Rebecca Whear

Does Participating in Physical Activity in Outdoor Natural Environments Have a Greater Effect on Physical and Mental Wellbeing than Physical Activity Indoors? A Systematic Review

Our objective was to compare the effects on mental and physical wellbeing, health related quality of life and long-term adherence to physical activity, of participation in physical activity in natural environments compared with physical activity indoors. We conducted a systematic review using the following data sources: Medline, Embase, Psychinfo, GreenFILE, SportDISCUS, The Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, Arts and Humanities Citation Index, Conference Proceedings Citation Index--Science and BIOSIS from inception to June 2010. Internet searches of relevant Web sites, hand searches of relevant journals, and the reference lists of included papers and other review papers identified in the search were also searched for relevant information. Controlled trials (randomized and nonrandomized) were included. To be eligible trials had to compare the effects of outdoor exercise initiatives with those conducted indoors and report on at least one physical or mental wellbeing outcome in adults or children. Screening of articles for inclusion, data extraction, and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Due to the heterogeneity of identified studies a narrative synthesis was performed. Eleven trials (833 adults) were included. Most participants (6 trials; 523 adults) were young students. Study entry criteria and methods were sparsely reported. All interventions consisted of a single episode of walking or running indoors with the same activity at a similar level conducted outdoors on a separate occasion. A total of 13 different outcome measures were used to evaluate the effects of exercise on mental wellbeing, and 4 outcome measures were used to assess attitude to exercise. Most trials (n = 9) showed some improvement in mental wellbeing on one or other of the outcome measures. Compared with exercising indoors, exercising in natural environments was associated with greater feelings of revitalization and positive engagement, decreases in tension, confusion, anger, and depression, and increased energy. However, the results suggested that feelings of calmness may be decreased following outdoor exercise. Participants reported greater enjoyment and satisfaction with outdoor activity and declared a greater intent to repeat the activity at a later date. None of the identified studies measured the effects of physical activity on physical wellbeing or the effect of natural environments on exercise adherence. The hypothesis that there are added beneficial effects to be gained from performing physical activity outdoors in natural environments is very appealing and has generated considerable interest. This review has shown some promising effects on self-reported mental wellbeing immediately following exercise in nature which are not seen following the same exercise indoors. However, the interpretation and extrapolation of these findings is hampered by the poor methodological quality of the available evidence and the heterogeneity of outcome measures employed. The review demonstrates the paucity of high quality evidence on which to base recommendations and reveals an undoubted need for further research in this area. Large, well designed, longer term trials in populations who might benefit most from the potential advantages of outdoor exercise are needed to fully elucidate the effects on mental and physical wellbeing. The influence of these effects on the sustainability of physical activity initiatives also awaits investigation.

Effectiveness of mindfulness-based stress reduction and mindfulness based cognitive therapy in vascular disease: A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE To determine the effectiveness of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) on psychological and physical outcomes for people with vascular disease. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES AMED, CINAHL, EMBASE, British Nursing Index, Medline, Web of Science, PsycINFO, Cochrane Database of Systematic Reviews, Central, Social Sciences Citation Index, Social Policy and Practice, and HMIC from inception to January 2013. REVIEW METHODS Articles were screened for inclusion independently by two reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Random-effects meta-analyses were performed. RESULTS Nine articles (from eight original randomised controlled trials) met eligibility criteria and were included in the final review. In total, 578 participants were enrolled across the trials, with participants presenting with prehypertension/hypertension (n=3 trials), type 1 or 2 diabetes (n=2), heart disease (n=2) and stroke (n=1). Meta-analyses, using standardised mean differences, showed evidence of reductions in stress (-0.36; 95% CI -0.67 to -0.09; p=0.01), depression (-0.35; 95% CI -0.53 to -0.16; p=0.003) and anxiety (-0.50; 95% CI -0.70 to -0.29; p<0.001). Effects on physical outcomes (blood pressure, albuminuria, stress hormones) were mixed. CONCLUSION Whilst populations with vascular disease appear to derive a range of psychological benefits from MBSR/MBCT intervention, the effects on physical parameters of disease are not yet established. More robust studies, with longer term follow-up, are required to ascertain full effectiveness of such intervention.

Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: A systematic review and meta-analysis

The need to improve the nutrition of the elderly living in long term care has long been recognised, but how this can best be achieved, and whether (and which) intervention is successful in reducing morbidity is less well understood. The aim of this systematic review was to determine the effectiveness of mealtime interventions for the elderly living in residential care. Mealtime interventions were considered as those that aimed to change/improve the mealtime routine, practice, experience or environment. Following comprehensive searches, review and appraisal, 37 articles were included. Inadequate reporting in over half of the articles limited data quality appraisal. Mealtime interventions were categorised into five types: changes to food service, food improvement, dining environment alteration, staff training and feeding assistance. Meta-analysis found inconsistent evidence of effects on body weight of changes to food service (0.5 kg; 95% CI: -1.1 to 2.2; p=0.51), food improvement interventions (0.4 kg; 95% CI: -0.8 to 1.7; p=0.50) or alterations to dining environment (1.5 kg; 95% CI: -0.7 to 2.8; p=0.23). Findings from observational studies within these intervention types were mixed, but generally positive. Observational studies also found positive effects on food/caloric intake across all intervention types, though meta-analyses of randomised studies showed little evidence of any effects on food/caloric intake in food improvement studies (-5 kcal; 95% CI: -36 to 26; p=0.74). There was some evidence of an effect on daily energy intakes within dining environment studies (181 kcal/day, 95% CI: -5 to 367, p=0.06). The need to improve the nutrition of the elderly living in residential long term care is well recognised. This review found some evidence that simple intervention around various aspects of mealtime practices and the mealtime environment can result in favourable nutritional outcomes. Further large scale pragmatic trials, however, are still required to establish full efficacy of such interventions.

Effectiveness of Mealtime Interventions on Behavior Symptoms of People With Dementia Living in Care Homes: A Systematic Review

OBJECTIVE Elderly residents with dementia commonly exhibit increased agitation at mealtimes. This interferes with eating and can be distressing for both the individual and fellow residents. This review examines the effectiveness of mealtime interventions aimed at improving behavioral symptoms in elderly people living with dementia in residential care. DESIGN Systematic review. DATA SOURCES Medline, PsycINFO, Embase, HMIC, AMED (OvidSP); CDSR, CENTRAL, DARE (Cochrane Library, Wiley); CINAHL (EBSCOhost); British Nursing Index (NHS Evidence); ASSIA (ProQuest); Social Science Citation Index (Web of Knowledge); EThOS (British Library); Social Care Online and OpenGrey from inception to November 2012. Forward and backward citation chases, hand searches of other review articles identified in the search, and key journals. TYPES OF STUDY All comparative studies were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Data were not suitable for meta-analysis so narrative synthesis was carried out. RESULTS A total of 6118 articles were identified in the original search. Eleven articles were finally included. Mealtime interventions were categorized into 4 types: music, changes to food service, dining environment alteration, and group conversation. Study quality was poor, making it difficult to reach firm conclusions. Although all studies showed a trend in favor of the intervention, only 6 reported a statistically significant improvement in behavioral symptoms. Four studies suggest cumulative or lingering effects of music on agitated and aggressive behaviors. CONCLUSION There is some evidence to suggest that mealtime interventions improve behavioral symptoms in elderly people with dementia living in residential care, although weak study designs limit the generalizability of the findings. Well designed, controlled trials are needed to further understand the utility of mealtime interventions in this setting.

Tumour necrosis factor-α inhibitor therapy in chronic physical illness: A systematic review and meta-analysis of the effect on depression and anxiety

OBJECTIVE Depression is more common among individuals with chronic physical illness than in the general population. New treatments for severe and chronic inflammatory conditions which inhibit tumour necrosis factor alpha (TNF-α), a pro-inflammatory cytokine, may be able to shed some light on the role of inflammatory mediators in depression. This systematic review and meta-analysis of randomised controlled trials determined the effects of TNF-α inhibitor therapy on depression and anxiety in people with chronic physical illness. METHODS Seven databases were searched from inception to January 2014: AMED, Central, Cochrane Database of Systematic Reviews, CINAHL, Embase, MEDLINE, and PsycINFO. Articles were screened for inclusion independently by two reviewers. Data extraction and appraisal were conducted by one reviewer and checked by a second. Random-effects meta-analyses were performed. RESULTS Six randomised controlled trials (reported in seven articles) met eligibility criteria and were included in the final review. In total 2540 participants were enrolled across the trials, with participants presenting with rheumatoid arthritis (n=3 trials), psoriasis (n=2) or ankylosing spondylitis (n=1). Meta-analyses, using standardised mean differences, showed evidence of small reductions in depression (-0.24; 95% CI -0.33 to -0.14; p<0.001), and anxiety (-0.17; 95% CI -0.31 to -0.02; p=0.02). CONCLUSION TNF-α inhibitor therapy reduces depression in people with chronic disease though the effects are small. Whilst this is consistent with inflammation contributing to the development of depression, further studies investigating a more detailed timeline of changes in depression, inflammatory biomarkers and disease activity status are required.

Are interventions to reduce the impact of arsenic contamination of groundwater on human health in developing countries effective?: a systematic review protocol

BackgroundChronic arsenic pollution is now recognised as a worldwide problem, with 21 countries experiencing arsenic groundwater contamination. It is a particularly important issue in developing countries, where groundwater is generally the preferred drinking source (as an alternative to polluted surface water). Technologies to remove or mitigate arsenic contamination of groundwater include pre-oxidation, adsorption, biological removal, and deep tubewells. Whilst technologies such as these may be effective in stable conditions (for example, at a laboratory scale), their effectiveness in real-world circumstances needs to be assessed to inform policy making.MethodsThis protocol details our proposed methods for conducting a systematic review to identify, appraise, and synthesise evidence to answer the following policy-relevant questions: a) In developing countries, are interventions to reduce the impact of arsenic contamination of groundwater on human health effective?, and b) What factors enable or constrain the effectiveness of these interventions in developing countries?

Psychiatric disorder or impairing psychology in children who have been excluded from school: A systematic review

When children with special educational needs are excluded from school, it should raise the concern that these children are not receiving adequate help and support. This systematic review aims to identify the prevalence of psychiatric disorder or impairing psychopathology among children who are excluded from school compared to children who are not excluded from school. The review follows the guidelines set out by the Centre of Research and Dissemination (Centre for Reviews and Dissemination, 2009). We used broad search terms (across 16 databases) in order to avoid missing papers, our initial screening stage involved 3712 titles and abstracts. Five studies finally met our inclusion criteria. The results from these studies suggest that the odds of children who have been excluded from school having some kind of impairing psychological or behavioural impairment is increased in comparison to children who have not been excluded (odds ratios ranging from 1.13–31.9). However, the paucity of primary research in this area, combined with methodological weaknesses in the identified studies makes it difficult to draw firm conclusions. The need for education and mental health professionals to work together to provide the appropriate support for all children at risk of exclusion is of great and immediate concern.

Interventions to reduce acute paediatric hospital admissions: a systematic review

Objective To compare the effectiveness of interventions aimed at reducing the rate of acute paediatric hospital admissions. Design Systematic review. Data sources Medline, Embase, PsychINFO, The Cochrane Library, Science Citation Index Expanded from inception to September 2010; hand searches of the reference lists of included papers and other review papers identified in the search. Review methods Controlled trials were included. Articles were screened for inclusion independently by two reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Results Seven papers were included. There is some evidence to suggest that short stay units may reduce admission rates. However, there is a general lack of detail in the reporting of interventions and the methods used in their evaluation which precludes detailed interpretation and extrapolation of the results. The authors found no evidence that the use of algorithms and guidelines to manage the admission decision was effective in reducing acute admission rates. Furthermore, the authors were unable to locate any eligible papers reporting the effects on admission rates of admission decision by paediatric consultant, telephone triage by paediatric consultant or the establishment of next day emergency paediatric clinics. Conclusion There is little published evidence upon which to base an optimal strategy for reducing paediatric admission rates. The evidence that does exist is subject to substantial bias. There is a pressing need for high quality, well conducted research to enable informed service change.

School exclusion in children with psychiatric disorder or impairing psychopathology: a systematic review

Childhood psychiatric disorders are associated with a wide range of adverse outcomes including poor academic attainment. For some children these difficulties are recognised through school Special Educational Need procedures (SEN) but many others may remain unidentified and/or unsupported. In Britain, government data suggests disproportionate representation of children with a SEN among children permanently excluded from school. This review asks whether school-aged children with impairing psychopathology were more likely to be excluded from school than those without. Databases covering education, social sciences, psychology and medicine were searched, experts were contacted and bibliographies of key papers were hand-searched. Studies were included if the population covered school-aged children, and if validated diagnostic measures had been used to assess psychopathology. Children with impairing psychopathology had greater odds of exclusion compared to the rest of the school-age population: odds ratios range from 1.13 (95% CI: 0.55–2.33) to 45.6 (95% CI: 3.8–21.3). These findings however need to be considered in light of the paucity of the literature and methodological weaknesses discussed.

The Clinical Effectiveness of Patient Initiated Clinics for Patients with Chronic or Recurrent Conditions Managed in Secondary Care: A Systematic Review

Background Missed or inappropriate hospital appointments cost the UK National Health Service millions of pounds each year and delay treatment for other patients. Innovative methods of appointment scheduling that are more flexible to patient needs, may improve service quality and preserve resources. Methods A systematic review of the evidence for the clinical effectiveness of patient initiated clinics in managing long term care for people with chronic or recurrent conditions in secondary care. Seven databases were searched including MEDLINE, Embase and PsycINFO (using the OVID interface), the Cochrane Library of Systematic Reviews and CENTRAL, Science Citation Index Expanded, Social Sciences Citation Index, and Conference Proceedings Citation Index (via the Web of Science interface) from inception to June 2013. Studies comparing patient initiated clinics with traditional consultant-led clinics in secondary care for people with long term chronic or recurrent diseases were included. Included studies had to provide data on clinical or resource use outcomes. Data were extracted and checked by two reviewers using a piloted, standardised data extraction form. Results Eight studies (n = 1927 individuals) were included. All were conducted in the UK. There were few significant differences in clinical outcomes between the intervention and control groups. In some instances, using the patient initiated clinics model was associated with savings in time and resource use. The risk of harm from using the patient initiated clinic model of organising outpatient care is low. Studies with longer follow-up periods are needed to assess the long term costs and the ongoing risk of potential harms. Conclusions The UK policy context is ripe for evidence-based, patient-centred services to be implemented, especially where the use of health care resources can be optimised without reducing the quality of care. Implementation of patient initiated clinics should remain cautious, with importance placed on ongoing evaluation of long term outcomes and costs.