Informing the development of services supporting self-care for long term mental health conditions: A mixed method study of community based mental health initiatives in England

Background Supporting self-care is being explored across health care systems internationally as an approach to improving care for long term conditions in the context of ageing populations and economic constraint. UK health policy advocates a range of approaches to supporting self-care, including the application of generic self-management type programmes across conditions. Within mental health, the scope of self-care remains poorly conceptualised and the existing evidence base for supporting self-care is correspondingly disparate. This paper aims to inform the development of support for self-care in mental health by considering how generic self-care policy guidance is implemented in the context of services supporting people with severe, long term mental health problems. Methods A mixed method study was undertaken comprising standardised psychosocial measures, questionnaires about health service use and qualitative interviews with 120 new referrals to three contrasting community based initiatives supporting self-care for severe, long term mental health problems, repeated nine months later. A framework approach was taken to qualitative analysis, an exploratory statistical analysis sought to identify possible associations between a range of independent variables and self-care outcomes, and a narrative synthesis brought these analyses together. Results Participants reported improvement in self-care outcomes (e.g. greater empowerment; less use of Accident and Emergency services). These changes were not associated with level of engagement with self-care support. Level of engagement was associated with positive collaboration with support staff. Qualitative data described the value of different models of supporting self-care and considered challenges. Synthesis of analyses suggested that timing support for self-care, giving service users control over when and how they accessed support, quality of service user-staff relationships and decision making around medication are important issues in supporting self-care in mental health. Conclusions Service delivery components – e.g. peer support groups, personal planning – advocated in generic self-care policy have value when implemented in a mental health context. Support for self-care in mental health should focus on core, mental health specific qualities; issues of control, enabling staff-service user relationships and shared decision making. The broad empirical basis of our research indicates the wider relevance of our findings across mental health settings

肝がん患者のセルフケア行動とセルフケア行動に影響する要因

肝がん患者のセルフケア行動およびセルフケア行動に影響する要因を明らかにすることを目的に,7名の肝がん患者を対象に面接調査を行い,内容分析を行った。その結果,肝がん患者の5つのセルフケア行動と12のセルフケア行動に影響を与える要因が抽出された。中でも肝がん患者に特徴的であったのは,治癒や症状緩和のために医師を頼る行動が見られたことである。これは体調の指標がとらえにくいため,回復のための自分自身の行動を評価しづらい肝がん患者にとって,自らのセルフケア行動を確立するために必要な行動であると考える。また,患者が家族を大切に思う気持ちがセルフケアに影響する要因としてあげられ,家族から支えられるだけでなく,患者自身が家族に対して思いやるという特徴が見られた。今後増加するであろう肝がん患者のセルフケア行動とセルフケア行動に影響を与える要因を明らかにすることで,肝がん患者の生活指導に貢献できるとともに,肝がん患者のQOLを高めるための援助に示唆を与えることができる。We conducted interviews with eight hepatoma patients and carried out a content analysis to clarify their self-care behavior and the factors that influence it. As a result, five categories for self-care behavior and twelve categories for the factors which influence self-care behavior of cancer patients were selected. Especially characteristic of hepatoma patients were behaviors which reflected reliance on doctors for cure and alleviation of symptoms. We believe that these behaviors are necessary for hepatoma patients, who find it difficult to self-assess their own self-care, in order for them to establish their own self-care behavior. In addition, the patients' thinking about their families emerged as a factor which influenced self-care behavior. A striking aspect of this was the patients' consideration for their families whilst at the same time receiving support from family members. These results help clarify self-care behavior, and the factors which influence it, in the increasing number of hepatoma patients. We believe that these results can provide suggestions for the health guidance we will offer to such patients in the future and help improve support for their QOL.報告Report国立情報学研究所で電子

短期入院による化学療法を継続する大腸がん患者のセルフケアに関する研究

本研究の目的は，短期入院による化学療法を継続する大腸がん患者のセルフケアを行う上での問題とセルフケアを明らかにし，セルフケアの促進に必要な援助を検討することである。対象者は，大腸がんで研究同意の得られた5名で，データ収集は，半構成的質問紙を用いて面接を行い，質的帰納的に分析を行った。患者のセルフケアを行う上での問題は，【がん罹患や病状に対する悲観】【治療処置そのものに関する懸念】【抗がん剤の副作用よる苦痛な身体症状】【副作用症状に対する否定的な思い】【化学療法を継続することに関する懸念】【不安定な現状と将来への不安】【社会的役割が遂行できない難しさ】の7つのカテゴリーとセルフケアは『自己調整型行動』『環境調整型行動』『感情調整型制御』の3つのカテゴリーが抽出された。以上の結果より，患者のセルフケアを促進する看護援助として，1）持続する副作用による苦痛な身体症状に対する援助，2）がん罹患や病状の進行への不安に対する援助，3）不確かで限られた治療を継続することを支える援助の3つの援助の必要性が示唆された。The purpose of this study was to determine problems regarding self-care in patients with colorectal cancer who continue chemotherapy through short-term hospitalization, and to consider the necessary support to facilitate such self-care.Subjects were those with colorectal cancer who provided consent for the study.Data were collected by interview using semi-structured questionnaires,and qualitative and inductive analyses were performed.Seven categories were selected for problems regarding patient’s self-care:“painful physical symptoms caused by side effects of anticancer agents”,“concerns about the treatment itself”,“negative feeling over symptoms of side effects”,“pessimism regarding the cancer and symptoms”,“concerns about continuing chemotherapy”,“anxiety over the fragile existing condition and future”,and “the difficulty of playing a social role”. Three categories were selected for self-care:“self-adjusting behavior”, “environment-adjusting behavior” and “emotion-adjusting control”. Therefore, the need to provide three kinds of support was suggested as support to facilitate patientself-care: “support for painful physical symptoms caused by continued side effects”“support for anxiety regarding the cancer and progression of symptoms”,and“support for the continuation of uncertain and limited treatment”.報告Report

Revisiting the symptom iceberg in today's primary care: results from a UK population survey

Peer reviewedPublisher PD

Who is a credible source of preventive advice? An experimental vignette study of general public attitudes towards role expansion in health and social care

© 2020 The Authors. British Journal of Health Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society Objectives: To investigate the general public’s source credibility attitudes towards health and social care professionals when giving advice associated with their ‘traditional role’ versus an ‘expanded health behaviour change’ role, to facilitate the implementation of the health behaviour change agenda. Design: A 3x3 experimental between-subjects vignette questionnaire study with nine scenarios in which a general practitioner (GP), health visitor, or firefighter offered advice on either stopping smoking, preventing cot death, or fire safety. Combinations were either congruent with a traditional role (e.g., health visitor and cot death) or an expanded role (e.g., firefighter and stopping smoking). Methods: Adults were recruited from metropolitan locations in northern England. Participants were randomized to one scenario and complete a validated 18-item source credibility questionnaire. Factor analysis explored source credibility components; ratings for traditional and expanded role scenarios were compared using Mann–Whitney tests. Results: 369 participants completed the questionnaire (49.3% women, 64% White British, age range: 16–83). Factor analysis confirmed three source credibility dimensions: competence, caring, and trustworthiness. Ratings were generally high across professions and scenarios; participants rated professionals as significantly more ‘competent’ where scenarios related to their traditional roles than expanded roles (U 9778.5, p <.001) but equally as caring (U = 14467.5, p<.485) and trustworthy (U 14250.5, p.348). Conclusions: GPs, health visitors, and firefighters were all perceived as credible sources of health behaviour change advice, but may be viewed as ‘less competent’ sources of messages associated with an expanded job role. Effective professional training and public engagement regarding the role expansion agenda are needed to support policy implementation. Statement of Contribution What is already known on this subject? Source credibility surrounds people’s perceptions of the source of advice and includes competence, caring, and trustworthiness dimensions. This may have an important influence on people’s attitudes and behaviour, especially when messages are complex or emotive. A wide range of public sector workers is now expected to routinely offer preventive health and safety advice, as part of role expansion. What does this study add? This experimental survey study compared source credibility perceptions of GPs, health visitors, and firefighters giving advice on topics associated with a traditional or expanded role. Professionals were perceived as less ‘competent’ when giving advice on ‘expanded role’ topics, such as a firefighter discussing smoking, with a small reduction in source credibility. This highlights that source credibility may be specific to professional identities. Policymakers may need to explore this further as part of implementing role expansion for prevention and self-management in health and social care

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes:Development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background: Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB. Objectives: To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers. Review methods: Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies. Design: ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants. Settings: ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England. Participants: ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews. Intervention: An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools. Main outcome measures: ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications. Results: ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings. Limitations: Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals. Conclusions: A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care. Future work: There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts

Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling.

BACKGROUND: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. OBJECTIVE: To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. DESIGN/DATA SOURCES: The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. REVIEW METHODS: In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. RESULTS: An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference -0.45, 95% confidence interval -0.65 to -0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. LIMITATIONS: The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. CONCLUSIONS: Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. FUTURE WORK: There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. STUDY REGISTRATION: This study is registered as PROSPERO CRD42015027042. FUNDING: The National Institute for Health Research Health Technology Assessment programme