Development of a group-based behaviour change intervention for people with severe obesity informed by the social identity approach to health.

INTRODUCTION: Interventions to support behaviour change in people living with chronic health conditions increasingly use patient groups as the mode of delivery, but these are often designed without consideration of the group processes that can shape intervention outcomes. This article outlines a new approach to designing group-based behaviour change interventions that prioritizes recipients' shared social identity as group members in facilitating the adoption of established behaviour change techniques (BCTs). The approach is illustrated through an example drawn from research focused on people living with severe obesity. METHODS: A prioritization process was undertaken in collaboration with stakeholders, including behaviour change experts, clinicians, and a former patient to develop an evidence-based, group intervention informed by the social identity approach to health. Three phases of development are reported: (1) identification of the health problem; (2) delineation of intervention mechanisms and operationalization of BCTs for group delivery and (3) intervention manualization. The fourth phase, intervention testing and optimization, is reported elsewhere. RESULTS: A group-based behaviour change intervention was developed, consisting of 12 group sessions and 3 one-to-one consultations. The intervention aimed to support the development of shared social identity among recipients, alongside the delivery of evidence-based BCTs, to improve the likelihood of successful intervention and health outcomes among people living with severe obesity. CONCLUSIONS: A manualized intervention, informed by the social identity approach to health, was systematically designed with input from stakeholders. The development approach employed can inform the design of behavioural interventions in other health contexts where group-based delivery is planned.

A Qualitative Exploration of Patient and Staff Experiences of the Receipt and Delivery of Specialist Weight Management Services in the UK.

BACKGROUND: Addressing the increasing prevalence of obesity is a global public health priority. Severe obesity (body mass index > 40) reduces life expectancy, due to its association with people developing complications (e.g. diabetes, cancer, cardiovascular disease), and greatly impairs quality of life. The National Health Service (NHS) in the UK provides specialist weight management services (SWMS) for people with severe obesity, but key uncertainties remain around patient access to and engagement with weight management services, as well as pathways beyond the service. METHODS: In this multiple methods study, using online forum data and semi-structured interviews, stakeholders' experiences of delivering and receiving SWMS were explored. Using the web search engine Google with keywords and web address (URL) identifiers, relevant public online platforms were sourced with snowball sampling and search strings used to identify threads related to people's experiences of accessing SWMS (n = 57). Interviews were conducted with 24 participants (nine patients, 15 staff), and data from all sources were analysed thematically using the framework approach. RESULTS: Six themes related to access to and engagement with SWMS emerged during data analysis: (1) making the first move, (2) uncertainty and confusion, (3) resource issues, (4) respect and understanding, (5) mode of delivery, and (6) desire for ongoing support. CONCLUSION: There is a mixed and varied picture of SWMS provision across the UK. The service offered is based on local clinical decision making and available resources, resulting in a range of patient experiences and perspectives. Whilst service capacity issues and patient anxiety were seen as barriers to accessing care, peer support and positive clinical and group interactions (connectedness between individuals) were considered to increase engagement.

"A disembodied voice over the telephone": a qualitative study of healthcare practitioners' experiences in geriatric medicine.

OBJECTIVES: This study explored the experience of delivering care remotely among practitioners in a UK geriatric medicine clinic. METHODS: Nine semi-structured interviews were conducted with consultants (n = 5), nurses (n = 2), a speech and language and an occupational therapist, and thematically analysed. RESULTS: Four themes developed; Challenges of remote consultations; Perceived advantages of remote consultations; Disruption of involvement of family members; Impact on care staff. Participants felt that rapport and trust had been more feasible to develop remotely than they had anticipated, although this was more challenging for new patients and those with cognitive or sensory impairments. While practitioners identified advantages of remote consultations, including involving relatives, saving time, and reducing anxiety, they also experienced disadvantages such as consultations feeling like a 'production line', missing visual cues and reduced privacy. Some participants felt their professional identity was threatened by the lack of face-to-face contact, linked to feeling that remote consultations are not suitable for frail older adults or those with cognitive deficits. DISCUSSION: Staff perceived barriers to remote consultations that went beyond practical concerns, and suggest support for building rapport, involving families, and protecting clinician identity and job satisfaction may be warranted.

A group-based behavioural intervention for weight management (PROGROUP) versus usual care in adults with severe obesity: a feasibility randomised controlled trial protocol.

BACKGROUND: Approximately 15 million people in the UK live with obesity, around 5 million of whom have severe obesity (body mass index (BMI) ≥35kg/m2). Having severe obesity markedly compromises health, well-being and quality of life, and substantially reduces life expectancy. These adverse outcomes are prevented or ameliorated by weight loss, for which sustained behavioural change is the cornerstone of treatment. Although NHS specialist 'Tier 3' Weight Management Services (T3WMS) support people with severe obesity, using individual and group-based treatment, the current evidence on optimal intervention design and outcomes is limited. Due to heterogeneity of severe obesity, there is a need to tailor treatment to address individual needs. Despite this heterogeneity, there are good reasons to suspect that a structured group-based behavioural intervention may be more effective and cost-effective for the treatment of severe obesity compared to usual care. The aims of this study are to test the feasibility of establishing and delivering a multi-centre randomised controlled clinical trial to compare a group-based behavioural intervention versus usual care in people with severe obesity. METHODS: This feasibility randomised controlled study is a partially clustered multi-centre trial of PROGROUP (a novel group-based behavioural intervention) versus usual care. Adults ≥18 years of age who have been newly referred to and accepted by NHS T3WMS will be eligible if they have a BMI ≥40, or ≥35 kg/m2 with comorbidity, are suitable for group-based care and are willing to be randomised. Exclusion criteria are participation in another weight management study, planned bariatric surgery during the trial, and unwillingness or inability to attend group sessions. Outcome assessors will be blinded to treatment allocation and success of blinding will be evaluated. Clinical measures will be collected at baseline, 6 and 12 months post-randomisation. Secondary outcome measures will be self-reported and collected remotely. Process and economic evaluations will be conducted. DISCUSSION: This randomised feasibility study has been designed to test all the required research procedures and additionally explore three key issues; the feasibility of implementing a complex trial at participating NHS T3WMS, training the multidisciplinary healthcare teams in a standard intervention, and the acceptability of a group intervention for these particularly complex patients. TRIAL REGISTRATION: ISRCTN number 22088800.

"I think we need to empower people to manage it better themselves": A qualitative interview study exploring UK healthcare practitioners' perspectives on treating young adults following a sport-related knee injury.

OBJECTIVES: To elicit healthcare practitioners' views on treatment following sport-related knee injury in young adults (18-35) and the potential for individuals to self-manage joint health. DESIGN: Semi-structured interviews were audio-recorded, transcribed and analysed systematically using an inductive approach. SETTING: South West UK. PARTICIPANTS: Twelve healthcare practitioners with experience of treating young adults. MAIN OUTCOME MEASURES: Understanding how healthcare practitioners treat young adults following knee injury and to what extent individuals may be able to self-manage knee health. RESULTS: Participants' perceptions were encapsulated in three consistent themes: [1] Treating patients; [2] Maintaining physical activity; and [3] Education and support. All participants described how staying physically active and maintaining a healthy weight were integral to conserving knee health, and that post-injury education was necessary to "empower" patients to self-manage knee health. A need for greater access to support, advice and guidance for patients was also articulated. CONCLUSIONS: Healthcare practitioners should tailor their treatment to young adults to account for individual characteristics, aspirations for sport and exercise participation, and their emotional wellbeing. Fulfilment of individuals' educational and supportive needs is key to the establishment of self-management behaviours that may help to conserve knee health.

Nobody says to you "come back in six months and we'll see how you're doing": a qualitative interview study exploring young adults' experiences of sport-related knee injury.

BACKGROUND: Regular exercise is vital for overall health, and key to the maintenance of joint health. However, whilst people are encouraged to participate in sport and exercise, many are unaware that they could be at risk of developing post-traumatic osteoarthritis (PTOA) in the years following sport-related injury. Younger adults (< 40 years) with PTOA can experience declining quality of life, comorbid health conditions, and symptoms that place a chronic burden on health services. Conserving knee health through careful self-management in the latency period between injury and the onset of PTOA may help to delay disease progression. In this regard, the development of self-management interventions can be facilitated by understanding the post-injury experiences of young adults and their attitudes towards joint health. METHODS: Semi-structured interviews were conducted with 13 young adults following a sport-related knee injury to explore their experiences of injury, and their attitudes and perceptions of self-managing knee health. The interviews were audio-recorded, transcribed and analysed systematically using an inductive approach. RESULTS: Four themes pertaining to participants' experiences were identified: [1] perceptions of current care provision; [2] long-term impact of knee injury; [3] motivation to conserve knee health; and [4] opportunities for supplementary support. The expression "Nobody says to you 'come back in six months and we'll see how you're doing'" personifies the long-term impact of knee injury on young adults and a paucity of care provision. CONCLUSION: Participants did not perceive that they had adequate care in the aftermath of knee injury, leading to a sense of frustration and uncertainty. This had implications for continued participation in sport and exercise, negatively impacting their athletic identity and sense of wellbeing. Activity tracking, symptom monitoring, advice provision and peer support were identified as tools to enable individuals to self-manage knee health.

Eating well in care homes: Testing the feasibility of a staff training programme aimed at improving social interaction and choice at mealtimes.

BACKGROUND: The health and well-being of care home residents are influenced by their experience of mealtimes, which provide an opportunity for residents to socialise and exercise control over their lives, as well as providing essential sustenance. Care home staff are pivotal to this experience, responsible for the provision of meals and eating assistance, but also for establishing a positive mealtime culture valued by residents. Despite this, mealtimes can be task-focussed, as the pressure on staff to perform multiple duties in limited time, or a lack of knowledge and awareness, means that resident needs and preferences risk being neglected. METHODS: A staff-focussed training programme aimed at improving social interaction, and resident choice was developed and delivered in a workshop. Intervention feasibility was assessed using a qualitative survey and workshop observations. A combination of descriptive and content analyses was conducted on the data. RESULTS: Thirteen women and one man took part in the workshops, representing multiple roles within two homes in the South West UK. The workshops were found to be deliverable and practicable. Participants responded positively to the workshops, anticipating that improvements to the mealtime experience would result from their workshop outputs. CONCLUSION: This study suggests that staff training workshops based on improving the mealtime experience are feasible to deliver within the day-to-day running of a care home and are acceptable to staff. Positive changes resulting from these workshops could improve the health and well-being of residents. IMPLICATIONS FOR PRACTICE: Mealtimes in care homes may be improved by increasing social interaction and by providing residents with greater choice. Management-faciltated staff training may be a useful tool to encourage staff to reflect on current practice and develop their own strategies to improve the mealtime experience for residents.

How does the public conceptualise the quality of care and its measurement in community pharmacies in the UK: a qualitative interview study.

OBJECTIVES: This study explored citizens' perspectives about the quality of community pharmacy services in the UK and whether and how the quality of community pharmacy services should be measured. DESIGN: Semistructured interviews and focus groups were conducted and were audio recorded, transcribed and analysed systematically using an interpretive approach. PARTICIPANTS: Members of the public were approached via networks, such as Health and Social Care Alliance Scotland, as well as community groups and personal networks. SETTING: Scotland, England and Wales. RESULTS: Data were collected from 20 participants: 11 interviews and 2 focus groups (in community settings, with five and four participants). Quality was conceptualised as multidimensional with inter-related overarching themes of person-centredness, professionalism and privacy. The importance of relational aspects with pharmacy personnel was emphasised including the need for a 'friendly' caring service, continuity of care, being known to personnel, including their awareness of individual's health conditions: 'it's quite a personal service I would say…I think it means that they care about your welfare'. Participants discussed the importance of a professional approach to customer interactions including staff behaviour and appearance. Pharmacy design influenced perceptions of privacy, including having sufficient space or a separate consultation room to promote confidential consultations with a pharmacist. Participants suggested that quality assurance is needed to improve quality and to inspire confidence in the public 'it would drive up quality standards overall' but suggested that quality ratings were unlikely to influence their use of specific pharmacies. They emphasised the need for multidimensional quality ratings and for transparency with their derivation. CONCLUSIONS: The public conceptualises quality of community pharmacy services as multidimensional and value relational aspects of care provided by personnel in this setting. While the development and application of quality indicators may drive improvement, it seems unlikely to influence the public's use of individual pharmacies.

Stakeholders perspectives on the key components of community-based interventions coordinating care in dementia: a qualitative systematic review.

BACKGROUND: Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to investigate the views of stakeholders on the key components of community-based interventions coordinating care in dementia. METHODS: We searched four databases from inception to June 2015; Medline, The Cochrane Library, EMBASE and PsycINFO, this was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted thematic synthesis on extracted data. RESULTS: A total of seven papers from five independent studies were included in the review, and encompassed the views of over 100 participants from three countries. Through thematic synthesis we identified 32 initial codes that were grouped into 5 second-order themes: (1) case manager had four associated codes and described preferences for the case manager personal and professional attributes, including a sound knowledge in dementia and availability of local services; (2) communication had five associated codes and emphasized the importance stakeholders placed on multichannel communication with service users, as well as between multidisciplinary teams and across organisations; (3) intervention had 11 associated codes which focused primarily on the practicalities of implementation such as the contact type and frequency between case managers and service users, and the importance of case manager training and service evaluation; (4) resources had five associated codes which outlined stakeholder views on the required resources for coordinating interventions and potential overlap with existing resources, as well as arising issues when available resources do not meet those required for successful implementation; and (5) support had seven associated codes that reflect the importance that was placed on the support network around the case manager and the investment of professionals involved directly in care as well as the wider professional network. CONCLUSION: The synthesis of relevant qualitative studies has shown how various stakeholder groups considered dementia care coordination interventions to be acceptable, useful and appropriate for dementia care, and have clear preferences for components, implementation methods and settings of these interventions. By incorporating stakeholders' perspectives and preferences when planning and developing coordinating interventions we may increase the likelihood of successful implementation and patient benefits.

The effectiveness of community-based coordinating interventions in dementia care: a meta-analysis and subgroup analysis of intervention components.

BACKGROUND: Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to evaluate the effectiveness of community-based care coordinating interventions on health outcomes and investigate whether specific components of interventions influence their effects. METHODS: We searched four databases from inception to April 2017: Medline, The Cochrane Library, EMBASE and PsycINFO. This was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted meta-analyses and subgroup analyses. RESULTS: A total of 14 randomised controlled trials (RCTs) involving 10,372 participants were included in the review. Altogether we carried out 12 meta-analyses and 19 subgroup analyses. Meta-analyses found coordinating interventions showed a statistically significant improvement in both patient behaviour measured using the Neuropsychiatric Inventory (NPI) (mean difference (MD) = -9.5; 95% confidence interval (CI): -18.1 to -1.0; p = 0.03; number of studies (n) = 4; I2 = 88%) and caregiver burden (standardised mean difference (SMD) = -0.54; 95% CI: -1.01 to -0.07; p = 0.02; n = 5, I2 = 92%) compared to the control group. Subgroup analyses found interventions using a case manager with a nursing background showed a greater positive effect on caregiver quality of life than those that used case managers from other professional backgrounds (SMD = 0.94 versus 0.03, respectively; p < 0.001). Interventions that did not provide supervision for the case managers showed greater effectiveness for reducing the percentage of patients that are institutionalised compared to those that provided supervision (odds ratio (OR) = 0.27 versus 0.96 respectively; p = 0.02). There was little evidence of effects on other outcomes, or that other intervention components modify the intervention effects. CONCLUSION: Results show that coordinating interventions in dementia care has a positive impact on some outcomes, namely patient behaviour and caregiver burden, but the evidence is inconsistent and results were not strong enough to draw definitive conclusions on general effectiveness. With the rising prevalence of dementia, effective complex interventions will be necessary to provide high quality and effective care for patients, and facilitate collaboration of health, social and third sector services.

Exploring residents' experiences of mealtimes in care homes: A qualitative interview study.

BACKGROUND: Many interventions aim to alleviate well-documented problems of malnutrition in residential care homes and improve residents' health and wellbeing. Despite some positive findings, little is known about how and why mealtime interventions might be effective, and in particular, what effects residents' experiences of mealtimes have on health outcomes. The aim of this study was to gain an insight into these experiences and explore some of the issues that may impact on residents' enjoyment of meals, and resulting health and wellbeing. METHODS: Semi-structured interviews were conducted with eleven residents from four care homes in the South West UK. Thematic analysis was used to derive content and meaning from transcribed interviews. Interviews were supplemented by researcher observations of mealtimes. RESULTS: The dining experience was a focal point for participants' broader experiences of residing in a care home. Three themes pertaining to residents' experiences were identified: (1) Emotional and psychological connections with other residents; (2) managing competing interests with limited resources; and (3) familiarity and routine. CONCLUSION: Mealtimes are a mainstay of life in a care home through which residents' experiences are characterised, exemplified and magnified. Understanding how residents interact with one another, accommodating their preferences and encouraging autonomy may enhance their mealtime experiences. It may also help to ease the transition from independent-living to life in care, which can be particularly stressful for some residents, and improve health and wellbeing over the long-term.

Attitudes, perceptions and experiences of mealtimes among residents and staff in care homes for older adults: A systematic review of the qualitative literature.

Addressing problems associated with malnutrition in care home residents has been prioritized by researchers and decision-makers. This review aimed to better understand factors that may contribute to malnutrition by examining the attitudes, perceptions and experiences of mealtimes among care home residents and staff. Five databases were searched from inception to November 2015: Medline, Embase, PsychINFO, AMED, and the Cochrane Database. Forward and backward citation checking of included articles was conducted. Titles, abstracts, and full texts were screened independently by two reviewers and quality was assessed using the Wallace criteria. Thematic analysis of extracted data was undertaken. Fifteen studies were included in the review, encompassing the views and opinions of a total of 580 participants set in nine different countries. Four main themes were identified: (1) organizational and staff support, (2) resident agency, (3) mealtime culture, and (4) meal quality and enjoyment. Organizational and staff support was an over-arching theme, impacting all aspects of the mealtime experience. Mealtimes are a pivotal part of care home life, providing structure to the day and generating opportunities for conversation and companionship. Enhancing the mealtime experience for care home residents needs to take account of the complex needs of residents while also creating an environment in which individual care can be provided in a communal setting. PROSPERO Registration: CRD42015025890.

Characteristics of high- and low-vigor lodgepole pine trees in old-growth stands.

Lodgepole pine (Pinus contorta var. latifolia Engelm.) trees in an old stand differed widely in appearance. Some appeared healthy, with deep crowns, high leaf areas, nearly conical-shaped crown tops, and branches with live needles extending well back from the tip. Others with similar-sized boles appeared to be in a state of decline, having much shallower crowns, lower leaf areas, crowns that were flattened at the top, and "tufted" branches with needles only near the ends of the branches. Ten trees, five each in these two apparent vigor classes, were selected from a one-hectare area of a mature stand. Trees in the two groups were found to have similar height, diameter at breast height, age, and total volume. As expected from the selection criteria, high-vigor trees had much deeper crowns (P = 0.01) and higher leaf areas (P = 0.10). The volume of heartwood in the bole was higher in the low-vigor trees (P = 0.08), and the volume of the sapwood was higher in the high-vigor trees (P = 0.13). Sapwood and heartwood ages were similar in both classes. This suggests that, in earlier years, low-vigor trees reached a larger volume, represented by the present heartwood, than did the high-vigor trees (i.e., the current vigor rankings are the reverse of what they had been). The ratio of sapwood volume to total leaf area was not significantly higher in the low-vigor trees (P = 0.24), although this ratio varied tenfold among the data. Results suggest that a physiological basis for assessing vigor involving leaf area, sapwood, heartwood, age, and incremental growth data would identify a continuum of response from high- to low-vigor trees rather than discrete groups based on visual appearance.