Showing papers on "Psychological intervention published in 2012"

Interventions for preventing falls in older people living in the community

Abstract: As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture. This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants. Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures. Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined. Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls. Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment. Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls. Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure. In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling. The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Mindsets That Promote Resilience: When Students Believe That Personal Characteristics Can Be Developed

Abstract: Because challenges are ubiquitous, resilience is essential for success in school and in life. In this article we review research demonstrating the impact of students’ mindsets on their resilience in the face of academic and social challenges. We show that students who believe (or are taught) that intellectual abilities are qualities that can be developed (as opposed to qualities that are fixed) tend to show higher achievement across challenging school transitions and greater course completion rates in challenging math courses. New research also shows that believing (or being taught) that social attributes can be developed can lower adolescents’ aggression and stress in response to peer victimization or exclusion, and result in enhanced school performance. We conclude by discussing why psychological interventions that change students’ mindsets are effective and what educators can do to foster these mindsets and create resilience in educational settings. When students struggle with their schoolwork, what determines whether they give up or embrace the obstacle and work to overcome it? And when students feel excluded or victimized by peers, what determines whether they seek revenge through aggression or seek more productive solutions? Resilience—or whether students respond positively to challenges—is crucial for success in school and in life. Yet what causes it? And what can be done to increase it? In this article we demonstrate the impact of students’ mindsets—or implicit theories about the malleability of human characteristics—on their academic and social resilience (Dweck, 2006; Dweck, Chiu, & Hong, 1995). We show how mindsets can contribute to two of the most important issues currently facing educators: (a) academic underachievement and (b) the impact of peer exclusion and victimization. Each of these problems is of great concern, yet each has been frustratingly difficult to address. For example, many of the large-scale interventions evaluated by the Institute of

Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies

Abstract: Stigma associated with mental illness has malignant effects on the lives of people with serious mental illnesses. Many strategies have been used to combat public stigma—the prejudice and discrimination endorsed by the general population. To identify the most effective approaches, researchers conducted a meta-analysis of data from 72 outcome studies in 14 countries. Overall, strategies that include education about mental illness and contact with people who have mental illness are effective. For adults, contact appears to be more effective, whereas education seems to work best among adolescents.

Developing core outcome sets for clinical trials: issues to consider.

Abstract: The selection of appropriate outcomes or domains is crucial when designing clinical trials in order to compare directly the effects of different interventions in ways that minimize bias. If the findings are to influence policy and practice then the chosen outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. There is a growing recognition that insufficient attention has been paid to the outcomes measured in clinical trials. These issues could be addressed through the development and use of an agreed standardized collection of outcomes, known as a core outcome set, which should be measured and reported, as a minimum, in all trials for a specific clinical area. Accumulating work in this area has identified the need for general guidance on the development of core outcome sets. Key issues to consider in the development of a core outcome set include its scope, the stakeholder groups to involve, choice of consensus method and the achievement of a consensus.

Socioeconomic status and smoking: a review

Abstract: Smoking prevalence is higher among disadvantaged groups, and disadvantaged smokers may face higher exposure to tobacco's harms. Uptake may also be higher among those with low socioeconomic status (SES), and quit attempts are less likely to be successful. Studies have suggested that this may be the result of reduced social support for quitting, low motivation to quit, stronger addiction to tobacco, increased likelihood of not completing courses of pharmacotherapy or behavioral support sessions, psychological differences such as lack of self-efficacy, and tobacco industry marketing. Evidence of interventions that work among lower socioeconomic groups is sparse. Raising the price of tobacco products appears to be the tobacco control intervention with the most potential to reduce health inequalities from tobacco. Targeted cessation programs and mass media interventions can also contribute to reducing inequalities. To tackle the high prevalence of smoking among disadvantaged groups, a combination of tobacco control measures is required, and these should be delivered in conjunction with wider attempts to address inequalities in health.

Mental health literacy: Empowering the community to take action for better mental health.

Abstract: For major physical diseases, it is widely accepted that members of the public will benefit by knowing what actions they can take for prevention, early intervention, and treatment. However, this type of public knowledge about mental disorders (mental health literacy) has received much less attention. There is evidence from surveys in several countries for deficiencies in (a) the public's knowledge of how to prevent mental disorders, (b) recognition of when a disorder is developing, (c) knowledge of help-seeking options and treatments available, (d) knowledge of effective self-help strategies for milder problems, and (e) first aid skills to support others affected by mental health problems. Nevertheless, there is evidence that a range of interventions can improve mental health literacy, including whole-of-community campaigns, interventions in educational settings, Mental Health First Aid training, and information websites. There is also evidence for historical improvements in mental health literacy in some countries. Increasing the community's mental health literacy needs to be a focus for national policy and population monitoring so that the whole community is empowered to take action for better mental health.

Interventions for providers to promote a patient‐centred approach in clinical consultations

Abstract: Problems may arise when healthcare providers focus on managing diseases rather than on people and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. The authors updated a 2001 systematic review of the effects of these training interventions for healthcare providers that aim to promote patient-centred care in clinical consultations. They found 29 new randomized trials (up to June 2010), bringing the total of studies included in the review to 43. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. These studies showed that training providers to improve their ability to share control with patients about topics and decisions addressed in consultations are largely successful in teaching providers new skills. Short-term training (less than 10 hours) is as successful in this regard as longer training. Results are mixed about whether patients are more satisfied when providers practice these skills. The impact on general health is also mixed, although the limited data that could be pooled showed small positive effects on health status. Patients' specific health behaviours show improvement in the small number of studies where interventions use provider training combined with condition-specific educational materials and/or training for patients, such as teaching question-asking during the consultation or medication-taking after the consultation. However, the number of studies is too small to determine which elements of these multi-faceted studies are essential in helping patients change their healthcare behaviours.

Persuasive System Design Does Matter: A Systematic Review of Adherence to Web-Based Interventions

Abstract: Background: Although web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed Technology as a means to communicate the content in web-based interventions has been neglected in research Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content In this paper we examine technology from a holistic perspective We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence Objective: This study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention Methods: We conducted a systematic review of studies into web-based health interventions Per intervention, intervention characteristics, persuasive technology elements and adherence were coded We performed a multiple regression analysis to investigate whether these variables could predict adherence Results: We included 101 articles on 83 interventions The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 29 out of a possible 70) Dialogue support and social support are less commonly employed (mean 15 and 12 out of a possible 70, respectively) When comparing the interventions of the different health care areas, we find significant differences in intended usage (p = 004), setup (p < 001), updates (p < 001), frequency of interaction with a counselor (p < 001), the system (p = 003) and peers (p = 017), duration (F = 6068, p = 004), adherence (F = 4833, p = 010) and the number of primary task support elements (F = 5631, p = 005) Our final regression model explained 55% of the variance in adherence In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence Conclusions: Using intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence Rather, the differences in technology and interaction predict adherence The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere

Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

Abstract: There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process.

The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.

Abstract: Background The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.

Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions

Abstract: Social ecological models that describe the interactive characteristics of individuals and environments that underlie health outcomes have long been recommended to guide public health practice. The extent to which such recommendations have been applied in health promotion interventions, however, is unclear. The authors developed a coding system to identify the ecological levels that health promotion programs target and then applied this system to 157 intervention articles from the past 20 years of Health Education & Behavior. Overall, articles were more likely to describe interventions focused on individual and interpersonal characteristics, rather than institutional, community, or policy factors. Interventions that focused on certain topics (nutrition and physical activity) or occurred in particular settings (schools) more successfully adopted a social ecological approach. Health education theory, research, and training may need to be enhanced to better foster successful efforts to modify social and political environments to improve health.

Role of Built Environments in Physical Activity, Obesity, and Cardiovascular Disease

Abstract: There is a growing consensus that large changes in population levels of physical activity and other behaviors required to improve cardiovascular health will require major modifications in environments and policies. Ecological models are the conceptual basis for comprehensive interventions that emphasize environmental and policy changes and that can have widespread and sustainable effects. These interventions are complemented with individual education and motivation and efforts to change social support and norms. Physical activity-specific ecological models indicate which environmental factors are expected to be related to physical activity in multiple life domains: Leisure/recreation/exercise, occupation (school for youth), transportation, and household. Over the past decade, a proliferation of interdisciplinary research has generally supported hypotheses derived from ecological models and identified specific built environment attributes and combinations of attributes that are related to physical activity, mainly for recreation and transportation purposes, and obesity. It is becoming clear that racial/ethnic minority and low-income communities are disadvantaged in access to recreation facilities, positive aesthetics, and protection from traffic. These results provide an empirical rationale for intervention. There are recent examples of environmental changes or community-wide multilevel interventions that had positive effects on physical activity or obesity. Continuing research needs are to improve the rigor of study designs, confirm subgroup- or context-specific built environment associations, identify optimal combinations of attributes, improve understanding of the policy change processes required to achieve environmental changes, and evaluate multilevel interventions. Both research teams and community-based initiatives are collaborating with a wide range of professionals and sectors of society, such as recreation, transportation, city planning, architecture, landscape architecture, geography, criminal justice, and law, in addition to health professionals and behavioral scientists. These diverse teams have stimulated innovations in research, new approaches to intervention, and improved connections with decision makers who can make environment and policy changes in nonhealth sectors of society. The practice of physical activity promotion, obesity prevention, and CVD risk reduction has changed to reflect the shift to multilevel interventions. Major foundations and public health agencies are implementing community-based interventions targeting environment and policy change. Continuing challenges for these community-wide interventions are to maintain support for the multisector, long-term efforts required to change environments, evaluate interventions so they become ever more evidence-based, and integrate explicit chronic disease prevention objectives into professional practices of diverse disciplines, government agencies, and industries whose primary work can affect physical activity and health. Among the largest initiatives was the Centers for Disease Control and Prevention's Communities Putting Prevention to Work grant program, which awarded more than $250 million in 2010 to change environments and policies to improve nutrition and physical activity and prevent obesity. Recommended strategies were based on MAPPS: Media, Access, Point of decision information, Price, and Social support/services. Strategies ranged from improving physical activity in school physical education (access) to subsidizing memberships to recreational facilities (price) to promoting safe routes to school (eg, social support/services). Experience with these initiatives, as well as systematic evaluations, will lead to a better understanding of how to accomplish policy and environmental change in diverse communities and provide important information about the impact of these changes. Language: en

Printed educational materials: effects on professional practice and healthcare outcomes

Abstract: Background Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. Objectives To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes. Search methods For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register. Selection criteria We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. Data collection and analysis Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. Main results The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness. Authors' conclusions The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Evolution of public attitudes about mental illness: a systematic review and meta-analysis

Abstract: Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, Angermeyer MC. Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Objective: To explore whether the increase in knowledge about the biological correlates of mental disorders over the last decades has translated into improved public understanding of mental illness, increased readiness to seek mental health care and more tolerant attitudes towards mentally ill persons. Method: A systematic review of all studies on mental illness-related beliefs and attitudes in the general population published before 31 March 2011, examining the time trends of attitudes with a follow-up interval of at least 2 years and using national representative population samples. A subsample of methodologically homogeneous studies was further included in a meta-regression analysis of time trends. Results: Thirty-three reports on 16 studies on national time trends met our inclusion criteria, six of which were eligible for a meta-regression analysis. Two major trends emerged: there was a coherent trend to greater mental health literacy, in particular towards a biological model of mental illness, and greater acceptance of professional help for mental health problems. In contrast, however, no changes or even changes to the worse were observed regarding the attitudes towards people with mental illness. Conclusion: Increasing public understanding of the biological correlates of mental illness seems not to result in better social acceptance of persons with mental illness.

Parent and Family Impact of Autism Spectrum Disorders: A Review and Proposed Model for Intervention Evaluation

Abstract: Raising a child with an autism spectrum disorder (ASD) can be an overwhelming experience for parents and families. The pervasive and severe deficits often present in children with ASD are associated with a plethora of difficulties in caregivers, including decreased parenting efficacy, increased parenting stress, and an increase in mental and physical health problems compared with parents of both typically developing children and children with other developmental disorders. In addition to significant financial strain and time pressures, high rates of divorce and lower overall family well-being highlight the burden that having a child with an ASD can place on families. These parent and family effects reciprocally and negatively impact the diagnosed child and can even serve to diminish the positive effects of intervention. However, most interventions for ASD are evaluated only in terms of child outcomes, ignoring parent and family factors that may have an influence on both the immediate and long-term effects of therapy. It cannot be assumed that even significant improvements in the diagnosed child will ameliorate the parent and family distress already present, especially as the time and expense of intervention can add further family disruption. Thus, a new model of intervention evaluation is proposed, which incorporates these factors and better captures the transactional nature of these relationships.

Childhood Adversities and First Onset of Psychiatric Disorders in a National Sample of US Adolescents

Abstract: Context Although childhood adversities (CAs) are known to be highly co-occurring, most research examines their associations with psychiatric disorders one at a time. However, recent evidence from adult studies suggests that the associations of multiple CAs with psychiatric disorders are nonadditive, arguing for the importance of multivariate analysis of multiple CAs. To our knowledge, no attempt has been made to perform a similar kind of analysis among children or adolescents. Objective To examine the multivariate associations of 12 CAs with first onset of psychiatric disorders in a national sample of US adolescents. Design A US national survey of adolescents (age range, 13-17 years) assessing DSM-IV anxiety, mood, behavior, and substance use disorders and CAs. The CAs include parental loss (death, divorce, and other separations), maltreatment (neglect and physical, sexual, and emotional abuse), and parental maladjustment (violence, criminality, substance abuse, and psychopathology), as well as economic adversity. Setting Dual-frame household-school samples. Participants In total, 6483 adolescent-parent pairs. Main Outcome Measures Lifetime DSM-IV disorders assessed using the World Health Organization Composite International Diagnostic Interview. Results Overall, exposure to at least 1 CA was reported by 58.3% of adolescents, among whom 59.7% reported multiple CAs. The CAs reflecting maladaptive family functioning were more strongly associated than other CAs with the onset of psychiatric disorders. The best-fitting model included terms for the type and number of CAs and distinguished between maladaptive family functioning and other CAs. The CAs predicted behavior disorders most strongly and fear disorders least strongly. The joint associations of multiple CAs were subadditive. The population-attributable risk proportions across DSM-IV disorder classes ranged from 15.7% for fear disorders to 40.7% for behavior disorders. The CAs were associated with 28.2% of all onsets of psychiatric disorders. Conclusions Childhood adversities are common, highly co-occurring, and strongly associated with the onset of psychiatric disorders among US adolescents. The subadditive multivariate associations of CAs with the onset of psychiatric disorders have implications for targeting interventions to reduce exposure to CAs and to mitigate the harmful effects of CAs to improve population mental health.

The role of parents and teachers in the development of gender-related math attitudes.

Abstract: Girls tend to have more negative math attitudes, including gender stereotypes, anxieties, and self-concepts, than boys. These attitudes play a critical role in math performance, math course-taking, and the pursuit of math-related career paths. We review existing research, primarily from U.S. samples, showing that parents’ and teachers’ expectancies for children’s math competence are often gender-biased and can influence children’s math attitudes and performance. We then propose three new directions for future research on the social transmission of gender-related math attitudes. First, parents’ and teachers’ own math anxieties and their beliefs about whether math ability is a stable trait may prove to be significant influences on children’s math attitudes. Second, a developmental perspective that investigates math attitudes at younger ages and in relation to other aspects of gender development, such as gender rigidity, may yield new insights into the development of math attitudes. Third, investigating the specific behaviors and mannerisms that form the causal links between parents’ and teachers’ beliefs and children’s math attitudes may lead to effective interventions to improve children’s math attitudes from a young age. Such work will not only further our understanding of the relations between attitudes and performance, but will lead to the development of practical interventions for the home and classroom that ensure that all students are provided with opportunities to excel in math.

Managing patients with multimorbidity: systematic review of interventions in primary care and community settings.

Abstract: Objective To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Design Systematic review. Data sources Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011). Eligibility criteria Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs. Data selection Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out. Results 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings. Conclusions Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.

The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review

Abstract: Aims This study provides a systematic review of existing research that has empirically evaluated interventions designed to reduce stigma related to substance use disorders. Methods A comprehensive review of electronic databases was conducted to identify evaluations of substance use disorder related stigma interventions. Studies that met inclusion criteria were synthesized and assessed using systematic review methods. Results Thirteen studies met the inclusion criteria. The methodological quality of the studies was moderately strong. Interventions of three studies (23%) focused on people with substance use disorders (self-stigma), three studies (23%) targeted the general public (social stigma) and seven studies (54%) focused on medical students and other professional groups (structural stigma). Nine interventions (69%) used approaches that included education and/or direct contact with people who have substance use disorders. All but one study indicated their interventions produced positive effects on at least one stigma outcome measure. None of the interventions have been evaluated across different settings or populations. Conclusions Arangeof interventionsdemonstratepromiseforachievingmeaningfulimprovementsinstigmarelated to substance use disorders. The limited evidence indicates that self-stigma can be reduced through therapeutic interventions such as group-based acceptance and commitment therapy. Effective strategies for addressing social stigma include motivational interviewing and communicating positive stories of people with substance use disorders. For changing stigma at a structural level, contact-based training and education programs targeting medical students and professionals (e.g. police, counsellors) are effective. add_3601 39..50

Mobile phone messaging for facilitating self-management of long-term illnesses.

Abstract: Background Long-term illnesses affect a significant proportion of the population in developed and developing countries Mobile phone messaging applications, such as Short Message Service (SMS) and Multimedia Message Service (MMS), may present convenient, cost-effective ways of supporting self-management and improving patients' self-efficacy skills through, for instance, medication reminders, therapy adjustments or supportive messages Objectives To assess the effects of mobile phone messaging applications designed to facilitate self-management of long-term illnesses, in terms of impact on health outcomes and patients' capacity to self-manage their condition Secondary objectives include assessment of: user evaluation of the intervention; health service utilisation and costs; and possible risks and harms associated with the intervention Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2009, Issue 2), MEDLINE (OvidSP) (January 1993 to June 2009), EMBASE (OvidSP) (January 1993 to June 2009), PsycINFO (OvidSP) (January 1993 to June 2009), CINAHL (EbscoHOST) (January 1993 to June 2009), LILACS (January 1993 to June 2009) and African Health Anthology (January 1993 to June 2009) We also reviewed grey literature (including trial registers) and reference lists of articles Selection criteria We included randomised controlled trials (RCTs), quasi-randomised controlled trials (QRCTs), controlled before-after (CBA) studies, or interrupted time series (ITS) studies with at least three time points before and after the intervention We selected only studies where it was possible to assess the effects of mobile phone messaging independent of other technologies or interventions Data collection and analysis Two review authors independently assessed all studies against the inclusion criteria, with any disagreements resolved by a third review author Study design features, characteristics of target populations, interventions and controls, and results data were extracted by two review authors and confirmed by a third Primary outcomes of interest were health outcomes as a result of the intervention and capacity to self-manage long-term conditions We also considered patients' and providers' evaluation of the intervention, perceptions of safety, health service utilisation and costs, and potential harms or adverse effects The included studies were heterogeneous in type of condition addressed, intervention characteristics and outcome measures Therefore, a meta-analysis to derive an overall effect size for the main outcome categories was not considered justified and findings are presented narratively Main results We included four randomised controlled trials involving 182 participants For the primary outcome of health outcomes, including physiological measures, there is moderate quality evidence from two studies involving people with diabetes showing no statistical difference from text messaging interventions compared with usual care or email reminders for glycaemic control (HbA1c), the frequency of diabetic complications, or body weight There is moderate quality evidence from one study of hypertensive patients that the mean blood pressure and the proportion of patients who achieved blood pressure control were not significantly different in the intervention and control groups, and that there was no statistically significant difference in mean body weight between the groups There is moderate quality evidence from one study that asthma patients receiving a text messaging intervention experienced greater improvements on peak expiratory flow variability (mean difference (MD) -1112, 95% confidence interval (CI) -1956 to -268) and the pooled symptom score comprising four items (cough, night symptoms, sleep quality, and maximum tolerated activity) (MD -036, 95% CI -056 to -017) compared with the control group However, the study found no significant differences between the groups in impact on forced vital capacity or forced expiratory flow in 1 second For the primary outcome of capacity to self-manage the condition, there is moderate quality evidence from one study that diabetes patients receiving the text messaging intervention demonstrated improved scores on measures of self-management capacity (Self-Efficacy for Diabetes score (MD 610, 95% CI 045 to 1175), Diabetes Social Support Interview pooled score (MD 439, 95% CI 285 to 592)), but did not show improved knowledge of diabetes There is moderate quality evidence from three studies of the effects on treatment compliance One study showed an increase in hypertensive patients' rates of medication compliance in the intervention group (MD 890, 95% CI 018 to 1762) compared with the control group, but in another study there was no statistically significant effect on rates of compliance with peak expiratory flow measurement in asthma patients Text message prompts for diabetic patients initially also resulted in a higher number of blood glucose results sent back (460) than email prompts did (235) For the secondary outcome of participants' evaluation of the intervention, there is very low quality evidence from two studies that patients receiving mobile phone messaging support reported perceived improvement in diabetes self-management, wanted to continue receiving messages, and preferred mobile phone messaging to email as a method to access a computerised reminder system For the secondary outcome of health service utilisation, there is very low quality evidence from two studies Diabetes patients receiving text messaging support made a comparable number of clinic visits and calls to an emergency hotline as patients without the support For asthma patients the total number of office visits was higher in the text messaging group, whereas the number of hospital admissions was higher for the control group Because of the small number of trials included, and the low overall number of participants, for any of the reviewed outcomes the quality of the evidence can at best be considered moderate Authors' conclusions We found some, albeit very limited, indications that in certain cases mobile phone messaging interventions may provide benefit in supporting the self-management of long-term illnesses However, there are significant information gaps regarding the long-term effects, acceptability, costs, and risks of such interventions Given the enthusiasm with which so-called mHealth interventions are currently being implemented, further research into these issues is needed

Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review

Abstract: Background Suboptimum medication adherence is common in the United States and leads to serious negative health consequences but may respond to intervention. Purpose To assess the comparative effectiveness of patient, provider, systems, and policy interventions that aim to improve medication adherence for chronic health conditions in the United States. Data sources Eligible peer-reviewed publications from MEDLINE and the Cochrane Library indexed through 4 June 2012 and additional studies from reference lists and technical experts. Study selection Randomized, controlled trials of patient, provider, or systems interventions to improve adherence to long-term medications and nonrandomized studies of policy interventions to improve medication adherence. Data extraction Two investigators independently selected, extracted data from, and rated the risk of bias of relevant studies. Data synthesis The evidence was synthesized separately for each clinical condition; within each condition, the type of intervention was synthesized. Two reviewers graded the strength of evidence by using established criteria. From 4124 eligible abstracts, 62 trials of patient-, provider-, or systems-level interventions evaluated 18 types of interventions; another 4 observational studies and 1 trial of policy interventions evaluated the effect of reduced medication copayments or improved prescription drug coverage. Clinical conditions amenable to multiple approaches to improving adherence include hypertension, heart failure, depression, and asthma. Interventions that improve adherence across multiple clinical conditions include policy interventions to reduce copayments or improve prescription drug coverage, systems interventions to offer case management, and patient-level educational interventions with behavioral support. Limitations Studies were limited to adults with chronic conditions (excluding HIV, AIDS, severe mental illness, and substance abuse) in the United States. Clinical and methodological heterogeneity hindered quantitative data pooling. Conclusion Reduced out-of-pocket expenses, case management, and patient education with behavioral support all improved medication adherence for more than 1 condition. Evidence is limited on whether these approaches are broadly applicable or affect longterm medication adherence and health outcomes. Primary funding source Agency for Healthcare Research and Quality.

The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial

Abstract: Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual. Design Multicentre randomised controlled non-inferiority trial. Setting 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services). Participants 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual. Interventions Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists. Outcomes The primary outcome was the change in score on the children’s depression rating scale-revised. Secondary outcomes included response and remission on the children’s depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children’s anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings. Results 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n=85, treatment as usual n=85) were assessed after intervention and 168 (90%, SPARX n=83, treatment as usual n=85) were assessed at the three month follow-up point. Per protocol analyses (n=143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as “possibly” or “probably” related to the intervention did not differ between groups (SPARX n=11; treatment as usual n=11). Conclusions SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment. Trial registration Australian New Zealand Clinical Trials ACTRN12609000249257.

Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel.

Abstract: Description: After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). ART adherence is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. Methods: A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. Recommendations: Recommendations are provided for monitoring of entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.

Computerized Cognitive Training with Older Adults: A Systematic Review

Abstract: A systematic review to examine the efficacy of computer-based cognitive interventions for cognitively healthy older adults was conducted. Studies were included if they met the following criteria: average sample age of at least 55 years at time of training; participants did not have Alzheimer’s disease or mild cognitive impairment; and the study measured cognitive outcomes as a result of training. Theoretical articles, review articles, and book chapters that did not include original data were excluded. We identified 151 studies published between 1984 and 2011, of which 38 met inclusion criteria and were further classified into three groups by the type of computerized program used: classic cognitive training tasks, neuropsychological software, and video games. Reported pre-post training effect sizes for intervention groups ranged from 0.06 to 6.32 for classic cognitive training interventions, 0.19 to 7.14 for neuropsychological software interventions, and 0.09 to 1.70 for video game interventions. Most studies reported older adults did not need to be technologically savvy in order to successfully complete or benefit from training. Overall, findings are comparable or better than those from reviews of more traditional, paper-and-pencil cognitive training approaches suggesting that computerized training is an effective, less labor intensive alternative.

Research Domain Criteria: cognitive systems, neural circuits, and dimensions of behavior.

Abstract: Current diagnostic systems for mental disorders were established before the tools of neuroscience were available, and although they have improved the reliability of psychiatric classification, progress toward the discovery of disease etiologies and novel approaches to treatment and prevention may benefit from alternative conceptualizations of mental disorders. The Research Domain Criteria (RDoC) initiative is the centerpiece of NIMH's effort to achieve its strategic goal of developing new methods to classify mental disorders for research purposes. The RDoC matrix provides a research framework that encourages investigators to reorient their research perspective by taking a dimensional approach to the study of the genetic, neural, and behavioral features of mental disorders, RDoCs integrative approach includes cognition along with social processes, arousal/regulatory systems, and negative and positive valence systems as the major domains, because these neurobehavioral systems have all evolved to serve the motivational and adaptive needs of the organism. With its focus on neural circuits informed by the growing evidence of the neurodevelopmental nature of many disorders and its capacity to capture the patterns of co-occurrence of behaviors and symptoms, the RDoC approach holds promise to advance our understanding of the nature of mental disorders.