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Parents’ experiences of complementary feeding among a United Kingdom culturally diverse and deprived communityComplementary feeding practices and adherence to health recommendations are influenced by a range of different and often interrelating factors such as socio-economic and cultural factors. However, the factors underlying these associations are often complex with less awareness of how complementary feeding approaches vary across the UK’s diverse population. This paper describes a qualitative investigation undertaken in a deprived and culturally diverse community in the UK which aimed to explore parents’ knowledge, beliefs and practices of complementary feeding. One hundred and ten mothers and fathers, self-identified as being White British, Pakistani, Bangladeshi, Black African/Caribbean or Polish took part in twenty-four focus group discussions, organised by age group, sex and ethnicity. The findings revealed that most parents initiated complementary feeding before the World Health Organisation (WHO) recommendation of 6 months. Early initiation was strongly influenced by breast feeding practices alongside the extent to which parents believed that their usual milk; that is, breastmilk or formula was fulfilling their infants' nutritional needs. The composition of diet and parents' approach to complementary feeding was closely aligned to traditional cultural practices; however, some contradictions were noted. The findings also acknowledge the pertinent role of the father in influencing the dietary practices of the wider household. Learning about both the common and unique cultural feeding attitudes and practices held by parents may help us to tailor healthy complementary feeding advice in the context of increasing diversity in the United Kingdom.
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Knowledge and practice of organ donation among police personnel in Tamil Nadu: a cross-sectional studyContext: Police officers are one of the key stakeholders involved in the process of deceased organ donation. In India, as road traffic accidents account for the majority of brain deaths, the police play an important role to ensure legal and ethical practices of organ donation. In many instances, the undue delays in the inquest and postmortem lead to difficulties in completing the donation and also cause distress among the family members who have said yes to organ donation despite their grief. Aim: This study aims to assess the police officers' knowledge of the organ donation process and their practice toward it. Design and Subjects and Methods: This cross-sectional survey was conducted among 627 police officers in the state of Tamil Nadu in India within a period of 18 months. A structured questionnaire with multiple choice questions was used. Microsoft Excel and SPSS version 21 were used to compile and statistically analyze the data collected. The knowledge level and willingness of the officers to follow certain practices were analyzed. Results: It was found that 95.5% of the participants were aware of organ donation. Further analysis revealed that 86.6% of the police personnel were aware of brain death, but only 35.6% were aware of the transplant law, 12.1% knew about the green corridor, and 20.7% about the donor card. Very few participants (9.6%) had experience in processing brain deaths and organ donation cases. Knowledge about postmortem formalities and inquest protocols was unsatisfactory. A significant association between work experience and the knowledge and awareness about organ donation was noted. Conclusions: Including modules on organ donation awareness, transplant law, and hospital protocols in the training syllabus for the recruited personnel, followed by regular refresher courses on the subject, would be the key to enhance the knowledge and work practices of this important group to help ease pain points in the medicolegal cases where organ donation consent is provided by the relatives. A change in the attitude of police officers while handling organ donation cases would have an overall positive impact on the program.
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Operationalising domain 4: additional care for women and newborn infants with complicationsIn this ninth article of The Practising Midwife’s education series, Domain 4 from the new Nursing and Midwifery Council (NMC) standards for proficiency is discussed. Domain 4 emphasises the midwife’s role as a coordinator of women and neonate’s care where additional care may be required. Highlighting curriculum changes at the University of Bedfordshire, Anna Madeley provides insights to how this domain has been implemented.
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Analysis of routinely collected data: determining associations of maternal risk factors and infant outcomes with gestational diabetes, in Pakistani, Indian, Bangladeshi and white British pregnant women in Luton, EnglandThis study aims to compare the prevalence of gestational diabetes in Indian, Pakistani, Bangladeshi and British women in Luton, England and further examine associations in maternal risk factors (age BMI, smoking status and birth outcome), with gestational diabetes, with maternal ethnicity. A retrospective analysis using routinely collected secondary data from Ciconia Maternity information System (CMiS), between 2008 and 2013. The ethnicity of women recorded as Indian, Pakistani, Bangladeshi and white British, residing in [removed] were included in the study. The outcomes for n=15,211 cases were analysed using adjusted standardised residuals, Pearson Chi-square, frequencies and percentages of women with gestational diabetes. = 43.1 df=4, p<0.001) and an early gestational age at delivery (24-37 weeks) (χ2= 4.084 df=1, p=0.043). There are important differences in the prevalence rates of gestational diabetes which varied by maternal ethnicity. Of the women who had GDM, 48.7% were Pakistani, compared with 28.3% Bangladeshi, 16.4% white British and 6.6% Indian. It is essential policy makers and service providers target GDM screening and associated interventions and future research seeks to understand the reasons behind these differences.
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Cloud services for culture aware conversation: socially assistive robots and virtual assistantsThis paper introduces a new Cloud platform providing services for culturally competent interaction, that has been developed to expand the capabilities of Socially Assistive Robots and virtual assistants interacting with older persons. The rationale behind the proposed architecture is discussed, by outlining key principles as well as the functionalities provided, with a specific focus on verbal interaction. Three case studies, the humanoid robot Pepper, a robotic medicine dispenser Pillo, and a custom-built Android-based virtual assistant, are analyzed in detail, by showing how robots and other assistants may easily access culturally competent Cloud services to expand their interaction capabilities. Transcripts of conversations are reported and commented, in order to outline both the positive features and the limitations of the system.
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A randomised controlled trial of energetic activity for depression in young people (READY): a multi-site feasibility trial protocolBackground: Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery. Methods: The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13–17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a ‘healthy living’ behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness. Discussion: UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression. Trial registration: ISRCTN, ISRCTN66452702. Registered 9 April 2020.
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Ethnic differences in body fat deposition and liver fat content in two UK-based cohortsObjective: Differences in the content and distribution of body fat and ectopic lipids may be responsible for ethnic variations in metabolic disease susceptibility. The aim of this study was to examine the ethnic distribution of body fat in two separate UK-based populations. Methods: Anthropometry and body composition were assessed in two separate UK cohorts: the Hammersmith cohort and the UK Biobank, both comprising individuals of South Asian descent (SA), individuals of Afro-Caribbean descent (AC), and individuals of European descent (EUR). Regional adipose tissue stores and liver fat were measured by magnetic resonance techniques. Results: The Hammersmith cohort (n = 747) had a mean (SD) age of 41.1 (14.5) years (EUR: 374 men, 240 women; SA: 68 men, 22 women; AC: 14 men, 29 women), and the UK Biobank (n = 9,533) had a mean (SD) age of 55.5 (7.5) years (EUR: 4,483 men, 4,873 women; SA: 80 men, 43 women, AC: 31 men, 25 women). Following adjustment for age and BMI, no significant differences in visceral adipose tissue or liver fat were observed between SA and EUR individuals in the either cohort. Conclusions: Our data, consistent across two independent UK-based cohorts, present a limited number of ethnic differences in the distribution of body fat depots associated with metabolic disease. These results suggest that the ethnic variation in susceptibility to features of the metabolic syndrome may not arise from differences in body fat.
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The vital role of health psychology in the response to COVID-19We had a huge response to our editorial and call for submissions of health psychology research related to the coronavirus pandemic (Arden & Chilcot, 2020). A total of 177 brief reports and papers have been submitted to BJHP since that call in March 2020. It has been a mammoth task for our associate editors, reviewers, and production team at Wiley to manage these papers (alongside non‐COVID submissions) in a shortened time frame, and the editors, Prof Arden and Dr Chilcot, would like to extend our sincere thanks to all who contributed their time and energies to this endeavour at what was a difficult time for everyone. This issue of BJHP includes a special section entitled COVID‐19: Health Psychology Theory and Research which includes the papers and brief reports on this topic accepted for publication to date.
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Health behaviour change considerations for weight loss and type 2 diabetes: nutrition, physical activity and sedentary behaviourGood nutrition, regular physical activity and low levels of sedentary behaviour are important in the prevention, management and treatment of obesity and type 2 diabetes mellitus (T2DM). Self-management requires individuals to have the capability to enact, opportunity to enable and motivation to perform relevant health behaviours. These behaviours, and the bio-psycho-social drivers of them, should be considered when working in the area of T2DM.
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Should we decolonise midwifery education?This year the Black Lives Matter movement gained momentum globally and more people are having uncomfortable but necessary conversations around race. While the recent focus on racism within healthcare has largely been on outcomes because of inequality, we must also examine how the education of healthcare professionals can also play a part in dismantling racism in clinical practice. In this article, Chelsea Beckford-Procyk discusses the ways in which student midwives, birthing people and society as a whole would benefit from the decolonisation of midwifery education.
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Under-mask beard cover (Singh Thattha technique) for donning respirator masks in COVID-19 patient careTight-fitting filtering facepiece (FFP3) face masks are essential respiratory protective equipment during aerosol-generating procedures in the coronavirus disease 2019 (COVID-19) environment, and require a fit test to assess mask–face seal competency. Facial hair is considered to be an impediment for achieving a competent seal. We describe an under-mask beard cover called the Singh Thattha technique, which obtained a pass rate of 25/27 (92.6%) by qualitative and 5/5 (100%) by quantitative fit test in full-bearded individuals. Sturdier versions of FFP3 were more effective. For individuals for whom shaving is not possible, the Singh Thattha technique could offer an effective solution to safely don respirator masks.
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Development of an instrumented chair to identify the phases of the sit-to-stand movementInstrumented versions of functional geriatric screening tests have been developed to improve clinical precision. Several different instrumented versions of the Sit-to-Stand (iSTS) test have been developed using a range of sensors such as accelerometers and cameras. An instrumented chair equipped with load cells and an ultrasound sensor was developed to detect phases of the STS (Sit to Stand). The chair was designed to be able to detect all the phases of the STS, including when the person was not in contact with the chair. Performance of the iSTS chair was compared between an RGB camera approach, and a data-fusion approach using the load-cell and ultrasound equipped chair. Ten adult subjects were tested performing the 5STS at two self-selected speeds. The accuracy of the load cell equipped chair was 70%, while the RGB camera achieved 76% accuracy. The ultrasound version of the chair and the fusion of the RGB and load cells technique both achieved significantly better accuracy at 86% and 89%, respectively. The new version of the instrumented chair obtained a high degree of accuracy in detecting the different phases of the STS and is suitable to detect STS phases without requiring additional sensors. Future work will test older subjects and aim to develop new parameters based on the phases of the STS as indicators of physical performance.
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Evaluating ‘Enhancing Pragmatic Language skills for Young children with Social communication impairments’ (E-PLAYS): a feasibility cluster-randomised controlled trialBackground This article reports the results from a feasibility study of an intervention (‘E-PLAYS’) aimed at supporting children who experience difficulties with social communication. E-PLAYS is based around a dyadic computer game, which aims to develop collaborative and communication skills. A pilot study found that when E-PLAYS was delivered by researchers, improvements on communication test scores and on collaborative behaviours were observed. The aim of this study was to ascertain the feasibility of running a full-scale trial to test the effectiveness of E-PLAYS in a National Health Service (NHS) setting with delivery by speech and language therapists and teaching assistants. Methods The study was a two-arm feasibility cluster-randomised controlled trial of the E-PLAYS intervention with a treatment as usual control arm. Data relating to recruitment and retention, treatment fidelity, acceptability to participants, suitability of outcomes and feasibility of collecting health economic measures and of determining cost-effectiveness were collected. Speech and language therapists selected suitable children (ages 4–7 years old) from their caseload. E-PLAYS intervention (experimental group) was then delivered by teaching assistants overseen by speech and language therapists. The control group received usual care. Assessments included blinded language measures and observations, non-blinded teacher-reported measures of peer relations and classroom behaviour and non-blinded parent-reported use of health and education resources and quality of life. Results Planned recruitment was for 70 children, in the event, 50 children were recruited which was sufficient for feasibility purposes. E-PLAYS was very highly rated by children, teaching assistants and speech and language therapists and treatment fidelity did not pose any issues. We were able to collect health economic data which suggests that E-PLAYS would be a low-cost intervention. Conclusion Based on recruitment, retention and adherence rates and our outcome measures, a full-scale randomised controlled trial estimated appears feasible and warranted to assess the effectiveness of E-PLAYS for use by the NHS and schools. Trial registration ISRCTN 14818949 (retrospectively registered)
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Study protocol for evaluation of aid to diagnosis for developmental dysplasia of the hip in general practice: controlled trial randomised by practiceIntroduction In the UK, a compulsory € 6-week hip check' is performed in primary care for the detection of developmental dysplasia of the hip (DDH). However, missed diagnoses and infants incorrectly labelled with DDH remain a problem, potentially leading to adverse consequences for infants, their families and the National Health Service. National policy states that infants should be referred to hospital if the 6-week check suggests DDH, though there is no available tool to aid examination or offer guidelines for referral. We developed standardised diagnostic criteria for DDH, based on international Delphi consensus, and a 9-item checklist that has the potential to enable non-experts to diagnose DDH in a manner approaching that of experts. Methods and analysis We will conduct a controlled trial randomised by practice that will compare a diagnostic aid against standard care for the hip check. The primary objective is to determine whether an aid to the diagnosis of DDH reduces the number of clinically insignificant referrals from primary care to hospital and the number of late diagnosed DDH. The trial will include a qualitative process evaluation, an assessment of professional behavioural change and a full health economic evaluation. We will recruit 152 general practitioner practices in England. These will be randomised to conduct the hip checks with useof the study diagnostic aid and/or as per usual practice. The total number of infants seen during a15-month recruitment period will be 110 per practice. Two years after the 6-week hip check, we willmeasure the number of referred infants that are (1) clinically insignificant for DDH and (2) those that constitute appropriate referrals. Ethics and dissemination This study has approval from the Health Research Authority (16/1/2020) and the Confidentiality Advisory Group (18/2/2020). Results will be published in peer-reviewed academic journals, disseminated to patient organisations and the media. Trial registration number NCT04101903; Pre-results.
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Intrinsic resistance to PIM kinase inhibition in AML through p38α-mediated feedback activation of mTOR signalingAlthough conventional therapies for acute myeloid leukemia (AML) and diffuse large B-cell lymphoma (DLBCL) are effective in inducing remission, many patients relapse upon treatment. Hence, there is an urgent need for novel therapies. PIM kinases are often overexpressed in AML and DLBCL and are therefore an attractive therapeutic target. However, in vitro experiments have demonstrated that intrinsic resistance to PIM inhibition is common. It is therefore likely that only a minority of patients will benefit from single agent PIM inhibitor treatment. In this study, we performed an shRNA-based genetic screen to identify kinases whose suppression is synergistic with PIM inhibition. Here, we report that suppression of p38α (MAPK14) is synthetic lethal with the PIM kinase inhibitor AZD1208. PIM inhibition elevates reactive oxygen species (ROS) levels, which subsequently activates p38α and downstream AKT/mTOR signaling. We found that p38α inhibitors sensitize hematological tumor cell lines to AZD1208 treatment in vitro and in vivo. These results were validated in ex vivo patient-derived AML cells. Our findings provide mechanistic and translational evidence supporting the rationale to test a combination of p38α and PIM inhibitors in clinical trials for AML and DLBCL.
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Social prescribing: implementation and deliveryIntroduction: Social prescription is an innovative approach that aims to link patients in primary care with sources of support within the community and voluntary sector to help improve their health, wellbeing, and care experience. Social prescription provides healthcare professionals with a non-medical referral option, which can operate alongside medical treatments, to address non-clinical factors that precipitate and perpetuate ill health and often lead to frequent primary and secondary care visits. It is based on the bio-psycho-social model of health that considers physical, as well as psychological and social factors as determinants of health and wellbeing. Research on social prescription indicates that there is a potential for psychosocial benefits and health and wellbeing improvements for service users. While most attention has been paid to outcome evaluations, there is a lack of research on factors affecting the implementation process of social prescription interventions. This study aimed to explore factors facilitating and hindering the implementation and delivery of a social prescription intervention in the East of England Luton. The Luton social prescribing programme is based in primary care and involves navigators, who support and work with referred patients to identify their non-medical needs. Methods: A qualitative study was conducted including 22 semi-structured interviews with managers and policy-makers 9, GPs 3, navigators 4, and service providers in the third sector 6 involved in the Luton social prescribing programme. Thematic analysis was used to analyse the data. Results: Due to the differences in stakeholders’ experiences and views, barriers and facilitators were often two sides of the same coin e.g. good communication/ poor communication. Therefore, the identified issues are presented by theme, rather than separately for barriers and facilitators. Identified issues include the availability of resources, stakeholder involvement and engagement, information technology, organisational culture and readiness, existing infrastructures, leadership, staff turnover, support and supervision, planning, communication, and relationships between stakeholders. Discussion: This study contributes to the development of an evidence base on barriers and facilitators to the implementation and delivery of social prescribing programmes. Some of the identified barriers and facilitators seem to be similar to those of other integrated care pilots in the UK, whereas others are specific to social prescribing interventions. Thus, it is important to conduct more robust and transparent research on social prescribing, to address potential barriers to implementation. Conclusion: This study produced evidence on factors that hinder and facilitate the implementation of a social prescription programme in the East of England. Findings can contribute to the development of an evidence base for social prescription programmes in the UK, and inform practice, policy, and future research in the field.
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Social prescribing: primary care patient and service user engagementIntroduction: Social Prescribing provides healthcare professionals with a non-medical referral option, in order to address the non-medical factors that determine patients’ health, wellbeing, and often lead to frequent primary and secondary care visits. To meet the non-medical needs of people, social prescribing links primary care patients with sources of support usually provided within the third sector. Research on social prescription indicates that there is a potential for psychosocial benefits, health, and wellbeing improvements for patients who engaged with the service. However, there is no research on factors affecting primary care patients’ decision to take part, or not to take part, in social prescribing. In addition, it is unclear why service users engage, and disengage, with the prescribed services. This study aimed to explore factors affecting the participation of primary care patients (uptake) and engagement of service users (adherence) with a social prescription intervention in the East of England (Luton). Methods: A qualitative study was conducted including 17 semi-structured interviews with GPs (3), navigators (4), and service users (10), analysed using thematic analysis. Results: Factors relating to perceived needs and benefits, the role of GPs, stigmatisation, the entrenchment in the medical model, and the nature of the social prescribing programme affected the participation of primary care patients. Changes in health and wellbeing, rewards, motivation, trust, perceived benefits, service provider-, family-, and navigator support, and the accessibility and availability of services were factors related to the engagement and disengagement of service users. Discussions: Findings of this study fill the existing knowledge gap on factors affecting primary care patients’ participation and engagement in social prescribing interventions. Identified factors can inform policy and practice and, if considered in the social prescribing pathway, potentially improve patient uptake and service user adherence in existing and future programmes. A limitation of this study is that primary care patients who refused to be referred into the social prescribing programme were not interviewed. Due to a lack of recording primary care patients who refused to be referred into the social prescribing programme, this patient group could not be identified. To gain an understanding of potential reasons for refusal, in this study GPs were asked about reasons for refusal in this patient group. However, to gain a deeper understanding of barriers to initial participation, more robust and transparent research in this field, including primary care patients who refused to get involved with social prescribing, is needed. Conclusions: This study produced evidence on factors affecting the participation of primary care patients and service user engagement in a social prescribing intervention in the UK. Findings can contribute to the development of an evidence base for social prescription programmes in the UK, and inform practice, policy, and future research in the field.
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Automated telephone communication systems for preventive healthcare and management of long-term conditionsBackground: Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention. Objectives: To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes. Search methods: We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015. Selection criteria: Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible. Data collection and analysis: We used standard Cochrane methods to select and extract data and to appraise eligible studies. Main results: We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions. Authors' conclusions: ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.
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Childhood maternal school leaving age (level of education) and risk markers of metabolic syndrome in mid-adulthood: results from the 1958 British birth cohortPurpose: The aim of this study is to investigate the relationship between childhood maternal level of education (CMLE) and changes in anthropometric and laboratory risk markers of metabolic syndrome (MetS) in mid-adulthood using results from the 1958 British Birth Cohort Study. Design: Cohort study. Participants: A total of 9376 study samples consisting of subjects that participated in the biomedical survey of the national child development study (NCDS) carried out between 2002 and 2004 were used for the analysis. Main Outcome Measures: Five risk markers of MetS: (i) HDL-cholesterol (ii) triglyceride (iii) blood pressure (BP) including systolic (SBP) and diastolic (DBP) (iv) waist circumference (WC) and (v) glycated haemoglobin (HbA1c). Methods: The NCDS or the 1958 British birth cohort data deposited in the UK data service by the centre for longitudinal studies were used for analyses. Ordinary least squares regression was used to determine unit changes in the outcome variables given CMLE. Results: The estimates for unadjusted regression analysis of individual risk markers indicated a significant relationship between CMLE and alterations in the five risk markers of MetS (HDL-cholesterol, triglyceride, WC, HbA1c, and BP) in midlife. After adjustment for birth and lifestyle characteristics/health behaviours, the relationship between CMLE and the risk markers was attenuated for HDL-cholesterol, triglycerides, and HbA1c but remained significant for WC 0.70 (95% confidence interval (CI) 0.065– 1.30, p< 0.001) and SBP 1.48 (95% CI 0.48– 2.47 p< 0.001). Conclusion: There was a positive association between lower CMLE and the risk of MetS using the NCDS data. Lifestyle characteristics may be influential determinants of MetS risk in mid-adulthood.
