Enhancing the quality of psychological interventions delivered by telephone in mental health services: increasing the likelihood of successful implementation using a theory of change

BACKGROUND

The implementation of new and complex interventions in mental health settings can be challenging. This paper explores the use of a Theory of Change (ToC) for intervention design and evaluation to increase the likelihood of complex interventions being effective, sustainable, and scalable. Our intervention was developed to enhance the quality of psychological interventions delivered by telephone in primary care mental health services.

METHODS

A ToC represents how our designed quality improvement intervention targeting changes at service, practitioner, and patient levels was expected to improve engagement in, and the quality of, telephone-delivered psychological therapies. The intervention was evaluated following implementation in a feasibility study within three NHS Talking Therapies services through a qualitative research design incorporating semi-structured interviews and a focus group with key stakeholders (patients, practitioners, and service leads) (N = 15). Data were analysed using the Consolidated Framework for Implementation Research (CFIR) and the ToC was examined and modified accordingly following the findings.

RESULTS

CFIR analysis highlighted a set of challenges encountered during the implementation of our service quality improvement telephone intervention that appeared to have weakened the contribution to the change mechanisms set out by the initial ToC. Findings informed changes to the intervention and refinement of the ToC and are expected to increase the likelihood of successful future implementation in a randomised controlled trial.

CONCLUSIONS

Four key recommendations that could help to optimise implementation of a complex intervention involving different key stakeholder groups in any setting were identified. These include: 1-developing a good understanding of the intervention and its value among those receiving the intervention; 2-maximising engagement from key stakeholders; 3-ensuring clear planning and communication of implementation goals; and 4-encouraging the use of strategies to monitor implementation progress.

Evidence that an intervention weakens the relationship between adolescent electronic cigarette use and tobacco smoking: a 24-month prospective study

BACKGROUND

The electronic cigarette (e-cigarette) use to subsequent smoking relationship in adolescents has received much attention. Whether an intervention to reduce smoking initiation attenuated this relationship was assessed.

METHOD

Data were from 3994 adolescent never smokers (aged 13-14 years at baseline) as part of a cluster randomised controlled trial. Self-report measures of smoking, e-cigarette use and covariates were assessed and used to predict ever smoked cigarettes, any recent tobacco smoking and regularly smoked cigarettes at 24-month follow-up.

RESULTS

Baseline ever use of e-cigarettes was associated with ever smoked cigarettes (OR=4.03, 95% CI 3.33 to 4.88; controlling for covariates, OR=2.78, 95% CI 2.20 to 3.51), any recent tobacco smoking (OR=3.38, 95% CI 2.72 to 4.21; controlling for covariates, OR=2.17, 95% CI 1.76 to 2.69) and regularly smoked cigarettes (OR=3.60, 95% CI 2.35 to 5.51; controlling for covariates, OR=1.27, 95% CI 1.17 to 1.39) at follow-up. For ever smoked cigarettes only, the impact of e-cigarette use was attenuated in the intervention (OR=1.83) compared with control (OR=4.53) condition. For ever smoked cigarettes and any recent tobacco smoking, the impact of e-cigarette use was attenuated among those with friends who smoked (OR=2.05 (ever smoked); 1·53 (any tobacco use)) compared with those without friends who smoked (OR=3.32 (ever smoked); 2·17 (any tobacco use)).

CONCLUSIONS

This is one of the first studies to show that e-cigarette use was robustly associated with measures of smoking over 24 months and the first to show an intervention to attenuate the relationship. Further research with a broader age range of adolescents is required.

Who is responsible for keeping children healthy? A qualitative exploration of the views of children aged 8-10 years old

OBJECTIVE

The issue of who is responsible for children's physical health is complex, with implications for targeting and developing strategies for health promotion and interventions to improve health. While there is evidence to suggest that children are able to construct notions of responsibility in relation to other areas of their lives, very little research has explored children's views of responsibility for their own health. The aim of this study was to explore children's views about who they feel is responsible for keeping them healthy.

DESIGN

Focus groups were used to gather qualitative data using a semistructured topic guide. Interpretative phenomenological analysis was used in an iterative, double hermeneutic approach to analyse the data.

SETTING

Focus groups took place in two UK primary schools in deprived inner city areas.

PARTICIPANTS

20 children aged 8-10 years took part in one of two focus groups (10 children in each group).

RESULTS

Three overarching themes were identified: (1) individual and collective responsibility, (2) marketing and conflict with taking responsibility, and (3) what people and organisations can do to help children to take responsibility. Children feel that they, parents, families, school staff, medical professionals, food producers, retail outlets, supermarkets, advertisers and the government are all responsible for their health and should thus demonstrate responsibility through their behaviours around children's health.

CONCLUSIONS AND IMPLICATIONS

Children's views were consistent with constructs of responsibility as both a moral obligation and a set of behaviours, and with wider sociopolitical philosophies of individual and collective responsibility. These findings further support a focus on integrated, system-wide approaches to children's health.

Study protocol: A cluster randomised controlled trial of implementation intentions to reduce smoking initiation in adolescents

Background

The current literature suggests that forming implementation intentions (simple ‘if-then’ plans) about how to refuse the offer of a cigarette may be an effective intervention to reduce smoking initiation in adolescents. This study is a pragmatic trial to test the effectiveness and cost-effectiveness of such an intervention in reducing smoking initiation in a sample of UK adolescents.

Methods/Design

A cluster randomised controlled trial with at least 36 schools randomised to receive an implementation intention intervention targeting reducing smoking initiation (intervention group) or increasing homework (control group). Interventions will be conducted at the classroom level and be repeated every six months for four years (eight interventions). Objectively assessed (carbon monoxide monitor) and self-reported smoking plus smoking related cognitions (e.g., smoking intentions, attitudes, norms and self-efficacy) will be assessed at baseline and 12, 24, 36 and 48 months post baseline. Objectively assessed smoking at 48 months post baseline will be the primary outcome variable. Health economic analyses will assess life years gained.

Discussion

The results of the trial will provide information on the impact of a repeated implementation intention for refusing offers of cigarettes on rates of smoking initiation in adolescents.

Trial registration

ISRCTN27596806

Giving Formative Feedback in Higher Education

There is substantial interest in increased use of formative assessment in higher education. We report on the introduction of a minimal formative assessment measure. Tutors on a level one undergraduate psychology course provided assessment of individual student contribution to tutorials. Using a combination of rating scales and open-ended questions, we examined student (n = 49) and tutor (n = 8) perceptions of the impact of this assessment measure. Students reported increases in their perceptions of preparation, contribution, motivation and reward as a result of the assessment, whereas tutors did not. Implications for higher education practice and theory are discussed.

Are we getting the message across? Trends among young men attending an inner city young people's clinic

BACKGROUND

A young people's clinic has been running at the Archway Sexual Health Clinic since 1997. This offers a weekly walk-in service to both young men and women under 20 years old.

OBJECTIVES

To review the audit data of over 7 years' experience from the dedicated young people's clinic at the Archway Sexual Health Clinic, the "Arch."

METHODS

These data were collected by retrospective notes review of a consecutive series of all male attendees over a 7 year period from 1997 to the end of 2003 with collection of data in Microsoft Excel database.

RESULTS

These figures show an overall increase in attendee numbers, but also a relative rise in the numbers of young men using the service. A high number of bacterial sexually transmitted infections were detected. In 2001 and 2003 respectively, 14.5% and 17.8% of the young men using the service were diagnosed with Chlamydia trachomatis. A user survey aimed to identify factors that may be encouraging the young men to access the service.

CONCLUSIONS

Responding to the views of young men using the service has played a part in service development. Initiatives at the "Arch" such as the condom policy and choice of gender of staff may be factors encouraging increasing attendances. Continuing to work with other agencies to develop ways to engage young men are recommended. Word of mouth recommendation cannot be underestimated in publicising the service.

Changing Student Evaluations by Means of the Numeric Values of Rating Scales

Student evaluation of modules is central to quality management and enhancement within higher education. However, the manner in which questionnaires are designed may inadvertently bias responses. Fifty-seven level 1 undergraduate students (45 women, 12 men) were randomised to evaluate an introductory psychology module on either bipolar (−2 to +2, n = 29) or unipolar (1 to 5, n = 28) scales. Consistent with previous research, ratings on bipolar scales generally elicited more positive evaluations than ratings on unipolar scales. The effects of the numeric values of rating scales were most pronounced when more abstract questions (e.g. ‘overall, how enjoyable was the module?’) than when more concrete questions (e.g. ‘how much did you contribute?’) were asked. Implications of the research for theory and practice in higher education are discussed.

Hormonal changes and mood in the puerperium

This investigation is an attempt to test the common supposition that postpartum emotional disturbance is related to hormone changes. A group of 27 normal pregnant women were assessed three times before delivery and sixteen times in the six weeks following delivery. During the first two interviews baseline data on personality and other personal variables were obtained. On each occasion blood was taken and three measures of clinical status and mood were completed. Plasma LH, FSH, total oestrogen and progesterone results are presented in detail and the results of prolactin assays mentioned more briefly. An attempt to correlate hormone findings and clinical findings is described. This failed to produce any strong evidence that hormones are related to mood at this time, although hormone changes were correlated weakly with a few specific symptoms. Some of the unexpected clinical findings and technical difficulties of the study are discussed, with special reference to possible further research in this area.