The development, usability and acceptability of a cervical screening informed-choice tool for women with severe mental illness

People with severe mental illness (SMI) die on average 10–20 years younger than the general population, including those with morbidity relating to cancer. People with SMI face specific barriers to attending cancer screening, including for cervical cancer and, as a consequence, they are underrepresented in cancer screening generally and have poorer survival rates following a positive diagnosis. The aim of this PhD was to develop a cervical screening ‘informed-choice tool’ for women with SMI. The tool was designed to address barriers to cervical screening uptake in order to help women with SMI make an informed choice about participating in screening. This research focused on three questions: (1) What are, if any, the specific design(s) and theoretical underpinning(s) of informed-choice tools developed for people with SMI? (2) What are service users’ and clinicians’ experiences of using the tool? (3) Does the tool have any impact on service users’ decisional conflict to attend screening? The tool was informed by a realist review of physical health interventions for people with SMI and by a systematic review of informed-choice tools for this population, which have now been published. A mixed-methods research design was used to develop the tool. The usability and acceptability of the tool was tested by service users and clinicians in two NHS Trusts using semi-structured interviews and the ‘think-aloud’ method. A preliminary evaluation of the tool was conducted to assess the impact on service users’ decisional conflict to attend cervical screening sessions. Results from the evaluation (n = 25) showed that the tool may have an impact on some women who are either overdue for their screening or have never attended. This work has resulted in a tool which is usable and acceptable by women with SMI and may impact on their screening uptake and hence their mortality rates from cervical cancer. An animated video has also been developed to illustrate the key findings of the tool. The tool and video have since been disseminated widely across the NHS and third sector organisations. Future research may involve further assessments of the real-world impact of the tool and its adaptation to other health-related decisions

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Interventions to increase access to or uptake of physical health screening in people with severe mental illness: a realist review

Objectives: To identify and evaluate interventions aimed at increasing uptake of, or access to, physical health screening by adults with severe mental illness; to examine why interventions might work. Design: Realist review. Setting: Primary, secondary and tertiary care. Results: A systematic search identified 1448 studies, of which 22 met the inclusion criteria. Studies were from Australia (n=3), Canada (n=1), Hong Kong (n=1), UK (n=11) and USA (n=6). The studies focused on breast cancer screening, infection preventive services and metabolic syndrome (MS) screening by targeting MSrelated risk factors. The interventions could be divided into those focusing on (1) health service delivery changes (12 studies), using quality improvement, randomised controlled trial, cluster randomised feasibility trial, retrospective audit, cross-sectional study and satisfaction survey designs and (2) tests of tools designed to facilitate screening (10 studies) using consecutive case series, quality improvement, retrospective evaluation and pre–post audit study designs. All studies reported improved uptake of screening, or that patients had received screening they would not have had without the intervention. No estimation of overall effect size was possible due to heterogeneity in study design and quality. The following factors may contribute to intervention success: staff and stakeholder involvement in screening, staff flexibility when taking physical measurements (eg, using adapted equipment), strong links with primary care and having a pharmacist on the ward. Conclusions: A range of interventions may be effective, but better quality research is needed to determine any effect size. Researchers should consider how interventions may work when designing and testing them in order to target better the specific needs of this population in the most appropriate setting. Behaviour-change interventions to reduce identified barriers of patient and health professional resistance to screening this population are required. Resource constraints, clarity over professional roles and better coordination with primary care need to be addresse

Barriers to effective diabetes management – a survey of people with severe mental illness

Background: People with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk of developing type 2 diabetes and have poorer health outcomes than those with diabetes alone. To maintain good diabetes control, people with diabetes are advised to engage in several self-management behaviours. The aim of this study was to identify barriers or enablers of diabetes self-management experienced by people with SMI. Methods: Adults with type 2 diabetes and SMI were recruited through UK National Health Service organisations and mental health and diabetes charities. Participants completed an anonymous survey consisting of: Summary of Diabetes Self-Care Activities (SDSCA); CORE-10 measure of psychological distress; a measure of barriers and enablers of diabetes self-management based on the Theoretical Domains Framework; Diabetes UK care survey on receipt of 14 essential aspects of diabetes healthcare. To identify the strongest explanatory variables of SDSCA outcomes, significant variables (p < .05) identified from univariate analyses were entered into multiple regressions. Results: Most of the seventy-seven participants had bipolar disorder (42%) or schizophrenia (36%). They received a mean of 7.6 (SD 3.0) diabetes healthcare essentials. Only 28.6% had developed a diabetes care plan with their health professional and only 40% reported receiving specialist psychological support. Engagement in self-management activities was variable. Participants reported taking medication on 6.1 (SD 2.0) days in the previous week but other behaviours were less frequent: general diet 4.1 (2.3) days; specific diet 3.6 (1.8) days, taking exercise 2.4 (2.1) days and checking feet on 1.7 (1.8) days. Smoking prevalence was 44%. Participants reported finding regular exercise and following a healthy diet particularly difficult. Factors associated with diabetes self22 management included: the level of diabetes healthcare and support received; emotional wellbeing; priority given to diabetes; perceived ability to manage diabetes or establish a routine to do so; and perceived consequences of diabetes self-management. Conclusions: Several aspects of diabetes healthcare and self-management are suboptimal in people with SMI. There is a need to improve diabetes self-management support for this population by integrating diabetes action plans into care planning and providing adequate psychological support to help people with SMI manage their diabetes

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Additional file 1: of Barriers to effective diabetes management – a survey of people with severe mental illness

Barriers and enablers of diabetes self-management questionnaire. Questionnaire items. (DOCX 35 kb