A Web-Based Intervention to Support the Mental Well-Being of Sexual and Gender Minority Young People: Mixed Methods Co-Design of Oneself

BACKGROUND

Sexual and gender minority youth are at greater risk of compromised mental health than their heterosexual and cisgender peers. This is considered to be due to an increased burden of stigma, discrimination, or bullying resulting in a heightened experience of daily stress. Given the increasing digital accessibility and a strong preference for web-based support among sexual and gender minority youth, digital interventions are a key means to provide support to maintain their well-being.

OBJECTIVE

This paper aims to explicate the co-design processes and underpinning logic of Oneself, a bespoke web-based intervention for sexual and gender minority youth.

METHODS

This study followed a 6-stage process set out by Hagen et al (identify, define, position, concept, create, and use), incorporating a systematic scoping review of existing evidence, focus groups with 4 stakeholder groups (ie, sexual and gender minority youth, professionals who directly support them, parents, and UK public health service commissioners), a series of co-design workshops and web-based consultations with sexual and gender minority youth, the appointment of a digital development company, and young adult sexual and gender minority contributors to create content grounded in authentic experiences.

RESULTS

Oneself features a welcome and home page, including a free accessible to all animation explaining the importance of using appropriate pronouns and the opportunity to create a user account and log-in to access further free content. Creating an account provides an opportunity (for the user and the research team) to record engagement, assess users' well-being, and track progress through the available content. There are three sections of content in Oneself focused on the priority topics identified through co-design: (1) coming out and doing so safely; (2) managing school, including homophobic, biphobic, or transphobic bullying or similar; and (3) dealing with parents and families, especially unsupportive family members, including parents or caregivers. Oneself's content focuses on identifying these as topic areas and providing potential resources to assist sexual and gender minority youth in coping with these areas. For instance, Oneself drew on therapeutic concepts such as cognitive reframing, stress reduction, and problem-solving techniques. There is also a section containing relaxation exercises, a section with links to other recommended support and resources, and a downloads section with more detailed techniques and strategies for improving well-being.

CONCLUSIONS

This study contributes to research by opening up the black box of intervention development. It shows how Oneself is underpinned by a logic that can support future development and evaluation and includes diverse co-designers. More interactive techniques to support well-being would be beneficial for further development. Additional content specific to a wider range of intersecting identities (such as care-experienced Asian sexual and gender minority youth from a minority faith background) would also be beneficial in future Oneself developments.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31036.

Feeling known and informed: Serial qualitative interviews evaluating a consultation support intervention for patients with high-grade glioma

OBJECTIVE

Interventions to support patients' engagement in shared decision making (SDM) are lacking within high-grade glioma (HGG) healthcare. Consultation Planning, Recording and Summarising (CPRS) has shown evidence of increasing patient decision self-efficacy, reducing uncertainty, and regret of decisions. This is the first study of CPRS within a HGG population and delivered over serial medical consultations.

METHOD

A one-arm prospective qualitative longitudinal design was used to evaluate the CPRS intervention and evaluated with participants at sequential clinic appointments depending on their care, in Edinburgh, Scotland. We report on serial semi structured interviews of 16 patients and their partners.

RESULTS

Consultation planning before the consultation supported patients to feel known by strengthening the patient voice within the consultation. It prepared patients to actively participate in the consultation, despite the distressing nature of the content. Recording and summarising supported patients to understand their situation. The provision of a consultation record enabled accurate recall, a paced uptake of information and supported the family to feel fully informed. Ultimately, patients understood why decisions were being made rather than being part of making decisions.

CONCLUSIONS

The CPRS intervention helped patients to understand and to feel known by increasing patient capacity for communication in the consultation, with support before, during, and after the consultation. The intervention focused on preparing patients for SDM but patients did not perceive that they had meaningful choices to make. Further research could look at the inclusion of patient decision aids to support this process.

Promoting Resilience and Well-being Through Co-design (The PRIDE Project): Protocol for the Development and Preliminary Evaluation of a Prototype Resilience-Based Intervention for Sexual and Gender Minority Youth

BACKGROUND

Sexual and gender minority youth (SGMY) are at an increased risk of a range of mental health problems. However, few evidence-informed interventions have been developed specifically to support their mental well-being. Interventions that are evidence-informed for the general population and are fine-tuned specifically with SGMY in mind proffer considerable potential. A particular opportunity lies in the delivery of engaging interventions on the web, where the focus is on enhancing the coping skills and building the resilience of SGMY, in a way that is directly relevant to their experiences. On the basis of earlier work related to an intervention called Rainbow SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), we seek to create a new resource, especially for SGMY in the United Kingdom.

OBJECTIVE

This project has 3 main objectives. First, together with SGMY as well as key adult experts, we aim to co-design a media-rich evidence-informed web-based SGMY well-being prototype toolkit aimed at those aged between 13 and 19 years. Second, we will explore how the web-based toolkit can be used within public health systems in the United Kingdom by SGMY and potentially other relevant stakeholders. Third, we aim to conduct a preliminary evaluation of the toolkit, which will inform the design of a future effectiveness study.

METHODS

The first objective will be met by conducting the following: approximately 10 interviews with SGMY and 15 interviews with adult experts, a scoping review of studies focused on psychosocial coping strategies for SGMY, and co-design workshops with approximately 20 SGMY, which will inform the creation of the prototype toolkit. The second objective will be met by carrying out interviews with approximately 5 selected adult experts and 10 SGMY to explore how the toolkit can be best used and to determine the parameters and user-generated standards for a future effectiveness trial. The final objective will be met with a small-scale process evaluation, using the think out loud methodology, conducted with approximately 10 SGMY.

RESULTS

The study commenced on September 1, 2021, and data gathering for phase 1 began in October 2021.

CONCLUSIONS

A considerable body of work has described the issues faced by the SGMY. However, there is a dearth of research seeking to develop interventions for SGMY so that they can thrive. This project aims to co-design such an intervention.

TRIAL REGISTRATION

Research Registry Reference researchregistry6815; https://www.researchregistry.com/browse-the-registry#home/registrationdetails/609e81bda4a706001c94b63a/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31036.

Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study

BACKGROUND

There is a lack of evidence of the effect of cue-based feeding compared with scheduled feeding on important outcomes for preterm infants.

OBJECTIVES

The objectives were as follows: (1) to describe the characteristics, components, theoretical basis and outcomes of approaches to feeding preterm infants transitioning from tube to oral feeding; (2) to identify operational policies, barriers and facilitators, and staff and parents' educational needs in neonatal units implementing cue-based feeding; (3) to co-produce an intervention for feeding preterm infants in response to feeding cues; (4) to appraise the willingness of parents and staff to implement and sustain the intervention; (5) to assess associated costs of implementing cue-based feeding; (6) to determine the feasibility and acceptability of a future trial; (7) to scope existing data-recording systems and potential outcome measures; and (8) to determine stakeholders' views of whether or not a randomised controlled trial of this approach is feasible.

DESIGN

This was a mixed-methods intervention development and feasibility study comprising (1) a systematic review, case studies, qualitative research and stakeholder consensus; (2) the co-production of the intervention; (3) a mixed-methods feasibility study; and (4) an assessment of stakeholder preferences for a future evaluation.

SETTING

Three neonatal units in the UK (two level 3 units and one level 2 unit).

PARTICIPANTS

Developmentally normal, clinically stable preterm infants receiving enteral feeds (n = 50), parents (n = 15 pre intervention development; n = 14 in the feasibility study) and health-care practitioners (n = 54 pre intervention development; n = 16 in the feasibility study).

INTERVENTION

An evidence-informed multicomponent intervention comprising training, a feeding protocol, feeding assessment tools, supplementary training materials [including posters, a film and a narrated PowerPoint (Microsoft Corporation, Redmond, WA, USA) presentation] and the 'Our Feeding Journey' document.

MAIN OUTCOME MEASURES

The main outcome measures were recruitment and screening rates, infant weight gain, duration of the intervention, feeding outcomes, implementation outcomes (contextual facilitators and barriers, acceptability, adoption, appropriateness and fidelity) and stakeholder preferences for a future evaluation.

RESULTS

The systematic review of 25 studies concluded that evidence in favour of cue-based feeding should be treated cautiously. The case studies and qualitative research highlighted contextual barriers to and facilitators of the implementation of cue-based feeding. The telephone survey found that many neonatal units are considering implementing cue-based feeding. We recruited 37% of eligible infants, and there was good retention in the study until discharge but a high loss to follow-up at 2 weeks post discharge. The mean number of days from intervention to transition to full oral feeding was 10.8, and the mean daily change in weight gain was 25 g. The intervention was acceptable to parents and staff, although there was dissatisfaction with the study documentation. Intervention training did not reach all staff. A cluster-randomised design with a composite outcome was suggested by stakeholders for a future study.

LIMITATIONS

The intervention was available only in English. Intervention training did not reach all staff. There was low recruitment to qualitative interviews and observations. Only a small number of medical staff engaged in either the training or the interviews.

CONCLUSIONS

It is feasible to implement a cue-based feeding intervention with improved training and documentation. Further work is needed to assess the feasibility of a future trial, noting evidence of existing lack of equipoise.

FUTURE WORK

The next steps are to digitalise the intervention and conduct a survey of all neonatal units in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018097317 and ISRCTN13414304.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 74. See the NIHR Journals Library website for further project information.

A Smartphone App for Supporting the Self-management of Daytime Urinary Incontinence in Adolescents: Development and Formative Evaluation Study of URApp

BACKGROUND

Daytime urinary incontinence (UI) is common in childhood and often persists into adolescence. UI in adolescence is associated with a range of adverse outcomes, including depressive symptoms, peer victimization, poor self-image, and problems with peer relationships. The first-line conservative treatment for UI is bladder training (standard urotherapy) that aims to establish a regular fluid intake and a timed schedule for toilet visits. The success of bladder training is strongly dependent on good concordance, which can be challenging for young people.

OBJECTIVE

This paper aims to describe the development of a smartphone app (URApp) that aims to improve concordance with bladder training in young people aged 11 to 19 years.

METHODS

URApp was designed by using participatory co-design methods and was guided by the person-based approach to intervention design. The core app functions were based on clinical guidance and included setting a daily drinking goal that records fluid intake and toilet visits, setting reminders to drink fluids and go to the toilet, and recording progress toward drinking goals. The development of URApp comprised the following four stages: a review of current smartphone apps for UI, participatory co-design workshops with young people with UI for gathering user requirements and developing wireframes, the development of a URApp prototype, and the user testing of the prototype through qualitative interviews with 23 young people with UI or urgency aged 10 to 19 years and 8 clinicians. The app functions and additional functionalities for supporting concordance and behavior change were iteratively optimized throughout the app development process.

RESULTS

Young people who tested URApp judged it to be a helpful way of supporting their concordance with a timed schedule for toilet visits and drinking. They reported high levels of acceptability and engagement. Preliminary findings indicated that some young people experienced improvements in their bladder symptoms, including a reduction in UI. Clinicians reported that URApp was clinically appropriate and aligned with the best practice guidelines for bladder training. URApp was deemed age appropriate, with all clinicians reporting that they would use it within their own clinics. Clinicians felt URApp would be of particular benefit to patients whose symptoms were not improving or those who were not engaging with their treatment plans.

CONCLUSIONS

The next stage is to evaluate URApp in a range of settings, including pediatric continence clinics, primary care, and schools. This research is needed to test whether URApp is an effective (and cost-effective) solution for improving concordance with bladder training, reducing bladder symptoms, and improving the quality of life.

Group and individual telehealth for chronic musculoskeletal pain: A scoping review

BACKGROUND CONTEXT

Musculoskeletal (MSK) pain presents a global challenge. Individual and group pain management programmes (PMPs) are recommended approaches for patients with chronic MSK disorders. With advances in remote healthcare capability, telehealth, and the recent COVID-19 pandemic, the importance of telehealth PMPs has become even more evident. Nevertheless, it is not known how patients perceive PMPs for their MSK complaint when delivered via telehealth.

OBJECTIVE

To synthesise the evidence of patients' experiences of group and individual telehealth PMPs for chronic MSK pain.

DESIGN

A scoping review informed by the PRISMA extension for scoping reviews.

DATA SOURCES

Based on a planned search strategy, modified following initial searches, an electronic search was conducted of key databases: Cochrane Library, Medline, CINAHL, EMBASE, AMED, SportDiscus and APA PsychInfo from 2010 until 11 May 2021.

STUDY SELECTION

Any qualitative or mixed methods study reporting patient experiences of telehealth PMPs for patients with MSK disorders.

DATA EXTRACTION AND DATA SYNTHESIS

Data were extracted and synthesised using thematic analysis.

RESULTS

From 446 identified studies, 10 were included. Just two studies investigated group telehealth PMPs for patients with MSK disorders, with eight delivered individually. Four main themes emerged: (1) Usability of the technology, (2) Tailored care, (3) Therapeutic alliance and (4) Managing behaviour. The findings highlight patient acceptability of telehealth to support self-management for chronic MSK disorders, with appropriate clinical and technical support. Group telehealth has the potential to empower patients with peer support. Remote delivery of PMPs also impacts on how patients and providers interact, communicate and develop a therapeutic relationship.

CONCLUSIONS AND IMPLICATIONS

Barriers and enablers to engagement in telehealth PMPs for patients with chronic MSK disorders have been identified. Peer support and group cohesiveness can be achieved remotely to enhance the patient experience. There is a critical need for further research in this area.

Guardians of public interest: the expectation and experience of non-executive directors in National Health Service commissioning boards in England

PURPOSE

The purpose of the study is to examine how Non-Executive Directors (NEDs) in the English National Health Service (NHS) commissioning bodies experienced their role and contribution to governance.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews were conducted with a purposive sample of 31 NEDs of Primary Care Trusts (PCTs) and 8 Clinical Commissioning Group (CCG) NEDs. Framework analysis was applied using a conceptualisation of governance developed by Newman, which has four models of governance: the hierarchy, self-governance, open systems and rational goal model.

FINDINGS

NEDs saw themselves as guardians of the public interest. NEDs' power is a product of the explicit levers set out in the constitution of the board, but also how they choose to use their knowledge and expertise to influence decisions for, as they see it, the public good. They contribute to governance by holding to account executive and professional colleagues, acting largely within the rational goal model. CCG NEDs felt less powerful than in those in PCTs, operating largely in conformance and representational roles, even though government policy appears to be moving towards a more networked, open systems model.

ORIGINALITY/VALUE

This is the first in-depth study of NEDs in English NHS local commissioning bodies. It is of value in helping to inform how the NED role could be enhanced to make a wider contribution to healthcare leadership as new systems are established in the UK and beyond.

Evaluation of uptake and effect on patient-reported outcomes of a clinician and patient co-led chronic musculoskeletal pain self-management programme provided by the UK National Health Service

In the United Kingdom, chronic pain affects approximately 28 million adults, creating significant healthcare and socio-economic costs. The aim was to establish whether a programme designed to use best evidence of content and delivery will be used by patients with significant musculoskeletal pain problems. Of 528 patients recruited, 376 participated in a 7-week-long group-based self-management programme (SMP) co-delivered by clinical and lay tutors. Of these, 308 patients (mean age, 53 years; 69% females, 94% White) completed at least five SMP sessions. Six months after pre-course assessment, participants reported significantly improved patient activation and health status, lower depression and anxiety scores, decreased pain severity and interference, and improved self-management skills. There were no improvements in health state and pain self-efficacy. Uptake rate was 71% and completion 82%. The results should be of value to commissioners of pathways of care for the large numbers of patients attending the English NHS for chronic musculoskeletal pain.

Educational videos for practitioners attending Baby Friendly Hospital Initiative workshops supporting breastfeeding positioning, attachment and hand expression skills: Effects on knowledge and confidence

UNICEF Baby Friendly Initiative (BFHI) is the global standard for maternity and community services requiring all practitioners to be trained to support mothers in the essential skills of supporting positioning and attachment, and hand expression. These studies aim to rigorously assess knowledge in nurses, midwives, and doctors in these skills, tested before and after watching short videos demonstrating these skills. Practitioners were attending BFHI education, and the video study was additional. In Phase 1 clinicians in England were randomised to one of two videos (practitioner role play or clinical demonstration). The results showed improvements in knowledge and confidence, and a preference for clinical demonstration by mothers and infants. The clinical demonstration video was evaluated in China in Phase 2 where expert trainers viewed the video after completing the BHFI workshop, and in Phase 3 practitioners viewed the video before the BHFI workshop. Phase 2 with expert trainers only showed improvement in knowledge of hand expression but not positioning and attachment. In Phase 3 clinicians showed improved knowledge for both skills. In all Phases there were statistically significant improvements in confidence in practice in both skills. Viewing short videos increased knowledge, particularly about teaching hand expression, and confidence in both skills.

Informing School Sex Education Using the Stages of Change Construct

A survey of 3820 school children in England aged 13-16 years examined sexual activity using the Transtheoretical Model (TTM) Stages of Change. A quarter (26%) of teens were sexually experienced, 44.8 per cent did not use contraception and 48.9 per cent did not use condoms, every time. Past history of condom and contraceptive use, and partner willingness to use condoms were the best predictors of being in Action or Maintenance stage for condom use. Of virgins, 19.82 per cent were in Contemplation or Preparation stages for intercourse, and 85.4 per cent would use condoms every time. Sex education should be tailored to Stage, and signposting to sexual health and contraception services.

Organizational interventions to promote risk management in primary care: the experience in Warwickshire, England

Primary care organizations are under-represented in research on quality improvement and risk management (RM), yet the potential for improving patient safety is possibly greater given the extent that clinical judgement is required to achieve a service tailored to the individual's personal health and lifestyle. This paper examines how a health authority in England promoted interventions to improve RM in General Practice that included the practices' own initiatives, significant event audit (SEA) and the Medical Defence Union's workshops which included SEA. All 75 practices were approached before the programmes and when they were finished, eight months later. The practice manager from each practice completed an audit of RM activities, from which a RM competence score was derived. Up to six staff per practice completed the Learning organization Culture Questionnaire (LCQ) at both times. There was evidence of improved competence in RM over the period of the study, particularly through a widening breadth of staff involved and in formal recording systems. There was little evidence that these improvements were mediated by organizational culture. It is argued that future interventions should more closely target specific competences (e.g. recording systems for adverse events, root cause analysis to understand error generation) and enable staff to see tangible personal and organizational benefits for the extra effort involved.

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention

BACKGROUND

Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice.

METHODS

We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention).

RESULTS

Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn't engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity.

CONCLUSIONS

A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices.

The development of a prototype measure of the co-production of health in routine consultations for people with long-term conditions

OBJECTIVES

(i) To develop a prototype measure of co-production of health (CPH) in consultations for people with long-term conditions (LTCs); and (ii) to undertake initial validation of it, using a measure of patient-centred care, as defined by the Roter interaction analysis system (RIAS).

METHODS

Mixed methods were applied. A qualitative study gathered 11 experts' views on what comprised CPH behaviours. These were operationalised and a prototype measure applied to a convenience sample of 50 video-recorded consultations involving clinicians trained in self-management support and patients with LTCs at health services in six UK locations.

RESULTS

Twenty-two CPH behaviours were identified. High frequencies of CPH behaviours in consultations were associated with greater patient-centeredness, less clinician verbal dominance, and more patient communication control in comparison to consultations where CPH behaviours were less frequent.

CONCLUSION

Although the CPH tool is promising, further testing is required in order to improve reliability and validity.

PRACTICAL IMPLICATIONS

In the future, the measure could be used to test interventions to promote patient participation in decision making about self-management.

An evaluation of a self-management program for patients with long-term conditions

OBJECTIVE

To evaluate a group-based self-management program (SMP) delivered as part of a quality improvement program, Co-Creating Health, for patients living with one of four long-term conditions (LTCs): chronic obstructive pulmonary disease, depression, diabetes, and musculoskeletal pain.

METHODS

The 7 week SMP was co-delivered by lay and health professional tutors. Patients completed self-reported outcome measures at pre-course and 6 months follow-up.

RESULTS

486 patients completed (attended ≥5 sessions) the SMP and returned pre-course and 6 months follow up data. Patients reported significant improvements in patient activation (ES 0.65, p<0.001), with 53.9% of all patients reporting a meaningful ≥4 point improvement. Health-related quality of life (ES 0.06, p=0.04), and health status (ES 0.33, p<0.001) were also significantly improved. Patients' anxiety (ES 0.37, p<0.001) and depression (ES 0.31, p<0.001) significantly improved. Patients also reported significant improvements in their self-management skills (p values from p<0.001 to p=0.028).

CONCLUSION

Attending the SMP led to improvements in a range of outcomes. Improvement in patient activation is important, as activated patients are more likely to perform self-care activities.

PRACTICE IMPLICATIONS

Co-delivered SMPs provide meaningful improvements in activation for >50% of those who complete and are a useful addition to self-management support provision.

Self-reported effects of attending the Health Foundation's Co-Creating Health self-management programme for patients with type 2 diabetes mellitus in London, England

INTRODUCTION

The purpose of this study was to determine the impact of the Health Foundation's Co-Creating Health (CCH) group self-management programme (SMP) for adult patients with type 2 diabetes on patient activation and quality of life.

MATERIAL AND METHODS

We conducted a multisite longitudinal study of 283 patients (mean age 62.3 years, SD 11.1; 43% ethnic minority; 51% female). Primary outcomes were patient activation, and diabetes and health related quality of life. Secondary outcomes included health status, psychological distress, and self-management ability. Data were collected immediately before the first SMP session (baseline) and 6 months after completing the programme. Quantitative analyses were based on mixed models using intent-to-treat and per-protocol procedures.

RESULTS

Sixty percent of patients who signed up for SMP completed the programme. Patient activation significantly improved 6 months after the SMP (p < 0.0001), and 60.2% of course completers showed meaningful improvement. Diabetes-related quality of life also improved significantly 6 months post course (p < 0.0001). About a quarter of SMP completers showed substantial improvement in self-management skills.

CONCLUSIONS

Attending the UK SMP for adults with type 2 diabetes leads to improvements in patient activation, diabetes-related quality of life, and improved confidence and ability to self-manage their condition. Improvement in patient activation is an important finding because activated patients participate in collaborative decision-making with their clinicians, report improved health-related behaviours and clinical outcomes, and better adhere to treatment.

Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study

Background

Prompt treatment following Transient Ischemic Attack (TIA) can reduce the risk of subsequent stroke and disability. However, many patients delay in making contact with medical services. This study aimed to explore TIA patients' accounts of delay between symptom onset and contacting medical services including how decisions to contact services were made and the factors discussed in relation to delay.

Methods

Twenty interviews were conducted with TIA patients in England. Using a previous systematic review as an initial framework, interview data were organised into categories of symptom recognition, presence of others and type of care sought. A thematic analysis was then conducted to explore descriptions of care-seeking relevant to each category.

Results

Delay in contacting medical services varied from less than an hour to eight days. Awareness of typical stroke symptoms could lead to urgent action when more severe TIA symptoms were present but could lead to delay when experienced symptoms were less severe. The role of friends and family varied widely from deciding on and enacting care-seeking decisions to simply providing transport to the GP practice. When family or friends played a greater role, and both made and enacted care-seeking decisions, delays were often shorter, even when patients themselves failed to identify symptoms. Healthcare professionals also impacted on patients' care-seeking with greater delays in seeking further care for the same episode described when patients perceived a lack of urgency during initial healthcare interactions.

Conclusions

This study provides new information on patients' decisions to contact medical services following TIA and identifies overlapping factors that can lead to delay in receiving appropriate treatment. While recognition of symptoms may contribute to delay in contacting medical services, additional factors, including full responsibility being taken by others and initial healthcare interactions, can over-ride or undermine the importance of patients' own identification of TIA.

Qualitative evaluation of a self-management intervention for people in the early stage of dementia

Self-management programs are effective for people living with chronic illnesses. However, there has been little research addressing self-management for people with dementia in the early stages. This study presents a qualitative evaluation of the experiences of attending a novel self-management program and initial process evaluation. The program was designed with and for people with dementia. It addresses: (a) relationship with family, (b) maintenance of an active lifestyle, (c) psychological well-being, (d) techniques to cope with memory changes and (e) information about dementia. Six participants with early stage dementia completed the intervention that was co-delivered by lay and clinical professional tutors. Participants and tutors attended focus group and interviews at the end of the program to explore their perceptions of the intervention. These were audio-recorded, transcribed verbatim and analysed thematically. Participants reported enjoyment and benefits from the intervention. This was despite some reporting concerns relating to their memory difficulties. The program's flexible nature, focus on strengths and the opportunity to spend time with other people living with dementia were particularly well received. Participants and tutors outlined areas for further improvement. The program was feasible and its flexible delivery appeared to facilitate participant benefit. Emphasis should be placed on maintaining activity and relationships, improving positive well-being and social interaction during the program. Memory of the pleasant experience and strengths focus was evidenced, which may impact positively on quality of life. The results highlight the usefulness and acceptability of self-management for people with early stage dementia and provide initial support for the program's structure and content.

Conceptualisation of self-management intervention for people with early stage dementia

Dementia is a major challenge for health and social care services. People living with dementia in the earlier stages experience a "care-gap". Although they may address this gap in care, self-management interventions have not been provided to people with dementia. It is unclear how to conceptualise self-management for this group and few published papers address intervention design. Initial focusing work used a logic mapping approach, interviews with key stakeholders, including people with dementia and their family members. An initial set of self-management targets were identified for potential intervention. Self-management for people living with dementia was conceptualised as covering five targets: (1) relationship with family, (2) maintaining an active lifestyle, (3) psychological wellbeing, (4) techniques to cope with memory changes, and (5) information about dementia. These targets were used to focus literature reviewing to explore an evidence base for the conceptualisation. We discuss the utility of the Corbin and Strauss (Unending work and care: managing chronic illness at home. Jossey-Bass, Oxford, 1988) model of self-management, specifically that self-management for people living with dementia should be conceptualised as emphasising the importance of "everyday life work" (targets 1 and 2) and "biographical work" (target 3), with inclusion of but less emphasis on specific "illness work" (targets 4, 5). We argue that self-management is possible for people with dementia, with a strengths focus and emphasis on quality of life, which can be achieved despite cognitive impairments. Further development and testing of such interventions is required to provide much needed support for people in early stages of dementia.

Planning for, implementing and assessing the impact of health promotion and behaviour change interventions: a way forward for health psychologists

Researchers in the field of health psychology have increasingly been involved in translating a body of knowledge about psychological factors associated with health-relevant behaviours, into the development and evaluation of interventions that seek to apply that knowledge. In this paper we argue that a changing economic and political climate, and the strong behavioural contribution to disease morbidity and mortality in developed nations, requires health psychologists to plan more rigorously for, and communicate more effectively, about how health promotion, social cognition and behaviour change interventions will have impact and be increasingly embedded into health services or health promotion activity. We explain academic and wider socio-economic uses of 'impact' in health services research. We describe the relationship between impact and dissemination, and impact as distinct from, but often used interchangeably with the terms 'implementation', 'knowledge transfer' and 'knowledge translation' (KT). The evidence for establishing impact is emergent. We therefore draw on a number of impact planning and KT frameworks, with reference to two self- management interventions, to describe a framework that we hope will support health psychologists in embedding impact planning and execution in research. We illustrate this further in an on-line annexe with reference to one of our own interventions, Mums-and-MS (see Supplemental Material).

Which outcome expectancies are important in determining young adults' intentions to use condoms with casual sexual partners?: a cross-sectional study

Background

The prevalence of unwanted pregnancy and sexually transmitted infection amongst young adults represents an important public health problem in the UK. Individuals’ attitude towards the use of condoms has been identified as an important determinant of behavioural intentions and action. The Theory of Planned Behaviour has been widely used to explain and predict health behaviour. This posits that the degree to which an individual positively or negatively values a behaviour (termed ‘direct attitude’) is based upon consideration of the likelihood of a number of outcomes occurring (outcome expectancy) weighted by the perceived desirability of those outcomes (outcome evaluation). Outcome expectancy and outcome evaluation when multiplied form ‘indirect attitude’. The study aimed to assess whether positive outcome expectancies of unprotected sex were more important for young adults with lower safe sex intentions, than those with safer sex intentions, and to isolate optimal outcomes for targeting through health promotion campaigns.

Methods

A cross-sectional survey design was used. Data was collected from 1051 school and university students aged 16–24 years. Measures of intention, direct attitude and indirect attitude were taken. Participants were asked to select outcome expectancies which were most important in determining whether they would use condoms with casual sexual partners.

Results

People with lower safe sex intentions were more likely than those with safer sex intentions to select all positive outcome expectancies for unprotected sex as salient, and less likely to select all negative outcome expectancies as salient. Outcome expectancies for which the greatest proportion of participants in the less safe sex group held an unfavourable position were: showing that I am a caring person, making sexual experiences less enjoyable, and protecting against pregnancy.

Conclusions

The findings point to ways in which the attitudes of those with less safe sex intentions could be altered in order to motivate positive behavioural change. They suggest that it would be advantageous to highlight the potential for condom use to demonstrate a caring attitude, to challenge the potential for protected sex to reduce sexual pleasure, and to target young adults’ risk appraisals for pregnancy as a consequence of unprotected sex with casual sexual partners.

A process evaluation using a Self Determination Theory measure of the co-delivery of self management training by clinicians and by lay tutors

OBJECTIVE

To evaluate the co-delivery style of lay and clinician co-tutors of courses for patients, and courses for clinicians to support their patients' self-management skills.

METHODS

Motivational style of course delivery was assessed in 37 patient course sessions and 14 clinician workshops by independent observers using four Self Determination Theory rating scales and ethnographic notes. Forty-five tutors and 35 attendees were interviewed about their experience of co-delivered courses.

RESULTS

Lay and clinician tutors had similar motivational styles, with significant differences between the four motivational style scales; patient courses (F(3, 216)=3.437, p=.018); and clinician courses (F(3, 78)=3.37, p=.025). The courses were experienced as co productive in style as suggested during interviews, but adherence to manuals limited the tutors' contributions. Lay and clinician tutors scored higher on providing structure and engaging participants than they scored on supporting autonomous decision making and involvement.

CONCLUSION

Co-delivery was a successful model, affording opportunities to demonstrate co-production skills.

PRACTICE IMPLICATIONS

There is more scope to enable lay and clinician tutors to use their respective expertise in supporting self-management, and for tutor training to encourage a less didactic delivery style.

A qualitative study of the childbearing experience of women living with multiple sclerosis

PURPOSE

Although at any time in the UK, there are about 20,000 women with MS who may be considering having children, healthcare system often fails to provide them with information and support they need to make informed decisions about their health and pregnancy management. The aim of this paper is to explore the childbearing experience of women with MS to determine what support and information may be useful to this target group.

METHOD

Interviews were conducted with women with MS (n = 9). Transcripts were analysed using thematic analysis.

RESULTS

Three major themes emerged from the interviews with women living with MS. We found women were concerned about both medical and practical issues associated with having children. Limited access to information about relationships between MS and childbearing and receiving conflicting or wrong information was recounted. Opinions of family members and clinicians regarding having children in the context of MS impacted on women's experience of making decision about having children and childbearing.

CONCLUSIONS

Women with MS can benefit from having access to comprehensive, structured sources of information about MS and childbearing. Healthcare professionals and family members 'support could be channelled more appropriately to enhance their experience of making choices about childbearing.

Sexual health professionals' evaluations of a prototype computer-based contraceptive planning intervention for adolescents: implications for practice

BACKGROUND

This paper aims to demonstrate how an online planning intervention to enhance contraceptive and condom use among adolescents was viewed by sexual health professionals. It identifies feedback that has facilitated improvement of the intervention both in terms of potential effectiveness and sustainability in practice. The data illustrate how professionals' feedback can enhance intervention development.

METHOD

Ten practitioners (two male; eight female) representing a range of roles in sexual health education and healthcare were given electronic copies of the prototype intervention. Interviews were conducted to elicit feedback. Transcripts of the interviews were subjected to thematic analysis.

RESULTS

Practitioners provided positive feedback about the intervention content, use of on-line media, the validity of planning techniques and the inclusion of males in contraceptive planning. Issues with rapport building, trust, privacy, motivation, and time and resources were raised, however, and the promotion of condom carrying was contentious.

CONCLUSIONS

Professionals' feedback provided scope for developing the intervention to meet practitioners' concerns, thus enhancing likely feasibility and acceptability in practice. Ways in which particular feedback was generalisable to wider theory-based and online intervention development are explored. Some responses indicated that health practitioners would benefit from training to embed theory-based interventions into sexual health education and healthcare.

Perceived barriers to self-management for people with dementia in the early stages

People with dementia in the early stages currently experience a care gap, which self-management may address. We explore perceived barriers to self-management. Using a systematic approach (logic mapping), 19 participants (people with dementia, carers, health care professionals and charity representatives) described self-management barriers facing people living with dementia. Thematic content analysis revealed six main themes: the lived experience of dementia, diagnosis, role of carer/family, impact of health care professionals, organisation of health services and societal views. People with dementia were seen as passive recipients of care, unable to self-manage owing to the impact of dementia on cognitive abilities. The need for interventions that are largely emotion focused, encourage activity maintenance and improve quality of life are described. Barriers to self-management exist at multiple levels, suggesting a whole-systems approach is required.

Development and psychometric properties of a self report measure to assess clinicians' practices in self management support for patients with long term conditions

OBJECTIVE

This paper presents a process of developing practices in self management support (PSMS) - a measure assessing clinicians' self reported use of self management support practices in clinical consultations for patients with long term conditions (LTCs).

METHODS

The development process comprised the following steps: literature review to define what skills clinicians need to effectively support patients to self manage, review of existing measures of SMS practices, construction of an initial pool of items, E Delphi study pilot survey to select items for final measure, data collection to confirm the factor structure and internal consistency of the final measure.

RESULTS

The PSMS comprises three subscales: Clinical SMS (14 items), Patient Centeredness (4 items) and Organizational SMS (7 items). All subscales have very good internal reliability (Cronbach α: 0.94, 0.78 and 0.85; all item-total correlations above 0.50).

CONCLUSIONS AND PRACTICE IMPLICATIONS

We believe PSMS measure is suitable for both research and programme evaluation in UK clinical settings. To complete the process of measure development we are now planning to conduct further analyses to establish the validity of PSMS measure in UK and non UK healthcare settings and test the validity of PSMS measure on a wider range of other LTC groups.

Evaluation and measurement for improvement in service-level quality improvement initiatives

The National Health Service (NHS) in England, as with other health services worldwide, currently faces the need to reduce costs and to improve the quality of patient care. Evidence gathered through effective and appropriate measurement and evaluation, is essential to achieving this. Through interviews with service improvement managers and analysis of comments in a seminar of NHS staff involved in health service improvement, we found a lack of understanding regarding the definition and methodology of both measurement and evaluation, which decreases the likelihood that NHS staff will be competent to commission or provide these skills. In addition, we highlight the importance of managers assessing their organizations' ‘readiness’ to undergo change before embarking on a quality improvement (QI) initiative, to ensure that the initiative's impact can be adequately judged. We provide definitions of measurement for improvement and of evaluation, and propose a comparative framework from which to gauge an appropriate approach. Examples of two large-scale QI initiatives are also given, along with descriptions of some of their problems and solutions, to illustrate the use of the framework. We recommend that health service managers use the framework to determine the most appropriate approach to evaluation and measurement for improvement for their context, to ensure that their decisions are evidence based.

An organisation-wide approach to training community practitioners in breastfeeding

A new self-study training programme was delivered to community practitioners as part of an organisation-wide breastfeeding training programme. Knowledge outcomes were measured before and after the training using the Coventry University Breastfeeding Assessment. Interviews with participants found the programme was well received and seen as a key way to ensure consistent evidence-based practice. Practitioners across all professional groups increased knowledge scores after training. Independent evaluation showed that self-study is flexible and acceptable, but requires self-motivation as well as basic computer skills and access. Self-study is potentially more affordable, and could provide a means to regularly refresh the knowledge of staff and bring new recruits to the same objectively assessed standard. Recommendations include the use of learning sets to encourage team learning, and the production of a combined web and hard copy programme came from the learning achieved by piloting this new programme.

How do young adults perceive the risk of chlamydia infection? A qualitative study

OBJECTIVES

This study aimed to improve understanding of how young UK genito-urinary medicine (GUM) patients perceive the risk of chlamydia, and identify implications for health education.

DESIGN

A qualitative methodology was chosen.

METHODS

Semi-structured interviews with 27 respondents aged 16-22 years old were conducted. Data were subjected to thematic analysis.

RESULTS

Respondents made assessments of the perceived seriousness of, and their personal susceptibility to, chlamydia infection. Judgements about seriousness were related to beliefs about the controllability of symptoms and the long-term health consequences of infection. Susceptibility estimates were related to beliefs about the extent to which personal exposure put them in contact with chlamydia, and about the prevalence of infection amongst their peer group. This is consistent with the content of illness risk representations proposed by Cameron (2003). Respondents demonstrated some beliefs, which appeared to influence perceptions of seriousness and susceptibility in unhelpful ways.

CONCLUSIONS

Young people may be underestimating their risk of chlamydia infection due to the presence of unhelpful beliefs. Dialogue between health professionals and patients within GUM clinics, or through consultations as part of the National Chlamydia Screening Programme (NCSP), could provide vehicles to deliver health education to target these. Suggested health education includes highlighting false reassurance provided by treatment beliefs and exposing the fallibility of using overt characteristics to judge the likelihood that a potential sexual partner poses a risk of infection.

Meeting the challenge of delivering high-quality breastfeeding training for all

Staff training is an essential element of achieving the prestigious UNICEF UK Baby Friendly Initiative (BFI) global standard for organisations seeking to provide services that support breastfeeding. A breastfeeding self-study training programme (workbook and DVD) was developed by Health Behaviour Research Limited and delivered to healthcare staff in primary care trusts (PCTs), children's centres and their maternity units. As part of this training knowledge outcomes are measured before and after the training using the CUBA (Coventry University Breastfeeding Assessment). Interviews with participants showed that they welcomed the programme as a way of ensuring staff use evidence-based practice consistently. Self study is flexible but requires self organisation, time management against competing priorities and basic ICT skills and access. Recommendations, including the use of learning sets to encourage team learning and the production of a combined web and hard copy programme, came from the learning achieved by piloting this new programme.

Perceptions and experiences of co-delivery model for self-management training for clinicians working with patients with long-term conditions at three healthcare economies in U.K

This paper presents a case study evaluation of self-management training courses for clinicians working with patients with COPD and Depression, at three NHS sites in United Kingdom. These courses were part of the Health Foundation's Co-Creating Health Initiative project and were co-delivered by a trained patient and clinician tutors. Interviews with 30 clinician attendees, four clinician tutors and two patient tutors suggested that the course content and delivery style were valued by everyone and clinicians reported a higher use of self-management skills following training. Analyses of the video-recorded consultation sessions of two trained clinicians showed limited use of co-production skills.

Does the professional and working context of United Kingdom clinicians predict if they use practices to support patients with long term conditions to self manage?

INTRODUCTION

Our study examines how the professional and employment context may influence clinicians' practice self management support for patients with long term conditions (LTC).

MATERIAL AND METHODS

We surveyed clinicians working with patients with depression, chronic obstructive pulmonary disorder (COPD), chronic musculo skeletal pain and diabetes.

RESULTS

Clinicians most frequently endorsed items on a scale concerned with patient centeredness, and less frequently endorsed items concerned with clinical and organizational self management support. The most important factors predicting these latter activities were the intensity of working experience with patients with LTC and attending professional training addressing the principles and practice of self management support. Practicing patient centeredness was endorsed by nearly all respondents, and so was not sensitive to variation on work variables.

CONCLUSIONS

The interaction of training and intensity of work with patients with LTC seems to have the most powerful effect on undertaking clinical and organizational self management support practices. To facilitate clinicians' practice of self management support for patients with LTC it is very important to provide relevant professional training and to build specialized patient care teams with professionals having complimentary skills.

'Breast is not always best': South Asian women's experiences of infant feeding in the UK within an acculturation framework

Acculturating to a host country has a negative impact on immigrant women's breastfeeding practices, particularly when coming from countries where breastfeeding rates are higher than Western countries. Whether this is true of those immigrating to the UK remains to be investigated. The study aimed to explore whether acculturating to the UK had detrimental effects on breastfeeding practices of South Asian women, and to provide explanations as to how acculturation may have exerted its influence. Twenty South Asian women completed semi-structured interviews exploring infant feeding experiences. Data were thematically analysed. A bidimensional measure assessed women's acculturation status. Women displaying low acculturation levels were aware of living in a formula-feeding culture but this had little influence on breastfeeding intentions/behaviours; drawing upon South Asian cultural teachings of the psychological benefits of breast milk. These women opted to formula-feed in response to their child's perceived demands or in a bid to resolve conflict; either when receiving information about the best feeding method or between their roles as a mother and daughter-in-law. Highly acculturated women also experienced such conflict; their awareness of the formula-feeding culture governed feeding choice. The findings provide a picture of how acculturation may affect South Asian women's breastfeeding intentions and behaviours; encouraging health service providers to meet the varying needs of an acculturating population. If breastfeeding is to be encouraged, it is necessary to understand factors influencing feeding choice; with particular attention to the acculturation pathways that may govern such decisions. This paper highlights ways to tailor information for South Asian women depending on levels of acculturation.

Survey evaluation of the National Patient Safety Agency's Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices

BACKGROUND

Root Cause Analysis (RCA) is a systematic approach to investigations, and is applied in many healthcare settings within comprehensive patient safety systems. The National Patient Safety Agency (NPSA) in England and Wales commissioned a survey evaluation of its national training programme which consisted of 3-day workshops and internet support materials.

METHODS

Anonymous survey of 374 health professionals immediately after they attended the programme (T1), and a further 350 participants 6 months after the programme (T 2), who had attended courses in England and Wales in 2005.

RESULTS

T1 knowledge tests showed a greater understanding of the frameworks and techniques of RCA but with less accuracy in application to scenarios. Personal beliefs about conducting RCAs were consistently positive at both times, but many participants experienced personal barriers to conducting RCA in their current role and trust context, and some felt low confidence in undertaking cascade training of other staff in their trust. There was also low confidence in implementing RCA as standard practice at both times. At T2, 76.7% were confident the outcomes from their RCA had been implemented, but only 12.1% were aware if improvements had been shared outside the local organisation. Barriers to RCA at both times most often concerned time and resources to apply RCA. At T1, there was particular concern for personal development, at T2 greater concern for organisational impediments.

CONCLUSIONS

The RCA programme enhanced knowledge of RCA, and participants valued the programme, but further personal development and organisational support are required to achieve continued improvement in practice and sustained organisational learning.

"What Should We Tell the Children About Relationships and Sex?"©: development of a program for parents using intervention mapping

This article describes the development of an intervention that aims to increase the quantity and quality of parent-child communication about sex and relationships. The intervention has been designed as part of a local strategic approach to teenage pregnancy and sexual health. The process and findings of Intervention Mapping (IM), a tool for the development of theory-and evidence-based interventions, are presented. The process involves a detailed assessment of the difficulties parents experience in communicating with their children about sex and relationships. The findings are translated into program and change objectives that specify what parents need to do to improve their communication. Theory-based practical strategies most likely to bring about the desired behavioral change are then identified and pretested. The intervention developed consists of a six-session facilitator-led program that targets parents' attitudes, knowledge, communication skills, and self-efficacy. Following on from Bartholomew's seminal work on IM, this article develops and extends the application of this process by presenting explicit detail on the behavioral change techniques used and their theoretical underpinnings. The strengths and weaknesses of IM as a process for the development of health behavior interventions are discussed.

Establishing User Requirements for a Patient Held Electronic Record System in the United Kingdom

In the UK, in emergency situations, health professionals rely on patients to provide information about their medical history. However, in some cases patients may not remember their medication, long term illnesses or allergies, or be able to communicate this information. As a national on-line integrated patient record system has not yet been established, a patient held electronic health record has been proposed. This paper summarizes the results of a survey to establish the public's and health care professionals requirements for such a system.

Improving patient safety incident reporting systems by focusing upon feedback – lessons from English and Welsh trusts

This paper describes practical implications and learning from a multi-method study of feedback from patient safety incident reporting systems. The study was performed using the Safety Action and Information Feedback from Incident Reporting model, a model of the requirements of the feedback element of a patient safety incident reporting and learning system, derived from a scoping review of research and expert advice from world leaders in safety in high-risk industries. We present the key findings of the studies conducted in the National Health Services (NHS) trusts in England and Wales in 2006. These were a survey completed by risk managers for 351 trusts in England and Wales, three case studies including interviews with staff concerning an example of good practice feedback and an audit of 90 trusts clinical risk staff newsletters. We draw on an Expert Workshop that included 71 experts from the NHS, from regulatory bodies in health care, Royal Colleges, Health and Safety Executive and safety agencies in health care and high-risk industries (commercial aviation, rail and maritime industries). We draw recommendations of enduring relevance to the UK NHS that can be used by trust staff to improve their systems. The recommendations will be of relevance in general terms to health services worldwide.

Fathers and parenting programmes: barriers and best practice

Fathers are particularly difficult to recruit to voluntary parenting programmes, despite the advantages of such programmes for confidence and skills in parenting and associated improvements in child behaviour. The apparent reluctance of fathers to engage in parenting services is recognised as a problem by health and social care practitioners, and the Department of Health identifies the engagement of fathers as a key service target. This review gathers information on barriers to fathers' engagement with parenting support services and identifies best practice for recruitment. It draws on published academic literature, government and community organisation reports and empirical data collection through interviews with parenting experts (n=9) and focus groups and questionnaires with fathers (n=29). The barriers identified were lack of awareness, work commitments, female-orientated services, lack of organisational support and concerns over programme content. Aspects of best practice included actively promoting services to fathers rather than parents, offering alternative forms of provision, prioritising fathers within organisations and taking different cultural and ethnic perspectives into account. Achieving greater engagement of fathers in parenting support programmes requires a greater understanding of the perspectives of fathers.

Changes in air quality and second-hand smoke exposure in hospitality sector businesses after introduction of the English Smoke-free legislation

BACKGROUND

To monitor and disseminate the short-term effects of the English Smoke-free legislation on air quality and employee exposure in businesses of the hospitality industry.

METHODS

Indoor particle concentrations and salivary cotinine levels were measured in businesses in the hospitality sector and non-smoking employees one month before and after the implementation of the legislation. Results were immediately released to the media to announce the improvements in air quality and employee exposure to the wider public.

RESULTS

Measurements were collected in 49 businesses and from 75 non-smoking individuals. Indoor PM(2.5) concentrations decreased by 95% from 217 microg/m(3) at baseline to 11 microg/m(3) at follow-up (P < 0.001). Salivary cotinine in employees was reduced by 75%, from 3.6 ng/ml at baseline to 0.9 ng/ml at follow-up (P < 0.001). The findings were presented to the public through press releases and interviews and were cited in over 20 media articles.

CONCLUSION

The project demonstrates the positive effects of the English Smoke-free legislation on air quality and second-hand smoke exposure in the hospitality industry sector. We believe that quick and positive feedback to the public on the effects of smoking restrictions is essential when introducing public health legislation such as the Smoke-free legislation.

Breastfeeding Best Start study: training midwives in a 'hands off' positioning and attachment intervention

The most common reasons cited by women for giving up breastfeeding early can be attributed to ineffective positioning and attachment and are therefore preventable. This study aimed to determine whether a 4-h training programme in 'hands off' positioning and attachment support increases midwives' knowledge and problem-solving skills. Using an unrelated comparison group and a pre- and post-intervention design, 108 midwives (experimental group) completed a 4-h standard breastfeeding training workshop focusing on effective positioning and attachment and the use of hands-off teaching methods. Knowledge and problem-solving skills were assessed using a modified form of the previously validated Breastfeeding Support Skills Tool. Pre- and post-training scores were compared with those of 27 student midwives (control group) who undertook the same assessments but without the breastfeeding training. Baseline knowledge scores of the midwives and the student midwives did not differ significantly (average difference 0.7 points to qualified midwives' advantage, 95% CI = -3.4 to 1.9). Following training, the qualified midwives' total scores increased significantly (7.2 points, 95% CI = 6.2-8.2). Minimal changes (1.4 points, 95% CI = -0.15 to 2.9) in students' scores were found. The additional increase owing to training above that which might be expected due to practice (i.e. the average difference in change scores between the two groups) was 5.8 points (95% CI = 3.75-7.96), representing a large effect size for the training (d = 0.95). There is a large variation in the breastfeeding knowledge of midwives working in post-natal care and, on average, they are no more skilled than senior student midwives. The study has shown that a 4-h workshop in a positioning and attachment intervention, using a 'hands-off' approach, can increase midwives' knowledge of breastfeeding support relevant to the immediate post-natal period. It is applicable to all midwives, and could be a cost-effective way of improving the ability of mothers to begin and continue to breastfeed successfully.

Rethinking research in breast-feeding: a critique of the evidence base identified in a systematic review of interventions to promote and support breast-feeding

Objective

To appraise critically the relevance and value of the evidence base to promote and support the duration of breast-feeding, with a specific focus on disadvantaged groups.

Design

A systematic review was conducted of intervention studies relevant to enhancing the duration of breast-feeding; topics included public health, public policy, clinical issues, and education, training and practice change. A systematic search was conducted. Eighty studies met the inclusion criteria. Data were systematically extracted and analysed. Full results and recommendations are reported elsewhere. Here a critique of the evidence base – topics, quality and gaps – is reported.

Results

Many studies were substantially methodologically flawed, with problems including small sample sizes, inconsistent definitions of breast-feeding and lack of appropriate outcomes. Few were based on relevant theory. Only a small number of included studies (10%) were conducted in the UK. Very few targeted disadvantaged subgroups of women. No studies of policy initiatives or of community interventions were identified. There were virtually no robust studies of interventions to prevent and treat common clinical problems, or of strategies related to women's health issues. Studies of health professional education and practice change were limited. Cost-effectiveness studies were rare.

Conclusions

Policy goals both in the UK and internationally support exclusive breast-feeding until 6 months of age. The evidence base to enable women to continue to breast-feed needs to be strengthened to include robust evaluations of policies and practices related to breast-feeding; a step change is needed in the quality and quantity of research funded.

A home-based, transtheoretical change model designed strength training intervention to increase exercise to prevent osteoporosis in Iranian women aged 40-65 years: a randomized controlled trial

Physical activity (PA) helps to prevent osteoporosis, but older women are often sedentary. This study used a pre-post randomized controlled design to evaluate a 12-week exercise education intervention program based on the stages of change (SoC) and processes of change from the transtheoretical change model (TTM) to improve adherence with strength and balance training recommendations at levels sufficient to prevent osteoporosis in Iranian women aged 40-65 years. The home-based exercise prescription consisted of strength and balance training that was progressive, individually tailored and included a walking program. Individuals in the training group (n=61) had a positive, significant progression in psychological SoC (P<0.001), whereas no progression in stages occurred in the control group (n=55). After the intervention, the training group demonstrated significant improvements in PA, lower body muscle strength, static and dynamic balance, with no significant changes in the control group. These results support the applicability of the TTM for a PA intervention and indicate that this training program is very effective in improving balance and lower body strength in older women.

A training needs survey of doctors' breastfeeding support skills in England

The study examined the training needs of paediatricians and general practitioners (GPs). Respondents rated their competence on 23 breastfeeding support skills, importance of update in the next 2 years, actual and potential helpfulness of different forms of professional updates, and accessibility in the next 2 years. The perception of organizational barriers to breastfeeding support and practitioners' knowledge of policies and guidance on breastfeeding were also examined. The sample comprised 120 paediatricians and 57 GPs. Response rates were estimated as between 4% and 29%, depending upon the method of recruitment. Although both groups rated themselves as fairly competent in most of the skill areas, they welcomed training in key areas of practice. Paediatricians identified more areas for update than GPs (t = 3.44; d.f. = 178; P < 0.00001). Those who believed that they were less competent in clinical skills were least likely to seek update (r = 0.35; P < 0.00001). Practical forms of training were most often welcomed. Only 47% of GPs and 62.5% of paediatricians had access to a local breastfeeding policy. There were evident gaps in knowledge on key aspects of public health policy, which could influence local practice; for example, 50.8% of GPs and 47.5% of paediatricians identified a younger age for introducing solids than the minimum according to current government guidance. Organizational barriers to breastfeeding support were experienced by all respondents. Recommendations include purposively targeting training to those least likely to seek training, and developing effective self-study and observational methods of learning. All training should be evaluated and implemented alongside breastfeeding policies and clinical leadership to improve the practice of all healthcare practitioners.