Maxine Johnson

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

BACKGROUND This review aimed to synthesize qualitative evidence for barriers and facilitators to effective implementation of screening and brief intervention for alcohol misuse in adults and children over 10 years. METHODS A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesized thematically. RESULTS A total of 47 papers varying in design and quality were included in the review. Most evaluated implementation in primary care settings. Implementation was reported to be limited by lack of resources, training and support from management, as well as workload. The appropriateness of context in which discussions take place was reported as an acceptability factor for patients and practitioners. Health professionals require sufficient knowledge about alcohol guidelines and risk in order to implement screening and intervention to those most in need. CONCLUSIONS Whilst brief screening and brief intervention have been shown to be effective in some settings, this review has identified a number of barriers and facilitators to implementation. Adequate resources, training and the identification of those at risk without stereotyping are the main facilitators in primary care. More research is needed to assess implementation in other settings.

Behavioural interventions for weight management in pregnancy: A systematic review of quantitative and qualitative data

BackgroundThere is a rising prevalence of excessive weight gain in pregnancy and an increasing number of pregnant women who are overweight or obese at the start of the pregnancy. Excessive weight gain during pregnancy is associated with adverse maternal and neonatal consequences and increases the risk of long-term obesity. Pregnancy therefore may be a key time to prevent excessive weight gain and improve the health of women and their unborn child. This systematic review sought to assess the effectiveness of behavioural interventions to prevent excessive weight gain in pregnancy and explore the factors that influence intervention effectiveness.MethodsWe undertook a systematic review of quantitative and qualitative evidence. This included a meta-analysis of controlled trials of diet and physical activity interventions to prevent excessive weight gain during pregnancy and a thematic synthesis of qualitative studies that investigated the views of women on weight management during pregnancy. A thorough search of eleven electronic bibliographic databases, reference lists of included studies, relevant review articles and experts in the field were contacted to identify potentially relevant studies.Two independent reviewers extracted data. RevMan software was used to perform the meta-analyses. Qualitative data was subject to thematic analysis. Both quantitative and qualitative data were aligned using a matrix framework.ResultsFive controlled trials and eight qualitative studies were included. The overall pooled effect size found no significant difference in gestational weight gain amongst participants in the intervention group compared with the control group (mean difference -0.28 95% CI -0.64 to 0.09). The study designs, participants and interventions all varied markedly and there was significant heterogeneity within this comparison in the meta-analysis (I2 67%). Subgroup and sensitivity analysis did not identify contextual elements that influenced the effectiveness of the intervention.In a thematic analysis of the qualitative studies, three major themes emerged relating to womens views of weight management in pregnancy: pregnancy as a time of transition and change, conflicting and contradictory messages and a perceived lack of control. When the results of both quantitative and qualitative data were aligned it was clear that some of the barriers that women described in achieving healthy weight gain in pregnancy were not addressed by the interventions evaluated. This may have contributed to the limited effectiveness of the interventions.ConclusionsDespite intense and often tailored interventions there was no statistically significant effect on weight gain during pregnancy. Inadequate and often contradictory information regarding healthy weight management was reported by women in qualitative studies and this was addressed in the interventions but this in itself was insufficient to lead to reduced weight gain. Multiple types of interventions, including community based strategies are needed to address this complex health problem.

Can diabetes prevention programmes be translated effectively into real-world settings and still deliver improved outcomes? A synthesis of evidence

Randomized trials provide evidence that intensive lifestyle interventions leading to dietary and physical activity change can delay or prevent Type 2 diabetes. Translational studies have assessed the impact of interventions based on, but less intensive than, trial protocols delivered in community settings with high‐risk populations. The aim of this review was to synthesize evidence from translational studies of any design to assess the impact of interventions delivered outside large randomized trials.

Preventing the progression to type 2 diabetes mellitus in adults at high risk: a systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions.

AIMS Individuals with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) have an increased risk of progression to Type 2 diabetes mellitus. The objective of this review was to quantify the effectiveness of lifestyle, pharmacological and surgical interventions in reducing the progression to Type 2 diabetes mellitus in people with IFG or IGT. METHODS A systematic review was carried out. A network meta-analysis (NMA) of log-hazard ratios was performed. Results are presented as hazard ratios and the probabilities of treatment rankings. RESULTS 30 studies were included in the NMA. There was a reduced hazard of progression to Type 2 diabetes mellitus associated with all interventions versus standard lifestyle advice; glipizide, diet plus pioglitazone, diet plus exercise plus metformin plus rosiglitazone, diet plus exercise plus orlistat, diet plus exercise plus pedometer, rosiglitazone, orlistat and diet plus exercise plus voglibose produced the greatest effects. CONCLUSIONS Lifestyle and some pharmacological interventions are beneficial in reducing the risk of progression to Type 2 diabetes mellitus. Lifestyle interventions require significant behaviour changes that may be achieved through incentives such as the use of pedometers. Adverse events and cost of pharmacological interventions should be taken into account when considering potential risks and benefits.

Weight management during pregnancy: A systematic review of qualitative evidence

BACKGROUND increasing overweight and obesity rates in pregnant women present health risks to mother and unborn infant. OBJECTIVES to identify barriers and facilitators to implementing and carrying out maternal weight management interventions. SEARCH STRATEGY searches were carried out in medical, midwifery and nursing databases, augmented by hand searching of midwifery journals. SELECTION CRITERIA articles were included that were published in the UK after 1990, with a focus on womens and health professionals views about weight management during pregnancy. DATA COLLECTION AND ANALYSIS from 6423 citations, 126 full text papers were retrieved. Of these, 18 (reporting 17 studies) fulfilled the inclusion criteria. Included papers were assessed for quality. Reported findings were analysed and synthesised using thematic analysis. MAIN RESULTS a major theme was access to relevant and appropriate information; advice was reported as vague or inadequate. Overweight or obese women reported feelings of stigmatisation during routine examinations. Health professionals reported a reluctance to discuss weight with larger women. Perceived risk to the fetus as well as changes in womens physiological responses to pregnancy, were reported barriers to optimal physical activity and dietary intake. Perceptions of control were related to womens feelings about their body image. CONCLUSION evidence suggests that the complexity of interactions with advice sources, bodily changes, feelings of control, as well as perceived risks may explain the relative ineffectiveness of weight management interventions during pregnancy. Focusing on healthy diet and physical activity levels may be more useful and less stigmatising than focusing on weight.

Meeting the educational needs of people at risk of diabetes-related amputation: a vignette study with patients and professionals.

Objective  To investigate how patients and professionals view the role of advice in diabetes foot care, in order to inform educational practice.

Community-based dietary and physical activity interventions in low socioeconomic groups in the UK: a mixed methods systematic review.

OBJECTIVE Low socioeconomic status (SES) is a risk factor for type 2 diabetes and changes in diet and physical activity can prevent diabetes. We assessed the effectiveness and acceptability of community-based dietary and physical activity interventions among low-SES groups in the UK. METHOD We searched relevant databases and web resources from 1990 to November 2009 to identify relevant published and grey literature using an iterative approach, focusing on UK studies. RESULTS Thirty-five relevant papers (nine quantitative, 23 qualitative and three mixed methods studies) were data extracted, quality assessed and synthesised using narrative synthesis and thematic analysis. The relationship between interventions and barriers and facilitators was also examined. Dietary/nutritional, food retail, physical activity and multi-component interventions demonstrated mixed effectiveness. Qualitative studies indicated a range of barriers and facilitators, which spanned pragmatic, social and psychological issues. The more effective interventions used a range of techniques to address some surface-level psychological and pragmatic concerns, however many deeper-level social, psychological and pragmatic concerns were not addressed. CONCLUSION Evidence on the effectiveness of community-based dietary and physical activity interventions is inconclusive. A range of barriers and facilitators exist, some of which were addressed by interventions but some of which require consideration in future research.

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety

Objectives Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. Methods An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Results Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. Conclusions Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).

Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units

AIM This paper is a report of a study to explore the experiences of individuals receiving Chest Pain Unit care and routine Emergency Department care for acute chest pain. BACKGROUND Chest Pain Units were established in the United States of America with the aim of reducing admissions and costs, whilst improving quality of life and care satisfaction. Trials showed these units to be safe and practical; however, there was a need to establish whether Chest Pain Units could be cost-effective in the United Kingdom, and whether use of a nurse-led protocol could be acceptable to patients. METHOD We carried out 26 semi-structured interviews in 2005-2006 with patients across seven trial Chest Pain Units in the United Kingdom (14 in intervention sites and 12 in control sites) to explore issues that patients considered were important in their care experiences, and to develop possible explanations for the main trial outcomes. We analysed transcripts using the Framework approach to identify themes relating to care experiences. FINDINGS Differences in care experiences were more distinct between individual sites than between control and intervention sites. Satisfaction with care was high overall. Interactions with healthcare professionals, in particular specialist nurses, were valued in terms of reassurance, calming effect and competence. Indications for care improvement concerned information-giving about investigations, diagnosis, and self-care advice. Patients with non-cardiac causes needed to feel more supported after discharge. CONCLUSION Differences between modes of care may not coincide with identified trial outcomes. Qualitative methods can identify aspects of care that improve patient acceptability. The specialist nurse role appears particularly important in providing satisfactory individualized chest pain care.

What are the barriers to primary prevention of type 2 diabetes in black and minority ethnic groups in the UK? A qualitative evidence synthesis.

BACKGROUND This review aimed to synthesise available qualitative evidence on barriers and facilitators to the implementation of community based lifestyle behaviour interventions to reduce the risk of diabetes in black and minority ethnic (BME) groups in the UK. METHODS A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesised thematically. RESULTS A total of 13 papers varying in design and of mainly good quality were included in the review. A limited number of intervention evaluations highlighted a lack of resources and communication between sites. A lack of understanding by providers of cultural and religious requirements, and issues relating to access to interventions for users was reported. Behaviour change was impeded by cultural and social norms, and resistance to change. There were variations in the way dietary change and physical activity was approached by different groups and contrasting practices between generations. CONCLUSIONS Qualitative data provided insight into the ways that providers might improve or better design future interventions. Acknowledgement of the way that different groups approach lifestyle behaviours may assist acceptability of interventions.