Enhancing the early home learning environment through a brief group parenting intervention: study protocol for a cluster randomised controlled trial

Background

The quality of the home learning environment has a significant influence on children’s language and communication skills during the early years with children from disadvantaged families disproportionately affected. This paper describes the protocol and participant baseline characteristics of a community-based effectiveness study. It evaluates the effects of ‘smalltalk’, a brief group parenting intervention (with or without home coaching) on the quality of the early childhood home learning environment.

Methods/design

The study comprises two cluster randomised controlled superiority trials (one for infants and one for toddlers) designed and conducted in parallel. In 20 local government areas (LGAs) in Victoria, Australia, six locations (clusters) were randomised to one of three conditions: standard care (control); smalltalk group-only program; or smalltalk plus (group program plus home coaching). Programs were delivered to parents experiencing socioeconomic disadvantage through two existing age-based services, the maternal and child health service (infant program, ages 6–12 months), and facilitated playgroups (toddler program, ages 12–36 months). Outcomes were assessed by parent report and direct observation at baseline (0 weeks), post-intervention (12 weeks) and follow-up (32 weeks). Primary outcomes were parent verbal responsivity and home activities with child at 32 weeks. Secondary outcomes included parenting confidence, parent wellbeing and children’s communication, socio-emotional and general development skills. Analyses will use intention-to-treat random effects (“multilevel”) models to account for clustering.

Recruitment and baseline data

Across the 20 LGAs, 986 parents of infants and 1200 parents of toddlers enrolled and completed baseline measures. Eighty four percent of families demonstrated one or more of the targeted risk factors for poor child development (low income; receives government benefits; single, socially isolated or young parent; culturally or linguistically diverse background).

Discussion

This study will provide unique data on the effectiveness of a brief group parenting intervention for enhancing the early home learning environment of young children from disadvantaged families. It will also provide evidence of the extent to which additional one-on-one support is required to achieve change and whether there are greater benefits when delivered in the 1st year of life or later. The program has been designed for scale-up across existing early childhood services if proven effective.

Trial registration

8 September 2011; ACTRN12611000965909.

Implementing a patient-initiated review system for people with rheumatoid arthritis: a prospective, comparative service evaluation

RATIONALE, AIMS AND OBJECTIVES

The management of rheumatoid arthritis (RA) usually entails regular hospital reviews with a specialist often when the patient is well rather than during a period of exacerbation. An alternative approach where patients initiate appointments when they need them can improve patient satisfaction and resource use whilst being safe. This service evaluation reports a system-wide implementation of a patient-initiated review appointment system called Direct Access (DA) for people with RA. The aim was to establish the impact on patient satisfaction of the new system versus usual care as well as evaluate the implementation processes.

METHODS

As all patients could not start on the new system at once, in order to manage the implementation, patients were randomly allocated to DA or to usual care. Instead of regular follow-up appointments, DA comprised an education session and access to a nurse-led telephone advice line where appointments could be accessed within two weeks. Usual care comprised routine follow-ups with the specialist. Data were collected on patient satisfaction, service use and outcomes of any contact to the advice line.

RESULTS

Three hundred and eleven patients with RA were assessed as being suitable for DA. In terms of patient satisfaction, between-group differences were found in favour of DA for accessibility and convenience, ease of contacting the nurse and overall satisfaction with the service. Self-reported visits to the general practitioner were also significantly lower. DA resulted in a greater number of telephone contacts (incidence rate ratio = 1.69; 95% confidence interval 1.07 to 2.68). Hospital costs of the two different service models were similar. Mean waiting time for an appointment was 10.8 days

CONCLUSION

This service evaluation found that DA could be implemented and it demonstrated patient benefit in a real-world setting. Further research establishing the broader cost-consequences across the whole patient pathway would add to our findings.

Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a randomised controlled trial

BACKGROUND

For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect.

METHODS/DESIGN

This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice.

DISCUSSION

We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN12595588 .

Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial

BACKGROUND

Around 17% of people eligible for UK cardiac rehabilitation programmes following an acute coronary syndrome report moderate or severe depressive symptoms. While maximising psychological health is a core goal of cardiac rehabilitation, psychological care can be fragmented and patchy. This study tests the feasibility and acceptability of embedding enhanced psychological care, composed of two management strategies of proven effectiveness in other settings (nurse-led mental health care coordination and behavioural activation), within the cardiac rehabilitation care pathway.

METHODS/DESIGN

This study tests the uncertainties associated with a large-scale evaluation by conducting an external pilot trial with a nested qualitative study. We aim to recruit and randomise eight comprehensive cardiac rehabilitation teams (clusters) to intervention (embedding enhanced psychological care into routine cardiac rehabilitation programmes) or control (routine cardiac rehabilitation programmes alone) arms. Up to 64 patients (eight per team) identified with depressive symptoms upon initial assessment by the cardiac rehabilitation team will be recruited, and study measures will be administered at baseline (before starting rehabilitation) and at 5 months and 8 months post baseline. Outcomes include depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Trial data on cardiac team and patient recruitment, and the retention and flow of patients through treatment will be used to assess intervention feasibility and acceptability. Qualitative interviews will be undertaken to explore trial participants' and cardiac rehabilitation nurses' views and experiences of the trial methods and intervention, and to identify reasons why patients declined to take part in the trial. Outcome data will inform a sample size calculation for a definitive trial.

DISCUSSION

The pilot trial and qualitative study will inform the design of a fully powered cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of the provision of enhanced psychological care within cardiac rehabilitation programmes.

TRIAL REGISTRATION

ISRCTN34701576 (Registered 29 May 2014).

Effectiveness and micro-costing of the KiVa school-based bullying prevention programme in Wales: study protocol for a pragmatic definitive parallel group cluster randomised controlled trial

BACKGROUND

Bullying refers to verbal, physical or psychological aggression repeated over time that is intended to cause harm or distress to the victims who are unable to defend themselves. It is a key public health priority owing to its widespread prevalence in schools and harmful short- and long-term effects on victims' well-being. There is a need to strengthen the evidence base by testing innovative approaches to preventing bullying. KiVa is a school-based bullying prevention programme with universal and indicated elements and an emphasis on changing bystander behaviour. It achieved promising results in a large trial in Finland, and now requires testing in other countries. This paper describes the protocol for a cluster randomised controlled trial (RCT) of KiVa in Wales.

METHODS/DESIGN

The study uses a two-arm waitlist control pragmatic definitive parallel group cluster RCT design with an embedded process evaluation and calculation of unit cost. Participating schools will be randomised a using a 1:1 ratio to KiVa plus usual provision (intervention group) or usual provision only (control group). The trial has one primary outcome, child self-reported victimisation from bullying, dichotomised as 'victimised' (bullied at least twice a month in the last couple of months) versus 'not victimised'. Secondary outcomes are: bullying perpetration; aspects of child social and emotional well-being (including emotional problems, conduct, peer relations, prosocial behaviour); and school attendance. Follow-up is at 12 months post-baseline. Implementation fidelity is measured through teacher-completed lesson records and independent school-wide observation. A micro-costing analysis will determine the costs of implementing KiVa, including recurrent and non-recurrent unit costs. Factors related to the scalability of the programme will be examined in interviews with head teachers and focus groups with key stakeholders in the implementation of school-based bullying interventions.

DISCUSSION

The results from this trial will provide evidence on whether the KiVa programme is transportable from Finland to Wales in terms of effectiveness and implementation. It will provide information about the costs of delivery and generate insights into factors related to the scalability of the programme.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN23999021 Date 10-6-13.

Attention Restoration Theory: A systematic review of the attention restoration potential of exposure to natural environments

Attention Restoration Theory (ART) suggests the ability to concentrate may be restored by exposure to natural environments. Although widely cited, it is unclear as to the quantity of empirical evidence that supports this. A systematic review regarding the impact of exposure to natural environments on attention was conducted. Seven electronic databases were searched. Studies were included if (1) they were natural experiments, randomized investigations, or recorded "before and after" measurements; (2) compared natural and nonnatural/other settings; and (3) used objective measures of attention. Screening of articles for inclusion, data extraction, and quality appraisal were performed by one reviewer and checked by another. Where possible, random effects meta-analysis was used to pool effect sizes. Thirty-one studies were included. Meta-analyses provided some support for ART, with significant positive effects of exposure to natural environments for three measures (Digit Span Forward, Digit Span Backward, and Trail Making Test B). The remaining 10 meta-analyses did not show marked beneficial effects. Meta-analysis was limited by small numbers of investigations, small samples, heterogeneity in reporting of study quality indicators, and heterogeneity of outcomes. This review highlights the diversity of evidence around ART in terms of populations, study design, and outcomes. There is uncertainty regarding which aspects of attention may be affected by exposure to natural environments.

Vitamin D and Memory Decline: Two Population-Based Prospective Studies

BACKGROUND

Vitamin D deficiency has been linked with dementia risk, cognitive decline, and executive dysfunction. However, the association with memory remains largely unknown.

OBJECTIVE

To investigate whether low serum 25-hydroxyvitamin D (25(OH)D) concentrations are associated with memory decline.

METHODS

We used data on 1,291 participants from the US Cardiovascular Health Study (CHS) and 915 participants from the Dutch Longitudinal Aging Study Amsterdam (LASA) who were dementia-free at baseline, had valid vitamin D measurements, and follow-up memory assessments. The Benton Visual Retention Test (in the CHS) and Rey's Auditory Verbal Learning Test (in the LASA) were used to assess visual and verbal memory, respectively.

RESULTS

In the CHS, those moderately and severely deficient in serum 25(OH)D changed -0.03 SD (95% CI: -0.06 to 0.01) and -0.10 SD (95% CI: -0.19 to -0.02) per year respectively in visual memory compared to those sufficient (p = 0.02). In the LASA, moderate and severe deficiency in serum 25(OH)D was associated with a mean change of 0.01 SD (95% CI: -0.01 to 0.02) and -0.01 SD (95% CI: -0.04 to 0.02) per year respectively in verbal memory compared to sufficiency (p = 0.34).

CONCLUSIONS

Our findings suggest an association between severe vitamin D deficiency and visual memory decline but no association with verbal memory decline. They warrant further investigation in prospective studies assessing different memory subtypes.

A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years

Background

Anxiety in children is common, impairs everyday functioning and increases the risk of severe mental health disorders in adulthood, yet few children with anxiety are identified and referred for treatment.

Objective

To investigate the clinical effectiveness and cost-effectiveness of a universal school-based preventative programme (FRIENDS) in reducing symptoms of anxiety and low mood.

Design

Cluster randomised controlled trial. Schools (n = 41) were randomly assigned after recruitment on a 1 : 1 : 1 basis to health-led FRIENDS, school-led FRIENDS and usual school provision.

Setting

Primary schools in three local education authorities in the south-west of England.

Participants

Children (n = 1362) aged 9–10 years attending school and participating in personal, social and health education (PSHE).

Interventions

The FRIENDS programme is a cognitive–behavioural therapy programme that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. The FRIENDS programme was led by either a trained member of the school or a health leader external to the school and was delivered over 9 consecutive weeks. The comparison group received usual school PSHE lessons. Interventions were delivered in the academic year September 2011–July 2012.

Main outcome measures

Clinical effectiveness assessed by child report of symptoms of anxiety (Revised Child Anxiety and Depression Scale, RCADS); cost-effectiveness based on RCADS and quality-adjusted life-years (Child Health Utility 9 Dimensions, CHU-9D) between baseline and 6 months; process evaluation, evaluation of reach and attrition and qualitative feedback from children, school staff and parents.

Results

At 12 months there was a difference in the adjusted mean RCADS scores for health-led FRIENDS compared with school-led FRIENDS [–3.91, 95% confidence interval (CI) –6.48 to –1.35] and for health-led FRIENDS compared with usual school provision (–2.66, 95% CI –5.22 to –0.09). At 24 months we were able to assess only 43.6% of our cohort. There were few differences in baseline characteristics between completers and non-completers. Child-reported anxiety in all three groups had reduced by 24 months and there were no longer any group effects. There were no between-group effects for any parent- or child-completed secondary outcomes at 12 or 24 months. The cost of the FRIENDS programme was £52–56 per child. We found no evidence that the FRIENDS programme was cost-effective over a 6-month period; however, our subgroup for the economic analysis differed significantly from our main trial cohort.

Conclusions

Although greater reductions in anxiety were noted at 12 months when the FRIENDS programme was delivered by health leaders, these additional benefits were not maintained at 24 months. Children’s anxiety levels improved irrespective of the intervention that they received. Our economic evaluation and 24-month assessment had significant shortcomings. However, the universal delivery of specific anxiety prevention programmes will result in additional costs that may be beyond the finances available to most schools. Future work should identify the active ingredients and potential moderators of universal anxiety programmes to determine whether programme length can be reduced, short-term effectiveness maintained and cost-effectiveness improved. At present, our results find limited evidence to support the universal provision of specific anxiety prevention programmes in UK primary schools.

Trial registration

Current Controlled Trials ISRCTN23563048.

Funding

The National Institute for Health Research Public Health Research programme.

Two-Year Outcomes of a Population-Based Intervention for Preschool Language Delay: An RCT

OBJECTIVE

We have previously shown short-term benefits to phonology, letter knowledge, and possibly expressive language from systematically ascertaining language delay at age 4 years followed by the Language for Learning intervention. Here, we report the trial's definitive 6-year outcomes.

METHODS

Randomized trial nested in a population-based ascertainment. Children with language scores >1.25 SD below the mean at age 4 were randomized, with intervention children receiving 18 1-hour home-based therapy sessions. Primary outcome was receptive/expressive language. Secondary outcomes were phonological, receptive vocabulary, literacy, and narrative skills; parent-reported pragmatic language, behavior, and health-related quality of life; costs of intervention; and health service use. For intention-to-treat analyses, trial arms were compared using linear regression models.

RESULTS

Of 1464 children assessed at age 4, 266 were eligible and 200 randomized; 90% and 82% of intervention and control children were retained respectively. By age 6, mean language scores had normalized, but there was little evidence of a treatment effect for receptive (adjusted mean difference 2.3; 95% confidence interval [CI] -1.2 to 5.7; P = .20) or expressive (0.8; 95% CI -1.6 to 3.2; P = .49) language. Of the secondary outcomes, only phonological awareness skills (effect size 0.36; 95% CI 0.08-0.65; P = .01) showed benefit. Costs were higher for intervention families (mean difference AU$4276; 95% CI: $3424 to $5128).

CONCLUSIONS

Population-based intervention targeting 4-year-old language delay was feasible but did not have lasting impacts on language, possibly reflecting resolution in both groups. Long-term literacy benefits remain possible but must be weighed against its cost.

Children's contact with people with disabilities and their attitudes towards disability: a cross-sectional study

PURPOSE

To explore the association between children's self-reported contact with people with disabilities and attitudes towards them, as well the potential mediating influence of anxiety about interacting with people with disabilities and empathy for them.

METHOD

1881 children, aged 7-16 years, from 20 schools in South West England completed a survey assessing their contact with people with disabilities and their attitudes towards them. Anxiety about interacting with people with disabilities and empathy towards them were examined as potential mediators. Gender, school year, perceived similarity between people with and without disabilities, proportion of children with additional needs at the school and socioeconomic status (SES) were assessed as moderators. A random effects ("multilevel") regression model was used to test the contact-attitude association and moderation, and path analysis was used to test for mediation.

RESULTS

Participants with more self-reported contact reported more positive attitudes towards disability (p < 0.001). Less anticipated anxiety and greater empathy together mediated around a third of this association. Only school year moderated the contact-attitude association (affective attitudes), with stronger contact-attitude associations in primary school children than secondary school children.

CONCLUSIONS

Self-reported contact was observed to be associated with more positive attitudes towards disability, which was partially mediated by empathy and anxiety. Providing opportunities for contact with people with disabilities that reduces anxiety and increases empathy may improve attitudes to disability and merits evaluation in interventions.

IMPLICATIONS FOR REHABILITATION

Children who reported greater levels of contact with people with disabilities had more positive attitudes towards disability. Anxiety about interacting with people with disabilities and empathy towards them partially mediated the contact-attitude associations. Providing opportunities for contact with people with disabilities, reducing anxiety and increasing empathy may improve children's attitudes to disability.

Teaching classroom management – a potential public health intervention?

Purpose

– The purpose of this paper is to explore the feasibility of a classroom management course as a public health intervention. Improved socio-emotional skills may boost children’s developmental and academic trajectory, while the costs of behaviour problems are enormous for schools with considerable impact on others’ well-being.

Design/methodology/approach

– In total, 40 teachers attended the Incredible Years (IY) Teacher Classroom Management (TCM) intervention in groups of ten. Afterwards teachers attended focus groups and semi-structured interviews were completed with headteachers to explore whether TCM was feasible, relevant and useful, research processes were acceptable and if it influenced teachers’ practice and pupils. Teachers completed standardised questionnaires about their professional self-efficacy, burnout and well-being before and after attendance.

Findings

– In all, 37/40 teachers completed the course. Teachers valued sharing experiences, the support of colleagues in the group and time out to reflect on practice and rehearse new techniques. Most teachers reported that they applied the strategies with good effect in their classrooms. Teachers’ questionnaires suggested an improvement in their self-efficacy in relation to classroom management (p=0.03); other scales changed in the predicted direction but did not reach statistical significance.

Research limitations/implications

– Although preliminary and small, these feasibility study findings suggest that it was worthwhile proceeding to a definitive randomised controlled trial (RCT).

Practical implications

– Should the RCT demonstrate effectiveness, then the intervention is an obvious candidate for implementation as a whole school approach.

Originality/value

– Successful intervention with one teacher potentially benefits every child that they subsequently teach and may increase the inclusion of socio-economically deprived children living in challenging circumstances in mainstream education.

Speech sound disorder at 4 years: prevalence, comorbidities, and predictors in a community cohort of children

AIM

The epidemiology of preschool speech sound disorder is poorly understood. Our aims were to determine: the prevalence of idiopathic speech sound disorder; the comorbidity of speech sound disorder with language and pre-literacy difficulties; and the factors contributing to speech outcome at 4 years.

METHOD

One thousand four hundred and ninety-four participants from an Australian longitudinal cohort completed speech, language, and pre-literacy assessments at 4 years. Prevalence of speech sound disorder (SSD) was defined by standard score performance of ≤79 on a speech assessment. Logistic regression examined predictors of SSD within four domains: child and family; parent-reported speech; cognitive-linguistic; and parent-reported motor skills.

RESULTS

At 4 years the prevalence of speech disorder in an Australian cohort was 3.4%. Comorbidity with SSD was 40.8% for language disorder and 20.8% for poor pre-literacy skills. Sex, maternal vocabulary, socio-economic status, and family history of speech and language difficulties predicted SSD, as did 2-year speech, language, and motor skills. Together these variables provided good discrimination of SSD (area under the curve=0.78).

INTERPRETATION

This is the first epidemiological study to demonstrate prevalence of SSD at 4 years of age that was consistent with previous clinical studies. Early detection of SSD at 4 years should focus on family variables and speech, language, and motor skills measured at 2 years.

Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink

Background

Time from symptomatic presentation to cancer diagnosis (diagnostic interval) is an important, and modifiable, part of the patient’s cancer pathway, and can be affected by various factors such as age, gender and type of presenting symptoms. The aim of this study was to quantify the relationships of diagnostic interval with these variables in 15 cancers diagnosed between 2007 and 2010 using routinely collected data from the Clinical Practice Research Datalink (CPRD) in the UK.

Methods

Symptom lists for each cancer were prepared from the literature and by consensus amongst the clinician researchers, which were then categorised into either NICE qualifying (NICE) or not (non-NICE) based on NICE Urgent Referral Guidelines for Suspected Cancer criteria. Multivariable linear regression models were fitted to examine the relationship between diagnostic interval (outcome) and the predictors: age, gender and symptom type.

Results

18,618 newly diagnosed cancer patients aged ≥40 who had a recorded symptom in the preceding year were included in the analysis. Mean diagnostic interval was greater for older patients in four disease sites (difference in days per 10 year increase in age; 95% CI): bladder (10.3; 5.5 to 15.1; P<0.001), kidney (11.0; 3.4 to 18.6; P=0.004), leukaemia (18.5; 8.8 to 28.1; P<0.001) and lung (10.1; 6.7 to 13.4; P<0.001). There was also evidence of longer diagnostic interval in older patients with colorectal cancer (P<0.001). However, we found that mean diagnostic interval was shorter with increasing age in two cancers: gastric (-5.9; -11.7 to -0.2; P=0.04) and pancreatic (-6.0; -11.2 to -0.7; P=0.03). Diagnostic interval was longer for females in six of the gender non-specific cancers (mean difference in days; 95% CI): bladder (12.2; 0.8 to 23.6; P=0.04), colorectal (10.4; 4.3 to 16.5; P=0.001), gastric (14.3; 1.1 to 27.6; P=0.03), head and neck (31.3; 6.2 to 56.5; P=0.02), lung (8.0; 1.2 to 14.9; P=0.02), and lymphoma (19.2; 3.8 to 34.7; P=0.01). Evidence of longer diagnostic interval was found for patients presenting with non-NICE symptoms in 10 of 15 cancers (mean difference in days; 95% CI): bladder (62.9; 48.7 to 77.2; P<0.001), breast (115.1; 105.9 to 124.3; P<0.001), cervical (60.3; 31.6 to 89.0; P<0.001), colorectal (25.8; 19.6 to 31.9; P<0.001), gastric (24.1; 3.4 to 44.8; P=0.02), kidney (22.1; 4.5 to 39.7; P=0.01), oesophageal (67.0; 42.1 to 92.0; P<0.001), pancreatic (48.6; 28.1 to 69.1; P<0.001), testicular (36.7; 17.0 to 56.4; P< 0.001), and endometrial (73.8; 60.3 to 87.3; P<0.001). Pooled analysis across all cancers demonstrated highly significant evidence of differences overall showing longer diagnostic intervals with increasing age (7.8 days; 6.4 to 9.1; P<0.001); for females (8.9 days; 5.5 to 12.2; P<0.001); and in non-NICE symptoms (27.7 days; 23.9 to 31.5; P<0.001).

Conclusions

We found age and gender-specific inequalities in time to diagnosis for some but not all cancer sites studied. Whilst these need further explanation, these findings can inform the development and evaluation of interventions intended to achieve timely diagnosis and improved cancer outcomes, such as to provide equity across all age and gender groupings.

Ethnic differences in patients' preferences for prostate cancer investigation: a vignette-based survey in primary care

BACKGROUND

Minority ethnic groups in the UK have worse outcomes for some cancer types compared with the white majority. Black males have worse staging at diagnosis of prostate cancer and often present as emergencies, suggesting possible delays in the diagnostic pathway. Delay may arise from lower awareness of cancer symptoms, reluctance to report symptoms, reduced desire for investigation, or a combination of these. Reduced desire for investigation was examined in this study

AIM

To investigate whether black males in the UK would choose to be tested for prostate cancer compared with the white majority.

DESIGN AND SETTING

A vignette (hypothetical scenario)-based, electronic survey of male patients aged ≥40 years from four general practices in Bristol, UK.

METHOD

The vignettes described possible prostate cancer symptoms (equating to risk levels of 2%, 5%, and 10%), investigative procedures, and possible outcomes. Participants indicated whether they would choose investigation in these scenarios. Analysis used logistic regression, with preference for investigation as the outcome variable and ethnicity as the main explanatory variable.

RESULTS

In total, 449 (81%) of 555 participants opted for investigation, regardless of risk levels; of these, the acceptance rate was 94% (251 out of 267) among white males and 70% (198 out of 285) among black males. In multivariable analyses, preference for investigation was lower in black males, even after controlling for relevant confounding factors including specific risk level (odds ratio 0.13; 95% confidence interval = 0.07 to 0.25; P<0.001).

CONCLUSION

Black males are less likely to opt for investigation at any risk level of prostate cancer compared with white males. This may explain some of their late-stage presentation at diagnosis and subsequent poorer outcomes.

Cost-effectiveness of classroom-based cognitive behaviour therapy in reducing symptoms of depression in adolescents: a trial-based analysis

BACKGROUND

A substantial minority of adolescents suffer from depression and it is associated with increased risk of suicide, social and educational impairment, and mental health problems in adulthood. A recently conducted randomized controlled trial in England evaluated the effectiveness of a manualized universally delivered age-appropriate CBT programme in school classrooms. The cost-effectiveness of the programme for preventing low mood and depression for all participants from a health and social care sector perspective needs to be determined.

METHODS

A trial-based cost-effectiveness analysis based on a cluster-randomized controlled trial (trial registration--ISRCTN 19083628) comparing classroom-based CBT with usual school provision of Personal Social and Health Education. Per-student cost of intervention was estimated from programme records. The study was undertaken in eight mixed-sex U.K. secondary schools, and included 3,357 school children aged 12 to 16 years (in the two trial arms evaluated in the cost-effectiveness analysis). The main outcome measures were individual self-reported data on care costs, Quality-Adjusted Life-Years (QALYs, based on the EQ-5D health-related quality-of-life instrument) and symptoms of depression (Short Mood and Feelings Questionnaire) at baseline, 6 and 12 months.

RESULTS

Although there was lower quality-adjusted life-years over 12 months (-.05 QALYs per person, 95% confidence interval -.09 to -.005, p = .03) with CBT, this is a 'clinically' negligible difference, which was not found in the complete case analyses. There was little evidence of any between-arm differences in SMFQ scores (0.19, 95% CI -0.57 to 0.95, p = .62), or costs (£142, 95% CI -£132 to £415, p = .31) per person for CBT versus usual school provision.

CONCLUSIONS

Our analysis suggests that the universal provision of classroom-based CBT is unlikely to be either more effective or less costly than usual school provision.

Functional status in children with ADHD at age 6-8: a controlled community study

OBJECTIVES

To examine the functional status (mental health, academic performance, peer problems) of a community-based sample of children who have attention-deficit/hyperactivity disorder (ADHD) and non-ADHD controls, and to investigate gender and subtype differences.

METHODS

Children aged 6 to 8 years were recruited through 43 Melbourne schools, using a 2-stage screening (parent and teacher Conners 3 ADHD index) and case confirmation (Diagnostic Interview Schedule for Children, Version IV; [DISC-IV]) procedure. Outcome measures were mental health disorders (DISC-IV), academic performance (Wide Range Achievement Test 4), and peer problems (Strength and Difficulties Questionnaire). Unadjusted and adjusted linear and logistic regression were used to compare ADHD and non-ADHD controls.

RESULTS

A total of 179 children who have ADHD and 212 non-ADHD controls were recruited. Compared with controls, children who had ADHD had higher odds of externalizing (odds ratio [OR], 11.0; 95% confidence interval [CI], 5.6-21.6; P < .001) and internalizing (OR, 2.9; 95% CI, 1.2-7.2; P = .02) disorders; poorer reading (effect size, -0.66) and mathematics (effect size, -0.69) performance; and more peer problems (P < .001). Boys and girls who had ADHD were equally impaired. Only 17% of children in our ADHD group had been previously diagnosed. Previous diagnosis was higher in the Combined group and for boys.

CONCLUSIONS

In their second year of school, children who had ADHD performed worse than controls across all functional domains, yet only a minority had been formally diagnosed with ADHD. Findings highlight the need for earlier diagnosis and intervention.

Block & replace regime versus titration regime of antithyroid drugs for the treatment of Graves' disease: a retrospective observational study

CONTEXT

Two widely used antithyroid drug (ATD) regimes for Graves' disease (GD) include the 'block & replace' (B&R) regime (a fixed high-dose of ATD combined with levothyroxine) and the 'titration' regime (a titrating dose of ATD). Anecdotally, it is believed that B&R is less prone to fluctuating thyroid function.

OBJECTIVE

To study whether, in routine clinical practice, the B&R regime, compared with the titration regime, is associated with more stable thyroid function.

METHODS

We retrospectively analysed case-records for 450 patients treated with ATDs for GD at a secondary care hospital. Exclusion criteria included treatment with ATDs for <6 months, thyrotoxicosis due to other causes, treatment with radioiodine or thyroidectomy and pregnancy.

RESULTS

Two hundred and twenty three patients were treated with the B&R regime ('B&R group'), 149 with the titration regime ('titration group') and 78 with both regimes. The number of thyroid function tests (TFTs) performed per year (mean(SD): 3·2(1·2) vs 3·4(1·5); adjusted mean difference = -0·4; 95% CI: -0·7 to -0·1; and P = 0·008) and the number of hospital clinic visits per year (mean (SD): 2·9 (1·0) vs 3·2 (1·3); adjusted mean difference = -0·4; 95% CI: -0·7 to -0·2; and P = 0·002) were lower in the B&R group than the titration group. The number of abnormal TFT results per year was similar in the two groups (mean(SD): 1·8(1·3) vs 1·8(1·4); adjusted mean difference = 0·05; 95%CI: -0·3 to 0·4; and P = 0·74).

CONCLUSIONS

In this retrospective study, there was little evidence that patients under B&R have more stable thyroid function. Further data from prospective studies, however, are needed to confirm this finding.

The Devon Active Villages Evaluation (DAVE) trial of a community-level physical activity intervention in rural south-west England: a stepped wedge cluster randomised controlled trial

BACKGROUND

The majority of adults are not meeting the guidelines for physical activity despite activity being linked with numerous improvements to long-term health. In light of this, researchers have called for more community-level interventions. The main objective of the present study was to evaluate whether a community-level physical activity intervention increased the activity levels of rural communities.

METHODS

128 rural villages (clusters) were randomised to receive the intervention in one of four time periods between April 2011 and December 2012. The Devon Active Villages intervention provided villages with 12 weeks of physical activity opportunities for all age groups, including at least three different types of activities per village. Each village received an individually tailored intervention, incorporating a local needs-led approach. Support was provided for a further 12 months following the intervention. The evaluation study used a stepped wedge cluster randomised controlled trial design. All 128 villages were measured at each of five data collection periods using a postal survey. The primary outcome of interest was the proportion of adults reporting sufficient physical activity to meet internationally recognised guidelines. Minutes spent in moderate-and-vigorous activity per week was analysed as a secondary outcome. To compare between intervention and control modes, random effects linear regression and marginal logistic regression models were implemented for continuous and binary outcomes respectively.

RESULTS

10,412 adults (4693 intervention, 5719 control) completed the postal survey (response rate 32.2%). The intervention did not increase the odds of adults meeting the physical activity guideline (adjusted OR 1.02, 95% CI: 0.88 to 1.17; P = 0.80), although there was weak evidence of an increase in minutes of moderate-and-vigorous-intensity activity per week (adjusted mean difference = 171, 95% CI: -16 to 358; P = 0.07). The ineffectiveness of the intervention may have been due to its low penetration-only 16% of intervention mode participants reported awareness of the intervention and just 4% reported participating in intervention events.

CONCLUSIONS

A community-level physical activity intervention providing tailored physical activity opportunities to rural villages did not improve physical activity levels in adults. Greater penetration of such interventions must be achieved if they are to increase physical activity prevalence at the community level.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37321160.

Impact of adiposity on cardiac structure in adult life: the Childhood Determinants of Adult Health (CDAH) study

BACKGROUND

We have examined the association between adiposity and cardiac structure in adulthood, using a life course approach that takes account of the contribution of adiposity in both childhood and adulthood.

METHODS

The Childhood Determinants of Adult Health study (CDAH) is a follow-up study of 8,498 children who participated in the 1985 Australian Schools Health and Fitness Survey (ASHFS). The CDAH follow-up study included 2,410 participants who attended a clinic examination. Of these, 181 underwent cardiac imaging and provided complete data. The measures were taken once when the children were aged 9 to 15 years, and once in adult life, aged 26 to 36 years.

RESULTS

There was a positive association between adult left ventricular mass (LVM) and childhood body mass index (BMI) in males (regression coefficient (β) 0.41; 95% confidence interval (CI): 0.14 to 0.67; p = 0.003), and females (β = 0.53; 95% CI: 0.34 to 0.72; p < 0.001), and with change in BMI from childhood to adulthood (males: β = 0.27; 95% CI: 0.04 to 0.51; p < 0.001, females: β = 0.39; 95% CI: 0.20 to 0.58; p < 0.001), after adjustment for confounding factors (age, fitness, triglyceride levels and total cholesterol in adulthood). After further adjustment for known potential mediating factors (systolic BP and fasting plasma glucose in adulthood) the relationship of LVM with childhood BMI (males: β = 0.45; 95% CI: 0.19 to 0.71; p = 0.001, females: β = 0.49; 95% CI: 0.29 to 0.68; p < 0.001) and change in BMI (males: β = 0.26; 95% CI: 0.04 to 0.49; p = 0.02, females: β = 0.40; 95% CI: 0.20 to 0.59; p < 0.001) did not change markedly.

CONCLUSIONS

Adiposity and increased adiposity from childhood to adulthood appear to have a detrimental effect on cardiac structure.

A cluster randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of classroom-based cognitive-behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents

BACKGROUND

Depression in adolescents is a significant problem that impairs everyday functioning and increases the risk of severe mental health disorders in adulthood. Although this is a major problem, relatively few adolescents with, or at risk of developing, depression are identified and referred for treatment. This suggests the need to investigate alternative approaches whereby preventative interventions are made widely available in schools.

OBJECTIVE

To investigate the clinical effectiveness and cost-effectiveness of classroom-based cognitive-behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents.

DESIGN

Cluster randomised controlled trial. Year groups ( n = 28) randomly allocated on a 1 : 1 : 1 basis to one of three trial arms once all schools were recruited and balanced for number of classes, number of students, Personal, Social and Health Education (PSHE) lesson frequency, and scheduling of PSHE.

SETTING

Year groups 8 to 11 (ages 12-16 years) in mixed-sex secondary schools in the UK. Data were collected between 2009 and 2011.

PARTICIPANTS

Young people who attended PSHE at participating schools were eligible ( n = 5503). Of the 5030 who agreed to participate, 1064 (21.2%) were classified as 'high risk': 392 in the classroom-based CBT arm, 374 in the attention control PSHE arm and 298 in the usual PSHE arm. Primary outcome data on the high-risk group at 12 months were available for classroom-based CBT ( n = 296), attention control PSHE ( n = 308) and usual PSHE ( n = 242).

INTERVENTIONS

The Resourceful Adolescent Programme (RAP) is a focused CBT-based intervention adapted for the UK (RAP-UK) and delivered by two facilitators external to the school. Control groups were usual PSHE (usual school curriculum delivered by teachers) and attention control (usual school PSHE with additional support from two facilitators). Interventions were delivered universally to whole classes.

PRIMARY OUTCOMES

Clinical effectiveness: symptoms of depression [Short Mood and Feelings Questionnaire (SMFQ)] in adolescents at high risk of depression 12 months from baseline. Cost-effectiveness: incremental cost-effectiveness ratios (ICERs) based on SMFQ score and quality-adjusted life-years (from European Quality of Life-5 Dimensions scores) between baseline and 12 months. Process evaluation: reach, attrition and qualitative feedback from service recipients and providers.

RESULTS

SMFQ scores had decreased for high-risk adolescents in all trial arms at 12 months, but there was no difference between arms [classroom-based CBT vs. usual PSHE adjusted difference in means 0.97, 95% confidence interval (CI) -0.34 to 2.28; classroom-based CBT vs. attention control PSHE -0.63, 95% CI -1.99 to 0.73]. Costs of interventions per child were estimated at £41.96 for classroom-based CBT and £34.45 for attention control PSHE. Fieller's method was used to obtain a parametric estimate of the 95% CI for the ICERs and construct the cost-effectiveness acceptability curve, confirming that classroom-based CBT was not cost-effective relative to the controls. Reach of classroom-based CBT was good and attrition was low (median 80% attending ≥ 60% of sessions), but feedback indicated some difficulties with acceptability and sustainability.

CONCLUSIONS

Classroom-based CBT, attention control PSHE and usual PSHE produced similar outcomes. Classroom-based CBT may result in increased self-awareness and reporting of depressive symptoms. Classroom-based CBT was not shown to be cost-effective. While schools are a convenient way of reaching a wide range of young people, implementing classroom-based CBT within schools is challenging, particularly with regard to fitting programmes into a busy timetable, the lack of value placed on PSHE, and difficulties engaging with teachers and young people. Wider use of classroom-based depression prevention programmes should not be undertaken without further research. If universal preventative approaches are to be pursued, their clinical effectiveness and cost-effectiveness with younger children (aged 10-11 years), before the incidence of depression increases, should be investigated. Alternatively, the clinical effectiveness of indicated school-based programmes targeting those already displaying symptoms of depression should be investigated.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19083628.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 47. See the HTA programme website for further project information.

Interarm blood pressure difference in people with diabetes: measurement and vascular and mortality implications: a cohort study

OBJECTIVE

Differences in blood pressure between arms are associated with vascular disease and increased mortality; this has not been reported in diabetes. We explored these associations, and assessed reference standard and pragmatic measurement techniques, in people with diabetes and in nondiabetic controls.

RESEARCH DESIGN AND METHODS

A prospective cohort study in Devon, England, recruited 727 people with type 1 or type 2 diabetes and 285 nondiabetic controls. Simultaneous repeated measurements of bilateral blood pressure were made at recruitment. Data were used to inform a pragmatic measurement strategy. Interarm differences were examined for cross-sectional associations with target organ disease and prospective mortality associations (median follow-up 52 months).

RESULTS

We found 8.6% of participants with diabetes and 2.9% of controls had systolic interarm differences ≥10 mmHg. Single pairs of blood pressure measurements had high negative predictive values (97-99%) for excluding interarm differences. Systolic interarm differences ≥10 mmHg in diabetes were associated with peripheral arterial disease (odds ratio [OR] 3.4 [95% CI 1.2-9.3]). Differences ≥15 mmHg were associated with diabetic retinopathy (OR 5.7 [1.5-21.6]) and chronic kidney disease (OR 7.0 [1.7-29.8]). Systolic interarm differences were associated prospectively with increased cardiovascular mortality: hazard ratios 3.5 (1.0-13.0) for ≥10 mmHg and 9.0 (2.0-41.0) for ≥15 mmHg.

CONCLUSIONS

Blood pressure should be measured in both arms during initial assessment in diabetes. Systolic interarm differences can be excluded with a single pair of measurements. In the population with diabetes, systolic differences may be associated with an increased risk of morbidity and mortality.

Effectiveness of training family physicians to deliver a brief intervention to address excessive substance use among young patients: a cluster randomized controlled trial

BACKGROUND

Brief interventions delivered by family physicians to address excessive alcohol use among adult patients are effective. We conducted a study to determine whether such an intervention would be similarly effective in reducing binge drinking and excessive cannabis use among young people.

METHODS

We conducted a cluster randomized controlled trial involving 33 family physicians in Switzerland. Physicians in the intervention group received training in delivering a brief intervention to young people during the consultation in addition to usual care. Physicians in the control group delivered usual care only. Consecutive patients aged 15-24 years were recruited from each practice and, before the consultation, completed a confidential questionnaire about their general health and substance use. Patients were followed up at 3, 6 and 12 months after the consultation. The primary outcome measure was self-reported excessive substance use (≥ 1 episode of binge drinking, or ≥ 1 joint of cannabis per week, or both) in the past 30 days.

RESULTS

Of the 33 participating physicians, 17 were randomly allocated to the intervention group and 16 to the control group. Of the 594 participating patients, 279 (47.0%) identified themselves as binge drinkers or excessive cannabis users, or both, at baseline. Excessive substance use did not differ significantly between patients whose physicians were in the intervention group and those whose physicians were in the control group at any of the follow-up points (odds ratio [OR] and 95% confidence interval [CI] at 3 months: 0.9 [0.6-1.4]; at 6 mo: 1.0 [0.6-1.6]; and at 12 mo: 1.1 [0.7-1.8]). The differences between groups were also nonsignificant after we restricted the analysis to patients who reported excessive substance use at baseline (OR 1.6, 95% CI 0.9-2.8, at 3 mo; OR 1.7, 95% CI 0.9-3.2, at 6 mo; and OR 1.9, 95% CI 0.9-4.0, at 12 mo).

INTERPRETATION

Training family physicians to use a brief intervention to address excessive substance use among young people was not effective in reducing binge drinking and excessive cannabis use in this patient population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, no. ACTRN12608000432314.

Who gets help for pre-school communication problems? Data from a prospective community study

OBJECTIVE

Pre-school communication problems are common, with implications for school readiness and educational achievement. Help is available from a variety of community healthcare providers. This study examined the extent to which help is received, and the predictors of service receipt.

DESIGN AND SETTING

Prospective community study, in Melbourne, Victoria.

PARTICIPANTS AND METHOD

At age 4 years, we assessed the speech, receptive and expressive language and fluency of 1607 children and gave feedback to their parents. At age 5 years, 983 families provided data on service use for communication problems between and 4 and 5 years. We compared service use between participants with and without impairment, and used logistic regression to estimate the strength of association between potential predictors (gender, socio-economic status, maternal education, English-speaking background status, family history of speech and language problems and parent concern) and service use (binary outcome).

RESULTS

Data were available for both communication status and service use for 753 children. Only 44.9% of the 196 children with communication impairment received help from a professional. Furthermore, 7% of the 557 that did not meet criteria for communication impairment nevertheless received help from a professional. Parent concern was the strongest predictor of service use (adjusted odds ratio = 9.0; 95% CI: 5.6-14.8).

CONCLUSIONS

Both over- and under-servicing for communication problems were evident. This study shows that accessing help for communication problems requires more than simply informing parents about the problem and having services available; there is a need for systematic support to get the right children to services.

Multiple component interventions for preventing falls and fall-related injuries among older people: systematic review and meta-analysis

Background

Limited attention has been paid in the literature to multiple component fall prevention interventions that comprise two or more fixed combinations of fall prevention interventions that are not individually tailored following a risk assessment. The study objective was to determine the effect of multiple component interventions on fall rates, number of fallers and fall-related injuries among older people and to establish effect sizes of particular intervention combinations.

Methods

Medline, EMBASE, CINAHL, PsychInfo, Cochrane, AMED, UK Clinical Research Network Study Portfolio, Current Controlled Trials register and Australian and New Zealand Clinical Trials register were systematically searched to August 2013 for randomised controlled trials targeting those aged 60 years and older with any medical condition or in any setting that compared multiple component interventions with no intervention, placebo or usual clinical care on the outcomes reported falls, number that fall or fall-related injuries. Included studies were appraised using the Cochrane risk of bias tool. Estimates of fall rate ratio and risk ratio were pooled across studies using random effects meta-analysis. Data synthesis took place in 2013.

Results

Eighteen papers reporting 17 trials were included (5034 participants). There was a reduction in the number of people that fell (pooled risk ratio = 0.85, 95% confidence interval (95% CI) 0.80 to 0.91) and the fall rate (pooled rate ratio = 0.80, 95% CI 0.72 to 0.89) in favour of multiple component interventions when compared with controls. There was a small amount of statistical heterogeneity (I² = 20%) across studies for fall rate and no heterogeneity across studies examining number of people that fell.

Conclusions

This systematic review and meta-analysis of randomised controlled trials found evidence that multiple component interventions that are not tailored to individually assessed risk factors are effective at reducing both the number of people that fall and the fall rate. This approach should be considered as a service delivery option.

Autoantibodies against C1q as a Diagnostic Measure of Lupus Nephritis: Systematic Review and Meta-analysis

OBJECTIVES

To evaluate the diagnostic accuracy of C1q autoantibodies in identifying lupus nephritis (LN) in patients with systemic lupus erythematosus (SLE).

DATA SOURCES AND METHODS

Citation indexes were searched and 370 articles published from 1977 to 2013 were evaluated. The 31 selected studies included in the meta-analysis were cross-sectional in design. Among the 31 studies, 28 compared anti-C1q antibodies in 2769 SLE patients with (n=1442) and without a history of LN (n=1327). Nine studies examined anti-C1q in 517 SLE patients with active (n=249) and inactive LN (n=268). Hierarchical summary receiver operating characteristic (HSROC) random effects models were fitted to pool estimates of accuracy across the studies.

RESULTS

Anti-C1q antibodies discriminated between patients with and without a history of LN, with a median specificity of 73.5%. The HSROC model estimated the corresponding sensitivity to be 70.4%. A hypothetical patient with a 55% prior probability of having a history of LN as opposed to no history (the median prevalence across 28 eligible studies) would have a post-test probability of 76.4% following a positive test result (positive predictive value) or 33.0% following a negative test result (negative predictive value). For discriminating active from inactive LN the median specificity of anti-C1q antibodies was 80%, with a corresponding estimated sensitivity value 75.7% based on the HSROC model. A hypothetical patient with a 56% prior probability of active as opposed to inactive LN (the median prevalence across the 9 eligible studies) would have a post-test probability of 82.8% following a positive test result or 27.9% following a negative test result.

CONCLUSIONS

Although C1q antibodies are associated with lupus nephritis the post-test probabilities are not sufficiently convincing to provide reasonable certainty of the presence or absence of history of disease/active disease.

Psychiatric disorder or impairing psychology in children who have been excluded from school: A systematic review

When children with special educational needs are excluded from school, it should raise the concern that these children are not receiving adequate help and support. This systematic review aims to identify the prevalence of psychiatric disorder or impairing psychopathology among children who are excluded from school compared to children who are not excluded from school. The review follows the guidelines set out by the Centre of Research and Dissemination ( Centre for Reviews and Dissemination, 2009 ). We used broad search terms (across 16 databases) in order to avoid missing papers, our initial screening stage involved 3712 titles and abstracts. Five studies finally met our inclusion criteria. The results from these studies suggest that the odds of children who have been excluded from school having some kind of impairing psychological or behavioural impairment is increased in comparison to children who have not been excluded (odds ratios ranging from 1.13–31.9). However, the paucity of primary research in this area, combined with methodological weaknesses in the identified studies makes it difficult to draw firm conclusions. The need for education and mental health professionals to work together to provide the appropriate support for all children at risk of exclusion is of great and immediate concern.

Ethnic inequalities in time to diagnosis of cancer: a systematic review

Background

Minimising diagnostic delays in cancer may help improve survival. Ethnic minorities have worse outcomes in some cancer types when compared to the majority; this may relate in part to differences during the diagnostic phase. Only a few British studies have specifically explored this relationship, and no synthesis of these exists. The present study aimed to systematically review evidence on ethnic inequalities in cancer diagnosis, focussing on patient and primary care intervals of diagnosis.

Methods

Six electronic databases were searched. Included studies were those conducted in the UK or elsewhere (where access to healthcare is comparable to the NHS) and those that described a time element during diagnosis. Study quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies and synthesis method was narrative.

Results

Seven of 8,520 studies retrieved by our search met the review criteria; six conducted in the UK, and one in New Zealand. Five (including one covering several sites) focused on breast cancer, one on prostate, and one on oesophagogastric cancer. The studies employed different methods of ascertainment and definition of ethnic groups and defined diagnostic delay in a non-standardised way; therefore, narrative synthesis was performed. In breast cancer, three studies reported longer diagnostic intervals among ethnic minorities and two found no evidence of differences by ethnicity. There was some evidence of longer diagnostic and referral intervals among ethnic minorities in oesophagogastric and colorectal cancers, but no evidence of this in prostate, non-Hodgkin’s lymphoma, lung, and ovarian cancers. None of the studies identified shorter patient or primary care intervals in ethnic minorities.

Conclusions

Existing studies provide insufficient evidence to confirm or refute ethnic inequalities in diagnostic intervals of cancer. Further studies are necessary to examine common cancer types including those frequently found in ethnic minorities (in addition to those covered here) and using current definitions of intervals in cancer diagnosis.

Personal, social, and environmental correlates of physical activity in adults living in rural south-west England: a cross-sectional analysis

BACKGROUND

Despite the health risks, physical inactivity is common. Identifying the correlates of physical activity to inform the design of interventions to reduce the disease burden associated with physical inactivity is a public health imperative. Rural adults have a unique set of characteristics influencing their activity behaviour, and are typically understudied, especially in England. The aim of this study was to identify the personal, social, and environmental correlates of physical activity in adults living in rural villages.

METHODS

The study used baseline data from 2415 adults (response rate: 37.7%) participating in the first time period of a stepped-wedge cluster randomised trial, conducted in 128 rural villages from south-west England. Data collected included demographic characteristics, social factors, perception of the local environment, village level factors (percentage male, mean age, population density, Index of Multiple Deprivation, and sport market segmentation), and physical activity behaviour. Random effects ("multilevel") logistic regression models were fitted to the binary outcome whether individuals met physical activity guidelines, and random effects linear regression models were fitted to the continuous outcome MET-minutes per week leisure time physical activity, using the personal, social, environmental, and village-level factors as predictors.

RESULTS

The following factors both increased the odds of meeting the recommended activity guidelines and were associated with more leisure-time physical activity: being male (p = 0.002), in good health (p < 0.001), greater commitment to being more active (p = 0.002), favourable activity social norms (p = 0.004), greater physical activity habit (p < 0.001), and recent use of recreational facilities (p = 0.01). In addition, there was evidence (p < 0.05) that younger age, lower body mass index, having a physical occupation, dog ownership, inconvenience of public transport, and using recreational facilities outside the local village were associated with greater reported leisure-time physical activity. None of the village-level factors were associated with physical activity.

CONCLUSIONS

This study adds to the current literature on the correlates of physical activity behaviour by focusing on a population exposed to unique environmental conditions. It highlights potentially important correlates of physical activity that could be the focus of interventions targeting rural populations, and demonstrates the need to examine rural adults separately from their urban counterparts.

Randomized trial of a population-based, home-delivered intervention for preschool language delay

OBJECTIVE

Population approaches to lessen the adverse impacts of preschool language delay remain elusive. We aimed to determine whether systematic ascertainment of language delay at age 4 years, followed by a 10-month, 1-on-1 intervention, improves language and related outcomes at age 5 years.

METHODS

A randomized trial nested within a cross-sectional ascertainment of language delay. Children with expressive and/or receptive language scores more than 1.25 SD below the mean at age 4 years entered the trial. Children randomly allocated to the intervention received 18 1-hour home-based therapy sessions. The primary outcomes were receptive and expressive language (Clinical Evaluation of Language Fundamentals - Preschool, 2(nd) Edition) and secondary outcomes were child phonological skills, letter awareness, pragmatic skills, behavior, and quality of life.

RESULTS

A total of 1464 children were assessed for language delay at age 4 years. Of 266 eligible children, 200 (13.6%) entered the trial, with 91 intervention (92% of 99) and 88 control (87% of 101) children retained at age 5 years. At age 5 years, there was weak evidence of benefit to expressive (adjusted mean difference, intervention - control, 2.0; 95% confidence interval [CI] -0.5 to 4.4; P = .12) but not receptive (0.6; 95% CI -2.5 to 3.8; P = .69) language. The intervention improved phonological awareness skills (5.0; 95% CI 2.2 to 7.8; P < .001) and letter knowledge (2.4; 95% CI 0.3 to 4.5; P = .03), but not other secondary outcomes.

CONCLUSIONS

A standardized yet flexible 18-session language intervention was successfully delivered by non-specialist staff, found to be acceptable and feasible, and has the potential to improve long-term consequences of early language delay within a public health framework.

Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis

The need to improve the nutrition of the elderly living in long term care has long been recognised, but how this can best be achieved, and whether (and which) intervention is successful in reducing morbidity is less well understood. The aim of this systematic review was to determine the effectiveness of mealtime interventions for the elderly living in residential care. Mealtime interventions were considered as those that aimed to change/improve the mealtime routine, practice, experience or environment. Following comprehensive searches, review and appraisal, 37 articles were included. Inadequate reporting in over half of the articles limited data quality appraisal. Mealtime interventions were categorised into five types: changes to food service, food improvement, dining environment alteration, staff training and feeding assistance. Meta-analysis found inconsistent evidence of effects on body weight of changes to food service (0.5 kg; 95% CI: -1.1 to 2.2; p=0.51), food improvement interventions (0.4 kg; 95% CI: -0.8 to 1.7; p=0.50) or alterations to dining environment (1.5 kg; 95% CI: -0.7 to 2.8; p=0.23). Findings from observational studies within these intervention types were mixed, but generally positive. Observational studies also found positive effects on food/caloric intake across all intervention types, though meta-analyses of randomised studies showed little evidence of any effects on food/caloric intake in food improvement studies (-5 kcal; 95% CI: -36 to 26; p=0.74). There was some evidence of an effect on daily energy intakes within dining environment studies (181 kcal/day, 95% CI: -5 to 367, p=0.06). The need to improve the nutrition of the elderly living in residential long term care is well recognised. This review found some evidence that simple intervention around various aspects of mealtime practices and the mealtime environment can result in favourable nutritional outcomes. Further large scale pragmatic trials, however, are still required to establish full efficacy of such interventions.

Natural history of stuttering to 4 years of age: a prospective community-based study

OBJECTIVES

To document the natural history of stuttering by age 4 years, including (1) cumulative incidence of onset, (2) 12-month recovery status, (3) predictors of stuttering onset and recovery, and (4) potential comorbidities. The study cohort was a prospective community-ascertained cohort (the Early Language in Victoria Study) from Melbourne, Australia, of 4-year-old children (n = 1619; recruited at age 8 months) and their mothers.

METHODS

Outcome was stuttering onset by age 4 years and recovery within 12 months of onset, defined using concurrent monthly parent and speech pathologist ratings. Potential predictors: child gender, birth weight, birth order, prematurity, and twinning; maternal mental health and education; socioeconomic status; and family history of stuttering. Potential comorbidities: preonset and concurrent temperament, language, nonverbal cognition, and health-related quality of life.

RESULTS

By age 4 years, the cumulative incidence of stuttering onset was 11.2% (95% confidence interval [CI]: 9.7% to 12.8%). Higher maternal education (P = .004), male gender (P = .02), and twinning (P = .005) predicted stuttering onset. At outcome, stuttering children had stronger language (mean [SD]: 105.0 [13.0] vs 99.6 [14.6]; mean difference 5.5, 95% CI: 3.1 to 7.8; P < .001) and nonverbal cognition (mean [SD]: 106.5 [11.4] vs 103.9 [13.7], mean difference 2.6, 95% CI: 0.4 to 4.8; P = .02) and better health-related quality of life but were otherwise similar to their nonstuttering peers. Only 9 of 142 children (6.3%; 95% CI: 2.9% to 11.7%) recovered within 12 months of onset.

CONCLUSIONS

Although stuttering onset is common in preschoolers, adverse affects are not the norm in the first year after onset.

Objectively measured physical activity, cardiorespiratory fitness and cardiometabolic risk factors in the Health Survey for England

OBJECTIVES

The study aims to test the hypothesis that physical activity (PA) and cardiorespiratory fitness (CRF) are associated with cardiometabolic risk factors; and to test the hypothesis that CRF modifies (changes the direction and/or strength of) the associations between PA and cardiometabolic risk factors.

METHODS

PA and CRF were objectively measured in the 2008 Health Survey for England and the present study included 536 adults who completed at least 4 min of the eight-minute sub-maximal step test and wore an accelerometer for at least 10 h on at least four days. Linear regression models were fitted to examine the relationship between PA and cardiometabolic risk factors and between CRF and cardiometabolic risk factors. A test of interaction was performed to examine whether CRF modifies the associations between PA and cardiometabolic risk factors.

RESULTS

PA and CRF were associated with HDL cholesterol, the ratio of total to HDL cholesterol, glycated haemoglobin and BMI after adjustment for potential confounders. There was little evidence that CRF changed the direction or strength of associations between PA and cardiometabolic risk factors.

CONCLUSIONS

PA and CRF are associated with cardiometabolic risk factors. A larger sample is required to determine if CRF modifies associations between PA and cardiometabolic risk factors.

Effectiveness of the Mindfulness in Schools Programme: non-randomised controlled feasibility study

BACKGROUND

Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness among young people.

AIMS

To assess the acceptability and efficacy of a schools-based universal mindfulness intervention to enhance mental health and well-being.

METHOD

A total of 522 young people aged 12-16 in 12 secondary schools either participated in the Mindfulness in Schools Programme (intervention) or took part in the usual school curriculum (control).

RESULTS

Rates of acceptability were high. Relative to the controls, and after adjusting for baseline imbalances, children who participated in the intervention reported fewer depressive symptoms post-treatment (P = 0.004) and at follow-up (P = 0.005) and lower stress (P = 0.05) and greater well-being (P = 0.05) at follow-up. The degree to which students in the intervention group practised the mindfulness skills was associated with better well-being (P<0.001) and less stress (P = 0.03) at 3-month follow-up.

CONCLUSIONS

The findings provide promising evidence of the programme's acceptability and efficacy.

A pilot randomised controlled trial of a preconsultation web-based intervention to improve the care quality and clinical outcomes of diabetes outpatients (DIAT)

INTRODUCTION

Diabetes is a chronic condition associated with many long-term complications. People with diabetes need to actively manage their condition, which can be complex. In consultations with healthcare professionals, patients receive advice about their diabetes but do not always discuss things which concern them, perhaps because of the perceived limited time or embarrassment. We want to test a 'preconsultation' intervention in which the patient is supported by a healthcare assistant to complete a web-based intervention aimed at producing an agenda to help them identify important areas for discussion in the consultation. Use of this agenda may enable the patient to play a more active role in that consultation and consequently become more confident, and hence more successful, in managing their condition.

METHODS AND ANALYSIS

In this pilot randomised controlled trial, 120 people with diabetes will be randomised with equal allocation to receive the intervention or usual clinical care. The primary outcome is reduction in glycosylated haemoglobin(HbA1c). Secondary outcomes are patient-reported communication, enablement, self-care activity, diabetes-dependent quality of life, empowerment, satisfaction, health-related quality of life and resource use. The aim of the pilot study was to estimate parameters to inform the design of the definitive trial. Follow-up on quantitative outcomes will be at 3 and 6 months. A nested qualitative study will collect data on the patients' experiences of producing an agenda. Resource use data and medication use will also be collected via a review of medical records for a sample of participants.

ETHICS AND DISSEMINATION

Approval was granted by the NHS Research Ethics Committee North West-Preston (13/NW/0123). Dissemination will include publication of quantitative and qualitative findings, and experience of public involvement in peer-reviewed journals. Results will also be disseminated to trial participants via workshops led by lay coapplicants.

TRIAL REGISTRATION

ISRCTN75070242.

The implementation of NICE guidance on venous thromboembolism risk assessment and prophylaxis: a before-after observational study to assess the impact on patient safety across four hospitals in England

Background

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis.

The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety.

Methods

A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.

Results

Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference −3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97).

Conclusions

The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis.

A parent-focused intervention to reduce infant obesity risk behaviors: a randomized trial

OBJECTIVE

To assess the effectiveness of a parent-focused intervention on infants' obesity-risk behaviors and BMI.

METHODS

This cluster randomized controlled trial recruited 542 parents and their infants (mean age 3.8 months at baseline) from 62 first-time parent groups. Parents were offered six 2-hour dietitian-delivered sessions over 15 months focusing on parental knowledge, skills, and social support around infant feeding, diet, physical activity, and television viewing. Control group parents received 6 newsletters on nonobesity-focused themes; all parents received usual care from child health nurses. The primary outcomes of interest were child diet (3 × 24-hour diet recalls), child physical activity (accelerometry), and child TV viewing (parent report). Secondary outcomes included BMI z-scores (measured). Data were collected when children were 4, 9, and 20 months of age.

RESULTS

Unadjusted analyses showed that, compared with controls, intervention group children consumed fewer grams of noncore drinks (mean difference = -4.45; 95% confidence interval [CI]: -7.92 to -0.99; P = .01) and were less likely to consume any noncore drinks (odds ratio = 0.48; 95% CI: 0.24 to 0.95; P = .034) midintervention (mean age 9 months). At intervention conclusion (mean age 19.8 months), intervention group children consumed fewer grams of sweet snacks (mean difference = -3.69; 95% CI: -6.41 to -0.96; P = .008) and viewed fewer daily minutes of television (mean difference = -15.97: 95% CI: -25.97 to -5.96; P = .002). There was little statistical evidence of differences in fruit, vegetable, savory snack, or water consumption or in BMI z-scores or physical activity.

CONCLUSIONS

This intervention resulted in reductions in sweet snack consumption and television viewing in 20-month-old children.

Four-year-old outcomes of a universal infant-toddler shared reading intervention: the let's read trial

OBJECTIVE

To determine the emergent literacy and language effects of a low-intensity literacy promotion program (Let's Read) provided via universal well-child services to parents during the first 4 years of their child's life.

DESIGN

Population-based, cluster randomized controlled trial performed between March 1, 2006, and December 10, 2010.

SETTING

Maternal and child health centers (clusters) in 5 relatively disadvantaged local government areas in Melbourne, Australia.

PARTICIPANTS

All parents attending their 4-week well-child appointments in participating centers were invited to take part in the study.

INTERVENTION

The Let's Read program was delivered at 4, 12, 18, and 42 months during universal well-child care visits.

MAIN OUTCOME MEASURE

Child emergent literacy skills (intrasyllabic, phonemic, and sound/letter knowledge) and language (core, receptive, and expressive), measured at 4 years of age.

RESULTS

A total of 630 parents participated, with 365 children in 32 intervention clusters and 265 children in 33 control clusters; 563 children (89.4%) were retained in the study to 4 years of age. The adjusted mean differences (intervention minus control) for emergent literacy was 0.2 (95% CI, -0.2 to 0.6; P = .29) for intrasyllabic units, 0.05 (95% CI, -0.4 to 0.5; P = .85) for phonemic awareness, and 0.1 (95% CI, -1.5 to 1.6; P = .92) for letter knowledge. For language, the differences were 1.6 (95% CI, -1.1 to 4.3; P = .25) for core, 0.8 (95% CI, -2.0 to 3.7; P = .56) for receptive, and 1.4 (95% CI, -1.4 to 4.2; P = .32) for expressive scores.

CONCLUSION

This population-wide primary care literacy promotion and book distribution program provided neither the anticipated benefits to literacy and language nor enhanced uptake of literacy activities at 4 years of age, even when targeted to relatively disadvantaged areas.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN04602902.

Physical activity and 3-year BMI change in overweight and obese children

OBJECTIVES

Targeting physical activity (PA) is a mainstay in obesity treatment, but its BMI benefits are poorly quantified. We studied long-term predictive PA-BMI relationships in overweight/obese children presenting to primary care.

METHODS

Three-year follow-up of 182 overweight/obese 5- to 10-year-olds recruited from 45 Melbourne general practices.

PREDICTOR

7-day accelerometry (counts per minute, cpm).

OUTCOMES

change in BMI z score, BMI category, and clinically significant BMI improvement (z score change ≥0.5).

ANALYSIS

Linear and logistic regression.

RESULTS

Mean (SD) baseline and 3-year BMI z scores were 1.8 (0.6) and 1.8 (0.7), and mean (SD) activity scores 334 (111) and 284 (104) cpm, respectively. Baseline activity did not predict BMI change. However, for every 100 cpm increase in change in activity over 3 years, BMI z score fell by 0.11 (95% confidence interval [CI] 0.03-0.20; P = .006). There were also trends toward greater odds of staying in the same, versus moving to a higher, BMI category (odds ratio 1.85, 95% CI 0.99-3.46) and clinically significant BMI improvement (odds ratio 1.96, 95% CI 0.90-4.27; P = .09). Change in percentage time spent in moderate-vigorous (P = .01), but not sedentary (P = .39) or light (P = .59), activity predicted reduced BMI z score.

CONCLUSIONS

Sustained increase in moderate-vigorous PA predicts reducing BMI z score over 3 years in overweight/obese children presenting to primary care. However, the small BMI change associated with even the largest activity changes may explain disappointing BMI outcomes of brief primary care interventions targeting PA.

The Children's Attention Project: a community-based longitudinal study of children with ADHD and non-ADHD controls

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) affects approximately 5% of children worldwide and results in significant impairments in daily functioning. Few community-ascertained samples of children with ADHD have been studied prospectively to identify factors associated with differential outcomes. The Children's Attention Project is the first such study in Australia, examining the mental health, social, academic and quality of life outcomes for children with diagnostically-confirmed ADHD compared to non-ADHD controls. The study aims to map the course of ADHD symptoms over time and to identify risk and protective factors associated with differential outcomes.

METHODS/DESIGN

The sample for this prospective longitudinal study is being recruited across 43 socio-economically diverse primary schools across Melbourne, Australia. All children in Grade 1, the second year of formal schooling (6-8 years), are screened for ADHD symptoms using independent parent and teacher reports on the Conners' 3 ADHD index (~N = 5260). Children screening positive for ADHD by both parent and teacher report, and a matched sample (gender, school) screening negative, are invited to participate in the longitudinal study. At baseline this involves parent completion of the NIMH Diagnostic Interview Schedule for Children IV (DISC-IV) to confirm likely ADHD diagnostic status and identify other mental health difficulties, direct child assessments (cognitive, academic, language and executive functioning; height and weight) and questionnaires for parents and teachers assessing outcomes, as well as a broad range of risk and protective factors (child, parent/family, teacher/school, and socio-economic factors). Families will be initially followed up for 3 years.

DISCUSSION

This study is the first Australian longitudinal study of children with ADHD and one of the first community-based longitudinal studies of diagnostically confirmed children with ADHD. The study's examination of a broad range of risk and protective factors and ADHD-related outcomes has the potential to inform novel strategies for intervention and prevention.

Variability in thyroid function test requests across general practices in south-west England

BACKGROUND

The number of thyroid function tests (TFTs) performed in the UK and other countries has increased considerably in recent years. Inconsistent clinical practice associated with inappropriate requests for tests is thought to be an important cause for this increase.

AIM

To study the extent of variability in requests for TFTs from general practices.

METHODS

We analysed routine data on all TFTs on patients aged 16 years and over carried out by two hospitals in south-west England (Royal Cornwall Hospital and Royal Devon & Exeter Hospital) during 2010 at the request of 107 general practices.

RESULTS

A total of 195 309 TFT requests were made for 148 412 patients (63% female). The total requests included 192 108 tests for thyroid-stimulating hormone (TSH), 43 069 for free thyroxine (FT4) and 1972 for free tri-iodothyronine (FT3). The number of TSH tests per 1000 list size varied widely across the practices, ranging from 84 to 482. Most of the variation was due to heterogeneity across practices and only 24% of this was accounted for by prevalence of hypothyroidism and socio-economic deprivation.

CONCLUSIONS

There is wide variation in TFT requests from general practice and scope to reduce both unnecessary TFTs and the variability in the clinical practice. Further studies are required to understand the causes for the variability in testing thyroid function.

Development of a fragile X syndrome (FXS) knowledge scale: towards a modified multidimensional measure of informed choice for FXS population carrier screening

BACKGROUND

Genetic carrier screening is increasingly possible for many conditions, but it is important to ensure decisions are informed. The multidimensional measure of informed choice (MMIC) is a quantitative instrument developed to evaluate informed choice in prenatal screening for Down syndrome, measuring knowledge, attitudes and uptake. To apply the MMIC in other screening settings, the knowledge scale must be modified.

OBJECTIVE

To develop and validate a modified MMIC knowledge scale for use with women undergoing carrier screening for fragile X syndrome (FXS).

SETTING AND PARTICIPANTS

Responses to MMIC items were collected through questionnaires as part of a FXS carrier screening pilot study in a preconception setting in Melbourne, Australia.

DESIGN

Ten knowledge scale items were developed using a modified Delphi technique. Cronbach's alpha and factor analysis were used to validate the new FXS knowledge scale. We summarized the knowledge, attitudes and informed choice status based on the modified MMIC.

RESULTS

Two hundred and eighty-five women were recruited, 241 eligible questionnaires were complete for analysis. The FXS knowledge scale items measured one salient construct and were internally consistent (alpha = 0.70). 71% (172/241) of participants were classified as having good knowledge, 70% (169/241) had positive attitudes and 27% (65/241) made an informed choice to accept or decline screening.

DISCUSSION AND CONCLUSIONS

We present the development of a knowledge scale as part of a MMIC to evaluate informed choice in population carrier screening for FXS. This can be used as a template by other researchers to develop knowledge scales for other conditions for use in the MMIC.

Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial

BACKGROUND AND OBJECTIVES

Randomized trials have demonstrated the short- to medium-term effectiveness of behavioral infant sleep interventions. However, concerns persist that they may harm children's emotional development and subsequent mental health. This study aimed to determine long-term harms and/or benefits of an infant behavioral sleep program at age 6 years on (1) child, (2) child-parent, and (3) maternal outcomes.

METHODS

Three hundred twenty-six children (173 intervention) with parent-reported sleep problems at age 7 months were selected from a population sample of 692 infants recruited from well-child centers. The study was a 5-year follow-up of a population-based cluster-randomized trial. Allocation was concealed and researchers (but not parents) were blinded to group allocation. Behavioral techniques were delivered over 1 to 3 individual nurse consultations at infant age 8 to 10 months, versus usual care. The main outcomes measured were (1) child mental health, sleep, psychosocial functioning, stress regulation; (2) child-parent relationship; and (3) maternal mental health and parenting styles.

RESULTS

Two hundred twenty-five families (69%) participated. There was no evidence of differences between intervention and control families for any outcome, including (1) children's emotional (P = .8) and conduct behavior scores (P = .6), sleep problems (9% vs 7%, P = .2), sleep habits score (P = .4), parent- (P = .7) and child-reported (P = .8) psychosocial functioning, chronic stress (29% vs 22%, P = .4); (2) child-parent closeness (P = .1) and conflict (P = .4), global relationship (P = .9), disinhibited attachment (P = .3); and (3) parent depression, anxiety, and stress scores (P = .9) or authoritative parenting (63% vs 59%, P = .5).

CONCLUSIONS

Behavioral sleep techniques have no marked long-lasting effects (positive or negative). Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression.

The Devon Active Villages Evaluation (DAVE) trial: study protocol of a stepped wedge cluster randomised trial of a community-level physical activity intervention in rural southwest England

BACKGROUND

Although physical inactivity has been linked with numerous chronic health conditions and overall mortality, the majority of English adults report doing insufficient physical activity. To increase population physical activity levels, researchers have called for more community-level interventions. To evaluate these complex public health interventions, innovative study designs are required. This study protocol describes Devon Active Villages, a community-level intervention providing physical activity opportunities to 128 rural villages in southwest England, and the methods used to evaluate its effectiveness in increasing physical activity levels.

METHODS/DESIGN

A stepped wedge cluster randomised trial will be used to evaluate whether Devon Active Villages leads to increased physical activity levels in rural communities. Community engagement will help tailor activity programmes for each village; communities will then be supported for a further twelve months. The intervention will be delivered over four periods, each lasting twelve weeks. Data collection consists of a postal survey of a random sample of adults aged 18 years and over, at baseline and after each of the four intervention periods. The questionnaire includes questions on participant demographics, physical activity behaviour, local environment characteristics, awareness of local activity programmes, and psychosocial factors. Based on detecting an increase in the proportion of people who meet physical activity guidelines (from 25% to 30%), at least ten respondents are needed from each of the 128 villages at each stage (80% power at the 5% level of significance). Anticipating a 20% response rate, 6,400 questionnaires will be sent out at each stage (i.e., 50 surveys to each village). Using data from all five periods, a comparison of study outcomes between intervention and control arms will be performed, allowing for time period (as a fixed effect) and the random effect induced by correlation of outcomes (clustering) within villages.

DISCUSSION

This paper describes the use of a stepped wedge cluster randomised trial to evaluate a complex, community-level physical activity intervention in an under-studied population of adults in rural communities in southwest England. The study addresses gaps in the current literature by providing new insights into physical activity levels in this population.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN37321160.

Improving outcomes of preschool language delay in the community: protocol for the Language for Learning randomised controlled trial

Background

Early language delay is a high-prevalence condition of concern to parents and professionals. It may result in lifelong deficits not only in language function, but also in social, emotional/behavioural, academic and economic well-being. Such delays can lead to considerable costs to the individual, the family and to society more widely. The Language for Learning trial tests a population-based intervention in 4 year olds with measured language delay, to determine (1) if it improves language and associated outcomes at ages 5 and 6 years and (2) its cost-effectiveness for families and the health care system.

Methods/Design

A large-scale randomised trial of a year-long intervention targeting preschoolers with language delay, nested within a well-documented, prospective, population-based cohort of 1464 children in Melbourne, Australia. All children received a 1.25-1.5 hour formal language assessment at their 4^th birthday. The 200 children with expressive and/or receptive language scores more than 1.25 standard deviations below the mean were randomised into intervention or ‘usual care’ control arms. The 20-session intervention program comprises 18 one-hour home-based therapeutic sessions in three 6-week blocks, an outcome assessment, and a final feed-back/forward planning session. The therapy utilises a ‘step up-step down’ therapeutic approach depending on the child’s language profile, severity and progress, with standardised, manualised activities covering the four language development domains of: vocabulary and grammar; narrative skills; comprehension monitoring; and phonological awareness/pre-literacy skills. Blinded follow-up assessments at ages 5 and 6 years measure the primary outcome of receptive and expressive language, and secondary outcomes of vocabulary, narrative, and phonological skills.

Discussion

A key strength of this robust study is the implementation of a therapeutic framework that provides a standardised yet tailored approach for each child, with a focus on specific language domains known to be associated with later language and literacy. The trial responds to identified evidence gaps, has outcomes of direct relevance to families and the community, includes a well-developed economic analysis, and has the potential to improve long-term consequences of early language delay within a public health framework.

Trial registration

Current Controlled Trials ISRCTN03981121.

Development of children's internalising and externalising problems from infancy to five years of age

OBJECTIVE

Mental health problems are an international public health issue affecting a substantial proportion of youth. This study aimed to identify groups of young children exhibiting distinct internalising and externalising symptom trajectories across early childhood compared to existing norms. Linear regression then identified child, parenting and family predictors from infancy in the development of internalising and externalising behaviours at age 5 years.

METHOD

This consisted of a follow-up of 5-year-old children from a longitudinal, population-based study with earlier surveys having been completed by primary caregivers when the children were aged 7, 12, 18, 24 and 36 months. Five hundred 5-year-olds (68% retention) were included from 733 children recruited at age 6-7 months from routine well-child appointments across six socio-economically diverse government areas in Victoria, Australia. Mothers then completed a further questionnaire when their children reached 5 years of age, repeating the instruments included in previous waves. The primary outcomes were the Child Behavior Checklist (CBCL), 1.5-5 internalising and externalising symptoms (T-scores in relation to norms) and behaviours (raw scores).

RESULTS

Across early childhood, three distinct profiles for each of the internalising and externalising symptoms (T-scores) were identified and compared to CBCL norms. Around 20% of this Australian child population exhibited consistently elevated symptoms for each problem. Regarding aetiology, longitudinally the strongest predictors of internalising behaviours at 5 years of age were harsh discipline, maternal stress, having no older siblings, single parenthood and maternal substance misuse. The strongest predictors of externalising behaviours at 5 years of age were male sex, harsh discipline and maternal stress. The predictors explained 22% of the variation in internalising behaviours and 24% of the variation in externalising behaviours at 5 years.

CONCLUSIONS

Starting as early as the toddler period, effective population approaches to preventing mental health problems are needed. Randomised trials of preventive interventions focused on improving parenting practices and reducing maternal stress are under way.

Preventing mental health problems in children: the Families in Mind population-based cluster randomised controlled trial

Background

Externalising and internalising problems affect one in seven school-aged children and are the single strongest predictor of mental health problems into early adolescence. As the burden of mental health problems persists globally, childhood prevention of mental health problems is paramount. Prevention can be offered to all children (universal) or to children at risk of developing mental health problems (targeted). The relative effectiveness and costs of a targeted only versus combined universal and targeted approach are unknown. This study aims to determine the effectiveness, costs and uptake of two approaches to early childhood prevention of mental health problems ie: a Combined universal-targeted approach, versus a Targeted only approach, in comparison to current primary care services (Usual care).

Methods/design

Three armed, population-level cluster randomised trial (2010–2014) within the universal, well child Maternal Child Health system, attended by more than 80% of families in Victoria, Australia at infant age eight months.

Participants were families of eight month old children from nine participating local government areas. Randomised to one of three groups: Combined, Targeted or Usual care.

The interventions comprises (a) the Combined universal and targeted program where all families are offered the universal Toddlers Without Tears group parenting program followed by the targeted Family Check-Up one-on-one program or (b) the Targeted Family Check-Up program. The Family Check-Up program is only offered to children at risk of behavioural problems.

Participants will be analysed according to the trial arm to which they were randomised, using logistic and linear regression models to compare primary and secondary outcomes. An economic evaluation (cost consequences analysis) will compare incremental costs to all incremental outcomes from a societal perspective.

Discussion

This trial will inform public health policy by making recommendations about the effectiveness and cost-effectiveness of these early prevention programs. If effective prevention programs can be implemented at the population level, the growing burden of mental health problems could be curbed.

Trial registration

ISRCTN61137690