Iain Atherton

Housing First: Considering Components for Successful Resettlement of Homeless People with Multiple Needs

‘Housing First’ programmes in the US involve the provision of mainstream scatter sited permanent housing at the initial stage of support for homeless individuals with multiple needs. This is in contrast to dominant approaches (in the US and Europe) that assert the need for successful progress towards treatment goals (usually whilst living in temporary congregate accommodation) prior to resettlement. Evaluations of Housing First indicate, however, that even those considered farthest from being housed can, with help, successfully maintain a mainstream tenancy of their own. It is asserted here that one locally based agency managing both the housing and assertively providing holistic non time-limited support packages may be important factors in the success rate of Housing First programmes. However, a caveat is added—to robustly assess the effectiveness of Housing First (and homelessness policy per se) requires continued consideration as to what ‘success’ refers to in the resettlement of formerly homeless people.

Mindfulness-based cognitive therapy for inflammatory bowel disease patients: findings from an exploratory pilot randomised controlled trial

BackgroundInflammatory bowel disease (IBD) is a chronic gastrointestinal condition with a relapsing disease course. Managing the relapsing nature of the disease causes daily stress for IBD patients; thus, IBD patients report higher rates of depression and anxiety than the general population.Mindfulness-based Cognitive Therapy (MBCT) is an evidence-based psychological program designed to help manage depressive and stress symptoms. There has been no randomized controlled trial (RCT) testing the use of MBCT in IBD patients.The purpose of this pilot study is to test the trial methodology and assess the feasibility of conducting a large RCT testing the effectiveness of MBCT in IBD.MethodsThe IBD patients, who were recruited from gastroenterology outpatient clinics at two Scottish NHS Boards, were randomly allocated to an MBCT intervention group (n = 22) or a wait-list control group (n = 22). The MBCT intervention consisted of 16 hours of structured group training over 8 consecutive weeks plus guided home practice and follow-up sessions. The wait-list group received a leaflet entitled ‘Staying well with IBD’. All participants completed a baseline, post-intervention and 6-month follow up assessment. The key objectives were to assess patient eligibility and recruitment/dropout rate, to calculate initial estimates of parameters to the proposed outcome measures (depression, anxiety, disease activity, dispositional mindfulness and quality of life) and to estimate sample size for a future large RCT.ResultsIn total, 350 patients were assessed for eligibility. Of these, 44 eligible patients consented to participate. The recruitment rate was 15 %, with main reasons for ineligibility indicated as follows: non-response to invitation, active disease symptoms, planned surgery or incompatibility with group schedule. There was a higher than expected dropout rate of 44 %. Initial estimates of parameters to the proposed outcomes at post-intervention and follow-up showed a significant improvement of scores in the MBCT group when compared to the control for depression, trait anxiety and dispositional mindfulness. The sample-size calculation was guided by estimates of clinically important effects in depression scores.ConclusionsThis pilot study suggests that a multicentre randomized clinical trial testing the effectiveness of MBCT for IBD patients is feasible with some changes to the protocol. Improvement in depression, trait anxiety and dispositional mindfulness scores are promising when coupled with patients reporting a perceived improvement of their quality of life.Trial registrationISRCTN27934462. 2 August 2013.

Prevalence of skin problems and leg ulceration in a sample of young injecting drug users.

BackgroundDrug users suffer harm from the injecting process, and clinical services are reporting increasing numbers presenting with skin-related problems such as abscesses and leg ulcers. Skin breakdown can lead to long-term health problems and increased service costs and is often the first indication of serious systemic ill health. The extent of skin problems in injecting drug users has not previously been quantified empirically, and there is a dearth of robust topical literature. Where skin problems have been reported, this is often without clear definition and generic terms such as ‘soft tissue infection’ are used which lack specificity. The aim of this study was to identify the range and extent of skin problems including leg ulceration in a sample of injecting drug users. Definitions of skin problems were developed and applied to descriptions from drug users to improve rigour.MethodsData were collected in needle exchanges and methadone clinics across Glasgow, Scotland, from both current and former drug injectors using face-to-face interviews.ResultsTwo hundred participants were recruited, of which 74% (n = 148) were males and 26% (n = 52) were females. The age range was 21–44 years (mean 35 years). Just under two thirds (64%, n = 127) were currently injecting or had injected within the last 6 months, and 36% (n = 73) had previously injected and had not injected for more than 6 months.Sixty per cent (n = 120) of the sample had experienced a skin problem, and the majority reported more than one problem. Most common were abscesses, lumps, track marks and leg ulcers. Fifteen per cent (n = 30) of all participants reported having had a leg ulcer.ConclusionsThis is an original empirical study which demonstrated unique findings of a high prevalence of skin disease (60%) and surprisingly high rates of leg ulceration (15%). Skin disease in injecting drug users is clearly widespread. Leg ulceration in particular is a chronic recurring condition that is costly to treat and has long-term implications for drug users and services caring for current or former injectors long after illicit drug use has ceased.

The influence of non-modifiable illness perceptions on attendance at cardiac rehabilitation

Background: Despite the established benefits of cardiac rehabilitation (CR) attendance rates remain variable. Physical barriers to attendance have been extensively investigated but relatively less is known about the relationship between attendance at CR and psychosocial variables such as illness perceptions and social isolation. Aim: To examine the influence of socio-demographic factors, illness perceptions and social isolation on patient attendance at cardiac rehabilitation. Methods: All individuals offered CR over a two-year period were invited to take part in a postal survey. The survey collected socio-demographic data and included completion of the Friendship Scale, to assess social isolation, and the Brief Illness Perceptions Questionnaire. Parametric and non-parametric statistical tests were used as appropriate. Results: One hundred and twenty-eight (47%) questionnaires were returned. Non-attendees reported higher total illness perception scores and those who attributed their illness to non-modifiable factors were significantly less likely to attend CR (p = 0.042). Attendees reported lower levels of social isolation; however, this finding was not statistically significant. No differences were found between attendees and non-attendees in terms of their age, gender, educational status or proximity to cardiac rehabilitation centre. Conclusion: Psychosocial barriers, specifically illness perceptions and attributions, were found to be significant with patients who did not attend CR reporting more negative illness perceptions. Distance to CR was not a significant factor influencing attendance. Early screening of perceived causal attributions may help to identify those who would benefit from early and targeted intervention to increase participation in CR. Future prospective studies would permit testing of screening approaches and early interventions.

Assessment of causal link between psychological factors and symptom exacerbation in inflammatory bowel disease: a protocol for systematic review of prospective cohort studies

BackgroundInflammatory bowel disease is an idiopathic chronic disease that affects around 28 million people worldwide. Symptoms are distressing and have a detrimental effect on patients’ quality of life. A possible link between exacerbation of symptoms and psychological factors has been suspected but not established. Previous reviews concerned with this link had conceptual and methodological limitations. In this paper we set out a protocol that lays the foundations for a systematic review that will address these shortcomings. The aim of this review is to provide researchers and clinicians with clarity on the role of psychological factors in inflammatory bowel disease symptom exacerbation.Method/designWe will identify all original, published, peer reviewed studies relevant to the topic and published in English from inception to November 2012. The databases MEDLINE, EMBASE, CINAHL and PsychINFO will be systematically searched. The search terms will include: inflammatory bowel disease, Crohn’s disease, ulcerative colitis, psychological stress, mental stress, life stress, family stress, hassles, social stress, coping, mood disorders, anxiety and depression in sequential combinations.Studies will be screened according to predetermined inclusion and exclusion criteria by two reviewers. We will include clinical prospective cohort studies of all human participants aged 18 years or over with a diagnosis of inflammatory bowel disease. All eligible papers will be independently and critically appraised using the Critical Appraisal Skills Programme (CASP) tool by two reviewers. Two reviewers will independently extract and synthesise data from the studies using a predefined data extraction sheet. Disagreements will be resolved by discussion between reviewers and a third party will be consulted if agreement is not reached. Synthesised data will be analysed using Bradford Hill criterion for causality. If data permits, meta-analysis will be performed.DiscussionThis study will provide the most comprehensive review and synthesis of current evidence around the link between psychological factors and symptom exacerbation in inflammatory bowel disease. Results will inform clinicians in appropriate intervention development for this patient group that would reduce symptom exacerbation and therefore improve patients’ quality of life.

Differences in 5-year survival after a ‘homeless’ or ‘housed’ drugs-related hospital admission: a study of 15–30-year olds in Scotland

Background Young drug misusers and the homeless both have a greater risk of death than their peers. This study sought to estimate the additional impact of homelessness on the risk of death for young drugs misusers. Methods From all admissions to NHS hospitals in Scotland between 1986 and 2001, those that were: drug misuse related, for people born between 1970 and 1986 and aged over 15 years (n=13 303), were selected. All subsequent admissions and registrations of death were linked to this dataset. Each admission was coded as homeless if the health board of residence was coded as ‘no fixed abode’. 5-year survival after an admission was modelled using (1) life table and (2) proportional hazard models and then (3) differences in causes of deaths were explored. Results Immediately after a drugs-related hospital admission there was no difference in survival between the homeless and those with a ‘fixed address’. However, over a 3-year period the risk for those who were homeless was 3.5 times greater (CI 95% 1.2 to 12.8). This elevated risk seemed to be particularly focused on the second year after an admission. The causes of death were similar for the two groups. Conclusion Although a homeless hospital admission is associated with a greater risk of death for young drug users, it is also a point in time when a young person is in contact with public services. An attempt to link their discharge with housing services would seem a potentially productive policy.

Does time matter? An investigation of knowledge and attitudes following blood transfusion training

The Scottish National Blood Transfusion service have developed an educational programme aimed at ensuring a high standard of care for blood transfusions to minimise risk to patients and healthcare practitioners. This paper investigates whether knowledge and understanding of, and attitudes towards, safe practice declined over time following completion of module 1 of the programme. An online survey was administered to a range of healthcare practitioners who had completed the module. The survey tool tested knowledge and ascertained views on blood transfusion practice and perceptions of the modules importance. Comparisons were made between participants 6-8 weeks, 12-14 months and 22-24 months since module completion. In-depth interviews were conducted with a sub-sample of survey respondents to explore attitudes in more detail. Findings indicate evidence of a slight though statistically significant reduction in the degree of emphasis respondents placed on the importance of understanding aspects of transfusions as time lapsed, but no difference was found in knowledge between those who took the course more recently and those who were up to two years post-module. The studys findings indicate that recognition of the importance of safe practice declines over time and thus also suggests that frequent refresher courses are important to maintain safe practice.

Cardiac misconceptions in healthcare workers

Background: Cardiac misconceptions are common and may have a detrimental effect on patients. Such misconceptions may be introduced or reinforced by vague and inconsistent advice from healthcare staff and can adversely affect health outcomes. Aim: To assess whether level of cardiac misconceptions significantly differs between groups of healthcare staff based on occupation. Methods: The 22-item York Cardiac Beliefs Questionnaire (YCBQ) was administered to a convenience sample of healthcare staff (n = 263) in direct contact with cardiac patients. Data was also collected on the occupation of healthcare staff and years worked. Results: Medical staff had the lowest mean score (17.5, CI 15.6–19.4), indicating fewest misconceptions, and unqualified healthcare workers had the highest mean score (32.1, CI 28.4–35.7). Analysis by ANOVA indicated differences between staff groups to be statistically significant (F = 17.66, p < 0.001). Length of time worked was found to be significantly associated with cardiac misconception score (Pearson’s r = − 0.243, p < 0.001). Further analysis demonstrated that significant differences between mean group scores remained when years worked was defined as a covariate, F = 15.68, p < 0.001). Conclusion: There is significant variability in cardiac misconceptions in different groups of healthcare staff. Education to correct cardiac misconceptions should be particularly targeted at unqualified healthcare staff. The importance of maintaining appropriate ratios of qualified to unqualified healthcare staff in the care of cardiac patients is supported by this study.

Obesity prevalence among healthcare professionals in England: a cross-sectional study using the Health Survey for England

Objective To estimate obesity prevalence among healthcare professionals in England and compare prevalence with those working outside of the health services. Design Cross-sectional study based on data from 5 years (2008–2012) of the nationally representative Health Survey for England. Setting England. Participants 20 103 adults aged 17–65 years indicating they were economically active at the time of survey classified into four occupational groups: nurses (n=422), other healthcare professionals (n=412), unregistered care workers (n=736) and individuals employed in non-health-related occupations (n=18 533). Outcome measure Prevalence of obesity defined as body mass index ≥30.0 with 95% CIs and weighted to reflect the population. Results Obesity prevalence was high across all occupational groups including: among nurses (25.1%, 95% CI 20.9% to 29.4%); other healthcare professionals (14.4%, 95% CI 11.0% to 17.8%); non-health-related occupations (23.5%, 95% CI 22.9% to 24.1%); and unregistered care workers who had the highest prevalence of obesity (31.9%, 95% CI 28.4% to 35.3%). A logistic regression model adjusted for sociodemographic composition and survey year indicated that, compared with nurses, the odds of being obese were significantly lower for other healthcare professionals (adjusted OR (aOR) 0.52, 95% CI 0.37 to 0.75) and higher for unregistered care workers (aOR 1.46, 95% CI 1.11 to 1.93). There was no significant difference in obesity prevalence between nurses and people working in non-health-related occupations (aOR 0.94, 95% CI 0.74 to 1.18). Conclusions High obesity prevalence among nurses and unregistered care workers is concerning as it increases the risks of musculoskeletal conditions and mental health conditions that are the main causes of sickness absence in health services. Further research is required to better understand the reasons for high obesity prevalence among healthcare professionals in England to inform interventions to support individuals to achieve and maintain a healthy weight.

Development and preliminary psychometric properties of the Care Experience Feedback Improvement Tool (CEFIT)

Objective To develop a structurally valid and reliable, yet brief measure of patient experience of hospital quality of care, the Care Experience Feedback Improvement Tool (CEFIT). Also, to examine aspects of utility of CEFIT. Background Measuring quality improvement at the clinical interface has become a necessary component of healthcare measurement and improvement plans, but the effectiveness of measuring such complexity is dependent on the purpose and utility of the instrument used. Methods CEFIT was designed from a theoretical model, derived from the literature and a content validity index (CVI) procedure. A telephone population surveyed 802 eligible participants (healthcare experience within the previous 12 months) to complete CEFIT. Internal consistency reliability was tested using Cronbachs α. Principal component analysis was conducted to examine the factor structure and determine structural validity. Quality criteria were applied to judge aspects of utility. Results CVI found a statistically significant proportion of agreement between patient and practitioner experts for CEFIT construction. 802 eligible participants answered the CEFIT questions. Cronbachs α coefficient for internal consistency indicated high reliability (0.78). Interitem (question) total correlations (0.28–0.73) were used to establish the final instrument. Principal component analysis identified one factor accounting for 57.3% variance. Quality critique rated CEFIT as fair for content validity, excellent for structural validity, good for cost, poor for acceptability and good for educational impact. Conclusions CEFIT offers a brief yet structurally sound measure of patient experience of quality of care. The briefness of the 5-item instrument arguably offers high utility in practice. Further studies are needed to explore the utility of CEFIT to provide a robust basis for feedback to local clinical teams and drive quality improvement in the provision of care experience for patients. Further development of aspects of utility is also required.