Cultural adaptation of the iSupport online training and support programme for caregivers of people with dementia in Castilla y León, Spain

BACKGROUND

E-learning has shown to be an effective intervention in helping informal caregivers of people living with dementia. It has the potential to reach people living in remote areas, increasing service coverage. As a response to the demographic context in Spain associated with a higher percentage of ageing, depopulation, and the complexities of health service delivery in rural areas, this paper describes the cultural adaptation and co-design of the iSupport online training and support programme for Castilla y León, Spain, as a potential e-health intervention to mitigate these constraints.

METHODS

The translation and cultural adaptation were performed following the WHO guidelines, with some adaptation due to the cultural context of Spain. Three focus groups were conducted with informal caregivers, health professionals, and a group of experts on cognitive impairment and dementia. The co-design process was performed as a Patient and Public Involvement activity with three groups consisting of people living with dementia, informal caregivers, rural population and experts on technology and dementia.

RESULTS

A total of 435 suggestions were proposed for adaptation associated with erroneous terminology, rewording text/writing, grammatical or punctuation marks errors, and repeated information or need for additional content. Several recommendations were exposed during the co-design process: preference for interactive material such as videos or images, a forum to receive feedback from health care professionals and to leave satisfaction comments, availability in multiple platforms (e.g., tablet, laptop, mobile), slide format for information presentation, and availability to edit letter size and background colours.

CONCLUSIONS

A culturally adapted version of the iSupport was developed for Castilla y León, Spain. The need for modification of words and expressions, information links to local resources websites, adjustments of characters' names and caregivers' scenarios, and additional content to some sections were recommended. Suggestions for the design should be taken into account for further adapted versions and platform developments.

Support for Aboriginal health services in reducing harms from alcohol: 2-year service provision outcomes in a cluster randomized trial

BACKGROUND AND AIMS

There is a higher prevalence of unhealthy alcohol use among Indigenous populations, but there have been few studies of the effectiveness of screening and treatment in primary health care. Over 24 months, we tested whether a model of service-wide support could increase screening and any alcohol treatment.

DESIGN

Cluster-randomized trial with 24-month implementation (12 months active, 12 months maintenance).

SETTING

Australian Aboriginal Community Controlled primary care services.

PARTICIPANTS

Twenty-two services (83 032 clients) that use Communicare practice software and see at least 1000 clients annually, randomized to the treatment arm or control arm.

INTERVENTION AND COMPARATOR

Multi-faceted early support model versus a comparator of waiting-list control (11 services).

MEASUREMENTS

A record (presence = 1, absence = 0) of: (i) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening (primary outcome), (ii) any-treatment and (iii) brief intervention. We received routinely collected practice data bimonthly over 3 years (1-year baseline, 1-year implementation, 1-year maintenance). Multi-level logistic modelling was used to compare the odds of each outcome before and after implementation.

FINDINGS

The odds of being screened within any 2-month reference period increased in both arms post-implementation, but the increase was nearly eight times greater in early-support services [odds ratio (OR) = 7.95, 95% confidence interval (CI) = 4.04-15.63, P < 0.001]. The change in odds of any treatment in early support was nearly double that of waiting-list controls (OR = 1.89, 95% CI = 1.19-2.98, P = 0.01) but was largely driven by decrease in controls. There was no clear evidence of difference between groups in the change in the odds of provision of brief intervention (OR = 1.95, 95% CI = 0.53-7.17, P = 0.32).

CONCLUSIONS

An early support model designed to aid routine implementation of alcohol screening and treatment in Aboriginal health services resulted in improvement of Alcohol Use Disorders Identification Test-Consumption screening rates over 24 months of implementation, but the effect on treatment was less clear.

Training and support for caregivers of people with dementia: The process of culturally adapting the World Health Organization iSupport programme to Portugal

BACKGROUND

Informal caregivers of people with dementia often struggle with several stressors, and their mental and physical health can be negatively affected by providing care. iSupport is an online self-help programme designed by the World Health Organization to provide education, skills training, and support to those caregivers.

PURPOSE

This paper describes the development of an adapted version of iSupport to the Portuguese culture. We present the adaptation process, methods used and results for the country-specific version.

METHODS

The adaptation of iSupport was operationalised in five steps: needs assessment; content translation by an authorised translator and technical accuracy check by health professionals; cultural adaptation; independent appraisal of contents by an expert panel; and fidelity check by programme authors.

RESULTS

Findings indicated the adjustments needed in the original iSupport contents. Overall, 323 text excerpts were proposed to adaptation, comprising semantic and conceptual equivalence of expressions, and adjustments to cultural habits, customs, traditions, local resources, and practices. The expert panel identified the need to reformulate definitions, designations, recommendations, and case studies to fine-tune the original contents to local knowledge and practices. Most adaptations were considered to be in line with the core concepts of the original programme.

CONCLUSIONS

iSupport is an innovative tool capturing the attention of several organisations around the world interested in translating, adapting, and using the programme. This paper is the first describing the methodological approach for culturally adapting iSupport, constituting an essential resource for those aiming to replicate the process or culturally adapting evidence-based interventions. Tailoring iSupport to the Portuguese context was critical to accommodate the cultural experiences of the target group as well as the knowledge, theoretical approaches, and practices of local professionals. The European-Portuguese version of iSupport introduces the adjustments needed to implement a useful new intervention programme aimed at minimising the psychological distress of Portuguese caregivers.

Financial Sector Workers' Experiences of Managing Suicidal Clients

BACKGROUND

Financial sector workers interface with indebted clients, who may be distressed and have heightened vulnerability to suicidality.

AIM(S)

This study examined the experiences of 10 Irish financial sector workers who had experiences of encountering distressed clients who discuss suicide.

METHOD

Semistructured interviews (open-ended questions) were used.

RESULTS

Interpretative phenomenological analysis (IPA) identified four themes, namely: (1) avoidance versus confrontation of reality (management of the debt); (2) role conflict (recovering the debt vs. supporting the client); (3) emotional impact and distancing from clients (coping with concerns for client welfare); (4) desire for support (practical and emotional training and support needs).

LIMITATIONS

The frequency with which such clients were encountered was not assessed.

CONCLUSION

These themes demonstrate the need to provide support to this group, and also the difficulties in providing training to manage suicidal clients in a context where the staff member's goal is to recover debt.

Delivery of Brief Interventions for Heavy Drinking in Primary Care: Outcomes of the ODHIN 5-Country Cluster Randomized Trial

PURPOSE

We aimed to test whether 3 strategies-training and support, financial reimbursement, and an option to direct screen-positive patients to an Internet-based method of giving brief advice-have a longer-term effect on primary care clinicians' delivery of screening and advice to heavy drinkers operationalized with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool.

METHODS

We undertook a cluster randomized factorial trial with a 12-week implementation period in 120 primary health care units throughout Catalonia, England, Netherlands, Poland, and Sweden. Units were randomized to 8 groups: care as usual (control); training and support alone; financial reimbursement alone; electronic brief advice alone; paired combinations of these conditions; and all 3 combined. The primary outcome was the proportion of consulting adult patients (aged 18 years and older) receiving intervention-screening and, if screen-positive, advice-at 9 months.

RESULTS

Based on the factorial design, the ratio of the log of the proportion of patients given intervention at the 9-month follow-up was 1.39 (95% CI, 1.03-1.88) in units that received training and support as compared with units that did not. Neither financial reimbursement nor directing screen-positive patients to electronic brief advice led to a higher proportion of patients receiving intervention.

CONCLUSIONS

Training and support of primary health care units has a lasting, albeit small, impact on the proportion of adult patients given an alcohol intervention at 9 months.

Scaling-up primary health care-based prevention and management of heavy drinking at the municipal level in middle-income countries in Latin America: Background and protocol for a three-country quasi-experimental study

Background: While primary health care (PHC)-based prevention and management of heavy drinking is clinically effective and cost-effective, it remains poorly implemented in routine practice. Systematic reviews and multi-country studies have demonstrated the ability of training and support programmes to increase PHC-based screening and brief advice activity to reduce heavy drinking. However, gains have been only modest and short term at best. WHO studies have concluded that a more effective uptake could be achieved by embedding PHC activity within broader community and municipal support.

Protocol: A quasi-experimental study will compare PHC-based prevention and management of heavy drinking in three intervention cities from Colombia, Mexico and Peru with three comparator cities from the same countries. In the implementation cities, primary health care units (PHCUs) will receive training embedded within ongoing supportive municipal action over an 18-month implementation period. In the comparator cities, practice as usual will continue at both municipal and PHCU levels. The primary outcome will be the proportion of consulting adult patients intervened with (screened and advice given to screen positives). The study is powered to detect a doubling of the outcome measure from an estimated 2.5/1,000 patients at baseline. Formal evaluation points will be at baseline, mid-point and end-point of the 18-month implementation period. We will present the ratio (plus 95% confidence interval) of the proportion of patients receiving intervention in the implementation cities with the proportions in the comparator cities. Full process evaluation will be undertaken, coupled with an analysis of potential contextual, financial and political-economy influencing factors.

Discussion: This multi-country study will test the extent to which embedding PHC-based prevention and management of alcohol use disorder with supportive municipal action leads to improved scale-up of more patients with heavy drinking receiving appropriate advice and treatment.

Study status: The four-year study will start on 1 ^st December 2017.

Attitudes and Learning through Practice Are Key to Delivering Brief Interventions for Heavy Drinking in Primary Health Care: Analyses from the ODHIN Five Country Cluster Randomized Factorial Trial

In this paper, we test path models that study the interrelations between primary health care provider attitudes towards working with drinkers, their screening and brief advice activity, and their receipt of training and support and financial reimbursement. Study participants were 756 primary health care providers from 120 primary health care units (PHCUs) in different locations throughout Catalonia, England, The Netherlands, Poland, and Sweden. Our interventions were training and support and financial reimbursement to providers. Our design was a randomized factorial trial with baseline measurement period, 12-week implementation period, and 9-month follow-up measurement period. Our outcome measures were: attitudes of individual providers in working with drinkers as measured by the Short Alcohol and Alcohol Problems Perception Questionnaire; and the proportion of consulting adult patients (age 18+ years) who screened positive and were given advice to reduce their alcohol consumption (intervention activity). We found that more positive attitudes were associated with higher intervention activity, and higher intervention activity was then associated with more positive attitudes. Training and support was associated with both positive changes in attitudes and higher intervention activity. Financial reimbursement was associated with more positive attitudes through its impact on higher intervention activity. We conclude that improving primary health care providers' screening and brief advice activity for heavy drinking requires a combination of training and support and on-the-job experience of actually delivering screening and brief advice activity.

Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial

AIM

To test if training and support, financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice (eBI) can increase primary health-care providers' delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers.

DESIGN

Cluster randomized factorial trial with 12-week implementation and measurement period.

SETTING

Primary health-care units (PHCU) in different locations throughout Catalonia, England, the Netherlands, Poland and Sweden.

PARTICIPANTS

A total of 120 PHCU, 24 in each of Catalonia, England, the Netherlands, Poland and Sweden.

INTERVENTIONS

PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR) and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI.

MEASUREMENTS

The primary outcome measure was the proportion of eligible adult (age 18+ years) patients screened during a 12-week implementation period. Secondary outcome measures were proportion of screen-positive patients advised; and proportion of consulting adult patients given an intervention (screening and advice to screen-positives) during the same 12-week implementation period.

FINDINGS

During a 4-week baseline measurement period, the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU (95% CI 0.034 to 0.084). Based on the factorial design, the ratio of the logged proportion screened during the 12-week implementation period was 1.48 (95% CI = 1.13-1.95) in PHCU that received TS versus PHCU that did not receive TS; for FR, the ratio was 2.00 (95% CI = 1.56-2.56). The option of referral to eBI did not lead to a higher proportion of patients screened. The ratio for TS plus FR was 2.34 (95% CI = 1.77-3.10), and the ratio for TS plus FR plus eBI was1.68 (95% CI = 1.11-2.53).

CONCLUSIONS

Providing primary health-care units with training, support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption. Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption.