Evaluating the effectiveness of health belief model interventions in improving adherence: a systematic review

Lack of adherence to health-promoting advice challenges the successful prevention and management of many conditions. The Health Belief Model (HBM) was developed in 1966 to predict health-promoting behaviour and has been used in patients with wide variety of disease. The HBM has also been used to inform the development of interventions to improve health behaviours. Several reviews have documented the HBM's performance in predicting behaviour, but no review has addressed its utility in the design of interventions or the efficacy of these interventions. A systematic review was conducted to identify interventional studies which use the HBM as the theoretical basis for intervention design. The HBM has been used continuously in the development of behaviour change interventions for 40 years. Of 18 eligible studies, 14 (78%) reported significant improvements in adherence, with 7 (39%) showing moderate to large effects. However, only six studies used the HBM in its entirety and five different studies measured health beliefs as outcomes. Intervention success appeared to be unrelated to HBM construct addressed challenging the utility of this model as the theoretical basis for adherence-enhancing interventions. Interventions need to be described in full to allow for the identification of effective components and replication of studies.     

Shame as a social phenomenon: A critical analysis of the concept of dispositional shame

An increased clinical interest in shame has been reflected in the growing number of research studies in this area. However, clinically orientated empirical investigation has mostly been restricted to the investigation of individual differences in dispositional shame. This study reviews recent work on dispositional shame but then argues that the primacy of this construct has been problematic in a number of ways. Most importantly, the notion of shame as a context‐free intrapsychic variable has distracted clinical researchers from investigating the management and repair of experiences of shame and shameful identities and has made the social constitution of shame less visible. Several suggestions are made for alternative ways in which susceptibility to shame could be conceptualized, which consider how shame might arise in certain contexts and as a product of particular social encounters. For example, persistent difficulties with shame may relate to the salience of stigmatizing discourses within a particular social context, the roles or subject positions available to an individual, the establishment of a repertoire of context‐relevant shame avoidance strategies and the personal meaning of shamefulness.     

Nonpharmacological interventions aimed at modifying health and behavioural outcomes for adults with asthma: a critical review

Evidence suggests that living with asthma is linked with psychological and behavioural factors including self‐management and treatment adherence, and therefore, there is a reasonable hypothesis that nonpharmacological treatments may improve health outcomes in people living with this condition. A systematic review of randomized controlled trials (RCTs) of nonpharmacological interventions for adults with asthma was designed. Databases searched included The Cochrane Airways Group Register of trials, CENTRAL and Psychinfo. The literature search was conducted until May 2014. Twenty‐three studies met the inclusion criteria and were organized into four groups: relaxation‐based therapies (n = 9); mindfulness (n = 1), biofeedback techniques (n = 3); cognitive behavioural therapies (CBT) (n = 5); and multicomponent interventions (n = 5). A variety of outcome measures were used, even when trials belonged to the same grouping, which limited the ability to conduct meaningful meta‐analyses. Deficiencies in the current evidence base, notably trial heterogeneity, means that application to clinical practice is limited and clear guidelines regarding the use of nonpharmacological therapies in asthma is limited. Relaxation and CBT, however, appear to have a consistent positive effect on asthma‐related quality of life and some psychological outcomes, and lung function (relaxation only). Future trials should be informed by previous work to harmonize the interventions under study and outcome measures used to determine their effectiveness; only then will meaningful meta‐analyses inform clinical practice.     

Teachable moments for health behavior change: A concept analysis

Objective

“Teachable moments” have been proposed as events or circumstances which can lead individuals to positive behavior change. However, the essential elements of teachable moments have not been elucidated. Therefore, we undertook a comprehensive review of the literature to uncover common definitions and key elements of this phenomenon.

Methods

Using databases spanning social science and medical disciplines, all records containing the search term “teachable moment^*” were collected. Identified literature was then systematically reviewed and patterns were derived.

Results

Across disciplines, ‘teachable moment’ has been poorly developed both conceptually and operationally. Usage of the term falls into three categories: (1) “teachable moment” is synonymous with “opportunity” (81%); (2) a context that leads to a higher than expected behavior change is retrospectively labeled a ‘teachable moment’ (17%); (3) a phenomenon that involves a cueing event that prompts specific cognitive and emotional responses (2%).

Conclusion

The findings suggest that the teachable moment is not necessarily unpredictable or simply a convergence of situational factors that prompt behavior change but suggest the possible creation of a teachable moment through clinician–patient interaction.

Practice implications

Clinician–patient interaction may be central to the creation of teachable moments for health behavior change.     

Computer-tailored health interventions delivered over the Web: review and analysis of key components

Objective

This systematic review explores how computer-tailored, behavioral interventions implemented and delivered via the Web have been operationalized in a variety of settings.

Methods

Computer-tailored, online behavioral intervention studies published from 1996 to early 2007 were selected and reviewed by two independent coders.

Results

Of 503 studies screened, 30 satisfied the selection criteria. The level of sophistication of these interventions varied from immediate risk/health assessment, tailored web content to full-blown customized health programs. The most common variables for tailoring content were health behaviors and stages of change. Message tailoring was achieved through a combination mechanisms including: feedback, personalization and adaptation.

Conclusions

Tailored, self-guided health interventions delivered via the Web to date have involved a great diversity of features and formats. While some programs have been relatively brief and simple, others have involved complex, theory-based tailoring with iterative assessment, tools for development of self-regulatory skills, and various mechanisms for providing feedback.

Practice implications

Our ability to fully optimize the use of computer-assisted tailoring will depend on the development of empirically based guidelines for tailoring across populations, health foci, health behaviors and situations. Further outcome research is needed to enhance our understanding of how and under what conditions computer-tailoring leads to positive health outcomes in online behavioral interventions.     

Evaluating health promotion: a tale of three errors

The main purpose of this article is to question the relevance of the Randomised Controlled Trial for the evaluation of health promotion programmes. In its concern to manage Type 1 error, the RCT underestimates or virtually ignores Type 2 and 3 errors. Because of the peculiar complexities of health promotion programmes and the importance of gaining insights into the effect of interventions--rather than merely recording whether or not they achieve their goals--a new kind of validity is needed. The central assertion here is that we should adopt a principle of "judicial review" which is based on a broad spectrum of triangulated evidence.     

Mechanisms,contexts and points of contention: operationalizing realist-informed research for complex health interventions

Background

The concept of “mechanism” is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).

Methods

In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.

Results

We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.

Conclusions

We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

     

Duration of untreated psychosis: a critical examination of the concept and its importance

BACKGROUND: The concept of duration of untreated psychosis (DUP) has recently attracted much interest because of its possible relationship to treatment outcome and implications for preventive efforts with reference to psychotic disorders, especially schizophrenia. In this paper we review critically the literature concerning the concept and its importance. METHODS: Articles concerned with measuring DUP and those that have been suggested to provide indirect or direct evidence of the effect of DUP on treatment outcome are reviewed. RESULTS: Evidence thus far suggests that DUP may be related to ease of reducing psychotic symptoms once treatment begins for first episode patients, but there is no evidence of a relationship to likelihood of relapse. There has been little investigation of the relationship of DUP to other long-term outcomes such as negative symptoms and cognitive functioning neither have the possible confounds of DUP been widely investigated or controlled. CONCLUSIONS: It is important that there should be more thorough investigations of DUP, its correlates, and the extent to which it does mediate any advantages of earlier intervention.     

Differential display: a critical analysis

Differential display (DD) is a well-established analytical tool for measuring gene expression that is still popular due to its documented success and ability to identify novel genes not yet available for analysis by more powerful microarray hybridization. For a comprehensive analysis of all mRNAs in a given cell, it is statistically predicted that at least 240 different DD primer combinations are required. This prediction, however, has never been empirically tested. Using far more primer combinations than that predicted to evaluate 90% of the mRNAs in a cell, plus other modifications, we identified and confirmed the induction of five mRNAs by hydrogen peroxide in HA-1 hamster cells. However, five other known oxidant-inducible mRNAs were not identified by DD. Filter microarray hybridization did not result in the identification of any additional species modulated twofold or greater but previous two-dimensional protein gel electrophoresis identified 15 induced protein species. We conclude that the current statistical prediction for comprehensive analysis of all the mRNAs in a given cell is inaccurate, at least in our hands, and further conclude that DD is a useful but less than comprehensive method for assessing changes in mRNA levels.     

Towards a critical health psychology practice

The field of critical psychology is exerting an influence in the way various sub-disciplines within psychology operate. In this article we use a critical psychology framework to review the field of health psychology. Through the use of values, assumptions and practices we review progress in health psychology and offer recommendations for aligning contemporary practices with current thinking in critical psychology. We discuss typical expectations, critical formulations and critical practice for interventions with individuals, groups and communities along these dimensions.     

Evaluating the efficacy of lay first aid classes. An analysis of 222 ambulance interventions in Vienna

In spite of the well known necessity of correct first aid, only a small part of all emergency patients in Vienna receive proper first aid support by lay people. Analysis of 222 cases of the Vienna emergency ambulance service shows, that patients receive correct first aid far more often after an accident that in an internal emergency. Only few patients receive psychical support in a medical emergency. The necessity of a change in the first aid course contents is discussed in this article.     

Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review

Primary care settings are the principal context for treating clinical depression, with researchers beginning to explore the efficacy of psychosocial and pharmacological treatments for depression within this infrastructure. Feasibility and process variables also are being assessed, including issues of cost-effectiveness, viability of collaborative care models, predictors of treatment outcome, and effectiveness of treatment providers without specialized mental health training. The Agency for Health Care Policy and Research and American Psychiatric Association initially released guidelines for the treatment of depression in primary care [American Psychiatric Association, 1993. Practice Guidelines for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26., American Psychiatric Association, 2000. Practice Guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157, 1-45], however, a vast literature has accumulated over the past several years, calling for a systematic re-evaluation of the status of depression treatment in primary care. The present study provides a contemporary review of outcome data for psychosocial and pharmacological interventions in primary care and extends beyond AHCPR guidelines insofar as focusing on feasibility and process variables, including the training and proficiency of primary care treatment providers, cost-effectiveness of primary care interventions, and predictors of treatment response and relapse. Based on current guidelines, problem-solving therapy (PST-PC), interpersonal psychotherapy, and pharmacotherapy would be considered efficacious interventions for major depression, with cognitive-behavioral and cognitive therapy considered possibly efficacious. Psychotherapy and pharmacotherapy generally are of comparable efficacy, and both modalities are superior to usual care in treating depression. Methodological limitations and directions for future research are discussed.     

Evaluating the efficacy of psycho-social interventions for informal carers of cancer patients: a systematic review of the research literature

Abstract

Recognition that informal cancer carers experience unmet needs and psychological distress has led to the development of a range of psycho-social interventions. The efficacy of such interventions is examined through a systematic review of the research literature, following National Health and Medical Research Council and Cochrane Collaboration guidelines. Of 13 level II randomised controlled trials (RCTs), only eight showed significant differences across groups, with moderate effect size. This included improvement in caregiver experience or appraisal of caregiving following psycho-education (two studies); improved sexual satisfaction, dyadic coping, relationship quality and communication, or reduced psychological distress, following couple counselling (4); reduced distress following family grief therapy (1); and reduction in distress in bereavement following home palliative care (1). Level III and IV studies were also reviewed, reporting positive effects of psycho-education (5), problem solving (3), an arts intervention (1) and a support group (1). However, methodological concerns limit the generalisability of findings of level III and IV studies. It is concluded that interventions should target those most in need of support; recognise specific needs of carers across cancer type and stage, gender and relationship context; be theory based; and evaluations should utilise RCT designs with outcome measures appropriate to the specific aims of the intervention, rather than global measures of distress.     

Predicting costs of mental health care: a critical literature review

BACKGROUND: Cost evaluation research in the mental health field is being increasingly recognized as a way to achieve a more effective deployment of scarce resources. However, there is a paucity of studies that seek to identify predictors of psychiatric service utilization and costs. This paper aims to critically review the published research in the field of psychiatric service utilization and costs, and discusses current methodological developments in this field. METHOD: Sixteen studies were identified and are critically reviewed. RESULTS: No single variable alone can explain variations in costs between patients; instead, a range of different clinical and non-clinical variables provides a greater explanation of cost variations. Having a history of previous psychiatric service use is the most consistent predictor of higher psychiatric costs. Only one study considers indirect costs incurred by users, their families and friends and society as a whole, with the remaining 15 studies focusing on direct mental health care costs. There is a lack of studies that consider the future psychiatric service utilization and costs of care of children and older people. The cross-validation of predictive models is not yet routine, with only four of the studies including a cross-validation procedure. CONCLUSIONS: The predictive approach in mental health cost evaluation has relevance for both mental health policy and practice. However, there is a paucity of studies that focus on children, older people and indirect costs. Furthermore, there remain a number of methodological challenges to address.     

Evaluating treatments in health care: The instability of a one-legged stool

Background  

Both scientists and the public routinely refer to randomized controlled trials (RCTs) as being the 'gold standard' of scientific evidence. Although there is no question that placebo-controlled RCTs play a significant role in the evaluation of new pharmaceutical treatments, especially when it is important to rule out placebo effects, they have many inherent limitations which constrain their ability to inform medical decision making. The purpose of this paper is to raise questions about over-reliance on RCTs and to point out an additional perspective for evaluating healthcare evidence, as embodied in the Hill criteria. The arguments presented here are generally relevant to all areas of health care, though mental health applications provide the primary context for this essay.     

Fibroids and female reproduction: a critical analysis of the evidence

Observational epidemiological studies aimed at elucidating the relationship between fibroids and infertility are inconclusive due to methodological limitations. However, two main pieces of clinical evidence support the opinion that the fibroids interfere with fertility. First, in IVF cycles, the delivery rate is reduced in patients with fibroids but is not affected in patients who have undergone myomectomy. Second, even if randomized studies are lacking, surgical treatment appears to increase the pregnancy rate: approximately 50% women who undergo myomectomy for infertility, subsequently conceive. Available evidence also suggests that submucosal, intramural and subserosal fibroids interfere with fertility in decreasing order of importance. Although more limited, some data supports an impact of the number and dimension of the lesions. Drawing clear guidelines for the management of fibroids in infertile women is difficult due to the lack of large randomized trials aimed at elucidating which patients may benefit from surgery. At present, physicians should pursue a comprehensive and personalized approach clearly exposing the pros and cons of myomectomy to the patient, including the risks associated with fibroids during pregnancy on one hand, and those associated with surgery on the other hand.