Patients' experience of and participation in a stroke self-management programme, My Life After Stroke (MLAS): a multimethod study.

OBJECTIVE: A self-management programme, My Life After Stroke (MLAS), was developed to support stroke survivors. This evaluation reports patients' experience. DESIGN: Multimethod, involving interviews and questionnaires. SETTING: 23 general practices in the intervention arm of a cluster randomised controlled trial in East of England and East Midlands, UK. PARTICIPANTS: People on the stroke registers of participating general practices were invited to attend an MLAS programme. INTERVENTIONS: MLAS comprises one-to-one and group-based sessions to promote independence, confidence and hope. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was uptake of the programme. Participants who declined MLAS were sent a questionnaire to ascertain why. Attendees of four programmes completed evaluation forms. Attendees and non-attendees of MLAS were interviewed. Ad-hoc email conversations with the lead author were reviewed. Thematic analysis was used for qualitative data. RESULTS: 141/420 (34%) participants (mean age 71) attended an MLAS programme and 103 (73%) completed 1. 64/228 (28%) participants who declined MLAS gave reasons as: good recovery, ongoing health issues, logistical issues and inappropriate. Nearly all attendees who completed questionnaires felt that process criteria such as talking about their stroke and outcomes such as developing a strong understanding of stroke had been achieved. CONCLUSIONS: MLAS was a positive experience for participants but many stroke survivors did not feel it was appropriate for them. Participation in self-management programmes after stroke might be improved by offering them sooner after the stroke and providing a range of delivery options beyond group-based, face-to-face learning. TRIAL REGISTRATION NUMBER: NCT03353519, NIH.

Improving Primary Care After Stroke (IPCAS) randomised controlled trial: protocol for a multidimensional process evaluation.

INTRODUCTION: Primary care interventions are often multicomponent, with several targets (eg, patients and healthcare professionals). Improving Primary Care After Stroke (IPCAS) is a novel primary care-based model of long-term stroke care involving a review of stroke-related needs, a self-management programme, a direct point of contact in general practice, enhanced communication between care services, and a directory of national and local community services, currently being evaluated in a cluster randomised controlled trial (RCT). Informed by Medical Research Council guidance for complex interventions and the Behaviour Change Consortium fidelity framework, this protocol outlines the process evaluation of IPCAS within this RCT. The process evaluation aimed to explore how the intervention was delivered in context and how participants engaged with the intervention. METHODS AND ANALYSIS: Mixed methods will be used: (1) design: intervention content will be compared with 'usual care'; (2) training: intervention training sessions will be audio/video-recorded where feasible; (3) delivery: healthcare professional self-reports, audio recordings of intervention delivery and observations of My Life After Stroke course (10% of reviews and sessions) will be coded separately; semistructured interviews will be conducted with a purposive sample of healthcare professionals; (4) receipt and (5) enactment: where available, structured stroke review records will be analysed quantitatively; semistructured interviews will be conducted with a purposive sample of study participants. Self-reports, observations and audio/video recordings will be coded and scored using specifically developed checklists. Semistructured interviews will be analysed thematically. Data will be analysed iteratively, independent of primary endpoint analysis. ETHICS AND DISSEMINATION: Favourable ethical opinion was gained from Yorkshire & The Humber-Bradford Leeds NHS Research Ethics Committee (19 December 2017, 17/YH/0441). Study results will be published in a peer-reviewed journal and presented at relevant conferences. TRIAL REGISTRATION NUMBER: NCT03353519; Pre-results.

A cross-cultural investigation of young children's spontaneous invention of tool use behaviours.

Through the mechanisms of observation, imitation and teaching, young children readily pick up the tool using behaviours of their culture. However, little is known about the baseline abilities of children's tool use: what they might be capable of inventing on their own in the absence of socially provided information. It has been shown that children can spontaneously invent 11 of 12 candidate tool using behaviours observed within the foraging behaviours of wild non-human apes (Reindl et al. 2016 Proc. R. Soc. B 283, 20152402. (doi:10.1098/rspb.2015.2402)). However, no investigations to date have examined how tool use invention in children might vary across cultural contexts. The current study investigated the levels of spontaneous tool use invention in 2- to 5-year-old children from San Bushmen communities in South Africa and children in a large city in Australia on the same 12 candidate problem-solving tasks. Children in both cultural contexts correctly invented all 12 candidate tool using behaviours, suggesting that these behaviours are within the general cognitive and physical capacities of human children and can be produced in the absence of direct social learning mechanisms such as teaching or observation. Children in both cultures were more likely to invent those tool behaviours more frequently observed in great ape populations than those less frequently observed, suggesting there is similarity in the level of difficulty of invention across these behaviours for all great ape species. However, children in the Australian sample invented tool behaviours and succeeded on the tasks more often than did the Bushmen children, highlighting that aspects of a child's social or cultural environment may influence the rates of their tool use invention on such task sets, even when direct social information is absent.

The decision-making processes adopted by rurally located mandated professionals when child abuse or neglect is suspected.

The reporting of suspected child abuse and neglect is a mandated role of medical doctors, nurses, police and teachers in Victoria, Australia. This paper reports on a research study that sought to explicate how mandated professionals working in rural Victorian contexts identify a child/ren at risk and the decisions they make subsequently.

Protocol for the ADDITION-Plus study: a randomised controlled trial of an individually-tailored behaviour change intervention among people with recently diagnosed type 2 diabetes under intensive UK general practice care.

BACKGROUND: The increasing prevalence of type 2 diabetes poses both clinical and public health challenges. Cost-effective approaches to prevent progression of the disease in primary care are needed. Evidence suggests that intensive multifactorial interventions including medication and behaviour change can significantly reduce cardiovascular morbidity and mortality among patients with established type 2 diabetes, and that patient education in self-management can improve short-term outcomes. However, existing studies cannot isolate the effects of behavioural interventions promoting self-care from other aspects of intensive primary care management. The ADDITION-Plus trial was designed to address these issues among recently diagnosed patients in primary care over one year. METHODS/DESIGN: ADDITION-Plus is an explanatory randomised controlled trial of a facilitator-led, theory-based behaviour change intervention tailored to individuals with recently diagnosed type 2 diabetes. 34 practices in the East Anglia region participated. 478 patients with diabetes were individually randomised to receive (i) intensive treatment alone (n = 239), or (ii) intensive treatment plus the facilitator-led individual behaviour change intervention (n = 239). Facilitators taught patients key skills to facilitate change and maintenance of key behaviours (physical activity, dietary change, medication adherence and smoking), including goal setting, action planning, self-monitoring and building habits. The intervention was delivered over one year at the participant's surgery and included a one-hour introductory meeting followed by six 30-minute meetings and four brief telephone calls. Primary endpoints are physical activity energy expenditure (assessed by individually calibrated heart rate monitoring and movement sensing), change in objectively measured dietary intake (plasma vitamin C), medication adherence (plasma drug levels), and smoking status (plasma cotinine levels) at one year. We will undertake an intention-to-treat analysis of the effect of the intervention on these measures, an assessment of cost-effectiveness, and analyse predictors of behaviour change in the cohort. DISCUSSION: The ADDITION-Plus trial will establish the medium-term effectiveness and cost-effectiveness of adding an externally facilitated intervention tailored to support change in multiple behaviours among intensively-treated individuals with recently diagnosed type 2 diabetes in primary care. Results will inform policy recommendations concerning the management of patients early in the course of diabetes. Findings will also improve understanding of the factors influencing change in multiple behaviours, and their association with health outcomes.

More than measurement: practice team experiences of screening for type 2 diabetes.

BACKGROUND: The feasibility, cost-effectiveness and best means to implement population screening for type 2 diabetes remain to be established. OBJECTIVE: To learn from the experiences of practice staff undertaking a diabetes screening programme in order to inform future screening initiatives. METHODS: Qualitative analysis of interviews with staff in six general practices in the 'ADDITION-Cambridge' trial; three randomly allocated to intensively manage screen-detected patients and three providing usual care. We conducted semi-structured interviews with seven nurses, four doctors, three health care assistants and four managers. Four researchers analysed the transcripts practice by practice, preparing vignettes and comparing interpretations. Participants commented on a summary report. RESULTS: Each practice team implemented the screening and intervention programme differently, depending on numbers at risk and decisions about staff contributions. Several emphasized the importance of administrative support. As they screened, they extended the reach of the programme, testing patients outside the target group if requested, checking other risk factors, providing health information and following up people with impaired glucose tolerance. Staff felt that patients accepted the screening and subsequent management as any other clinical activity. CONCLUSIONS: Although those developing screening programmes attempt to standardize them, primary care teams need to adapt the work to fit local circumstances. Staff need a sense of ownership, training, well-designed information technology systems and protected time. Furthermore, screening is more than measurement; at the individual level, it is a complete health care interaction, requiring individual explanations, advice on health-related behaviour and appropriate follow-up. The UK 'NHS Health Checks' programme should embrace these findings.

Synthesis, pharmacological studies and molecular modeling of some tetracyclic 1,3-diazepinium chlorides.

Seven new 1,3-diazepinium chlorides exhibiting some structural similarities to the 1,4-benzodiazepines were synthesized. In a Hippocratic screen using mice, three of these salts, 3-methoxy-6-oxo-7,13-dihydro-6H-benzofuro[2,3-e]pyrido[1,2-a][1,3]diazepin-12-ium chloride (8a), 3-methoxy-9-methyl-6-oxo-7,13-dihydro-6H-benzofuro[2,3-e]pyrido[1,2-a][1,3]diazepin-12-ium chloride (8c) and 3-methoxy-11-methyl-6-oxo-7,13-dihydro-6H-benzofuro[2,3-e]pyrido[1,2-a][1,3]diazepin-12-ium chloride (8e) were examined for their effect on the central nervous system, and their activities compared to that of diazepam. On their own, salts 8a, 8c and 8e solicited no sedative effects on the behaviour of the animals. However, they elicited significant effects in combination with diazepam on diazepam-induced activities such as decreased motor activity, ataxia and loss of righting reflex. Compounds 8a and 8c were fitted into the pharmacophore/receptor model developed by Cook et al. with interaction at the L(1), H(1) and A(2) sites indicating that they are potential inverse agonists of the Bz receptor. The compounds displayed some affinity for the alpha1 isoform of the GABA(A)/BzR (L(Di) interaction) but are non-selective for alpha5 (no L(2) interaction). Results of binding affinity studies showed that compound 8a is mildly selective for the alpha1 receptor although not very potent (K(i)=746.5nM). The significant potentiation of diazepam-induced ataxia and decreased motor activity by compounds 8a and 8c in the Hippocratic screen may be associated with alpha1 selectivity.

New and emerging roles in out of hospital emergency care: a review of the international literature.

AIMS: The aim of the literature review was to identify new and emerging out of hospital emergency care roles and to describe their activity and impact. BACKGROUND: Demographic changes, increased demands for health services, altered working practices, and health system economic pressures have led to the development of a disparate set of new health care roles. DATA SOURCES: MEDLINE, EMBASE and CINAHL databases, and the two search engines Google and Google Scholar were searched for contemporary studies in the identified study area. REVIEW METHODS: All publications identified through the search were assessed for relevance. Those that discussed new roles were included (n=34) and empirical studies (n=14) analysed in detail. RESULTS: Emergency care and paramedic practitioner roles (ECP & PP) are having an impact on patient care, including an average 25% reduction in the conveyance rate to hospital, improved inter-professional working, immediacy of treatment and referral, and high patient satisfaction. Limited economic data suggests savings of between pound31 (USD 55) and pound37 (USD 65) per case when ECPs replace standard ambulance responders. Concerns have been expressed about patient safety, recruitment and training levels, regulatory and role implementation issues. CONCLUSION: Further work is required to fully understand the patient safety, clinical practice, professional role and financial implications of these new roles.

UK research staff perspectives on improving recruitment and retention to primary care research; nominal group exercise.

BACKGROUND: Primary care studies often encounter recruitment difficulties, but there is little evidence to inform solutions. As part of a National Institute for Health Research School for Primary Care Research and UK Clinical Research Network programme, we elicited research staff perspectives on factors facilitating or obstructing recruitment. OBJECTIVE: To identify factors that experienced research staff consider important in successful recruitment and retention and their confidence in achieving them. METHODS: An iterative series of three workshops was held. The third used a modified nominal group technique to categorize whether factors related to the 'context' in which the research took place, the 'content' of the study or the recruitment 'process' and to prioritize them by their importance to success. RESULTS: Eighteen research staff participated in the prioritization workshop. They prioritized positive attitudes of primary care staff towards research and trust of researchers by potential participants as major contextual factors affecting recruitment. Studies needed to be considered safe and relevant by staff and fit with practice systems. They proposed that researchers strengthen relationships with staff and participants and minimize workload for primary care teams. Although confident in many recruitment processes, respondents remained uncertain how to achieve cultural change so that research became part of normal practice activity and how best to motivate patients to participate. CONCLUSIONS: Research workers taking part identified factors which might be important in recruitment, several of which they expressed little confidence in addressing. Understanding how to improve recruitment is crucial if current efforts to strengthen primary care research are to bear fruit.

Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials.

PURPOSE: We wanted to identify published randomized trials of interventions to alter the interaction between patients and practitioners, develop taxonomies of the interventions and outcomes, and assess the evidence that such interventions improve patients' health and well-being. METHODS: Undertaking a systematic review of randomized trials, we sought trials in primary and secondary care with health-related outcomes, which we found by searching MEDLINE, HealthSTAR, and PsycINFO bibliographic databases through 1999. We also completed one round of manual citation searching. RESULTS: Thirty-five trials were included. Most were set in primary care in North America. Trials were heterogeneous in populations, settings, interventions, and measures. Interventions frequently combined several poorly described elements. Explicit theoretical underpinning was rare, and only one study linked intervention through process to outcome measures. Health outcomes were rarely measured objectively (6 of 35), and only 4 trials with health outcomes met predefined quality criteria. Interventions frequently altered the process of interactions (significantly in 73%, 22 of 30 trials). Principal outcomes favored the intervention group in 74% of trials (26 of 35), reaching statistical significance in 14 (40%). Positive effects on health outcomes achieved statistical significance in 44% of trials (11 of 25); negative effects were uncommon (5 of 25, 20%). Simple approaches to increasing the participation of patients in the clinical encounter, such as providing practitioners with a note from patients about their concerns beforehand, showed promise, as did more complex programs providing specific information about disease and attention to emotion. Apparently similar interventions varied in effectiveness across studies. CONCLUSIONS: Successful interactions between patients and their practitioners lie at the heart of medicine, yet there are few rigorous trials of well-specified interventions to inform best practice. Trial evidence suggests that a range of approaches can achieve changes in this interaction, and some show promise in improving patients' health. To advance knowledge further, we need to replicate promising studies using rigorous methods. These should include explicit theoretical frameworks designed to link effects on key communication and interaction characteristics through to effects on health outcomes.