6,446 research outputs found

    Strategies to prevent Type 2 Diabetes in the postnatal period, in women with history of Gestational Diabetes Exploring different research methodologies based on dietary and pharmacological interventions

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    Aim and objectives The aim of this thesis is to investigate methods to prevent the progression to type 2 diabetes in the immediate postnatal period, in women diagnosed with gestational diabetes mellitus (GDM). The objectives of this thesis are to explore the views of pregnant women diagnosed with gestational diabetes and healthcare professionals, with regards to the use of an app in the postnatal period which will provide information about diet for type 2 diabetes prevention. The development of a protocol for a single-arm feasibility study on a Mediterranean-style diet for the prevention of type 2 diabetes in the postnatal period. To pilot the trial design and study processes and assess the feasibility of a large-scale trial on the effectiveness of a Mediterranean-style diet in postnatal period for type 2 diabetes prevention. To examine the acceptability of a Mediterranean-style diet for type 2 diabetes prevention in women taking part in a feasibility study and explore the opinions of women and healthcare professionals on trial processes. To develop a protocol for a pilot trial on metformin for the prevention of type 2 diabetes in the postnatal period. Pilot the trial design and study processes and assess the feasibility of a large-scale trial on the effectiveness of metformin in postnatal period for type 2 diabetes prevention. Methods The methods employed in this thesis include a cross-sectional survey, a single arm mixed method feasibility study with qualitative evaluation (which included the use of an app) and a mixed method randomised controlled double blind feasibility study with the use of metformin or placebo. Results Survey The survey demonstrated that app usage is part of everyday life, with 84% (85/101) of pregnant GDM women and 82% (71/87) of healthcare professionals using apps daily. All pregnant women who participated in this survey had a device by which they could access apps (100%, 101/101) and 95% (179/188) of the participants had a smartphone. The participants agreed that an app which provides dietary information in the postnatal period for diabetes prevention would be welcomed by postnatal women with GDM history. Single arm feasibility study on a Mediterranean-style diet for the prevention of T2D in the postnatal period (MERIT) A total of 69% (83/121) of eligible multi-ethnic women agreed to participate and 67% (56/83) of those initially recruited commenced the intervention. The last visit (12 months postnatally) was completed by 73.2% (41/56) of participants. A higher number of participants completed visit 2 (which is at 6 months postnatally) 80.4% (45/56), but this visit was completed remotely due to COVID-19 pandemic lockdown restrictions, whereas visit 3 was completed face-to-face. Participants had high engagement with the coach, both face-to-face and via phone-calls or text messages. Adherence based on the ESTEEM diet questionnaire was high at the end of the study. There was a trend of reduction of total dysglycaemia, and the participants weight was also reduced by 1.3kg, from visit 1 (6 to 13 weeks) to visit 3 (12 months postnatally). Clinical effectiveness discussion is exploratory due to the small sample size. The intervention and trial processes were acceptable to women and healthcare professionals, adherence was high when women had a supportive environment, provided by their family and the health coach. The group chat function was not successful in this study. Randomised double-blind placebo-controlled pilot trial on metformin for the prevention of T2D in the postnatal period (OMAhA) A total of 57.9% (175/302) of eligible multi-ethnic women agreed to take part in the study, out of those 82.3% (144/175) were randomised to receive metformin or placebo. The attendance rates for visits 2 (6 months) and 3 (12 months) were similar, with 54.6% (71/130) and 55.7 (64/115) attending each visit respectively. Due to the COVID-19 pandemic visit 3 was completed over the phone for 21.7% (39/115) of the participants which led to limited blood samples collection. Total dysglycaemia reduction was evident in the metformin group (18.3%) compared to the placebo group (24.7%) but this discussion is exploratory, and the study is not powered to measure effectiveness. The metformin group maintained their weight throughout the study, whereas the placebo group gained 400g. Adherence was 54.1% (participants who took at least 75% of the recommended dosage). The study was acceptable to both women and healthcare professionals, but the element of peer-support should be included in future studies. Conclusion It is feasible and acceptable to recruit women in the postnatal period in studies that are focused on diabetes prevention and introduce dietary or pharmacological interventions. The MERIT protocol will have to be revised to address how follow-up rates can be improved. The OMAhA protocol will also be revised to target improvement in adherence and follow-up rates. The COVID-19 pandemic lockdown restrictions and staffing issues have impacted data collection of both studies. More research is needed in this population with larger sample sizes to be able to prove efficacy. The strongest motivator that affects adherence and retention is the woman’s perception of her own risk of developing diabetes. Future studies should include the element of peer support and an education session about the risk of Type 2 Diabetes in postnatal period

    Musculoskeletal complaints in primary care:Constraining healthcare costs, rethinking the deployment of healthcare professionals

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    Worldwide policy makers are challenged to account for rising healthcare costs and increased healthcare demand. Also, in the Netherlands there is a growing concern how to maintain high-quality and accessible care while keeping costs in check. Access to care is under pressure as the demand for care is rising fast, due to an aging population and an increasing number of chronically ill people. Not only at the policy level, but also in clinical practice challenges exist. The workload in the health care sector is high, causing health workers, such as general practitioners (GPs), to leave this sector. To keep costs in check available resources need be allocated as efficiently as possible. A good starting point for evaluating healthcare costs may be assessing large patient groups that are responsible for high resource use and costs, such as patients with musculoskeletal conditions treated in general practice. Another point may be identifying prognostic factors for higher healthcare costs. Besides lowering costs, it is also of importance to keep GP care accessible by lowering GPs’ workload. One of the ways to address GPs’ high workload is task reallocation. Internationally, positive effects have been found for an Advanced Physiotherapy Practitioner (APP) model of care, in which APPs take over tasks from a physician in the care for patients with musculoskeletal conditions. This model of care could potentially be of value in reducing the workload of Dutch GPs and keeping GP care accessible. Besides lowering healthcare cost and decreasing GPs’ workload maintaining good quality care is essential. One of the most widely used Patient Reported Outcome Measures (PROMs) in assessing quality of healthcare is the EQ-5D, a preference-based measurement instrument that measures health related quality of life and is used to estimate utility values that represent the preferences of the general population of a country for given health states. These utility values are needed for estimating Quality-Adjusted Life-Years (QALYs) in cost effectiveness analysis. However, quality-of-life measurements are generally not available when data are collected for clinical purposes, such as data from GP electronic medical records. Therefore, researchers are exploring ways to estimate EQ-5D based utility values by means of outcomes on other available health related outcome measures. This thesis aimed to explore some of the challenges in Dutch primary care by evaluating 1) healthcare utilization and associated cost of GP-guided care in patients with musculoskeletal complaints, 2) the introduction of an APP model of care, and 3) different approaches to estimate missing EQ-5D based utility values

    An examination of the verbal behaviour of intergroup discrimination

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    This thesis examined relationships between psychological flexibility, psychological inflexibility, prejudicial attitudes, and dehumanization across three cross-sectional studies with an additional proposed experimental study. Psychological flexibility refers to mindful attention to the present moment, willing acceptance of private experiences, and engaging in behaviours congruent with one’s freely chosen values. Inflexibility, on the other hand, indicates a tendency to suppress unwanted thoughts and emotions, entanglement with one’s thoughts, and rigid behavioural patterns. Study 1 found limited correlations between inflexibility and sexism, racism, homonegativity, and dehumanization. Study 2 demonstrated more consistent positive associations between inflexibility and prejudice. And Study 3 controlled for right-wing authoritarianism and social dominance orientation, finding inflexibility predicted hostile sexism and racism beyond these factors. While showing some relationships, particularly with sexism and racism, psychological inflexibility did not consistently correlate with varied prejudices across studies. The proposed randomized controlled trial aims to evaluate an Acceptance and Commitment Therapy intervention to reduce sexism through enhanced psychological flexibility. Overall, findings provide mixed support for the utility of flexibility-based skills in addressing complex societal prejudices. Research should continue examining flexibility integrated with socio-cultural approaches to promote equity

    The Effect of Smartphone-based Self-care Education on Awareness, Perceived Severity and Self-care Behaviors in Pregnant Women at Risk of Preterm Birth during COVID-19 Pandemic: A Quasi-Experimental Study

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    Background & aim: The fear of being affected by COVID-19 has significantly reduced perinatal care. The current study aimed to evaluate the impact of smartphone-based self-care education on awareness, perceived severity, and self-care of pregnant women at risk of preterm birth during a covid-19 pandemic.Methods: This quasi-experimental study was conducted on 115 pregnant women at risk of preterm birth that was assigned into intervention (N=58) and control (N=57) groups. The research tools included the demographic and preterm delivery screening checklist, awareness, perceived severity, and self-care questionnaires. The intervention group received training files using WhatsApp software within two weeks. The control group received no intervention. The questionnaires were completed before (T1), 8 (T2) and 12 (T3) weeks after the implementation of the intervention in two groups. ANOVA, ANCOVA, independent t-test, chi-square, and Fisher's exact test were used to analyze the data using SPSS software (version 24)  Results: No significant difference was found between baseline data (T1) before the intervention in two groups (p>0.05); while after the intervention, a significant increase was observed in the mean score of awareness at T2 and T3 compared to T1 (P<0.001) as well as self-care at T2 and T3 compared to T1 (P<0.001). Also, a significant decrease was observed in the mean score of perceived severity (P<0.001) in the intervention and control group over time. Conclusion: It appears that distance learning to provide care for pregnant women and informing healthcare providers about their condition can be useful, especially for those who are at risk during pandemics

    Factors of well-being of youth with complex medical conditions from the experience of hospitalization and convalescence: A pilot study

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    Well-being in children with a complex medical condition (CMC) impacts the way they view and communicate with their immediate environment as well as their development, and it is thus necessary to inquire about the contextual issues and different needs that a CMC car- ries. This pilot study aimed to identify factors of pediatric well-being from the experience of hospitalization and convalescence of youth with CMC and their caregivers, in a cross-sec- tional analysis using a selective methodology complemented by an indirect observational methodology. We analyzed the quality of life and well-being of youth with CMC using a vali- dated KINDLR questionnaire. We collected 35 surveys: 11 from youth with CMC and 24 from caregivers from Spain. We focused the analysis on sociodemographics, well-being perceptions, and coping strategies variables. The results show that children aged between 3 and 6 years and their caregivers scored physical well-being the lowest out of all dimen- sions of well-being, and they scored family well-being the highest. Moreover, youth between the ages of 7 and 17 years and their caregivers scored school-related well-being the lowest. Coping strategies to deal with stressful situations differ between children and caregivers. While children mainly engage in social withdrawal, caregivers engage in cognitive restruc- turing and expressing emotions. However, we did not find a relationship between coping strategies and well-being perceptions. These results highlight the need to facilitate commu- nication spaces with both families and health professionals where the voice of children is considered

    Effectiveness of a blended school-based mindfulness program for the prevention of co-rumination and internalizing problems in Dutch secondary school girls:a cluster randomized controlled trial

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    BackgroundA growing body of literature indicates that adolescent girls who talk with close friends about interpersonal problems or worries in an excessive, speculative way, and with an intense focus on distress (i.e., co-rumination) are at heightened risk for developing internalizing symptoms and disorders as well as reduced friendship quality. However, to date, there are no prevention programs available that target high levels of co-rumination between adolescent girls. As such, we developed the blended school-based mindfulness prevention program Happy Friends, Positive Minds (HFPM) that targets co-rumination at the dyadic level, i.e., between two close female friends. The aim of this trial is to evaluate the effectiveness of HFPM to reduce co-rumination and internalizing problems and to enhance wellbeing and social-emotional behavior in Dutch adolescent girls.MethodsA cluster Randomized Controlled Trial (cRCT) will be conducted to evaluate HFPM effectiveness. We will recruit 160 female friendship dyads (n = 320 girls) aged 13 to 15 years who will be characterized by high levels of self-reported co-rumination. The cRCT has two arms: (1) an intervention condition in which 160 girls (80 friendship dyads) will receive the 14-week HFPM program in two consecutive cohorts (cohort 1 in academic year 2023/2024 and cohort 2 in academic year 2024/2025, and (2) a control condition in which 160 girls (80 dyads) will receive care-as-usual (CAU) in two consecutive cohorts (cohort 1 in academic year 2023/2024 and cohort 2 in academic year 2024/2025). Data will be collected at baseline (T0), during the program (T1;T2; T3), immediately after the program (T4), and at 1-year follow-up (T5). Participant-level self-reported risk for (early onset) depression and anxiety, self-reported and observed co-rumination, self- and friend-reported friendship quality, self-reported positive and negative affect, self-reported interpersonal responses to positive affect, and self-reported anhedonia symptoms will be the outcome variables.DiscussionThis study will provide insights into the short-term and long-term effects of the HFPM program on girls’ internalizing problems, wellbeing, and social-emotional behavior.Trial registrationInternational Standard Randomized Controlled Trials, identifier: ISRCTN54246670. Registered on 27 February 2023

    The Effects of High School Instrumental Music Performance Anxiety on the Accelerated Recovery of Social Anxiety

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    This quantitative correlational study aims to examine the challenges secondary students encounter in sustaining positive mental health and how the benefits of music performance anxiety in secondary school students can aid in the accelerated recovery of social anxiety. There is a present gap in the research exploring the benefits of situational anxiety on clinically diagnosed anxiety disorders and noting that this situational anxiety is a standard expectation and volunteered for when participating in performing arts environments. The objective is to understand the therapeutic benefits of micro-dosing the brain with music performance anxiety in a controlled environment and its potential uses in aiding students\u27 mental resilience development. This quantitative study uses a correlational approach guided by the theoretical framework of Edward Thorndike’s learning theory of connectionism. This research aims to gain a comparative understanding of individuals that have consistent music performance anxiety within a controlled environment and how that can assist the brain in its ability to process the symptoms of an anxiety disorder efficiently. The study focuses on the research obtained from data collected in a survey administered to secondary school-aged students. The questions in the survey center on music performance anxiety and how that affects the students. Findings revealed by the research lead to rejecting the null hypothesis as there is evidence for instrumental music experience’s predictive nature and improvement in musical performance anxiety on general anxiety disorder

    It doesn't end with closure:Optimizing health care throughout life after esophageal atresia repair

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    Measuring socioeconomic position in studies of health inequalities

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    There is a consistent finding that the higher the socioeconomic position (SEP), the better the health. The choice of SEP indicator is crucial in explaining these socioeconomic inequalities. However, a poorly motivated use of SEP indicators prevails in the literature on social health inequalities, hampering the transparency and comparability across studies. Its primary aim is to explore different ways of measuring SEP to identify social inequalities in health. The thesis focuses on the most common, objective SEP indicators (education, occupation, and income); subjective SEP; and childhood circumstances. This thesis consists of three papers. Papers I and III apply data from the Tromsø Study, and Paper II is based on an online survey investigating people's views on SEP, conducted in Norway and Australia. Paper I investigates the potential to combine education and income into a composite score for SEP and how it predicts inequalities in health-related quality of life (HRQoL). Paper II assesses the relative importance of objective SEP indicators and childhood circumstances in estimating subjective SEP. Paper III explores the role of circumstances and lifestyle factors in estimating inequalities in HRQoL and self-rated health. While we found that the combination of education and income demonstrated a non-linear relationship with overall SEP, the composite SEP score was not superior as a predictor of HRQoL compared to including education and income separately. Furthermore, we found that childhood circumstances demonstrated a lasting, independent impact on subjective SEP. Paper III revealed that there were inequalities arising from circumstances, with substantial contributions from financial circumstances in childhood and education. This thesis demonstrates the need to motivate the choice of SEP indicator in studies of health inequalities. It also stresses the importance of early-life factors as determinants of adult health, advocating for policies targeting childhood circumstances in equalising early life chances.Et svært vanlig funn på tvers av land, studiepopulasjoner og helseutfall er at desto høyere sosioøkonomisk posisjon (SEP), desto bedre helse. Valg av SEP-indikator som skal reflektere de sosioøkonomiske dimensjonene i helse er avgjørende for å forklare disse helseulikhetene. Likevel er det slik at bruken av SEP-indikatorer i studier om sosial ulikhet i helse ofte preges av svak eller ingen begrunnelse med utgangspunkt i teori og hypoteser, noe som begrenser muligheten til sammenligning mellom studier. Denne avhandlingen bruker ulike tilnærminger for å måle SEP i studier av helseulikhet. Et overordnet formål er å utforske ulike måter å måle sosial posisjon for å identifisere sosiale ulikhet i helse, og hvordan livsstilsfaktorer i tillegg påvirker dette forholdet. Fokuset vil være på de tre vanligste objektive SEP-indikatorene (utdanning, yrke og inntekt); subjektiv SEP; og indikatorer for barndomsforhold. Avhandlingen består av tre artikler. Artikkel I og III er basert på data fra Tromsøundersøkelsen, mens Artikkel II benytter data fra på en nettbasert spørreundersøkelse om folks betraktninger omkring SEP, som har blitt gjennomført i Norge og Australia. Alle de tre artiklene utforsker bruken av ulike SEP-indikatorer i en helseulikhetssammenheng. Artikkel I undersøker potensialet for å kombinere utdanning og inntekt til en samleindikator for SEP, samt hvordan denne samleindikatoren predikerer helse-relatert livskvalitet (HRQoL). Artikkel II måler objektive SEP-indikatorer (utdanning, yrke og inntekt) og barndomsforholds relative betydning i å estimere subjektiv SEP. Artikkel III utforsker hvordan variabler om barndomsforhold på den ene siden og livsstilsfaktorer på den andre estimerer HRQoL og selvrapportert helse, både på et bestemt tidspunkt og over tid. Vi fant at kombinasjonen av utdanning og inntekt viste en sterk ikke-lineær sammenheng med total SEP, mens samleindikatoren for SEP viste seg å ikke være bedre i å predikere HRQoL sammenlignet med å inkludere utdanning og inntekt separat. Videre fant vi at barndomsforhold så ut til å ha en vedvarende påvirkning på subjektiv SEP, som var uavhengig av objektiv SEP. Artikkel III viste at det var ulikheter i helse med røtter i barndomsforhold, med særlig påvirkning fra økonomiske forhold i barndommen og egen utdanning. Denne avhandlingen viser behovet for å gjøre et faglig motivert valg av SEP-indikator i studier av helseulikhet. Den understreker også viktigheten av barndomsforhold som bestemmende faktorer for helseutfall senere i livet, og etterlyser dermed politikk rettet mot tidlige barndomsforhold for å utjevne ulikheter og sikre gode livssjanser

    A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation

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    Background: People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease. Aim: Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation. Design: We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity. Setting: Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant\u27s own home or at a local NHS facility, and by telephone. Participants: Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate. Intervention: The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral. Main outcome measures: Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use. Results: We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference \ua3770.24, 95% confidence interval -\ua327.91 to \ua31568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants\u27 lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants. Conclusions: The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients. Trial registration: This trial is registered as ISRCTN59537391. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.People with long-standing lung problems, such as chronic obstructive pulmonary disease, often also have anxiety and depression, which further reduces their quality of life. Two existing treatments could help. Pulmonary rehabilitation (a programme of exercise and education) improves both the physical and mental health of people with chronic obstructive pulmonary disease. Cognitive–behavioural therapy (a talking therapy) may reduce anxiety and depression. The TANDEM [Tailored intervention for Anxiety and Depression Management in chronic obstructive pulmonary disease (COPD)] intervention linked these two treatments by providing talking therapy based on cognitive–behavioural therapy during the waiting time following referral for pulmonary rehabilitation. The TANDEM treatment was delivered by respiratory healthcare professionals (e.g. nurses or physiotherapists) trained to deliver the talking therapy in six to eight weekly sessions. The sessions were conducted in the participant’s home (or another convenient location), with brief telephone support during the pulmonary rehabilitation. Of 423 participants recruited to the study, 242 participants received TANDEM talking therapy and 181 participants received usual care (including a referral to pulmonary rehabilitation). We measured mental health, quality of life, social life, attendance at pulmonary rehabilitation and healthcare use in both groups at 6 and 12 months. Forty-three carers joined the study and we assessed their mental well-being. We interviewed patients, carers and health professionals to find out their views and experience of the TANDEM treatment. We also examined whether or not the TANDEM treatment was good value for money. The TANDEM treatment did not improve the mental or the physical health of people with chronic obstructive pulmonary disease. In addition, the TANDEM treatment cost the NHS an extra \ua3770 per patient, which was not good value for money. The TANDEM treatment was well received, and many participants told us how it had helped them. Heath-care professionals noted how participants did not just have chronic obstructive pulmonary disease, but were coping with many physical, mental and social problems. The TANDEM intervention was not effective and, therefore, other strategies will be needed to help people with chronic obstructive pulmonary disease and mental health problems live with their condition
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