A dietitian-led low-FODMAP diet webinar: a pre-post study evaluating its impact on symptoms of irritable bowel syndrome.

BACKGROUND: Evidence suggests that the low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet improves irritable bowel syndrome (IBS) symptoms when delivered by a dietitian. However, demand for dietetic appointments exceeds supply. Prerecorded webinars are acceptable and cost-effective for delivering first-line IBS dietary advice. METHODOLOGY: This study, using a pre-post design, aimed to evaluate the effectiveness of a low-FODMAP diet restriction phase webinar at improving IBS symptoms. Participants with self-reported IBS symptoms were asked to report their IBS symptoms, stool frequency, stool consistency and IBS medication use, before and 8 weeks postwebinar via an online questionnaire. The presence and severity of participants' symptoms and bowel habits were captured using validated tools and a global symptom question. RESULTS: In total 228 participants responded to both pre- and postsurveys. A statistically significant improvement in all symptoms was observed 8 weeks postwebinar (p < 0.05). The proportion of participants rating their overall symptoms as moderate-to-severe reduced from 85.5% at baseline to 34.6% postwebinar (50.9% reduction [p < 0.001]). The proportion of participants reporting normal stool consistency and frequency significantly increased postwebinar (23.2%-39.9% [p < 0.001] and 76.3%-89% [p < 0.001], respectively). Satisfactory relief of symptoms increased from 16.7% to 53.1%, (p < 0.001) 8 weeks postwebinar. CONCLUSIONS: These results are comparable with literature on the efficacy of face-to-face delivery of low-FODMAP diet education. Dietitians should consider directing triaged patients with IBS, who have tried first-line dietary advice, to this webinar as an alternative or alongside current practice.

Improving adult behavioural weight management services for diverse UK Black Caribbean and Black African ethnic groups: a qualitative study of insights from potential service users and service providers.

Background: A significantly higher proportion of UK Black ethnic adults live with overweight or obesity, compared to their White British counterparts. The role of obesity in excess infection rates and mortality from COVID-19 has increased the need to understand if weight management interventions are appropriate and effective for Black ethnic groups. There is a paucity of existing research on weight management services in Black populations, and whether anticipated or experienced institutional and interpersonal racism in the healthcare and more widely affects engagement in these services. Understanding the lived experience of target populations and views of service providers delivering programmes is essential for timely service improvement. Methods: A qualitative study using semi-structured interviews was conducted in June-October 2021 among 18 Black African and Black Caribbean men and women interested in losing weight and 10 weight management service providers. Results: The results highlighted a positive view of life in the United Kingdom (UK), whether born in the UK or born abroad, but one which was marred by racism. Weight gain was attributed by participants to unhealthy behaviours and the environment, with improving appearance and preventing ill health key motivators for weight loss. Participants relied on self-help to address their overweight, with the role of primary care in weight management contested as a source of support. Anticipated or previously experienced racism in the health care system and more widely, accounted for some of the lack of engagement with services. Participants and service providers agreed on the lack of relevance of existing services to Black populations, including limited culturally tailored resources. Community based, ethnically matched, and flexibly delivered weight management services were suggested as ideal, and could form the basis of a set of recommendations for research and practice. Conclusion: Cultural tailoring of existing services and new programmes, and cultural competency training are needed. These actions are required within systemic changes, such as interventions to address discrimination. Our qualitative insights form the basis for advancing further work and research to improve existing services to address the weight-related inequality faced by UK Black ethnic groups.

'Health Connections': study protocol for the development of a coproduced, community-based diet, physical activity, and healthy weight intervention for UK black and Asian adults.

INTRODUCTION: A limited number of diet, physical activity and weight management programmes suitable for UK black and Asian populations have been evaluated. We aim to coproduce 'Health Connections'-an ambitious new intervention to support dietary and physical activity choices, and maintaining a healthier weight, tailored to the needs of black Caribbean, black African and South Asian adults. Our existing research and public engagement work suggests that the intervention should be designed to be embedded in communities and delivered by peer educators supported by health professionals. METHODS AND ANALYSIS: The project is underpinned by a systems perspective that posits collective efficacy within communities, behaviour change theory and coproduction. Project activities will be conducted in three stages. Stage 1: semistructured interviews will be conducted with adults from diverse South Asian ethnic groups to understand their experiences, perspectives and intervention needs, adding to our existing data from black ethnic groups. We will synthesise the data, literature, available intervention resources and local practice, and develop the theoretical framework to codevelop intervention goals, programme theory and a draft logic model of change. Stage 2: a theorised list of potential intervention components, session content and mode/s of delivery will be explored in a modified Delphi exercise and workshop to achieve consensus on the intervention format. We will also develop prototype materials and a formal implementation plan. Stage 3: a description of the intervention will be documented. ETHICS AND DISSEMINATION: The study has received ethical approval from the School of Health Research Ethics Committee, Leeds Beckett University. Information on the project aims and voluntary participation is provided in the study participation information sheet. Consent will be certified by the completion and signing of a consent form prior to data collection. Dissemination for a range of stakeholders and audiences will include publications, presentations, short films and an infographic.

Feasibility of a Community Healthy Eating and Cooking Intervention Featuring Traditional African Caribbean Foods from Participant and Staff Perspectives.

Culturally appropriate healthy eating resources are intended to help people from different ethnic backgrounds consume diets reflecting government dietary recommendations, yet evidence on use in the target groups is lacking. This study evaluated the feasibility of a new brief culturally appropriate community intervention that aimed to introduce food-based healthy eating and recipe resources featuring African Caribbean foods, which were recently co-developed with people from these ethnic backgrounds. Working with a community organization in the UK, a single-arm study was used to collect verbal data from participants and staff on the acceptability of intervention whilst knowledge, skills and behaviours related to healthy eating were evaluated using pre-, post- and follow-up questionnaires. A total of 30 participants were recruited, and 22 completed all three questionnaires; who were mostly female aged 55 years+ (n = 17) and of African Caribbean ethnicity (45%, n = 10), with 32% (n = 7) reporting no educational attainment. At post-intervention and follow-up, most participants reported high satisfaction (n = 21, 95%) with the intervention sessions and high levels of confidence in using the resources at home within budget. The number of participants who were familiar with the healthy eating guidance featuring Caribbean foods increased from pre- (36%, n = 8) to post-intervention/follow-up (n = 22, 100%) (p < 0.05). Findings suggest the intervention is feasible in a community setting and could help increase awareness and use of culturally appropriate healthy eating guidance amongst a diverse group.

Comparison of the Effectiveness of Low Carbohydrate Versus Low Fat Diets, in Type 2 Diabetes: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The clinical benefit of low carbohydrate (LC) diets compared with low fat (LF) diets for people with type 2 diabetes (T2D) remains uncertain. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare their efficacy and safety in people with T2D. RCTs comparing both diets in participants with T2D were identified from MEDLINE, Embase, Cochrane Library, and manual search of bibliographies. Mean differences and relative risks with 95% CIs were pooled for measures of glycaemia, cardiometabolic parameters, and adverse events using the following time points: short-term (3 months), intermediate term (6 and 12 months) and long-term (24 months). Twenty-two RCTs comprising 1391 mostly obese participants with T2D were included. At 3 months, a LC vs. LF diet significantly reduced HbA1c levels, mean difference (95% CI) of -0.41% (-0.62, -0.20). LC diet significantly reduced body weight, BMI, fasting insulin and triglycerides and increased total cholesterol and HDL-C levels at the short-to-intermediate term, with a decrease in the requirement for antiglycaemic medications at intermediate-to-long term. There were no significant differences in other parameters and adverse events. Except for reducing HbA1c levels and adiposity parameters at short-to-intermediate terms, a LC diet appears to be equally effective as a LF diet in terms of control of cardiometabolic markers and the risk of adverse events in obese patients with T2D.

Improving Vitamin D Intake in Young Children-Can an Infographic Help Parents and Carers Understand the Recommendations?

Vitamin D deficiency is a serious public health issue in the United Kingdom. Those at increased risk, such as pregnant women, children under 5 years and people from ethnic groups with dark skin, are not all achieving their recommended vitamin D. Effective vitamin D education is warranted. A qualitative study was undertaken to evaluate the acceptability and understanding of a vitamin D infographic, developed using recommendations from previous research. Fifteen parents/carers, recruited through local playgroups and adverts on popular parent websites, participated in focus groups and telephone interviews. The majority were female, White British and educated to degree level. A thematic analysis methodology was applied. The findings indicated that understanding and acceptability of the infographic were satisfactory, but improvements were recommended to aid interpretation and create more accessible information. These included additional content (what vitamin D is; other sources; its health benefits; methods/doses for administration and scientific symbols used) and improved presentation (eye-catching, less text, simpler language, more images and a logo). Once finalized, the infographic could be a useful tool to educate families around vitamin D supplementation guidelines, support the UK Healthy Start vitamins scheme and help improve vitamin D status for pregnant and lactating women and young children.

Nutrient Composition of Popularly Consumed African and Caribbean Foods in The UK.

(1) Background: Traditional foods are important in the diets of Black Africans and Caribbeans and, more widely, influence UK food culture. However, little is known about the nutritional status of these ethnic groups and the nutrient composition of their traditional foods. The aim was to identify and analyse African and Caribbean dishes, snacks and beverages popularly consumed in the UK for energy, macronutrients and micronutrients. (2) Methods: Various approaches including focus group discussions and 24-h dietary recalls were used to identify traditional dishes, snacks, and beverages. Defined criteria were used to prioritise and prepare 33 composite samples for nutrient analysis in a UK accredited laboratory. Quality assurance procedures and data verification were undertaken to ensure inclusion in the UK nutrient database. (3) Results: Energy content ranged from 60 kcal in Malta drink to 619 kcal in the shito sauce. Sucrose levels did not exceed the UK recommendation for adults and children. Most of the dishes contained negligible levels of trans fatty acid. The most abundant minerals were Na, K, Ca, Cu, Mn and Se whereas Mg, P, Fe and Zn were present in small amounts. (4) Conclusion: There was wide variation in the energy, macro- and micronutrients composition of the foods analysed.

Gamma-glutamyltransferase and risk of hypertension: a systematic review and dose-response meta-analysis of prospective evidence.

The objective of this review was to obtain a reliable estimate of the magnitude of the prospective association between gamma-glutamyltransferase (GGT) and risk of hypertension, and to characterize the nature of the dose-response relationship. We conducted a systematic review and dose-response meta-analysis of published prospective studies. Relevant studies were identified in a literature search of MEDLINE, EMBASE, and Web of Science databases up to May 2015. Study-specific relative risks (RRs) were meta-analyzed using random effects models. We examined a potential nonlinear relationship using restricted cubic splines. Of the 612 titles reviewed, we included 14 cohort studies with data on 44 582 participants and 5 270 hypertension cases. In a comparison of extreme thirds of baseline levels of GGT, RR for hypertension in pooled analysis of all 14 studies was 1.32 (95% confidence interval: 1.23-1.43). There was heterogeneity among the studies (P < 0.001), which was to a large part explained by average age of participants at baseline, average duration of follow-up, and the degree of confounder adjustment. In a pooled dose-response analysis of 10 studies with relevant data, there was evidence of a linear association between GGT and hypertension risk (P for nonlinearity = 0.37). The pooled RR of hypertension per 5 U/l increment in GGT levels was 1.08 (95% confidence interval: 1.04-1.13). Baseline circulating GGT level is associated with an increased risk of hypertension in the general population, consistent with a linear dose-response relationship. Further investigation of any potential relevance of GGT in hypertension prevention is warranted.

Association of serum total osteocalcin with type 2 diabetes and intermediate metabolic phenotypes: systematic review and meta-analysis of observational evidence.

Serum total osteocalcin, a marker of bone formation, may regulate glucose metabolism and influence the risk of developing adverse metabolic outcomes. We conducted a systematic review and meta-analysis of published observational evidence, to assess and quantify the associations of serum total osteocalcin with type 2 diabetes and intermediate metabolic phenotypes [e.g., metabolic syndrome (MetS)]. Relevant studies were identified in a literature search of MEDLINE, EMBASE, Web of Science, and reference lists of relevant studies to May 2015. Mean differences and risk estimates (odds ratios or relative risks) with 95% CIs were aggregated using random-effects models. Fifty-two observational (38 cross-sectional, eight cohort, five case-control, and one both cross-sectional and cohort) studies with data on 46,998 non-overlapping participants were included. Baseline serum total osteocalcin levels were significantly lower in type 2 diabetes compared with non-type 2 diabetes and in MetS compared with non-MetS in pooled analysis of cross-sectional evidence. Pooled risk estimates (95% CIs) for type 2 diabetes in a comparison of extreme fourths of total osteocalcin levels were 0.23 (95% CI 0.12, 0.46) and 0.89 (95% CI 0.78, 1.01) for cross-sectional and cohort studies respectively. The corresponding estimate was 0.39 (0.27, 0.56) for MetS from cross-sectional evidence. In both cross-sectional and cohort studies, a unit increase in serum total osteocalcin levels was associated with a significant mean increase in HOMA-B and mean reduction in HbA1c; with significant mean reductions in fasting plasma glucose levels, HOMA-IR, and body mass index in only cross-sectional studies. Available evidence--mainly from cross-sectional studies, supports inverse associations of serum total osteocalcin with risk of adverse metabolic outcomes. Large-scale prospective studies are needed to establish whether serum total osteocalcin may be useful in the prevention of adverse metabolic outcomes such as type 2 diabetes.

Gamma glutamyltransferase, alanine aminotransferase and risk of cancer: systematic review and meta-analysis.

The prospective evidence for the associations of gamma glutamyltransferase (GGT) and alanine aminotransferase (ALT) with risk of cancer in the general population is uncertain. We conducted a systematic review and meta-analysis of published prospective observational studies evaluating the associations of baseline levels of GGT and ALT with risk of overall (incidence and/or mortality) and site-specific cancers. Relevant studies were identified in a literature search of MEDLINE, EMBASE, Web of Science, reference lists of relevant studies to April 2014 and email contact with investigators. Study specific relative risks (RRs) were meta-analyzed using random effects models. Fourteen cohort studies with data on 1.79 million participants and 57,534 cancer outcomes were included. Comparing top versus bottom thirds of baseline circulating GGT levels, pooled RRs (95% confidence intervals) were 1.32 (1.15-1.52) for overall cancer, 1.09 (0.95-1.24) for cancers of the breast and female genital organs, 1.09 (1.02-1.16) for cancers of male genital organs, 1.94 (1.35-2.79) for cancers of digestive organs and 1.33 (0.94-1.89) for cancers of respiratory and intrathoracic organs. For ALT, corresponding RRs for overall cancer were 0.96 (0.94-0.99) and 1.65 (1.52-1.79) in European and Asian populations, respectively. There was an increased risk of cancers of the digestive organs 2.44 (1.23-4.84). The pooled RR for overall cancer per 5 U/L increment in GGT levels was 1.04 (1.03-1.05). Available observational data indicate a positive log-linear association of GGT levels with overall cancer risk. The positive association was generally evident for site-specific cancers. There are geographical variations in the association of ALT and overall cancer.

Liver enzymes and risk of cardiovascular disease in the general population: a meta-analysis of prospective cohort studies.

BACKGROUND: Gamma glutamyltransferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP), commonly used markers of liver dysfunction, have been implicated with risk of cardiovascular disease (CVD). However, the strength and consistency of their associations in the general population have not been reliably quantified. METHODS: We synthesized available prospective epidemiological data on the associations of baseline levels of GGT, ALT, AST, and ALP with CVD [composite CVD, coronary heart disease (CHD), or stroke outcomes]. Relevant studies were identified in a literature search of MEDLINE, EMBASE, and Web of Science up to December 2013. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random effects models. RESULTS: Twenty-nine unique cohort studies with aggregate data on over 1.23 million participants and 20,406 cardiovascular outcomes were included. The pooled fully adjusted RRs (95% CIs) for CVD were 1.23 (1.16-1.29) and 1.08 (1.03-1.14) per 1-standard deviation change in log baseline levels of GGT and ALP levels respectively. There was no evidence of an association of ALT or AST with CVD, however, ALT was somewhat inversely associated with CHD 0.95 (0.90-1.00) and positively associated with stroke 1.01 (1.00-1.02) in stratified analysis. Tests for nonlinearity were suggestive of linear relationships of GGT and ALP levels with CVD risk. CONCLUSIONS: Baseline levels of GGT and ALP are each positively associated with CVD risk and in a log-linear fashion. There may be variations in the associations of ALT with cause-specific cardiovascular endpoints, findings which require further investigation.

Liver enzymes and risk of all-cause mortality in general populations: a systematic review and meta-analysis.

BACKGROUND: Gamma glutamyltransferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP), commonly used as markers of liver dysfunction, have been implicated with risk of all-cause mortality. The prospective evidence on the associations in general populations has not been reliably quantified. METHODS: We conducted a systematic review and meta-analysis of published prospective cohort studies evaluating the associations of baseline levels of these enzymes with all-cause mortality in general populations. Relevant studies were identified in a literature search of MEDLINE, EMBASE and Web of Science up to March 2013. Authors of unpublished studies provided data on request. RESULTS: Nineteen unique cohort studies with aggregate data on over 9.24 million participants and 242 953 all-cause mortality outcomes were included. In a comparison of extreme thirds of baseline GGT and ALP levels, relative risks (RRs) (95% confidence intervals) for all-cause mortality were 1.60 (1.42-1.80) and 1.38 (1.17-1.63), respectively. The corresponding RRs for ALT were 0.82 (0.78-0.86) and 1.43 (1.08-1.90) in North American and Asian populations, respectively. There was no strong evidence of an association of AST with all-cause mortality: RR 1.23 (0.80-1.88). The pooled RRs per 5 U/l increment in GGT and ALP levels were 1.07 (1.04-1.10) and 1.03 (1.01-1.06), respectively. CONCLUSIONS: Available data indicate positive independent associations of baseline levels of GGT and ALP with all-cause mortality, consistent with linear dose-response relationships. There were geographical variations in the association of ALT with all-cause mortality which require further investigation. The potential incremental prognostic values of GGT and ALP in mortality risk assessment need evaluation.

Liver aminotransferases and risk of incident type 2 diabetes: a systematic review and meta-analysis.

We evaluated the associations of liver aminotransferases with risk of type 2 diabetes (T2D) in general populations by conducting a systematic review and meta-analysis of published prospective studies. Studies were identified in a literature search of PubMed, EMBASE, and Web of Science from 1950 through October 2012. Of the 2,729 studies reviewed, 17 studies involving 60,359 participants and 3,890 incident T2D events were included. All of the studies assessed associations between alanine aminotransferase (ALT) level and T2D, with heterogeneous findings (I(2) = 88%, 95% confidence interval (CI): 82, 92; P < 0.001). The pooled fully adjusted relative risk of T2D was 1.26 (95% CI: 1.14, 1.41) per 1-standard-deviation change in log baseline ALT level. This association became nonsignificant after trim-and-fill correction for publication bias. Nine studies evaluated associations between aspartate aminotransferase (AST) levels and T2D risk, with a corresponding relative risk of 1.02 (95% CI: 0.99, 1.04). The relative risk of T2D per 5-IU/L increase in ALT level was 1.16 (95% CI: 1.08, 1.25). Available data indicate moderate associations of ALT with risk of T2D events, which may be attributable to publication bias. There was no evidence for an increased risk of T2D with AST. Large prospective studies may still be needed to establish the magnitude and nature of these associations.

Vitamin D and risk of future hypertension: meta-analysis of 283,537 participants.

The evidence on the association between baseline vitamin D status and risk of incident hypertension in general populations is limited and has not been reliably quantified. We conducted a systematic review and meta-analysis of published prospective studies evaluating the associations of baseline vitamin D status (circulating 25-hydroxyvitamin D [25(OH)D] levels and dietary vitamin D intake) with risk of hypertension. Eligible studies were identified in a literature search of MEDLINE, EMBASE, and Web of Science up to November 2012. Pooled relative risks (RRs) with 95% confidence intervals were calculated using random effects models. Generalized least-squares trend estimation was used to assess dose-response relationships. Of the 2,432 articles reviewed for eligibility, eight unique prospective cohorts with aggregate data on 283,537 non-overlapping participants and 55,816 incident hypertension cases were included. The RRs (95% CIs) for hypertension in a comparison of extreme thirds of baseline levels of vitamin D were 0.70 (0.58, 0.86) for seven studies that measured blood 25(OH) D levels and 1.00 (0.95, 1.05) for four studies that assessed dietary vitamin D intake. The pooled RR of incident hypertension per 10 ng/mL increment in baseline 25(OH)D levels was 0.88 (0.81, 0.97) in dose-response analysis. Evidence was lacking of heterogeneity among studies that measured blood 25(OH) D levels and those that assessed dietary vitamin D status. Studies are needed to determine whether the association of vitamin D with hypertension represents a causal association and also to determine whether vitamin D therapy may be beneficial in the prevention or the treatment of hypertension.

Ferritin levels and risk of type 2 diabetes mellitus: an updated systematic review and meta-analysis of prospective evidence.

BACKGROUND: Emerging evidence suggests that a strong link that exists between elevated baseline body iron stores and high risk of incident type 2 diabetes mellitus (T2DM) in general populations, but the precise magnitude of the associations remains uncertain. METHODS: We conducted a systematic review and meta-analysis of published prospective studies evaluating the associations of baseline ferritin (a biomarker of body iron stores) levels with risk of T2DM in general populations. A subsidiary review of dietary heme iron status and T2DM risk associations was also conducted. Studies were identified in a literature search of PubMed, EMBASE, and Web of Science up to October 2012. RESULTS: Of the 730 studies reviewed for eligibility, 12 published studies involving 185 462 participants and 11 079 incident T2DM events were included in the analyses. Nine studies assessed associations between ferritin levels and T2DM with heterogeneous findings (I(2) = 58%, 12-80%, p = 0.014). The pooled fully adjusted relative risk (RR) with (95% confidence interval) for T2DM was 1.73 (1.35-2.22) in a comparison of extreme fifths of baseline ferritin levels. Three studies evaluated associations between dietary heme iron status and T2DM with a corresponding RR for T2DM of 1.28 (1.16-1.41). In dose-response analyses, the pooled RRs for an increment of 5 ng/mL in ferritin levels and 5 mg/day in dietary heme iron were, respectively, 1.01 (0.99-1.02) and 3.24 (2.05-5.10). CONCLUSION: Elevated levels of ferritin may help identify individuals at high risk of T2DM. Further research is warranted to establish causality of these associations and to ascertain which patients are likely to benefit from lifestyle or therapeutic interventions.

Room for improvement? Leadership, innovation culture and uptake of quality improvement methods in general practice.

BACKGROUND: Leadership and innovation are currently seen as essential elements for the development and maintenance of high-quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. METHOD: Self-administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. RESULTS: Sixty-three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation (r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. CONCLUSIONS: Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate.

General practitioners' preferences for managing insomnia and opportunities for reducing hypnotic prescribing.

RATIONALE, AIMS AND OBJECTIVES: Insomnia and sleep problems are common with many sufferers seeking medical help from general practitioners (GPs) whose clinical response is limited, often involving prescription of hypnotic drugs. The case for improving the quality of care for patients with insomnia is compelling but there is little evidence about how better care could be achieved in a primary care setting. The aim of this study was to investigate GPs' management preferences for sleep problems and their awareness and perception of opportunities for improving care as well as reducing the use of benzodiazepines and Z drugs. METHODS: Cross-sectional survey of GPs using a self-administered postal questionnaire in 2005 to all GPs in West Lincolnshire Primary Care Trust Lincolnshire, UK. RESULTS: A total of 84 of 107 (78.5%) questionnaires sent to GP principals were returned after one reminder. Respondents favoured Z drugs over benzodiazepines for the majority of indications. Respondent attitudes to benzodiazepines and Z drugs were generally negative whereas they were positive towards initiatives to reduce hypnotic prescribing through personal guidance, awareness-raising strategies and organizational interventions. CONCLUSIONS: GPs were negative in attitude towards hypnotics and positive towards reducing prescribing for sleep problems. They need to develop resources and better strategies for assessment and non-pharmacological management of patients presenting with insomnia for the first time as well as those on long-term hypnotics. The feasibility and effectiveness of psychosocial interventions tailored to patient and service needs in primary care setting should be evaluated systematically seeking to understand potential clinical benefits as well as potential undesirable effects of service changes.

Patients' and clinicians' experiences of consultations in primary care for sleep problems and insomnia: a focus group study.

BACKGROUND: Insomnia affects around one-third of adults in the UK. Many sufferers seek help from primary care. AIM: To explore patients' and primary care practitioners' expectations, experiences, and outcomes of consultations for sleep difficulties, as a basis for improving the treatment of insomnia in primary care. DESIGN OF STUDY: A qualitative phenomenological approach. METHOD: Separate focus groups for GPs and nurse prescribers and patients recruited from eight general practices that were in a quality improvement collaborative. Constant comparative analysis was used. RESULTS: Emergent themes from 14 focus groups comparing participating patients (n = 30) and practitioners (n = 15), provided insights on presentation, beliefs, expectations, and management of sleep problems. Patients initially tried to resolve insomnia themselves; consulting was often a last resort. Patients felt they needed to convince practitioners that their sleep difficulties were serious. They described insomnia in terms of the impact it was having on their life, whereas clinicians tended to focus on underlying causes. By the time patients consulted, many expected a prescription. Clinicians often assumed this was what patients wanted, and felt this would hamper patients' ability to take non-drug treatments seriously. Clinicians expected patients who were already on sleeping tablets to be resistant to stopping them, whereas patients were often open to alternatives. CONCLUSION: Better management of insomnia should take into account the perceptions and interactions of patients and practitioners. Practitioners need to empathise, listen, elicit patients' beliefs and expectations, assess sleep better, and offer a range of treatments, including cognitive and behavioural therapies, tailored to individual needs. Practitioner education should incorporate understanding of patients' decision-making processes, the clinicians' role during the consultation, and how to negotiate and deliver strategies for resolving sleep problems.

Strategies for improving patient recruitment to focus groups in primary care: a case study reflective paper using an analytical framework.

BACKGROUND: Recruiting to primary care studies is complex. With the current drive to increase numbers of patients involved in primary care studies, we need to know more about successful recruitment approaches. There is limited evidence on recruitment to focus group studies, particularly when no natural grouping exists and where participants do not regularly meet. The aim of this paper is to reflect on recruitment to a focus group study comparing the methods used with existing evidence using a resource for research recruitment, PROSPeR (Planning Recruitment Options: Strategies for Primary Care). METHODS: The focus group formed part of modelling a complex intervention in primary care in the Resources for Effective Sleep Treatment (REST) study. Despite a considered approach at the design stage, there were a number of difficulties with recruitment. The recruitment strategy and subsequent revisions are detailed. RESULTS: The researchers' modifications to recruitment, justifications and evidence from the literature in support of them are presented. Contrary evidence is used to analyse why some aspects were unsuccessful and evidence is used to suggest improvements. Recruitment to focus group studies should be considered in two distinct phases; getting potential participants to contact the researcher, and converting those contacts into attendance. The difficulty of recruitment in primary care is underemphasised in the literature especially where people do not regularly come together, typified by this case study of patients with sleep problems. CONCLUSION: We recommend training GPs and nurses to recruit patients during consultations. Multiple recruitment methods should be employed from the outset and the need to build topic related non-financial incentives into the group meeting should be considered. Recruitment should be monitored regularly with barriers addressed iteratively as a study progresses.