Home Exercise Program Adherence in Physical Therapy: Application of the Transtheoretical Model

Home exercise programs (HEPs) are a foundational component of physical therapy (PT). However, the majority of patients are not compliant with their HEP; they lack the motivation and habits necessary to be compliant. The transtheoretical model (TTM) is a framework for understanding the decision-making of the individual and is a model of intentional change. When properly understood and applied, the TTM can improve a physical therapist’s ability to help patients to change their behavior and to become HEP compliant. This paper seeks to address patient exercise noncompliance by educating and instructing physical therapists in the application of the TTM, which includes the stages of change, processes of change, decisional balance, self-efficacy, initial stage assessment, mutual goal setting, verbal communication, nonverbal communication, and the proper utilization of the intimate patient-provider treatment setting

Pacific Consumer Acculturation in New Zealand: Understanding the dynamics of consumption using video diaries

New Zealand, the land of milk and honey, is the „dream‟ of many Pacific people. Expectations of New Zealand were high as Pacific people dreamt of „the better life‟ from migrated family members who retold their experiences confirming their version of life in New Zealand. Many Pacific migrants came with the intention of improving the lives of their families and for themselves. Positioned within the situational context of understanding Pacific migrants isolated from their culture, this thesis aims to understand how island-born Pacific people acculturate to New Zealand society as consumers. The research question centers on understanding how Pacific people living in New Zealand experience consumer acculturation. This research founded on a critical ethnographic stance addresses traditionally unbalanced power relations between researcher and participant and ensures participants are in control of their involvement in the study. Video diaries are used to capture routine, daily experiences of Pacific consumers. Participants narrated and reflected on their lives in New Zealand and considered how this differed from their lives in the islands. Video diaries were conducted with nine participants from two cities in New Zealand; Hamilton and Dunedin. Participants are from; Samoa (3), Tonga (2), Fiji (3) and Cook Islands (1). Each participant is tasked with recording aspects of their lives for the duration of 6 to 8 weeks, meeting regularly with the researcher to discuss progress, change tapes, and, most importantly build a relationship. Upon completion of the diary fieldwork stage, the researcher and participant meet for a final interview to collaborate on themes and clarify any issues outstanding. Participant narratives are expressed within five storylines: premigration expectations; change of the collective; becoming an individual; consumption desires; and, cultural maintenance. These storylines explore themes surrounding the consumer acculturation process in New Zealand. They illustrate that the reality of life in New Zealand varies considerably from participants‟ initial expectations. Participants acknowledged that they needed to become more independent and take on more individualistic values to fit into their new environment. Participants attempted to maintain aspects of their culture, in particular, the "circle of giving" through obligation. However, this was not always possible. Consumer acculturation appeared throughout the everyday experiences of participants. This included; in public and private situations, in the home, work and at social occasions. Individual adaptation of consumption values from Pacific to Western pervaded all areas of participant lives. By looking at contemporary Pacific consumption patterns we learn that there is similarity to previous patterns of Western consumption. Consumption feeds the desires of many Pacific people to want more, have more, own more and replaces more traditional values like community ownership and reciprocity. A process of consumer acculturation developed from these understandings, highlights the movement of participants as they graduate to-and-from different phases of the process, i.e., from the dream, to the reality of life in New Zealand. Understanding individual journeys of Pacific consumers highlights the acculturation processes that Pacific people go through to merge into New Zealand society. Through this insight, the meaning of consumption is considered and in turn how this translates to the wider culture, both in New Zealand and in the Pacific. Through understanding these consumption meanings and experiences, we consider ways to alleviate negative consumer acculturative experience. The bigger picture brings us back to questioning the relevance and structure of a consumer lifestyle. Within a New Zealand context, Pacific consumers would benefit from the integration of their core values into their daily lives and the embracing of their value system by wider societal structures. Seeking solutions from collective methods would encourage the retention of cultural values. Undoubtedly taking the "the best from both worlds" would be the ultimate route to navigating life in New Zealand

Heterogeneity of Plaque Structural Stress Is Increased in Plaques Leading to MACE: Insights From the PROSPECT Study.

OBJECTIVES: This study sought to determine if plaque structural stress (PSS) and other plaque stress parameters are increased in plaques that cause future major adverse cardiovascular event(s) (MACE) and if incorporating these parameters improves predictive capability of intravascular ultrasonography (IVUS). BACKGROUND: Less than 10% of coronary plaques identified as high-risk by intravascular imaging result in subsequent MACE. Thus, more specific measurements of plaque vulnerability are required for effective risk stratification. METHODS: Propensity score matching in the PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study plaque cohort resulted in 35 nonculprit lesions (NCL) associated with future MACE and 66 matched NCL that remained clinically silent. PSS was calculated by finite element analysis as the mechanical loading within the plaque structure in the periluminal region. RESULTS: PSS was increased in the minimal luminal area (MLA) regions of NCL MACE versus no MACE plaques for all plaques (PSS: 112.1 ± 5.5 kPa vs. 90.4 ± 3.3 kPa, respectively; p = 0.001) and virtual histology thin-cap fibroatheromas (VH-TCFAs) (PSS: 119.2 ± 6.6 kPa vs. 95.8 ± 5.0 kPa, respectively; p = 0.005). However, PSS was heterogeneous over short segments, and PSS heterogeneity index (HI) was markedly greater in NCL MACE than in no-MACE VH-TCFAs (HI: 0.43 ± 0.05 vs. 0.29 ± 0.03, respectively; p = 0.01). Inclusion of PSS in plaque assessment improved the identification of NCLs that led to MACE, including in VH-TCFAs (p = 0.03) and plaques with MLA ≤4 mm2 (p = 0.03). Incorporation of an HI further improved the ability of PSS to identify MACE NCLs in a variety of plaque subtypes including VH-TCFA (p = 0.001) and plaques with MLA ≤4 mm2 (p = 0.002). CONCLUSIONS: PSS and variations in PSS are increased in the peri-MLA regions of plaques that lead to MACE. Moreover, longitudinal heterogeneity in PSS is markedly increased in MACE plaques, especially VH-TCFAs, potentially predisposing to plaque rupture. Incorporation of PSS and heterogeneity in PSS may improve the ability of IVUS to predict MACE.BH

Whole Systems Approach to Diet and Healthy Weight – A longitudinal Process Evaluation in East Scotland

© Royal Society for Public Health 2023. This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/)Aims: Obesity contributes to morbidity and early mortality, affecting people of all ages and socio-demographic backgrounds. Despite attempts to address obesity, efforts to date have only had limited success. Adopting a Whole Systems Approach (WSA) may potentially address obesity and emphasises complex inter-relating factors beyond individual choice. This study aimed to assess implementation of WSA to diet and healthy weight in two council areas of Scotland, longitudinally exploring enablers and barriers. One area followed a Leeds Beckett WSA model (LBM) of implementation, while the other used a hybrid model incorporating existing working systems. Methods: To assess the process of implementing a WSA, interviews and focus groups were conducted after initiation and one year later. Results: Main enablers included: belief in WSA effectiveness; positive relationships between key personnel; buying at community and national levels; funding availability; the working group responsible for coordinating the system development comprising individuals with diverse expertise; good communication; and existing governance structures. Barriers included: insufficient funding; high staff turnover; inadequate training in WSA methodology; engaging all relevant stakeholders and reverting to ‘old ways’ of non-WSA working. The LBM provided a framework for system setup and generating an action plan. Conclusion: This study provides the first independent longitudinal process evaluation of WSAs that have incorporated Leeds Beckett methodology, and offers insights into how a WSA can be implemented to address diet and healthy weight.Peer reviewe

Interventions to improve antibiotic prescribing practices for hospital inpatients

Background Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. Objectives To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. Selection criteria We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. Data collection and analysis Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. Main results This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias. More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention. The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence). Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence). There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomes We analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. Authors' conclusions We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions

Plaque Rupture in Coronary Atherosclerosis Is Associated With Increased Plaque Structural Stress.

OBJECTIVES: The aim of this study was to identify the determinants of plaque structural stress (PSS) and the relationship between PSS and plaques with rupture. BACKGROUND: Plaque rupture is the most common cause of myocardial infarction, occurring particularly in higher risk lesions such as fibroatheromas. However, prospective intravascular ultrasound-virtual histology studies indicate that 135 kPa was a good predictor of rupture in higher risk regions. CONCLUSIONS: PSS is determined by plaque composition, plaque architecture, and lumen geometry. PSS and PSS variability are increased in plaques with rupture, particularly at proximal segments. Incorporating PSS into plaque assessment may improve identification of rupture-prone plaques.This work was supported by British Heart Foundation grants CH/20000003/12800, FS/13/33/30168, and FS/15/26/31441; Heart Research UK grant RG2638/14/16 and MRC Confidence in Concepts award; and the NIHR Cambridge Biomedical Research Centre

Urban Rural Differences in Breast Cancer in New Zealand

Many rural communities have poor access to health services due to a combination of distance from specialist services and a relative shortage of general practitioners. Our aims were to compare the characteristics of urban and rural women with breast cancer in New Zealand, to assess breast cancer-specific and all-cause survival using the Kaplan–Meier method and Cox proportional hazards model, and to assess whether the impact of rurality is different for Māori and New Zealand (NZ) European women. We found that rural women tended to be older and were more likely to be Māori. Overall there were no differences between urban and rural women with regards their survival. Rural Māori tended to be older, more likely to be diagnosed with metastatic disease and less likely to be screen detected than urban Māori. Rural Māori women had inferior breast cancer-specific survival and all-cause survival at 10 years at 72.1% and 55.8% compared to 77.9% and 64.9% for urban Māori. The study shows that rather than being concerned that more needs to be done for rural women in general it is rural Māori women where we need to make extra efforts to ensure early stage at diagnosis and optimum treatment