Evaluating a community lifestyle intervention: adherence and the role of perceived support

Background Interventions that increase participation in physical activity and positive dietary changes may improve the health of the community through modifying the lifestyle contribution to preventable disease. However, previous evaluations have identified concerns about inequitable and unsustainable uptake, adherence and retention within healthy lifestyle schemes.Intervention study The intervention evaluated here was designed to be a 12-week intervention for participants, offering free testing of physiological indicators of health, one-to-one health advice and a range of exercise, activity and cookery classes, at no or reduced cost, at local venues throughout the community. This paper reports the findings from a small qualitative study undertaken to explore the experiences and reflections of those who took part in the intervention to different extents, including those who fully and partially participated as well as those who dropped out or declined to take part.Method Sixteen respondents took part in semi-structured interviews (5 male, 11 female; 8 black, 8 white; age range 25&ndash;85).Findings The findings suggest that participants assessed the healthy lifestyle intervention in terms of how well it met their pre-existing needs and opportunities for change, and that they selected the aspects of the scheme that suited them, interested them and were perceived as delivering salient results. There is also evidence for a stronger role of perceived support in influencing uptake and maintenance of lifestyle changes, and that support was conceptualised by participants as one of the services offered by the scheme. Perceived support and related perceptions of reliance on the scheme to sustain lifestyle changes also suggested that in some cases full adherence to a scheme is not as likely to produce long-term adherence to lifestyle changes as compared to partial, but more realistic adherence and smaller lifestyle changes. Implications for delivering and evaluating healthy lifestyle interventions are also discussed.<br /

Digging deeper: quality of patient-provider communication across Hispanic subgroups

<p>Abstract</p> <p>Background</p> <p>Recent research suggests that ethnic subgroup designation plays an important role in health-related disparities among Hispanics. Our objective was to examine the influence of Hispanics' self-reported ethnic subgroup designation on perceptions of their health care providers' communication behaviors.</p> <p>Methods</p> <p>Cross-sectional analysis of the 2005 Medical Expenditure Panel Survey (MEPS). Participants included non-institutionalized Hispanics (n = 5197; US population estimate = 27,070,906), aged ≥18 years, reporting visiting a health care provider within the past 12 months. Six (n = 6) items were used to capture respondents' perceptions of their health care providers' communication behaviors.</p> <p>Results</p> <p>After controlling for socio-demographic covariates, compared to Other Hispanics (reference group), very few differences in perceptions of health care providers communication emerged across ethnic subgroups. Puerto Ricans were more likely to report that their health care provider "always" showed respect for what they had to say (OR = 2.16, 95% CI 1.16-4.03). Both Puerto Ricans (OR = 2.28, 95% CI 1.06-4.92) and Mexicans (OR = 1.88, 95% CI 1.02-3.46) were more likely to indicate that their health care provider "always" spent enough time with them as compared to Other Hispanics.</p> <p>Conclusions</p> <p>We observed very few differences among Hispanics respondents in their perceived quality of interactions with health care providers as a function of their ethnic subgroup designation. While our findings somewhat contradict previous research, they do suggest that other underlying factors may influence the quality of perceived interactions with health care providers.</p

Exploring the views of UK regional primary care practitioners on the use and role of screening tools for learning disabilities in their services

BackgroundPeople with learning disabilities are at increased risk of physical health conditions and mortality compared to the general population. Initiatives to address these health inequalities include the introduction of learning disability registers, through which people with learning disabilities can be identified and offered annual health checks and reasonable adjustments in their healthcare provision. A barrier to offering such initiatives to people with learning disabilities is that practitioners/providers may be unaware of the presence of a learning disability, and people who meet criteria may not be entered onto general practice learning disability registers. Screening tools can be used to help identify people with learning disabilities in order that they can be offered appropriate health services and reasonable adjustments. This study aimed to explore the awareness and views of UK primary care staff about the existence and role of screening tools for learning disability in their services.Materials and MethodsA qualitative approach was used; semi-structured online interviews were conducted with a purposive sample of primary care staff recruited via a regional professional network of primary care practitioners. Five general practitioners and one nurse practitioner, representing five primary care practices in the North-East of England participated. Interview transcripts were analysed using thematic analysis.FindingsTwo themes and associated sub-themes were identified. Within Theme 1 (‘I haven’t had anything much to do with them’) two subthemes related to never using screening tools and reasons why screening tools were not routinely used. Theme 2 (‘I think they’re great that they exist’) comprised two subthemes that explored the benefits of screening tools, for example for those practitioners less experienced with people with learning disabilities, and also explored potential reluctance to use them.ConclusionsThe study found that most practitioners had some knowledge of screening tools and the general consensus was that they are beneficial. However, the tendency of participants was not to use screening tools in a consistent and/or systematic way, instead relying on informal approaches or other services for identifying the presence of learning disabilities. The study findings highlight the need for changes in practice to support primary care staff to access and systematically use evidence-based effective and efficient screening tools for learning disability

Cost-effectiveness of an extended-role general practitioner clinic for persistent physical symptoms: results from the Multiple Symptoms Study 3 (MSS3) pragmatic randomised controlled trial

ObjectivesTo evaluate the cost-effectiveness of an extended-role general practitioner (GP) symptoms clinic (SC), added to usual care (UC) for patients with multiple persistent physical symptoms (sometimes known as "medically unexplained symptoms").MethodsA 52-week within-trial cost-utility analysis of a pragmatic multicentre randomised controlled trial comparing SC+UC (n=178) against UC alone (n=176), conducted from the primary perspective of the UK National Health Service (NHS) and personal and social services (PSS). Base-case quality-adjusted life-years (QALYs) were measured using EQ-5D-5L. Missing data were imputed using multiple imputation (MI). Cost-effectiveness results were presented as incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits (INMBs). Uncertainty was explored using cost-effectiveness acceptability curves (using 1000 non-parametric bootstrapped samples) and sensitivity analysis (including societal costs, using SF-6D and capability ICECAP-A outcomes to estimate QALYs and years of full capability (YFC) respectively, varying intervention costs, missing data mechanism assumptions).ResultsMultiple imputation analysis showed that, compared to UC alone, SC+UC was more expensive [(adjusted mean cost difference: 704; 95% CI:£605, £807)] and more effective [(adjusted mean QALY difference: 0.0447 (95% CI:0.0067, 0.0826)] yielding an ICER of £15,765/QALY, INMB of £189.22 (95% CI:−£573.62, £948.28) and a 69% probability of the SC+UC intervention arm being cost-effective at a threshold of £20000 per QALY. Results were robust to most sensitivity analyses, but sensitive to missing data assumptions (2 of the 8 scenarios investigated), SF-6D and ICECAP-A quality of life outcomes.ConclusionsA Symptoms Clinic is likely to be a potentially cost-effective treatment for patients with persistent physical symptoms.<br/

Characteristics of people with low health literacy on coronary heart disease GP registers in South London: A cross-sectional study

Objective To explore characteristics associated with, and prevalence of, low health literacy in patients recruited to investigate the role of depression in patients on General Practice (GP) Coronary Heart Disease (CHD) registers (the Up-Beat UK study). Design Cross-sectional cohort. The health literacy measure was the Rapid Estimate of Health Literacy in Medicine (REALM). Univariable analyses identified characteristics associated with low health literacy and compared health service use between health literacy statuses. Those variables where there was a statistically significant/borderline significant difference between health literacy statuses were entered into a multivariable model. Setting 16 General Practices in South London, UK. Participants Inclusion: patients >18 years, registered with a GP and on a GP CHD register. Exclusion: patients temporarily registered. Primary outcome measure REALM. Results Of the 803 Up-Beat cohort participants, 687 (85.55%) completed the REALM of whom 106 (15.43%) had low health literacy. Twenty-eight participants could not be included in the multivariable analysis due to missing predictor variable data, leaving a sample of 659. The variables remaining in the final model were age, gender, ethnicity, Indices of Multiple Deprivation score, years of education, employment; body mass index and alcohol intake, and anxiety scores (Hospital Anxiety and Depression Scale). Univariable analysis also showed that people with low health literacy may have more, and longer, practice nurse consultations than people with adequate health literacy. Conclusions There is a disadvantaged group of people on GP CHD registers with low health literacy. The multivariable model showed that patients with low health literacy have significantly higher anxiety levels than people with adequate health literacy. In addition, the univariable analyses show that such patients have more, and longer, consultations with practice nurses. We will collect 4-year longitudinal cohort data to explore the impact of health literacy in people on GP CHD registers and the impact of health literacy on health service use

Study protocol for the Multiple Symptoms Study 3: a pragmatic, randomised controlled trial of a clinic for patients with persistent (medically unexplained) physical symptoms

Introduction: Persistent physical symptoms (which cannot be adequately attributed to physical disease) affect around 1 million people (2% of adults) in the UK. They affect patients’ quality of life and account for at least one third of referrals from General Practitioners (GPs) to specialists. These referrals give patients little benefit but have a real cost to health services time and diagnostic resources. The symptoms clinic has been designed to help people make sense of persistent physical symptoms (especially if medical tests have been negative) and to reduce the impact of symptoms on daily life. Methods and analysis: This pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of the symptoms clinic intervention plus usual care compared with usual care alone. Patients were identified through GP searches and mail-outs and recruited by the central research team. 354 participants were recruited and individually randomised (1:1). The primary outcome is the self-reported Physical Health Questionnaire-15 at 52 weeks postrandomisation. Secondary outcome measures include the EuroQol 5 dimension 5 level and healthcare resource use. Outcome measures will also be collected at 13 and 26 weeks postrandomisation. A process evaluation will be conducted including consultation content analysis and interviews with participants and key stakeholders. Ethics and dissemination: Ethics approval has been obtained via Greater Manchester Central Research Ethics Committee (Reference 18/NW/0422). The results of the trial will be submitted for publication in peer-reviewed journals, presented at relevant conferences and disseminated to trial participants and patient interest groups. Trial registration number: ISRCTN57050216

Health literacy: setting an international collaborative research agenda

<p>Abstract</p> <p>Background</p> <p>Health literacy is an increasingly important topic in both the policy and research agendas of many countries. During the recent 36^thAnnual Meeting of the North American Primary Care Research Group, the authors led an audio-taped 3-hour forum, "<it>Studying Health Literacy: Developing an International Collaboration</it>," where the current state of health literacy (HL) in the United States (US) and United Kingdom (UK) was presented and attendees were encouraged to debate a future research agenda.</p> <p>Discussion of Forum Themes</p> <p>The debate centred around three distinct themes, including: (1) refining HL definitions and conceptual models, (2) HL measurement and assessment tools, and (3) developing a collaborative international research agenda. The attendees agreed that future research should be theoretically grounded and conceptual models employed in studies should be explicit to allow for international comparisons to be drawn.</p> <p>Summary and Authors Reflections</p> <p>The importance of HL research and its possible contribution to health disparities is becoming increasingly recognised internationally. International collaborations and comparative studies could illuminate some of the possible determinants of disparities, and also possibly provide a vehicle to examine other research questions of interest.</p

Effectiveness of a symptom-clinic intervention delivered by general practitioners with an extended role for people with multiple and persistent physical symptoms in England:the Multiple Symptoms Study 3 pragmatic, multicentre, parallel-group, individually randomised controlled trial

BACKGROUND: People with multiple and persistent physical symptoms have impaired quality of life and poor experiences of health care. We aimed to evaluate the effectiveness of a community-based symptom-clinic intervention in people with multiple and persistent physical symptoms, hypothesising that this symptoms clinic plus usual care would be superior to usual care only.METHODS: The Multiple Symptoms Study 3 was a pragmatic, multicentre, parallel-group, individually randomised controlled trial conducted in 108 general practices in the UK National Health Service in four regions of England between Dec 6, 2018, and June 30, 2023. Participants were individually randomised (1:1) to the symptom-clinic intervention plus usual care or to usual care only via a computer-generated, pseudo-random list stratified by trial centre. Allocation was done by the trial statistician and concealed with a centralised, web-based randomisation system; masking participants was not possible due to the nature of the intervention. The symptom-clinic intervention was a sequence of up to four medical consultations that aimed to elicit a detailed clinical history, fully hear and validate the participant, offer rational explanations for symptoms, and assist the participant to develop ways of managing their symptoms; it was delivered by general practitioners with an extended role. The primary outcome was Patient Health Questionnaire-15 (PHQ-15) score 52 weeks after randomisation, analysed by intention to treat. The trial is registered on the ISRCTN registry (ISRCTN57050216).FINDINGS: 354 participants were randomly assigned; 178 (50%) were assigned to receive the community-based symptoms clinic plus usual care and 176 (50%) were assigned to receive usual care only. At the primary-outcome point of 52 weeks, PHQ-15 scores were 14·1 (SD 3·7) in the group receiving usual care and 12·2 (4·5) in the group receiving the intervention. The adjusted between-group difference of -1·82 (95% CI -2·67 to -0·97) was statistically significantly in favour of the intervention group (p&lt;0·0001). There were 39 adverse events in the group receiving usual care and 36 adverse events in the group receiving the intervention. There were no statistically significant between-group differences in the proportion of participants who had non-serious adverse events (-0·03, 95% CI -0·11 to 0·05) or serious adverse events (0·02, -0·02 to 0·07). No serious adverse event was deemed to be related to the trial intervention.INTERPRETATION: Our symptom-clinic intervention, which focused on explaining persistent symptoms to participants in order to support self-management, led to sustained improvement in multiple and persistent physical symptoms.FUNDING: UK National Institute for Health and Care Research.</p

Study protocol for the Multiple Symptoms Study 3:A pragmatic, randomised controlled trial of a clinic for patients with persistent (medically unexplained) physical symptoms

Introduction: Persistent physical symptoms (which cannot be adequately attributed to physical disease) affect around 1 million people (2 of adults) in the UK. They affect patients’ quality of life and account for at least one third of referrals from GPs to specialists. These referrals give patients little benefit but have a real cost to health services time and diagnostic resources. The Symptoms Clinic has been designed to help people make sense of persistent physical symptoms (especially if medical tests have been negative) and to reduce the impact of symptoms on daily life.Methods and analysis:This pragmatic, multi-centre, randomised controlled trial will assess the clinical and cost-effectiveness of the Symptoms Clinic intervention plus usual care compared with usual care alone. Patients were identified through GP searches and mail-outs and recruited by the central research team. 354 participants were recruited and individually randomised (1:1). The primary outcome is the self-reported PHQ-15 at 52 weeks post-randomisation. Secondary outcome measures include the EQ-5D-5L and health care resource use. Outcome measures will also be collected at 13 and 26 weeks post-randomisation. A process evaluation will be conducted including consultation content analysis and interviews with participants and key stakeholders.Ethics and dissemination:Ethics approval has been obtained via Greater Manchester Central Research Ethics Committee (Reference 18/NW/0422). The results of the trial will be submitted for publication in peer-reviewed journals, presented at relevant conferences and disseminated to trial participants and patient interest groups.Trial Registration ISRCTN5705021