Implementation of a Cancer Education Program in Rural Counties with the Lowest HPV Vaccination Rates and Health Rankings.

Background: Human papillomavirus (HPV) is the most common sexually transmitted infection (STI). To address STIs, one rural county public school district developed a series of Family Life Programs to educate pre-teens about pertinent health information. The Schooling Cancer Program (SCP) was developed in partnership with the local Cancer Research and Resource Center to raise awareness about cancer risk factors including HPV-related cancers and HPV prevention methods. Methods: We collected a post-evaluation survey from students who attended a SCP session at one of the targeted middle schools. The SCP educated students about topics focusing on healthy lifestyles. The survey asked students' knowledge on the SCP topics, HPV knowledge, tobacco usage, and factors that reduced cancer development. Results: 87% agreed that tobacco products are associated with cancer, and 81% did not agree that E-cigarettes are scientifically proven to be safer than cigarettes. Although we do not have pre-evaluation data about these students' HPV knowledge, our evaluation survey shows that 80% of students correctly identified HPV as the most common STI, and 84% of students correctly identified the factors that decrease their risk of developing cancer. Conclusion: Through this initiative, students learned essential health concepts and HPV-related risk factors.

Project COALESCE-An Example of Academic Institutions as Conveners of Community-Clinic Partnerships to Improve Cancer Screening Access.

In Virginia, 56% of colorectal cancers (CRC) are diagnosed late, making it one of three enduring CRC mortality hotspots in the US. Cervical cancer (CCa) exhibits a similar pattern, with 48% late-stage diagnosis. Mortality for these cancers is worse for non-Latinx/e(nL)-Black people relative to nL-White people in Virginia, but preventable with equitable screening access and timely diagnostic follow-up. However, structural barriers, such as fractured referral systems and extended time between medical visits, remain. Because Federally Qualified Health Centers (FQHCs) care for a large proportion of racial and ethnic minorities, and underserved communities, regardless of ability to pay, they are ideal partners to tackle structural barriers to cancer screenings. We piloted a quality improvement initiative at five FQHCs in southcentral Virginia to identify and address structural, race-related barriers to CRC, as well as CCa screening and diagnostic follow-up using evidence-based approaches. Uniquely, FQHCs were paired with local community organizations in a didactic partnership, to elevate the community's voice while together, increase support, acceptance, uptake, and intervention sustainability. We report on project development, and share preliminary data within the context of project goals, namely, to increase cancer screenings by 5-10%, improve knowledge and diagnostic follow-up processes, and build longitudinal partnerships.

Engaging rural communities in cancer prevention and control research: Development and preliminary insights from a community-based research registry.

OBJECTIVE: To report on the development and preliminary findings of a community-based cancer registry, including the community-engaged approach to recruitment, participant profile, and distribution of cancer risk factors by race/ethnicity and geography. METHODS: Community outreach and engagement best practices were used to recruit a diverse convenience sample of Virginia residents (≥18 years) that oversampled residents living in rural areas, defined as Rural-Urban Continuum Codes (RUCC) 4-9 and African American (AA)/Black residents. Multiple survey administration methods included electronic (e-survey) and in-person survey by community-based staff. RESULTS: At the time of this analysis, 595 participants are enrolled; 73% are rural, 46% are AA/Black. AA/Black participants reported similar education but lower income (p < 0.01) and health literacy (p < 0.01), lower alcohol use (p < 0.001), fewer sedentary behaviors (p = 0.01), but greater BMI (p < 0.05) compared to White participants. Rural residents reported significantly lower household income (p < 0.001) and greater use of Medicaid (p = 0.01) compared to urban participants. Biennial mammography was reported by 82% of women aged 45-74 years old and colonoscopy by 77% of participants ≥50 years old. Tobacco use was reported by 17%; no differences in cancer screening or tobacco use were identified by geography or by race. CONCLUSION AND RELEVANCE: Community engagement strategies successfully enrolled diverse residents within the cancer service area. AA/Black participants reported fewer cancer risk behaviors, similar educational attainment but lower income and health literacy compared to White respondents. Nuanced examinations of interactions among multilevel factors are needed to understand how individual, community, and institutional factors converge to maintain cancer disparities among AA/Black Virginians. Additional findings indicate a need for tobacco cessation, lung cancer screening, obesity treatment, and prevention initiatives.

Afterbirth support provision for women following a traumatic/distressing birth: Survey of NHS hospital trusts in England.

OBJECTIVE: Despite recommendations within postnatal care guidelines, many National Health Service (NHS) hospital trusts in the UK provide an afterbirth, debriefing type service for women who have had a traumatic/distressing birth. Currently there are a lack of insights into what, how, and when this support is provided. The aim of this study was to explore afterbirth provision for women who have had a traumatic/distressing birth in NHS hospital trusts in England. DESIGN: An online survey comprising forced choice and open text comments was disseminated via direct email and social media to NHS hospital trusts in England. Questions explored the types of support provided, when the support was offered, how and when the service was promoted to women, funding issues, and the role/training of service providers. PARTICIPANTS: Fifty-nine respondents completed the survey, with responses from 54 different NHS hospital trusts from all geographic regions in England (40% of all trusts) included. FINDINGS: While the numbers of women accessing afterbirth services varied, this was often associated with a lack of dedicated funding (∼52%), and poor recording mechanisms. Some 83.3% of services had evolved based on women's needs rather than wider research/literature. Midwives are commonly the sole provider of afterbirth services (59.3%) and in 40.7% of cases the professionals who provide afterbirth support had received no specific training. In only 51.9% of trusts were 'all' women routinely given information about the service, and women were more likely to self-refer (79.6%) rather than be referred via routine screening (11.1%) or obstetric criteria (27.8%). Almost all services offered flexible access (92.6%) and many offered multiple contacts (70.3%). While most services enabled women to discuss and review their birth, only 55.6% furnished women with information on birth trauma. Approximately 89% of services referred women to specialist provision (i.e. mental health) as needed, although directing support within personal (63%) or wider support (55.6%) networks was less evident. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: While women want, and value opportunities to discuss the birth with a maternity professional following a traumatic/difficult birth, evidence suggests that resource provision is insufficient, hampered by a lack of funding, publicity, and recording systems. While further research is needed, funds to establish a well-resourced, evidence-based and well-promoted service should be prioritised.

Self-Report Measures of Parental Self-Efficacy: A Systematic Review of the Current Literature.

Parenting self-efficacy (PSE) describes a parent's belief in their ability to perform the parenting role successfully. Higher levels of PSE have consistently been shown to be correlated with a wide range of parenting and child outcomes. Consequently, many parenting interventions aim to improve PSE. PSE measurement has typically been via self-report measures. However, the wide range of available measures has resulted in their limited use, inconsistent terminology and ambiguous theoretical grounding. The purpose of this systematic review was to examine the psychometric and administrative qualities of the available PSE measures and offer clarity to the terminology and the theory underpinning their use so that the future use of PSE measures can be appropriate. Eleven electronic databases were searched. Articles were included if they introduced a new measure or were psychometric evaluations of an available measure of PSE for parents of children (from infancy until 18 years of age). Thirty-four measures were identified and their psychometric and administrative qualities were examined. Overall, the quality of the available measures was varied. Whilst this review makes recommendations regarding PSE measures for parents of infants through to adolescents, some caution should be applied when choosing the most appropriate measure. The theoretical grounding of each measure was clarified so that appropriate measures can be chosen under the relevant circumstances. The implications of refinement of the available measures are discussed and further research into improving PSE measurement is identified.

Recruitment strategies for British South Asians in 5 depression trials: A mixed method study.

BACKGROUND: In the United Kingdom, ethnic minority group's particularly British South Asian women have higher rates of depression than their white counterparts. Despite this they remain under represented in mental health trials. Whilst the US legislation mandates the inclusion of ethnic minorities into research, there are no similar initiatives in the UK. Barriers in recruiting these hard to reach ethnic groups are cited as major reasons behind this under representation. Once these barriers are encountered it becomes a challenge for the researchers to overcome them. As there is paucity of research in this specific area through this paper we want to share our strategies in recruiting British South Asians thus encouraging other researchers to consider ethnic minority inclusion into research. METHODS: Our published systematic review on the barriers to recruitment of ethnic minority participants into mental health research developed a typology of thirty three ethnic recruitment barriers described under five themes. We aimed to find strategies to overcome these barriers from five depression trials for British South Asians conducted by our research group. Firstly we extracted data on recruitment strategies from the published papers. Later researchers involved in these five trials formed a working group to add to these extracted strategies. Finally these strategies were matched to the individual barriers described in the typology. RESULTS: Multiple recruitment strategies were described by the researchers. These strategies were matched to all but two recruitment barriers related to psychopathology/substance misuse by the participants and paucity of healthcare related resources. Multiple strategies were found to be effective against each barrier and appropriate ones could be selected by the researchers after considering available resources at hand. CONCLUSIONS: Findings from this paper have implications for the design of recruitment strategies for hard to recruit ethnic minority groups to health care research. There is need for wider training and support of researchers to give them the skills to recruit these ethnic groups. Further development and evaluation of these strategies will lead to increased recruitment accruals.

Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease.

OBJECTIVE: To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions. DESIGN: Cluster randomised controlled trial. SETTING: 36 general practices in the north west of England. PARTICIPANTS: 387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥ 10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial. INTERVENTIONS: Collaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses. MAIN OUTCOME MEASURES: The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF). RESULTS: 19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval -0.41 to -0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support. CONCLUSIONS: Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity. TRIAL REGISTRATION: ISRCTN80309252.

Update on the collaborative interventions for circulation and depression (COINCIDE) trial: changes to planned methodology of a cluster randomized controlled trial of collaborative care for depression in people with diabetes and/or coronary heart disease.

BACKGROUND: The COINCIDE trial aims to evaluate the effectiveness and cost-effectiveness of a collaborative care intervention for depression in people with diabetes and/or coronary heart disease attending English general practices. DESIGN: This update details changes to the cluster and patient recruitment strategy for the COINCIDE study. The original protocol was published in Trials (http://www.trialsjournal.com/content/pdf/1745-6215-13-139.pdf). Modifications were made to the recruitment targets in response to lower-than-expected patient recruitment at the first ten general practices recruited into the study. In order to boost patient numbers and retain statistical power, the number of general practices recruited was increased from 30 to 36. Follow-up period was shortened from 6 months to 4 months to ensure that patients recruited to the trial could be followed up by the end of the study. RESULTS: Patient recruitment began on the 01/05/2012 and is planned to be completed by the 30/04/2013. Recruitment for general practices was completed on 31/10/2012, by which time the target of 36 practices had been recruited. The main trial results will be published in a peer-reviewed journal. CONCLUSION: The data from the trial will provide evidence on the effectiveness and cost-effectiveness of collaborative care for depression in people with diabetes and/or coronary heart disease. TRIAL REGISTRATION NUMBER: ISRCTN80309252.

The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: systematic review and meta-analysis.

BACKGROUND: Depression and anxiety are very common in people with chronic obstructive pulmonary disease (COPD) and are associated with excess morbidity and mortality. Patients prefer non-drug treatments and clinical guidelines promote non-pharmacological interventions as first line therapy for depression and anxiety in people with long term conditions. However the comparative effectiveness of psychological and lifestyle interventions among COPD patients is not known. We assessed whether complex psychological and/or lifestyle interventions are effective in reducing symptoms of anxiety and depression in patients with COPD. We then determined what types of psychological and lifestyle interventions are most effective. METHODS AND FINDINGS: Systematic review of randomised controlled trials of psychological and/or lifestyle interventions for adults with COPD that measured symptoms of depression and/or anxiety. CENTRAL, Medline, Embase, PsychINFO, CINAHL, ISI Web of Science and Scopus were searched up to April 2012. Meta-analyses using random effects models were undertaken to estimate the average effect of interventions on depression and anxiety. Thirty independent comparisons from 29 randomised controlled trials (n = 2063) were included in the meta-analysis. Overall, psychological and/or lifestyle interventions were associated with small reductions in symptoms of depression (standardised mean difference -0.28, 95% confidence interval -0.41 to -0.14) and anxiety (standardised mean difference -0.23, 95% confidence interval -0.38 to -0.09). Multi-component exercise training was the only intervention subgroup associated with significant treatment effects for depression (standardised mean difference -0.47, 95% confidence interval -0.66 to -0.28), and for anxiety (standardised mean difference -0.45, 95% confidence interval -0.71 to -0.18). CONCLUSIONS: Complex psychological and/or lifestyle interventions that include an exercise component significantly improve symptoms of depression and anxiety in people with COPD. Furthermore, multi-component exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population.

Characteristics of psychological interventions that improve depression in people with coronary heart disease: a systematic review and meta-regression.

OBJECTIVE: Despite previous intervention trials, it is unclear which psychological treatments are most effective for people with coronary heart disease (CHD). We have conducted a systematic review with meta-regression to identify the characteristics of psychological interventions that improve depression and depressive symptoms among people with CHD. METHODS: Searches of multiple electronic databases up to March 2012 were conducted, supplemented by hand-searching of identified reviews and citation tracing of eligible studies. Studies were included if they reported a randomized controlled trial of a psychological intervention for people with CHD and included depression as an outcome. Data on main effects and characteristics of interventions were extracted from eligible studies. Standardized mean differences (SMDs) were calculated for each study and pooled using random-effects models. Random-effects multivariate meta-regression was performed to identify treatment characteristics associated with improvements in depression. RESULTS: Sixty-four independent treatment comparisons were identified. Psychological interventions improved depression, although the effect was small (SMD=0.18, p<.001). Problem solving (SMD=0.34), general education (SMD=0.19), skills training (SMD=0.25), cognitive-behavioral therapy (CBT; SMD=0.23), and relaxation (SMD=0.15) had small effects on CHD patients who were recruited irrespective of their depression status. Among high-quality trials of depressed CHD patients, only CBT showed significant but small effects (SMD=0.31). When entered into multivariable analysis, no individual treatment component significantly improved depression. CONCLUSIONS: CBT and problem solving should be considered for inclusion in future treatment developments and randomized controlled trials. However, the effects are small in magnitude, and there is room to develop new interventions that may be more effective.

Collaborative Interventions for Circulation and Depression (COINCIDE): study protocol for a cluster randomized controlled trial of collaborative care for depression in people with diabetes and/or coronary heart disease.

BACKGROUND: Depression is up to two to three times as common in people with long-term conditions. It negatively affects medical management of disease and self-care behaviors, and leads to poorer quality of life and high costs in primary care. Screening and treatment of depression is increasingly prioritized, but despite initiatives to improve access and quality of care, depression remains under-detected and under-treated, especially in people with long-term conditions. Collaborative care is known to positively affect the process and outcome of care for people with depression and long-term conditions, but its effectiveness outside the USA is still relatively unknown. Furthermore, collaborative care has yet to be tested in settings that resemble more naturalistic settings that include patient choice and the usual care providers. The aim of this study was to test the effectiveness of a collaborative-care intervention, for people with depression and diabetes/coronary heart disease in National Health Service (NHS) primary care, in which low-intensity psychological treatment services are delivered by the usual care provider - Increasing Access to Psychological Therapies (IAPT) services. The study also aimed to evaluate the cost-effectiveness of the intervention over 6 months, and to assess qualitatively the extent to which collaborative care was implemented in the intervention general practices. METHODS: This is a cluster randomized controlled trial of 30 general practices allocated to either collaborative care or usual care. Fifteen patients per practice will be recruited after a screening exercise to detect patients with recognized depression (≥10 on the nine-symptom Patient Health Questionnaire; PHQ-9). Patients in the collaborative-care arm with recognized depression will be offered a choice of evidence-based low-intensity psychological treatments based on cognitive and behavioral approaches. Patients will be case managed by psychological well-being practitioners employed by IAPT in partnership with a practice nurse and/or general practitioner. The primary outcome will be change in depressive symptoms at 6 months on the 90-item Symptoms Checklist (SCL-90). Secondary outcomes include change in health status, self-care behaviors, and self-efficacy. A qualitative process evaluation will be undertaken with patients and health practitioners to gauge the extent to which the collaborative-care model is implemented, and to explore sustainability beyond the clinical trial. DISCUSSION: COINCIDE will assess whether collaborative care can improve patient-centered outcomes, and evaluate access to and quality of care of co-morbid depression of varying intensity in people with diabetes/coronary heart disease. Additionally, by working with usual care providers such as IAPT, and by identifying and evaluating interventions that are effective and appropriate for routine use in the NHS, the COINCIDE trial offers opportunities to address translational gaps between research and implementation. TRIAL REGISTRATION NUMBER: ISRCTN80309252 TRIAL STATUS: Open.

Accessing primary health care: a meta-ethnography of the experiences of British South Asian patients with diabetes, coronary heart disease or a mental health problem.

OBJECTIVES: To develop an explanatory framework of the problems accessing primary care health services experienced by British South Asian patients with a long-term condition or mental health problem. METHODS: This study used meta-ethnographic methods. Published qualitative studies were identified from a structured search of six databases and themes synthesized across studies to develop a new explanatory framework. RESULTS: Initial searches identified 951 potentially relevant records from which a total of 27 articles were identified that met inclusion and exclusion criteria. Twelve of these articles were chosen on the basis of their quality and relevance. These 12 articles described themes relating to the cultural, spatial and temporal dimensions of patient experiences of accessing and using health care. Our interpretive synthesis showed that access to primary care among British South Asians with diabetes, coronary heart disease and psychological health problems is co-constructed and negotiated over time and space along the key domains of the candidacy model of access: from help-seeking to interactions at the interface to following treatment advice. In the case of each condition, British South Asians' claims to candidacy were constrained where their individual as well as broader social and cultural characteristics lacked fit with professionals' ways of working and cultural typifications. CONCLUSION: Interventions that positively affect professionals' capacity to support patient claims to candidacy are likely to help support British South Asians overcome a broad range of barriers to care for physical and mental health problems.

Talking about depression: a qualitative study of barriers to managing depression in people with long term conditions in primary care.

BACKGROUND: The risk of depression is increased in people with long term conditions (LTCs) and is associated with poorer patient outcomes for both the depressive illness and the LTC, but often remains undetected and poorly managed. The aim of this study was to identify and explore barriers to detecting and managing depression in primary care in people with two exemplar LTCs: diabetes and coronary heart disease (CHD). METHODS: Qualitative in-depth interviews were conducted with 19 healthcare professionals drawn predominately from primary care, along with 7 service users and 3 carers (n = 29). One focus group was then held with a set of 6 healthcare professionals and a set of 7 service users and 1 carer (n = 14). Interviews and the focus group were digitally recorded, transcribed verbatim, and analysed independently. The two data sets were then inspected for commonalities using a constant comparative method, leading to a final thematic framework used in this paper. RESULTS: Barriers to detecting and managing depression in people with LTCs in primary care exist: i) when practitioners in partnership with patients conceptualise depression as a common and understandable response to the losses associated with LTCs - depression in the presence of LTCs is normalised, militating against its recognition and treatment; ii) where highly performanced managed consultations under the terms of the Quality and Outcomes Framework encourage reductionist approaches to case-finding in people with CHD and diabetes, and iii) where there is uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management. CONCLUSION: Depression was often normalised in the presence of LTCs, obviating rather than facilitating further assessment and management. Furthermore, structural constraints imposed by the QOF encouraged reductionist approaches to case-finding for depression in consultations for CHD and diabetes. Future work might focus on how interventions that draw on the principles of the chronic care model, such as collaborative care, could support primary care practitioners to better recognise and manage depression in patients with LTCs.