Cultural Influences on Making Nutritional Adjustments in Type 2 Diabetes in Pakistan: The Perspectives of People Living With Diabetes and Their Family Members.

In Pakistan, type 2 diabetes is widespread, and although dietary recommendations from healthcare professionals are critical to its treatment, cultural norms can have a great influence on the dietary habits of people living with diabetes (PLwD). Understanding the social aspects of the lives of PLwD is crucial when examining the effectiveness of nutritional recommendations and adjustments. This study investigated (1) how PLwD and their family members adjust their nutrition to the recommendations of healthcare professionals to manage type 2 diabetes mellitus (T2DM) and (2) what do PLwD and their family members perceive as enablers and barriers to the necessary nutritional adjustments for managing T2DM. Prime consideration was given to experiences of living in Pakistan as the cultural context. Semi-structured interviews were conducted with 30 PLwD and 17 family members; the data were analysed thematically. Three themes emerged: (i) 'Influence of family system, gender, and age on meals prepared at home': family hierarchy and opinions based on gender and age can enable or hinder nutritional adjustment in meals prepared at home; (ii) 'Temptations of "unhealthy" foods, festivals, cultural interactions, and social etiquette': family/social interactions at home, gatherings, or festivities can affect PLwD's ability to resist temptations to eat foods prohibited by healthcare professionals; and (iii) 'Folk knowledge, folk remedy, and the balance between culture and Western medicine': PLwD and their family members in Pakistan hold strong beliefs concerning foods' medicinal properties. Power dynamics within families need to be considered when making nutritional recommendations. Medical guidelines should acknowledge personal agency and cultural beliefs.

Does trait mindfulness mediate the relationship between borderline personality symptoms and emotion dysregulation?

BACKGROUND: Emotion dysregulation is core to many biopsychosocial models of Borderline Personality Disorder (BPD) and is often targeted as part of their associated psychological therapies. Several distinct specialist psychotherapies are thought to be effective for people diagnosed with BPD but it is unclear whether they share common change mechanisms. Some evidence suggests that Mindfulness Based Interventions improve competency in emotion regulation as well as trait mindfulness, which are both plausibly associated with good treatment outcomes. It is unclear whether the association between the severity of BPD symptoms and emotion dysregulation is mediated by trait mindfulness. Would improvement in trait mindfulness mediate an association between lower severity of BPD symptoms and fewer problems of emotion dysregulation? METHODS: One thousand and twelve participants completed online, single time-point, self-report questionnaires. RESULTS: As predicted, the severity of BPD symptoms was significantly and positively associated with emotion dysregulation with a large effect size (r = .77). Trait mindfulness mediated this relationship as the 95% confidence interval for the indirect effect did not cross zero (size of direct effect = .48 and size of indirect effect = .29 [.25, .33]. CONCLUSIONS: The relationship between the severity of BPD symptoms and emotion dysregulation was confirmed in this dataset. As hypothesised, this relationship was mediated by trait mindfulness. Process measures of emotion dysregulation and mindfulness should be included in intervention studies for people diagnosed with BPD to understand if improvements in these factors are a universal occurrence with good response to treatment. Other process measures should also be explored to identify other factors involved in the relationship between BPD symptoms and emotion dysregulation.

Clinical Effectiveness and Cost-Effectiveness of Supported Mindfulness-Based Cognitive Therapy Self-help Compared With Supported Cognitive Behavioral Therapy Self-help for Adults Experiencing Depression: The Low-Intensity Guided Help Through Mindfulness (LIGHTMind) Randomized Clinical Trial.

Importance: Depression is prevalent. Treatment guidelines recommend practitioner-supported cognitive behavioral therapy self-help (CBT-SH) for mild to moderate depression in adults; however, dropout rates are high. Alternative approaches are required. Objective: To determine if practitioner-supported mindfulness-based cognitive therapy self-help (MBCT-SH) is superior to practitioner-supported CBT-SH at reducing depressive symptom severity at 16 weeks postrandomization among patients with mild to moderate depression and secondarily to examine if practitioner-supported MBCT-SH is cost-effective compared with practitioner-supported CBT-SH. Design, Setting, and Participants: This was an assessor- and participant-blinded superiority randomized clinical trial with 1:1 automated online allocation stratified by center and depression severity comparing practitioner-supported MBCT-SH with practitioner-supported CBT-SH for adults experiencing mild to moderate depression. Recruitment took place between November 24, 2017, and January 31, 2020. The study took place in 10 publicly funded psychological therapy services in England (Improving Access to Psychological Therapies [IAPT]). A total of 600 clients attending IAPT services were assessed for eligibility, and 410 were enrolled. Participants met diagnostic criteria for mild to moderate depression. Data were analyzed from January to October 2021. Interventions: Participants received a copy of either an MBCT-SH or CBT-SH workbook and were offered 6 support sessions with a trained practitioner. Main Outcomes and Measures: The preregistered primary outcome was Patient Health Questionnaire (PHQ-9) score at 16 weeks postrandomization. The primary analysis was intention-to-treat with treatment arms masked. Results: Of 410 randomized participants, 255 (62.2%) were female, and the median (IQR) age was 32 (25-45) years. At 16 weeks postrandomization, practitioner-supported MBCT-SH (n = 204; mean [SD] PHQ-9 score, 7.2 [4.8]) led to significantly greater reductions in depression symptom severity compared with practitioner-supported CBT-SH (n = 206; mean [SD] PHQ-9 score, 8.6 [5.5]), with a between-group difference of -1.5 PHQ-9 points (95% CI, -2.6 to -0.4; P = .009; d = -0.36). The probability of MBCT-SH being cost-effective compared with CBT-SH exceeded 95%. However, although between-group effects on secondary outcomes were in the hypothesized direction, they were mostly nonsignificant. Three serious adverse events were reported, all deemed not study related. Conclusions and Relevance: In this randomized clinical trial, practitioner-supported MBCT-SH was superior to standard recommended treatment (ie, practitioner-supported CBT-SH) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness. Findings suggest that MBCT-SH for mild to moderate depression should be routinely offered to adults in primary care services. Trial Registration: isrctn.org Identifier: ISRCTN13495752.

A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive-compulsive disorder.

Exposure and response prevention (ERP) is the gold standard in the treatment of the obsessive-compulsive disorder (OCD). It can be delivered effectively using an individual or group therapy format. Nonetheless, a sizeable proportion of people diagnosed with OCD do not experience OCD symptom remission following ERP. Research suggests that participant engagement with ERP tasks predicts therapy outcomes but there is little consistent evidence across studies on what predicts engagement. A recent meta-analysis of participant engagement in cognitive-behavioral therapy for OCD found that group ERP had a comparatively lower dropout rate than individual ERP. Little is known about participant perceptions of ERP to guide an understanding of how the group therapy format may affect participant engagement. This study conducted a qualitative exploration of what helps or hinders participants' engagement in group ERP. It involved thematic analysis of semi-structured interview data collected at a 6-month follow-up from 15 adults with OCD who took part in group ERP. The study identified five main themes that captured participants' perceived facilitators and barriers to engagement in therapy: 'Group processes', 'Understanding how to overcome OCD', 'Personal relevance', 'Personal circumstances', and 'Attitudes towards ERP', which captured dynamically inter-related barriers and facilitators at the level of the client, therapist, therapy and social environment. Each theme and associated sub-themes are discussed in turn, followed by a consideration of the study's limitations and implications.

Experiences of living with type 2 diabetes in Pakistan: the role of culture and family in physical activity.

BACKGROUND: Diabetes-related guidelines recommend lifestyle changes for people living with type 2 diabetes (PLwD). In South Asian (SA) families, cultural and contextual expectations often influence people's decisions. However, broad explanations provided in the existing literature and theories concerning family involvement can increase the chance of health professionals overlooking the complexities of family roles within SA communities. Previous literature has identified the need to examine the perspectives of PLwD and their family members in Pakistan to shed light on factors perceived to support and hinder recommended physical activity (PA) to manage type 2 diabetes. This study explored (1) the enablers of and barriers to PA in the context of PLwD in Pakistan and (2) family involvement regarding PLwD's engagement with PA. METHODS: Semi-structured interviews were conducted with 30 PLwD and 17 family members of PLwD who were recruited in metropolitan Lahore (Pakistan) and primarily used state health services available to relatively disadvantaged populations. Interviews were transcribed and analysed using thematic analysis. RESULTS: Three themes were identified: (1) Going for a walk as a feasible PA; (2) the role of family members in influencing PA; and (3) gender differences and cultural acceptability of an activity. PA enablers for PLwD consist of gender-specific opportunities for activity facilitated by peers and family members. Culturally acceptable opportunities for PA in Pakistan for specific genders and age groups within the socio-cultural context constituted an essential factor. In this study, all women with diabetes described walking as the only acceptable form of PA, whereas some men mentioned other activities such as running, playing cricket, and cycling. CONCLUSIONS: Medical guidelines must consider patients' daily routines, account for cultural and familial expectations of different genders and age groups, and address social and physical barriers encountered by these different groups to encourage PA among PLwD in SA cultures.

A three-dimensional scar assessment tool for keloid scars: Volume, erythema and melanin quantified.

BACKGROUND: There is no non-invasive objective assessment tool to measure keloid scar characteristics over time. This study aimed to ascertain the ability of the Antera 3D® camera to detect differences in keloid features pre- and post-steroid injection. In order to identify whether those variation could be considered as treatment response predicting factors. METHODS: Enrolled patients received three intra-lesional steroid injections at four-weekly intervals. Images were taken with the Antera 3D camera 12 and 24 weeks after treatment. Keloids' colour, volume, and area as well as haemoglobin and melanin average levels and variation have been analysed pre- and post-steroid injection. t Tests and relative risk have been used to analyse the significance and association strength of our finding. RESULTS: Forty patients have been enrolled in the study. Significant changes as been recorded in keloids' volume and colour after steroid injection (P < 0.05). 53% have recorded a Hb reduction showing no recurrence of pathology, patient who had increase in Hb showed an early recurrence. Melanin variation was significant after steroid injection (P < 0.05) but no correlation has been found with treatment response. CONCLUSIONS: The Antera 3D camera is able to detect differences in the investigated keloid's features helping in two ways: by providing an objective, longitudinal method to monitor and document changes in scar morphology, and through monitoring haemoglobin change, which strongly correlates to both response to treatment and likelihood of recurrence. Allowing clinicians to identify which patients will respond early, in order to change treatment if necessary, limiting morbidity and costs.

Collegial surface acting emotional labour, burnout and intention to leave in novice and pre-retirement nurses in the United Kingdom: A cross-sectional study.

Aim: To investigate the relationship between surface and deep acting in nurses' patient-focused and collegial emotional labour, with emotional exhaustion, depersonalization and personal accomplishment and intention to leave. Design: A cross-sectional descriptive study using the Emotional Labour Scale, the Maslach Burnout Inventory and intention to leave Yes/No questions with 118 Registered Nurses to measure patient-focused and collegial emotional labour, burnout and intention to leave. Results: Surface acting in patient-focused and collegial emotional labour was found to have positive associations with burnout and intention to leave their current job. Only surface acting in patient-focused emotional labour was positively associated with intention to leave the organization and/or the profession. The novice nurses carried out more deep acting collegial emotional labour than the pre-retirement nurses. Conclusions: Collegial emotional labour is significant to nurses' intention to leave their current job but not their intention to leave the organization and/or the profession.

Evaluation of facial electromyographic pain responses in healthy participants.

Aim: Assessing pain perception through self-reports may not be possible in some patients, for example, sedated. Our group considered if facial electromyography (fEMG) could provide a useful alternative, by testing on healthy participants subjected to experimental pain. Materials & methods: Activity of four facial muscles was recorded using fEMG alongside self-reported pain scores and physiological parameters. Results: The pain stimulus elicited significant activity on all facial muscles of interest as well as increases in heart rate. Activity from two of the facial muscles correlated significantly against pain intensity. Conclusion: Pain perception can be assessed through fEMG on healthy participants. We believe that this model would be valuable to clinicians that need to diagnose pain perception in circumstances where verbal reporting is not possible.

Participant perspectives on the acceptability and effectiveness of mindfulness-based cognitive behaviour therapy approaches for obsessive compulsive disorder.

Cognitive behavioural therapy (CBT) which includes Exposure and Response (ERP) is a highly effective, gold standard treatment for Obsessive-Compulsive Disorder (OCD). Nonetheless, not all patients with OCD significantly benefit from CBT. This has generated interest in the potential benefits of Mindfulness-Based Interventions (MBIs), either integrated with CBT, to enhance engagement with ERP tasks, or delivered as a stand-alone, first-line or therapy to augment CBT. This paper reports on two qualitative studies that involved a thematic analysis of interview data with participants in a 10-week Mindfulness-Based ERP (MB-ERP) course (study 1) and a 9-week Mindfulness-Based Cognitive Therapy course adapted for OCD (MBCT-OCD) (study 2). Whilst MB-ERP integrated a mindfulness component into a standard ERP protocol, MBCT-OCD adapted the psychoeducational components of the standard MBCT for depression protocol to suit OCD, but without explicit ERP tasks. Three common main themes emerged across MB-ERP and MBCT-OCD: 'satisfaction with course features', 'acceptability of key therapeutic tasks 'and 'using mindfulness to respond differently to OCD'. Sub-themes identified under the first two main themes were mostly unique to MB-ERP or MBCT-OCD, with the exception of '(struggles with) developing a mindfulness practice routine' whilst most of the sub-themes under the last main theme were shared across MB-ERP and MBCT-OCD participants. Findings suggested that participants generally perceived both MBIs as acceptable and potentially beneficial treatments for OCD, in line with theorised mechanisms of change.

Low-Intensity Guided Help Through Mindfulness (LIGHTMIND): study protocol for a randomised controlled trial comparing supported mindfulness-based cognitive therapy self-help to supported cognitive behavioural therapy self-help for adults experiencing depression.

BACKGROUND: Depression has serious personal, family and economic consequences. It is estimated that it will cost £12.15 billion to the economy each year in England by 2026. Improving access to psychological therapies (IAPT) is the National Health Service talking therapies service in England for adults experiencing anxiety or depression. Over 1 million people are referred to IAPT every year, over half experiencing depression. Where symptoms of depression are mild to moderate, people are typically offered cognitive behavioural therapy (CBT) self-help (CBT-SH) supported by a psychological well-being practitioner. The problem is that over half of people who complete treatment for depression in IAPT remain depressed despite receiving National Institute of Health and Care Excellent recommended treatment. Furthermore, less than half of IAPT service users complete treatment. This study seeks to investigate the effectiveness of an alternative to CBT-SH. Mindfulness-based cognitive therapy (MBCT) differs from CBT in focus, approach and practice, and may be more effective with a higher number of treatment completions. METHODS/DESIGN: This is a definitive randomised controlled trial comparing supported MBCT self-help (MBCT-SH) with CBT-SH for adults experiencing mild to moderate depression being treated in IAPT services. We will recruit 410 participants experiencing mild to moderate depression from IAPT services and randomise these to receive either an MBCT-based self-help workbook or a CBT-based self-help workbook. Participants will be asked to complete their workbook within 16 weeks, with six support sessions with a psychological well-being practitioner. The primary outcome is depression symptom severity on treatment completion. Secondary outcomes are treatment completion rates and measures of generalized anxiety, well-being, functioning and mindfulness. An exploratory non-inferiority analysis will be conducted in the event the primary hypothesis is not supported. A semi-structured interview with participants will guide understanding of change processes. DISCUSSION: If the findings from this randomised controlled trial demonstrate that MBCT-SH is more effective than CBT-SH for adults experiencing depression, this will provide evidence for policy makers and lead to changes to clinical practice in IAPT services, leading to greater choice of self-help treatment options and better outcomes for service users. If the exploratory non-inferiority analysis is conducted and this indicates non-inferiority of MBCT-SH in comparison to CBT-SH this will also be of interest to policy makers when seeking to increase service user choice of self-help treatment options for depression. TRIAL REGISTRATION: Current Controlled Trial registration number: ISRCTN 13495752. Registered on 31 August 2017 (www.isrctn.com/ISRCTN13495752).

Mindfulness-based exposure and response prevention for obsessive compulsive disorder: Findings from a pilot randomised controlled trial.

BACKGROUND: Only about half of people with obsessive compulsive disorder (OCD) show clinically significant improvement following the recommended therapy, exposure and response prevention (ERP), partly due to poor therapy acceptability. A mindfulness-based approach to ERP (MB-ERP) has the potential to improve acceptability and outcomes. METHODS: This was an internal pilot randomised controlled trial (RCT) of group MB-ERP compared to group ERP. 37 participants meeting DSM-IV OCD criteria were randomly allocated to MB-ERP or ERP. RESULTS: Both groups improved in OCD symptom severity. However, MB-ERP did not lead to clinically important improvements in OCD symptom severity at post-intervention compared to ERP - the minimum clinically important difference was not contained in the 95% confidence intervals. There were negligible between-group differences in engagement and MB-ERP did not appear to have broader benefits compared to ERP on depression, wellbeing or OCD-related beliefs. Conversely, MB-ERP led to medium/medium-large improvements in mindfulness compared to ERP. CONCLUSIONS: MB-ERP is unlikely to lead to clinically meaningful improvements in OCD symptom severity compared to ERP alone. We underline the importance of adhering to treatment guidelines recommending ERP for OCD. Insufficient attention may have been given to mindfulness practice/discussion in MB-ERP and further research is recommended to explore this possibility.

Objectively measuring pain using facial expression: is the technology finally ready?

Currently, clinicians observe pain-related behaviors and use patient self-report measures in order to determine pain severity. This paper reviews the evidence when facial expression is used as a measure of pain. We review the literature reporting the relevance of facial expression as a diagnostic measure, which facial movements are indicative of pain, and whether such movements can be reliably used to measure pain. We conclude that although the technology for objective pain measurement is not yet ready for use in clinical settings, the potential benefits to patients in improved pain management, combined with the advances being made in sensor technology and artificial intelligence, provide opportunities for research and innovation.

Mindfulness-based exposure and response prevention for obsessive compulsive disorder: study protocol for a pilot randomised controlled trial.

BACKGROUND: Obsessive Compulsive Disorder (OCD) is a distressing and debilitating condition affecting 1-2% of the population. Exposure and response prevention (ERP) is a behaviour therapy for OCD with the strongest evidence for effectiveness of any psychological therapy for the condition. Even so, only about half of people offered ERP show recovery after the therapy. An important reason for ERP failure is that about 25% of people drop out early, and even for those who continue with the therapy, many do not regularly engage in ERP tasks, an essential element of ERP. A mindfulness-based approach has the potential to reduce drop-out from ERP and to improve ERP task engagement with an emphasis on accepting difficult thoughts, feelings and bodily sessions and on becoming more aware of urges, rather than automatically acting on them. METHODS/DESIGN: This is a pilot randomised controlled trial of mindfulness-based ERP (MB-ERP) with the aim of establishing parameters for a definitive trial. Forty participants diagnosed with OCD will be allocated at random to a 10-session ERP group or to a 10-session MB-ERP group. Primary outcomes are OCD symptom severity and therapy engagement. Secondary outcomes are depressive symptom severity, wellbeing and obsessive-compulsive beliefs. A semi-structured interview with participants will guide understanding of change processes. DISCUSSION: Findings from this pilot study will inform future research in this area, and if effect sizes on primary outcomes are in favour of MB-ERP in comparison to ERP, funding for a definitive trial will be sought. TRIAL REGISTRATION: Current Controlled Trials registration number ISRCTN52684820. Registered on 30 January 2014.

The adaptation of health technology assessment reports: identification of the need for, and development of, a toolkit to aid the process.

OBJECTIVES: Europe has many health technology assessment (HTA) agencies, each producing their own HTA reports. Adapting HTA reports for different contexts could reduce the need for multiple reports on the same health technology with resultant saving of time and resources. This study aims to examine and understand the process of adaptation, and to develop a toolkit that would help the adaptation of reports produced by other countries. METHODS: The methods used were a review of the literature; a survey of twenty-nine European HTA organizations, two rounds of a Delphi survey, a face-to-face meeting of twenty-one European network for Health Technology Assessment (EUnetHTA) representatives, iterative rounds of review, and two rounds of quality assurance testing (termed applicability testing). RESULTS: Descriptions of previous examples of adaptation in the literature are sparse. Most respondents had previous experience in adapting reports, and all believed that adaptation was useful, and there was the ability to benefit from the use of a toolkit to aid in the process. EUnetHTA Partners developed and tested an adaptation toolkit. The toolkit is composed of a series of checklists and resources that identify or clarify the relevance, reliability, and transferability of data and information from existing reports. CONCLUSIONS: Consensus of opinion from twenty-nine European organizations/networks has indicated that the adaptation of HTA reports would be desirable and beneficial. A toolkit was developed to help with the adaptation of HTA reports produced in other settings. This collection of resources is available for use by all HTA agencies and can be accessed at: http://www.eunethta.net/upload/WP5/EUnetHTA_HTA_Adaptation_Toolkit_October08.pdf.

The health technology assessment adaptation toolkit: description and use.

OBJECTIVES: Adapting health technology assessment (HTA) reports for different contexts could reduce the need for multiple reports on the same health technology with resultant saving of time and resources. This article describes an instrument, the adaptation toolkit, which has been developed to aid in the process of adaptation of HTA reports. METHODS: The toolkit was developed by a partnership of HTA agencies and networks from across Europe. The role of the toolkit is to guide the user through the process of selecting possible relevant material from these report(s), assessing the relevance, reliability, and transferability of the material, and adapting it for the desired context. RESULTS: The adaptation toolkit has been developed, it comprises a collection of resources that help the user assess whether data and information in existing HTA reports should and could be adapted for their own setting. The toolkit contains two sections: a preliminary speedy sifting section and the main toolkit. The main toolkit includes five domains: (i) technology use and development, (ii) safety, (iii) effectiveness (including efficacy), (iv) economic evaluation, and (v) organizational aspects. Legal, ethical, and social aspects are beyond the scope of the toolkit. The toolkit is designed for the adaptation of evidence synthesis rather than primary research. CONCLUSIONS: The completed current version of the toolkit contains checklists and resources to aid in the adaptation of HTA reports. This collection of resources is available for use by all HTA agencies and can be accessed at: http://www.eunethta.net/upload/WP5/EUnetHTA_HTA_Adaptation_Toolkit_October08.pdf..

Enhancing understanding: the development of a glossary of health technology assessment adaptation terms.

BACKGROUND: The way people use health technology assessment (HTA) terms varies considerably across Europe. Such variation can lead to misunderstandings when reading HTA reports from different contexts. This work is one of the outputs of the EUnetHTA Project and was undertaken between 2006 and 2008. OBJECTIVES: The aim of this study was to develop a glossary of HTA adaptation terms to help reduce the misunderstandings of terms used in HTA reports from contexts other than the reader's own. METHODS: Several HTA glossaries were examined to identify ways in which an additional glossary could offer readers something new and to identify adaptation terms for inclusion. Twenty-eight European HTA organizations provided terms for the glossary and drafted descriptions and examples of how each specific term was used in their particular setting. The organizations then commented on the descriptions provided by the other groups and worked together to draft a single description for certain terms. RESULTS: A glossary of HTA adaptation terms was developed. It provides a comprehensive range of descriptions, examples, and comments for forty-two potentially confusing HTA terms related to adaptation. CONCLUSIONS: This glossary will be a valuable resource for European HTA agencies when reading HTA reports produced in different contexts and for adapting HTA reports produced in other countries. The glossary will help improve understanding and help facilitate the adaptation process.