Group membership and staff turnover affect outcomes in group CBT for persistent pain

The effects of two contextual factors, group membership and staff turnover, on the outcome of group cognitive behavioral therapy (CBT) for persistent pain were investigated. The data came from end of treatment and one month follow-up assessments of 3050 individuals who attended an intensive group programme over sixteen years. Intraclass correlations (ICC) showed significant intragroup effects on self-efficacy (ICC = 0.16 at end of treatment; 0.12 at one month), catastrophizing (ICC = 0.06; 0.13) and distance walked (ICC = 0.20; 0.19). This underlines the importance of modelling group membership when analyzing data from group interventions. Linear regression showed that high periods of staff turnover were significantly related to poorer outcomes on self-efficacy and distance walked at end of treatment, with the effect on self-efficacy persisting to one month follow-up. Having demonstrated significant contextual effects in an existing data set, further research is needed to explore the mechanisms by which these effects operate

Computerised cognitive-behavioural therapy for prevention and early intervention in anxiety and depression: a case study of Xanthis

Introduction: Mental health issues such as anxiety and depression are a leading cause of morbidity and a huge public health cost. Prevention and early treatment are effective, but are difficult to deliver in traditional forms to large populations. Internet-delivered approaches, such as computerised CBT (cCBT), appear promising as a cost-effective way of reaching populations for what are sensitive and stigmatised conditions. However, there are challenges to achieving this within a viable financial model. Objective: Explore the use of cCBT in sub-clinical or preventative care, within a work-based delivery model. Method: A realist methodology was adopted for a programme of research as it provides a flexible and pluralistic approach to deconstructing complex interventions. This included: a systematic literature review on cCBT in a preventative context; and data collected around use of Xanthis, a commercial sub-clinical cCBT package. Xanthis was made available to all employees, accessible over the Internet, in three large, UK, public sector organisations: Dyfed-Powys Police, Cardiff University and Oxford University. Its use was tied into Occupational Health/Human Resources policies. User numbers were monitored. Interviews were conducted with purchasers of the package. At Dyfed-Powys Police, a before/after questionnaire was conducted on users. Results: The literature on cCBT in prevention and early treatment is heterogeneous. Five papers specifically considered cCBT in the prevention of depression and anxiety, showing mixed results. There were further papers on cCBT as a community-based, sub-clinical treatment rather than specifically as prevention. These vary in terms of method, cCBT package, population and conditions treated. Outcomes were generally positive. Research was mostly on high risk groups rather than the general population. Terminology and definitions varied between and within papers. Attrition rates remain high in internet-based spontaneous self help. Xanthis user numbers peaked after launch in all organisations before settling at 5-10% staff. Users find the tool a useful support and like that it is confidential, accessible, increases knowledge and understanding about problems, and links to sources of help. However, there were many problems associated with the implementation and launch of the tool. Different organisations sought to use Xanthis in different ways and in conjunction with other activity. How the tool was promoted internally was critical. Commercialisation was constrained by the resources typically devoted to Occupational Health. Conclusion: cCBT in prevention and early management of mental illness is a new but promising field. Technology offers a new delivery platform for reaching individuals at different illness stages, confidentially and accessibly. cCBT can reduce symptoms in sub-clinical populations, including spontaneous Internet users, but adherence and attrition rates are a challenge. The financing and implementation of sub-clinical cCBT packages must be researched, including determining which are suitable for use in different user populations and circumstances. Packages such as Xanthis have potential for use within sub-clinical care in a variety of contexts, but there are challenges in its commercialisation, delivery and use within a work-based delivery model which must be overcome

Realist literature review of computerised cognitive behavioural therapy (cCBT) for prevention and early intervention in anxiety and depression

Objective: Computerised CBT is an accepted treatment for anxiety and depression. There is now a public health focus on the prevention and early management of these conditions. Internet-delivered approaches appear promising as a cost-effective way of reaching a large population for what are sensitive and stigmatised conditions. Prevention of mental illness and use of cCBT are both fields new in development. We sought to systematically review the relevant literature. Methodology: A realist review method was used as it provides a more flexible and pluralistic approach to deconstructing complex interventions, allowing us to examine all relevant literature. A structured search methodology was developed and key medical databases searched. Results: We found very different papers invesitgating whether cCBT works in prevention and early treatment. Only five specifically considered cCBT in the prevention of depression and anxiety, providing mixed results. There were further papers on cCBT as a community-based, sub-clinical treatment rather than specifically for prevention. These vary hugely in terms of method, cCBT package, population and conditions treated. Outcomes are generally positive. Research was mostly on high risk groups rather than the general population. Terminology and definitions varied between and within papers. Conclusions: cCBT in prevention and early management of mental illness is a new but promising field. Technology offers a new delivery platform for reaching individuals at different illness stages, confidentially and accessibly. cCBT can reduce symptoms in sub-clinical populations, including spontaneous Internet users, but adherence and attrition rates are a challenge. More research is needed

Real world case studies of a preventative computerised cognitive behavioural (cCBT) package being used to support employees within large UK organisations

Objective: Computerised CBT promises a way of bringing an effective intervention to a large population. However, there are challenges to achieving this within a viable business model. One approach may be through Occupational Health departments. Methodology: Case study of the introduction of the Xanthis system, a cCBT package, in three large, public sector organisations in the UK: Dyfed-Powys Police, Cardiff University and Oxford University. Xanthis was made confidentially available to all employees, accessible over the Internet. Its use was tied into Occupational Health/Human Resources policies. Different research methods were conducted to investigate use. User numbers were monitored; results now cover three years. Interviews were conducted with purchasers of the package. At Dyfed-Powys Police, a before/after questionnaire was conducted on users. Conclusions: User numbers peaked after launch in all organisations before settling at 5-10% staff. Users find the tool a useful support and like that it is confidential, accessible, increases knowledge and understanding about problems, and links to sources of help. The best testimonial was from a suicidal individual who used Xanthis to gain understanding of their situation and then seek help. The experience shows that technology has a role within organisations for the support of employees and in early intervention for mental health problems. There were many problems associated with the implementation and launch of the tool. Different organisations wanted to use Xanthis in different ways and in conjunction with other activity. How the tool was promoted internally was critical. Commercialisation was constrained by the resources devoted to Occupational Health

What you haven't heard: lessons from 130 years of health technology innovation

Many technology innovations in health have failed, so why is healthcare such a difficult area? And how does the social nature of mobile help

A meta-narrative review of electronic patient records

This session comprises four papers that consider how systematic review methods may be developed in order to make the best use of complex evidence in education and health. The methods and approaches reflected upon in these papers are not drawn from a single research tradition, but share a common goal of broadening the methodological scope of systematic reviews and better understanding the utilisation of knowledge produced in this way. The first paper (Henry Potts) reports an ongoing review using a meta-narrative approach to make sense of the diverse sources of knowledge regarding electronic patient records. The review method has stressed the importance of understanding knowledge from within the research tradition in which it was produced; it is argued that this has important implications for the way that evidence is utilised in the policy making process. The second paper (Geoff Wong) reflects upon the experience of using an explicit realist approach in the synthesis of the evidence in Internet based learning. This realist synthesis offers a method of making sense of the highly heterogeneous and context dependent evidence which exists in this field thus enabling greater insights into what makes such educational interventions ‘work’. The third paper (Rod Sheaff) reports a review of the predominantly qualitative research literature on organisational structures and their impacts upon policy outcomes in health systems. A scoping study found 14389 relevant papers of which 1568 were selected for review. These studies were very variable in the amount and quality of the qualitative data, hence 'evidence', which they reported. The paper describes an attempt to adapt realist methods so as to synthesise such bodies of research in ways which take account of this variation in the strength of qualitative evidence. The fourth paper (Mark Pearson) draws upon the work of Donald Campbell and colleagues in order to gain a fuller understanding of how systematic reviews are utilised in the policy making process. It is argued that interpretive approaches to understanding policy making (such as rhetorical analysis) need to be tempered with a more nuanced understanding of research validity. The case is made that interpretive approaches not only can, but should, be melded with research validity to increase understanding of the policy making process

The feasibility and acceptability of an app-based intervention with brief behavioural support (APPROACH) to promote brisk walking in people diagnosed with breast, prostate and colorectal cancer in the UK

Introduction Increased moderate to vigorous physical activity (MVPA) can improve clinical and psychosocial outcomes for people living with and beyond cancer (LWBC). This study aimed to assess the feasibility and acceptability of trial procedures in a pilot randomised controlled trial (RCT) of a theory-driven app-based intervention with behavioural support focused on promoting brisk walking (a form of MVPA) in people LWBC (APPROACH). Methods Participants diagnosed with breast, prostate or colorectal cancer were recruited from a single UK hospital site. Assessments at baseline and 3 months included online questionnaires, device-measured brisk walking (activPAL accelerometer) and self-reported weight and height. Participants were randomised to intervention or control (care as usual). The intervention comprised a non-cancer-specific app to promote brisk walking (National Health Service ‘Active 10’) augmented with print information about habit formation, a walking planner and two behavioural support telephone calls. Feasibility and acceptability of trial procedures were explored. Initial estimates for physical activity informed a power calculation for a phase III RCT. A preliminary health economics analysis was conducted. Results Of those medically eligible, 369/577 (64%) were willing to answer further eligibility questions and 90/148 (61%) of those eligible were enrolled. Feasibility outcomes, including retention (97%), assessment completion rates (>86%) and app download rates in the intervention group (96%), suggest that the trial procedures are acceptable and that the intervention is feasible. The phase III RCT will require 472 participants to be randomised. As expected, the preliminary health economic analyses indicate a high level of uncertainty around the cost-effectiveness of the intervention. Conclusions This pilot study demonstrates that a large trial of the brisk walking intervention with behavioural support is both feasible and acceptable to people LWBC. The results support progression onto a confirmatory phase III trial to determine the efficacy and cost-effectiveness of the intervention