Jane Dyas

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

Abstract Objective To evaluate an occupational therapy intervention to improve outdoor mobility after stroke. Design Randomised controlled trial. Setting General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital. Participants 168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group. Interventions Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group). Main outcome measures Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire. Results Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months. Conclusion A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study

Objective To explain the current delivery of healthcare to residents living in UK care homes. Design Qualitative interview study using a grounded theory approach. Setting 6 UK care homes and primary care professionals serving the homes. Participants Of the 32 participants, there were 7 care home managers, 2 care home nurses, 9 care home assistants, 6 general practitioners (GPs), 3 dementia outreach nurses, 2 district nurses, 2 advanced nurse practitioners and 1 occupational therapist. Results 5 themes were identified: complex health needs and the intrinsic nature of residents’ illness trajectories; a mismatch between healthcare requirements and GP time; reactive or anticipatory healthcare?; a dissonance in healthcare knowledge and ethos; and tensions in the responsibility for the healthcare of residents. Care home managers and staff were pivotal to healthcare delivery for residents despite their perceived role in social care provision. Formal healthcare for residents was primarily provided via one or more GPs, often organised to provide a reactive service that did not meet residents’ complex needs. Deficiencies were identified in training required to meet residents’ needs for both care home staff as well as GPs. Misunderstandings, ambiguities and boundaries around roles and responsibilities of health and social care staff limited the development of constructive relationships. Conclusions Healthcare of care home residents is difficult because their needs are complex and unpredictable. Neither GPs nor care home staff have enough time to meet these needs and many lack the prerequisite skills and training. Anticipatory care is generally held to be preferable to reactive care. Attempts to structure care to make it more anticipatory are dependent on effective relationships between GPs and care home staff and their ability to establish common goals. Roles and responsibilities for many aspects of healthcare are not made explicit and this risks poor outcomes for residents.

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial.

BackgroundSleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety.Methods and designThis will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing.DiscussionPrevious studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation.Trial RegistrationClinicalTrials.gov ID ISRCTN55001433 – http://www.controlled-trials.com/ISRCTN55001433

Baby walker safety - baby's minder or parent's problem? A qualitative analysis of clients' knowledge, attitudes and practices regarding baby walker use

Objective To investigate the range of knowledge, attitudes and practices of parents regarding baby walkers. Design A qualitative study using a focus group approach. Setting Three focus groups were held in community mother and toddler drop-in centres, and one in a hospital antenatal clinic. Methods Four focus groups were held over a two-month period in 2000. Parents from areas with differing levels of deprivation (including walker users and nonusers) and antenatal parents were recruited. Data were thematically analysed. Revisiting the data for conflicting evidence tested any themes. Results Some parents believe that walkers could help a child to walk and to build up strength in the legs and that walkers must be safe if British Safety Standards have been met. Other parents want to make life a little easier for themselves and appear to be prepared to take a calculated risk with their childs safety in order to achieve this. Walkers themselves are acknowledged by most parents as being involved in accidents but the blame is attributed to lack of supervision. Most nursery equipment alternatives are seen to have safety problems in their own right, but there is some support for engaging in floor play with children. All the above themes were identified in the discussions of both affluent and deprived walker users and nonusers. Conclusions Any education aimed at reducing walker-related injuries should include an explanation of ways to facilitate motor development, raise awareness of safety standards for walkers, acknowledge the difficulties of life with an active baby and emphasise the need for passive safety measures.