Angel M. Chater

Culture and Health: UCL- Lancet Commission.

Planned and unplanned migrations, diverse social practices, and emerging disease vectors transform how health and wellbeing are understood and negotiated. Simultaneously, familiar illnesses—both communicable and non-communicable—continue to affect individual health and household, community, and state economies. Together, these forces shape medical knowledge and how it is understood, how it comes to be valued, and when and how it is adopted and applied. Perceptions of physical and psychological wellbeing differ substantially across and within societies. Although cultures often merge and change, human diversity assures that different lifestyles and beliefs will persist so that systems of value remain autonomous and distinct. In this sense, culture can be understood as not only habits and beliefs about perceived wellbeing, but also political, economic, legal, ethical, and moral practices and values. Although culture can be considered as a set of subjective values that oppose scientific objectivity, we challenge this view in this Commission by claiming that all people have systems of value that are unexamined. Such systems are, at times, diffuse, and often taken for granted, but are always dynamic and changing. They produce novel and sometimes perplexing needs, to which established caregiving practices often adjust slowly. Ideas about health are, therefore, cultural. They vary widely across societies and should not merely be defined by measures of clinical care and disease. Health can be defined in worldwide terms or quite local and familiar ones. Yet, in clinical settings, a tendency to standardise human nature can be, paradoxically, driven by both an absence of awareness of the diversity with which wellbeing is contextualised and a commitment to express both patient needs and caregiver obligations in universally understandable terms. We believe, therefore, that the perceived distinction between the objectivity of science and the subjectivity of culture is itself a social fact (a common perception). We attribute the absence of awareness of the cultural dimensions of scientific practice to this distinction, especially for macrocultures and large societies, which define only small-scale, microcultures as cultural. We recommend a broad view of culture that embraces not only social systems of belief as cultural, but also presumptions of objectivity that permeate views of local and global health, health care, and health-care delivery. If the role of cultural systems of value in health is ignored, biological wellness can be focused on as the sole measure of wellbeing, and the potential for culture to become a key component in health maintenance and promotion can be eroded. This erosion is especially true where resources are scarce or absent. Under restricted and pressured conditions, behavioural variables that affect biological outcomes are dismissed as merely sociocultural, rather than medical. Especially when money is short, or when institutions claim to have discharged fully their public health obligations, blame for ill health can be projected onto those who are already disadvantaged. As a result, many thinkers in health-care provision across disciplines attribute poor health-care outcomes to factors that are beyond the control of care providers—namely, on peculiar, individual, or largely inaccessible cultural systems of value. Others, having witnessed the ramifications of such thinking, argue that all health-care provision should, rather, be made more culturally sensitive. Yet others declare merely that multiculturalism has failed and the concept should be abandoned, citing its divisive potential.1 Irrespective of who is blamed, failure to recognise the intersection of culture with other structural and societal factors creates and compounds poor health outcomes, multiplying financial, intellectual, and humanitarian costs. However, the effect of cultural systems of values on health outcomes is huge, within and across cultures, in multicultural settings, and even within the cultures of institutions established to advance health. In all cultural settings—local, national, worldwide, and even biomedical—the need to understand the relation between culture and health, especially the cultural factors that affect health-improving behaviours, is now crucial. In view of the financial fragility of so many systems of care around the world, and the wastefulness of so much of health-care spending, a line can no longer be drawn between biomedical care and systems of value that define our understanding of human wellbeing. Where economic limitations dictate what is feasible, socioeconomic status produces its own cultures of security and insecurity that cut across nationality, ethnic background, gender orientation, age, and political persuasion. Socioeconomic status produces new cultures defined by degrees of social security and limitations on choice that privilege some people and disadvantage others. Financial equity is, therefore, a very large part of the cultural picture; but it is not the entire picture. The capacity to attend to adversity—to believe that one can affect ones own future—is conditioned by a sense of social security that is only partly financial. In this Commission, we review health and health practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address those pressing issues and emerging needs. We examine overlapping domains of culture and health: cultural competence, health inequalities, and communities of care. In these three domains, we show how inseparable health is from culturally affected perceptions of wellbeing. After examination of these key domains, we identify 12 findings in need of immediate attention: Medicine should accommodate the cultural construction of wellbeing • Culture should be better defined • Culture should not be neglected in health and health-care provision • Culture should become central to care practices • Clinical cultures should be reshaped • People who are not healthy should be recapacitated within the culture of biomedicine • Agency should be better understood with respect to culture • Training cultures should be better understood • Competence should be reconsidered across all cultures and systems of care • Exported and imported practices and services should be aligned with local cultural meaning • Building of trust in health care should be prioritised as a cultural value • New models of wellbeing and care should be identified and nourished across cultures We believe that these points are imperative to the advancement of health worldwide and are the greatest challenges for health. Together, they constitute an agenda for reversal of the systematic neglect of culture in health, the single biggest barrier to advancement of the highest attainable standard of health worldwide.

Effective behaviour change techniques in the prevention and management of childhood obesity.

Rates of childhood obesity are increasing, and it is essential to identify the active components of interventions aiming to prevent and manage obesity in children. A systematic review of behaviour change interventions was conducted to find evidence of behaviour change techniques (BCTs) that are most effective in changing physical activity and/or eating behaviour for the prevention or management of childhood obesity. An electronic search was conducted for randomised controlled trials published between January 1990 and December 2009. Of 4309 titles and abstracts screened, full texts of 135 articles were assessed, of which 17 published articles were included in this review. Intervention descriptions were coded according to the behaviour-specific CALO-RE taxonomy of BCTs. BCTs were identified and compared across obesity management (n=9) vs prevention (n=8) trials. To assess the effectiveness of individual BCTs, trials were further divided into those that were effective (defined as either a group reduction of at least 0.13 body mass index (BMI) units or a significant difference in BMI between intervention and control groups at follow-up) vs non-effective (reported no significant differences between groups). We reliably identified BCTs utilised in effective and non-effective prevention and management trials. To illustrate the relative effectiveness of each BCT, effectiveness ratios were calculated as the ratio of the number of times each BCT was a component of an intervention in an effective trial divided by the number of times they were a component of all trials. Results indicated six BCTs that may be effective components of future management interventions (provide information on the consequences of behaviour to the individual, environmental restructuring, prompt practice, prompt identification as role model/position advocate, stress management/emotional control training and general communication skills training), and one that may be effective in prevention interventions (prompting generalisation of a target behaviour). We identified that for management trials, providing information on the consequences of behaviour in general was a feature of non-effective interventions and for prevention trials, providing information on the consequences of behaviour in general, providing rewards contingent on successful behaviour and facilitating social comparison were non-effective. To design effective behaviour change programmes for the prevention and management of childhood obesity, we would recommend utilising the BCTs identified as effective in this review. The impact on intervention effectiveness of combining BCTs should be the topic of further research.

Implementation intention and planning interventions in Health Psychology: Recommendations from the Synergy Expert Group for research and practice

The current article details a position statement and recommendations for future research and practice on planning and implementation intentions in health contexts endorsed by the Synergy Expert Group. The group comprised world-leading researchers in health and social psychology and behavioural medicine who convened to discuss priority issues in planning interventions in health contexts and develop a set of recommendations for future research and practice. The expert group adopted a nominal groups approach and voting system to elicit and structure priority issues in planning interventions and implementation intentions research. Forty-two priority issues identified in initial discussions were further condensed to 18 key issues, including definitions of planning and implementation intentions and 17 priority research areas. Each issue was subjected to voting for consensus among group members and formed the basis of the position statement and recommendations. Specifically, the expert group endorsed statements and recommendations in the following areas: generic definition of planning and specific definition of implementation intentions, recommendations for better testing of mechanisms, guidance on testing the effects of moderators of planning interventions, recommendations on the social aspects of planning interventions, identification of the preconditions that moderate effectiveness of planning interventions and recommendations for research on how people use plans.

Autonomous and controlled motivational regulations for multiple health-related behaviors: between- and within-participants analyses.

Self-determination theory has been applied to the prediction of a number of health-related behaviors with self-determined or autonomous forms of motivation generally more effective in predicting health behavior than non-self-determined or controlled forms. Research has been confined to examining the motivational predictors in single health behaviors rather than comparing effects across multiple behaviors. The present study addressed this gap in the literature by testing the relative contribution of autonomous and controlling motivation to the prediction of a large number of health-related behaviors, and examining individual differences in self-determined motivation as a moderator of the effects of autonomous and controlling motivation on health behavior. Participants were undergraduate students (N = 140) who completed measures of autonomous and controlled motivational regulations and behavioral intention for 20 health-related behaviors at an initial occasion with follow-up behavioral measures taken four weeks later. Path analysis was used to test a process model for each behavior in which motivational regulations predicted behavior mediated by intentions. Some minor idiosyncratic findings aside, between-participants analyses revealed significant effects for autonomous motivational regulations on intentions and behavior across the 20 behaviors. Effects for controlled motivation on intentions and behavior were relatively modest by comparison. Intentions mediated the effect of autonomous motivation on behavior. Within-participants analyses were used to segregate the sample into individuals who based their intentions on autonomous motivation (autonomy-oriented) and controlled motivation (control-oriented). Replicating the between-participants path analyses for the process model in the autonomy- and control-oriented samples did not alter the relative effects of the motivational orientations on intention and behavior. Results provide evidence for consistent effects of autonomous motivation on intentions and behavior across multiple health-related behaviors with little evidence of moderation by individual differences. Findings have implications for the generalizability of proposed effects in self-determination theory and intentions as a mediator of distal motivational factors on health-related behavior.

A U.K. case study of who uses NHS Direct: investigating the impact of age, gender, and deprivation on the utilization of NHS Direct

OBJECTIVES National Health Service (NHS) Direct provides a 24/7 telephone-based healthcare advice and information service to the public in England. Locally based studies have suggested variation in the uptake of this service among the United Kingdoms diverse population. This study seeks to examine this issue at a national level. SUBJECTS AND METHODS One months period of national data was collected (July 2010) from the NHS Direct Clinical Assessment System for all 0845 4647 calls in England. Calls were matched to place of residence and were analyzed for age, gender, and deprivation using negative binominal regression. RESULTS Within the context of NHS Direct the pattern of calls was highest for children 5 years old and under, with lowest call rates found for males and older people (65+ years old). Furthermore, call rates were lowest in the most deprived areas for children (0-15 years old). Gender differences were noted, whereby male call rates were higher in the most deprived areas for all age groups. Furthermore, call rates for or on behalf of older females (60+ years old) were lower in areas of extreme deprivation. CONCLUSIONS The findings suggest there is variation in usage of NHS Direct. Such usage appears to be influenced by age, gender, and deprivation. Further research is required to examine the underlying factors that contribute to variation in uptake of these services. This will enable the development of future promotional campaigns that can target particular sections of the population to encourage use of telephone-based health services.

Profiling patient attitudes to phosphate binding medication: A route to personalising treatment and adherence support

Objective: Nonadherence to phosphate binding medication (PBM) compromises the efficacy of treatment for chronic kidney disease, but its causes are poorly understood. This study sought to explore patient attitudes towards PBM and to evaluate the utility of the necessity-concerns framework for understanding adherence to PBM. Design: A sample of 221 dialysis patients currently prescribed PBM were surveyed from eight UK renal units. Main Outcome Measures: Demographic data and clinical information, alongside the Beliefs about Medicines Questionnaire and the medication adherence report scale were reported. Results: Low adherence to PBM was predicted by reduced beliefs in personal need for PBM (OR = .34; 95% CI: .14–.83; p < .05), and increased concerns about PBM (OR = 3.17; 95% CI: 1.87–5.37; p < .001). Patients were categorised into attitudinal groups based on their beliefs about PBM and being ‘skeptical’ of PBM (low necessity beliefs and high concerns) was most associated with low adherence. Conclusion: Strategies to improve adherence to PBM should aim to elicit and address patients’ beliefs about their personal need for PBM and their concerns about this medication.

Young people's use of NHS Direct: a national study of symptoms and outcome of calls for children aged 0-15

Objectives National Health Service (NHS) Direct provides 24/7 expert telephone-based healthcare information and advice to the public in England. However, limited research has explored the reasons to why calls are made on behalf of young people, as such this study aimed to examine call rate (CR) patterns in younger people to enable a better understanding of the needs of this population in England. Setting NHS Direct, England, UK. Participants and methods CRs (expressed as calls/100 persons/annum) were calculated for all calls (N=358 503) made to NHS Direct by, or on behalf of, children aged 0–15 during the combined four ‘1-month’ periods within a year (July 2010, October 2010, January 2011 and April 2011). χ² Analysis was used to determine the differences between symptom, outcome and date/time of call. Results For infants aged <1, highest CRs were found for ‘crying’ for male (n=14, 440, CR=13.61) and female (n=13 654, CR=13.46) babies, which is used as a universal assessment applied to all babies. High CRs were also found for symptoms relating to ‘skin/hair/nails’ and ‘colds/flu/sickness’ for all age groups, whereby NHS Direct was able to support patients to self-manage and provide health information for these symptoms for 59.7% and 51.4% of all cases, respectively. Variations in CRs were found for time and age, with highest peaks found for children aged 4–15 in the 15:00–23:00 period and in children aged <1 in the 7:00–15:00 period. Conclusions This is the first study to examine the symptoms and outcome of calls made to NHS Direct for and on behalf of young children. The findings revealed how NHS Direct has supported a range of symptoms through the provision of health information and self-care support which provides important information about service planning and support for similar telephone-based services.

A prospective study exploring the construct and predictive validity of the COM-B model for physical activity:

This study examined the constructs of capability, opportunity and motivation from the COM-B model and their influence on moderate-to-vigorous physical activity. Using a prospective survey design, 186 healthy adults completed measures representing the theoretical domains framework mapped to the COM-B, and moderate-to-vigorous physical activity 1 week later. The main indicators for the COM constructs were ‘habits’ (Capability), ‘subjective norms’ (Opportunity) and ‘exercise self-identity’ (Motivation). Motivation (77%) and moderate-to-vigorous physical activity (50%) were strongly predicted, with Capability and Motivation as key drivers of behaviour. Motivation was a strong mediator for Capability on behaviour. Future research should consider this approach for other populations and behaviours.

Why we should understand the patient experience: clinical empathy and medicines optimisation

To critically discuss the need for pharmacists to underpin their consultations with appropriate ‘clinical empathy’ as part of effective medicines optimisation.

What are the most effective behaviour change techniques to promote physical activity and/or reduce sedentary behaviour in inactive adults? A systematic review protocol

Introduction Large proportions of the population are not meeting recommended levels of physical activity and have increasingly sedentary lifestyles. Low levels of physical activity are predictive of poor health outcomes and time spent sedentary is related to a host of risk factors independently of physical activity levels. Building an evidence base of the best approaches to intervene in the lifestyles of inactive individuals is crucial in preventing long-term disease, disability and higher mortality rates. Methods and analysis Systematic searches will be conducted on all relevant databases (eg, PubMed, Scopus, CINAHL, PsycINFO). Studies will be included if they assess interventions aimed at changing physical activity or sedentary behaviour levels in adults (over 18) who are inactive and do not suffer from chronic conditions. Studies must also be randomised controlled trials (RCTs), have a primary outcome of physical activity or sedentary behaviour, and measure outcomes at least 6 months after intervention completion. Studies will be coded using the Behaviour Change Technique (BCT) taxonomy v1 and Template for Intervention Description and Replication (TIDieR) guidelines. 2 reviewers will independently screen full-text articles and extract data on study characteristics, participants, BCTs, intervention features and outcome measures. Study quality will also be assessed independently by 2 reviewers using the Cochrane risk of bias tool. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. GRADE criteria will be used to assess quality of evidence. Dissemination This will be the first review to systematically appraise interventions aimed at changing the physical activity or sedentary behaviour of inactive individuals using RCT designs with a 6-month follow-up post-intervention. This review will better inform intervention designers targeting inactive populations and inform the design of a future complex intervention. Review registration number This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 17 October 2014 (registration number: CRD42014014321).