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Perry R, Herbert G, Atkinson C, England C, Northstone K, Baos S, Brush T, Chong A, Ness A, Harris J, Haase A, Shah S, Pufulete M. Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis. BMJ Open 2021; 11:e050806. [PMID: 34593498 PMCID: PMC8487197 DOI: 10.1136/bmjopen-2021-050806] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020). SETTING Secondary care. PARTICIPANTS Patients (≥18 years) undergoing major elective surgery (curative or palliative). INTERVENTIONS Any intervention administered in the preoperative period with the aim of improving postoperative outcomes. OUTCOMES AND MEASURES Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use. REVIEW METHODS Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials. RESULTS 178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64). CONCLUSIONS Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low. PROSPERO REGISTRATION NUMBER CRD42015019191.
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Affiliation(s)
- Rachel Perry
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Georgia Herbert
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Charlotte Atkinson
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Clare England
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
- Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK
| | - Kate Northstone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Baos
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim Brush
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Chong
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Andy Ness
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
- School of Oral and Dental Science, University of Bristol, Bristol, UK
| | - Jessica Harris
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Anne Haase
- Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - Sanjoy Shah
- University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
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Papas RK, Gakinya BN, Mwaniki MM, Lee H, Keter AK, Martino S, Klein DA, Liu T, Loxley MP, Sidle JE, Schlaudt K, Nafula T, Omodi VM, Baliddawa JB, Kinyanjui DW, Maisto SA. A randomized clinical trial of a group cognitive-behavioral therapy to reduce alcohol use among human immunodeficiency virus-infected outpatients in western Kenya. Addiction 2021; 116:305-318. [PMID: 32422685 PMCID: PMC7671944 DOI: 10.1111/add.15112] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/28/2019] [Accepted: 05/11/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Culturally relevant and feasible interventions are needed to address limited professional resources in sub-Saharan Africa for behaviorally treating the dual epidemics of HIV and alcohol use disorder. This study tested the efficacy of a cognitive-behavioral therapy (CBT) intervention to reduce alcohol use among HIV-infected outpatients in Eldoret, Kenya. DESIGN Randomized clinical trial. SETTING A large HIV outpatient clinic in Eldoret, Kenya, affiliated with the Academic Model Providing Access to Healthcare collaboration. PARTICIPANTS A total of 614 HIV-infected outpatients [312 CBT; 302 healthy life-styles (HL); 48.5% male; mean age: 38.9 years; mean education 7.7 years] who reported a minimum of hazardous or binge drinking. INTERVENTION AND COMPARATOR A culturally adapted six-session gender-stratified group CBT intervention compared with HL education, each delivered by paraprofessionals over six weekly 90-minute sessions with a 9-month follow-up. MEASUREMENTS Primary outcome measures were percentage of drinking days (PDD) and mean drinks per drinking day (DDD) computed from retrospective daily number of drinks data obtained by use of the time-line follow-back from baseline to 9 months post-intervention. Exploratory analyses examined unprotected sex and number of partners. FINDINGS Median attendance was six sessions across condition. Retention at 9 months post-intervention was high and similar by condition: CBT 86% and HL 83%. PDD and DDD marginal means were significantly lower in CBT than HL at all three study phases. Maintenance period, PDD - CBT = 3.64 (0.696), HL = 5.72 (0.71), mean difference 2.08, 95% confidence interval (CI) = 0.13 - 4.04; DDD - CBT = 0.66 (0.96), HL = 0.98 (0.098), mean difference = 0.31, 95% CI = 0.05 - 0.58. Risky sex decreased over time in both conditions, with a temporary effect for CBT at the 1-month follow-up. CONCLUSIONS A cognitive-behavioral therapy intervention was more efficacious than healthy lifestyles education in reducing alcohol use among HIV-infected Kenyan outpatient drinkers.
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Affiliation(s)
| | - Benson N. Gakinya
- Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | | | - Hana Lee
- Brown University School of Public Health, Providence, RI, USA
| | - Alfred K. Keter
- Academic Model providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Steve Martino
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Tao Liu
- Brown University School of Public Health, Providence, RI, USA
| | | | - John E. Sidle
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Tobista Nafula
- Academic Model providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Victor M. Omodi
- Academic Model providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Joyce B. Baliddawa
- Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Daniel W. Kinyanjui
- Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
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Cognitive behavioural therapy training in Tanzania: a qualitative study of clinicians’ experiences. COGNITIVE BEHAVIOUR THERAPIST 2019. [DOI: 10.1017/s1754470x19000084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractCognitive behaviour therapy (CBT) in an effective technique used widely in Western countries. However, there is limited evidence as to the utility, perception and understanding of CBT in developing countries. This study describes and investigates the experience of CBT training and practice in a group of practitioners in Tanzania. A qualitative approach to the investigation was used, and seven participants from Tanzania’s only psychiatric hospital who had completed CBT training were interviewed. The resulting verbatim transcripts were analysed via interpretative phenomenological analysis. Five superordinate themes emerged from the analysis: ‘the medical model’, ‘novelty’, ‘practicalities’, ‘process’ and ‘therapist effects’. The two themes ‘therapist effects’ and ‘process’ are discussed in detail as these may be particularly relevant to the clinical application of the therapy in a new culture and context. The implications for future development of CBT in Tanzania are considered. In developing CBT for dissemination in Tanzania, specific cultural and clinical issues highlighted by indigenous clinicians need consideration.Key learning aims(1)To identify what range of factors may influence clinicians’ perception of and learning about CBT when CBT training is delivered in a mental health setting in Tanzania, or to those with East African origins.(2)To consider the use of qualitative research approaches to inform the early stages of adapting CBT for use in new settings and applications.(3)To be able to apply knowledge about cultural differences to standard CBT in order to promote culturally sensitive practice.
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Galárraga O, Gao B, Gakinya BN, Klein DA, Wamai RG, Sidle JE, Papas RK. Task-shifting alcohol interventions for HIV+ persons in Kenya: a cost-benefit analysis. BMC Health Serv Res 2017; 17:239. [PMID: 28351364 PMCID: PMC5371255 DOI: 10.1186/s12913-017-2169-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and poor adherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problems remains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention’s cost-effectiveness in dollars-per-health-outcome, and the long-term economic impact —or “return on investment” in monetary terms. Methods We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440 outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across a six-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administering task-shifted CBT therapy. Benefits included the economic impact of lowered HIV incidence as well as the improvements in household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses to test the robustness of our results. Results Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and the benefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratio remained above unity indicating that the intervention was cost-saving (i.e., had positive return on investment). The duration of the treatment effect most effected the results in sensitivity analyses. Conclusions CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The intervention can generate not only reductions in morbidity and mortality, but also economic savings for the health system in the medium and long term. The findings have implications for other countries with generalized HIV epidemics, high prevalence of alcohol consumption, and shortages of mental health professionals. Trial registration This paper uses data derived from “Cognitive Behavioral Treatment to Reduce Alcohol Use Among HIV-Infected Kenyans (KHBS)” with ClinicalTrials.gov registration NCT00792519 on 11/17/2008; and preliminary data from “A Stage 2 Cognitive-behavioral Trial: Reduce Alcohol First in Kenya Intervention” (NCT01503255, registered on 12/16/2011).
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Affiliation(s)
- Omar Galárraga
- Brown University School of Public Health, G-S121-7, 121 South Main Street, Providence, RI, 02912, USA
| | - Burke Gao
- Brown University School of Public Health, G-S121-7, 121 South Main Street, Providence, RI, 02912, USA.,Brown University Alpert Medical School, 222 Richmond Street, Providence, RI, 02912, USA
| | - Benson N Gakinya
- Moi University & Moi Teaching and Referral Hospital, Nandi Rd, Eldoret, Kenya
| | | | - Richard G Wamai
- Northeastern University, Integrated Initiative for Global Health, 360 Huntington Avenue, 220G RP, Boston, MA, 02115, USA
| | - John E Sidle
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rebecca K Papas
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, 02912, USA.
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Papas RK, Sidle JE, Gakinya BN, Baliddawa JB, Martino S, Mwaniki MM, Songole R, Omolo OE, Kamanda AM, Ayuku DO, Ojwang C, Owino-Ong'or WD, Harrington M, Bryant KJ, Carroll KM, Justice AC, Hogan JW, Maisto SA. Treatment outcomes of a stage 1 cognitive-behavioral trial to reduce alcohol use among human immunodeficiency virus-infected out-patients in western Kenya. Addiction 2011; 106:2156-66. [PMID: 21631622 PMCID: PMC3208780 DOI: 10.1111/j.1360-0443.2011.03518.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Dual epidemics of human immunodeficiency virus (HIV) and alcohol use disorders, and a dearth of professional resources for behavioral treatment in sub-Saharan Africa, suggest the need for development of culturally relevant and feasible interventions. The purpose of this study was to test the preliminary efficacy of a culturally adapted six-session gender-stratified group cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use among HIV-infected out-patients in Eldoret, Kenya. DESIGN Randomized clinical trial comparing CBT against a usual care assessment-only control. SETTING A large HIV out-patient clinic in Eldoret, Kenya, part of the Academic Model for Providing Access to Healthcare collaboration. PARTICIPANTS Seventy-five HIV-infected out-patients who were antiretroviral (ARV)-initiated or ARV-eligible and who reported hazardous or binge drinking. MEASUREMENTS Percentage of drinking days (PDD) and mean drinks per drinking days (DDD) measured continuously using the Time line Follow back method. FINDINGS There were 299 ineligible and 102 eligible out-patients with 12 refusals. Effect sizes of the change in alcohol use since baseline between the two conditions at the 30-day follow-up were large [d=0.95, P=0.0002, mean difference=24.93, 95% confidence interval (CI): 12.43, 37.43 PDD; d=0.76, P=0.002, mean difference=2.88, 95% CI: 1.05, 4.70 DDD]. Randomized participants attended 93% of the six CBT sessions offered. Reported alcohol abstinence at the 90-day follow-up was 69% (CBT) and 38% (usual care). Paraprofessional counselors achieved independent ratings of adherence and competence equivalent to college-educated therapists in the United States. Treatment effect sizes were comparable to alcohol intervention studies conducted in the United States. CONCLUSIONS Cognitive-behavioral therapy can be adapted successfully to group paraprofessional delivery in Kenya and may be effective in reducing alcohol use among HIV-infected Kenyan out-patients.
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Affiliation(s)
- Rebecca K Papas
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI 02906,USA.
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Papas RK, Sidle JE, Martino S, Baliddawa JB, Songole R, Omolo OE, Gakinya BN, Mwaniki MM, Adina JO, Nafula T, Owino-Ong'or WD, Bryant KJ, Carroll KM, Goulet JL, Justice AC, Maisto SA. Systematic cultural adaptation of cognitive-behavioral therapy to reduce alcohol use among HIV-infected outpatients in western Kenya. AIDS Behav 2010; 14:669-78. [PMID: 19967441 PMCID: PMC2949418 DOI: 10.1007/s10461-009-9647-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Two-thirds of those with HIV worldwide live in sub-Saharan Africa. Alcohol use is associated with the HIV epidemic through risky sex and suboptimal ARV adherence. In western Kenya, hazardous drinking was reported by HIV (53%) and general medicine (68%) outpatients. Cognitive behavioral treatment (CBT) has demonstrated strong efficacy to reduce alcohol use. This article reports on a systematic cultural adaptation and pilot feasibility study of group paraprofessional-delivered CBT to reduce alcohol use among HIV-infected outpatients in Eldoret, Kenya. Following adaptation and counselor training, five pilot groups were run (n = 27). Overall attendance was 77%. Percent days abstinent from alcohol (PDA) before session 1 was 52-100% (women) and 21-36% (men), and by session 6 was 96-100% (women) and 89-100% (men). PDA effect sizes (Cohen's d) between first and last CBT session were 2.32 (women) and 2.64 (men). Participants reported treatment satisfaction. Results indicate feasibility, acceptability and preliminary efficacy for CBT in Kenya.
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Affiliation(s)
- Rebecca K Papas
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
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