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School-based studies, despite the large number of studies conducted, have reported inconclusive results on obesity prevention. The sample size is a major constraint in such studies by requiring large samples. This pooled analysis overcomes this problem by analysing 5926 students (mean age 11·5 years) from five randomised school-based interventions. These studies focused on encouraging students to change their drinking and eating habits, and physical activities over the one school year, with monthly 1-h sessions in the classroom; culinary class aimed at developing cooking skills to increase healthy eating and attempts to family engagement. Pooled intention-to-treat analysis using linear mixed models accounted for school clusters. Control and intervention groups were balanced at baseline. The overall result was a non-significant change in BMI after one school year of positive changes in behaviours associated with obesity. Estimated mean BMI changed from 19·02 to 19·22 kg/m2 in the control group and from 19·08 to 19·32 kg/m2 in the intervention group (P value of change over time = 0·09). Subgroup analyses among those overweight or with obesity at baseline also did not show differences between intervention and control groups. The percentage of fat measured by bioimpedance indicated a small reduction in the control compared with intervention (P = 0·05). This large pooled analysis showed no effect on obesity measures, although promising results were observed about modifying behaviours associated with obesity.
To evaluate differences in food consumption of Brazilian adults according to the presence of children and adolescents in the household.
Averages of two non-consecutive days of food records from the first Brazilian National Dietary Survey were analysed and classified into eighteen food groups according to nutritional characteristics and use in diet. We compared the mean percentage contribution to total daily energy intake of each food group according to three groups of household composition: adults living alone or with other adults (32·7 %), adults living with children (35·6 %) and adults living with adolescents (31·7 %).
Brazilian nationwide survey, 2008–2009.
Adults aged 20–59 years (n 6312; 52·1 % female).
Women living alone or with other adults had higher consumption of vegetables, milk and other drinks, and lower consumption of beans and rice, compared with those living with children or adolescents. Men living alone or with other adults had higher consumption of sweets & desserts and vegetables, and lower consumption of beans, compared with those living with children or adolescents. According to household income, adults in the highest tertile who lived with children or adolescents presented a mixed consumption of healthy and unhealthy foods, whereas their counterparts in the first income tertile presented a marked consumption of foods considered traditional of the Brazilian population.
There are differences in food consumption based on the presence of children and adolescents in the household, with greater variation according to gender and household income.
Many school-based interventions for obesity prevention have been proposed with positive changes in behaviour, but with unsatisfactory results on weight change. The objective was to verify the effectiveness of a combined school- and home-based obesity prevention programme on excessive weight gain in adolescents. Teachers delivered the school-based primary prevention programme to fifth- and sixth-graders (nine schools, forty-eight control classes, forty-nine intervention classes), which included encouraging healthy eating habits and physical activity. A subgroup of overweight or obese adolescents also received a home-based secondary prevention programme delivered by community health professionals. Schools were randomised to intervention or control group. Intent-to-treat analysis used mixed models for repeated continuous measures and considered the cluster effect. The main outcomes were changes in BMI and percentage body fat (%body fat) after one school-year of intervention and follow-up. Against our hypothesis, BMI increased more in the intervention group than in the control group (Δ = 0·3 kg/m2; P = 0·05) with a greater decrease in %body fat among boys (Δ = –0·6 %; P = 0·03) in the control group. The intervention group increased physical activity by 12·5 min per week compared with the control group. Female adolescents in the intervention group ate healthier items more frequently than in the control group. The subgroup that received both the school and home interventions had an increase in %body fat than in the control group (Δ = 0·89 %; P = 0·01). In the present study, a behavioural change led to a small increase in physical activity and healthy eating habits but also to an overall increase in food intake.
To identify risk behaviour patterns for chronic non-communicable diseases (NCD) in the Brazilian population and to investigate associated socio-economic and demographic factors.
Factor analysis was used to identify patterns considering the following risk behaviours: consumption of soft drinks/artificial juice, sweet foods, red meat with apparent fat, chicken skin; inadequate consumption of fruits and vegetables; alcohol abuse; smoking; absence of physical activity during leisure time; and time spent watching television. The χ2 test was used to compare ratios. All analyses accounted for weighting factors and the study’s complex sampling design effect. The socio-economic and demographic variables evaluated were gender, age, schooling level and macro region of residence.
National Health Survey, a household survey with national representation, conducted in 2013 in Brazil.
Individuals (n 60202) aged 18 years or over.
Four risk behaviour patterns were identified: ‘Physical inactivity in leisure time and Inadequate consumption of fruits and vegetables’, ‘Saturated fat’, ‘Alcohol and Smoking’ and ‘Sedentary behaviour and Sugar’, explaining 52·01 % of the total variance. Overall, greater adherence to ‘Saturated fat’ and ‘Alcohol and Smoking’ patterns was observed among men and those with lower education level. The ‘Sedentary behaviour and Sugar’ and ‘Physical inactivity in leisure time and Inadequate consumption of fruits and vegetables’ patterns had greater adherence among younger individuals, and the first was associated with higher education whereas the second with less education among individuals residing in the North and Northeast regions.
Risk behaviour patterns for NCD were heterogeneous, reflecting the socio-economic and demographic differences in Brazil.
Although patients value evidence-based therapeutic activities, little is known about nurses' perceptions.
To investigate whether implementing an activities training programme would positively alter staff perceptions of the ward or be detrimental through the increased workload (trial registration: ISRCTN 06545047).
We conducted a stepped wedge cluster randomised trial involving 16 wards with psychology-led nurse training as the intervention. The main outcome was a staff self-report measure of perceptions of the ward (VOTE) and secondary outcomes measuring potential deterioration were the Index of Work Satisfaction (IWS) and the Maslach Burnout Inventory (MBI). Data were analysed using mixed-effects regression models, with repeated assessments from staff over time.
There were 1075 valid outcome measurements from 539 nursing staff. VOTE scores did not change over time (standardised effect size 0.04, 95% CI –0.09 to 0.18, P = 0.54), neither did IWS or MBI scores (IWS, standardised effect size 0.02, 95% CI –0.11 to 0.16, P = 0.74; MBI standardised effect size –0.09, 95% CI –0.24 to 0.06, P = 0.24). There was a mean increase of 1.5 activities per ward (95% CI –0.4 to 3.4, P = 0.12) and on average 6.3 more patients attended groups (95% CI –4.1 to 16.6, P = 0.23) following training. Staff feedback on training was positive.
Our training programme did not change nurses' perceptions of the ward, job satisfaction or burnout. During the study period many service changes occurred, most having a negative impact through increased pressure on staffing, patient mix and management so it is perhaps unsurprising that we found no benefits or reduction in staff skill.
To evaluate the quality of food choices according to adolescent individual earnings in Brazil.
Adolescents were classified according to their individual earnings as having or not having spending power for their own expenses. Food records from two non-consecutive days of the Brazilian National Dietary Survey (NDS 2008–2009) were used to estimate food intake. Quality of food choices was based on two approaches: (i) the NOVA classification, which classifies processed and ultra-processed foods and drinks as unhealthy food groups; and (ii) traditional classification, with beans, milk, fruits and vegetables as healthy food groups, and soft drinks, sweets, snacks and crackers classified as unhealthy. We compared mean food intake (g/kJ or ml/kJ) according to per capita household income (tertiles) and adolescent individual earnings, with adolescent earnings adjusted for household income, using multiple linear regression.
Brazilian households (n 13 569).
Adolescents aged 14–18 years (n 3673).
Males without individual earnings had higher per capita household income than those with individual earnings. Household income was associated with all three food groups of the NOVA classification and seven of the eight groups of the traditional classification. However, only beans and snacks were consumed in significantly greater quantities by adolescents with individual earnings compared with those without earnings.
Adolescent individual earnings were not the main driver of food choices; however, per capita household income was associated with food choices. The consumption of both healthy and unhealthy items increased with increasing household income.
Coercion remains a central aspect of many people's mental healthcare. It can include the use of legislation to restrict freedoms, the use of physical restraint, the restriction of freedom of movement and/or association, and the forced or covert administration of medication. There is good evidence that the use of such measures can traumatise service users. This article reports the findings of a survey of service users regarding their experiences of coercion and restraint and embeds this in the wider international and institutional environment.
Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs.
To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations.
Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers.
Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between −8% and +6%.
Recommended enhancements to care pathways only marginally increase individual-level costs.
Patients are at the core of therapeutic encounters, yet often in psychiatric settings in particular they feel ignored. However, over the past few decades this has started to change, albeit far too slowly.
It is now a central plank of government policy that the NHS should be patient-driven, that there should be a high level of patient and public involvement in health services and that there should be a rapid expansion of choice. This represents a cultural shift and a rebalancing of power relations between patients and doctors. The Department of Health recognises that this is not easy, as doctors may not wish to hand over power to patients (Department of Health & Farrell, 2004). A further part of this cultural shift comes in the wake of the Francis inquiry into the failings of Mid Staffordshire NHS Foundation Trust. The report highlights the importance of the patient experience as of equal status to clinical outcomes (Francis, 2010).
In this context, there is a crucial dilemma for psychiatrists. The culture shift described above is supposed to be transferable to all medical disciplines and the mental health user movement has long struggled to bring this about in the psychiatric domain. It has to be said that there have been some successes here. The dilemma is that psychiatrists have the power to take all choice and control away from psychiatric patients by use of the Mental Health Act 1983. The 2007 amendments to the Act make the grounds for compulsory treatment wider and extended powers to compulsion in the community. Many psychiatrists were opposed to this, but it shows that government policy is pulling in two directions at once – more choice and involvement on the one hand and more control and coercion on the other.
In this chapter I will look at the mental health user movement, what it has achieved and what it has still to achieve. I will then look at research which has tried to determine what users want and do not want in terms of services, especially from psychiatrists. Much of this research has been userled or carried out in collaboration with service user researchers.
Background: Cognitive remediation (CR) is a psychological therapy, effective in improving cognitive performance and functioning in people with schizophrenia. As the therapy becomes more widely implemented within mental health services its longevity and uptake is likely to depend on its feasibility and acceptability to service users and clinicians. Aims: To assess the feasibility and acceptability of a new strategy-based computerized CR programme (CIRCuiTS) for people with psychosis. Method: Four studies were conducted using mixed methods. Perceptions of attractiveness, comprehensibility, acceptability and usability were assessed using self-report questionnaires in 34 non-clinical participants (study 1), and five people with a schizophrenia diagnosis and three experienced CR therapists (studies 2 and 3). The ease with which pre-specified therapy programmes could be assembled was also assessed by three therapists (Study 2). Finally, the satisfaction of 20 service users with a diagnosis of schizophrenia regarding their experience of using CIRCuiTS in the context of a course of the CR therapy was assessed in a qualitative interview study (study 4). Results: Ratings of perceived attractiveness, comprehensibility, acceptability and usability consistently exceeded pre-set high targets by non-clinical, clinical and therapist participants. Qualitative analysis of satisfaction with CIRCuiTS showed that receiving the therapy was generally seen to be a positive experience, leading to perceptions that cognitive functioning had improved and attempts to incorporate new strategy use into daily activities. Conclusions: CIRCuiTS demonstrates high acceptability and ease of use for both service users with a schizophrenia diagnosis and clinicians.
The present study investigated the LDL-cholesterol (LDL-C)-lowering effects of psyllium in Brazilian dyslipidaemic children and adolescents. A total of fifty-one individuals (6–19 years) with mild-to-moderate hypercholesterolaemia were evaluated by conducting a randomised, double-blind, placebo-controlled, parallel clinical trial. Over an 8-week trial period, the participants were randomly allocated to one of two groups (control: n 25 and psyllium: n 26) using a computer-generated random number sequence. Fasting blood samples, dietary records and anthropometric data were collected. Both groups were treated with the National Cholesterol Education Program Step 2 diet for 6 weeks before randomisation. After this run-in period, a daily supplement of 7·0 g psyllium was given to the intervention group, while an equivalent amount of cellulose was given to the control group. Statistically significant changes between the control and intervention groups over time were observed for total cholesterol (7·7 %; − 0·39 mmol/l; P= 0·003) and LDL-C (10·7 %; − 0·36 mmol/l; P= 0·01). None of the participants reported any aversion to the smell, taste, appearance or texture of psyllium. No serious adverse effects were reported during the study. In addition to causing a significant reduction in LDL-C concentrations, psyllium therapy was found to be both safe and acceptable for the treatment of hypercholesterolaemic children and adolescents.
Hospital care is still an integral part of mental healthcare services.
But the impact of ward design on treatment outcomes is unclear.
To review the effects of ward design on patient outcomes and patient and
A systematic review of literature was carried out on Medline, Embase and
PsycINFO. Papers on psychogeriatric and child and adolescent wards were
excluded as these necessitate specific safety features.
Twenty-three papers were identified. No strong causal links between
design and clinical outcomes were found. Private spaces and a homely
environment may contribute to patient well-being. Different stakeholders
may experience ward design in conflicting ways; design has a symbolic and
social dimension for patients.
Data on the impact of design on treatment outcomes are inconclusive.
Rigorous randomised controlled trials, qualitative studies and novel
methods are called for. Different stakeholders' responses to the ward as
a symbolic environment merit further investigation.
This chapter reviews some definitions of global health and mental health diplomacy. It explores heuristic instances where global health drives foreign policy and vice versa, bearing in mind that these two processes frequently overlap and sometimes intersect. The cornerstone of Norwegian policy is to promote and respect fundamental human rights. The principle of equal access to health services based on comprehensive, robust health systems serves as a guideline. The Helsinki Accord emphasized "Respect for human rights and fundamental freedoms, including the freedom of thought, conscience, religion, or belief". The future of global health and mental health depends at least to some extent on the fate of globalization. Bearing in mind that political and economic serendipities can occur at any time, it is hazardous to predict the future with a great deal of confidence.
Service user contributions to mental health conferences are now routine. How effective they are at promoting dialogue is not clear. We report a difficult exchange following a presentation about coercive treatment, with our individual reflections on what we learnt.
Suggestions are made to improve both the clinical practice and the dialogue.
People with borderline personality disorder frequently experience crises.
To date, no randomised controlled trials (RCTs) of crisis interventions
for this population have been published.
To examine the feasibility of recruiting and retaining adults with
borderline personality disorder to a pilot RCT investigating the
potential efficacy and cost-effectiveness of using a joint crisis
An RCT of joint crisis plans for community-dwelling adults with
borderline personality disorder (trial registration: ISRCTN12440268). The
primary outcome measure was the occurrence of self-harming behaviour over
the 6-month period following randomisation. Secondary outcomes included
depression, anxiety, engagement and satisfaction with services, quality
of life, well-being and cost-effectiveness.
In total, 88 adults out of the 133 referred were eligible and were
randomised to receive a joint crisis plan in addition to treatment as
usual (TAU; n=46) or TAU alone (n=42).
This represented approximately 75% of our target sample size and
follow-up data were collected on 73 (83.0%) participants.
Intention-to-treat analysis revealed no significant differences in the
proportion of participants who reported self-harming (odds ratio (OR)
=1.9, 95% CI 0.53-6.5,P = 0.33) or the frequency of
self-harming behaviour (rate ratio (RR)=0.74, 95% CI 0.34-1.63,
P=0.46) between the two groups at follow-up. No
significant differences were observed between the two groups on any of
the secondary outcome measures or costs.
It is feasible to recruit and retain people with borderline personality
disorder to a trial of joint crisis plans and the intervention appears to
have high face validity with this population. However, we found no
evidence of clinical efficacy in this feasibility study.
England's Time To Change (TTC) social marketing campaign emphasised social contact between people with and without mental health problems to reduce stigma and discrimination.
We aimed to assess the effectiveness of the mass media component and also that of the mass social contact events.
Online interviews were performed before and after each burst of mass media social marketing to evaluate changes in knowledge, attitudes and behaviour and associations between campaign awareness and outcomes. Participants at social contact events were asked about the occurrence and quality of contact, attitudes, readiness to discuss mental health and intended behaviour towards people with mental health problems.
Prompted campaign awareness was 38-64%. A longitudinal improvement was noted for one intended behaviour item but not for knowledge or attitudes. Campaign awareness was positively associated with greater knowledge (β = 0.80, 95% CI 0.52-1.08) and more favourable attitudes (commonality OR 1.37, 95% CI 1.10-1.70; dangerousness OR 1.41, 95% CI 1.22-1.63) and intended behaviour (β = 0.75, 95% CI 0.53-0.96). Social contact at events demonstrated a positive impact (M=2.68) v. no contact (M = 2.42) on perceived attitude change; t(211)= 3.30, P=0.001. Contact quality predicted more positive attitude change (r=0.33, P<0.01) and greater confidence to challenge stigma (r=0.38, P<0.01).
The favourable short-term consequences of the social marketing campaign suggest that social contact can be used by anti-stigma programmes to reduce stigma.
Better newspaper coverage of mental health-related issues is a target for the Time to Change (TTC) anti-stigma programme in England, whose population impact may be influenced by how far concurrent media coverage perpetuates stigma and discrimination.
To compare English newspaper coverage of mental health-related topics each year of the TTC social marketing campaign (2009-2011) with baseline coverage in 2008.
Content analysis was performed on articles in 27 local and national newspapers on two randomly chosen days each month.
There was a significant increase in the proportion of anti-stigmatising articles between 2008 and 2011. There was no concomitant proportional decrease in stigmatising articles, and the contribution of mixed or neutral elements decreased.
These findings provide promising results on improvements in press reporting of mental illness during the TTC programme in 2009-2011, and a basis for guidance to newspaper journalists and editors on reporting mental illness.
Research suggests that levels of discrimination against people using mental health services are high; however, reports of these people's experiences are rare.
To determine whether the Time to Change (TTC) programme target of 5% reduction in discrimination has been achieved.
Separate samples of people using mental health services were interviewed annually from 2008 to 2011 using the Discrimination and Stigma Scale to record instances of discrimination.
Ninety-one per cent of participants reported one or more experiences of discrimination in 2008 compared with 88% in 2011 (z=-1.9, P=0.05). The median negative discrimination score was 40% in 2008 and 28% in 2011 (Kruskal-Wallis χ2=83.4, P < 0.001).
The proportion of participants experiencing no discrimination increased significantly over the course of TTC but by less than the initial target The overall median discrimination score fell by 11.5%. Data from 2010 and 2011 suggest that these gains may be hard to maintain during economic austerity.
Mental health service users are at high risk of domestic violence but
this is often not detected by mental health services.
To explore the facilitators and barriers to disclosure of domestic
violence from a service user and professional perspective.
A qualitative study in a socioeconomically deprived south London borough,
UK, with 18 mental health service users and 20 mental health
professionals. Purposive sampling of community mental health service
users and mental healthcare professionals was used to recruit
participants for individual interviews. Thematic analysis was used to
determine dominant and subthemes. These were transformed into conceptual
maps with accompanying illustrative quotations.
Service users described barriers to disclosure of domestic violence to
professionals including: fear of the consequences, including fear of
Social Services involvement and consequent child protection proceedings,
fear that disclosure would not be believed, and fear that disclosure
would lead to further violence; the hidden nature of the violence;
actions of the perpetrator; and feelings of shame. The main themes for
professionals concerned role boundaries, competency and confidence.
Service users and professionals reported that the medical diagnostic and
treatment model with its emphasis on symptoms could act as a barrier to
enquiry and disclosure. Both groups reported that enquiry and disclosure
were facilitated by a supportive and trusting relationship between the
individual and professional.
Mental health services are not currently conducive to the disclosure of
domestic violence. Training of professionals in how to address domestic
violence to increase their confidence and expertise is recommended.