Mind the gap! Factors that predict progression to bariatric surgery indicate that more psychological treatment may be required.

In the UK, the number of adults living with obesity is increasing. Bariatric surgery is an available treatment for those living with a BMI (kg/m2 ) ≥40 and above, or ≥35 with obesity-related comorbidities. Guidelines highlight the importance of providing psychological support pre- and post-surgery owing to the complex psychopathology present in those living with obesity. There are a lack of studies examining which patients proceed to surgery and the factors that predict progression. Routine patient data were collected within one NHS regional service in the UK, comprising 733 patients between 3 August 2018 and 26 July 2019, aged between 17 and 76 years (M = 43.20, SD = 12.32). The only exclusion criteria were patients still awaiting a final decision for surgical outcome at the point of analysis (N = 29), which resulted in 704 patients included in analysis. Binary Logistic Regression revealed those who were more likely to progress to surgery had a lower-level use of maladaptive external substances; lower level of self-harm and/or suicidality, were older in age; had a lower BMI; and had less comorbidities than those who did not progress. Findings support existing literature in that bariatric patients often present with physical and mental health complexity. Two thirds of patients in this study did not progress to surgery. Service commissioning decisions meant that these patients did not have access to psychology treatment. Consequently, in cases where bariatric surgery is considered, a final treatment option and otherwise clinically appropriate, lack of access to specialist services may result in unmet patient need owing particularly to a lack of psychological treatment provision.

The forgotten patient: A psychological perspective on the implementation of bariatric surgery guidelines.

There is strong evidence demonstrating the impact of bariatric surgery on weight-loss and comorbidity improvement. In the UK, there is specific guidance to facilitate the assessment of a person's suitability for bariatric surgery. This paper highlights the clinical reality of routinely implementing this guidance, supported by literature and the perspectives of practicing psychologists. The consequences of the implementation of clinical guidelines within the context of the typical biopsychosocial profile of those referred for bariatric surgery are discussed. The ramifications of a screening approach rather than a clinical formulation-based approach to assessment, impact of a possible unconscious bias in commissioning and an overemphasis on a biomedical model approach to treatment are also presented. These contextual factors are argued to contribute to a population of "forgotten patients" that is, patients who have been assessed as not suitable for bariatric surgery, and thus "stuck" in their journey toward better health. For these individuals the only option left are energy balance only approaches, which are the very same approaches to weight-loss and comorbidity improvement that have been attempted, often for many years. Not only have these approaches not resulted in weight-loss and health improvement, they also fail to address the underlying psychological causes of obesity. Consequently, this lack of support means that patients continue to suffer from poor quality of life, with no clear pathway to improved health and wellbeing. This paper illuminates the clear gaps in weight management service provision, the implementation of guidelines in practice, and offers practical suggestions to reduce the unintended consequences of clinical guidelines for bariatric surgery.

Case formulation-A vehicle for change? Exploring the impact of cognitive behavioural therapy formulation in first episode psychosis: A reflexive thematic analysis.

OBJECTIVES: Formulation is considered a fundamental process of cognitive behavioural therapy for psychosis (CBTp). However, an exploration into the personal impact of different levels of case formulation (CF) from a service user (SU) perspective is lacking, particularly for those experiencing a first episode of psychosis. DESIGN: This Big Q qualitative design used semi-structured interviews. METHODS: Reflexive thematic analysis (TA) was used to analyse 10 participant interviews. NVivo 12 computer-assisted qualitative data analysis software aided data organisation and analysis. RESULTS: One overarching theme 'CF - A vehicle for change?' was developed as a pattern of shared meaning across the data set. Three main themes related to the overarching theme: (1) Vicious cycles: 'I never really thought about it being me maintaining the problems' (including one subtheme - Self-empowerment: 'Only you can make the changes for yourself'); (2) Early life experiences: 'My experiences have shaped the person that I am, therefore, it's not my fault' (including one subtheme - Disempowerment: '[My] core beliefs have been damaged'); and (3) Keep it simple: 'Don't push it too far over the top in case it becomes like spaghetti'. CONCLUSIONS: Maintenance formulations may be experienced as self-blaming, but also self-empowering, which may help to facilitate change. Longitudinal formulations may be experienced as non-blaming, but also disempowering, which may inhibit change. Simple CF diagrams may also facilitate change, whereas overly complex CFs may inhibit change. How CBTp therapists might look to improve the impact of different levels of CF for service users (SUs) in first episode psychosis (FEP) are described.

The torchlight model of mapping in cognitive analytic therapy (CAT) reformulation: A qualitative investigation.

OBJECTIVES: Despite the central role of formulation in psychological therapy, there is limited research on how formulations are constructed in clinical practice. In Cognitive Analytic Therapy (CAT), a formulation diagram (or CAT map) is used in transforming the client's narrative into a psychological understanding of the difficulties. The objective was to build a theoretical model of the processes involved in the early stages of CAT mapping. DESIGN: A qualitative research design using constructivist Grounded Theory Methodology (GTM) incorporating Interpersonal Process Recall (IPR) methods. METHODS: CAT therapists participated in a role-play therapy session with an actor (the 'client') and made an initial attempt at formulation by mapping. A video recording then formed the basis for a semi-structured therapist interview. Following data analysis, a conceptual model and visual metaphor of the early process of CAT mapping was generated. RESULTS: The Torchlight model conceptualizes the mapping process as a coming together of unique factors brought by client and therapist, alongside the conceptual apparatus of CAT. Each factor brings a unique light to the unfolding process of mapping and intermixes through a dialogical, collaborative process, analogous to coloured lights mixing to form new colours. The model outlines the mapping process itself as an iterative sequence of tasks, achieved through collaboration, within a growing therapeutic relationship. CONCLUSIONS: The model offers an empirical underpinning to existing accounts of CAT mapping, and a potential tool for training. PRACTITIONER POINTS: The process by which individual CAT reformulation diagrams are started appears to be as unique to the therapist-client dyad as the contents of the map, on the basis of the findings. Mapping faithfully enacts the dialogical and developmental theoretical principles underpinning the CAT approach. The Torchlight model is the first empirically based model of the processes taking place in the creation of CAT reformulation diagrams, in the early stages.

It's not just 'What' you do, it's also the 'Way' that you do it: Patient and Public Involvement in the Development of Health Research.

PURPOSE: This article presents a reflective account of Patient and Public Involvement (PPI) in the development of obesity and binge eating research. METHOD: We established Patient Advisory Groups (PAGs) at two English regional National Health Service (NHS) weight management services. PPI was evaluated as follows: (i) PAG members completed a Post Participation Evaluation Questionnaire, (ii) PAG meetings captured group discussion on PPI involvement, (iii) practitioner and researchers produced written reflections on PPI and (iv) sources one to three were consolidated during reflections that took place via e-mail and telephone correspondence between researchers and practitioners, culminating in a summary SKYPE meeting between one practitioner and one researcher involved in the PAGs. RESULTS: Results in the form of reflections suggest guidelines on undertaking PPI were helpful with regard 'what to do', but less helpful on 'how'. For example, suggestions for the management of interpersonal factors such as eliciting self-disclosure and managing power differentials are insufficiently addressed in existing guidelines. CONCLUSIONS: The present case study illustrated how interpersonal considerations can help or hinder the optimal use of PPI. Recommendations for practitioners and researchers planning PPI are offered.

Health psychology: It's not what you do, it's the way that you do it.

Despite the growth in theoretical understandings of health behaviour and standardised approaches to health interventions (e.g. behaviour change taxonomies), health psychology has paid comparatively less attention to the importance of the implementation processes - 'how to' rather than 'what to' of such interventions. The clinical and interpersonal skills that often reflect these implementation processes are poorly defined within the health psychology literature. The level of proficiency in such skills expected of Health and Care Professions Council registered practitioner health psychologists is unclear and poorly documented within the UK training requirements. This article explores the potential impact of this and offers some pragmatic solutions.

Laser targeting with C-arm fluoroscopy: effect on radiation exposure for pediatric patients.

The primary purpose of obtaining laser targeting devices for C-arm fluoroscopy was to attempt to reduce radiation to the pediatric population in Connecticut Children's Medical Center's commitment to Imaging Gently. Fluoroscopy times for placing central lines in the operating rooms were documented for two months prior to the installation of the lasers and then for twenty procedures after installation and training on the devices. Fluoroscopy times trended down 25% calculated by a simple mean and standard deviation.

Exploring the perceptions of success in an exercise referral scheme: a mixed method investigation.

BACKGROUND: Exercise referral schemes feature as one of the prevalent primary care physical activity interventions in the United Kingdom, without extensive understanding of how those involved in providing and participating view success. The present research explores and reveals the constituents of "success," through comparison, contradiction, and integration of qualitative and quantitative research findings. METHOD: A population-based cohort design formed the basis for a mixed method approach to the research. The quantitative component used a three-stage binary logistic regression to identify patient sociodemographic characteristics and referral reasons associated with three outcomes (n=1,315). The qualitative component (n=28) comprised four focus groups with patients (n=17), individual interviews with exercise providers (n=4), and referring health professionals (n=7). The research components were compared at discussion stage to offer insights into the concept of "success." RESULTS: The integrated findings highlighted the multidimensional nature of the concept of success, containing a wide range of concepts such as empowerment, inclusion, and confidence. The traditional notions of success such as, attendance, weight loss, and blood pressure reduction featured amid a more holistic view which incorporated psychological and social aspects as both influences and outcomes. CONCLUSION: These findings can enable future development of more representative evaluations of the benefits of exercise referral. This mixed methods research approach can facilitate the development of sophisticated, tailored, evidence-based interventions in the future.

Factors associated with physical activity referral completion and health outcomes.

Participant socio-demographic characteristics and referral reason were investigated in relation to completion and health outcomes in a Primary Care Physical Activity Referral Scheme using a prospective population-based longitudinal design. Participants (n = 1735) were recruited over a 2-year period. A three-stage binary logistic regression analysis identified the factors associated with the outcomes of completion (model 1), body mass reduction (model 2) and blood pressure reduction (model 3). Participant's age, gender, ethnicity, occupation and referral reason were the independent variables for model 1, with the variables of completion added in model 2 and completion and body mass reduction added in model 3. Logistic regression analysis revealed that increasing age is associated with the likelihood of completion (Odds Ratio, OR = 1.019; Confidence Interval, CI = 1.008-1.030; P = 0.001). Participants with a pulmonary condition are less likely to complete (OR = 0.546; CI = 0.346-0.860; P < 0.01) compared to those referred for cardiovascular conditions. For ethnicity, in comparison to the white category, patients in the mixed category are significantly more likely to achieve a reduction in body mass (OR = 3.991; CI = 1.191-13.373; P < 0.05). Those who complete are more likely to achieve a reduction in body mass (OR = 3.541; CI = 2.721-4.608; P < 0.001). When compared to the unemployed category, the skilled manual category had an increased likelihood of achieving a reduction in blood pressure (OR = 1.875; CI = 1.044-3.227; P < 0.05). Participants who completed also demonstrated an increased likelihood of a reduction in blood pressure (OR = 1.680; CI = 1.250-2.003; P < 0.001). Furthermore, those participants who achieved a reduction in body mass had an increased likelihood of achieving a reduction in blood pressure (OR = 1.292; CI = 1.008-1.641; P < 0.05). Completion is associated with health outcomes of reduced body mass and blood pressure.

Physical activity behavior change interventions based on the transtheoretical model: a systematic review.

This review critically examines Transtheoretical Model (TTM)-based interventions for physical activity (PA) behavior change. It has been suggested that the TTM may not be the most appropriate theoretical model for applications to PA behavior change. However, previous reviews have paid little or no attention to how accurately each intervention represents the TTM. Findings comprise two sections: sample characteristics of each intervention reviewed and a summary outlining the use of the TTM to develop the interventions. Results reveal numerous inconsistencies regarding the development and implementation/application of TTM-based interventions. Specifically, the majority of interventions reported to be based on the TTM fail to accurately represent all dimensions of the model. Therefore, until interventions are developed to accurately represent the TTM, the efficacy of these approaches and the appropriateness of the underpinning theoretical model cannot be determined.

Uptake and participation in physical activity referral schemes in the UK: an investigation of patients referred with mental health problems.

The study compared outcomes of uptake, attendance, and completion between two patient groups (mental health, n = 134 and physical health, n = 2767) in a physical activity referral scheme in the UK during 2000 to 2003. Despite similar rates for the physical health and mental health groups for initial progression (94% vs. 90%), referral uptake (60% vs. 69%; p < 0.001) and programme completion (22% vs. 34%; p < 0.001) were significantly lower in the mental health referrals. In conclusion, physical activity referral schemes appear to be less well suited to the needs of the mental health patient. Further research is recommended.

Physical activity counseling content and competency: a systematic review.

BACKGROUND: Physical activity (PA) counseling is becoming commonplace in primary care settings, although there is a high degree of variation in the quality and quantity of this intervention. The purpose of this review was to examine the theory on which the intervention is based and the level of treatment fidelity applied at all stages of the intervention. METHODS: A systematic review was carried out for interventions that reported an element of PA counseling. Results were mapped according to a treatment fidelity framework of intervention design, training, delivery, receipt, and enactment. RESULTS: Most studies were underpinned by the transtheoretical model. Few studies described the frequency or duration of PA counseling training or competence level of the interventionist. The most common outcome measures were behavioral and physiological, with few studies including a cognitive outcome measure. CONCLUSIONS: Most research focuses on outcome and significance rather than intervention processes, with limited consideration of treatment fidelity. The design, training, delivery, and receipt of PA counseling should be reported more thoroughly.

Factors associated with physical activity referral uptake and participation.

The aim of this study was to examine participant and scheme characteristics in relation to access, uptake, and participation in a physical activity referral scheme (PARS) using a prospective population-based longitudinal design. Participants (n = 3762) were recruited over a 3-year period. Logistic regression analyses identified the factors associated with the outcomes of referral uptake, participation, and completion (> or = 80% attendance). Participant's age, sex, referral reason, referring health professional, and type of leisure provider were the independent variables. Based on binary logistic regression analysis (n = 2631), only primary referral reason was associated with the PARS coordinator making contact with the participants. In addition to the influence of referral reason, females were also more likely (odds ratio 1.250, 95% confidence interval 1.003-1.559, P = 0.047) to agree to be assigned to a leisure provider. Referral reason and referring health professional were associated with taking up a referral opportunity. Older participants (1.016, 1.010-1.023, P < 0.001) and males were more likely to complete the referral. In conclusion, the PARS format may be less appropriate for those more constrained by time (women, young adults) and those with certain referral reasons (overweight/obesity, mental health conditions). More appropriate targeting at the point of referral could improve participation rates by revealing or addressing barriers that might later result in dropout.

Socio-demographic patterning of referral, uptake and attendance in Physical Activity Referral Schemes.

BACKGROUND: Inadequate monitoring and participant profiling have so far prevented a detailed examination of who Physical Activity Referral Schemes (PARS) are accessible to and appropriate for. As a result, the nature of the role for PARS within public health is unknown. METHODS: Participants were all those referred to a countywide PARS during a three-year period (n = 3568). Participant age, gender and the deprivation level and rurality of their area of residence were compared with the average for the county population. Characteristics associated with referral uptake (attending > or =1 exercise session) and completion (> or =80% attendance), were identified using logistic regression. RESULTS: Compared with the county average, participants were older, more predominantly female (61.1 vs 51.4%) and lived in more deprived areas (p < 0.001). Referral uptake (n = 2864) was most likely in those aged 60-69 years, and least likely for residents of rural villages and the most deprived areas (all p < 0.001). For participants who took up referral, completion was most likely in men and the over-seventies (p < 0.001). CONCLUSIONS: The PARS format may be inappropriate for younger adults or people living in relative deprivation and rural areas. They appear most appropriate for adults of middle-to-old age who are more likely to require supervision, and should be targeted accordingly.