Development of an intervention to support medication management in patients with multimorbidity in primary care

The overarching aim of this thesis was to develop an intervention to support patient-centred prescribing in the context of multimorbidity in primary care. Methods A range of research methods were used to address different components of the Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in health care. The existing evidence on GPs’ perceptions of the management of multimorbidity was systematically reviewed. In qualitative interviews, chart-stimulated recall was used to explore the challenges experienced by GPs when prescribing for multimorbid patients. In a cross-sectional study, the psychosocial issues that complicate the management of multimorbidity were examined. To develop the complex intervention, the Behaviour Change Wheel (BCW) was used to integrate behavioural theory with the findings of these three studies. A feasibility study of the new intervention was then conducted with GPs. Results The systematic review revealed four domains of clinical practice where GPs experienced difficulties in multimorbidity. The qualitative interview study showed that GPs responded to these difficulties by ‘satisficing’. In multimorbid patients perceived as stable, GPs preferred to ‘maintain the status quo’ rather than actively change medications. In the cross-sectional study, the significant association between multimorbidity and negative psychosocial factors was shown. These findings informed the development of the ‘Multimorbidity Collaborative Medication Review and Decision-making’ (MY COMRADE) intervention. The intervention involves peer support: two GPs review the medications prescribed to a complex multimorbid patient together. In the feasibility study, GPs reported that the intervention was appropriate for the context of general practice; was widely applicable to their patients with multimorbidity; and recommendations for optimising medications arose from all collaborative reviews. Conclusion Applying theory to empirical data has led to an intervention that is implementable in clinical practice, and has the potential to positively change GPs’ behaviour in the management of medications for patients with multimorbidity.

Estado nutricional y etapas de cambio comportamental frente a la actividad física niños y adolescentes de Bogotá, Colombia: Estudio FUPRECOL

Objetivo: El propósito del estudio fue relacionar la etapa en el cambio en el comportamiento frente a la actividad física y el estado nutricional en escolares entre 9 y 17 años de Bogotá- Colombia, pertenecientes al estudio FUPRECOL. Método: Se trata de un estudio transversal, en 6.606 niños y adolescentes entre 9 y 17 años, pertenecientes a 24 instituciones educativas, de Bogotá-Colombia. Se aplicó de manera auto-diligenciada el cuestionario de cambio de comportamiento en función a la intensión de realizar actividad física (CCC-Fuprecol) y se midió el peso y la estatura para determinar el estado nutricional con el índice de masa corporal (IMC). Resultados: El porcentaje de respuesta fue 94% y se consideraron válidos 6,606 registros, siendo 58.3 % (n=3.850) niñas con un promedio de edad de 12,7±2,3 años. En la población general, el 5,3 % de los escolares se encontraban en etapa de pre-contemplación, 31,8 % en contemplación, el 26,7 % en acción y el 36,2 % en etapa de mantenimiento. Al comparar la etapa de cambio con el estado nutricional por IMC, los escolares clasificados en obesidad mostraron mayor frecuencia de respuesta en la etapa de pre-contemplación, mientras que los escolares con peso saludable acusaron mayores porcentajes en la etapa de mantenimiento. Conclusión: En escolares de Bogotá, Colombia, se encontró una relación estadísticamente significativa entre a la intensión de realizar actividad con el estado nutricional medido con el IMC. Fomentar la promoción de la actividad física y monitorear el estado nutricional, deberá ser una prioridad en las agendas y políticas públicas dentro del ámbito escolar.

Etapas de cambio conductual relacionado al consumo de frutas y verduras en escolares de Bogotá, Colombia

Objetivo: Describir la relación de las etapas de cambio conductual frente al consumo de frutas y verduras con el estado nutricional en un grupo de escolares de Bogotá, Colombia, pertenecientes al estudio FUPRECOL. Métodos: Estudio de corte transversal en 1.922 niños y adolescentes entre 9 y 17 años, pertenecientes a nueve instituciones educativas oficiales de Bogotá. Se aplicó de manera auto-diligenciada el cuestionario de cambio de comportamiento (CCC-Fuprecol) validado en el “estudio FUPRECOL” y se calculó el Índice de Masa Corporal (IMC) como marcador del estado nutricional. Se calcularon prevalencias y se establecieron asociaciones mediante modelos de regresión logística binaria. Resultados: La muestra estuvo conformada por 1.045 niños-niñas y adolescentes vs hombres (45.6%) y mujeres (54.3%) y 877. La mayor proporción de consumo de frutas en el subgrupo de hombres (niños entre 9 y 12 años vs. adolescentes entre 13 y 17 años) se observó en la etapa de mantenimiento, (53.3 % vs. 38.8 %, X2 p<0.001), seguido de preparación/acción (25.0 % vs. 32.4 %, X2 p<0.001). En mujeres entre 9 y 12 años, la mayor proporción se ubicó en la etapa de mantenimiento (54.4 %), a diferencia de las adolescentes entre 13 y 17 años que acusaron mayor frecuencia la etapa de preparación/acción (42.0 %). Se observó que pertenecer al grupo de mujeres, se asociaba como variable para el cumplimiento de la recomendación mínima de frutas y verduras con valores de OR 1.54 (IC95% 1.22-1.93) y OR 1.48 (IC95% 1.19-1.84), respectivamente. Conclusiones: Aproximadamente, 66 % de los participantes tienen la intención o la voluntad de cumplir las recomendaciones de consumo de frutas y verduras. La identificación temprana de niños y adolescentes con bajo consumo de alimentos vegetales, permitirá implementar intervenciones para promover comportamientos saludables a fin de prevenir el riesgo cardiometabólico en la edad adulta.

Understanding food waste through behavioural theories in different settings

SDG 12.3 aims to promote sustainable consumption and production patterns by addressing the global food loss and waste problem. Given the multiple interrelated impacts, food waste is recognized as one of the major food system challenges. The scope of this work is to contribute to the understanding on food waste generation and potential approaches to tackle it. This work was specifically designed to achieve the following goals: 1) Understand specific factors that affect individual behaviours to generate FW at household, 2) Analyse the effective ways to reduce FW through behaviour change perspective given the catering and hospitality sector, and 3) Provide an evidence synthesis on intervention study that incorporate stakeholder insights focus on school meals. The first goal of identifying food waste drivers was achieved by the systematically reviewing on peer-reviewed and grey literature. The Motivation-Opportunity-Ability (MOA) framework was applied to frame consumer behavioural drivers and identify levers that could be potentially utilized to reduce food waste. Consumer segmentation was further discussed to provide insights for developing tailored food waste reduction interventions. The second goal required the identification on practical interventions, which has been accomplished by systematic literature review basing on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The efficiency and working mechanism of interventions were evaluated basing on the combination of MOA and behavioural change wheel. Building on the evidence of effective interventions, a roadmap was developed for policymakers and practitioners to lead their own pathway on intervention study and upscaling. The third aim has been achieved with a school meals interventions mapping and the implementation of stakeholder workshops. The method was built on the literature review and then enriched by intervention co-design dialogue among stakeholders. The overall conclusion addressed challenges of food waste determents identification, tailored reduction interventions developing, sustainable consumption promotion with school meals.

Exploring Change in Neanderthal Behavioural Complexity: An Innovative Approach to the Study of Neanderthal Behaviour

Diachronic approaches provide potential for a more sophisticated framework within which to examine change in Neanderthal behavioural complexity using archaeological proxies such as symbolic artefacts, faunal assemblages and technology. Analysis of the temporal appearance and distribution of such artefacts and assemblages provide the basis for identifying changes in Neanderthal behavioural complexity in terms of symbolism, faunal extraction and technology respectively. Although changes in technology and faunal extraction were examined in the wider study, only the results of the symbolic study are presented below to illustrate the potential of the approach.

Fashion communication: a way to change comsumption behaviour towards ethical fashion

In view of the major social and environmental problems, with which we are faced nowadays, we noticed a certain absence of values in society, where man draws many more resources than nature can replace in the short or medium term. Within the framework of fashion emerges the ethical fashion as a movement in this direction, intending to change this current paradigm. Ethical fashion encompasses different concepts such as fair trade, sustainability, working conditions, raw materials, social responsibility and the protection of animals. This study aims to determine which type of communication are fashion brands using in this context, and if this communication aims at educating the consumer for a more ethical consumer behavior. For this study were selected 44 fashion brands associated with the Ethical Trade Initiative. The method used for the research development was content analysis for which first was made a data collection of the information provided on the websites and social networks of the selected fashion brands. The data was analyzed taking into account the quality and type of information published related to ethical fashion, for which an ordinal scale was created as a way of measuring and comparing results.

L’appel conjoint de la FEE et d’Eurosif pour une amélioration de la divulgation de l’information extra-financière : « drive change in corporate behaviour »

Suite à la table ronde qui s’est tenue le 29 avril 2009 au Parlement européen consacrée au thème de la « Sustainability Disclosure », la Fédération des Experts comptables Européens (FEE) et l’European Sustainable Investment Forum (Eurosif) viennent de diffuser un plan d’actions destiné à améliorer la divulgation des informations extra-financières des sociétés cotées et non cotées contenues dans leurs documents financiers.

Researching farmer behaviour in climate change adaptation and sustainable agriculture: lessons learned from five case studies

Understanding farmer behaviour is needed for local agricultural systems to produce food sustainably while facing multiple pressures. We synthesize existing literature to identify three fundamental questions that correspond to three distinct areas of knowledge necessary to understand farmer behaviour: 1) decision-making model; 2) cross-scale and cross-level pressures; and 3) temporal dynamics. We use this framework to compare five interdisciplinary case studies of agricultural systems in distinct geographical contexts across the globe. We find that these three areas of knowledge are important to understanding farmer behaviour, and can be used to guide the interdisciplinary design and interpretation of studies in the future. Most importantly, we find that these three areas need to be addressed simultaneously in order to understand farmer behaviour. We also identify three methodological challenges hindering this understanding: the suitability of theoretical frameworks, the trade-offs among methods and the limited timeframe of typical research projects. We propose that a triangulation research strategy that makes use of mixed methods, or collaborations between researchers across mixed disciplines, can be used to successfully address all three areas simultaneously and show how this has been achieved in the case studies. The framework facilitates interdisciplinary research on farmer behaviour by opening up spaces of structured dialogue on assumptions, research questions and methods employed in investigation.

Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis

This study investigates predictors of outcome in a secondary analysis of dropout and completer data from a randomized controlled effectiveness trial comparing CBTp to a wait-list group (Lincoln et al., 2012). Eighty patients with DSM-IV psychotic disorders seeking outpatient treatment were included. Predictors were assessed at baseline. Symptom outcome was assessed at post-treatment and at one-year follow-up. The predictor x group interactions indicate that a longer duration of disorder predicted less improvement in negative symptoms in the CBTp but not in the wait-list group whereas jumping-to-conclusions was associated with poorer outcome only in the wait-list group. There were no CBTp specific predictors of improvement in positive symptoms. However, in the combined sample (immediate CBTp+the delayed CBTp group) baseline variables predicted significant amounts of positive and negative symptom variance at post-therapy and one-year follow-up after controlling for pre-treatment symptoms. Lack of insight and low social functioning were the main predictors of drop-out, contributing to a prediction accuracy of 87%. The findings indicate that higher baseline symptom severity, poorer functioning, neurocognitive deficits, reasoning biases and comorbidity pose no barrier to improvement during CBTp. However, in line with previous predictor-research, the findings imply that patients need to receive treatment earlier.

Farmers behaviour on mitigation and adaptation to climate change: A case study in Kenya.

Farmers in Africa are facing climate change and challenging rural livelihoods while maintaining agricultural systems that are not resilient. By 2050 the mean estimates of production of key staple crops in Africa such as maize, sorghum, millet, groundnut, and cassava are expected to decrease by between 8 and 22 percent (Schlenker and Lobell 2010). In Kenya, although projections of rainfall do not show dramatic decreases, the distribution of impacts is clearly negative for most crops. As increases in temperature will lead to increases in evapotranspiration, a potential increase in rainfall in Kenya may not offset the expected increases in agricultural water needs (Herrero et al. 2010). In order to respond to these present and future challenges, potential mitigation and adaptation options have been developed. However, implementation is not evident. In addition to their benefits in either mitigating or reducing the vulnerability of climate change effects, many of these options do not have economic costs and even provide economic benefits (e.g. savings in the consumption of energy or natural resources). Nevertheless, it is demonstrated that even when there are no biophysical, technological or economic constraints and despite their potential benefits from either the economic or environmental climate change point of view, not all farmers are willing to adopt these measures. This reflects the key role that behavioural barriers can play in the uptake of mitigation and adaptation measures.

Cognitive change process during group cognitive behaviour therapy for depression

Background: This study extended that of Kwon and Oei [Kwon, S.M., Oei, T.P.S., 2003. Cognitive change processes in a group cognitive behavior therapy of depression. J. Behav. Ther. Exp. Psychiatry, 3, 73-85], which outlined a number of testable models based on Beck's cognitive theory of depression. Specifically, the current study tested the following four competing models: the causal, consequential, fully and partially interactive cognitive models in patients with major depressive disorder. Methods: A total of 168 clinically depressed outpatients were recruited into a 12-week group cognitive behaviour therapy program. Data was collected at three time points: baseline, mid- and at termination of therapy using the ATQ DAS and BD1. The data were analysed with Amos 4.01 (Arbuckle, J.L., 1999. Amos 4.1. Smallwaters, Chicago.) structural equation modelling. Results: Results indicated that dysfunctional attitudes, negative automatic thoughts and symptoms of depression reduced significantly during treatment. Both the causal and consequential models equally provided an adequate fit to the data. The fully interactive model provided the best fit. However, after removing non-significant pathways, it was found that reduced depressive symptom contributed to reduced depressogenic automatic thoughts and dysfunctional attitudes, not the reverse. Conclusion: These findings did not fully support Beck's cognitive theory of depression that cognitions are primary in the reduction of depressed mood. (c) 2006 Elsevier B.V. All rights reserved.