Designing an intervention for improving primary care management of sleep problems (REST: Resources for Effective Sleep Treatment)

Brief outline of context An improvement project was begun in a Primary Care Trust in Lincolnshire a large rural county in the East Midlands of the United Kingdom comprising almost 700,000 patients. The projects included patients, general practitioners and their primary care teams, pharmacists and research and audit teams. Brief outline of problem Hypnotic prescribing rates from general practice Prescribing Analysis and Cost Data was identified by the executive as high in Lincolnshire compared to the rest of the East Midlands and the United Kingdom. Published research has shown that the clinical benefits of hypnotic drugs are small with significant risks of complications from adverse cognitive, psychiatric or psychomotor effects which may persist for several months after stopping the drug. The extent of the problem, its nature and the barriers to improvement were not well understood given that previous attempts to improve prescribing rates in this area of practice had failed. Assessment of problem and analysis of its causes Previous efforts to improve this aspect of quality and safety in healthcare in Lincolnshire and nationally have been hampered because of practitioner and patient attitudes, lack of organisational support or systems for change and an emphasis on other areas of healthcare. To understand the barriers to improving prescribing more fully we used questionnaires to general practitioners and patients and measured variation in prescribing rates across practices. Unforeseen and hitherto invisible problems were revealed by the responses. In addition, the views of patients prescribed hypnotics in the previous six months exposed high rates of inappropriate long term prescribing (94.9%had taken benzodiazepine or Z drug hypnotics for four weeks or more), side effects (41.8%reported at least one side effect), a wish to stop taking drugs (Z-drugs vs. benzodiazepines: 22.7 vs. 12.3%; p=0.001) and previous attempts by patients to come off medication (Z-drugs vs. benzodiazepines: 52.4% vs. 41.0%; p=0.001). Potential barriers to improvement included attitudes of general practitioners which supported prescribing of newer (Z drug) hypnotics for the majority of indications. More positively, practitioners were aware of their practice prescribing rates to the extent that they were able to identify whether they were in a high, intermediate or low prescribing practice. Most doctors held a negative perception of hypnotics and were positive to the idea of reducing prescribing in this area. Practitioners’ favoured methods for reducing prescribing helped inform potential strategies for change and will be presented. On the basis of these results it was felt that systematic efforts at implementation and improvement were likely to be successful given appropriate organisational support from the Primary Care Trust. Strategy for change: How did you implement the proposed change? What staff or other groups were involved? How did you disseminate the results of your analysis and your plans for change to the groups involved with/affected by the planned change? What was the timetable for change? A change project was developed, Resources for Effective Sleep Treatment (REST), with a number of stakeholders including partner organisation and patients. The aims of this project are to produce measurable improvements in the management of insomnia, specifically to: a. Reduce rate and (costs) of z-drug prescribing by 50% in 3 years b. Reduce the rate (costs) of benzodiazepine hypnotic prescribing by 25% in 3 years c. Increase use of recorded non-pharmacological measures in insomnia by at least 100% in 3 years. d. Improve the user experience of management of insomnia. We will use evidence based methods to develop an effective spread and adoption strategy to effect a sustained and sustainable change in practice in relation to management of insomnia. We will initially work with 10 pilot practices (10% of the total) using rapid experimentation (plan, do, study, act) cycles. We plan to work with these willing adopter practices and practitioners to develop a network of good practice, measurement and improvement tools, opinion leaders and champions for good practice using rapid cycle of change. We will also undertake focus groups with prescribing practitioners and patients to help understand more fully the barriers and facilitators, to identify good practice and to design appropriate improvement methods and interventions in this area of practice. Tailored interventions for practices involving clinician, pharmacy, secondary care and administrative support could help bring about change in clinical management. Measurement of improvement We will gather and analyse prescribing and improvement data from all practices in the county to enable systematic spread and adoption of improvements in prescribing and improvement methods more generally in the county. Lessons learned This project has emphasised the importance of gathering data at the onset of quality improvement initiatives to understand invisible barriers or facilitators for change and of involvement of patients and practitioners in their initial and ongoing development. Message for others Quality improvement projects benefit from research as well as quality improvement expertise in order to analyse, present and utilise information for their appropriate design

Methods of producing new nutrient data for popularly consumed multi ethnic foods in the UK

Minority ethnic groups in UK disproportionately suffer from nutrition related diseases compared to the mainstream population, contributing to widening health inequalities. However, reliable nutrient composition data of the traditional foods of these ethnic groups, which play an important part in their diets, is lacking. This makes it impossible to provide adequate and culturally acceptable nutrition interventions to reduce prevalent metabolic disorders. This study aimed to identify and analyse popularly consumed African and Caribbean foods in the UK for macro and micronutrients. Various approaches including focus group discussions, individual interviews and 24 hr dietary recalls were used to identify traditional foods. Defined criteria were used to prioritise and prepare 33 composite samples (26 dishes, 4 snacks and 3 beverages) for nutrient analyses in a UK accredited laboratory. This study methodology is novel because it uses various approaches to generate new data of commonly consumed ethnic foods and traditional recipes. In addition, the approach used in preparation of the food samples enhanced their authenticity and representativeness compared to previously published work. This paper describes the procedures undertaken and analytical methods used to develop a multi ethnic nutrient data for inclusion in UK food composition tables

Informing diet and physical activity interventions with family involvement in an urban setting: views of children and adults in Lagos, Nigeria

There is limited evidence on diet and physical activity (PA) interventions to prevent childhood over- and under-nutrition in Nigeria, particularly those with parental involvement. The aim of this qualitative cross-sectional study was to explore parents’, children’s, and other stakeholders’ views on what might enable or hinder participation in diet and PA interventions with parental involvement, and potential intervention components likely to be feasible and acceptable. The study took place in Lagos State, Nigeria. Sixteen boys and girls aged 8–11 years in four participating schools were involved in the study. In addition, women (n = 19) and men (n = 13) aged 18–60 years took part. These included parents, teachers, school heads, community leaders, health professionals, and health or education civil servants, recruited via the participating schools, community and professional links. Data were collected in schools, homes, and places of work via one-to-one interviews and focus groups, audio-recorded with participants’ consent. Topics included knowledge about a balanced diet and active living; frequency of exercise and barriers and facilitators of participation; and ideas for fostering good diet and physical activity habits. Socio-demographic data were collected orally at the start of each discussion. Thematic analysis of verbatim transcripts of the recordings was conducted. Three overarching themes were identified: (1) Active community collaboration; (2) strategies for involving families; and (3) schools as key settings for interventions. The main barriers to participation in potential interventions included poor access to clean water, safe outdoor play space, and menstrual hygiene products. Suggested solutions included increased security, infrastructure improvements using recycled materials, school gardening, and health campaigns funded by local dignitaries. Health literacy education for parents, tailored to local dialects, was considered an important potential intervention component that would engage families. The feasibility and acceptability of grassroots suggestions for intervention components and parental involvement could usefully be explored in future pilot studies

Comparison of the Effectiveness of Low Carbohydrate Versus Low Fat Diets, in Type 2 Diabetes: Systematic Review and Meta-Analysis of Randomized Controlled Trials

The clinical benefit of low carbohydrate (LC) diets compared with low fat (LF) diets for people with type 2 diabetes (T2D) remains uncertain. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare their efficacy and safety in people with T2D. RCTs comparing both diets in participants with T2D were identified from MEDLINE, Embase, Cochrane Library, and manual search of bibliographies. Mean differences and relative risks with 95% CIs were pooled for measures of glycaemia, cardiometabolic parameters, and adverse events using the following time points: short-term (3 months), intermediate term (6 and 12 months) and long-term (24 months). Twenty-two RCTs comprising 1391 mostly obese participants with T2D were included. At 3 months, a LC vs. LF diet significantly reduced HbA1c levels, mean difference (95% CI) of −0.41% (−0.62, −0.20). LC diet significantly reduced body weight, BMI, fasting insulin and triglycerides and increased total cholesterol and HDL-C levels at the short-to-intermediate term, with a decrease in the requirement for antiglycaemic medications at intermediate-to-long term. There were no significant differences in other parameters and adverse events. Except for reducing HbA1c levels and adiposity parameters at short-to-intermediate terms, a LC diet appears to be equally effective as a LF diet in terms of control of cardiometabolic markers and the risk of adverse events in obese patients with T2D

Improving Vitamin D Intake in Young Children—Can an Infographic Help Parents and Carers Understand the Recommendations?

Vitamin D deficiency is a serious public health issue in the United Kingdom. Those at increased risk, such as pregnant women, children under 5 years and people from ethnic groups with dark skin, are not all achieving their recommended vitamin D. Effective vitamin D education is warranted. A qualitative study was undertaken to evaluate the acceptability and understanding of a vitamin D infographic, developed using recommendations from previous research. Fifteen parents/carers, recruited through local playgroups and adverts on popular parent websites, participated in focus groups and telephone interviews. The majority were female, White British and educated to degree level. A thematic analysis methodology was applied. The findings indicated that understanding and acceptability of the infographic were satisfactory, but improvements were recommended to aid interpretation and create more accessible information. These included additional content (what vitamin D is; other sources; its health benefits; methods/doses for administration and scientific symbols used) and improved presentation (eye-catching, less text, simpler language, more images and a logo). Once finalized, the infographic could be a useful tool to educate families around vitamin D supplementation guidelines, support the UK Healthy Start vitamins scheme and help improve vitamin D status for pregnant and lactating women and young children

Feasibility of a community healthy eating and cooking intervention featuring traditional African Caribbean foods from participant and staff perspectives

Culturally appropriate healthy eating resources are intended to help people from different ethnic backgrounds consume diets reflecting government dietary recommendations, yet evidence on use in the target groups is lacking. This study evaluated the feasibility of a new brief culturally appropriate community intervention that aimed to introduce food-based healthy eating and recipe resources featuring African Caribbean foods, which were recently co-developed with people from these ethnic backgrounds. Working with a community organization in the UK, a single-arm study was used to collect verbal data from participants and staff on the acceptability of intervention whilst knowledge, skills and behaviours related to healthy eating were evaluated using pre-, post- and follow-up questionnaires. A total of 30 participants were recruited, and 22 completed all three questionnaires; who were mostly female aged 55 years+ (n = 17) and of African Caribbean ethnicity (45%, n = 10), with 32% (n = 7) reporting no educational attainment. At post-intervention and follow-up, most participants reported high satisfaction (n = 21, 95%) with the intervention sessions and high levels of confidence in using the resources at home within budget. The number of participants who were familiar with the healthy eating guidance featuring Caribbean foods increased from pre- (36%, n = 8) to post-intervention/follow-up (n = 22, 100%) (p < 0.05). Findings suggest the intervention is feasible in a community setting and could help increase awareness and use of culturally appropriate healthy eating guidance amongst a diverse group

Views on risk, prevention and management of type 2 diabetes among UK Black Caribbeans

Background: Development of effective, culturally-tailored interventions to address excess risk of type 2 diabetes among Black Caribbeans in the United Kingdom (UK) requires understanding of the views and experiences of the target population. We explored the social context of views on risk, prevention and management of type 2 diabetes among this ethnic group. Methods: The Food, Diabetes and Ethnicity (FOODEY) study included 56 Black Caribbean men and women aged 24-90 years (21 (38%) diagnosed with diabetes or pre-diabetes). Nine focus groups were conducted in community hubs in Leeds, Bradford, Birmingham, and Huddersfield, UK. Inductive themes were identified through thematic analysis of transcripts. Results: While family history was considered a key risk factor, there was a clearly articulated view of the interaction between “bad genes” and unfavourable dietary and physical activity (PA) habits. Rich descriptions of food habits and food related negotiations among family and friends included cost and low availability as barriers to maintaining traditional foodways, and high intake of convenience foods. The perception that diabetes risk was greater in the UK than in home countries was widely held, and it was felt that this was due to the lack of PA, cold weather and stress due to racism experienced in the UK. The Caribbean was deemed a suitable setting for consuming traditional foods and high sugar intake as this was mitigated by active living, organic vegetable consumption, and the hot climate. Trust in health professionals’ diabetes advice was evident, however behaviour change was preferred to medication, and the need for choice regarding healthcare decisions was emphasised. Faith beliefs coincided with acceptability of health-related advice and underpinned views on personal responsibility for health. Conclusions: Complex explanatory models of risk, encompassing lifestyle, economic, cultural, religious and psychosocial contexts, have implications for developing interventions to address type 2 diabetes among UK Black Caribbeans

Nutrient Composition of Popularly Consumed African and Caribbean Foods in The UK.

(1) Background: Traditional foods are important in the diets of Black Africans and Caribbeans and, more widely, influence UK food culture. However, little is known about the nutritional status of these ethnic groups and the nutrient composition of their traditional foods. The aim was to identify and analyse African and Caribbean dishes, snacks and beverages popularly consumed in the UK for energy, macronutrients and micronutrients. (2) Methods: Various approaches including focus group discussions and 24-h dietary recalls were used to identify traditional dishes, snacks, and beverages. Defined criteria were used to prioritise and prepare 33 composite samples for nutrient analysis in a UK accredited laboratory. Quality assurance procedures and data verification were undertaken to ensure inclusion in the UK nutrient database. (3) Results: Energy content ranged from 60 kcal in Malta drink to 619 kcal in the shito sauce. Sucrose levels did not exceed the UK recommendation for adults and children. Most of the dishes contained negligible levels of trans fatty acid. The most abundant minerals were Na, K, Ca, Cu, Mn and Se whereas Mg, P, Fe and Zn were present in small amounts. (4) Conclusion: There was wide variation in the energy, macro- and micronutrients composition of the foods analysed

Applying the trigger review method after a brief educational intervention: potential for teaching and improving safety in GP specialty training?

&lt;p&gt;Background: The Trigger Review Method (TRM) is a structured approach to screening clinical records for undetected patient safety incidents (PSIs) and identifying learning and improvement opportunities. In Scotland, TRM participation can inform GP appraisal and has been included as a core component of the national primary care patient safety programme that was launched in March 2013. However, the clinical workforce needs up-skilled and the potential of TRM in GP training has yet to be tested. Current TRM training utilizes a workplace face-to-face session by a GP expert, which is not feasible. A less costly, more sustainable educational intervention is necessary to build capability at scale. We aimed to determine the feasibility and impact of TRM and a related training intervention in GP training.&lt;/p&gt; Methods We recruited 25 west of Scotland GP trainees to attend a 2-hour TRM workshop. Trainees then applied TRM to 25 clinical records and returned findings within 4-weeks. A follow-up feedback workshop was held. &lt;p&gt;Results: 21/25 trainees (84%) completed the task. 520 records yielded 80 undetected PSIs (15.4%). 36/80 were judged potentially preventable (45%) with 35/80 classified as causing moderate to severe harm (44%). Trainees described a range of potential learning and improvement plans. Training was positively received and appeared to be successful given these findings. TRM was valued as a safety improvement tool by most participants.&lt;/p&gt; &lt;p&gt;Conclusion: This small study provides further evidence of TRM utility and how to teach it pragmatically. TRM is of potential value in GP patient safety curriculum delivery and preparing trainees for future safety improvement expectations.&lt;/p&gt