The role of stress and health behaviour in linking weight discrimination and health: a secondary data analysis in England.

OBJECTIVE: To examine the role of stress and health-risk behaviours in relationships between weight discrimination and health and well-being. DESIGN: Secondary data analysis of an observational cohort study. SETTING: The English Longitudinal Study of Ageing. PARTICIPANTS: Data were from 4341 adults (≥50 years) with overweight/obesity. PRIMARY OUTCOME MEASURES: We tested associations between perceived weight discrimination at baseline (2010/2011) and self-rated health, limiting long-standing illness, depressive symptoms, quality of life and life satisfaction over 4-year follow-up (2010/2011; 2014/2015). Potential mediation by stress exposure (hair cortisol) and health-risk behaviours (smoking, physical inactivity, alcohol consumption) was assessed. RESULTS: Cross-sectionally, perceived weight discrimination was associated with higher odds of fair/poor self-rated health (OR=2.05 (95% CI 1.49 to 2.82)), limiting long-standing illness (OR=1.76 (95% CI 1.29 to 2.41)) and depressive symptoms (OR=2.01 (95% CI 1.41 to 2.85)) and lower quality of life (B=-5.82 (95% CI -7.01 to -4.62)) and life satisfaction (B=-2.36 (95% CI -3.25 to -1.47)). Prospectively, weight discrimination was associated with higher odds of fair/poor self-rated health (OR=1.63 (95% CI 1.10 to 2.40)) and depressive symptoms (OR=2.37 (95% CI 1.57 to 3.60)) adjusting for baseline status. Those who reported discrimination had higher hair cortisol concentrations (B=0.14 (95% CI 0.03 to 0.25)) and higher odds of physical inactivity (OR=1.90 (95% CI 1.18 to 3.05)). These variables did not significantly mediate associations between discrimination and health outcomes. CONCLUSIONS: Weight discrimination is associated with poor health and well-being. While this discrimination is associated with stress exposure and physical inactivity, these variables explain little of the association between discrimination and poorer outcomes.

The Behaviour Change Technique Ontology: Transforming the Behaviour Change Technique Taxonomy v1.

Background: The Behaviour Change Technique Taxonomy v1 (BCTTv1) specifies the potentially active content of behaviour change interventions. Evaluation of BCTTv1 showed the need to extend it into a formal ontology, improve its labels and definitions, add BCTs and subdivide existing BCTs. We aimed to develop a Behaviour Change Technique Ontology (BCTO) that would meet these needs. Methods: The BCTO was developed by: (1) collating and synthesising feedback from multiple sources; (2) extracting information from published studies and classification systems; (3) multiple iterations of reviewing and refining entities, and their labels, definitions and relationships; (4) refining the ontology via expert stakeholder review of its comprehensiveness and clarity; (5) testing whether researchers could reliably apply the ontology to identify BCTs in intervention reports; and (6) making it available online and creating a machine-readable version. Results: Initially there were 282 proposed changes to BCTTv1. Following first-round review, 19 BCTs were split into two or more BCTs, 27 new BCTs were added and 26 BCTs were moved into a different group, giving 161 BCTs hierarchically organised into 12 logically defined higher-level groups in up to five hierarchical levels. Following expert stakeholder review, the refined ontology had 247 BCTs hierarchically organised into 20 higher-level groups. Independent annotations of intervention evaluation reports by researchers familiar and unfamiliar with the ontology resulted in good levels of inter-rater reliability (0.82 and 0.79, respectively). Following revision informed by this exercise, 34 BCTs were added, resulting in a final version of the BCTO containing 281 BCTs organised into 20 higher-level groups over five hierarchical levels. Discussion: The BCT Ontology provides a standard terminology and comprehensive classification system for the content of behaviour change interventions that can be reliably used to describe interventions.

Behaviour change techniques taxonomy v1: Feedback to inform the development of an ontology.

Background: To build cumulative evidence about what works in behaviour change interventions, efforts have been made to develop classification systems for specifying the content of interventions. The Behaviour Change Techniques (BCT) Taxonomy v1 (BCTTv1) is one of the most widely used classifications of behaviour change techniques across a variety of behaviours. The BCTTv1 was intentionally named version 1 to allow for further revisions to the taxonomy. This study aimed to gather data to improve the BCTTv1 and provide recommendations for developing it into a more elaborated knowledge structure, an ontology.  Methods: Feedback from users of BCTTv1 about limitations and proposed improvements was collected through the BCT website, user survey, researchers and experts involved in the Human Behaviour-Change Project, and a consultation. In addition, relevant published research reports and other classification systems of BCTs were analysed. These data were synthesised to produce recommendations to inform the development of an ontology of BCTs. Results: A total of 282 comments from six sources were reviewed and synthesised into four categories of suggestions: additional BCTs, amendments to labels and definitions of specific BCTs, amendments to the groupings, and general improvements. Feedback suggested some lack of clarity regarding understanding and identifying techniques from labels, definitions, and examples; distinctions and relations between BCTs; and knowing what they would look like in practice. Three recommendations to improve the BCTTv1 resulted from this analysis: to review the label and definition of each BCT, the 16 groupings of BCTs, and the examples illustrating BCTs. Conclusions : This review of feedback about BCTTv1 identified the need to improve the precision and knowledge structure of the current taxonomy. A BCT ontology would enable the specification of relationships between BCTs, more precise definitions, and allow better interoperability with other ontologies. This ontology will be developed as part of the Human Behaviour-Change Project.

Interventions to increase personal protective behaviours to limit the spread of respiratory viruses: A rapid evidence review and meta-analysis.

PURPOSE: Increasing personal protective behaviours is critical for stopping the spread of respiratory viruses, including SARS-CoV-2: We need evidence to inform how to achieve this. We aimed to synthesize evidence on interventions to increase six personal protective behaviours (e.g., hand hygiene, face mask use, maintaining physical distancing) to limit the spread of respiratory viruses. METHODS: We used best practice for rapid evidence reviews. We searched Ovid MEDLINE and Scopus. Studies conducted in adults or children with active or passive comparators were included. We extracted data on study design, intervention content, mode of delivery, population, setting, mechanism(s) of action, acceptability, practicability, effectiveness, affordability, spill-over effects, and equity impact. Study quality was assessed with Cochrane's risk-of-bias tool. A narrative synthesis and random-effects meta-analyses were conducted. RESULTS: We identified 39 studies conducted across 15 countries. Interventions targeted hand hygiene (n = 30) and/or face mask use (n = 12) and used two- or three-arm study designs with passive comparators. Interventions were typically delivered face-to-face and included a median of three behaviour change techniques. The quality of included studies was low. Interventions to increase hand hygiene (k = 6) had a medium, positive effect (d = .62, 95% CI = 0.43-0.80, p < .001, I2 = 81.2%). Interventions targeting face mask use (k = 4) had mixed results, with an imprecise pooled estimate (OR = 4.14, 95% CI = 1.24-13.79, p < .001, I2 = 89.67%). Between-study heterogeneity was high. CONCLUSIONS: We found low-quality evidence for positive effects of interventions targeting hand hygiene, with unclear results for interventions targeting face mask use. There was a lack of evidence for most behaviours of interest within this review.

Acceptability and facilitators of and barriers to point-of-care HIV testing in a homeless-focused service in Gloucestershire: a qualitative evaluation.

OBJECTIVES: Late HIV diagnosis increases the risks of onward transmission, morbidity and mortality. Rapid point-of-care testing (POCT) reaches people who have never been tested and people living with HIV who are undiagnosed. This study explored the acceptability and feasibility of HIV POCT from the perspectives of service providers and users. METHODS: A pilot study introduced HIV POCT to one service in Gloucestershire, England. Eleven semi-structured interviews with service users and a focus group with three service providers were conducted. The Theoretical Framework of Acceptability and the Theoretical Domains Framework were used to design the topic guide and analysis. RESULTS: Acceptability of HIV POCT was high. Seven facilitators were identified (e.g. understanding the test purpose and process), alongside two potential barriers, one relevant to service providers and users (anxiety) and the other to service users (stigma). CONCLUSIONS: To maximize the benefits of implementation of HIV POCT, health care providers require appropriate training and supervision to offer and administer POCT.

The impact of COVID-19 related regulations and restrictions on mobility and potential for sustained climate mitigation across the Netherlands, Sweden and the UK: a data-based commentary.

Human behaviour change is necessary to meet targets set by the Paris Agreement to mitigate climate change. Restrictions and regulations put in place globally to mitigate the spread of COVID-19 during 2020 have had a substantial impact on everyday life, including many carbon-intensive behaviours such as transportation. Changes to transportation behaviour may reduce carbon emissions. Behaviour change theory can offer perspective on the drivers and influences of behaviour and shape recommendations for how policy-makers can capitalise on any observed behaviour changes that may mitigate climate change. For this commentary, we aimed to describe changes in data relating to transportation behaviours concerning working from home during the COVID-19 pandemic across the Netherlands, Sweden and the UK. We display these identified changes in a concept map, suggesting links between the changes in behaviour and levels of carbon emissions. We consider these changes in relation to a comprehensive and easy to understand model of behaviour, the Opportunity, Motivation Behaviour (COM-B) model, to understand the capabilities, opportunities and behaviours related to the observed behaviour changes and potential policy to mitigate climate change. There is now an opportunity for policy-makers to increase the likelihood of maintaining pro-environmental behaviour changes by providing opportunities, improving capabilities and maintaining motivation for these behaviours.

Improving recruitment to healthcare research studies: clinician judgements explored for opting mental health service users out of the time to change viewpoint survey.

BACKGROUND: There are significant challenges across the research pathway, including participant recruitment. This paper aims to explore the impact of clinician recruitment decision-making on sampling for a national mental health survey. METHOD: Clinical teams in 20 English mental healthcare provider organisations screened caseload lists, opting-out people whom, in their judgement, should not be approached to participate in a survey about stigma and discrimination. The reasons for each individual opted-out were requested. We assess these reasons against study recruitment criteria and investigated the impact of variations in opt-out rates on response rates and study findings. RESULTS: Over 4 years (2009-2012), 37% (28,592 people) of the total eligible sampling frame were excluded. Exclusions comprised three categories: clinical teams did not screen their lists within recruitment period (12,392 people: 44%); protocol-specified exclusions (8364 people: 29%); clinician opt-outs queried by research team (other reasons were given) (7836, 28%). Response rates were influenced by decision-making variations. CONCLUSIONS: Large numbers of people were denied the opportunity to choose for themselves whether to participate or not in the Viewpoint Survey. The clinical research community, and their employing organisations, require support to better understand the value of research and best practice for research recruitment.

Improving mental health service responses to domestic violence and abuse.

Domestic violence and abuse is a considerable international public health problem, which is associated with mental disorders in both women and men. Nevertheless, victimization and perpetration remain undetected by mental health services. This paper reviews the evidence on mental health service responses to domestic violence, including identifying, referring, and providing care for people experiencing or perpetrating violence. The review highlights the need for mental health services to improve rates of identification and responses to domestic violence and abuse, through the provision of specific training on domestic violence and abuse, the implementation of clear information sharing protocols and evidence-based interventions, and the establishment of care referral pathways. This review also highlights the need for further research into mental health service users who perpetrate domestic violence and abuse.

Internalised stigma in people with rheumatoid arthritis: a cross sectional study to establish the psychometric properties of the ISMI-RA.

BACKGROUND: Internalised stigma is theorized to be the internalisation and legitimisation of stereotypes of the diagnosis held in society and has not been quantified within patients with Rheumatoid Arthritis. This study aimed to: validate a modified version of a measure of internalised stigma, (the Internalised Stigma of Mental Illness scale, ISMI) for use in a group of patients diagnosed with rheumatoid arthritis; establish the consistency of the construct being measured, and to explore the levels of internalised stigma within this group. METHODS: A cross-sectional survey was conducted in London, UK with participants receiving out-patient treatment for Rheumatoid Arthritis. Participants completed the ISMI-Rheumatoid Arthritis (ISMI-RA) and a measure of self-esteem. RESULTS: One hundred respondents were interviewed by phone. The ISMI-RA was found to be reliable using a measure of internal consistency (α = 0.85) showed concurrent validity with the Index of Self Esteem (r = 0.58, p < 0.01) and discriminant validity with no association with gender (t = 1.43, p = 0.61). A quarter of respondents reported internalised stigma to a 'severe' level. Acceptability and feasibility were established. A confirmatory factor analysis provided some support for the model of internalised stigma. CONCLUSIONS: The application of the ISMI-RA among the Rheumatoid Arthritis population looks promising. Internalised stigma was found to be present within this group. More research is needed to generalize these results and to explore the effects of internalised stigma on treatment adherence and quality of life.

How does self stigma differ across people with psychiatric diagnoses and rheumatoid arthritis, and how does it impact on self-esteem and empowerment?

Self stigmatising attitudes have been found in people who have psychiatric diagnoses, however, research assessing self stigma in physical illnesses is rare. It is known that receiving a diagnosis of rheumatoid arthritis (RA) can affect a person's identity and self esteem. This study aimed to compare levels of self stigma, self esteem and empowerment between people diagnosed with psychiatric illnesses and people diagnosed with RA to establish whether self stigma, and specifically endorsement of negative stereotypes, is associated with self esteem and empowerment across these two groups. A total of 202 participants (psychiatric group n = 102; RA group n = 100) were interviewed using the Internalised Stigma of Mental Illness scale (ISMI), or the Internalized Stigma of Mental Illness scale- Rheumatoid Arthritis (ISMI-RA), the Index of Self Esteem (ISE) and the Mental Health Confidence Scale (MHCS). Overall, the psychiatric group had higher self stigma scores (2.5 vs. 2.2, p < .01), lower self esteem (48.7 vs. 36.8, p < .001) and lower empowerment scores (3.8 vs. 4.3, p < .001) than the RA group. However, sizable proportions of both groups had high self stigma scores. ISMI/ISMI-RA was associated with the ISE and the MHCS. The stereotype endorsement subscale of the ISMI/ISMI-RA was not related to self esteem or empowerment in either group. Interventions that aim to decrease self stigma and increase self esteem could focus on alienation.

Experience of stigma and discrimination reported by people experiencing the first episode of schizophrenia and those with a first episode of depression: The FEDORA project.

AIM: To record and measure the nature and severity of stigma and discrimination experienced by people during a first episode of schizophrenia and those with a first episode of major depressive disorder. METHODS: The Discrimination and Stigma Scale (DISC-12) was used in a cross-sectional survey to elicit service user reports of anticipated and experienced discrimination by 150 people with a diagnosis of first-episode schizophrenia and 176 with a diagnosis of first-episode major depressive disorder in seven countries (Austria, Croatia, Czech Republic, Poland, Romania, Sweden and Turkey). RESULTS: Participants with a diagnosis of major depressive disorder reported discrimination in a greater number of life areas than those with schizophrenia, as rated by the total DISC-12 score (p = .03). With regard to specific life areas, participants with depression reported more discrimination in regard to neighbours, dating, education, marriage, religious activities, physical health and acting as a parent than participants with schizophrenia. Participants with schizophrenia reported more discrimination with regard to the police compared to participants with depression. CONCLUSION: Stigma and discrimination because of mental illness change in the course of the mental diseases. Future research may take a longitudinal perspective to better understand the beginnings of stigmatisation and its trajectory through the life course and to identify critical periods at which anti-stigma interventions can most effectively be applied.

Effect of the Time to Change anti-stigma campaign on trends in mental-illness-related public stigma among the English population in 2003-13: an analysis of survey data.

BACKGROUND: Understanding trends and effective mechanisms that are likely to reduce public stigma and discrimination towards people with mental illness is important. We aimed to assess changes in public stigma in England after the introduction of the Time to Change anti-stigma campaign. METHODS: We used data from the 2003 and 2007-13 national Attitudes to Mental Illness surveys to investigate 10-year trends in public attitudes across England before and during the Time to Change anti-stigma campaign. We present annual mean scores for attitude items related to prejudice and exclusion, and tolerance and support for community care. We also present an extrapolated linear trend line for the years 2009-13 and estimate population attitude scores without the campaign. We present unadjusted and adjusted linear regression models. In addition, we used multivariable linear regression models fitted to data aggregated by region to investigate whether a dose-effect response exists between campaign awareness and regional outcomes related to knowledge, attitudes, and intended behaviour. FINDINGS: About 1700 respondents were surveyed each year. Significant increases in positive attitudes related to prejudice and exclusion occurred after the Time to Change campaign. In the multivariable analysis, we noted a significant increase in positive attitudes in relation to prejudice and exclusion after the launch of Time to Change (reverse-coded Z score 0·02, 95% CI 0·01 to 0·05; p=0·01), but not for tolerance and support for community care (Z score 0·01, -0·01 to 0·03; p=0·27). We also found evidence for a dose-effect relation between campaign awareness and regional improvement in knowledge (p=0·004) and attitudes (tolerance and support p<0·0001; prejudice and exclusion p=0·001), but not intended behaviour (p=0·20). INTERPRETATION: The positive effects of Time to Change seem to be significant and moderate. Although attitudes are probably more at risk of deterioration during times of economic hardship, anti-stigma programmes might still play an active part in long-term reduction of stigma and discrimination, especially in relation to prejudice and exclusion of people with mental health problems. FUNDING: UK Department of Health, Comic Relief, Big Lottery.

Discrimination in relation to parenthood reported by community psychiatric service users in the UK: a framework analysis.

BACKGROUND: Experienced discrimination refers to an individual's perception that they have been treated unfairly due to an attribute and is an important recent focus within stigma research. A significant proportion of mental health service users report experiencing mental illness-based discrimination in relation to parenthood. Existing studies in this area have not gone beyond prevalence, therefore little is known about the nature of experienced discrimination in relation to parenthood, and how is it constituted. This study aims to generate a typology of community psychiatric service users' reports of mental illness-based discrimination in relation to becoming or being a parent. A secondary aim is to assess the prevalence of these types of experienced discrimination. METHODS: In a telephone survey 2026 community psychiatric service users in ten UK Mental Health service provider organisations (Trusts) were asked about discrimination experienced in the previous 12 months using the Discrimination and Stigma Scale (DISC). The sample were asked if, due to their mental health problem, they had been treated unfairly in starting a family, or in their role as a parent, and gave examples of this. Prevalence is reported and the examples of experienced discrimination in relation to parenthood were analysed using the framework method of qualitative analysis. RESULTS: Three hundred and four participants (73% female) reported experienced discrimination, with prevalences of 22.5% and 28.3% for starting a family and for the parenting role respectively. Participants gave 89 examples of discrimination about starting a family and 228 about parenting, and these occurred in social and professional contexts. Ten themes were identified. These related to being seen as an unfit parent; people not being understanding; being stopped from having children; not being allowed to see their children; not getting the support needed; children being affected; children avoiding their parents; children's difficulties being blamed on the parent's mental health problem; not being listened to; and being undermined as a parent. CONCLUSIONS: This research highlights the need for: greater support for parents with mental illness, those wishing to have children, and those who lose access or custody; services to better meet the needs of children with a mentally ill parent; training about discrimination for professionals; and parenting issues to be included in anti-stigma programmes.

Mass social contact interventions and their effect on mental health related stigma and intended discrimination.

BACKGROUND: Stigma and discrimination associated with mental health problems is an important public health issue, and interventions aimed at reducing exposure to stigma and discrimination can improve the lives of people with mental health problems. Social contact has long been considered to be one of the most effective strategies for improving inter-group relations. For this study, we assess the impact of a population level social contact intervention among people with and without mental health problems. METHODS: This study investigated the impact of social contact and whether presence of specific facilitating factors (equal status, common goals, cooperation and friendship potential): (1) improves intended stigmatising behaviour; (2) increases future willingness to disclose a mental health problem; and (3) promotes behaviours associated with anti-stigma campaign engagement. Two mass participation social contact programmes within England's Time to Change campaign were evaluated via a 2-part questionnaire. 403 participants completed initial questionnaires (70% paper, 30% online) and 83 completed follow-up questionnaires online 4-6 weeks later. RESULTS: This study investigated the impact of social contact and whether presence of specific facilitating factors (equal status, common goals, cooperation and friendship potential): (1) improves intended stigmatising behaviour; (2) increases future willingness to disclose a mental health problem; and (3) promotes behaviours associated with anti-stigma campaign engagement. Two mass participation social contact programmes within England's Time to Change campaign were evaluated via a 2-part questionnaire. 403 participants completed initial questionnaires (70% paper, 30% online) and 83 completed follow-up questionnaires online 4-6 weeks later. Campaign events facilitated meaningful intergroup social contact between individuals with and without mental health problems. Presence of facilitating conditions predicted improved stigma-related behavioural intentions and subsequent campaign engagement 4-6 weeks following social contact. Contact, however, was not predictive of future willingness to disclose mental health problems. CONCLUSIONS: Findings emphasise the importance of facilitating conditions to promote positive social contact between individuals and also suggest that social contact interventions can work on a mass level. Future research should investigate this type of large scale intervention among broader and more representative populations.

England's time to change antistigma campaign: one-year outcomes of service user-rated experiences of discrimination.

OBJECTIVE: This study evaluated the progress at one year of England's Time to Change (TTC) program, launched in 2009, toward meeting its target to reduce mental health-related stigma and discrimination by 5%. METHODS: TTC comprises three national components: antistigma marketing campaign activities, mass physical exercise events (Time to Get Moving) to facilitate social contact between people with and without mental health problems, and an online resource on mental health and employment (Time to Challenge). Part of the TTC evaluation consists of an annual national phone survey of mental health service users. Participants (537 in 2008 and 1,047 in 2009) were current outpatient service users aged 18-65 registered with National Health Service community mental health teams that are selected annually to represent the range of socioeconomic deprivation. Telephone interviews were conducted with service users with the Discrimination and Stigma Scale (DISC) to document experienced discrimination and anticipated discrimination in the past 12 months. RESULTS: One or more experiences of discrimination were reported by 9-1% of participants in 2008 and 87% of participants in 2009 (p = .03). In 2009 significantly less discrimination was reported from a number of common sources, including family (reported by 53% in 2008 and 46% in 2009), friends (53% and 39%), finding employment (24% and 16%), and keeping employment (from 17% to 13%). Experiences of discrimination from mental health professionals did not change significantly (reported by about one-third of participants in both years). CONCLUSIONS: Results suggest positive progress toward meeting the program's targeted 5% reduction in discrimination.

Ovarian and cervical cancer awareness: development of two validated measurement tools.

BACKGROUND: The aim of the study was to develop and validate measures of awareness of symptoms and risk factors for ovarian and cervical cancer (Ovarian and Cervical Cancer Awareness Measures). METHODS: Potentially relevant items were extracted from the literature and generated by experts. Four validation studies were carried out to establish reliability and validity. Women aged 21-67 years (n=146) and ovarian and cervical cancer experts (n=32) were included in the studies. Internal reliability was assessed psychometrically. Test-retest reliability was assessed over a 1-week interval. To establish construct validity, Cancer Awareness Measure (CAM) scores of cancer experts were compared with equally well-educated comparison groups. Sensitivity to change was tested by randomly assigning participants to read either a leaflet giving information about ovarian/cervical cancer or a leaflet with control information, and then completing the ovarian/cervical CAM. RESULTS: Internal reliability (Cronbach's α=0.88 for the ovarian CAM and α=0.84 for the cervical CAM) and test-retest reliability (r=0.84 and r=0.77 for the ovarian and cervical CAMs, respectively) were both high. Validity was demonstrated with cancer experts achieving higher scores than controls [ovarian CAM: t(36)= -5.6, p<0.001; cervical CAM: t(38)= -3.7, p=0.001], and volunteers who were randomised to read a cancer leaflet scored higher than those who received a control leaflet [ovarian CAM: t(49)=7.5, p<0.001; cervical CAM: t(48)= -5.5, p<0.001]. CONCLUSIONS: This study demonstrates the psychometric properties of the ovarian and cervical CAMs and supports their utility in assessing ovarian and cervical cancer awareness in the general population.

Newspaper coverage of mental illness in the UK, 1992-2008.

BACKGROUND: Recent years have seen a number of attempts to reduce the stigma related to mental illness; the media can play a significant role in perpetuating this stigma. This paper analyses trends in newspaper coverage of mental illness in the UK between 1992-2008 across a range of psychiatric diagnoses. METHODS: A content analysis was performed on a sample of articles (n = 1361) about mental illness in a range of UK newspapers in 1992, 2000, and 2008. RESULTS: There was a significant proportional reduction in negative articles about mental illness between 1992 and 2008, and a significant increase in articles explaining psychiatric disorders. Coverage improved for depression but remained largely negative for schizophrenia. CONCLUSIONS: Newspaper coverage of mental illness became less stigmatising overall in the 1990s and 2000s, but this was not true for all diagnoses.