Barriers and facilitators to use of compression therapy by people with venous leg ulcers: A qualitative exploration

AIMS

To explore barriers to, and facilitators of, adherence to compression therapy, from the perspective of people with venous leg ulcers.

DESIGN

An interpretive, qualitative, descriptive study involving interviews with patients.

METHODS

Participants were purposively sampled from respondents to a survey exploring attitudes to compression therapy in people with venous leg ulcers. Sampling continued until data saturation: 25 interviews between December 2019 and July 2020. Inductive thematic analysis of interview transcripts was undertaken to create a framework for the data, followed by deductive analysis informed by the Common-Sense Model of Self-Regulation.

RESULTS

A range of knowledge and understanding about the cause of venous leg ulcers and the mechanisms of compression therapy was demonstrated, which was not particularly related to adherence. Participants talked about their experience with different compression methods and their concerns about the length of time healing could take. They also spoke about aspects of the organization of services which affected their care.

CONCLUSION

Identifying specific, individual barriers/facilitators to compression therapy is not simple, rather factors combine to make adherence more or less likely or possible. There was no clear relationship between an understanding of the cause of VLUs or the mechanism of compression therapy and adherence; different compression therapies presented different challenges for patients; unintentional non-adherence was frequently mentioned; and the organization of services could impact on adherence. Ways in which people could be supported to adhere to compression therapy are indicated. Implications for practice include issues relating to communication with patients; taking into account patients' lifestyles and ensuring that they know about useful 'aids'; providing services that are accessible and provide continuity of appropriately trained staff; minimizing unintentional non-adherence; and acknowledging that healthcare professionals will always need to support/advise those who cannot tolerate compression.

IMPACT

Compression therapy is a cost-effective, evidence-based treatment for venous leg ulcers. However, there is evidence that patients do not always adhere to this therapy and there is limited research investigating reasons why patients do not wear compression. The study found no clear relationship between an understanding of the cause of VLUs or the mechanism of compression therapy and adherence; that different compression therapies presented different challenges for patients; that unintentional non-adherence was frequently mentioned and that the organization of services could impact on adherence. Attending to these findings offers the opportunity to increase the proportion of people undergoing appropriate compression therapy and achieving complete wound healing, the main outcome desired by this group.

PATIENT/PUBLIC CONTRIBUTION

A patient representative sits on the Study Steering Group, contributing to the work from developing the study protocol and interview schedule to interpretation and discussion of findings. Members of a Wounds Research Patient and Public Involvement Forum were consulted about interview questions.

What promotes or prevents greater use of appropriate compression in people with venous leg ulcers? A qualitative interview study with nurses in the north of England using the Theoretical Domains Framework

OBJECTIVES

To investigate factors that promote and prevent the use of compression therapy in people with venous leg ulcers.

DESIGN

Qualitative interview study with nurses using the Theoretical Domains Framework (TDF).

SETTING

Three National Health Service Trusts in England.

PARTICIPANTS

Purposive sample of 15 nurses delivering wound care.

RESULTS

Nurses described factors which made provision of compression therapy challenging. Organisational barriers (TDF domains environmental context and resources/knowledge, skills/behavioural regulation) included heavy/increasing caseloads; lack of knowledge/skills and the provision of training; and prescribing issues (variations in bandaging systems/whether nurses could prescribe). Absence of specialist leg ulcer services to refer patients into was perceived as a barrier to providing optimal care by some community-based nurses. Compression use was perceived to be facilitated by clinics for timely initial assessment; continuity of staff and good liaison between vascular/leg ulcer clinics and community teams; clear local policies and care pathways; and opportunities for training such as 'shadowing' in vascular/leg ulcer clinics. Patient engagement barriers (TDF domains goals/beliefs about consequences) focused on getting patients 'on board' with compression, and supporting them in using it. Clear explanations were seen as key in promoting compression use.

CONCLUSIONS

Rising workload pressures present significant challenges to enhancing leg ulcer services. There may be opportunities to develop facilitated approaches to enable community nursing teams to make changes to practice, enhancing quality of patient care. The majority of venous leg ulcers could be managed in the community without referral to specialist community services if issues relating to workloads/skills/training are addressed. Barriers to promoting compression use could also be targeted, for example, through the development of clear patient information leaflets. While the patient engagement barriers may be easier/quicker to address than organisational barriers, unless organisational barriers are addressed it seems unlikely that all people who would benefit from compression therapy will receive it.

Patient-Reported Outcome Measures in Dermatology: A Systematic Review

By relying on data from existing patient-reported outcome measures of quality of life, the true impact of skin conditions on patients’ lives may be underestimated. This study systematically reviewed all dermatology-specific (used across skin conditions) patient-reported outcome measures and makes evidence-based recommendations for their use. The study protocol is registered on PROSPERO (CRD42018108829). PubMed, PsycInfo and CINAHL were searched from inception to 25 June 2018. The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria were used to assess the measurement properties and methodological quality of studies. A total of 12,925 abstracts were identified. Zero patient-reported outcome measures were assigned to category A (ready for use without further validation), 31 to category B (recommended for use, but only with further validation) and 5 to category C (not recommended for use). There is no gold-standard dermatology-specific patient-reported outcome measure that can be recommended or used without caution. A new measure that can comprehensively capture the impact of dermatological conditions on the patient’s life is needed.

Preventing pressure ulcers in nursing homes using a care bundle: A feasibility study

Pressure ulcers can be painful and negatively affect health-related quality of life and healthcare costs. Many people living in nursing homes are at risk of developing a pressure ulcer. Nursing home staff, tissue viability nurses and researchers have co-designed the first theory and evidence-informed care bundle specifically for nursing homes, which consists of three prevention practices (skin inspection, support surfaces, repositioning) and a range of behaviour change techniques to promote these practices. We conducted a mixed methods feasibility study of the use of this care bundle in one nursing home in the North of England using an uncontrolled, before-and-after study design. We collected quantitative data on pressure ulcer prevention behaviours of the nursing home staff and pressure ulcer incidence rates for 5 weeks prior to implementing the bundle. Data collection continued for a further 9 weeks during the bundle implementation phase. We explored adherence to the bundle and participants' experiences of using it. The Conceptual Framework for Implementation Fidelity and the Theoretical Domains Framework informed the semi-structured interviews. Quantitative and qualitative data were analysed using descriptive statistics and deductive framework analysis respectively. We collected data for 462 resident bed days prior to implementing the bundle; five new pressure ulcers were recorded and repositioning was the only documented pressure ulcer prevention behaviour. We collected data for 1,181 resident bed days during the intervention phase; no new pressure ulcers developed and the documented prevention behaviours included repositioning, skin inspection and checking support surfaces. Participants reported that the bundle enhanced the care they delivered and offered suggestions for future improvements. Our findings have highlighted a number of feasibility issues surrounding recruitment and retention, collecting data and implementation fidelity. A pressure ulcer prevention bundle specifically designed for nursing homes was acceptable. The feasibility work has highlighted the potential for the intervention and the areas that require development and refinement.

Preventing pressure injury in nursing homes: developing a care bundle using the Behaviour Change Wheel

OBJECTIVE

To develop, with nurse specialists and nursing home care staff, a theory and evidence-informed pressure injury prevention care bundle for use in nursing home settings.

DESIGN

The development of a care bundle.

METHODS

We undertook a detailed, multistaged and theoretically driven development process. First, we identified evidence-informed pressure injury prevention practices: these formed an initial set of possible target behaviours to be considered for inclusion in the bundle. During a 4-hour workshop and supplemental email consultation with a total of 13 healthcare workers, we agreed the key target behaviours for the care bundle. We explored with staff the barriers and facilitators to prevention activity and defined intervention functions and behaviour change practices using the Behaviour Change Wheel.

SETTING

North West England.

RESULTS

The target behaviours consisted of three elements: support surfaces, skin inspection and repositioning. We identified capability, opportunity and reflective motivation as influencing the pressure injury prevention behaviours of nursing home care staff. The intervention functions (education, training, modelling) and behaviour change techniques (information about social and environmental consequences, information on health consequences, feedback on behaviour, feedback on the outcome of behaviour, prompts/cues, instruction on how to perform the behaviour, demonstration of behaviour) were incorporated into the care bundle.

CONCLUSION

This is the first description of a pressure injury prevention care bundle for nursing homes developed using the Behaviour Change Wheel. Key stakeholders identified and prioritised the appropriate target behaviours to aid pressure injury prevention in a nursing home setting.

A systematic review of the effectiveness of physical activity interventions in adults with breast cancer by physical activity type and mode of participation

OBJECTIVES

Engaging in physical activity following a diagnosis in breast cancer patients improves both survival rates and psychosocial health outcomes. The factors influencing the effectiveness of physical activity interventions for breast cancer patients remain unclear. This systematic review focuses on two questions: are there differences in outcomes depending on; the mode of physical activity undertaken; and whether group-based, or individual, programmes are proposed.

METHODS

Five databases were searched (PsycINFO, CINAHL, MEDLINE, EMBASE, and Central). Randomised control trials were included if they reported an intervention aiming to increase physical activity amongst breast cancer patients. A total of 1561 records were screened with 17 studies identified for final inclusion. Data extraction and risk of bias analysis were undertaken. A meta-analysis was not possible due to methodological differences between studies.

RESULTS

Findings indicate no evident differences in outcomes based on exercise mode adopted. There are some indications that group interventions may have additional beneficial outcomes, in comparison to individual interventions, but this conclusion cannot be drawn definitively due to confounds within study designs, lack of group-based intervention designs, and overall lack of long-term intervention effects.

CONCLUSIONS

Although there are no indications of negative intervention effects, only 6 of 17 trials demonstrated significant intervention effects were maintained. Greater transparency in reporting of interventions, and research enabling a comparison of physical activity delivery and mode is needed to determine optimum physical activity interventions to maintain patient physical activity and outcomes.

The effects of care bundles on patient outcomes: a systematic review and meta-analysis

BACKGROUND

Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles.

METHODS

This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups.

RESULTS

In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness).

CONCLUSIONS

Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain.

TRIAL REGISTRATION

PROSPERO, CRD42016033175.

Design and synthesis of new potent human cytomegalovirus (HCMV) inhibitors based on internally hydrogen-bonded 1,6-naphthyridines

1,6-Naphthyridine-2-carboxylic acid benzylamides are potent anti-HCMV compounds. Replacement of the amide moiety by other groups containing internal hydrogen bonds was undertaken to extend the SAR. Our results indicated that the urca derivatives showed very good activity.

Substituted 1,6-naphthyridines as human cytomegalovirus inhibitors: conformational requirements

Substituted 1,6-naphthyridine derivatives, a new class of human cytomegalovirus inhibitors, were prepared to demonstrate the role of intramolecular hydrogen bonds to maintain the compounds in their active conformation.

Isoquinoline-6-carboxamides as potent and selective anti-human cytomegalovirus (HCMV) inhibitors

Structure-activity relationship studies on our newly identified anti-HCMV compounds, the 1,6-naphthyridines led to the identification of isoquinoline-6-carboxamides as potent and selective anti-HCMV agents.

Pyrido [1,2a] indole derivatives identified as novel non-nucleoside reverse transcriptase inhibitors of human immunodeficiency virus type 1

Pyrido [1,2a] indole derivatives were identified as potent inhibitors of human immunodeficiency virus type 1 (HIV-1) replication during a random screening programme. The compounds showed no antiviral activity against HIV-2 or in cells chronically infected with HIV-1, but had good inhibitory effect against purified HIV-1 reverse transcriptase (RT) in an in vitro assay. They were therefore classified as non-nucleoside RT inhibitors (NNRTI). The synthesis of additional compounds of the same class revealed a structure-activity relationship. The most potent compound of the series, BCH-1, had similar antiviral activity to the licensed NNRTI nevirapine against laboratory strains of HIV-1 cultured in cell lines and primary clinical isolates of HIV-1 cultured in peripheral blood mononuclear cells. However, BCH-1 showed greater cytotoxicity, providing a narrow selectivity index in the order of 35. BCH-1 had equivalent antiviral activity against viruses resistant to the nucleoside RT inhibitors zidovudine, didanosine and lamivudine and maintained better activity (less than threefold change in IC50) than nevirapine against viruses resistant to a range of NNRTIs with the single amino acid changes L100I, K103N, E138K or Y181C in the RT. Viruses with single V106A or Y188C amino acid changes showed five- and 10-fold resistance to BCH-1, respectively, in contrast to nevirapine, which had a > 100-fold change in IC50. However, virus with both V106A and Y188C amino acid changes showed higher level resistance (> 15-fold) to BCH-1. Virus with > 10-fold resistance to BCH-1 was rapidly selected for after growth in increasing concentrations of compound and was shown to be cross-resistant to nevirapine. Sequencing of this virus revealed two amino acid changes at positions 179 (V to D) and 181 (Y to C) in the RT. BCH-1 represents a new class of NNRTI, which may act as a lead to identify more selective compounds.