Ruth Jepson

The effectiveness of interventions to change six health behaviours: a review of reviews

BackgroundSeveral World Health Organisation reports over recent years have highlighted the high incidence of chronic diseases such as diabetes, coronary heart disease and cancer. Contributory factors include unhealthy diets, alcohol and tobacco use and sedentary lifestyles. This paper reports the findings of a review of reviews of behavioural change interventions to reduce unhealthy behaviours or promote healthy behaviours. We included six different health-related behaviours in the review: healthy eating, physical exercise, smoking, alcohol misuse, sexual risk taking (in young people) and illicit drug use. We excluded reviews which focussed on pharmacological treatments or those which required intensive treatments (e.g. for drug or alcohol dependency).MethodsThe Cochrane Library, Database of Abstracts of Reviews of Effectiveness (DARE) and several Ovid databases were searched for systematic reviews of interventions for the six behaviours (updated search 2008). Two reviewers applied the inclusion criteria, extracted data and assessed the quality of the reviews. The results were discussed in a narrative synthesis.ResultsWe included 103 reviews published between 1995 and 2008. The focus of interventions varied, but those targeting specific individuals were generally designed to change an existing behaviour (e.g. cigarette smoking, alcohol misuse), whilst those aimed at the general population or groups such as school children were designed to promote positive behaviours (e.g. healthy eating). Almost 50% (n = 48) of the reviews focussed on smoking (either prevention or cessation). Interventions that were most effective across a range of health behaviours included physician advice or individual counselling, and workplace- and school-based activities. Mass media campaigns and legislative interventions also showed small to moderate effects in changing health behaviours.Generally, the evidence related to short-term effects rather than sustained/longer-term impact and there was a relative lack of evidence on how best to address inequalities.ConclusionsDespite limitations of the review of reviews approach, it is encouraging that there are interventions that are effective in achieving behavioural change. Further emphasis in both primary studies and secondary analysis (e.g. systematic reviews) should be placed on assessing the differential effectiveness of interventions across different population subgroups to ensure that health inequalities are addressed.

Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne

BACKGROUNDnHirsutism is the presence of excessive hair growth in women and is an important cosmetic condition often resulting in severe distress. The most common cause is by increased production of male sex hormones (androgens). It is also affected by increased sensitivity to androgens in the hair follicles, and secretory glands around hair follicles (sebaceous glands). Spironolactone is an antiandrogen and aldosterone antagonist used to treat hirsutism.nnnOBJECTIVESnThe objective was to investigate the effectiveness of spironolactone and/or in combination with steroids (oral contraceptive pill included) in reducing excess hair growth and/or acne in women.nnnSEARCH STRATEGYnThe Cochrane Menstrual Disorders and Subfertility Group (MDSG) trials register was searched (April 2008). The Cochrane MDSG register is based on regular searches of MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL, handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. In addition, all reference lists of relevant trials were searched and drug companies contacted for details of unpublished trials.nnnSELECTION CRITERIAnAll randomised controlled comparisons of spironolactone versus: placebo, steroids (oral contraceptive pill included), spironolactone of varying dosages, or spironolactone and steroids versus steroids alone when used to reduce hair growth and acne in women.nnnDATA COLLECTION AND ANALYSISnNine trials were included in the review, eight trials were excluded. Two other trials are awaiting assessment. Only one trial studied acne as an outcome, the remainder were concerned with hirsutism. Major outcome measures include the following: subjective observations, Ferriman and Gallwey hair scores, hormonal and biochemical parameters, side effects, sebum production measurement.nnnMAIN RESULTSnIn the two trials that compared 100 mg of spironolactone with placebo significant differences were reported for subjective improvements in hair growth (OR 7.18, 95% CI 1.96 to 26.28), although not the Ferriman-Galwey score (WMD 7.20, 95% CI -10.98 to -3.42)). Data could not be otherwise pooled as only one trial reported an outcome.nnnAUTHORS CONCLUSIONSnFrom the studies included in this review, there is some evidence to show that spironolactone is an effective treatment to decrease the degree of hirsutism but there was no evidence for effectiveness for the treatment of acne vulgaris. Studies in this area are scarce and small. Individual study data indicates some superiority of spironolactone over other drugs but results cannot be generalised.

Understanding what helps or hinders asthma action plan use: A systematic review and synthesis of the qualitative literature

OBJECTIVEnTo understand better what helps and/or hinders asthma action plan use from the professionals and patients/carers perspective.nnnMETHODSnSystematic review and qualitative synthesis (using meta-ethnography).nnnRESULTSnNineteen studies (20 papers) were included in an analysis of patients/carers and professionals views. Seven main influences on action plan implementation were identified including perceived un-helpfulness and irrelevance of the plans. Translation and synthesis of the original authors interpretations suggested that action plan promotion and use was influenced by professional and patient/carers asthma beliefs and attitudes and patient/carer experiences of managing asthma. Action plan use is hindered because professionals and patients/carers have different explanatory models of asthma, its management and their respective roles in the management process. Patients/carers, based on their experiential knowledge of their condition, perceive themselves as capable, effective in managing their asthma, but health professionals do not always share this view.nnnCONCLUSIONnProfessionally provided medically focused action plans that do not fit with and incorporate the patients/carers views of asthma, and their management strategies, will continue to be under-utilised.nnnPRACTICE IMPLICATIONSnProfessionals need to develop a more patient-centred, partnership-based, approach to the joint development and review of action plans, recognising the experiential asthma knowledge of patients/carers.

Cranberries for treating urinary tract infections.

BACKGROUNDnCranberries (particularly in the form of cranberry juice) have been used widely for several decades for the prevention and treatment of urinary tract infections. The aim of this review is to assess the effectiveness of cranberries in treating such infections.nnnOBJECTIVESnTo assess the effectiveness of cranberries for the treatment of urinary tract infections.nnnSEARCH STRATEGYnThe search strategy developed by the Cochrane Renal Group was used. Also, companies involved with the promotion and distribution of cranberry preparations were contacted; electronic databases and the Internet were searched using English and non English language terms; reference lists of review articles and relevant trials were also searched.nnnSELECTION CRITERIAnAll randomised or quasi randomised controlled trials of cranberry juice or cranberry products for the treatment of urinary tract infections. Trials of men, women or children were included.nnnDATA COLLECTION AND ANALYSISnTitles and abstracts of studies that were potentially relevant to the review were screened by one reviewer, RJ, who discarded studies that were clearly ineligible but aimed to be overly inclusive rather than risk losing relevant studies. Reviewers RJ and LM independently assessed whether the studies met the inclusion criteria. Further information was sought from the authors where papers contained insufficient information to make a decision about eligibility.nnnMAIN RESULTSnNo trials were found which fulfilled all of the inclusion criteria. Two trials were excluded because they did not have any relevant outcomes.nnnREVIEWERS CONCLUSIONSnAfter a thorough search, no randomised trials which assessed the effectiveness of cranberry juice for the treatment of urinary tract infections were found. Therefore, at the present time, there is no good quality evidence to suggest that it is effective for the treatment of urinary tract infections. Well-designed parallel group, double blind trials comparing cranberry juice and other cranberry products versus placebo to assess the effectiveness of cranberry juice in treating urinary tract infections are needed. Outcomes should include reduction in symptoms, sterilisation of the urine, side effects and adherence to therapy. Dosage (amount and concentration) and duration of therapy should also be assessed. Consumers and clinicians will welcome the evidence from these trials.

How information about other people's personal experiences can help with healthcare decision-making: A qualitative study ☆

OBJECTIVEnTo investigate peoples views of using general facts and information about other peoples personal experiences for health-related decision-making.nnnMETHODSnSixty-two people, who between them had experience of five different focal health issues, participated in 12 focus groups and 9 interviews. Exploration of uses of the two types of information was supported by discussion of illustrative excerpts.nnnRESULTSnThere was less discussion of general facts; participants thought it obvious that good decisions required these. Participants reported having used personal experiences information to: recognise decisions that needed consideration; identify options; appraise options and make selections (including by developing and reflecting on their reasoning about possible choices); and support coping strategies. Their inclination to use personal experiences information was apparently moderated by assessments of personal relevance, the motives of information providers and the balance of experiences presented.nnnCONCLUSIONnPeople can use personal experiences information in various ways to support their decision-making, and exercise some discrimination as they do.nnnPRACTICE IMPLICATIONSnPersonal experiences information may help people in a number of ways in relation to decision-making. However, personal experiences information does not replace the need for general facts and care should be taken when it is used in resources for patients.

Lipid‐lowering for lower limb atherosclerosis

BACKGROUNDnRaised lipid levels, including cholesterol, are important risk factors in the development of lower limb arterial disease (atherosclerosis).nnnOBJECTIVESnThe objective of this review was to assess the effects of lipid lowering therapy in patients with lower limb atherosclerosis.nnnSEARCH STRATEGYnThe reviewers searched the Cochrane Peripheral Vascular Diseases Group trials register, Embase, reference lists of relevant articles, and contacted trial investigators in Europe and pharmaceutical companies.nnnSELECTION CRITERIAnRandomised trials of lipid-lowering therapy in patients with lower limb atherosclerosis. The main outcomes were mortality, non-fatal events, direct tests of disease progression, indirect measurements of disease, and subjective measures.nnnDATA COLLECTION AND ANALYSISnTwo reviewers extracted data and assessed trial quality independently. The reviewers contacted investigators to obtain information needed for the review that could not be found in published reports.nnnMAIN RESULTSnThere were nine eligible trials, but two were excluded because of poor methodology. The seven remaining trials involved a total of 698 participants from seven different countries. Men and women participated in all but one trial and were generally middle aged to elderly. The follow-up period varied from four months to three years. The overall quality of the included trials was high. The trials were heterogeneous in terms of inclusion criteria, type of drugs used and outcomes measured. Lipid-lowering therapy produced a marked but non-significant reduction in mortality (odds ratio 0.21, 95% confidence interval 0. 03 to 1.17), but little change in non-fatal events (odds ratio 1.21, 95% confidence interval 0.80 to 1.83). In two trials there was a significant overall reduction in disease progression on angiogram (odds ratio 0.47, 95% confidence interval 0.29 to 0.77). The changes in ankle brachial pressure index and walking distance were inconsistent, although trials showed a general improvement in symptoms that could not be combined in a meta-analysis. Side effects were generally mild, with the exceptions of liver toxicity produced by betapyridil and the adverse effect of probucol on lipoprotein profile.nnnREVIEWERS CONCLUSIONSnLipid-lowering therapy may be useful in preventing deterioration of underlying disease and alleviating symptoms. These results cannot determine whether one lipid-lowering regimen is better than another.

Oral contraceptive pills for heavy menstrual bleeding.

BACKGROUNDnMenorrhagia (heavy menstrual bleeding) is a benign yet debilitating social and health condition. The widely accepted clinical definition of menorrhagia is blood loss of 80ml or more per period. This figure is derived from population studies that have shown that the average blood loss is between 30 and 40ml, and 90% of women have blood losses of less than 80ml. Excessive menstrual bleeding is the commonest cause of iron deficiency in the United Kingdom affecting 20-25% of the fertile female population. Menorrhagia is a common problem accounting for 12% of all gynaecological referral in the UK. Ranges of medical therapies are prescribed in order to reduce excessive menstrual blood loss, including prostaglandin synthetase inhibitors, antifibrinolytics, the oral contraceptive pill and other hormones. The combined oral contraceptive pill (OCP) is claimed to have a variety of beneficial, inducing a regular shedding of a thinner endometrium and inhibiting ovulation thus having the effect of treating menorrhagia and providing contraception.nnnOBJECTIVESnTo determine whether: 1. the OCP is an effective medical therapy to reduce menorrhagia in both the short term and long term. 2. the effectiveness of combined oral contraceptive pills (OCP) compared with other medical therapies for the treatment of menorrhagia. 3. OCP is a more cost effective method than any other medical treatments of menorrhagia. 4. OCP has fewer side effects than other drugs used for menorrhagia.nnnSEARCH STRATEGYnAll publications which describe randomised trials of OCP for the treatment of menorrhagia were obtained using the search strategy developed by the Menstrual Disorders Group.nnnSELECTION CRITERIAnAll randomised controlled comparisons of OCP versus other medical therapies, placebo or no treatment for the treatment of menorrhagia. Women of reproductive years with regular heavy periods, measured either objectively or subjectively and greater than, or equal to, two months follow up.nnnDATA COLLECTION AND ANALYSISnAll assessments of the quality of trials and data extraction were performed unblinded by at least two reviewers. Only one trial met the inclusion criteria and none were excluded. The included trial involved a total of 45 women.nnnMAIN RESULTSnAs the trial used a cross-over design, only data from the first treatment period (cycles 3 and 4 ) were analysed. The results from all the three mefanamic acid groups were combined. There was no significant difference in menstrual blood loss (MBL) between those patients treated with the OCP and danazol, mefenamic acid or naproxen.nnnREVIEWERS CONCLUSIONSnThe one small study identified [Fraser 1991] found no significant difference between groups treated with OCP, mefenamic acid, low dose danazol or naproxen. Overall, the evidence from the one study identified [Fraser 1991] is not sufficient to adequately assess the effectiveness of OCP. This review was unable to achieve its stated objectives because of the paucity of the data.

Assessing the unintended health impacts of road transport policies and interventions: translating research evidence for use in policy and practice

BackgroundTransport and its links to health and health inequalities suggest that it is important to assess both the direct and unintended indirect health and related impacts of transport initiatives and policies. Health Impact Assessment (HIA) provides a framework to assess the possible health impacts of interventions such as transport. Policymakers and practitioners need access to well conducted research syntheses if research evidence is to be used to inform these assessments. The predictive validity of HIA depends heavily on the use and careful interpretation of supporting empirical evidence. Reviewing and digesting the vast volume and diversity of evidence in a field such as transport is likely to be beyond the scope of most HIAs. Collaborations between HIA practitioners and specialist reviewers to develop syntheses of best available evidence applied specifically to HIA could promote the use of evidence in practice.MethodsBest available research evidence was synthesised using the principles of systematic review. The synthesis was developed to reflect the needs of HIA practitioners and policymakers.ResultsAside from injury reduction measures, there is very little empirical data on the impact of road transport interventions. The possibility of impacts on a diverse range of outcomes and differential impacts across groups, make it difficult to assess overall benefit and harm. In addition, multiple mediating factors in the pathways between transport and hypothesised health impacts further complicate prospective assessment of impacts. Informed by the synthesis, a framework of questions was developed to help HIA practitioners identify the key questions which need to be considered in transport HIA.ConclusionPrinciples of systematic review are valuable in producing syntheses of best available evidence for use in HIA practice. Assessment of the health impacts of transport interventions is characterised by much uncertainty, competing values, and differential or conflicting impacts for different population groups at a local or wider level. These are issues pertinent to the value of HIA generally. While uncertainty needs explicit acknowledgement in HIA, there is still scope for best available evidence to inform the development of healthy public policy.

Garlic for peripheral arterial occlusive disease

BACKGROUNDnCommercially available preparations of garlic have been reported to have beneficial effects on some of the risk factors associated with atherosclerosis.nnnOBJECTIVESnTo assess the effects of garlic (both dried and non-powdered preparations) for the treatment of peripheral arterial occlusive disease.nnnSEARCH METHODSnFor this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12).nnnSELECTION CRITERIAnRandomised trials of garlic therapy in patients with lower limb atherosclerosis were included. The main outcomes were objective measures of progression of underlying atherosclerosis (e.g. ankle pressure measurements, treadmill testing) and subjective measures (e.g. symptom progression).nnnDATA COLLECTION AND ANALYSISnTwo review authors (RJ and JK) independently extracted data and assessed trial quality. One author (RJ) contacted investigators to obtain information needed for the review that could not be found in published reports.nnnMAIN RESULTSnOne eligible trial with 78 participants was found. Both men and women (aged 40 to 75) were included. The follow-up period was short, 12 weeks only.After twelve weeks of treatment, pain-free walking distance increased from 161 to 207 metres in the group receiving garlic and from 172 to 203 metres in the placebo group. This was not a statistically significant difference. There was no difference in change of systolic or diastolic blood pressure, heart rate, ankle and brachial pressures. No severe side effects were observed and nine patients taking garlic (28%) and four patients taking placebo (12%) complained of a noticeable garlic smell.Three trials were excluded from the review because they did not include any clinical measurements.nnnAUTHORS CONCLUSIONSnOne small trial of short duration found no statistically significant effect of garlic on walking distance.

Physical Activity in South Asians: An In-Depth Qualitative Study to Explore Motivations and Facilitators

Background People of South Asian backgrounds living in the UK have a five-fold increased risk of diabetes and a two-fold increased risk of heart disease when compared to the general population. Physical activity can reduce the risk of premature death from a range of conditions. The aim of the study was to explore the motivating and facilitating factors likely to increase physical activity for South Asian adults and their families, in order to develop successful interventions and services. Methodology/Principal Findings This was a qualitative study using focus groups and in-depth interviews. Participants were 59 purposively selected Bangladeshi-, Indian- and Pakistani-origin men and women with an additional 10 key informants. The setting was three urban areas of Scotland: Aberdeen, Glasgow and Edinburgh. We undertook a theoretically informed thematic analysis of data. Study participants described engaging in a range of physical activities, particularly football and the gym for men, and walking and swimming for women. The main motivators for taking part in physical activity were external motivators – i.e. undertaking physical activity as a means to an end, which included the opportunities that physical activity provided for social activity and enjoyment. The goals of weight reduction and improving mental and physical health and were also mentioned. Role models were seen as important to inspire and motivate people to undertake activities that they may otherwise lack confidence in. Few people undertook physical activity for its own sake (intrinsic motivation). Conclusions/Significance Attempts at promoting physical activity in people of South Asian origin need to take account of the social context of peoples lives and the external motivators that encourage them to engage in physical activity. Undertaking group based physical activity is important and can be facilitated through religious, community, friendship or family networks. Role models may also prove particularly helpful.