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Purgato M, Prina E, Ceccarelli C, Cadorin C, Abdulmalik JO, Amaddeo F, Arcari L, Churchill R, Jordans MJ, Lund C, Papola D, Uphoff E, van Ginneken N, Tol WA, Barbui C. Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries. Cochrane Database Syst Rev 2023; 10:CD014722. [PMID: 37873968 PMCID: PMC10594594 DOI: 10.1002/14651858.cd014722.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.
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Affiliation(s)
- Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Eleonora Prina
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Caterina Ceccarelli
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Camilla Cadorin
- Department of Neurosciences, Biomedicine and Movement Sciences, Verona, Italy
| | | | - Francesco Amaddeo
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Rachel Churchill
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Jd Jordans
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Crick Lund
- King's Global Health Institute, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Davide Papola
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Wietse Anton Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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Price DW, Davis DA, Filerman GL. "Systems-Integrated CME": The Implementation and Outcomes Imperative for Continuing Medical Education in the Learning Health Care Enterprise. NAM Perspect 2021; 2021:202110a. [PMID: 34901778 PMCID: PMC8654469 DOI: 10.31478/202110a] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- David W Price
- University of Colorado Anschutz School of Medicine and the American Board of Family Medicine
| | - David A Davis
- AXDEV Group, University of Toronto and Mohammed Bin Rashid University of Medicine & the Health Sciences
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Ramasubbu R, McAusland L, Chopra S, Clark DL, Bewernick BH, Kiss ZHT. Personality changes with subcallosal cingulate deep brain stimulation in patients with treatment-resistant depression. J Psychiatry Neurosci 2021; 46:E490-E499. [PMID: 34609949 PMCID: PMC8519494 DOI: 10.1503/jpn.210028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/11/2021] [Accepted: 05/27/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is a promising investigational approach for treatment-resistant depression. However, reports suggesting changes in personality with DBS for movement disorders have raised clinical and ethical concerns. We prospectively examined changes in personality dimensions and antidepressant response to subcallosal cingulate (SCC)-DBS for treatment-resistant depression. METHODS Twenty-two patients with treatment-resistant depression underwent SCC-DBS. We used the NEO Five-Factor Inventory for personality assessment at baseline and every 3 months until 15 months post-DBS. We assessed depression severity monthly using the Hamilton Depression Rating Scale. RESULTS We found a significant decrease in neuroticism (p = 0.002) and an increase in extraversion (p = 0.001) over time, showing a change toward normative data. Improvement on the Hamilton Depression Rating Scale was correlated with decreases in neuroticism at 6 months (p = 0.001) and 12 months (p < 0.001), and with an increase in extraversion at 12 months (p = 0.01). Changes on the Hamilton Depression Rating Scale over time had a significant covariate effect on neuroticism (p < 0.001) and extraversion (p = 0.001). Baseline openness and agreeableness predicted response to DBS at 6 (p = 0.006) and 12 months (p = 0.004), respectively. LIMITATIONS Limitations included a small sample size, a lack of sham control and the use of subjective personality evaluation. CONCLUSION We observed positive personality changes following SCC-DBS, with reduced neuroticism and increased extraversion related to clinical improvement in depression, suggesting a state effect. As well, pretreatment levels of openness and agreeableness may have predicted subsequent response to DBS. The NEO Five-Factor Inventory assessment may have a role in clinical decision-making and prognostic evaluation in patients with treatment-resistant depression who undergo SCC-DBS.
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Affiliation(s)
- Rajamannar Ramasubbu
- From the Department of Psychiatry, University of Calgary, Calgary, Alberta (Ramasubbu, McAusland, Chopra, Clark, Kiss); the Clinical Neurosciences, University of Calgary, Calgary, Alberta (Ramasubbu, McAusland, Clark, Kiss); the Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, Alberta (Ramasubbu, McAusland, Chopra, Clark, Kiss); the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta (Ramasubbu, Chopra, Clark, Kiss); The Department of Geriatric Psychiatry and Section for Medical Psychology of the Department of Psychiatry and Psychotherapy, University Hospital Bonn, Germany (Bewernick)
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Durán Agúero S, Silva Ocampo P, Giménez Sánchez J, Fleta Sánchez Y, Moya Tillería J. Stages of change in the purchase of packaged foods after phase 1 of the implementation of the new food policy in Chile 2017. Nutrition 2019; 71:110593. [PMID: 31837643 DOI: 10.1016/j.nut.2019.110593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim of this study was to determine the stage of change in which Chilean adults find themselves, with respect to their intention of purchasing packaged, popular foods with a warning label for critical nutrients. METHODS This was a cross-sectional study conducted with a nationally representative sample. Each participant was asked age, weight, and height. The stage of the change was identified according to the timing of intention to purchase for each of the foods. RESULTS The sample included 2331 individuals, of whom 60.4% were women. More than 50% of the population was in the precontemplation stage, reaching 66.6% for breakfast cereals. The lowest value was in sweetened beverages with 43.4%. When comparing by sex, a higher proportion of men than women were in the precontemplation stage for sugar-sweetened beverages and cured meats/sausage (P < 0.05). When comparing by nutritional status, the higher the weight status, the higher the prevalence of participants in the three initial stages: precontemplation, contemplation, and preparation (P < 0.01). CONCLUSION We found that the majority of the respondents were in the precontemplation stage for most foods, except for sugar-sweetened beverages. In the case of sugar-sweetened beverages, most respondents were in the preparation, action, and maintenance stages.
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Affiliation(s)
- Samuel Durán Agúero
- School of Dietetics and Nutrition, Faculty of Health Care Sciences, University of San Sebastián, Santiago, Chile
| | - Paulo Silva Ocampo
- School of Dietetics and Nutrition, Faculty of Health Care Sciences, University of San Sebastián, Santiago, Chile
| | | | | | - Jessica Moya Tillería
- School of Dietetics and Nutrition, Faculty of Health Care Sciences, University of San Sebastián, Santiago, Chile.
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Tyler I, Pauly B, Wang J, Patterson T, Bourgeault I, Manson H. Evidence use in equity focused health impact assessment: a realist evaluation. BMC Public Health 2019; 19:230. [PMID: 30808317 PMCID: PMC6390302 DOI: 10.1186/s12889-019-6534-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Equity-focused health impact assessment (EFHIA) can function as a framework and tool that supports users to collate data, information, and evidence related to health equity in order to identify and mitigate the impact of a current or proposed initiative on health inequities. Despite education efforts in both the clinical and public health settings, practitioners have found implementation and the use of evidence in completing equity focussed assessment tools to be challenging. METHODS We conducted a realist evaluation of evidence use in EFHIA in three phases: 1) developing propositions informed by a literature scan, existing theoretical frameworks, and stakeholder engagement; 2) data collection at four case study sites using online surveys, semi-structured interviews, document analysis, and observation; and 3) a realist analysis and identification of context-mechanism-outcome patterns and demi-regularities. RESULTS We identified limited use of academic evidence in EFHIA with two explanatory demi-regularities: 1) participants were unable to "identify with" academic sources, acknowledging that evidence based practice and use of academic literature was valued in their organization, but seen as less likely to provide answers needed for practice and 2) use of academic evidence was not associated with a perceived "positive return on investment" of participant energy and time. However, we found that knowledge brokering at the local site can facilitate evidence familiarity and manageability, increase user confidence in using evidence, and increase the likelihood of evidence use in future work. CONCLUSIONS The findings of this study provide a realist perspective on evidence use in practice, specifically for EFHIA. These findings can inform ongoing development and refinement of various knowledge translation interventions, particularly for practitioners delivering front-line public health services.
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Affiliation(s)
| | - Bernie Pauly
- School of Nursing, Scientist, Canadian Institute for Substance Use Research, UVIC Community Engaged Scholar , University of Victoria, Victoria, BC, Canada
| | | | | | - Ivy Bourgeault
- Telfer School of Management, the University of Ottawa, Canadian Institutes of Health Research Chair in Gender, Work and Health Human Resources, Ottawa, Canada
| | - Heather Manson
- Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, Ontario, Canada
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Khoo S, Simms LJ. Links between depression and openness and its facets. Personal Ment Health 2018; 12:203-215. [PMID: 29611346 DOI: 10.1002/pmh.1417] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/13/2018] [Accepted: 02/12/2018] [Indexed: 12/16/2022]
Abstract
Most studies on depression and personality have focused on the role of Neuroticism and Extraversion. Openness is a much less studied trait in this literature, as past studies investigating Openness and depression often have found non-significant correlations between them. However, past studies mostly have investigated Openness and depression at the domain level and used non-clinical samples. In the present study, the relationship between depression and Openness at the domain and facet levels was examined in a sample of 266 participants recruited from outpatient psychiatric settings. Findings showed that although the Openness domain was significantly related to depression, it did not account for a significant proportion of unique variance for depression. However, Openness did account for a significant proportion of unique variance for depression at the facet level, even after accounting for sex, age, Neuroticism and Extraversion. Specifically, unique effects emerged for the facets of Aesthetics positively predicting Depression and Values negatively predicting Depression and Anhedonia. Clinical and theoretical implications are discussed. Copyright © 2018 John Wiley & Sons, Ltd.
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Affiliation(s)
- Shereen Khoo
- Department of Psychology, University of Notre Dame, Notre Dame, IN, USA
| | - Leonard J Simms
- Department of Psychology, University at Buffalo, The State University of New York, Buffalo, NY, USA
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Arvandi Z, Emami A, Zarghi N, Alavinia SM, Shirazi M, Parikh SV. Linking medical faculty stress/burnout to willingness to implement medical school curriculum change: a preliminary investigation. J Eval Clin Pract 2016; 22:86-92. [PMID: 26563562 DOI: 10.1111/jep.12439] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Balancing administrative demands from the medical school while providing patient support and seeking academic advancement can cause personal hardship that ranges from high stress to clinically recognizable conditions such as burnout. Regarding the importance of clinical faculties' burnout and its effects on different aspects of their professional career, this study was conducted and aimed to evaluate the relationship between willingness to change teaching approaches as characterized by a modified stage-of-change model and measures of stress and burnout. METHODS This descriptive analytic study was conducted on 143 clinical faculty members of Tehran University of Medical Sciences in Iran. Participants were asked to complete three questionnaires: a modified stages of change questionnaire the Maslach Burnout Inventory and the General Health Questionnaire. Data were analysed by SPSS: 16 using non-parametric statistical tests such as multiple regression and ICC (intra-class coefficient) and Spearman correlation coefficient test. RESULT A significant relationship was found between faculty members' readiness to change teaching approaches and the subscales of occupational burnout. Specifically, participants with low occupational burnout were more likely to be in the action stage, while those with high burnout were in the attitude or intention stage, which could be understood as not being ready to implement change. There was no significant correlation between general health scores and stage of change. CONCLUSIONS We found it feasible to measure stages of change as well as stress/burnout in academic doctors. Occupational burnout directly reduces the readiness to change. To have successful academic reform in medical schools, it therefore would be beneficial to assess and manage occupational burnout among clinical faculty members.
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Affiliation(s)
- Zeinab Arvandi
- EDO, Faculty of Dentistry, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Amirhossein Emami
- Department of Medical Education, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Nazila Zarghi
- PhD Candidate in Medical Education, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran.,Faculty Member of EDC (Education Development Center), Mashhad, Iran
| | | | - Mandana Shirazi
- EDC, Tehran University of Medical Sciences (TUMS), Tehran, Iran.,Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
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Baker R, Camosso‐Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki‐Cwirko M, van Lieshout J, Jäger C. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev 2015; 2015:CD005470. [PMID: 25923419 PMCID: PMC7271646 DOI: 10.1002/14651858.cd005470.pub3] [Citation(s) in RCA: 306] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants. OBJECTIVES To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants. SEARCH METHODS We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals. SELECTION CRITERIA Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified. MAIN RESULTS We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression. AUTHORS' CONCLUSIONS Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.
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Affiliation(s)
- Richard Baker
- University of LeicesterDepartment of Health Sciences22‐28 Princess Rd WestLeicesterLeicestershireUKLE1 6TP
| | | | - Clare Gillies
- University of LeicesterUniversity Division of Medicine for the ElderlyThe Glenfield HospitalGroby RoadLeicesterUKLE5 4PW
| | - Elizabeth J Shaw
- National Institute for Health and Care Excellence (NICE)Level 1A, City PlazaPiccadilly PlazaManchesterUKM1 4BD
| | - Francine Cheater
- School of Health Sciences, University of East AngliaEdith Cavell BuildingNorwichNorfolkUK
| | - Signe Flottorp
- Norwegian Knowledge Centre for the Health ServicesBox 7004, St. Olavs plassOsloNorway0130
| | - Noelle Robertson
- Leicester UniversitySchool of Psychology (Clinical Section)104 Regent RoadLeicesterLeicestershireUKLE1 7LT
| | - Michel Wensing
- Radboud University Medical CenterRadboud Institute for Health SciencesPO Box 9101117 KWAZONijmegenNetherlands6500 HB
| | | | - Martin P Eccles
- Newcastle UniversityInstitute of Health and SocietyBadiley Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Maciek Godycki‐Cwirko
- Medical University of LodzCentre for Family and Community MedicineKopcindkiego 20LodzPoland90‐153
| | - Jan van Lieshout
- Radboud University Medical CenterScientific Institute for Quality of HealthcareP.O.Box 9101NijmegenNetherlands6500 HB
| | - Cornelia Jäger
- University Hospital of HeidelbergDepartment of General Practice and Health Services ResearchVoßstr. 2, Geb. 37HeidelbergGermany69115
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Johnson SS, Castle PH, Van Marter D, Roc A, Neubauer D. The effect of physician continuing medical education on patient-reported outcomes for identifying and optimally managing obstructive sleep apnea. J Clin Sleep Med 2015; 11:197-204. [PMID: 25845903 DOI: 10.5664/jcsm.4524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of continuing medical education (CME) activities on patient reported outcomes with regard to (1) screening for excessive sleepiness (ES) and obstructive sleep apnea (OSA) and (2) appropriate referral and treatment. METHODS A total of 725 patients were recruited from 75 providers who either participated or did not participate in Transtheoretical Model (TTM)-based OSA CME activities. Patient reported outcomes from participating (n = 36) and non-participating providers (n = 39) were compared using generalized estimating equations examining random effects of provider as unit of assignment. RESULTS Patients' reports demonstrate that participating physicians were 1.7 times more likely to initiate discussion of sleep problems than non-participating physicians (t1,411 = 3.71, p = 0.05) and 2.25-2.86 times more likely to administer validated measures for OSA (Epworth Sleepiness Scale and STOP-BANG). Patient reports also indicated that participating clinicians (79.9%) were significantly more likely to recommend seeing a sleep specialist compared to non-participating clinicians (60.7%; t1,348 = 9.1, p < 0.01, OR = 2.6). Furthermore, while 89.4% of participating clinicians recommended a sleep study, only 73.2% of the non-participating physicians recommended one (t1,363 = 11.46, p < 0.001, OR = 3.1). CONCLUSIONS Participation in TTM-based OSA CME activities was associated with improved patient reported outcomes compared to the non-participating clinicians.
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Saleh S, Alameddine M, Mourad Y, Natafgi N. Quality of care in primary health care settings in the Eastern Mediterranean region: a systematic review of the literature. Int J Qual Health Care 2015; 27:79-88. [PMID: 25574040 DOI: 10.1093/intqhc/mzu103] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2014] [Indexed: 12/20/2022] Open
Abstract
PURPOSE This systematic review aims at offering a comprehensive synthesis of studies addressing quality of care in the primary healthcare (PHC) sector of the Eastern Mediterranean Region (EMR). DATA SOURCES A systematic search was conducted using Medline, Embase and Global Health Library (IMEMR) electronic databases to identify studies related to quality in PHC between years 2000 and 2012. STUDY SELECTION/DATA EXTRACTION One hundred and fifty-nine (159) studies fulfilled the eligibility criteria. Each paper was independently reviewed by two reviewers, and the following information was extracted/calculated: dimension of care investigated (structure, processes and outcomes), focus, disease groups, study design, sample size, unit of analysis, response rate, country, setting (public or private) and level of rigor (LOR) score. RESULTS OF DATA SYNTHESIS Most of the studies were descriptive/cross-sectional in nature with a relatively modest LOR score. Assessment of quality of care revealed that the process dimension of quality, specifically clinical practice and patient-provider relationship, is an area of major concern. However, interventions targeting enhanced quality in PHC in the EMR countries had favorable and effective outcomes in terms of clinical practice. CONCLUSION These findings highlight gaps in evidence on quality in PHC in the EMR; such evidence is key for decision-making. Researchers and policy-makers should address these gaps to generate contextualized information and knowledge that ensures relevance and targeted high-impact interventions.
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Affiliation(s)
- Shadi Saleh
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Mohamad Alameddine
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Yara Mourad
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Nabil Natafgi
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa, USA
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Abstract
This paper addresses: 1) Situations where human behaviour is involved in relation to antibiotics, focusing on providers and consumers; 2) Theories about human behaviour and factors influencing behaviour in relation to antibiotics; 3) How behaviour in relation to antibiotics can change; and, 4) Antibiotic mainstreaming as an approach to facilitate changes in human behaviour as regards antibiotics. Influencing human behaviour in relation to antibiotics is a complex process which includes factors like knowledge, attitudes, social norms, socio-economic conditions, peer pressure, experiences, and bio-physical and socio-behavioural environment. Further, key concepts are often perceived in different ways by different individuals. While designing and implementing projects or programmes for behavioural change with respect to antibiotics for professionals or consumers it is helpful to consider theories or models of behaviour change, e.g. the 'stages of change model', including pre-contemplation, contemplation, preparation, action, and maintenance. People in different stages of change are susceptible to different behaviour modification strategies. Application of marketing principles to 'global good', so-called 'social marketing', to improve 'welfare of the individual and society' is gaining increased attention in public health. In conclusion, just providing correct knowledge is not sufficient although it is a pre-requisite for behaviour modification in the desired direction. We can never change the behaviour of any other human, but we can facilitate for others to change their own behaviour. One possibility is to implement 'antibiotic mainstreaming' as a potentially effective way for behaviour modification, i.e. to address consequences for maintaining effective antibiotics in all activities and decisions in society.
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Affiliation(s)
- Cecilia Stålsby Lundborg
- Global Health, IHCAR, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Ashok J. Tamhankar
- Global Health, IHCAR, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Indian Initiative for Management of Antibiotic Resistance (IIMAR), Department of Environmental Medicine, R.D. Gardi Medical College, Ujjain, India
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Shirazi M, Lonka K, Parikh SV, Ristner G, Alaeddini F, Sadeghi M, Wahlstrom R. A tailored educational intervention improves doctor's performance in managing depression: a randomized controlled trial. J Eval Clin Pract 2013; 19:16-24. [PMID: 21883718 DOI: 10.1111/j.1365-2753.2011.01761.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
RATIONAL AND OBJECTIVES To assess the effects of a tailored and activating educational intervention, based on a three-stage modified Prochaska model of readiness-to-change, on the performance of general physicians in primary care (GPs) regarding management of depressive disorders. METHODS Parallel group, randomized control trial. Primary hypothesis was that performance would improve by 20 percentage units in the intervention arm. The setting was primary care in southern Tehran. The participants were 192 GPs stratified on stage of readiness-to-change, sex, age and work experience. The intervention was a 2-day interactive workshop for a small group of GPs' at a higher stage of readiness-to-change ('intention') and a 2-day interactive large group meeting for those with lower propensity to change ('attitude') at the pre-assessment. GPs in the control arm participated in a standard educational programme on the same topic. The main outcome measures were validated tools to assess GPs' performance by unannounced standardized patients, regarding diagnosis and treatment of depressive disorders. The assessments were made 2 months before and 2 months after the intervention. RESULTS GPs in the intervention arm significantly improved their overall mean scores for performance regarding both diagnosis, with an intervention effect of 14 percentage units (P = 0.007), and treatment and referral, with an intervention effect of 20 percentage units (P < 0.0001). The largest improvement after the intervention appeared in the small group: 30 percentage units for diagnosis (P = 0.027) and 29 percentage units for treatment and referral (P < 0.0001). CONCLUSIONS Activating learning methods, tailored according to the participants' readiness to change, improved clinical performance of GPs in continuing medical education and can be recommended for continuing professional development.
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Di Noia J, Mauriello L, Byrd-Bredbenner C, Thompson D. Validity and reliability of a dietary stages of change measure among economically disadvantaged African-American adolescents. Am J Health Promot 2012; 26:381-9. [PMID: 22747321 DOI: 10.4278/ajhp.100903-quan-302] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the construct validity and 2-month test-retest reliability of a staging measure for assessing readiness to consume five or more daily servings of fruits and vegetables among economically disadvantaged African-American adolescents. DESIGN Longitudinal survey. SETTING Youth services agencies serving low-income communities in New York, New Jersey, and Pennsylvania. SUBJECTS African-American adolescents (N = 390) aged 11 to 14 years. MEASURES Self-report measures of stage of change and fruit and vegetable consumption. ANALYSIS Correlation analysis and analysis of covariance were used to examine, cross-sectionally, whether fruit and vegetable consumption differed by stage of change (validity assessment). Correlation analysis and Cohen's kappa (κ) were used to assess the degree of association and level of agreement between stages longitudinally (test-retest reliability assessment). RESULTS Fruit and vegetable consumption was moderately correlated with stage of change (r ≥ .54, p = .000). Consistent with the transtheoretical model, youths' consumption increased from earlier to later stages (p = .000). Forty-six percent of youths were in the same stage at both measurements. The correlation between stages was .26, and Cohen's κ was .20 (p = .000). CONCLUSIONS Despite preliminary evidence of construct validity, the low test-retest reliability found suggests that further research and testing are needed to improve the stability of the measure.
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Affiliation(s)
- Jennifer Di Noia
- Department of Sociology, William Paterson University, Wayne, NJ 07470, USA.
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Cloutier MM, Tennen H, Wakefield DB, Brazil K, Hall CB. Improving clinician self-efficacy does not increase asthma guideline use by primary care clinicians. Acad Pediatr 2012; 12:312-8. [PMID: 22634077 PMCID: PMC3398244 DOI: 10.1016/j.acap.2012.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 04/06/2012] [Accepted: 04/09/2012] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The purpose of this study was to show the association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing). METHODS A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy. RESULTS At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (relative rate [RR], 1.34; 95% confidence interval [CI], 1.04-1.72; P = .04) but not treatment plan development (RR, 0.63; 95% CI, 0.29-1.35; P = .23) or anti-inflammatory use (RR, 1.76; 95% CI, 0.92-3.35; P = .09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (P = .01) and more clinicians were in an action stage of change (P = .001) but these changes were not associated with changes in primary or secondary outcomes. CONCLUSIONS Self-efficacy scores correlated with program use at baseline and increased in the intervention arm, but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change.
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Affiliation(s)
- Michelle M Cloutier
- Department of Pediatrics, University of Connecticut Health Center, Farmington, CT, USA.
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Weir C, McLeskey N, Brunker C, Brooks D, Supiano MA. The role of information technology in translating educational interventions into practice: an analysis using the PRECEDE/PROCEED model. J Am Med Inform Assoc 2011; 18:827-34. [PMID: 21571745 PMCID: PMC3197988 DOI: 10.1136/amiajnl-2010-000076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 03/19/2011] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The evidence base for information technology (IT) has been criticized, especially with the current emphasis on translational science. The purpose of this paper is to present an analysis of the role of IT in the implementation of a geriatric education and quality improvement (QI) intervention. DESIGN A mixed-method three-group comparative design was used. The PRECEDE/PROCEED implementation model was used to qualitatively identify key factors in the implementation process. These results were further explored in a quantitative analysis. METHOD Thirty-three primary care clinics at three institutions (Intermountain Healthcare, VA Salt Lake City Health Care System, and University of Utah) participated. The program consisted of an onsite, didactic session, QI planning and 6 months of intense implementation support. RESULTS Completion rate was 82% with an average improvement rate of 21%. Important predisposing factors for success included an established electronic record and a culture of quality. The reinforcing and enabling factors included free continuing medical education credits, feedback, IT access, and flexible support. The relationship between IT and QI emerged as a central factor. Quantitative analysis found significant differences between institutions for pre-post changes even after the number and category of implementation strategies had been controlled for. CONCLUSIONS The analysis illustrates the complex dependence between IT interventions, institutional characteristics, and implementation practices. Access to IT tools and data by individual clinicians may be a key factor for the success of QI projects. Institutions vary widely in the degree of access to IT tools and support. This article suggests that more attention be paid to the QI and IT department relationship.
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Affiliation(s)
- Charlene Weir
- Geriatric Research, Education, and Clinical Center, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah 84148, USA.
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Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010:CD005470. [PMID: 20238340 PMCID: PMC4164371 DOI: 10.1002/14651858.cd005470.pub2] [Citation(s) in RCA: 438] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain. OBJECTIVES To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes. SEARCH STRATEGY For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints. MAIN RESULTS We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions. AUTHORS' CONCLUSIONS Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.
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Affiliation(s)
- Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Clare Gillies
- University Division of Medicine for the Elderly, University of Leicester, Leicester, UK
| | - Elizabeth J Shaw
- National Institute for Health and Clinical Excellence, Manchester, UK
| | - Francine Cheater
- Institute of Health and Wellbeing, Glasgow Caledonian University, Glasgow, UK
| | - Signe Flottorp
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Noelle Robertson
- School of Psychology (Clinical Section), Leicester University, Leicester, UK
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Houston TK, Richman JS, Ray MN, Allison JJ, Gilbert GH, Shewchuk RM, Kohler CL, Kiefe CI. Internet delivered support for tobacco control in dental practice: randomized controlled trial. J Med Internet Res 2008; 10:e38. [PMID: 18984559 PMCID: PMC2630831 DOI: 10.2196/jmir.1095] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 06/30/2008] [Accepted: 07/12/2008] [Indexed: 02/01/2023] Open
Abstract
Background The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized. Objective To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings. Methods Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention. Results Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices’ mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK. Conclusion This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit. Trial Registration clinicaltrials.gov NCT00627185; http://clinicaltrials.gov/ct2/show/NCT00627185 (Archived by WebCite at http://www.webcitation.org/5c5Kugvzj)
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Affiliation(s)
- Thomas K Houston
- Surgical and Medical Acute care and Advanced illness Research and Transition sciences (SMAART) Center, VA HSR&D REAP, Birmingham VA Medical Center, Birmingham, AL, USA.
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