Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background Breastfeeding impacts multiple health outcomes but less than 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding. Objectives To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS. Design Evidence syntheses with stakeholder engagement. Review methods Systematic reviews examined effectiveness of breastfeeding support for i) healthy women, and ii) women with long-term conditions using Cochrane Pregnancy and Childbirth group methods. Mixed methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women, and experiences of receiving/providing support for breastfeeding women. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following NICE guidance. All searches were conducted May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were: 23 stakeholders, 16 parents in the parents panels, 15 women in the focus groups, and 87 stakeholders attended the workshops. Results We found considerably more interventions that were designed for healthy women (Review 1) compared to those aimed at women with long-term conditions (Reviews 1 and 4, approximately half the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and possibly the impact of support may be different in these populations. Despite this, studies from Review 2 found that women perceived the provision of support as positive, important and needed. Studies from Review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g., partners, family, friends, peers, external professionals, web-based resources) and involving them in the provision of breastfeeding support for women with long-term conditions. In Reviews 3 and 6, there was uncertainty in the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good quality evidence. Limitations There is lack of evidence for effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information about intervention characteristics reported. Conclusions ‘Breastfeeding only’ support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for ‘breastfeeding plus’ interventions is less consistent but may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women’s and supporters’ needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK. Future work Evaluation of breastfeeding support for all women, in particular those at risk of poor breastfeeding outcomes (e.g., long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies

COVIDiSTRESS diverse dataset on psychological and behavioural outcomes one year into the COVID-19 pandemic

During the onset of the COVID-19 pandemic, the COVIDiSTRESS Consortium launched an open-access global survey to understand and improve individuals’ experiences related to the crisis. A year later, we extended this line of research by launching a new survey to address the dynamic landscape of the pandemic. This survey was released with the goal of addressing diversity, equity, and inclusion by working with over 150 researchers across the globe who collected data in 48 languages and dialects across 137 countries. The resulting cleaned dataset described here includes 15,740 of over 20,000 responses. The dataset allows cross-cultural study of psychological wellbeing and behaviours a year into the pandemic. It includes measures of stress, resilience, vaccine attitudes, trust in government and scientists, compliance, and information acquisition and misperceptions regarding COVID-19. Open-access raw and cleaned datasets with computed scores are available. Just as our initial COVIDiSTRESS dataset has facilitated government policy decisions regarding health crises, this dataset can be used by researchers and policy makers to inform research, decisions, and policy

Self‐efficacy, sympathy, and attributions: Understanding helping intentions towards disclosers of mental health concerns on social media

Mental health disclosures increasingly occur on online platforms. In a moderated‐ mediation analysis, we assessed an adapted Corrigan's attribution model (2003) including factors such as the sincerity of online disclosure and support self‐efficacy to predict helping intentions on social media. Participants (N = 177) were randomly allocated to one of three conditions and presented with a social media vignette experimentally manipulating controllability attributions (low, high, neutral controlla?bility). Participants completed controllability, sincerity, sympathy, self‐efficacy, and helping intentions questionnaires. While preliminary exploratory analyses revealed that the proposed model significantly explained helping intentions, the proposed mechanisms of serial‐mediation via sincerity of disclosure and sympathy was not supported, nor was this dependent on self‐efficacy. Nonetheless, sympathy and self‐ efficacy uniquely and significantly explained helping intentions. Thus, an intervention that upskills individuals in online support provision offers promise in terms of accessible, online, community‐based treatment initiatives. </p

Online neurocognitive remediation therapy to improve cognition in community-living individuals with a history of depression: A pilot study

Major depression is a highly prevalent psychopathology with high relapse rates. Following remission from a depressive episode, neurocognitive difficulties in attention, working memory and executive function often persist, preventing full clinical recovery. These neurocognitive deficits are often present since the first depressive episode and have been shown to predict relapse. The efficacy of computerised neurocognitive remediation therapy (NCRT) to improve attention, memory and executive function has been demonstrated in several clinical populations but randomised controlled trials (RCT) have not been conducted in depression. The present study aimed to conduct a pilot, randomised study, of computerised NCRT for individuals with past depression, currently in remission. Twenty two individuals remitted from depression were randomly assigned to receive 20 one-hour sessions over 5 week of ether computerised NCRT or a component-equivalent allocation (play online computer games). The NCRT group showed significantly larger improvements in performance relative to the Games group in the three targeted neurocognitive domains: divided attention, verbal working memory, and planning, but also in non-targeted domains of long-term verbal memory and switching abilities. No significant effect was observed in the NCRT-targeted domain visual working memory. These preliminary results suggest computerised NCRT efficacy to improve targeted neurocognitive processes during depression remission and support its potential value as preventative connected intervention tool

Neuropsychological rehabilitation interventions for people with an acquired brain injury and their caregivers. A protocol for a systematic review of economic evaluation

Background: New emerging evidence has demonstrated the need for effective interventions to help people living with an acquired brain injury (ABI). Evidence on cost-effectiveness, which can help inform use of limited resources, is scarce in this area and therefore the purpose of this systematic review is to critically appraise and consolidate the current evidence on economic evaluations of ABI rehabilitation interventions.Methods: Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial-based model economic evaluations) of ABI treatment interventions in adults. A systematic literature search will be conducted on the following electronic databases: EMBASE, Econlit, CINAHL, Medline, Econlit, the National Health Service Economic Evaluation Database and PsyclNFO. This review will only include cost-effectiveness analysis studies (e.g., cost per life year gained), cost-benefit and cost minimisation analyses in which the designs were randomised controlled trials (RCTs), non-RCT studies, cost-utility analyses (e.g., cost per quality-adjusted life year (QALY) gained or cost per disability-adjusted life year averted), cohort studies, and modeling studies. Only studies that were published in English, associated with adults who have an ABI will be included. There will be no restrictions on perspective, sample size, country, follow-up duration or setting. The search strategy terms will include the following: acquired brain injury, brain*; cost*; or cost–benefit analysis*. Following data extraction, a narrative summary and tables will be used to summarize the characteristics and results of included studies.Discussion: The findings from this review will be beneficial to health policy decision makers when examining the evidence of economic evaluations in this field. In addition, it is anticipated that this review will identify gaps in the current economic literature to inform future-related research

Neuropsychological rehabilitation interventions for people with an acquired brain injury and their caregivers. A protocol for a systematic review of economic evaluation

Background: New emerging evidence has demonstrated the need for effective interventions to help people living with an acquired brain injury (ABI). Evidence on cost-effectiveness, which can help inform use of limited resources, is scarce in this area and therefore the purpose of this systematic review is to critically appraise and consolidate the current evidence on economic evaluations of ABI rehabilitation interventions.Methods: Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial-based model economic evaluations) of ABI treatment interventions in adults. A systematic literature search will be conducted on the following electronic databases: EMBASE, Econlit, CINAHL, Medline, Econlit, the National Health Service Economic Evaluation Database and PsyclNFO. This review will only include cost-effectiveness analysis studies (e.g., cost per life year gained), cost-benefit and cost minimisation analyses in which the designs were randomised controlled trials (RCTs), non-RCT studies, cost-utility analyses (e.g., cost per quality-adjusted life year (QALY) gained or cost per disability-adjusted life year averted), cohort studies, and modeling studies. Only studies that were published in English, associated with adults who have an ABI will be included. There will be no restrictions on perspective, sample size, country, follow-up duration or setting. The search strategy terms will include the following: acquired brain injury, brain*; cost*; or cost–benefit analysis*. Following data extraction, a narrative summary and tables will be used to summarize the characteristics and results of included studies.Discussion: The findings from this review will be beneficial to health policy decision makers when examining the evidence of economic evaluations in this field. In addition, it is anticipated that this review will identify gaps in the current economic literature to inform future-related research

Clinical efficacy and economic evaluation of online cognitive behavioral therapy for major depressive disorder: a systematic review and meta-analysis

<p><b>Introduction</b>: Leading cause of disability worldwide, depression is the most prevalent mental disorder with growing societal costs. As mental health services demand often outweighs provision, accessible treatment options are needed. Our systematic review and meta-analysis evaluated the clinical efficacy and economic evidence for the use of online cognitive behavioral therapy (oCBT) as an accessible treatment solution for depression.</p> <p><b>Areas covered</b>: Electronic databases were searched for controlled trials published between 2006 and 2016. Of the reviewed 3,324 studies, 29 met the criteria for inclusion in the efficacy meta-analysis. The systematic review identified five oCBT economic evaluations. Therapist-supported oCBT was equivalent to face-to-face CBT at improving depressive symptoms and superior to treatment-as-usual, waitlist control, and attention control. Depression severity, number of sessions, or support did not affect efficacy. From a healthcare provider perspective, oCBT tended to show greater costs with greater benefits in the short term, relative to comparator treatments.</p> <p><b>Expert commentary</b>: Although efficacious, further economic evidence is required to support the provision of oCBT as a cost-effective treatment for depression. Economic evaluations that incorporate a societal perspective will better account for direct and indirect treatment costs. Nevertheless, oCBT shows promise of effectively improving depressive symptoms, considering limited mental healthcare resources.</p

A hot-cold cognitive model of depression: Integrating the neuropsychological approach into the cognitive theory framework

Background: In the 50 years following Beck’s cognitive theory, empirical research has consistently supported the role of dysfunctional, ‘hot’ cognition in the onset and maintenance of major depressive disorder. Compromised ‘cold’ cognition in attention, memory, and executive control abilities, independent of the affective state, has attracted much clinical interest for its role throughout the course of illness and into remission. We propose integrating cold cognition into Beck’s cognitive theory framework to account for the complementary roles of both hot and cold cognition in depression onset and maintenance. Method: A critical review of cognitive research was conducted to inform an integrated hot-cold cognitive model of depression. Results: Cold cognitive deficits likely act as a gateway to facilitate the activation and expression of the hot cognitive biases through a weakened ability to attend, retrieve, and critically assess information. Cold deficits become exacerbated by the negative mood state, essentially ‘becoming hot’, lending to maladaptive emotion regulation through ruminative processes. Depleted cognitive resources contribute to the manifestation of further deficit in problem-solving ability in everyday life, which in itself, may act as a stressor for the onset of recurrent episodes, perpetuating the depressive cycle. Conclusion: We discuss the interaction between hot and cold cognition within the cognitive theory framework and the potential of complementary hot-cold pathways to elucidate novel means of prevention and treatment for depression

Young people's experience of the therapeutic alliance: A systematic review

Objective: The aim of this systematic review was to synthesise qualitative evidence on young people's conceptualisation, utilisation and experiences of the therapeutic alliance in individual psychotherapy or counselling and its role in bringing about change. Method: The thematic synthesis method was used to synthesise data. The methodological quality of included studies was assessed using the CASP checklist for qualitative research.  Results: Four superordinate analytical themes were generated: (1) valuable therapist qualities, (2) conditions for the development and maintenance of the therapeutic alli?ance, (3) therapeutic processes and (4) barriers to the development of the therapeutic alliance. Findings indicate that young people appreciated the uniqueness of the therapeutic relationship that provided a sense of safety, choice and autonomy. Flexibility and accessibility were noted as important elements of therapeutic alliance building as they elicited a sense of agency. Young people emphasised the non-linear nature of therapy and prioritised process variables such as improvement in self-understanding, self-efficacy and self-worth. Conclusion: The current systematic review is a comprehensive overview of qualitative studies of experiences of therapy from young people's perspectives. Important practical implications derived from this review as the role of autonomy in the change process and the formation and maintenance of the therapeutic relationship were outlined as important elements in youth therapy.</p