A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial.

Background: increasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause on going disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland). Methods: the intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development. Results: the final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains (physiotherapy, dietetics, occupational therapy, and speech/language therapy), with specific training in post-critical illness issues. The intervention was from ICU discharge to 3 months post-discharge, including inpatient and post-hospital discharge elements. Clear strategies to provide information to patients/families were included. A detailed taxonomy was developed to define and describe the processes undertaken, and capture them during the trial. The detailed process measure description, together with a range of patient, health service, and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions. Conclusions: the MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention. Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting. These data will be useful when interpreting the results of the randomised trial, will increase internal and external trial validity, and help others implement the intervention if the intervention proves clinically and cost effective.

Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.

Importance: critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. Objective: to evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post–intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. Design, Setting, and Participants: a parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. Interventions: during the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. Main Outcomes and Measures: the Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). Results: median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, −0.2 [95% CI, −1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, −0.1 [95% CI, −3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, −3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. Conclusions and Relevance: post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery.

A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol.

Introduction and background: Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care. Methods and analysis: The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients’ needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the ‘Timing it Right’ framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventions throughout the recovery process. Ethics and dissemination: The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database (study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups.

The relationships between illness and treatment perceptions with adherence to diabetes self-care: A comparison between Arabic-speaking migrants and Caucasian English-speaking patients

Aims
To compare illness and treatment perceptions between Arabic-speaking immigrants and Caucasian English-speaking people with type 2 diabetes, and explore the relationships between these beliefs and adherence to self-care activities.
Methods

A cross-sectional study was conducted in healthcare settings with large Arabic populations in metropolitan and rural Victoria, Australia. Adherence to self-care activities, illness and treatment perceptions, and clinical data were recorded. Bivariate associations for continuous normally distributed variables were tested with Pearson's correlation. Non-parametric data were tested using Spearman's rank correlation coefficient.
Results

701 participants were recruited; 392 Arabic-speaking participants (ASPs) and 309 English-speaking participants (ESPs). There were significant relationships between participants’ illness and treatment perceptions and adherence to diabetes self-care activities. ASPs’ negative beliefs about diabetes were strongly and significantly correlated with poorer adherence to diet recommendations, exercise, blood glucose testing and foot care. ASPs were significantly less adherent to all aspects of diabetes self-care compared with ESPs: dietary behaviours (P = <0.01; 95% confidence interval (CI) = −1.17, −0.84), exercise and physical activity (P = <0.001, 95% CI −1.14, −0.61), blood glucose testing (P = <0.001) and foot-care (P = <0.001). 52.8% of ASPs were sceptical about prescribed diabetes treatment compared with only 11.2% of the ESPs. 88.3% of ASPs were non-adherent to prescribed medication, compared with 45.1% of ESPs.

Conclusions
Arabic-speaking migrants’ illness and treatment perceptions were significantly different from the English-speaking group. There is a pressing need to develop new innovative interventions that deliver much-needed improvements in adherence to self-care activities and key health outcomes.

Statistically modelling the relationships between Type D personality and social support, health behaviors and symptom severity in chronic illness groups

OBJECTIVE: The study aimed to develop a predictive model of how Type D personality influences health behaviours, social support and symptom severity and assess its generalisability to a range of chronic illnesses.

DESIGN: Participants were classified as either healthy (n = 182) or having a chronic illness (n = 207). Participants completed an online survey measuring Type D and a range of health-related variables. Chronic illness participants were classified as having either a functional somatic syndrome (i.e. chronic fatigue syndrome or fibromyalgia), where the underlying pathological processes were unclear, or illnesses such as type 2 diabetes, osteoarthritis or rheumatoid arthritis, where the causes are well understood.

MAIN OUTCOME MEASURES: Outcome measures were health behaviours, social support and both physical and psychological symptoms.

RESULTS: The rate of Type D was higher in chronic illness participants (53%) than in healthy controls (39%). Negative affectivity (NA) and social inhibition (SI) both correlated with outcome measures, although NA was generally the stronger predictor. Using NA and SI as independent subscales led to superior prediction of health outcomes than using categorical or continuous representations.

CONCLUSION: Findings suggest that the relationship between Type D and health outcomes may generalise across different chronic illnesses.

Successful Aging with Illness

In twenty years almost one in four Canadians will be over the age of 65. How successfully these people age will influence their quality of life and contribute to their physical health. Illness and disease are frequent components of aging; however, ‘successful aging’ research normally excludes people with illness. Older people living with illness, even life threatening illness, often self-report a good quality of life and continue to experience psychological well-being and a significant engagement in social life. This dissertation uses a three manuscript approach to examine successful aging among people with illness. The first manuscript employed a scoping review to examine the models used in recent successful aging research, compiling the most frequently used constructs which included: engagement, optimism and/or positive attitude, resilience, spirituality and/or religiosity, self-efficacy and/or self-esteem, and gerotranscendence. The second manuscript utilized data gathered via interviews (online or in person) with people over the age of 65 years living with illness. The majority of these participants reported success in aging; only resilience was predictive in the binomial regression analysis. The third manuscript examined the role of social determinants of health on successful aging. The analysis revealed that disengagement from community-activities showed a significant association with higher self-reported successful aging. The best fitting model for predicting rate of successful aging with illness was a linear combination of participants’ ageism score and community activity score, while controlling for gender and age. When considered together, the results from these three manuscripts suggest that successful aging can be experienced by older adults aging with illness. And that, among these older adults, resilience, community interaction and ageism may all play a part in determining the extent to which aging is experienced as successful. Recommendations include the suggestion that we embrace the idea that people with illness can self-define as successful agers. Further, since some of the associated constructs (e.g. resilience) can be fostered, successful aging could be bolstered by education or programs to build skills along with the usual treatment modalities for the illnesses that co-exist.

Associations between access to recreational physical activity facilities and body mass index in Scottish adults

BACKGROUND: The aim of this country-wide study was to link individual health and behavioural data with area-level spatial data to examine whether the body mass index (BMI) of adults was associated with access to recreational physical activity (PA) facilities by different modes of transport (bus, car, walking, cycling) and the extent to which any associations were mediated by PA participation. METHODS: Data on individual objectively-measured BMI, PA (number of days of (a) ≥20 min of moderate-to-vigorous PA, and (b) ≥15 min of sport or exercise, in previous 4 weeks), and socio-demographic characteristics were obtained from a nationally representative sample of 6365 adults. The number of accessible PA facilities per 1,000 individuals in each small area (data zones) was obtained by mapping a representative list of all fixed PA facilities throughout mainland Scotland. A novel transport network was developed for the whole country, and routes on foot, by bike, by car and by bus from the weighted population centroid of each data zone to each facility were calculated. Separate multilevel models were fitted to examine associations between BMI and each of the 24 measures of accessibility of PA facilities and BMI, adjusting for age, gender, longstanding illness, car availability, social class, dietary quality and urban/rural classification. RESULTS: We found associations (p < 0.05) between BMI and 7 of the 24 accessibility measures, with mean BMI decreasing with increasing accessibility of facilities-for example, an estimated decrease of 0.015 BMI units per additional facility within a 20-min walk (p = 0.02). None of these accessibility measures were found to be associated with PA participation. CONCLUSIONS: Our national study has shown that some measures of the accessibility of PA facilities by different modes of transport (particularly by walking and cycling) were associated with BMI; but PA participation, as measured here, did not appear to play a part in this relationship. Understanding the multi-factorial environmental influences upon obesity is key to developing effective interventions to reduce it.