 lockdown: A service evaluation in the Northwest of England.

The purpose of this study was to compare clients' prevalence and explore the characteristics that predicted access and engagement with IAPT treatment before, during, and after Lockdown.We conducted a retrospective observational service evaluation, using routinely collected IAPT data from n = 13,019 clients who entered treatment between March and September in 2019, 2020, and 2021. Chi-square and multiple logistic regression were used to explore associations and potential predictors of access and engagement with IAPT treatment.The number of people accessing and engaging with IAPT treatment was significantly higher after lockdown compared to before. Unemployed clients were less likely to access treatment during and after lockdown. Yet, perinatal clients and people from a black ethnic background were more likely to access treatment during lockdown. Being young and being unemployed were predictors of treatment disengagement across all three time points, whereas perinatal clients were less likely to engage only before and during lockdown. Clients who were not prescribed medication and clients with a long-term condition were more likely to engage during lockdown.The demonstrated changes in access and engagement with IAPT treatment after the introduction of remote therapy urges the services to further consider the individual needs of specific client groups.

Prevalence of medically unexplained symptoms in adults who are high users of healthcare services and magnitude of associated costs: a systematic review.

INTRODUCTION: Medically unexplained symptoms (MUS) is a common clinical syndrome in primary and secondary healthcare service. Outcomes for patients with persistent MUS include increased disability, poorer quality of life and higher healthcare costs. The aim of this systematic review was to determine the prevalence of MUS in patients who are high users of healthcare or high-cost patients in comparison with routine users and the magnitude of associated costs. DESIGN: A systematic review of the available literature. DATA SOURCES AND ELIGIBILITY CRITERIA: The following electronic databases were systematically searched without language restriction from inception to June 2018 and updated on 22 October 2021: MEDLINE, PsycINFO, EMBASE, CINAHL and PROSPERO. Inclusion criteria included studies investigating adults aged ≥18 years, who were high healthcare users or accrued high healthcare costs, in which the prevalence and/or associated costs of MUS was quantified. Two reviewers independently extracted information on study characteristics, exposure and outcomes. RESULTS: From 5622 identified publications, 25 studies from 9 countries involving 31 650 patients were selected for inclusion. Due to high risk of bias in many studies and heterogeneity between studies, results are described narratively. There were wide variations in prevalence estimates for MUS in high users of healthcare (2.9%-76%), but MUS was more prevalent in high use groups compared with low use groups in all but one of the 12 studies that included a comparator group. Only three studies investigated healthcare costs associated with MUS, and all three reported greater healthcare costs associated with MUS. CONCLUSION: MUS has been found to be more prevalent in high use healthcare populations than comparator groups, but the magnitude of difference is difficult to estimate due to considerable heterogeneity between studies and potential for bias. Future studies should prioritise a standardised approach to this research area, with agreed definitions of MUS and high healthcare use. PROSPERO REGISTRATION NUMBER: CRD42018100388.

Prevalence of depression and anxiety in patients with chronic obstructive pulmonary disease and their association with psychosocial outcomes: A cross-sectional study from Pakistan.

OBJECTIVES: Chronic obstructive pulmonary disease contributes to substantial health and economic burden worldwide. Co-morbid depression and anxiety are highly prevalent in patients with chronic obstructive pulmonary disease. Depressive symptoms in chronic obstructive pulmonary disease are associated with poorer survival, longer hospitalisation and impaired quality of life. Literature on chronic obstructive pulmonary disease is largely derived from high-income countries; yet 90% of deaths related to chronic obstructive pulmonary disease occur in low- and middle-income countries. We aimed to establish the prevalence of anxiety and depression in patients with chronic obstructive pulmonary disease, as well as the association with psychosocial outcomes. METHODS: This was a cross-sectional study of chronic obstructive pulmonary disease patients attending outpatient primary care clinics in Karachi, Pakistan. The Patient Health Questionnaire-9 was used to assess depression and the Generalised Anxiety Disorder-7 scale was used for the assessment of anxiety. Health-related quality of life was assessed with EuroQol-Five Dimensions, social support with Oslo-3 and social stress with Life Events Checklist. We recruited 293 subjects. RESULTS: The prevalence of depression and anxiety in the sample was 51% (n = 149) and 20% (n = 59), respectively. Depressed chronic obstructive pulmonary disease patients reported significantly lower health-related quality of life scores as compared to non-depressed patients. Participants with depression had significantly higher levels of anxiety, less social support, higher social stress and more subjective impairment in quality of life. CONCLUSION: Given the association with reduced social support and increased perceived stress, the role of psychosocial interventions must be explored in improving outcomes of chronic obstructive pulmonary disease patients in Pakistan.

Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis.

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects. METHOD: We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747. RESULTS: We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I2, 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]). CONCLUSION: Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.

Recruitment and methodological issues in conducting dementia research in British ethnic minorities: A qualitative systematic review.

OBJECTIVE: Identifying existing recruitment and methodological issues within dementia research conducted in UK studies that included ethnic minorities. METHODS: We searched for and included any publication detailing dementia research in the UK that included any ethnic minority. The search results and all titles and abstracts were screened according to the inclusion criteria followed by screening of the full texts. We extracted data regarding the recruitment and methodological issues faced by the researchers. This data was combined and listed, and related issues were grouped into overarching themes and subthemes. RESULTS: Of 52 publications suitable for analysis, 33 provided data collated into six themes: attitudes and beliefs about dementia in ethnic minority communities, recruitment process, data collection issues, practical issues, researcher characteristics, and lack of published research and normative data. These themes allowed us to identify three areas responsible for addressing these recruitment and methodological issues: community and patient education, health services, and researchers' training. CONCLUSIONS: This is the first review identifying recruitment and methodological issues within UK dementia research that included ethnic minorities. We now have a compilation of reported existing issues and a framework of areas responsible for addressing them and devising solutions.

Preventing depression in the community by voluntary sector providers (PERSUADE): intervention development and protocol for a parallel randomised controlled feasibility trial.

INTRODUCTION: Depression is now the most common illness worldwide affecting more than 300 million people. Studies modelling the impact of depression interventions have shown that the burden of depression cannot be minimised by more than 35% with existing treatments. There is a need to develop better preventative interventions. The overall aim of this programme of work is to develop interventions to reduce depression symptom scores and prevent development of depression in people with subthreshold depression. The objectives are to adapt a low intensity community-based depression prevention intervention, establish the acceptability and uptake of this model and conduct a parallel randomised controlled feasibility trial to inform a full-scale trial. METHODS AND ANALYSIS: Focus groups will be run with members of the public, voluntary sector providers and researchers to inform the adaptation of an existing depression prevention course. Sixty-four people with subthreshold depression, as represented by a score of between 5 and 9 on the Patient Health Questionnaire-9 depression measure, will be recruited to take part in the feasibility trial. Participants will be randomised equally to the intervention or usual care control groups. Participants in the intervention group will receive the new revised manual and attend a 1-day workshop delivered by voluntary sector service providers. Outcome measures will be completed 3 months after baseline. Quantitative data on recruitment, randomisation, attendance, retention, questionnaire completion rates will be collected. Primary analyses will be descriptive and a process evaluation will be conducted to assess the processes involved in implementing the intervention. Interviews will be conducted to explore acceptability and framework analysis will be used to analyse the data. ETHICS AND DISSEMINATION: The study has been reviewed and approved by NHS Research and Ethics Committee: NW-Greater Manchester East. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, the internet and community engagement activities. TRIAL REGISTRATION NUMBER: ISRCTN23278208;Pre-results.

The experiences of lay health workers trained in task-shifting psychological interventions: a qualitative systematic review.

INTRODUCTION: The prevalence of common mental disorders, such as depression and anxiety, is high and the demand for psychological interventions and talking therapies is increasing. In order to meet this need, it is necessary to explore alternative methods to deliver talking therapies. Training lay health workers (LHWs) to deliver psychological interventions might be one possible solution to address current gaps in service provision. A number of studies have successfully used this approach to deliver psychological interventions in order to meet the demand for mental health care. Despite increased interest in this area, the evidence has not been synthesised or systematically reviewed. METHODS: Electronic databases (MEDLINE, EMBBASE, PsycINFO and CINHAL) were systematically searched to specifically capture studies on task-shifting psychological interventions for common mental disorders. Data were extracted on the experiences of the lay-workers on training and therapy delivery. Thematic analysis was used to analyse the data. Themes and subthemes of LHWs views on receiving training, barriers and facilitators to therapy delivery, factors required to become a successful therapist and the impact of training and therapy delivery on the therapists are described. RESULTS: 10 studies were eligible for inclusion. Key messages were: LHWs were satisfied with training but wanted more robust supervision; not enough time was given to training on understanding mental health problems; LHWs grew in confidence and this impacted on their personal relationships with others. CONCLUSION: This is the first review to explore LHWs experiences in training and therapy delivery by synthesising existing qualitative research. A number of key messages derived out of this review can help in further improving the quality of the training programmes and highlighting the benefits that are available for the LHW in delivering psychological interventions.

Prevalence of common mental health disorders in adults who are high or costly users of healthcare services: protocol for a systematic review and meta-analysis.

INTRODUCTION: In all healthcare settings, a small proportion of patients account for a large level of healthcare use and associated high healthcare costs. Depression and anxiety are common co-morbidities in patients who are high users of care. The aims of this systematic review are to: (1) estimate the prevalence of anxiety/depression in adults who are high users of general physical healthcare services and/or who accrue high healthcare costs (2) estimate the magnitude of healthcare use associated with the presence of anxiety/depression. METHODS AND ANALYSIS: This review will include any studies where patients are high users of primary, secondary or emergency healthcare services and/or accrue high healthcare costs. This is the first systematic review to focus on patients who are over the age of 18, whose degree of anxiety/depression has been evaluated with a standardised questionnaire or by a clinical interview generating a diagnosis according to international diagnostic criteria. The review will include eligible studies indexed in Medline, PsychINFO, Embase, Cumulative Index to Nursing and Allied Health Literature, Prospective Register of Systematic Reviews, Cochrane Library from inception to 1 April 2019. We will estimate the prevalence of anxiety/depression in these populations and the magnitude of use associated with anxiety/depression across various general physical healthcare settings. We will provide a narrative description of findings and factors that may influence them. A meta-analysis may be pursued if the degree of heterogeneity across studies is acceptable. ETHICS AND DISSEMINATION: This systematic review will use data from existing studies, hence no ethical approvals are required. Findings will be disseminated in a peer-reviewed publication and at relevant academic meetings. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42018102628.

Satisfaction with a digitally-enabled telephone health coaching intervention for people with non-diabetic hyperglycaemia.

International evidence shows that lifestyle interventions can effectively reduce the risk of developing diabetes in people with non-diabetic hyperglycaemia (NDH). A candidate intervention that has potential to be rolled out at population level is health coaching. Digital interventions offer the means to potentially enhance user satisfaction with health coaching and improve efficiencies. We used a randomised controlled trial to test whether a digitally-enabled health coaching intervention that included an online dashboard and telephone health coaching improved user satisfaction and cost-efficiencies compared with a telephone only health coaching intervention. The primary outcome was satisfaction measured by Client Satisfaction Questionnaire (CSQ-8). 103 participants with NDH were allocated to the telephone coaching only intervention and 106 participants with NDH were allocated to the digital and telephone coaching intervention. In an intention-to-treat analysis satisfaction was higher in participants allocated to the digital and telephone coaching intervention than those allocated to the telephone only intervention, but the difference was not significant. There were no significant differences between the groups on secondary outcomes (HbA1c, BMI, activation, depression, self-management, health status). From a service commissioning perspective the mean incremental cost of the digitally-enabled intervention was £236 ($332; €270). Call times, including administration, were longer for participants allocated to the digitally-enabled intervention. The results show that user satisfaction with digitally-enabled intervention is broadly equivalent with that of telephone delivered interventions in the context of routinely delivered diabetes prevention programmes. There is scope for future work that assesses how economies of scale can be achieved at larger user bases.

Prevalence of medically unexplained symptoms in adults who are high users of health care services: a systematic review and meta-analysis protocol.

INTRODUCTION: Medically unexplained symptoms (MUS) are common in primary-care and secondary-care settings. Persistent symptoms of MUS are associated with a variety of poor outcomes including increased disability, poor quality of life and high healthcare costs. The aim of this systematic review is to review the relevant literature to determine the prevalence of MUS in patients who are high users of healthcare and/or who accrue high healthcare costs. METHODS AND ANALYSIS: This review will include studies with cases that are either high users of general healthcare or are patients who accrue high healthcare costs, aged ≥18 years and where a recognised measure of MUS, either a standardised clinical interview or questionnaire, was employed. The following citation databases MEDLINE, PsycINFO, EMBASE, CINAHL, PROSPERO and the Cochrane library will be systematically searched from inception to 30 June 2018. The Cochrane library was included because of the significant proportion of non-observational studies currently published in the database. The prevalence of MUS and associated disorders along with the costs or use of healthcare associated with the presence of MUS will be estimated with 95% CI. If possible, study results will be pooled into a meta-analysis. However, if heterogeneity is high, data analysis will be presented descriptively. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review since only data from existing studies will be used. Results of this review will be disseminated in peer-reviewed publications and at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42018100388.

Does health coaching improve health-related quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? A systematic review and meta-analysis.

PURPOSE: To systematically review the evidence for health coaching as an intervention to improve health-related quality of life (HRQoL) and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD). METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, and CINAHL from database inception to August 2018 to identify all randomized controlled trials (RCTs) of health coaching for people with COPD. Eligible health coaching interventions had to include three components: goal setting, motivational interviewing, and COPD-related health education. Data were extracted on study characteristics and the effects of the intervention on HRQoL, hospital admissions, physical activity, self-care behaviour, and mood. Study quality was appraised by two authors using the Cochrane tool for assessing the risk of bias in RCTs. Effect sizes (standardized mean differences [SMD] or odds ratios [OR]) with 95% confidence intervals (CIs) were calculated and pooled using random effects meta-analyses. RESULTS: Of 1578 articles, 10 RCTs were included. Meta-analysis showed that health coaching has a significant positive effect on HRQoL (SMD = -0.69, 95% CI: -1.28, -0.09, p = .02, from k = 4) and leads to a significant reduction in COPD-related hospital admissions (OR = 0.46, 95% CI: 0.31, 0.69, p = .0001, from k = 5), but not in all-cause hospital admissions (OR = 0.70, 95% CI: 0.41-1.12, p = .20, from k = 3). Three of four studies reported significant improvements to self-care behaviours such as medication adherence and exercise compliance. CONCLUSIONS: This is the first systematic review to show that health coaching may be a candidate intervention to improve HRQoL and reduce costly hospital admissions in people with COPD. Statement of contribution What is already known on this subject? COPD is a leading cause of death worldwide and considerably reduces HRQoL. In turn, HRQoL is associated with a range of adverse health outcomes in COPD. Health coaching is a self-management intervention for people with long-term conditions such as COPD. Studies have examined whether health coaching improves HRQOL and other health outcomes in people with COPD, but no systematic review has been conducted. What does this study add? The first systematic review and meta-analysis of RCTs of health coaching for people with COPD. Health coaching may be a candidate intervention for improving HRQoL and reducing COPD-related hospital admissions in people with COPD. The need to establish the most effective health coaching components, delivery modality, and economic impact.

The Push and Pull of Self-Managing Mild COPD: An Evaluation of Participant Experiences of a Nurse-Led Telephone Health Coaching Intervention.

Health coaching is a novel population intervention to support self-management but it is untested in people with mild disease. People with chronic obstructive pulmonary disease with mild dyspnea are a population excluded from supported self-management and whose illness might progress without intervention. We explored participants' experiences about how health coaching motivated behavior change. Interviews were conducted with 21 intervention and 10 control participants at 6 months, and 20 intervention participants at 12 months. Participants were identified from a randomized controlled trial of telephone health coaching. Data were analyzed using the framework method. Participants positively enacted behavior change to become more physically active. Participants took advantage of environmental affordances to pull themselves toward activity targets, or relied on being pushed to be more active by the health coach or significant others. Behavior change was maintained where efforts to be more active were built into the everyday lifeworld of participants.

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'.

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).

Dementia in UK South Asians: a scoping review of the literature.

OBJECTIVE: Over 850 000 people live with dementia in the UK. A proportion of these people are South Asians, who make up over 5% of the total UK population. Little is known about the prevalence, experience and treatment of dementia in the UK South Asian population. The aim of this scoping review is to identify dementia studies conducted in the UK South Asian population to highlight gaps in the literature which need to be addressed in future research. METHOD: Databases were systematically searched using a comprehensive search strategy to identify studies. A methodological framework for conducting scoping reviews was followed. An extraction form was developed to chart data and collate study characteristics and findings. Studies were then grouped into six categories: prevalence and characteristics; diagnosis validation and screening; knowledge, understanding and attitudes; help-seeking; experience of dementia; service organisation and delivery. RESULTS: A total of 6483 studies were identified, 27 studies were eligible for inclusion in the scoping review. We found that studies of prevalence, diagnosis and service organisation and delivery in UK South Asians are limited. We did not find any clinical trials of culturally appropriate interventions for South Asians with dementia in the UK. The existing evidence comes from small-scale service evaluations and case studies. CONCLUSIONS: This is the first scoping review of the literature to identify priority areas for research to improve care for UK South Asians with dementia. Future research should first focus on developing and validating culturally appropriate diagnostic tools for the UK South Asians and then conducting high-quality epidemiological studies in order to accurately identify the prevalence of dementia in this group. The cultural adaptation of interventions for dementia and testing in randomised controlled trials is also vital to ensure that there are appropriate treatments available for the UK South Asians to access.

Effect of health literacy on the quality of life of older patients with long-term conditions: a large cohort study in UK general practice.

PURPOSE: The levels of health literacy in patients with long-term conditions (LTCs) are critical for better disease management and quality of life (QoL). However, the impact of health literacy on QoL in older adults with LTCs is unclear. This study examined the association between health literacy and domains of QoL in older people with LTCs, investigating key socio-demographic and clinical variables, as confounders. METHODS: A prospective cohort study was conducted on older adults (n = 4278; aged 65 years and over) with at least one LTC, registered in general practices in Salford, UK. Participants completed measures of health literacy, QoL, multi-morbidity, depression, social support, and socio-demographic characteristics. Multivariate linear regressions were performed to examine the effects of health literacy on four QoL domains at baseline, and then changes in QoL over 12 months. RESULTS: At baseline, poor health literacy was associated with lower scores in all four QoL domains (physical, psychological, social relationships and environment), after adjusting for the effects of multi-morbidity, depression, social support and socio-demographic factors. At 12-month follow-up, low health literacy significantly predicted declines in the physical, psychological and environment domains of QoL, but not in social relationships QoL. CONCLUSIONS: This is the largest, most complete assessment of the effects of health literacy on QoL in older adults with LTCs. Low health literacy is an independent indicator of poor QoL older patients with LTCs. Interventions to improve health literacy in older people with LTCs are encouraged by these findings.

The cohort multiple randomized controlled trial design was found to be highly susceptible to low statistical power and internal validity biases.

OBJECTIVES: The "cohort multiple randomized controlled trial" (cmRCT) is a recent innovation by which novel interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice. The use of cmRCTs is outpacing its methodological understanding, and more appropriate methods for designing and analyzing such trials are urgently needed. STUDY DESIGN AND SETTING: We established the UK Comprehensive Longitudinal Assessment of Salford Integrated Care cohort of 4,377 patients with long-term conditions within which we are conducting a cmRCT ("Proactive Telephone Coaching and Tailored Support") of telephone-based health coaching. RESULTS: We identify some key methodological challenges to the use of the cmRCT in actual practice. Principal are issues around statistical power, sample size, and treatment effect estimation, for which we provide appropriate methods. Sampling procedures commonly applied in conventional RCTs can result in unintentional selection bias. The fixed data collection points that feature in cmRCTs can also threaten validity. CONCLUSION: The cmRCT may offer advantages over conventional trial designs. However, a cmRCT requires appropriate power calculation, sampling, and analysis procedures; else, studies may be underpowered or subject to validity biases. We offer solutions to some of the key issues, but further methodological investigations are needed. Cohort multiple RCT-specific Consolidated Standards of Reporting Trials guidance may be indicated.

Barriers and facilitators in accessing dementia care by ethnic minority groups: a meta-synthesis of qualitative studies.

BACKGROUND: It is estimated that there are about 25,000 people from UK ethnic minority groups with dementia. It is clear that there is an increasing need to improve access to dementia services for all ethnic groups to ensure that everyone has access to the same potential health benefits. The aim was to systematically review qualitative studies and to perform a meta-synthesis around barriers and facilitators to accessing care for dementia in ethnic minorities. METHODS: Databases were searched to capture studies on barriers and facilitators to accessing care for dementia in ethnic minorities. Analysis followed the guidelines for meta-ethnography. All interpretations of data as presented by the authors of the included papers were extracted and grouped into new themes. RESULTS: Six hundred and eighty four papers were identified and screened. Twenty eight studies were included in the meta-synthesis. The analysis developed a number of themes and these were incorporated into two overarching themes: 'inadequacies' and 'cultural habitus'. CONCLUSIONS: The two overarching themes lend themselves to interventions at a service level and a community level which need to happen in synergy. TRIAL REGISTRATION: The review was registered with PROSPERO: CRD42016049326 .

Associations of participation in community assets with health-related quality of life and healthcare usage: a cross-sectional study of older people in the community.

BACKGROUND: Community assets are promoted as a way to improve quality of life and reduce healthcare usage. However, the quantitative impact of participation in community assets on these outcomes is not known. METHODS: We examined the association between participation in community assets and health-related quality of life (HRQoL) (EuroQol-5D-5L) and healthcare usage in 3686 individuals aged ≥65 years. We estimated the unadjusted differences in EuroQol-5D-5L scores and healthcare usage between participants and non-participants in community assets and then used multivariate regression to examine scores adjusted for sociodemographic and limiting long-term health conditions. We derived the net benefits of participation using a range of threshold values for a quality-adjusted life year (QALY). RESULTS: 50% of individuals reported participation in community assets. Their EuroQol-5D-5L scores were 0.094 (95% CI 0.077 to 0.111) points higher than non-participants. Controlling for sociodemographic characteristics reduced this differential to 0.081 (95% CI 0.064 to 0.098). Further controlling for limiting long-term conditions reduced this effect to 0.039 (95% CI 0.025 to 0.052). Once we adjusted for sociodemographic and limiting long-term conditions, the reductions in healthcare usage and costs associated with community asset participation were not statistically significant. Based on a threshold value of £20 000 per QALY, the net benefits of participation in community assets were £763 (95% CI £478 to £1048) per participant per year. CONCLUSIONS: Participation in community assets is associated with substantially higher HRQoL but is not associated with lower healthcare costs. The social value of developing community assets is potentially substantial.

Patient activation in older people with long-term conditions and multimorbidity: correlates and change in a cohort study in the United Kingdom.

BACKGROUND: Patient Activation is defined as the knowledge, skill, and confidence a patient has in managing their health. Higher levels of patient activation are associated with better self-management, better health outcomes, and lower healthcare costs. Understanding the drivers of patient activation can allow better tailoring of patient support and interventions. There are few data on patient activation in UK patients with long-term conditions. METHODS: A prospective cohort design was used. Questionnaires were mailed to 12,989 patients over the age of 65 years with at least one long-term condition in Salford, UK. They completed the Patient Activation Measure and self-report measures of: depression, health literacy, social support, health-related quality of life, and impact of multimorbidity. We report descriptive data on baseline activation and change over time, and use multivariate regression to model associations with patient activation at baseline and predictors of change in Activation over 6 months. RESULTS: The cohort included 4377 (33.6 %) older people, of whom 4225 were mailed a further questionnaire at 6 months; 3390 returned it complete (80.2 %). At baseline, 15 % self-reported PAM level 1, 16 % level 2, 45 % level 3, and 25 % level 4. Across all patients, depression had the strongest association with patient activation. Other important factors were: older age, being retired, poor health literacy, health-related quality of life, and social support. Total number of self-reported comorbidities and the perceived impact of comorbidities were also important for patients with more than one long-term condition. Patient activation scores were reasonably enduring over time (r = 0.43 between baseline and at six months), although nearly half changed 'levels' of activation over that time. Few variables predicted change in activation over 6 months. CONCLUSIONS: This is the first large scale assessment of patient activation in the UK. Our data may be useful in identifying patients who need support with patient activation, and allow interventions (such as health coaching) to be tailored to better support older patients with long-term conditions who have symptoms of depression, poor social support and impaired health literacy. Further analyses of longitudinal studies will be necessary to better understand the causal relationships between patient activation and variables such as depression.

Comparison of active treatments for impaired glucose regulation: a Salford Royal Foundation Trust and Hitachi collaboration (CATFISH): study protocol for a randomized controlled trial.

BACKGROUND: Diabetes is highly prevalent and contributes to significant morbidity and mortality worldwide. Behaviour change interventions that target health and lifestyle factors associated with the onset of diabetes can delay progression to diabetes, but many approaches rely on intensive one-to-one contact by specialists. Health coaching is an approach based on motivational interviewing that can potentially deliver behaviour change interventions by non-specialists at a larger scale. This trial protocol describes a randomized controlled trial (CATFISH) that tests whether a web-enhanced telephone health coaching intervention (IGR3) is more acceptable and efficient than a telephone-only health coaching intervention (IGR2) for people with prediabetes (impaired glucose regulation). METHODS: CATFISH is a two-parallel group, single-centre individually randomized controlled trial. Eligible participants are patients aged ≥18 years with impaired glucose regulation (HbA1c concentration between 42 and 47 mmol/mol), have access to a telephone and home internet and have been referred to an existing telephone health coaching service at Salford Royal NHS Foundation Trust, Salford, UK. Participants who give written informed consent will be randomized remotely (via a clinical trials unit) to either the existing pathway (IGR2) or the new web-enhanced pathway (IGR3) for 9 months. The primary outcome measure is patient acceptability at 9 months, determined using the Client Satisfaction Questionnaire. Secondary outcome measures at 9 months are: cost of delivery of IGR2 and IGR3, mental health, quality of life, patient activation, self-management, weight (kg), HbA1c concentration, and body mass index. All outcome measures will be analyzed on an intention-to-treat basis. A qualitative process evaluation will explore the experiences of participants and providers with a focus on understanding usability of interventions, mechanisms of behaviour change, and impact of context on delivery and user acceptability. Qualitative data will be analyzed using Framework. DISCUSSION: The CATFISH trial will provide a pragmatic assessment of whether a web-based information technology platform can enhance acceptability of a telephone health coaching intervention for people with prediabetes. The data will prove critical in understanding the role of web applications to improve engagement with evidence-based approaches to preventing diabetes. TRIAL REGISTRATION: ISRCTN16534814 . Registered on 7 February 2016.