4,945 research outputs found

    Implementing screening and brief Interventions for excessive alcohol consumption in primary health care

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    O consumo de bebidas alcoólicas é um dos principais fatores de risco da morbilidade e mortalidade prematura a nível mundial. As pessoas que consomem este género de bebidas têm um risco aumentado de vir a desenvolver mais de 200 problemas de saúde diferentes. A maioria do impacto do consumo de álcool na saúde humana é determinado por duas dimensões: o volume total de álcool consumido e o padrão de consumo. Existem várias medidas com comprovada eficácia que podem ser empregues para reduzir o risco associado ao consumo de álcool, entre as quais se encontra a deteção precoce e intervenção breve ao nível dos Cuidados de Saúde Primários. A maioria dos profissionais de saúde neste nível de cuidados considera o consumo de álcool como um importante problema de saúde e manifesta o seu apoio a medidas que visem reduzir o seu impacto. No entanto, poucos são os profissionais dos Cuidados de Saúde Primários que de forma sistemática identificam e aconselham os seus doentes relativamente aos seus hábitos etílicos. Como tal, o objetivo geral desta tese foi investigar como implementar a deteção precoce e intervenção breve no consumo excessivo de álcool nos Cuidados de Saúde Primários. Foi realizada uma revisão sistemática das barreiras e facilitadores à implementação da deteção precoce e intervenção breve no consumo excessivo de álcool nos Cuidados de Saúde Primários. As barreiras e facilitadores identificados nesta revisão foram analisados à luz da teoria de modificação comportamental para compreender a ligação destes fatores aos determinantes da mudança de comportamento, e para identificar as estratégias conceptualmente mais eficazes para abordar as barreiras e facilitadores à mudança de comportamento dos profissionais dos Cuidados de Saúde Primários no sentido de aumentar as taxas de deteção precoce e intervenção breve no consumo excessivo de álcool. Esta metodologia foi utilizada para desenhar um programa de implementação com base em pressupostos teóricos que foi testado num estudo experimental randomizado e controlado em clusters. Esta tese identificou diversas barreiras à implementação, ligadas a todos os domínios teóricos da mudança comportamental. As barreiras mais frequentemente mencionadas pelos profissionais foram: preocupação sobre as suas competências e eficácia para realizar a deteção precoce e intervenção breve; falta de conhecimento específico sobre o consumo de álcool; falta de tempo; falta de materiais; falta de apoio; e atitudes para com o doente com consumos excessivos de álcool. Esta tese mostrou também a existência de dois grupos distintos de médicos de família com base nas suas atitudes para com estes doentes, um com atitudes mais positivas, o outro com atitudes mais negativas. Esta tese mostrou ainda que um programa de implementação da deteção precoce e intervenção breve, desenhado com base em pressupostos teóricos de modificação comportamental, adaptado às barreiras e facilitadores da implementação, aumenta de forma significativa as taxas de identificação precoce dos consumos de álcool. Esta tese contribui para aumentar o conhecimento atual no sentido em que põe à disposição dos investigadores evidência prática sobre como abordar os fatores com influência na implementação da identificação precoce e intervenção breve para o consumo de álcool ao nível dos Cuidados de Saúde Primários. Esta tese contribui também para um melhor entendimento dos mecanismos subjacentes à resistência e à mudança de comportamento dos profissionais dos Cuidados de Saúde Primários no que respeita à implementação da deteção precoce e intervenção breve do consumo de álcool. Os resultados desta tese poderão ser usados por investigadores e decisores políticos para desenhar novos programas de implementação tendo como objetivo modificar esta prática clínica ao nível dos Cuidados de Saúde Primários.Alcohol use is among the leading risk factors for the global burden of disease and premature death. People who drink alcoholic beverages are at risk of developing more than 200 diseases and injury conditions. Most of the impact of alcohol consumption on human health and well-being is determined by two dimensions of drinking: the total volume of alcohol consumed and the pattern of drinking. Several effective strategies exist to reduce the harmful use of alcohol, which includes screening and brief interventions for excessive alcohol use in primary health care. The majority of primary health care providers agree that the excessive consumption of alcohol is an important health issue and express their support to policies for reducing the impact of alcohol on the health of their patients. Notwithstanding, implementation of screening and brief interventions is low at the primary health care level. Therefore, the overall aim of this thesis is to investigate how to implement screening and brief interventions for excessive alcohol consumption in primary health care. This thesis reviewed the barriers of, and facilitators for, the implementation of alcohol screening and brief interventions in primary health care. Behaviour change theory was used to understand how these factors linked to the determinants of behaviour change and how they could be addressed in order to change primary health care providers’ behaviour, i.e. to increase the delivery of alcohol screening and brief interventions. A comprehensive theory-based implementation programme was designed and tested in a cluster randomized controlled trial. This thesis identified several barriers to implementation which were mapped to all the theoretical domains of behaviour change. Primary health care providers concerns about their ability to deliver alcohol screening and brief interventions and to help patients to cut down, lack of alcohol-related knowledge, lack of time, lack of materials and support, and providers’ attitudes towards at-risk drinkers were among the most commonly cited barriers. This thesis found evidence that the attitudes of family physicians could be used to divide practitioners into two distinct groups, one with more positive and the other with more negative attitudes towards at-risk drinkers. This thesis also found that a behaviour change theory-based programme, tailored to the barriers for, and facilitators of, the implementation of screening and brief intervention in primary health care is effective in increasing alcohol screening rates. This thesis contributed to the evidence base by providing researchers with practical evidence on how to address the factors influencing the implementation of screening and brief interventions in primary health care. This thesis also provides researchers with insight into the behavioural mechanisms mediating primary health care providers’ decision to deliver alcohol screening and brief interventions. The results of this thesis could be used by researchers and policymakers to inform the design of novel theory-oriented interventions to support the implementation of alcohol screening and brief interventions in primary health care

    Mapping Critical Practice In A Transdisciplinary Urban Studio

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    Architecture and Planning exist to make positive changes to our environment. Future practitioners in these disciplines will be responsible for how our cities develop and are managed - they will be required to exercise their professional judgement in complex and unpredictable contexts. There is increasing interest in transdisciplinary urbanism, but implementation in academic contexts has to date been relatively limited. This thesis aims to build on these examples, through a detailed account of one academic design studio which operates across architecture and urban planning; in doing so it aims to make the case for transdisciplinary, problem and place-based studio teaching. The study considers how a transdisciplinary studio environment supported students to develop a critical approach to practice through collaborative discourse. It looked at studio methods/practices; what it means to practice ‘critically’ in the context of design; and the role ‘going public’ by sharing ideas in public fora might play in developing critical positions. The study was undertaken in collaboration with nine students, a single cohort undertaking the final year of a hybrid master’s qualification in Architecture with Urban Planning. It adopts socio-material and spatial approaches to follow how the studio environment and the students’ emerging interdisciplinary identities shaped both their individual and their shared work. It mapped how their approach to their practice evolved through observations, interviews, and informal conversations, and through their drawings, models and journals. In carrying out these observations, and their analysis, I have returned to drawing methods common in architecture. This allowed me to explore and record aspects of studio practice which might otherwise be missed and revealed the importance of visual and spatial thinking to my own practice. Observations revealed how material spaces, tools and artefacts acted to structure social relations in the studio, and how these relations shaped individual approaches to critical practice

    Exploring the use of nature as an adjunct to psychological interventions for depression in young populations

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    Depression in adolescence is a global priority and it is critical to identify effective and accessible interventions. This systematic review aimed to synthesise experimental research on nature-based interventions (NBIs), to determine effects on depressive symptoms in young people. The secondary research question sought to understand characteristics of effective NBIs. A comprehensive systematic search was conducted across major and grey literature databases and papers were screened according to specified criteria. Participants’ ages were required to be between 10 and 24 years and studies needed to use an experimental design, including a control group. Experimental conditions were defined by psychotherapeutic interventions with nature exposure and outcomes measured either clinical symptomatology or subjective states of depression. Ten papers were identified, quality assessed and summarised in a narrative synthesis. Thirteen significant effects were reported in nine studies, highlighting the potential for NBIs as effective interventions for depressive symptoms in young people. However, due to methodological biases, such as lack of randomisation or control over group differences and frequent use of passive control groups, there remains considerable uncertainty over the effectiveness of NBIs. Characteristics of effective NBIs are tentatively discussed, however, further work is needed to clarify which aspects specifically contribute to the beneficial effects observed. Future research should seek to address the limitations of small samples, selection biases and test NBIs against more comparable and evidence-based interventions. It is hoped future studies will consider the inclusion of clinical populations, to explore the utility of NBIs as a treatment option for adolescent depression

    Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results

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    Objective The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. Design Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. Results Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. Conclusion Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. Trial registration number ISRCTN41353774

    A randomised phase II trial of temozolomide with or without cannabinoids in patients with recurrent glioblastoma (ARISTOCRAT):Protocol for a multi-centre, double-blind, placebo-controlled trial

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    BackgroundGlioblastoma (GBM) is the most common adult malignant brain tumour, with an incidence of 5 per 100,000 per year in England. Patients with tumours showing O -methylguanine-DNA methyltransferase (MGMT) promoter methylation represent around 40% of newly diagnosed GBM. Relapse/tumour recurrence is inevitable. There is no agreed standard treatment for patients with GBM, therefore, it is aimed at delaying further tumour progression and maintaining health-related quality of life (HRQoL). Limited clinical trial data exist using cannabinoids in combination with temozolomide (TMZ) in this setting, but early phase data demonstrate prolonged overall survival compared to TMZ alone, with few additional side effects. Jazz Pharmaceuticals (previously GW Pharma Ltd.) have developed nabiximols (trade name Sativex®), an oromucosal spray containing a blend of cannabis plant extracts, that we aim to assess for preliminary efficacy in patients with recurrent GBM.MethodsARISTOCRAT is a phase II, multi-centre, double-blind, placebo-controlled, randomised trial to assess cannabinoids in patients with recurrent MGMT methylated GBM who are suitable for treatment with TMZ. Patients who have relapsed ≥ 3 months after completion of initial first-line treatment will be randomised 2:1 to receive either nabiximols or placebo in combination with TMZ. The primary outcome is overall survival time defined as the time in whole days from the date of randomisation to the date of death from any cause. Secondary outcomes include overall survival at 12 months, progression-free survival time, HRQoL (using patient reported outcomes from QLQ-C30, QLQ-BN20 and EQ-5D-5L questionnaires), and adverse events.DiscussionPatients with recurrent MGMT promoter methylated GBM represent a relatively good prognosis sub-group of patients with GBM. However, their median survival remains poor and, therefore, more effective treatments are needed. The phase II design of this trial was chosen, rather than phase III, due to the lack of data currently available on cannabinoid efficacy in this setting. A randomised, double-blind, placebo-controlled trial will ensure an unbiased robust evaluation of the treatment and will allow potential expansion of recruitment into a phase III trial should the emerging phase II results warrant this development.Trial registration ISRCTN: 11460478. ClinicalTrials.Gov: NCT0562970

    The development and initial validation of an outcome measure for children and young people with life-limiting and life-threatening conditions

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    BackgroundThere is no validated outcome measure for use in children's palliative care outside of sub-Saharan Africa. Development of such a measure is required to realise the benefits of patient-centred outcome measure use that has been demonstrated in adult palliative care. Previous research into what is important to children and young people with life-limiting and life-threatening conditions has primarily focused on those with a cancer diagnosis. Much of this pre-existing research focuses on the perspectives of proxies, rather than those of the child or young person.AimTo develop an outcome measure, the children's palliative outcome scale (C-POS), for use by children and young people with life-limiting and life-threatening conditions and their families, and to establish face and content validity, comprehensiveness, comprehensibility, feasibility, and acceptability of use.MethodsA sequential mixed-methods study was conducted in three phases, following the principles of patient-reported outcome measurement design described by Rothrock and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN).Phase 1 - gathering inputA systematic review was conducted with the aim of appraising the evidence on optimal recall period, response format and mode of administration to enable children and young people to participate in self-reporting on their health outcomes. A young person's advisory group was also consulted on the same topic.To inform face and content validity of C-POS a semi-structured qualitative interview study was conducted to seek the perspectives of children and young people, their parents/carers and siblings, health care professionals and NHS commissioners on priority symptoms, concerns, and care priorities. Participants were also asked to identify their preferences for the design of C-POS, in terms of recall period, response scale format and administration mode.Phase 2 - item generationPart 1: Parents and professionals with experience in caring for a child or young person with a life-limiting or life-threatening condition participated in a three-round modified ranking-type Delphi survey with the aim of establishing which outcomes identified in phase 1 of this thesis should be included in C-POS.Part 2: The young person’s advisory group were asked to select their priority outcomes from the items ranked in rounds 2 and 3 of the Delphi survey.Part 3: An item generation meeting was conducted with key stakeholders to develop initial C-POS versions based on the evidence collected so far.Phase 3 - item improvementCross-sectional cognitive interview study to establish acceptability, comprehensiveness, and comprehension of the initial C-POS versions within the target population.ResultsPhase 1 - gathering inputSystematic review: Findings showed that children under five years old cannot validly and reliably self-report health outcomes. Face scales demonstrated better psychometric properties than visual analogue or Likert scales. Computerised and paper scales generally show equivalent construct validity and children prefer computerised measures. Children seven years old and younger often think dichotomously so may need two response options. Those over eight years old can reliably use a three-point scale.Qualitative interview study: 106 participants were recruited: 26 children, 40 parents, 13 siblings, 15 health care professionals and 12 commissioners. Children found a short recall period and a visually appealing measure with 10 questions or fewer most acceptable. Children with life-limiting conditions were more familiar with using rating scales such as numeric and Likert than their healthy siblings and emphasised the importance of completing the measure alongside interactions with a healthcare professional. Parents assumed that electronic completion methods would be most feasible and acceptable but a small number of children preferred paper measures.Participants described many inter-related symptoms, concerns and care priorities impacting on all aspects of life. Data revealed an overarching theme of pursuing ‘normality’, described as children’s desire to undertake usual childhood activities. Parents need support with practical aspects of care to help realise this desire for normality.Phase 2 - item generationPart 1: Delphi survey (n=82). Ranking agreement between participants increased over the rounds, indicating movement towards consensus. Agreement between professional and parent ranking was poor. Professionals prioritised physical symptoms, whereas parents prioritised psychosocial and practical concerns.Part 2: 22 children and young people attended the young person's advisory group. They prioritised items related to living a ‘normal life’ such as seeing friends and attending school, in addition to items prioritised by the adult participants in the Delphi survey.Part 3: 22 participants attended the item generation meeting. Fiveage/developmental stage appropriPhase 3 - item improvementForty-eight individuals participated (36 parents; 12 children) in cognitive testing of the C-POS versions. This revealed challenges in the acceptability of some items for parents of non-verbal children and refinements were made. C-POS content and length were acceptable, and all questions were considered important. Parents reported that completing a measure that asks about what matters may be distressing but this is anticipated and acceptable.ConclusionsThis thesis demonstrates the development of the first UK patient-centred outcome measure for use with children and young people with life-limiting and life-threatening conditions and their families. By following established methodological criteria for patient-centred outcome measure development this thesis demonstrates that CPOS has robust face and content validity and is feasible and acceptable for use within the target population.</div

    Regional variation in diagnosis, prognosis and treatment of Guillain-Barré syndrome

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    How the Migration Process drives the establishment of a Psychological Home: An Italian mixed methods study in the light of Community Psychology

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    The concept of "home" holds profound significance for individuals, yet its definition becomes complex amid changes in living environments, particularly for migrants. This doctoral project explores how migrants construct their psychological sense of home and its impact on well-being. Defense mechanisms, such as idealization or assimilation, play a pivotal role in shaping migrants' psychological sense of home, evolving over time. Despite recognizing the significance of home in migrants' lives, there is a research gap in understanding their psychological sense of home. The study adopts a community psychology approach to migration research, emphasizing relational aspects, contextual interactions, and intervention development. Italy's social scenario, marked by cultural pluralism, makes this approach particularly relevant. The thesis comprises five chapters, offering a theoretical framework, exploring the concept of home, presenting the research question, describing the Italian context, and detailing the methodology. The main studies include a literature review, qualitative interviews, and a quantitative study, each contributing to a comprehensive understanding of migrants' psychological sense of home. The final chapter integrates findings, elucidating the process of establishing a psychological home for migrants. It explores bridging gaps between individual and community-focused migration studies, highlights study limitations, suggests future research, and outlines practical implications. The study contributes valuable insights into the intricate relationship between migrants' psychological sense of home, well-being, and community interactions

    Multimorbidity of cardiometabolic diseases and effectiveness of integrated healthcare system response in sub-Saharan Africa

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    This thesis aims to strengthen the responsiveness of healthcare systems to the management of cardiometabolic multimorbidity in sub-Saharan Africa (SSA). More specifically, four main issues on cardiometabolic multimorbidity in SSA were investigated: the burden of cardiometabolic multimorbidity, chronic care models, the readiness of healthcare facilities to provide integrated care, and the effect of multimorbidity on self-care interventions. A latent class analysis and hierarchical agglomerative cluster analysis in part one show that cardiometabolic diseases occur in distinct clusters of concordant and discordant multimorbidity. These clusters are significant predictors of outpatient visits, hospitalisation, functional disability and quality of life. Multimorbidity is disproportionately highest among persons of high socioeconomic status, women, the middle and old-aged, and those with sedentary lifestyles and obesity. A systematic review and meta-analysis in part two shows that integrated care versus standard care improved systolic blood pressure control in people with multimorbidity. In part three, a national facility assessment survey in Kenya shows that only one in every four healthcare facilities (at all levels) was ready to provide integrated care for cardiovascular diseases and type 2 diabetes. The clinical integration barriers included vertical and unresponsive healthcare services. In part four, a quasi-experimental study of patients with hypertension undergoing a home-based self-care program in Kenya shows that multimorbidity attenuated the effectiveness of patient support groups for hypertension. Overall, the findings of this thesis provide crucial evidence for multimorbidity risk stratification and underscore the importance of tailoring patient-centered care interventions to match the needs of people with cardiometabolic multimorbidity in SSA
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