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On average, countries implemented just under half of the 18 non-communicable disease (NCD) policies recommended by WHO in 2017, and implementation is slowly improving over time.
Nurse-delivered sleep restriction therapy to improve insomnia disorder in primary care: the HABIT RCT
Background: Insomnia is a prevalent and distressing sleep disorder. Multicomponent cognitive– behavioural therapy is the recommended first-line treatment, but access remains extremely limited, particularly in primary care where insomnia is managed. One principal component of cognitive– behavioural therapy is a behavioural treatment called sleep restriction therapy, which could potentially be delivered as a brief single-component intervention by generalists in primary care. Objectives: The primary objective of the Health-professional Administered Brief Insomnia Therapy trial was to establish whether nurse-delivered sleep restriction therapy in primary care improves insomnia relative to sleep hygiene. Secondary objectives were to establish whether nurse-delivered sleep restriction therapy was cost-effective, and to undertake a process evaluation to understand intervention delivery, fidelity and acceptability. Design: Pragmatic, multicentre, individually randomised, parallel-group, superiority trial with embedded process evaluation. Setting: National Health Service general practice in three regions of England. Participants: Adults aged ≥ 18 years with insomnia disorder were randomised using a validated webbased randomisation programme. Interventions: Participants in the intervention group were offered a brief four-session nurse-delivered behavioural treatment involving two in-person sessions and two by phone. Participants were supported to follow a prescribed sleep schedule with the aim of restricting and standardising time in bed. Participants were also provided with a sleep hygiene leaflet. The control group received the same sleep hygiene leaflet by e-mail or post. There was no restriction on usual care. Main outcome measures: Outcomes were assessed at 3, 6 and 12 months. Participants were included in the primary analysis if they contributed at least one post-randomisation outcome. The primary end point was self-reported insomnia severity with the Insomnia Severity Index at 6 months. Secondary outcomes were health-related and sleep-related quality of life, depressive symptoms, work productivity and activity impairment, self-reported and actigraphy-defined sleep, and hypnotic medication use. Costeffectiveness was evaluated using the incremental cost per quality-adjusted life-year. For the process evaluation, semistructured interviews were carried out with participants, nurses and practice managers or general practitioners. Due to the nature of the intervention, both participants and nurses were aware of group allocation. Results: We recruited 642 participants (n = 321 for sleep restriction therapy; n = 321 for sleep hygiene) between 29 August 2018 and 23 March 2020. Five hundred and eighty participants (90.3%) provided data at a minimum of one follow-up time point; 257 (80.1%) participants in the sleep restriction therapy arm and 291 (90.7%) participants in the sleep hygiene arm provided primary outcome data at 6 months. The estimated adjusted mean difference on the Insomnia Severity Index was −3.05 (95% confidence interval −3.83 to −2.28; p < 0.001, Cohen’s d = −0.74), indicating that participants in the sleep restriction therapy arm [mean (standard deviation) Insomnia Severity Index = 10.9 (5.5)] reported lower insomnia severity compared to sleep hygiene [mean (standard deviation) Insomnia Severity Index = 13.9 (5.2)]. Large treatment effects were also found at 3 (d = –0.95) and 12 months (d = −0.72). Superiority of sleep restriction therapy over sleep hygiene was evident at 3, 6 and 12 months for self-reported sleep, mental health-related quality of life, depressive symptoms, work productivity impairment and sleep-related quality of life. Eight participants in each group experienced serious adverse events but none were judged to be related to the intervention. The incremental cost per quality-adjusted life-year gained was £2075.71, giving a 95.3% probability that the intervention is cost-effective at a cost-effectiveness threshold of £20,000. The process evaluation found that sleep restriction therapy was acceptable to both nurses and patients, and delivered with high fidelity. Limitations: While we recruited a clinical sample, 97% were of white ethnic background and 50% had a university degree, which may limit generalisability to the insomnia population in England. Conclusions: Brief nurse-delivered sleep restriction therapy in primary care is clinically effective for insomnia disorder, safe, and likely to be cost-effective. Future work: Future work should examine the place of sleep restriction therapy in the insomnia treatment pathway, assess generalisability across diverse primary care patients with insomnia, and consider additional methods to enhance patient engagement with treatment. Trial registration: This trial is registered as ISRCTN42499563.
Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation
Background Sleep restriction therapy (SRT) is a behavioural therapy for insomnia. Aim To conduct a process evaluation of a randomised controlled trial comparing SRT delivered by primary care nurses plus a sleep hygiene booklet with the sleep hygiene booklet only for adults with insomnia disorder. Design and setting A mixed-methods process evaluation in a general practice setting. Method Semi-structured interviews were conducted in a purposive sample of patients receiving SRT, the practice nurses who delivered the therapy, and also GPs or practice managers at the participating practices. Qualitative data were explored using framework analysis, and integrated with nurse comments and quantitative data, including baseline Insomnia Severity Index score and serial sleep efficiency outcomes to investigate the relationships between these. Results In total, 16 patients, 13 nurses, six practice managers, and one GP were interviewed. Patients had no previous experience of behavioural therapy, needed flexible appointment times, and preferred face-to-face consultations; nurses felt prepared to deliver SRT, accommodating patient concerns, tailoring therapy, and negotiating sleep timings despite treatment complexity and delays between training and intervention delivery. How the intervention produced change was explored, including patient and nurse interactions and patient responses to SRT. Difficulties maintaining SRT, negative attitudes towards treatment, and low self-efficacy were highlighted. Contextual factors, including freeing GP time, time constraints, and conflicting priorities for nurses, with suggestions for alternative delivery options, were raised. Participants who found SRT a positive process showed improvements in sleep efficiency, whereas those who struggled did not. Conclusion SRT was successfully delivered by practice nurses and was generally well received by patients, despite some difficulties delivering and applying the intervention in practice.
Sleep and motor learning in stroke (SMiLES): A longitudinal study investigating sleep-dependent consolidation of motor sequence learning in the context of recovery after stroke
Introduction There is growing evidence that sleep is disrupted after stroke, with worse sleep relating to poorer motor outcomes. It is also widely acknowledged that consolidation of motor learning, a critical component of poststroke recovery, is sleep-dependent. However, whether the relationship between disrupted sleep and poor outcomes after stroke is related to direct interference of sleep-dependent motor consolidation processes, is currently unknown. Therefore, the aim of the present study is to understand whether measures of motor consolidation mediate the relationship between sleep and clinical motor outcomes post stroke. Methods and analysis We will conduct a longitudinal observational study of up to 150 participants diagnosed with stroke affecting the upper limb. Participants will be recruited and assessed within 7 days of their stroke and followed up at approximately 1 and 6 months. The primary objective of the study is to determine whether sleep in the subacute phase of recovery explains the variability in upper limb motor outcomes after stroke (over and above predicted recovery potential from the Predict Recovery Potential algorithm) and whether this relationship is dependent on consolidation of motor learning. We will also test whether motor consolidation mediates the relationship between sleep and whole-body clinical motor outcomes, whether motor consolidation is associated with specific electrophysiological sleep signals and sleep alterations during subacute recovery. Ethics and dissemination This trial has received both Health Research Authority, Health and Care Research Wales and National Research Ethics Service approval (IRAS: 304135; REC: 22/LO/0353). The results of this trial will help to enhance our understanding of the role of sleep in recovery of motor function after stroke and will be disseminated via presentations at scientific conferences, peer-reviewed publication, public engagement events, stakeholder organisations and other forms of media where appropriate. Trial registration number ClinicalTrials.gov: NCT05746260, registered on 27 February 2023.
Managing an ageing cystic fibrosis population: challenges and priorities.
The increasing life expectancy of people with cystic fibrosis (pwCF), largely driven by advancements in early diagnosis, multidisciplinary care and the recent introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies, is likely to herald a shift in the focus of care toward managing the complexities of ageing. This review highlights key challenges and research priorities for addressing the health needs of an ageing CF population. A growing body of evidence underscores the heightened risks of cancers, cardiovascular diseases and changing nutritional and metabolic profiles as pwCF age. CFTR modulators have improved clinical outcomes, but their effects on inflammation, immunity and long-term disease trajectories remain incompletely understood. Nutritional management, particularly the implications of obesity and body composition, poses new challenges, as does the potential accelerated ageing of immune and pulmonary systems in CF. Emerging issues such as menopause in females with CF, lifetime antimicrobial resistance and the interplay between chronic inflammation and ageing further complicate the care landscape. The review emphasises the urgent need for multidisciplinary research programmes that integrate clinical, patient and community perspectives. Leveraging established CF registries, clinical trial networks and collaborations with ageing research frameworks is critical to addressing these challenges. Ultimately, the goal is to ensure that pwCF not only live longer but also experience improved quality of life and holistic wellbeing as they realise the full benefits of therapeutic advances.
Targeted Interventions to Improve the Systematic Collection of Acute Respiratory Infection Clinical Data from Primary Care Computerised Medical Records.
Data quality in primary care is important for surveillance and research projects based on routinely collected computerised medical records data. We present the results of a targeted intervention of incentives and tools to record specific data about acute respiratory infectious disease. As part of an epidemiological study, practices received a template to code this information, which could also act as a consultation template. Use of the template was not restricted to patients taking part in the epidemiological study. We saw significant increases in coded data for patients in the study in the four areas that we examined; oxygen saturation, body temperature, respiratory rate and history of fever. For patients not included in the study we saw only small differences between study practices and non-study practices. There was an increased frequency of recording of measured body temperature in study practices but the effect was small (1.1%) 95% CI [0.56%,1.66%]. Primary care data quality can be improved with targeted interventions and support, but the effect does not transfer out of the specific patients for which it has been incentivised.
Contrasting cultures of emergency department care: A qualitative study of patients' experiences of attending the emergency department for low back pain in the UK
Objectives This article aimed to explore patients' experiences of attending the emergency department (ED) for low back pain (LBP) and provides a theoretically informed analysis of the ED cultures perceived by patients to inform their experiences of care. Design Multisite, cross-sectional qualitative interview study. Setting Four NHS Emergency Departments located in the UK. Participants 47 adults (aged 23-79 years) who, in the past 6 weeks, had attended the ED for LBP (all types and durations). Purposive sampling was used to gain variation in the recruiting sites, and participants' LBP and demographic characteristics. Interventions Data were collected using individual, semistructured, telephone interviews (median 45 min duration) which were audio-recorded and transcribed verbatim. Analysis was informed using reflexive thematic analysis and ideal type analysis. Cycles of inductive and deductive analysis were undertaken, with Bourdieu's concepts of field and habitus employed to help explain the findings. Results We present three contrasting cultures of ED care for LBP, comprising (1) emergency screening only, (2) 'cynicism and neglect' and (3) appropriate and kind care. Taking each culture (field) in turn, we explore important differences in the content and delivery of care. Drawing on Bourdieu's concepts of field and habitus, we consider the social and institutional norms and misrepresentations likely to underpin the thoughts and behaviours of ED staff (their habitus), and why these tended to vary based on where and by whom the patient was managed in the ED. Conclusions Strategies to improve patients' experience need to review the social and institutional norms that underpin staff habitus, the assumptions informing these norms and the voices that validate and reproduce them. ISRCTN registration number ISRCTN77522923.
People, Place and Innovation: How Organizational Culture and Physical Environment Shaped the Implementation of the NHS TC Programme
This chapter describes the experience of an organizational change in the English National Health Service (NHS) by focusing on the interconnections between culture and place in shaping that change. We use the term ‘place’ to mean space in the sense of the physical environment, architecture and lay-out, rather than location or setting. The idea that culture structures change is familiar, but perhaps the influence of physical environments, architecture and spatial configuration is less well examined. Organizational culture and negotiated order theories have been successfully employed to understand organizational change, and while these perspectives sometimes acknowledge the importance of physical context, few empirical studies have examined the interplay of culture and place in the change process. This chapter therefore focuses on the interaction between people and place in shaping organizational change. It looks at the intersection of culture and place in the context of an ethnography of the development of an innovative form of health care delivery, namely NHS Treatment Centres. Of particular interest are the stories participants in this study told us about the physical environment and the ways in which place influenced their sense-making and decisions around the implementation of this change programme. The chapter considers the possibilities and limitations to organizational change that arise from the powerful structuring effects and interplay of culture, physical and geographical environment, by exploring how Treatment Centres were adapted to the particular local configurations of people and place and then by reflecting on the impact of place on understanding organizational change.
Introduction: Why Focus on Culture and Climate?
This book brings together a series of papers which detail recent international research on the theme of culture and climate in health care organizations. It is the sixth edition in the Palgrave series of edited collections on organizational behaviour in health care and was developed from the highly successful Organizational Behaviour in Health Care Conference held at the University of New South Wales, Sydney in March 2008.
Conclusion: Culture and Climate in Health Care Organizations — Evidentiary, Conceptual and Practical progress
In this final chapter we bring the range of contributions to a conclusion. To accomplish this, we provide a synthesis of the terrain we have covered and offer some suggestions about where this might lead us in the future. Health care organizations involve a diverse mix of managerial, professional and ancillary groups of workers the result of which is that health services are made up of culturally complex organizations. This diversity encapsulates multiple value systems, beliefs and attitudes as well as considerable power differentials. Therefore, health care organizations offer a rich landscape for study. ‘Culture’ and ‘climate’ have been central themes in this volume, which has included broad ranging studies that are of interest to health care professionals, managers, policy makers and the informed public as well as the community of health care organizational researchers.
Chasing Chameleons, Chimeras and Caterpillars: Evaluating an Organizational Innovation in the National Health Service
Although some might argue that too little attention is paid to the evaluation of health service innovations, evaluation research has burgeoned alongside the ubiquitous healthcare reform of the UK NHS which escalated under the Conservative government of the 1980s and has continued under the Labour government since the late 1990s. In terms of funding and activity health service evaluation is something of an industry: to give just one example the NHS Service Delivery and Organization (SDO) R&D Programme has spent some £6m since 2002 funding research to evaluate models of service delivery(http://sdo.lshtm.ac.ukhttp://sdo.lshtm.ac.uk).Evaluative research is a quest for evidence and an answer to ‘what works (or doesn’t) for whom in which context?’ often driven by a desire to inform the change process. This chapter is about one particular evaluative research project which examined an organizational innovation introduced as part of wider NHS reforms undertaken by the New Labour government. Our focus is not on answering the ‘what works’ question per se, but instead we critically examine what makes evaluation research difficult. We draw on our experience of researching one innovation, but the challenges arising from the specifics of this particular project are not unique; indeed we argue that the chameleons, chimeras and caterpillars we encountered may well be persistent features of evaluative research.
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