A narrative systematic review of factors affecting diabetes prevention in primary care settings.

BACKGROUND: Type 2 diabetes is impacting millions of people globally; however, many future cases can be prevented through lifestyle changes and interventions. Primary care is an important setting for diabetes prevention, for at-risk populations, because it is a patient's primary point of contact with the health care system and professionals can provide lifestyle counselling and support, as well as monitoring health outcomes. These are all essential elements for diabetes prevention for at-risk adults. AIM: To understand the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries. METHODS: For this narrative systematic review, we combined qualitative and quantitative studies of diabetes prevention within a primary care setting for patients at-risk of developing the condition. We used an iterative approach for evidence collection, which included using several databases (MEDLINE, Embase, Pysch info, BNI, SSCI, CINAHL, ASSIA), where we combined diabetes terms with primary care terms. Narrative and thematic synthesis were utilised to identify the prominent themes emerging from the data. RESULTS: A database of 6646 records was screened by the research team, and 18 papers were included. Three major themes were identified in this review. The first theme of context and setting of diabetes progression includes the risk and progression of diabetes, primary care as a setting, and where the responsibility for change is thought to lie. This review also found mixed views on the value of preventative services within primary care. The second theme focused on the various patient factors associated with diabetes prevention such as a patient's motivation to modify their current lifestyle, perceptions and knowledge (or lack thereof) of the impacts of diabetes, lack of follow-up in healthcare settings, and trust in healthcare professionals. The third theme was centred on professional factors impacting on diabetes prevention which included workload, time constraints, resources, self-efficacy and knowledge as well as professionals' perception of patient motivations towards change. CONCLUSION: This review explored the factors influencing diabetes prevention in primary care, and identified the context of prevention, as well as patient and professional factors related to preventative services being offered in primary care. This systematic review complements previous reviews of real-world settings by exploring the significant factors in prevention, and the findings are relevant to academics, policymakers, patients and practitioners interested in understanding the factors associated with the delivery and uptake of diabetes prevention interventions.

Weight management during pregnancy: a systematic review of qualitative evidence.

BACKGROUND: increasing overweight and obesity rates in pregnant women present health risks to mother and unborn infant. OBJECTIVES: to identify barriers and facilitators to implementing and carrying out maternal weight management interventions. SEARCH STRATEGY: searches were carried out in medical, midwifery and nursing databases, augmented by hand searching of midwifery journals. SELECTION CRITERIA: articles were included that were published in the UK after 1990, with a focus on women's and health professional's views about weight management during pregnancy. DATA COLLECTION AND ANALYSIS: from 6423 citations, 126 full text papers were retrieved. Of these, 18 (reporting 17 studies) fulfilled the inclusion criteria. Included papers were assessed for quality. Reported findings were analysed and synthesised using thematic analysis. MAIN RESULTS: a major theme was access to relevant and appropriate information; advice was reported as vague or inadequate. Overweight or obese women reported feelings of stigmatisation during routine examinations. Health professionals reported a reluctance to discuss weight with larger women. Perceived risk to the fetus as well as changes in women's physiological responses to pregnancy, were reported barriers to optimal physical activity and dietary intake. Perceptions of control were related to women's feelings about their body image. CONCLUSION: evidence suggests that the complexity of interactions with advice sources, bodily changes, feelings of control, as well as perceived risks may explain the relative ineffectiveness of weight management interventions during pregnancy. Focusing on healthy diet and physical activity levels may be more useful and less stigmatising than focusing on weight.

A systematic review of contextual factors relating to smokeless tobacco use among South Asian users in England.

INTRODUCTION: Certain types of smokeless tobacco (ST) are popular among some people of South Asian origin in England; however, little is known about the contextual factors surrounding use in this population. This systematic review explores the factors associated with ST use among people of South Asian origin in England. METHODS: An iterative search strategy in targeted databases and grey literature sources was conducted in the summer of 2011. Data extractions and quality assessments were completed and verified by two reviewers, and results were presented as a narrative. RESULTS: A total of 2,968 references were screened by two reviewers who agreed on the inclusion of 14 studies. ST use is more prevalent among older participants who may have started chewing in India; however, the evidence suggests that some younger English-born South Asians are using ST as well. Reasons for chewing included the use of these products in times of stress, boredom or simply to relax. Traditional health messages and prior held beliefs may lead them to chew these products because of misconceptions about their health benefits, since very few people were aware of the health risks. Many expressed a desire to quit, however found it difficult to go without ST. CONCLUSION: This review examines the complex factors that underpin and influence ST use among South Asians in England with the potential of informing targeted interventions and health policy.

A pilot study to identify areas for further improvements in patient and public involvement in health technology assessments for medicines.

BACKGROUND: Patient and public participation in health technology assessment (HTA) of medicines has been cited as an important component of the decision-making structure; however, how to actually achieve meaningful involvement is less understood. OBJECTIVES: Our objectives were to conduct a pilot study to form the basis of future research and to gain insight into how to practically and meaningfully advance patient and public input in HTAs for medicines. METHODS: Semi-structured interviews (n = 13) with informants in Australia (n = 7), Canada (n = 3), and the UK (n = 3) were conducted across agencies and experts (n = 9), as well as patient and advocacy groups (n = 4). RESULTS: This pilot study identified through structured interviews three areas for further consideration. Advancement area 1 indicates that industry could help bring the patient perspective into the HTA process through incorporating patient experiences early in the drug development process and by including qualitative research on patient experiences in HTA dossiers. Advancement area 2 involves recognizing and supporting the role of patient advocacy groups, and making use of their access to the genuine patient perspective and experience of living with the condition in question. Finally, advancement area 3 is the continuous development of HTA systems and processes to better facilitate involvement, increasing transparency and feedback, exploring new options for reaching patients, and focusing on creating an active and informed health consumer. CONCLUSIONS: The HTA process is becoming increasingly transparent to patients and the public; however, more effort is required to fully engage patients in the decision-making processes for medicine HTAs. This pilot study identified three key areas for further advancement in this field, and recognized a need for further research in the areas of measuring the impact of patient engagement on decision making in medicine HTAs, as well as the best methods to better prepare patient advocacy groups through HTA education and training. These research recommendations will form the basis of a future study with a larger, more comprehensive sample.

Understanding patient perceptions following a psycho-educational intervention for psychogenic non-epileptic seizures.

This study formed part of an evaluation of a brief educational intervention for patients with psychogenic non-epileptic seizures (PNES). The sessions provide information, seizure control techniques and management planning. The qualitative component of the research reported here aimed to provide insight into the participants' perceptions following the intervention. Semi-structured interviews were conducted with twelve patients. Interviews were tape-recorded, transcribed and analyzed, using principles of thematic analysis. Six key themes were identified: getting answers; understanding the link with emotions; seeking a physiological explanation; doubting the diagnosis; the role of medication; and finding a way forward. The findings highlight considerable individual variation in response, with evidence of changed perceptions or enhanced understanding in some patients while others continued to seek answers or explanations about the cause of their seizures. There were no clear links between reported improved understanding or acceptance of the diagnosis and a perceived improvement in the condition.

Behavioural interventions for weight management in pregnancy: a systematic review of quantitative and qualitative data.

BACKGROUND: There is a rising prevalence of excessive weight gain in pregnancy and an increasing number of pregnant women who are overweight or obese at the start of the pregnancy. Excessive weight gain during pregnancy is associated with adverse maternal and neonatal consequences and increases the risk of long-term obesity. Pregnancy therefore may be a key time to prevent excessive weight gain and improve the health of women and their unborn child. This systematic review sought to assess the effectiveness of behavioural interventions to prevent excessive weight gain in pregnancy and explore the factors that influence intervention effectiveness. METHODS: We undertook a systematic review of quantitative and qualitative evidence. This included a meta-analysis of controlled trials of diet and physical activity interventions to prevent excessive weight gain during pregnancy and a thematic synthesis of qualitative studies that investigated the views of women on weight management during pregnancy. A thorough search of eleven electronic bibliographic databases, reference lists of included studies, relevant review articles and experts in the field were contacted to identify potentially relevant studies.Two independent reviewers extracted data. RevMan software was used to perform the meta-analyses. Qualitative data was subject to thematic analysis. Both quantitative and qualitative data were aligned using a matrix framework. RESULTS: Five controlled trials and eight qualitative studies were included. The overall pooled effect size found no significant difference in gestational weight gain amongst participants in the intervention group compared with the control group (mean difference -0.28 95% CI -0.64 to 0.09). The study designs, participants and interventions all varied markedly and there was significant heterogeneity within this comparison in the meta-analysis (I2 67%). Subgroup and sensitivity analysis did not identify contextual elements that influenced the effectiveness of the intervention.In a thematic analysis of the qualitative studies, three major themes emerged relating to women's views of weight management in pregnancy: pregnancy as a time of transition and change, conflicting and contradictory messages and a perceived lack of control. When the results of both quantitative and qualitative data were aligned it was clear that some of the barriers that women described in achieving healthy weight gain in pregnancy were not addressed by the interventions evaluated. This may have contributed to the limited effectiveness of the interventions. CONCLUSIONS: Despite intense and often tailored interventions there was no statistically significant effect on weight gain during pregnancy. Inadequate and often contradictory information regarding healthy weight management was reported by women in qualitative studies and this was addressed in the interventions but this in itself was insufficient to lead to reduced weight gain. Multiple types of interventions, including community based strategies are needed to address this complex health problem.

The effectiveness of interventions to establish smoke-free homes in pregnancy and in the neonatal period: a systematic review.

This review considers the effectiveness of interventions to encourage the establishment of smoke-free homes during pregnancy and the neonatal period. A comprehensive search of the literature was undertaken to find relevant studies via electronic databases, citations and reference lists of included studies. The searches identified 17 papers that met the inclusion criteria. These were quality assessed and data extracted. Due to heterogeneity of the papers, a narrative synthesis was completed. Interventions were categorized in terms of those based on counselling, counselling plus additional elements, individually adapted programmes and motivational interviewing. The findings suggest inconclusive evidence relating to these intervention types, with a range of outcome measures reported. There were limitations throughout the papers in terms of study quality (especially sample size) and poor reporting of results in relation to effectiveness. The review was limited by its very specific population; however, it suggests that currently there is mixed evidence for the effectiveness of interventions to reduce parental environmental tobacco smoke in early infancy.

Factors relating to the uptake of interventions for smoking cessation among pregnant women: a systematic review and qualitative synthesis.

INTRODUCTION: The review had the aim of investigating factors enabling or discouraging the uptake of smoking cessation services by pregnant women smokers. METHODS: The literature was searched for papers relating to the delivery of services to pregnant or recently pregnant women who smoke. No restrictions were placed on study design. A qualitative synthesis strategy was adopted to analyze the included papers. RESULTS: Analysis and synthesis of the 23 included papers suggested 10 aspects of service delivery that may have an influence on the uptake of interventions. These were whether or not the subject of smoking is broached by a health professional, the content of advice and information provided, the manner of communication, having service protocols, follow-up discussion, staff confidence in their skills, the impact of time and resource constraints, staff perceptions of ineffectiveness, differences between professionals, and obstacles to accessing interventions. DISCUSSION: The findings suggest variation in practice between services and different professional groups, in particular regarding the recommendation of quitting smoking versus cutting down but also in regard to procedural aspects, such as recording status and repeat advice giving. These differences offer the potential for a pregnant woman to receive contradicting advice. The review suggests a need for greater training in this area and the greater use of protocols, with evidence of a perception of ineffectiveness/pessimism toward intervention among some service providers.