Christopher Shiels

Why are patients in clinical trials of heart failure not like those we see in everyday practice

BACKGROUND/OBJECTIVES Evidence-based research has been criticized for not being relevant to the real world of patient care in the community, mainly because participants in research studies are dissimilar to those typically seen in every day practice. This article examines recruitment difficulties, and identifies the main reasons why patients with heart failure declined to participate in a research trial. METHODS Postal survey of potential trial participants (n=667), at time of recruitment. Analysis of (1) clinical and sociodemographic characteristics of respondents and nonrespondents to survey, and decliners and consenters to participation in a randomized controlled trial. RESULTS No significant differences were found between respondents and nonrespondents in respect to sociodemographic or clinical variables. Males (OR=1.58, CI=1.04-2.41), younger patients (OR=1.05, CI=1.03-1.08), and those prescribed an angiotensin converting enzyme (ACE) inhibitor (OR=1.68, CI=1.10-2.57) were significantly more likely to consent to participate. Main reasons for nonparticipation were perceptions of being too old, too unwell, or too busy. CONCLUSIONS Explanations of the purpose of research need to counter against perceptions among participants and clarify the benefits and disadvantages of participating in an intervention study when unwell. Study design should recognize that many elderly patients have busy lives and caring responsibilities. Financial support for participation should be considered.

Patient and provider perspectives on home telecare : preliminary results from a randomized controlled trial

A randomized controlled trial of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease has been undertaken in the north-west of England. A videophone was used that communicates via the ordinary telephone network. The intervention period for each participant was two weeks. Participants in the telecare arm of the trial were asked to complete logbooks to record their experiences of each telecare encounter. A simple, self-completed, 10–item questionnaire was used that consisted of a Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). Fourteen nurses completed 150 logbooks and 22 patients completed 145 logbooks. These results demonstrate significant differences in perception between patients and their health-care providers with regard to telecare encounters across all the domains addressed. Participating patients consistently demonstrated more positive views of the telecare encounters than their health-care providers.

A prospective study of the roles, responsibilities and stresses of chaplains working within a hospice

Spiritual care is an integral part of palliative care and if asked, most members of a palliative care team would state they address spiritual issues. The majority of hospices have support from a chaplain. This study was to determine the roles of chaplains within hospices and to look at their levels of stress. A questionnaire containing both open and closed questions was sent to chaplains working within hospices in the UK. The questionnaire enquired about number of sessions, specific roles of chaplain, whether they were members of the multidisciplinary team and their sources of internal support. Stress was measured on a 10-point Likert scale and the GHQ12. One hundred and fifteen questionnaires were returned, with a 72% response rate. The majority (62%) defined their denomination as Church of England and Free Church (24%); 71% of respondents had parish commitments in addition to their hospice role. Roles were predominantly defined as spiritual care of patients and staff (95%) and bereavement support of relatives (76%) and 75% regularly attended the multidisciplinary meetings. Senior medical and nursing staff and other chaplains were perceived as providing most support. Median Likert score for stressfulness was 5, and 23% scored at or above the threshold on the GHQ12 for identifiable psychological morbidity. Clear role definition was associated with less perceived stress whereas the provision of bereavement support was associated with statistically significant increased perceived stress. The role of a chaplain within a hospice is varied and this study suggests that the provision of training and formal support is to be recommended.

Recruitment difficulties in a home telecare trial

We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.

Factors associated with the length of fit note-certified sickness episodes in the UK

Objectives To identify diagnostic, patient/employee, general practitioner (GP) and practice factors associated with length of certified sickness episodes. Methods Twelve-month collection of fit note data at 68 general practices in eight regions of England, Wales and Scotland between 2011 and 2013. Secondary analysis of sick note data collected at seven general practices in 2001/2002. All employed patients receiving at least one fit note at practices within the collection period were included in the study. Main study outcomes were certified sickness episodes lasting longer than 3, 6 and 12 weeks. Results The data from seven practices contributing in 2013, and a decade previously, suggest that periods of long-term sickness absence may be falling overall (risk >12 weeks absence, OR=0.65) but the proportion of mild–moderate mental disorder-related (M-MMD) episodes is rising (26% to 38%). Over 32% (8064/25 078) of fit notes issued to working patients in the 68 practices were for a M-MMD. A total of 13 994 patient sickness ‘episodes’ were identified. Diagnostic category of episode, male patients, older patient age and higher social deprivation were significantly associated with the >3 week, >6 week and long-term (>12 week) outcomes, and GP partner status with the long-term outcome only. Conclusions In the context of a rapidly changing legislative environment, the study used the largest sickness certification database constructed in the UK to enhance the evidence base relating to factors contributing to long-term work incapacity.

Inequalities in immunisation and breast feeding in an ethnically diverse urban area: cross-sectional study in Manchester, UK

Objectives To examine inequalities in immunisation and breast feeding by ethnic group and their relation to relative deprivation. Design Cross-sectional study. Setting Manchester, UK. Participants 20 203 children born in Manchester (2002–2007), who had been coded as of white, mixed, Indian, Pakistani, Bangladeshi and black or black British ethnicity in the Child Health System database. Main outcome measures Breast feeding at 2 weeks post partum; uptake of triple vaccine (diphtheria, pertussis and tetanus) at 16 weeks post partum; uptake of the measles, mumps and rubella vaccine (MMR) by the age of 2. Results Black or black British infants had the highest rates of breast feeding at 2 weeks post partum (89%), and South Asian infants had the highest triple and MMR vaccination rates (Indian, 95%, 96%; Pakistani 95%, 95%; Bangladeshi 96%, 95%) after area level of deprivation, parity, parenthood status and age had been controlled for. White infants were least likely to be breast fed at 2 weeks post partum (36%), and to be vaccinated with triple (92%) and MMR vaccines (88%). Within the white ethnic group, lower percentages of immunisation and breast feeding were significantly associated with living in a deprived area and with increasing parity. This was not found within black or black British and Pakistani ethnic groups. Discussion Practices that are protective of child health were consistently less likely to be adopted by white mothers living in deprived areas. Methods of health education and service delivery that are designed for the general population are unlikely to be successful in this context, and evidence of effective interventions needs to be established.

Beliefs of people taking antidepressants about the causes of their own depression

BACKGROUND The beliefs of people receiving treatment about the causes of their own mental health problems are researched less often than the causal beliefs of the public, but have important implications for relationships with prescribers, treatment choices and recovery. METHOD An online survey on a range of beliefs about depression, and experiences with antidepressants, was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants. RESULTS Six of 17 beliefs about the causes of their own depression were endorsed by more than half the sample: chemical imbalance, family stress, work stress, heredity, relationship problems and distressing events in childhood. There were some marked differences in content, structure and level of conviction of beliefs about one׳s own depression and the sample׳s previously published beliefs about depression in general. There were also significant differences between the beliefs of demographic groupings. Regression analyses revealed that self-reported effectiveness of the antidepressants was positively associated with bio-genetic causal beliefs. The quality of the relationship with the prescribing doctor was positively related to a belief in chemical imbalance as a cause and negatively related to a belief in unemployment as a cause. LIMITATIONS The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression. CONCLUSIONS People experiencing depression hold complex, multifactorial and idiosyncratic sets of beliefs about the causes of their own depression, apparently based at least in part on their own life experiences and circumstances. Exploring those beliefs may enhance the doctor-patient relationship and selection of appropriate treatment modality.

Understanding the non-pharmacological correlates of self-reported efficacy of antidepressants

To explore the non‐pharmacological correlates of the perceived effectiveness of antidepressants (ADs), thereby enhancing understanding of the mechanisms involved in recovery from depression while taking ADs.

Determinants of Care Seeking for Children With Pneumonia and Diarrhea in Guatemala: Implications for Intervention Strategies

OBJECTIVES We identified barriers to care seeking for pneumonia and diarrhea among rural Guatemalan children. METHODS A population-based survey was conducted twice from 2008 to 2009 among 1605 households with children younger than 5 years. A 14-day calendar recorded episodes of carer-reported pneumonia (n = 364) and diarrhea (n = 481), and formal (health services, public, private) and informal (neighbors, traditional, local shops, pharmacies) care seeking. RESULTS Formal care was sought for nearly half of severe pneumonias but only for 27% within 2 days of onset, with 31% and 18%, respectively, for severe diarrhea. In multivariable analysis, factors independently associated with formal care seeking were knowing the Community Emergency Plan, mothers perception of illness severity, recognition of World Health Organization danger signs, distance from the health center, and having someone to care for family in an emergency. CONCLUSIONS Proximal factors associated with recognizing need for care were important in determining formal care, and were strongly linked to social determinants. In addition to specific action by the health system with an enhanced community health worker role, a systems approach can help ensure barriers are addressed among poorer and more remote homes.

Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk community sample?

To date, most condom research has focused on young or high-risk groups, with little evidence about influences on condom use amongst lower-risk community samples. These groups are not risk free and may still wish to negotiate safer sex; yet the considerations involved could be different from those in higher-risk groups. Our research addresses this gap: We report a cross-sectional questionnaire study enquiring about recent condom use and future use intentions in community settings. Our sample (n = 311) purposively included couples in established relationships, known to be condom users. Items included demographics, sexual history and social-cognitive variables taken from the theory of planned behaviour. The strongest association with condom use/use intentions amongst our respondents was sexual partner’s perceived willingness to use them. This applied across both univariate and multivariate analyses. Whilst most social-cognitive variables (attitudes; self-efficacy and peer social norms) were significant in univariate analyses, this was not supported in multivariate regression. Of the social-cognitive variables, only “condom-related attitudes” were retained in the model explaining recent condom use, whilst none of them entered the model explaining future use intentions. Further analysis showed that attitudes concerning pleasure, identity stigma and condom effectiveness were most salient for this cohort. Our results suggest that, in community samples, the decision to use a condom involves different considerations from those highlighted in previous research. Explanatory models for established couples should embrace interpersonal perspectives, emphasising couple-factors rather than individual beliefs. Messages to this cohort could usefully focus on negotiation skills, condom advantages (other than disease prevention) and reducing the stigma associated with use.