Do health education initiatives assist socioeconomically disadvantaged populations? A systematic review and meta-analyses

[Educational strategy for prevention of cervical cancer in Indigenous peoples: a participatory action research experience]

This study aimed to evaluate changes in knowledge, attitudes, and practices on cervical cancer after an educational intervention in the framework of participatory action research with Indigenous peoples of the El Paujil reservation, Guainía, Colombia. A diagnosis was made with an intercultural and participatory approach. Subsequently, the educational strategy was designed and implemented. Community leaders actively participated in the research during all stages. The strategy was evaluated via a survey on knowledge, attitudes, and practices about cervical cancer. The effects were determined by comparing pre- and post-intervention questionnaires with the Mann-Whitney and chi-squared tests. Overall, 957 women participated in the educational strategy. The level of knowledge about cervical cancer significantly improved, increasing from 8.5% to 12.5%, before and after the intervention (p < 0.001), respectively. The percentage of Pap smear testing also increased, from 64.4% to 73.9% (p = 0.0467). However, the limited knowledge about the relationship between HPV and cervical cancer, and about risk factors such as multiparity or early initiation of sexual intercourse remained the same. After the intervention, a significant increase in the knowledge of women with low educational level was found. Health education with an intercultural approach within the participatory action research framework is effective in improving knowledge and practices for the prevention of cervical cancer in vulnerable communities. However, for optimal results, it is important to hold long-term projects in order to build trust relationships with the communities.

The Application of Cognitive Load Theory to the Design of Health and Behavior Change Programs: Principles and Recommendations

Health and behavior change programs play a crucial role in improving health behaviors at individual and family levels. However, these programs face challenges with engagement and retention and typically show modest efficacy. Cognitive load theory is an established and highly used educational theory that proposes individuals have a finite capacity to process new information ("working memory"). Learning, engagement, and performance are negatively impacted when working memory is exceeded. Cognitive load theory is grounded in an understanding of human cognition and conceptualizes different types of cognitive loads imposed on individuals by a learning experience. Cognitive load theory aims to guide the design of learning experiences, considering how the human mind works, leading to more meaningful and effective learning. Cognitive load theory is increasingly applied to domains outside the classroom, such as designing patient and clinical education. Applying cognitive load theory to the design of health programs, their materials, and interfaces can provide insights. By considering the cognitive demands placed on individuals when interacting with health programs, design can be optimized to reduce cognitive load and better facilitate learning and behavior adoption. This may enhance engagement, retention, and effectiveness of programs. Cognitive load theory may be particularly valuable for individuals with diminished working memory due to high levels of mental load and stress. Design principles are presented to consolidate knowledge from cognitive load theory and existing approaches to guide researchers, policymakers, and health programmers. Further research and interdisciplinary collaboration are needed to realize the potential of cognitive load theory in health.

Insights for dementia risk reduction among lower SES adults in OECD countries: scoping review of interventions targeting multiple common health risk factors

The number of people living with dementia is expected to rise to 153 million cases globally by 2050. This will come at a high economic and human cost to societies with disproportionate effects on socioeconomically disadvantaged groups who experience greater exposures to- and fewer protections from- the environmental, social and behavioural drivers of dementia risk. Almost half (45%) of dementia incidence could theoretically be prevented or delayed by addressing 14 modifiable risk factors. While several studies have demonstrated the feasibility of multidomain dementia risk reduction interventions in relatively older, educated and wealthy populations, we are not aware of any studies to date explicitly targeting younger adults (< 50 years) with lower socioeconomic status. To inform future strategies, we conducted a scoping review of intervention studies targeting multiple 'dementia-related' risk factors among adults with lower socioeconomic status in developed country contexts. We identified 1003 unique records; 34 met our criteria for inclusion - involving more than 17,500 participants from 13 countries. While none of the studies explicitly targeted dementia risk reduction, they reported on 30 relevant multidomain interventions targeting common risk factors associated with dementia including; diet (28), physical inactivity (27), obesity (22), diabetes (9), hypertension (8), smoking (6), alcohol use (6), depression (3) and social isolation (1). While most studies recorded positive effects on one or more health behaviours, there was a diversity in the design, approach and outcomes of interventions, with significant intervention effects being associated with the use of a wider range of behaviour change techniques. We suggest that designing interventions to reduce dementia risk and disparities requires a high degree of contextual specificity and propose a structured and participatory approach.

Increasing access to pain care services to improve rural pain management: a realist review investigating factors affecting uptake, implementation, and sustainability

ABSTRACT

Guideline-based care for chronic pain is challenging to deliver in rural settings. Evaluations of programs that increase access to pain care services in rural areas report variable outcomes. We conducted a realist review to gain a deep understanding of how and why such programs may, or may not, work. Our review incorporated interest-holder input in all review phases. We conducted CLUSTER searching to identify literature relevant to understanding the factors affecting the uptake, implementation, and sustainability of programs offering pain care services to rural general practitioners. We used retroductive analysis to generate and test context-mechanism-outcome configurations. Our results are informed by 74 studies. We identified that awareness of the program, provision of necessary resources, and positive attitudes towards the program are required to enable program uptake. When looking for suitable patients to refer, general practitioners need to trust their ability to discuss a referral with a patient in their allocated appointment time. Program sustainability requires clear roles for all providers and sufficient program coordination. Increased access to pain care services enabled interprofessional learning that increased local providers' confidence to manage chronic pain. Many barriers can interfere with successful uptake, implementation, and sustainability of programs that increase access to pain care services in rural settings. It is important to tailor rural workforce programs to local community needs to increase the likelihood of success. Our findings include recommendations for future program planners to consider.

Multiple chronic diseases and psychological distress among adults in the United States: the intersectionality of chronic diseases, race/ethnicity, immigration, sex, and insurance coverage

PURPOSE

Psychological distress significantly contributes to the burdens of morbidity and mortality in the United States (U.S.), but our understanding is limited with regards to the risk factors associated with psychological distress. We used nationally representative data to examine (1) the comorbidities of chronic diseases and their risks for psychological distress and (2) the ways in which chronic diseases combine with demographic factors such as sex, race/ethnicity, immigration status, and health insurance coverage to affect the patterning of psychological distress.

METHODS

We analyzed the 2005-2018 National Health Survey Interview cross-sectional data on U.S. adults aged ≥ 18 years (n = 351,457). We fitted sequential multivariable logistic regression models.

RESULTS

There was a dose-response relationship between the number of chronic diseases and psychological distress, with increased number of chronic diseases associated with increased psychological distress risk. Females (vs. males) and those without health insurance (vs. insured) were more likely to experience psychological distress. Immigrants (vs. non-immigrants) and racial/ethnic minorities (vs. White individuals) were less likely to experience psychological distress. There were significant interactions between chronic diseases and insurance coverage, immigration status, and race/ethnicity, but the three-way interactions were not statistically significant with psychological distress: chronic disease status vs. immigration status vs. health insurance coverage, and chronic disease vs. race/ethnicity vs. immigration status.

CONCLUSION

The findings suggest a critical need to consider the complex ways in which chronic diseases and psychosocial factors combine to affect psychological distress and their implications for tailoring mental health screening, initiatives to reduce distress, and prevention strategies for effectively addressing health-related disparities in the general population.

Community Paramedicine Program in Social Housing and Health Service Utilization: A Cluster Randomized Clinical Trial

Importance

Community Paramedicine at Clinic (CP@clinic) is a chronic disease prevention program that decreases 911 calls for emergency medical services, but its wider system effects are unknown.

Objective

To evaluate the effects of CP@clinic vs usual care on individual-level health service utilization outcomes.

Design, Setting, and Participants

This open-label, pragmatic cluster randomized clinical trial evaluated all residents 55 years or older in 30 social housing buildings in Ontario, Canada, that had (1) a unique postal code, (2) at least 50 apartments, (3) 60% or more residents 55 years or older, and (4) a similar building for pairing (15 intervention and 15 control buildings, pair-matched randomization). The 12-month intervention had a staggered start date from January 1, 2015, to December 1, 2015, and ended between December 31, 2015, and November 30, 2016. Administrative health data analysis was conducted in May 2022.

Intervention

CP@clinic was a health promotion and disease prevention program led by specially trained community paramedics who held weekly drop-in sessions in social housing buildings. These paramedics conducted 1-on-1 risk assessments, provided health education and referrals to relevant community resources, and, with consent, sent assessments to family physicians. Control buildings received usual care (universal health care, including free primary and specialty medical care).

Main Outcome and Measures

Individual-level health service utilization was measured from administrative health data, with ED visits via ambulance as the primary outcome; secondary outcomes included ED visits for any reason, primary care visits, hospitalizations, length of hospital stay, laboratory tests, receipt of home care, transfer to long-term care, and medication initiation. Generalized estimating equations were used to estimate intervention effects on individual-level health service utilization, accounting for trial design and individual-level baselines.

Results

The 30 social housing buildings had 3695 residents (1846 control and 1849 intervention participants; mean [SD] age, 72.8 [9.1] years; 2400 [65.0%] female). Intention-to-treat analysis found no significant difference in ED visits by ambulance (445 of 1849 [24.1%] vs 463 of 1846 [25.1%]; adjusted odds ratio [AOR], 0.97; 95% CI, 0.89-1.05) but found higher antihypertensive medication initiation (74 of 500 [14.8%] vs 47 of 552 [8.5%]; AOR, 1.74; 95% CI, 1.19-2.53) and lower anticoagulant initiation (48 of 1481 [3.2%] vs 69 of 1442 [4.8%]; AOR, 0.68; 95% CI, 0.53-0.86) in the intervention arm vs the control arm. CP@clinic attendance was associated with higher incidence of primary care visits (adjusted incidence rate ratio, 1.10; 95% CI, 1.03-1.17), higher odds of receiving home care (AOR, 1.07; 95% CI, 1.01-1.13), and lower odds of long-term care transfers (AOR, 0.32; 95% CI, 0.13-0.81).

Conclusions and Relevance

In this cluster randomized clinical trial of CP@clinic, the intervention did not affect the rate of ED visits by ambulance; however, there were increased primary care visits and connections to home care services, which may have increased antihypertensive medication initiation and reduced long-term care transfers from social housing. Health policymakers should consider CP@clinic's impact as an upstream approach to improve care for older adults with low income.

Trial Registration

ClinicalTrials.gov Identifier: NCT02152891.

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Effects of non-pharmacological interventions for adults with subjective cognitive decline: a network meta-analysis and component network meta-analysis

BACKGROUND

Non-pharmacological interventions have a myriad of available intervention options and contain multiple components. Whether specific components of non-pharmacological interventions or combinations are superior to others remains unclear. The main aim of this study is to compare the effects of different combinations of non-pharmacological interventions and their specific components on health-related outcomes in adults with subjective cognitive decline.

METHODS

PubMed, Embase, Cochrane, CINAHL, PsycINFO, CENTRAL, Web of Science, and China's two largest databases, CNKI and Wanfang, were searched from inception to 22nd, January 2023. Randomized controlled trials using non-pharmacological interventions and reporting health outcomes in adults with subjective cognitive decline were included. Two independent reviewers screened studies, extracted data, and assessed risk of bias. Component network meta-analysis was conducted employing an additive component model for network meta-analysis. This study followed the PRISMA reporting guideline and the PRISMA checklist is presented in Additional file 2.

RESULTS

A total of 39 trials with 2959 patients were included (range of mean ages, 58.79-77.41 years). Resistance exercise might be the optimal intervention for reducing memory complaints in adults with subjective cognitive decline; the surface under the cumulative ranking p score was 0.888, followed by balance exercise (p = 0.859), aerobic exercise (p = 0.832), and cognitive interventions (p = 0.618). Music therapy, cognitive training, transcranial direct current stimulation, mindfulness therapy, and balance exercises might be the most effective intervention components for improving global cognitive function (iSMD, 0.83; 95% CI, 0.36 to 1.29), language (iSMD, 0.31; 95% CI, 0.24 to 0.38), ability to perform activities of daily living (iSMD, 0.55; 95% CI, 0.21 to 0.89), physical health (iSMD, 3.29; 95% CI, 2.57 to 4.00), and anxiety relief (iSMD, 0.71; 95% CI, 0.26 to 1.16), respectively.

CONCLUSIONS

The form of physical activity performed appears to be more beneficial than cognitive interventions in reducing subjective memory complaints for adults with subjective cognitive decline, and this difference was reflected in resistance, aerobic, and balance exercises. Randomized clinical trials with high-quality and large-scale are warranted to validate the findings.

TRIAL REGISTRATION

PROSPERO registry number. CRD42022355363.

Teaching Patients About Pain: The Emergence of Pain Science Education, its Learning Frameworks and Delivery Strategies

Since it emerged in the early 2000's, intensive education about 'how pain works', widely known as pain neuroscience education or explaining pain, has evolved into a new educational approach, with new content and new strategies. The substantial differences from the original have led the PETAL collaboration to call the current iteration 'Pain Science Education'. This review presents a brief historical context for Pain Science Education, the clinical trials, consumer perspective, and real-world clinical data that have pushed the field to update both content and method. We describe the key role of educational psychology in driving this change, the central role of constructivism, and the constructivist learning frameworks around which Pain Science Education is now planned and delivered. We integrate terminology and concepts from the learning frameworks currently being used across the PETAL collaboration in both research and practice-the Interactive, Constructive, Active, Passive framework, transformative learning theory, and dynamic model of conceptual change. We then discuss strategies that are being used to enhance learning within clinical encounters, which focus on the skill, will, and thrill of learning. Finally, we provide practical examples of these strategies so as to assist the reader to drive their own patient pain education offerings towards more effective learning. PERSPECTIVE: Rapid progress in several fields and research groups has led to the emergence 'Pain Science Education'. This PETAL review describes challenges that have spurred the field forward, the learning frameworks and educational strategies that are addressing those challenges, and some easy wins to implement and mistakes to avoid.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

Multidomain Dementia Risk Reduction in Primary Care is Feasible: A Proof-of-concept study

Background

Dementia risk reduction is a public health priority, but interventions that can be easily implemented in routine care are scarce.

Objective

To evaluate the feasibility of integrating dementia risk reduction in regular consultations in primary care and the added value of a dedicated smartphone app ('MyBraincoach').

Methods

188 participants (40-60 years), with modifiable dementia risk factors were included from ten Dutch general practices in a cluster-randomized trial (NL9773, 06/10/2021). Practices were randomly allocated (1 : 1) to provide a risk-reduction consultation only or to additionally provide the app. During the consultation, participants learned about dementia risk reduction and how to improve their risk profile. The app group received daily microteaching-notifications about their personally relevant risk factors. Feasibility was evaluated after 3 months using questionnaires assessing knowledge on dementia risk reduction and health behavior change. The primary outcome was change in the validated "LIfestyle for BRAin health" (LIBRA) score. In-depth interviews were conducted with participants and primary care providers (PCPs).

Results

The interventions were positively perceived, with 72.0% finding the consultation informative and 69.2% considering the app useful. Drop-out was low (6.9%). LIBRA improved similarly in both groups, as did Mediterranean diet adherence and body mass index. Knowledge of dementia risk reduction increased, but more in the app group. Interviews provided insight in participants' and PCPs' needs and wishes.

Conclusions

Integrating dementia risk reduction in primary care, supported by a smartphone app, is a viable approach towards dementia risk reduction. Larger trials are needed to establish (cost-)effectiveness.

Ethnic differences of the care pathway following an out-of-hospital cardiac event: A systematic review

AIM

This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations.

METHODS

A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines.

RESULTS

Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies.

CONCLUSION

The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations.