An evaluation of the Clinical Directed Enhanced Service for People with Learning Disabilities in the Yorkshire and the Humber Region.

The Yorkshire and Humber Healthy Ambitions Programme Board commissioned Speakup Self Advocacy (a national self advocacy organisation run by people with learning disabilities) and Sheffield Hallam University to undertake an evaluation of the Clinical Directed Enhanced Service (hereafter referred to as the DES) for People with Learning Disabilities across the Yorkshire and Humber region between July and October, 2010. This report presents a summary of the design, implementation and findings of this evaluation. - From Introductio

Group motivational interviewing in the 'Small Changes' weight management project: a quasi-experimental trial

Background - Motivational interviewing has been recommended as an effective counselling intervention for weight management with overweight and obese individuals. Nevertheless, there is a paucity of research for the use of motivational interviewing in weight management groups and research in the area often lacks sufficient 'treatment fidelity', failing to accurately report the consistency, style, content and competence of those delivering the intervention. The current study examined the efficacy of the Small Changes weight management programme comparing motivational interviewing in groups to treatment as usual. Methods - Those in the motivational interviewing group intervention received 12 sessions of 2 hours, which comprised 9 group and 3 one to one sessions over 12 months. The motivational interviewing group were treated in a motivational interviewing consistent manner throughout; for example, change talk was identified, evoked and strengthened via specific micro-skills such as open questions, affirmations and reflections. In the treatment as usual group, subjects also received 9 group and 3 one to one sessions over a 12 month period. The treatment as usual group were required to self-select a 'Small Change' at each meeting with the facilitator. All subjects were measured at five time points: baseline, 3, 6, 9 and 12 months, outcome measures included: weight, body mass index, body-fat percentage, waist to hip ratio, number of minutes of daily physical activity, fruit and vegetable consumption and feelings of well-being. A treatment fidelity framework was applied to the motivational interviewing groups' intervention to ensure a consistent, reliable and reproducible approach. Results - After 12 months, improvements were shown for all variables measured in the motivational interviewing groups; only the composite measure of physical and psychological wellbeing improved statistically in the treatment as usual groups, . When comparing approaches: significant differences were found between motivational interviewing and treatment as usual in favour of the motivational interviewing intervention for mean percentage change in weight and body mass index but not for % body fat, waist to hip ratio, fruit and vegetable consumption, feelings of well-being or physical activity levels. The retention rates in the motivational interviewing groups were higher with 64% of subjects returning for the 12 month outcome measures versus 14% in the treatment as usual groups. Conclusions - This study indicates improvements to weight loss outcome measures after 12 months for an intervention implementing motivational interviewing for weight management groups when compared to an existing weight management programme. Future research is needed to establish the empirical basis for the use of motivational interviewing for weight management groups, with heterogeneity of dose and treatment fidelity as essential features. Keywords : Motivational interviewing, treatment fidelity, weight managemen

Effectiveness of training final-year undergraduate nutritionists in motivational interviewing

Objectives - To assess the efficacy of a motivational interviewing (MI) training programme on trainee nutritionists. Methods - A repeated measures design was applied to assess clinician behaviours in a ‘helping’ conversation. Participants were 32 nutrition students, assessed at baseline and one-month follow-up. Results - The training significantly reduced the use of closed questions and MI non-adherent behaviours (MINA) (P for both = <0.001). Trainees significantly increased reflections, affirmations, summaries (P for all = <0.001) and the use of open questions (P = <0.013) which are all key indicators of MI beginner-competence. The talk-time ratio of the nutritionists also changed significantly, in favour of the client which serves as an indication of MI being used effectively. There were also significant increases in ‘global' scores for empathy, direction, autonomy/support, collaboration and evocation. Conclusions - Newly trained nutritionists 1 month post-training have a consultation style which suggested positive outcomes for clients. The trainees' scores at the one month post-training assessment were verifiable as ‘beginning proficiency'. Practice implications - Behaviour change counselling skills for nutritionists were enhanced, at one month post-training. MI training workshops with video feedback enhances communication skills which are likely to lead to positive consultation-behaviour changes in the trainee nutritionists

Leadership styles used by senior medical leaders : patterns, influences and implications for leadership development

Purpose: Clinician leadership is important in healthcare delivery and service development. The use of different leadership styles in different contexts can influence individual and organisational effectiveness. The purpose of this study was to determine the predominant leadership styles used by medical leaders and factors influencing leadership style use. Design: A mixed methods approach was used, combining a questionnaire distributed electronically to 224 medical leaders in acute hospital trusts with in depth ‘critical incident’ interviews with six medical leaders. Questionnaire responses were analysed quantitatively to determine firstly the overall frequency of use of six predefined leadership styles, and secondly, individual leadership style based on a consultative/decision-making paradigm. Interviews were analysed thematically using both a confirmatory approach with predefined leadership styles as themes; and also an inductive grounded theory approach exploring influencing factors. Findings: Leaders used a range of styles, the predominant styles being democratic, affiliative and authoritative. Although leaders varied in their decision-making authority and consultative tendency, virtually all leaders showed evidence of active leadership. Organisational culture, context, individual propensity and ‘style history’ emerged during the inductive analysis as important factors in determining use of leadership styles by medical leaders. Implications: The outcomes of this evaluation are useful for leadership development at the level of the individual, organisation and wider NHS. Originality/value: This study adds to the very limited evidence base on patterns of leadership style use in medical leadership and reports a novel conceptual framework of factors influencing leadership style use by medical leaders.</p

Differences in dietary pattern by maternal age in the Born in Bradford cohort : A comparative analysis

Objective Explore associations between dietary patterns and maternal age Design Population based cohort study Setting Maternity department of a large hospital in northern England Sample Women delivering a singleton at Bradford Royal Infirmary between March 2007 and December 2010 (N = 5,083). Methods Survey data including maternal dietary patterns derived from food frequency questionnaire data using principal component analysis (PCA) were compared by maternal age using one-way ANOVA and chi-squared as appropriate. Main outcome measures Dietary pattern PCA scores, supplement use, familiarity and compliance with 5-a-day fruit and vegetable recommendations, consumption of cola, maternal BMI. Results Three distinct dietary patterns were derived from the data; snack and processed foods, meat and fish and grains and starches. Mean PCA score for snack and processed foods was higher among women aged ≤19 (0.6, CI 0.4 to 0.8) than women aged 20–34 (-0.02, CI -0.1 to 0.01) and those aged 35≥ (-0.3, CI -0.4 to -0.2). Women aged 35≥ had a significantly higher mean PCA score for the grains and starches dietary pattern (0.1, CI 0.03 to 0.3) compared to both the 20–34 years (-0.01, CI -0.05 to 0.02) and the ≤19 (-0.04, CI -0.2 to 0.1) groups. No differences were observed between groups in mean PCA scores for the meat and fish dietary pattern. Adolescent women also had higher intakes of sugar sweetened cola (0.9 cups per day, CI 0.7 to 1.1) and reported lower levels of fruit and vegetable and supplement intake. Women aged 35≥ had a higher mean BMI (28.0, CI 27.5 to 28.4) and higher prevalence of overweight (36.8%) and obesity (29.6%, p<0.001). Conclusions Significant differences were observed between age groups both in terms of diet quality and BMI. Interventions targeted by age group may be advantageous in improving maternal nutrition and contribute to healthy pregnancies

Self-determining medical leadership needs of occupational health physicians

Purpose: Medical leadership is seen as crucial to the transformation of healthcare services, yet leadership programmes are often designed with a top-down and centrally-commissioned 'one-size-fits-all' approach. In the UK the Smith Review (2015) concluded that more decentralised and locally-designed leadership development programmes were needed to meet the healthcare challenges of the future. However, there is an absence of an evidence-base to inform the design of effective strategies to motivate doctors to take up leadership roles, while at the same time the development of clinical leadership roles is becoming an increasingly popular strategy in order to secure formal leadership roles for doctors in healthcare organisations. The problem is further compounded by a lack of validated leadership qualities assessment instruments which support researching this problem further. The purpose of this national study was to frame an inquiry of medical leadership self-assessment within Self Determination Theory (SDT) in order to identify the extent to which a group of Occupational Health physicians (OHP) were able to self-determine their leadership needs, accurately and reliably using a National Health Service (NHS) England competency approach promoted by the NHS England Leadership Academy as a self-assessment leadership diagnostic. Design/Methodology/approach: The analysis draws on a sample of about 25% of the total population size of the Faculty of Occupational Medicine (n=250). The questionnaire used was the Leadership Qualities Framework tool as a form of online self-assessment (NHS Leadership academy, 2012a). The data were analysed using descriptive statistics and simple inferential methods. Findings: OH Physician Consultants are open about reporting their leadership strengths and leadership development needs and recognise leadership learning as an ongoing development need regardless of their level of personal competence. This study found that the single most important factor to affect a doctor’s confidence in leadership is their experience in a management role. Management experience accounted for the usefulness of leadership training, suggesting that doctors learn best through applied 'leadership learning' as opposed to theory-driven programmes. Drawing on Self Determination Theory (SDT) this article provides a theoretical framework that helps to understand those doctors who are likely to engage in leadership and management activities in the organisation. More choice and self-determination of medical leadership programmes is likely to result in more relevant leadership learning that builds on doctors' previous experience in this area. Research Limitations and Implications: While this study benefitted from a large sample size, it was limited to the use of purely quantitative methods. Future studies would benefit from the application of a mixed methodology. Practical Implications: This study suggests that doctors are able to determine their own learning needs reliably and that they are more likely to increase their confidence in leadership and management if they are exposed to leadership and management experience. Originality Value: This is the first large scale study of this kind with a large sample within a single medical specialty. The study is considered as insider research as the first author is an Occupational Health Physician with knowledge of how to engage OH Physicians in this work

Factors associated with risk of stroke-associated pneumonia in patients with dysphagia: A systematic review

Dysphagia is associated with increased risk of stroke-associated pneumonia (SAP). However, it is unclear what other factors contribute to that risk or which measures may reduce it. This systematic review aimed to provide evidence on interventions and care processes associated with SAP in patients with dysphagia. Studies were screened for inclusion if they included dysphagia only patients, dysphagia and non-dysphagia patients or unselected patients that included dysphagic patients and evaluated factors associated with a recorded frequency of SAP. Electronic databases were searched from inception to February 2017. Eligible studies were critically appraised. Heterogeneity was evaluated using I2. The primary outcome was SAP. Eleven studies were included. Sample sizes ranged from 60 to 1088 patients. There was heterogeneity in study design. Measures of immunodepression are associated with SAP in dysphagic patients. There is insufficient evidence to justify screening for aerobic Gram-negative bacteria. Prophylactic antibiotics did not prevent SAP and proton pump inhibitors may increase risk. Treatment with metoclopramide may reduce SAP risk. Evidence that nasogastric tube (NGT) placement increases risk of SAP is equivocal. A multidisciplinary team approach and instrumental assessment of swallowing may reduce risk of pneumonia. Patients with impaired mobility were associated with increased risk. Findings should be interpreted with caution given the number of studies, heterogeneity and descriptive analyses. Several medical interventions and care processes, which may reduce risk of SAP in patients with dysphagia, have been identified. Further research is needed to evaluate the role of these interventions and care processes in clinical practice

Impact of dysphagia assessment and management on risk of stroke-associated pneumonia: A systematic review

Background Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed during the acute phase. The aim of this review was to identify which methods of assessment and management in acute stroke influence the risk of stroke-associated pneumonia. Studies of stroke patients that reported dysphagia screening, assessment or management and occurrence of pneumonia during acute phase stroke were screened for inclusion after electronic searches of multiple databases from inception to November 2016. The primary outcome was association with stroke-associated pneumonia. Summary Twelve studies of 87824 patients were included. The type of dysphagia screening protocol varied widely across and within studies. There was limited information on what comprised a specialist swallow assessment and alternative feeding was the only management strategy, which was reported for association with stroke-associated pneumonia. Use of a formal screening protocol, early dysphagia screening and assessment by a speech and language pathologist (SLP) was associated with a reduced risk of stroke-associated pneumonia. There was marked heterogeneity between the included studies, which precluded meta-analysis. Key Messages There is variation in assessment and management of dysphagia in acute stroke. There is increasing evidence that early dysphagia screening and specialist swallow assessment by a SLP may reduce the odds of stroke-associated pneumonia. There is the potential for other factors to influence incidence of stroke-associated pneumonia during the acute phase

Impact of adolescent age on maternal and neonatal outcomes in the Born in Bradford cohort

Explore associations between maternal and neonatal outcomes and maternal age, with particular reference to adolescent women. Population-based cohort study. Maternity department of a large hospital in Northern England. Primiparous women delivering a singleton at Bradford Royal Infirmary between March 2007 and December 2010 aged ≤19 years (n=640) or 20-34 years (n=3951). Subgroup analysis was performed using women aged ≤16 years (n=68). Women aged 20-34 years were used as the reference group. Maternal and neonatal outcomes. The odds of extremely low birth weight (<1000 g) were significantly higher in the adolescent group (≤19 years) compared with the reference group (adjusted OR (aOR) 4.13, 95% CI 1.41 to 12.11). The odds of very (<32 weeks) and extremely (<28 weeks) preterm delivery were also higher in the adolescent group (aOR 2.12, 95% CI 1.06 to 4.25 and aOR 5.06, 95% CI 1.23 to 20.78, respectively).Women in the adolescent group had lower odds of gestational diabetes (aOR 0.35, 95% CI 0.20 to 0.62), caesarean delivery (aOR 0.53, 95% CI 0.42 to 0.67 and instrumental delivery (aOR 0.53, 95% CI 0.41 to 0.67). This study identifies important differences in maternal and neonatal outcomes between women by age group. These findings could help in identifying at-risk groups for additional support and tailored interventions to minimise the risk of adverse outcomes for these vulnerable groups. Further work is needed to identify the causal mechanisms linking age with outcomes in adolescent women where significant gaps in the literature exist. [Abstract copyright: © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis

Objective: Secondary vascular risk reduction is critical to preventing recurrent stroke. We aimed to evaluate the effect of exercise interventions on vascular risk factors and recurrent ischaemic events after stroke or transient ischaemic attack (TIA). Design: Intervention systematic review and meta-analysis. Data sources: OVID MEDLINE, PubMed, The Cochrane Library, Web of Science, The National Institute for Health and Care Excellence, TRIP Database, CINAHL, PsycINFO, SCOPUS, UK Clinical Trials Gateway and the China National Knowledge Infrastructure were searched from 1966 to October 2017. Eligibility criteria: Randomised controlled trials evaluating aerobic or resistance exercise interventions on vascular risk factors and recurrent ischaemic events among patients with stroke or TIA, compared with control. Results: Twenty studies (n=1031) were included. Exercise interventions resulted in significant reductions in systolic blood pressure (SBP) −4.30 mm Hg (95% CI −6.77 to −1.83) and diastolic blood pressure −2.58 mm Hg (95% CI −4.7 to −0.46) compared with control. Reduction in SBP was most pronounced among studies initiating exercise within 6 months of stroke or TIA (−8.46 mm Hg, 95% CI −12.18 to −4.75 vs −2.33 mm Hg, 95% CI −3.94 to −0.72), and in those incorporating an educational component (−7.81 mm Hg, 95% CI −14.34 to −1.28 vs −2.78 mm Hg, 95% CI −4.33 to −1.23). Exercise was also associated with reductions in total cholesterol (−0.27 mmol/L, 95% CI −0.54 to 0.00), but not fasting glucose or body mass index. One trial reported reductions in secondary vascular events with exercise, but was insufficiently powered. Summary: Exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education