A Study to Understand and Compare Evidence Based Practice Among Health Professionals Involved in Pain Management

Pain management is a common concern of multiple health professionals. Evidence-based practice (EBP) in pain management is a recognized approach used to improve health outcomes. EBP tools can facilitate its implementation. PAIN+ is a tool that provides access to pre-appraised current best research evidence on pain to support clinical decisions. It is important to understand the knowledge, attitudes and behavior of professionals towards EBP and more specifically how they access research about pain management. The overarching purpose of this thesis is to better understand how clinicians from different professions involved in pain management view EBP and implement specific strategies to find pain related research evidence. We conducted a series of studies incorporating various methods to address these questions. Data was collected supplementary to a large randomized control trial to compare “Push” vs. “Pull” strategies for uptake of pain research. In the first study, we compared the knowledge, attitudes, outcomes expectations and behaviors of physicians, nurses, physiotherapists, occupational therapists and psychologists towards EBP in pain management using a validated knowledge attitude and behavior (KABQ) questionnaire. In the second study, we used a mixed methods approach to understand the competencies of clinicians accessing electronic databases to search for evidence on pain management. In the third study, we performed a structured classification of the abstracts that were viewed by clinicians to understand their access behaviors. In the last part of the thesis, we compared the usefulness of PAIN+ with PubMed using a randomized crossover trial approach. The results of this thesis indicate that the professionals involved in pain management have good knowledge of and attitudes towards EBP, but behavior i.e. implementation of EBP in practice and perception of outcomes of implementing EBP were low. In the second study, we found that professionals had acceptable levels of basic literature searching skills but had low levels of use of more advanced skills, and were not aware of using clinical queries in their search. In the third study, we found that all professionals accessed research evidence when provided alerts about pain research and some variations in the types of studies accessed were observed. Differences in access behaviors might reflect differences in professional approach to pain management. In our fourth study the crossover randomized controlled trial; we found PAIN+ and PubMed were both rated useful in retrieving pain evidence for clinicians. Professionals showed an interest in evidence-based pain management, but their skills for finding evidence were limited, they appeared to need training in locating and appraising pain related research evidence, and may benefit from tools that reduce this burden

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

Background: Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited. Objectives: To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention. Data sources: All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014. Review methods: A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation. Results: Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from ‘goals and planning’ and ‘identity’ groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation. Limitations: There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity. Conclusions: Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention. Future work: There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity

Community Involvement in TB Research

While communities at risk have been both drivers and partners in HIV research, their important role in TB research is yet to be fully realized. Involvement of communities in tuberculosis care and prevention is currently on the international agenda. This creates opportunities and indicates the urgency to also engage communities in TB research

User Interfaces for Patient-Centered Communication of Health Status and Care Progress

The recent trend toward patients participating in their own healthcare has opened up numerous opportunities for computing research. This dissertation focuses on how technology can foster this participation, through user interfaces to effectively communicate personal health status and care progress to hospital patients. I first characterize the design space for electronic information communication to patients through field studies conducted in multiple hospital settings. These studies utilize a combination of survey instruments, and low- and high-fidelity prototypes, including a document-editing prototype through which users can view and manage clinical data to automatically associate it with progress notes. The prototype, activeNotes, includes the first known techniques supporting clinical information requests directly within a document editor. A usage study with ICU physicians at New York-Presbyterian Hospital (NYP) substantiated our design and revealed how electronic information related to patient status and care progress is derived from a typical Electronic Health Record system. Insights gained from this study informed following studies to understand how to design abstracted, plain-language views suitable for patients. We gauged both patient and physician responses to information display prototypes deployed in patient rooms for a formative study exploring their design. Following my reports on this study, I discuss the design, development and pilot evaluations of a prototype Personal Health Record application providing live, abstracted clinical information for patients at NYP. The portal, evaluated by cardiothoracic surgery patients, is the first of its kind to allow patients to capture and monitor live data related to their care. Patient use of the portal influenced the subsequent design of tools to support users in making sense of online medication information. These tools, designed with nurses and pharmacists and evaluated by cardiothoracic surgery patients at NYP, were developed using topic modeling approaches and text analysis techniques. Embodied in a prototype called Remedy, they enable rapid filtering and comparison of medication-related search results, based on a number of website features and content topics. I conclude by discussing how findings from this series of studies can help shape the ongoing design and development of patient-centered technology

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities. Aims The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice. Methods We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff. Findings Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely. Future Research Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc

Unmet goals of tracking: within-track heterogeneity of students' expectations for

Educational systems are often characterized by some form(s) of ability grouping, like tracking. Although substantial variation in the implementation of these practices exists, it is always the aim to improve teaching efficiency by creating homogeneous groups of students in terms of capabilities and performances as well as expected pathways. If students’ expected pathways (university, graduate school, or working) are in line with the goals of tracking, one might presume that these expectations are rather homogeneous within tracks and heterogeneous between tracks. In Flanders (the northern region of Belgium), the educational system consists of four tracks. Many students start out in the most prestigious, academic track. If they fail to gain the necessary credentials, they move to the less esteemed technical and vocational tracks. Therefore, the educational system has been called a 'cascade system'. We presume that this cascade system creates homogeneous expectations in the academic track, though heterogeneous expectations in the technical and vocational tracks. We use data from the International Study of City Youth (ISCY), gathered during the 2013-2014 school year from 2354 pupils of the tenth grade across 30 secondary schools in the city of Ghent, Flanders. Preliminary results suggest that the technical and vocational tracks show more heterogeneity in student’s expectations than the academic track. If tracking does not fulfill the desired goals in some tracks, tracking practices should be questioned as tracking occurs along social and ethnic lines, causing social inequality

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

BackgroundThe NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.ObjectivesTo use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.DesignRealist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.Data sourcesSystematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.ResultsThe IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.LimitationsThe studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.ConclusionsMultidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.Study registrationThis study is registered as PROSPERO CRD42016038900.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

Where can teens find health information? A survey of web portals designed for teen health information seekers

The Web is an important source for health information for most teens with access to the Web (Gray et al, 2005a; Kaiser, 2001). While teens are likely to turn to the Web for health information, research has indicated that their skills in locating, evaluating and using health information are weak (Hansen et al, 2003; Skinner et al, 2003, Gray et al, 2005b). This behaviour suggests that the targeted approach to finding health information that is offered by web portals would be useful to teens. A web portal is the entry point for information on the Web. It is the front end, and often the filter, that users must pass through in order to link to actual content. Unlike general search engines such as Google, content that is linked to a portal has usually been pre-selected and even created by the organization that hosts the portal, assuring some level of quality control. The underlying architecture of the portal is structured and thus offers an organized approach to exploring a specific health topic. This paper reports on an environmental scan of the Web, the purpose of which was to identify and describe portals to general health information, in English and French, designed specifically for teens. It answers two key questions. First of all, what portals exist? And secondly, what are their characteristics? The portals were analyzed through the lens of four attributes: Usability, interactivity, reliability and findability. Usability is a term that incorporates concepts of navigation, layout and design, clarity of concept and purpose, underlying architecture, in-site assistance and, for web content with text, readability. Interactivity relates to the type of interactions and level of engagement required by the user to access health information on a portal. Interaction can come in the form of a game, a quiz, a creative experience, or a communication tool such as an instant messaging board, a forum or blog. Reliability reflects the traditional values of accuracy, currency, credibility and bias, and in the web-based world, durabililty. Findability is simply the ease with which a portal can be discovered by a searcher using the search engine that is most commonly associated with the Web by young people - Google - and using terms related to teen health. Findability is an important consideration since the majority of teens begin their search for health information using search engines (CIBER, 2008; Hansen et al, 2003). The content linked to by the portals was not evaluated, nor was the portals’ efficacy as a health intervention. Teens looking for health information on the Web in English have a wide range of choices available but French-language portals are much rarer and harder to find. A majority of the portals found and reviewed originated from hospitals, associations specializing in a particular disease, and governmental agencies, suggesting that portals for teens on health related topics are generally reliable. However, only a handful of the portals reviewed were easy to find, suggesting that valuable resources for teens remain buried in the Web

Understanding and Identifying Specific Learning Difficulties: Dyslexia, Autism Spectrum, and Attention Deficit/Hyperactivity in the Adult ESL/EFL Classroom

Specific learning difficulties (SLDs), including dyslexia, autism spectrum disorders, and attention deficit/hyperactivity disorders, are significant factors that influence the way and rate at which students learn English as an additional language. However, few Teaching English to Speakers of Other Languages (TESOL) training programs address the cognitive and behavioral strengths and challenges these conditions carry for adult learners, in part due to concerns about bias in the over- and under- identification of learning disabilities among K-12 English language learners. Informed by Critical Disability Theory, and framed within a realistic discussion of the obstacles that remain in identifying and researching the parallel adult population and their learning needs, this thesis argues that all students in an English as a Second/Additional Language and English as a Foreign Language (ESL/EFL) classrooms benefit when SLDs are more readily recognized and teachers have a repertoire of research-backed, inclusive teaching strategies to draw on. The field project responds to this need for training with a teacher guidebook that explains U.S. legal requirements concerning students with disabilities, the effects of SLDs on second language acquisition, and the uses and limitations of current screening tools for SLDs in adult ESL/EFL populations. The guidebook also provides an annotated bibliography of effective adaptive and inclusive teaching strategies. Informed teachers will be better able to understand student needs, set realistic program and individual goals, participate in holistic identification processes, adopt effective teaching strategies, and serve as advocates for this understudied group of learners

How to Use Litigation Technology to Prepare & Present Your Case at Trial October 27, 2021

Meeting proceedings of a seminar by the same name, held October 27, 2021