Process evaluation for complex interventions in primary care: understanding trials using the normalization process model

Background: the Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.Method: in this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.Results: application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.Conclusion: the model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare setting

Brazilian Multicentre Study Of Common Mental Disorders In Primary Care: Rates And Related Social And Demographic Factors [estudo Multicêntrico Brasileiro Sobre Transtornos Mentais Comuns Na Atenção Primária: Prevalência E Fatores Sociodemográficos Relacionados]

Mental health problems are common in primary health care, particularly anxiety and depression. This study aims to estimate the prevalence of common mental disorders and their associations with socio-demographic characteristics in primary care in Brazil (Family Health Strategy). It involved a multicenter cross-sectional study with patients from Rio de Janeiro, São Paulo, Fortaleza (Ceará State) and Porto Alegre (Rio Grande do Sul State), assessed using the General Health Questionnaire (GHQ-12) and the Hospital Anxiety and Depression Scale (HAD). The rate of mental disorders in patients from Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre were found to be, respectively, 51.9%, 53.3%, 64.3% and 57.7% with significant differences between Porto Alegre and Fortaleza compared to Rio de Janeiro after adjusting for confounders. Prevalence proportions of mental problems were especially common for females, the unemployed, those with less education and those with lower incomes. 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Fatigue Intervention by Nurses Evaluation - The FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610]

Background: Chronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP). Methods and design: This study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients' homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions' mechanisms of change, and also GPs' drivers and barriers towards referral

Rede De Apoio Social, Saúde Mental E Qualidade De Vida: Um Estudo Transversal Na Atenção Primária

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)The objective of this study was to identify the association between emotional distress and social support networks with quality of life in primary care patients. This was a cross-sectional study involving 1,466 patients in the cities of São Paulo and Rio de Janeiro, Brazil, in 2009/2010. The General Health Questionnaire, the Hospital Anxiety and Depression Scale and the brief version of the World Health Organization Quality of Life Instrument were used. The Social Support Network Index classified patients with the highest and lowest index as socially integrated or isolated. A bivariate analysis and four multiple linear regressions were conducted for each quality of life outcome. The means scores for the physical, psychological, social relations, and environment domains were, respectively, 64.7; 64.2; 68.5 and 49.1. In the multivariate analysis, the psychological domain was negatively associated with isolation, whereas the social relations and environment domains were positively associated with integration. Integration and isolation proved to be important factors for those in emotional distress as they minimize or maximize negative effects on quality of life. © 2016, Fundacao Oswaldo Cruz. All rights reserved.3212CNPq, Conselho Nacional de Desenvolvimento Científico e TecnológicoConselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Topological Structure of the SU(3) Vacuum

We investigate the topological structure of the vacuum in SU(3) lattice gauge theory. We use under-relaxed cooling to remove the high-frequency fluctuations and a variety of "filters" to identify the topological charges in the resulting smoothened field configurations. We find a densely packed vacuum with an average instanton size, in the continuum limit, of about 0.5 fm. The density at large sizes decreases as a large inverse power of the size. At small sizes we see some sign of a trend towards the asymptotic perturbative behaviour. We find that an interesting polarisation phenomenon occurs: the large topological charges tend to have, on the average, the same sign and are over-screened by the smaller charges which tend to have, again on the average, the opposite sign to the larger instantons. We also calculate the topological susceptibility for which we obtain a continuum value of about 187 MeV. We perform the calculations for various volumes, lattice spacings and numbers of cooling sweeps, so as to obtain some control over the associated systematic errors. The coupling range is from beta=6.0 to beta=6.4 and the lattice volumes range from 16x16x16x48 to 32x32x32x64.Comment: LaTeX. Self-unpacking, uuencoded tar-compressed fil

Screening of the topological charge in a correlated instanton vacuum

Screening of the topological charge due to he fermion-induced interactions is an important phenomenon, closely related with the resolution of the strong CP and U(1) problems. We study the mechanism of such screening in a 'correlated instanton vacuum', as opposed to the 'random' one. Both scalar and pseudoscalar gluonic correlators are analyzed by means of an observable that minimizes finite size effects. Screening of the topological charge is established. This allows us to calculate the $\eta'$ mass without having to invert the Dirac operator. We suggest that this method might be used in lattice QCD calculations as well. Our results for the screening of the topological charge are in agreement with the chiral Ward identities, and the scalar gluonic correlator satisfies a low energy theorem first derived by Novikov et al. \cite{Novikov-etal}. We also propose to evaluate the topological susceptibility in the Witten-Veneziano formula not in an infinite box in an world $without$ fermions but in an infinitesimal box in a world $with$ fermions.Comment: 22 pages + 5 postscript figures, SUNY-NTG/94-25. Corrected LATEX erro

Popular Concepts of Justice and Hybrid Judicial Institutions in Ghana

The provision of effective, legitimate and accessible justice is one of the most fundamental public goods expected from a well?governed state. In this article, we compare the legitimacy of three state or state?supported Ghanaian dispute settlement institutions: the magistrate's courts, the Commission on Human Rights and Administrative Justice (CHRAJ) and the land dispute committees of the neo?traditional Customary Land Secretariats (CLSs). It was found that popular beliefs and expectations are predominantly focused on the notion that justice requires a ‘balanced process for establishing the truth’, and that the procedures, codes and remedies used by the magistrate's courts and the CHRAJ were more congruent with these beliefs than those of the CLSs. The findings challenge stereotypes of popular and traditional justice as being primarily about reconciliation or restoration of communal harmony, and suggest that state institutions should be supported in their current development of hybrid and informal kinds of dispute settlement