Co-designing an intervention using the COM-B model to change an eating behaviour in people living with achalasia.

Background: Achalasia is a rare motility disorder affecting the oesophagus, leading to difficulties with eating and drinking. Participants in previous studies reported that they needed more social, clinical and behavioural support in the long-term management of achalasia. This study, therefore aimed to 1) identify the most challenging eating behaviour for people living with achalasia and 2) co-design a behaviour change intervention to help address the challenges they experience. Methods: This study used a qualitative approach involving online focus groups. The COM-B model was the theoretical framework, with behaviour change techniques (BCTs) as the active ingredients that target a mixture of capability, opportunity and/or motivation. Three focus groups were undertaken to obtain a range of input from different people living with achalasia. Participants in this study identified the target behaviour, prioritised the different BCTs which most resonated with them to design an intervention and decided on the mode of delivery. The research team analysed the techniques that helped participants with their eating behaviour using the COM-B model as a framework to create the intervention. Results: The 24 participants in this study identified "eating in a social setting" as the target behaviour for the intervention. A workbook that can be personalised by the individual was the most suitable intervention. The workbook structure aligns with the constructs of the COM-B model. It includes reflection, activities and goal-setting sections based on what was indicated to be useful for the majority of the participants. Key techniques to overcome the challenges with eating in a social setting included social support, regulation to reduce negative emotions, goals and planning. Conclusion: Using a focus group approach with the COM-B model as the theoretical framework, the participants in this study developed an intervention to support people living with achalasia. In order to achieve long-term behaviour change, engagement with a personalised workbook could facilitate eating in a social setting. Future work will need to pilot the workbook to ensure it can support people to improve their quality of life and complement the ongoing care they receive from health services.

People's experiences living with peripheral neuropathy: a qualitative study.

Introduction: Peripheral neuropathy is a neurological disorder characterised by pain, numbness, or tingling due to nerve damage. Peripheral neuropathy is one of the main health issues in Kuwait and is a rising concern which affects a large proportion of the population, therefore the lived experience needs to be explored to identify areas for improvement in care. This qualitative study explored the experiences of people living with peripheral neuropathy in Kuwait. Methods: Semi-structured interviews were conducted with 25 participants recruited from the Neurology Outpatient Clinic of the Ibn Sina Hospital in Kuwait. The interview questions explored their experiences and understanding of pain along with the impact on their daily life. The interviews were audio recorded, transcribed and translated into English then coded using NVivo 12. Thematic analysis was conducted to identify patterns and themes in the data. Results: Three major themes were identified including treatment beliefs (perceived effectiveness of treatment and seeking alternative treatments), the barriers to pain management (medication side effects, relationships with healthcare professionals and lack of information and access to healthcare), and the impact on quality of life (impact on work and social, physical, and psychological consequences). Self-efficacy was a key construct and over-arching theme that was discussed in all aspects, which finds reflection in the protection motivation theory. Discussion: This paper presents the experiences of people living with peripheral neuropathy and highlights there is scope for improvement of current treatments in Kuwait. Self-management strategies are recommended alongside prescribed medication and healthcare professionals are encouraged to use a patient-centered approach. More importantly, information and support on the condition to promote coping strategies and self-efficacy should be adopted to improve quality of life. These findings can be implemented locally and globally to improve the quality of care provided to people living with peripheral neuropathy.

Educating health care professionals on the importance of proper diets. An online course on nutrition, health, and sustainability.

The majority of university curricula for health professionals does not incorporate courses on human nutrition and its links with human and planetary health. This primarily applies to medical and pharmacy students, who have important counselling roles and are at the forefront of public health. To address this important issue, EIT Food recently launched an online course on nutrition, health, and sustainability. Learners were able to provide feedback on the course through an end-of-course survey and social interaction on the FutureLearn platform. The course was very well attended worldwide and received positive feedback from learners. A total of 3,858 students enrolled in the program, from >20 countries. Learners reported inadequate training on nutrition in their own curriculum and indicated they would use key insights from the course to inform their own practice. This report provides insights from the course, which could be used as guidance for future initiatives.

Adolescents' lived experience of panic disorder: an interpretative phenomenological analysis.

BACKGROUND: Panic disorder is a debilitating anxiety disorder that has a serious impact on adolescents' social and academic functioning and general wellbeing. Panic disorder is experienced by around 1 to 3% of the adolescent population. The aim of this study was to examine adolescents' experiences of having panic disorder. METHODS: Semi-structured interviews were conducted with eight adolescents with a primary diagnosis of panic disorder. Interpretative Phenomenological Analysis was used to gain an understanding of adolescents' lived experience of panic disorder. RESULTS: Two superordinate themes were identified: (1) Drowning in sensations, and (2) An unacceptable self. The findings show that adolescents experience panic disorder as extremely overwhelming and unpleasant, with debilitating feelings of drowning in sensations. Adolescents' experiences largely fit with the cognitive model of panic, in which catastrophic misinterpretation of bodily sensations is associated with anxiety, avoidance, and safety behaviours, creating a vicious cycle. Attempts to avoid or prevent the attacks appear to inadvertently make them worse. Social worries, feeling broadly misunderstood, and unhelpful responses from others, contributed to feelings of being different or abnormal and were connected to a negative self-concept. Negative social interactions with teachers and peers in the school environment were particularly damaging. CONCLUSIONS: These findings offer new insight into these adolescents' lived experience of panic disorder and highlight the need for adolescents to access timely, evidence-based treatment, as well as the need for increased awareness and understanding of panic disorder in schools.

Mapping the experiences of people with achalasia from initial symptoms to long-term management.

BACKGROUND: Achalasia is a rare motility disorder affecting the oesophagus, which is associated with a range of symptoms and different treatment strategies. Currently, little is known about people's experiences with achalasia and its management. This study aimed to understand the experiences of people living with achalasia, from the initial onset of symptoms to long-term management. METHOD: This qualitative study explored the journey of people living with achalasia and outlined the care pathway using a process map. Ten female and five male participants living with achalasia (age range: 40-73) took part, and all aspects of their diagnosis, treatment and management were discussed. A process map showing people's experiences by separating the management of their condition into a series of steps was developed to present the pathway in the participants' journey. The analysis involved discussing the process map within the research team. RESULTS: The process map comprised of 10 steps, which occurred before and after diagnosis. The developed map indicates that most participants managed their on-going symptoms through stress management techniques and dietary changes. Key issues that participants highlighted about their journey managing achalasia were misdiagnosis, delay in diagnosis and lack of support in the long-term management of achalasia. CONCLUSIONS: This research was a novel study exploring patients' experiences and management of achalasia and mapping their journey. Two distinct phases to their journeys were identified: before and after diagnosis. Areas highlighted by this study can provide a basis for future research, in particular behaviour change to support the long-term management of achalasia.

Antibiotic Prescribing in Primary Care for Urinary Tract Infections (UTIs) in Pregnancy: An Audit Study.

Urinary tract infections (UTIs) are associated with negative pregnancy outcomes and are treated with antibiotics. Although beneficial, antibiotic use causes antimicrobial resistance (AMR), and therefore their use needs to be carefully balanced. Antimicrobial guidelines are developed to facilitate appropriate prescribing of antibiotics. This study assessed antibiotic prescribing for UTIs in pregnancy against the National Institute for Health and Care Excellence (NICE) guideline NG109. Fifty antibiotic prescribing records dated from 1st October 2018 to 1st July 2019 were identified from three London-based GP practices. The results show that a mid-stream sample of urine, which is important for the review and tailoring of antibiotic treatment, was collected in 77.6% of cases. Prescribing the first-line antibiotic is important for adequate treatment and good antimicrobial stewardship and results show that 44% of prescriptions were for the first-choice antibiotic. Most prescriptions (56%) were for a second-line or non-recommended antibiotic. Providing self-care advice is key to empowering pregnant women in managing their own health but only 16% of records documented provision of self-care advice. This study highlights important areas of concern in the management of UTIs in pregnancy. However, due to the retrospective design, future work is needed to evaluate the role of AMR in the prescriber's treatment decision-making process.

'There is no choice apart from antibiotics ': Qualitative analysis of views on urinary infections in pregnancy and antimicrobial resistance.

BACKGROUND: Antimicrobial resistance (AMR) is a health risk as it can lead to life-threatening infections. There has been a rise in resistant urinary tract infections (UTIs) which is the most common infection in pregnancy. This can be challenging in pregnancy due to the additional need to safeguard foetal development. The study's aim was to explore views about AMR in women who experienced UTIs in pregnancy. DESIGN: Fifteen semi-structured interviews were conducted in the UK and analysed using thematic analysis. RESULTS: Results highlighted two themes: conceptualization of AMR and pregnancy as a deviation from the norm, with an overarching theme of 'self-efficacy'. Results show that participants were concerned about AMR but uncertain about the effect on society compared to individual's taking antibiotics and about completing antibiotic courses. Participants reported an unsparing use of antibiotics was justified in pregnancy, and behaviours like drinking adequate water were ineffective at preventing UTIs. In summary, women had low self-efficacy regards tackling AMR and managing their health. CONCLUSION: Misconceptions about how AMR affects society vs the individual translated into viewing it as a future problem to be tackled by the health-care sector. Consequently, AMR requires reconceptualization as a current problem requiring collective action. This research also indicates women endorse a biomedical model of UTIs in pregnancy which attributes resolving illness to interventions such as medicines, implying an automatic reliance on antibiotics. Subsequently, there is a need for self-efficacy by focusing on a behavioural model which emphasizes behaviours for infection prevention, thus reducing the need for antibiotics.

The Experiences of People Living with Peripheral Neuropathy in Kuwait-A Process Map of the Patient Journey.

Peripheral neuropathy is a neurological disease characterised by pain, numbness, tingling, swelling or muscle weakness due to nerve damage, caused by multiple factors such as trauma, infections and metabolic diseases such as diabetes. In Kuwait 54% of the diabetic population, has peripheral neuropathy. In this exploratory, qualitative study conducted in Kuwait, 25 subjects with peripheral neuropathy took part in one-on-one, semi-structured interviews lasting 45-60 min. Interviews were transcribed, translated into English and coded using NVivo 12. Four individual patient journeys were mapped out in detail, then compared and condensed into a single process map. The remaining 21 interviews were then reviewed to ensure the final map represented all patient journeys. Participants reported similar healthcare pathways for their peripheral neuropathy and faced various difficulties including lack of psychological support, administrative issues (long waiting referral periods, loss of medical documents, shortage of specialists and lack of centralized electronic medical records) and inadequate medical care (shortage of new treatments and deficient follow-ups). Mapping the patient journey in Kuwait showed similar pharmacological treatment to UK guidelines, except that some medicines were unavailable. The map also indicated the need for an integrated referral approach, the use of technology for electronic medical recording and report transmission, alongside education on self-management, coping mechanisms and treatment options for people living with peripheral neuropathy.

Urinary tract infections and antibiotic use in pregnancy - qualitative analysis of online forum content.

BACKGROUND: Antibiotics are standard treatment for asymptomatic and symptomatic urinary tract infections (UTIs) in pregnancy. Their overuse, however, can contribute to antimicrobial resistance (AMR) and expose the foetus to drugs that might affect its development. Preventative behaviours are currently the best option to reduce incidences of UTIs and to avoid the use of antibiotics in pregnancy. The aim of this study was to explore women's experiences of UTIs in pregnancy to develop an understanding of their concerns and to optimise and encourage behaviours that facilitate appropriate use of antibiotics. METHODS: An online pregnancy forum in the United Kingdom (UK) was used to collect data on women's discussions of UTIs. A total of 202 individual threads generated by 675 different usernames were selected for analysis. The data was organised using NVivo 11® software and then analysed qualitatively using inductive thematic analysis. RESULTS: Women's perceptions of UTIs and antibiotic use in pregnancy were driven by their pre-natal attachment to the foetus. UTIs were thought to be common and high risk in pregnancy, which meant that antibiotics were viewed as essential in the presence of suspected symptoms. The dominant view about antibiotics was that their use was safe and of little concern in pregnancy. Women reported an emotional reaction to developing a UTI. They coped by seeking information about behaviour change strategies to assist with recovery and through emotional support from the online forum. CONCLUSIONS: Women face dual risks when they experience UTIs; the risk from the infection and the risk from antibiotic treatment. Pre-natal attachment to the foetus is highlighted in the decision making process. The focus is on the shorter term risk from UTIs while undermining the longer term risks from antibiotic use, especially the risk of AMR. A balanced view needs to be presented, and evidence-based infection prevention strategies should be promoted, to women to ensure appropriate antibiotic use in pregnancy, to address the global challenge of AMR.

A systematic review of non-antibiotic measures for the prevention of urinary tract infections in pregnancy.

BACKGROUND: Urinary tract infections (UTIs) are common in pregnancy and account for the highest proportion of primary care antibiotic prescriptions issued to pregnant women in the UK. It is well known that antibiotic use is associated with increased antimicrobial resistance and therefore measures to minimise antibiotic use for UTI prevention have been studied. The efficacy and safety of these measures in pregnancy have not been addressed and therefore the aim of this study was to systematically review the literature to identify and evaluate potential measures to prevent UTIs in pregnant women. METHODS: Ten databases (EMBASE, AMED, BNI, CINAHL, Medline, PubMed, PsycINFO, Cochrane Trials, Scopus and Science Direct) were systematically searched in July 2017 for studies reporting non-antibiotic measures to prevent UTIs in pregnancy. The terms ("urinary tract infection" or UTI or bacteriuria or cystitis) AND (prevention) AND (pregnan*) were used. The quality of the publications was appraised using the Critical Appraisal Skills Programme (CASP) checklists for cohort study, case-control study and randomised controlled trial. The results were synthesised using a textual narrative approach. RESULTS: Search results yielded 3276 publications and after reviewing titles and removing duplicates, 57 full text articles were assessed for eligibility and eight were included in the review. Five different approaches (hygiene measures, cranberry juice, immunisation, ascorbic acid and Canephron® N) have been identified, all of which are reported to be safe in pregnancy. CONCLUSION: The quality of the evidence varied considerably and only hygiene measures were supported by evidence to be recommended in practice. Future work needs to concentrate on strengthening the evidence base through improved design and reporting of studies with a focus on immunisation, ascorbic acid and Canephron® N.

The Role of Attachment in Body Weight and Weight Loss in Bariatric Patients.

PURPOSE: The aim of this study is to explore the role of attachment styles in obesity. MATERIAL AND METHODS: The present study explored differences in insecure attachment styles between an obese sample waiting for bariatric surgery (n = 195) and an age, sex and height matched normal weight control group (n = 195). It then explored the role of attachment styles in predicting change in BMI 1 year post bariatric surgery (n = 143). RESULTS: The bariatric group reported significantly higher levels of anxious attachment and lower levels of avoidant attachment than the control non-obese group. Baseline attachment styles did not, however, predict change in BMI post surgery. CONCLUSION: Attachment style is different in those that are already obese from those who are not. Attachment was not related to weight loss post surgery.

Gaining weight after taking orlistat: A qualitative study of patients at 18-months follow-up.

Orlistat is currently the only prescribed form of pharmacological management for obesity and functions by reducing the amount of fat absorbed from food eaten. Although frequently prescribed, there is marked variability in outcomes. A total of 10 participants' experiences of gaining weight after taking orlistat were analysed using thematic analysis. Participants attributed their failed weight loss to mechanisms of the medication, emphasised a medical model of obesity with barriers to their weight loss and other weight-loss methods which had also failed. Overall, their weight gain was considered an inevitable part of their self-identity, reflecting their self-fulfilling prophecy of being a perpetual dieter.

A randomised control trial assessing the impact of an investment based intervention on weight-loss, beliefs and behaviour after bariatric surgery: study protocol.

BACKGROUND: Although obesity surgery is currently the most effective method for achieving weight loss, not all patients lose the desired amount of weight and some show weight regain. Previous research shows that successful weight loss may be associated with the amount of investment the patient feels that they have made in their operation. For example, those who feel that it has taken more time and effort to organise, has cost more money, has been more disruptive to their lives and has caused pain are more likely to lose weight after their operation. Therefore, it seems as if the greater the sense of investment, the greater the motivation to make the operation a success. The present study aims to build on these findings by encouraging weight loss surgery patients to focus on the investment they have made, thus making their investment more salient to them and a means to improve weight loss outcomes. METHODS: The study involves an open randomised parallel group control trial with patients allocated either to the control or investment intervention group. Using third party blinded randomization, half the patients will be asked to rate and describe the investment they have made in their operation just before surgery then 3 and 6 months after surgery. All patients will record their weight, beliefs about food, intentions to change and actual eating and exercise behaviour at baseline then 3, 6 and 12 months follow up. Patients will be recruited from the bariatric surgery pre-assessment clinic at University College Hospital, London. The primary outcome is to explore the impact of the investment based intervention on patient's weight and BMI, with secondary outcomes of patients' beliefs about foods, behavioural intentions and diet and exercise behaviours. DISCUSSION: It is predicted that the investment intervention will improve excess weight loss post-surgery, together with beliefs about food, intentions to change and actual change in diet and exercise behaviour. This has cost implications for the NHS and other healthcare providers as improved effectiveness of bariatric surgery reduces the health costs of obese patients in the longer term and this simple, easy to administer and low cost intervention could become routine practice for bariatric patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02045628; December 2, 2013.

The impact of psychological support on weight loss post weight loss surgery: a randomised control trial.

BACKGROUND: The purpose of the present study is to evaluate the impact of a health psychology-led bariatric rehabilitation service (BRS) on patient weight loss following bariatric surgery at 1 year. METHODS: A single-site open-randomised parallel group control trial based at St. Richard's Hospital in Chichester in the UK. Patients (n = 162) were recruited immediately prior to Roux-en-Y gastric bypass and randomly allocated to receive either treatment as usual (n = 80) or the BRS (n = 82). The BRS involved three 50-min one-to-one sessions with a health psychologist and provided information, support and mentoring pre and post surgery addressing psychological issues such as dietary control, self esteem, coping and emotional eating. Weight loss was assessed at 1 year. The key outcome variable was BMI and change in BMI. RESULTS: Follow-up weight was available for 145 patients. Intention-to-treat analysis (n = 162) using last measured weights showed that mean change in BMI by 1 year post surgery was -16.49. There was no significant difference between the two groups (control group = -16.37, 95 % CI = 15.15-17.57; intervention = -16.6, 95 % CI = 15.42-17.81; η p (2) = 0.001). Similarly, explanatory analysis (n = 145) showed a mean change in BMI of -17.17. The difference between the two groups was not significant (control group = -16.9, 95 % CI = 15.78-18.18; intervention = -17.35, 95 % CI = 18.5-16.16; η p (2) = 0.001). CONCLUSIONS: Psychological support pre and post bariatric surgery had no impact on weight loss as measured by BMI and change in BMI by 1 year. It is argued that psychological support should be targeted to patients who start to demonstrate weight regain at a later stage. TRIAL REGISTRATION: ClinicalTrials.gov NCT01264120.

The impact of a bariatric rehabilitation service on weight loss and psychological adjustment--study protocol.

BACKGROUND: Bariatric surgery is currently the most effective form of obesity management for those whose BMI is greater than 40 (or 35 with co morbidities). A minority of patients, however, either do not show the desired loss of excess weight or show weight regain by follow up. Research highlights some of the reasons for this variability, most of which centres on the absence of any psychological support with patients describing how although surgery fixes their body, psychological issues relating to dietary control, self esteem, coping and emotional eating remain neglected.The present study aims to evaluate the impact of a health psychology led bariatric rehabilitation service (BRS) on patient health outcomes. The bariatric rehabilitation service will provide information, support and mentoring pre and post surgery and will address psychological issues such as dietary control, self esteem, coping and emotional eating. The package reflects the rehabilitation services now common place for patients post heart attack and stroke which have been shown to improve patient health outcomes. METHODS/DESIGN: The study is a randomised control trial and patients will be allocated to receive either usual care or the bariatric rehabilitation service pre and post bariatric surgery. Follow up measures of weight loss and psychological issues will be taken at baseline (2 weeks preoperatively), 3, 6 and 12 months postoperatively. The contents of the bariatric service and the follow up measures are based on previous pilot work and have been developed further by the research team working closely with two patient support groups (BOSPA & WLSinfo). This study will take place in St Richard's Hospital in Chichester in the UK. DISCUSSION: It is predicted that a bariatric rehabilitation service will improve weight loss following surgery and will also facilitate changes in other psychological variables such as quality of life, dietary control, self esteem, coping and emotional eating. This also has cost implications for the NHS and other healthcare providers as improved effectiveness of bariatric surgery reduces the health costs of obese patients in the longer term. TRIAL REGISTRATION: ClinicalTrials.gov NCT01264120.

Taking Orlistat: Predicting Weight Loss over 6 Months.

This study explored the predictors of weight loss following orlistat with a focus on both baseline variables and changes in beliefs and behaviours occurring over the course of taking the drug. Patients (n = 566) prescribed orlistat completed a questionnaire at baseline and after 6 months concerning their weight, beliefs and behaviours. By 6 months the majority had lost some weight and showed improvements in diet. Many had also stopped taking the drug and a large minority reported using it flexibly as a lifestyle drug. Those who lost most weight showed a decrease in beliefs in a medical solution, a decrease in unhealthy eating, an increased belief in treatment control and an increased belief that the unpleasant consequences are both due to their eating behaviour and just part of the drug. When taken with fatty food orlistat causes symptoms such as anal leakage and oily stools. These may encourage some patients to focus on the behavioural aspects of their weight problem thus promoting the dietary changes needed for both short and longer term weight loss. When prescribing orlistat, clinicians should encourage patients to see the consequences as an education as a means to promote the effectiveness of this form of medical management.

Informed choice to undergo prenatal screening for thalassemia: a description of written information given to pregnant women in Europe and beyond.

PURPOSE: To investigate whether prenatal screening for thalassemia is presented as a choice, and how the condition is described in written information given to pregnant women in different countries. METHOD: One leaflet from each of seven countries (UK, The Netherlands, Greece, Italy, Israel, India and China) was collected for evaluation. Statements relating to choice and those describing the condition were extracted for analysis. RESULTS: The leaflets varied in length from 26 to 74 sentences (mean: 42). Overall, more sentences were devoted to describing the condition (mean: 5) than to conveying choice (mean: 2). Leaflets from Northern Europe contained the highest proportion of sentences relating to choice, while those from Italy and Israel contained none. The majority of sentences describing thalassemia were classified as negative. The leaflets from China and India contained the highest proportion of negative sentences and the leaflets from the Netherlands and Italy, the lowest. CONCLUSION: For women to make an informed decision they need to be offered a choice and given balanced information regarding the condition for which screening is being offered. The results of this study raise doubts as to the extent to which prenatal services in many countries are facilitating informed choices.

Undergoing prenatal screening for Down's syndrome: presentation of choice and information in Europe and Asia.

To date, studies assessing whether the information given to people about screening tests facilitates informed choices have focussed mainly on the UK, US and Australia. The extent to which written information given in other countries facilitates informed choices is not known. The aim of this study is to describe the presentation of choice and information about Down's syndrome in written information about prenatal screening given to pregnant women in five European and two Asian countries. Leaflets were obtained from clinicians in UK, Netherlands, Spain, Italy, Czech Republic, China and India. Two analyses were conducted. First, all relevant text relating to the choice about undergoing screening was extracted and described. Second, each separate piece of information or statement about the condition being screened for was extracted and then coded as either positive, negative or neutral. Only Down's syndrome was included in the analysis since there was relatively little information about other conditions. There was a strong emphasis on choice and the need for discussion about prenatal screening tests in the leaflets from the UK and Netherlands. The leaflet from the UK gave most information about Down's syndrome and the smallest proportion of negative information. By contrast, the Chinese leaflet did not mention choice and gave the most negative information about Down's syndrome. Leaflets from the other countries were more variable. This variation may reflect cultural differences in attitudes to informed choice or a failure to facilitate informed choice in practice. More detailed studies are needed to explore this further.