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Background: Communities of practice could contribute to transformations in health professions education to meet complex and emerging challenges. However, little is known about the underlying mechanisms of communities of practice in this setting, and how context influences outcomes., Objective: To understand when, why and how communities of practice with health professions education faculty work to facilitate higher education change., Design: A realist synthesis according to the RAMESES standards and steps described by Pawson and colleagues., Review Methods: Early scoping of the literature informed the development of an initial program theory to describe underlying assumptions about how communities of practice in higher education, implemented with health professions education faculty, were likely to work. The theory was tested and further refined through a realist synthesis. A systematic search for evidence using search terms 'faculty', 'communities of practice' and 'higher education' and related terms was supplemented with citation tracking and hand searching of significant authors and journals. Following study appraisal, data were extracted and synthesised from 21 manuscripts describing 16 communities of practice. The realist synthesis focused on identifying patterns in context-mechanism-outcome interactions, and the alignment with substantive theory., Results: From the included manuscripts, ten context-mechanism-outcome configurations were identified that describe a range of individual, interpersonal and institutional outcomes of communities of practice with health professions education faculty and context-mechanism interactions that contribute to achieving these outcomes., Conclusions: This study expands theoretical understandings of how and why communities of practice work. There is value in communities of practice in the higher education sector, primarily in the field of health professions education. Communities of practice implemented in the context of complex change with participants who have a desire to participate can facilitate change in health professions education, including institutional level changes, through reflection, experiential learning and creating a shared agenda for change. Findings from this study can be used by policy and decision-makers within health education to best apply communities of practice to achieve meaningful outcomes., Competing Interests: Declaration of competing interest The authors have no funding or conflicts/competing interests to declare. Ethics approval was not required for this study., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: While general practice involves supporting patients to modify their behaviour, General Practitioners (GPs) vary in their approach to behaviour change during consultations. We aimed to identify mechanisms supporting GPs to undertake successful behaviour change in consultations for people with T2DM by exploring (a) the role of GPs in behaviour change, (b) what happens in GP consultations that supports or impedes behaviour change and (c) how context moderates the behaviour change consultation., Methods: Semi-structured interviews with academic clinicians ( n  = 13), GPs ( n  = 7) and patients with T2DM ( n  = 16) across Australia. Data were analysed thematically using a realist evaluation approach., Results: Perspectives about the role of GPs were highly variable, ranging from the provision of test results and information to a relational approach towards shared goals. A GP-patient relationship that includes collaboration, continuity and patient-driven care may contribute to a sense of successful change. Different patient and GP characteristics were perceived to moderate the effectiveness and experience of behaviour change consultations., Discussion: When patient factors are recognised in consultations, a relational approach becomes possible and priorities around behaviour change, that might be missed in a transactional approach, can be identified. Therefore, GP skills for engaging patients are linked to a person-centred approach., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The objective of this report was to identify the main mechanisms of home-based remote monitoring programs for cardiac rehabilitation (RM CR) and examine how these mechanisms vary by context., Methods: This was a systematic review using realist synthesis. To be included, articles had to be published in English between 2010 and November 2020 and contain specific data related to mechanisms of effect of programs. MEDLINE All (1946-) via Ovid, Embase (1974-) via Ovid, APA PsycINFO (1806-), CINAHL via EBSCO, Scopus databases, and gray literature were searched., Results: From 13 747 citations, 91 focused on cardiac conditions, with 23 reports including patients in CR. Effective RM CR programs more successfully adapted to different patient home settings and broader lives, incorporated individualized patient health data, and had content designed specifically for patients in cardiac rehabilitation. Relatively minor but common technical issues could significantly reduce perceived benefits. Patients and families were highly receptive to the programs and viewed themselves as fortunate to receive such services. The RM CR programs could be improved via incorporating more connectivity to other patients. No clear negative effects on perceived utility or outcomes occurred by patient age, ethnicity, or sex. Overall, the programs were seen to best suit highly motivated patients and consolidated rather than harmed existing relationships with health care professionals and teams., Conclusions: Remote monitoring CR programs are perceived by patients to be beneficial and attractive. Future RM CR programs should consider adaptability to different home settings, incorporate individualized health data, and contain content specific to patient needs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Priority patients in primary care include people from low-income, rural, or culturally and linguistically diverse communities, and First Nations people., Aim: To describe the effectiveness, feasibility, and acceptability of behaviour change tools that have been tested by family doctors working with priority patients., Design and Setting: A global systematic review., Method: Five databases were searched for studies published from 2000 to 2021, of any design, that tested the effectiveness or feasibility of tangible, publicly available behaviour change tools used by family doctors working with priority patients. The methodological quality of each study was appraised using the Mixed Methods Appraisal Tool., Results: Thirteen of 4931 studies screened met the eligibility criteria, and described 12 tools. The health-related behaviours targeted included smoking, diet and/or physical activity, alcohol and/or drug use, and suicidal ideation. Six tools had an online/web/app-based focus; the remaining six utilised only printed materials and/or in-person training. The effectiveness of the tools was assessed in 11 studies, which used diverse methods, with promising results for enabling behaviour change. The nine studies that assessed feasibility found that the tools were easy to use and enhanced the perceived quality of care., Conclusion: Many of the identified behaviour change tools were demonstrated to be effective at facilitating change in a target behaviour and/or feasible for use in practice. The tools varied across factors, such as the mode of delivery and the way the tool was intended to influence behaviour. There is clear opportunity to build on existing tools to enable family doctors to assist priority patients towards achieving healthier lifestyles., (© The Authors.)

Competing Interests: Conflict of interest: none declared.

Background: The 5As framework is a recognized underpinning of behaviour change guidelines, teaching, and research in primary care. Supporting patients to improve their lifestyle behaviours, including diet and physical activity, is a common aspect of type 2 diabetes mellitus (T2DM) management. The 5As framework often informs behaviour change for patients with T2DM., Objective: To explore the experience and perspectives of general practitioners (GPs) and primary care academics and behaviour change experts regarding using the 5As framework when caring for patients with T2DM to better understand how and why the 5As are effective in practice., Methods: We recruited 20 practising GPs, primary care academics, and behaviour change experts for an individual semistructured interview and analysed the data using a realist evaluation approach., Results: There were diverse accounts of how GPs use the 5As in practice and few of the participants could name each "A." The 5As were commonly regarded as a framework best suited to beginners and although GPs expressed they followed the broad direction of the 5As, they did not consciously follow the framework in an instructive manner. Elements that could enhance the 5As included more emphasis on motivational interviewing, changing how "Ask" is included in the consultation, and increased person-centredness., Conclusion: Although it is a ubiquitous framework in primary care, the 5As are understood in diverse ways and applied variably in practice. There is room to enhance how the 5As support behaviour change consultations to optimize outcomes in primary care., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Many people with heart failure do not receive cardiac rehabilitation despite a strong evidence base attesting to its effectiveness, and national and international guideline recommendations. A more holistic approach to heart failure rehabilitation is proposed as an alternative to the predominant focus on exercise, emphasising the important role of education and psychosocial support, and acknowledging that this depends on patient need, choice and preference. An individualised, needs-led approach, exploiting the latest digital technologies when appropriate, may help fill existing gaps, improve access, uptake and completion, and ensure optimal health and wellbeing for people with heart failure and their families. Exercise, education, lifestyle change and psychosocial support should, as core elements, unless contraindicated due to medical reasons, be offered routinely to people with heart failure, but tailored to individual circumstances, such as with regard to age and frailty, and possibly for recipients of cardiac implantable electronic devices or left ventricular assist devices., Competing Interests: Disclosure: DRT is on the Cardiac Failure Review editorial board; this did not influence peer review. All other authors have no conflicts of interest to declare., (Copyright © 2022, Radcliffe Cardiology.)

Purpose: To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care., Method: Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present., Results: From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care., Conclusions: We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively., Systematic Review Registration Number: CRD42018091338 in PROSPERO (International prospective register of systematic reviews)., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose of Review: To review the application of intersectionality to heart failure. Intersectionality refers to the complex ways in which disenfranchisement and privilege intersect to reproduce and influence health and social outcomes., Recent Findings: Intersectionality challenges approaches that focus on a single or small number of socio-demographic characteristics, such as sex or age. Instead, approaches should take account of the nature and effects of a full range of socio-demographic factors linked to privilege, including: race and ethnicity, social class, income, age, gender identity, disability, geography, and immigration status. Although credible and well established across many fields - there is limited recognition of the effects of intersectionality in research into heart disease, including heart failure. This deficiency is important because heart failure remains a common and burdensome syndrome that requires complex pharmacological and nonpharmacological care and collaboration between health professionals, patients and caregivers during and at the end-of-life., Summary: Approaches to heart failure clinical care should recognize more fully the nature and impact of patients' intersectionality- and how multiple factors interact and compound to influence patients and their caregivers' behaviours and health outcomes. Future research should explicate the ways in which multiple factors interact to influence health outcomes., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: To identify clinical symptoms and nursing interventions for stem cell therapy in autoimmune diseases., Design: This is a retrospective, cross-sectional study., Methods: This study was undertaken with patients diagnosed with type 1 diabetes or multiple sclerosis, undergoing autologous haematopoietic stem cell transplantation from January 2004 - December 2018. Data were registered in a questionnaire, taken during the conditioning regimen comprising cyclophosphamide and rabbit anti-thymocyte globulin. Descriptive statistics and Fisher's exact test were used for data analysis., Results: There were 68 and 23 patients in the multiple sclerosis and type 1 diabetes groups respectively. Skin rash, nausea, vomiting and fever were more frequent and diverse in the type 1 diabetes group. Steroids were used as prophylaxis for anti-thymocyte globulin-associated allergic reactions in 97% of multiple sclerosis patients. Most of the identified symptoms and nursing interventions were more associated with one or other disease group (p < .05) and were more frequent in the type 1 diabetes group., Conclusion: Patients with autoimmune diseases who underwent stem cell therapy present differences in their repertoire of adverse events and require disease-specific nursing actions., Impact: Our results may enable nurses to establish transplant and disease-specific guidelines to improve prevention and management of adverse events and therefore optimize patient care and therapeutic success., (© 2020 John Wiley & Sons Ltd.)

Background: Self-care adherence remains low in patients with heart failure (HF); little is known about the influence of patients' values on self-care decisions and behaviors., Objectives: The aim of this study was to explore how participants living with HF perceive their values and how those values are reportedly expressed in self-care decision making., Methods: The Interpretative Phenomenological Analysis approach was used. Semistructured interviews were conducted with 12 patients 60 years or older; with New York Heart Association class II and III HF; and able to speak, read, and understand English. Participants recruited via convenience sampling (January-December 2016) from 2 urban sites in Western Canada., Results: Values were reported to pivotally influence HF self-care decisions and behaviors. Overarching themes addressed aspects of values and decision making: notably, directness and complexity. Two main types of values, functional and emotional values, were involved in both adherent and nonadherent decisions. Values were often in flux, with the pursuit of these values being frequently in conflict with physical ability and changing over time., Conclusion: Two types of values serve influence self-care decisions and adherence. As HF and its self-care prevent patients from pursuing their prioritized values, patients are often nonadherent. Thus, patients with HF should be supported to find alternative ways to enact their values.

Background: Most patients with advanced heart failure are ill-prepared and poorly supported during the end of life. To date, research has focused primarily on generalized patient accounts of the management or self-care phase of the syndrome. Little research has examined the end of life in depth or from the perspectives of family members., Aims: The purpose of this study is to describe how people diagnosed with heart failure and their family members describe uncertainty related to impending death., Methods and Results: A narrative inquiry was undertaken using a social constructionist perspective. Twenty participants took part in over 60 interviews: 12 participants with heart failure (eight male and four female; mean = 67.3 years) and eight family members (mean = 61.6 years) engaged in two in-depth interviews, approximately 3-4 months apart, followed by a telephone follow-up 2-3 months later. Six key themes/storylines were identified. These included: prognosis messages received from physicians; whenever I die, I die; loss isn't new to me but … ; carrying on amidst the fragility of life; ultimately living not knowing; and the need to prepare., Conclusion: The six key storylines of death and dying with advanced heart failure were consistent for both patients and family members. There was a desire for better communication with physicians. Many participants were critical of how the prognosis of advanced heart failure was communicated to them, even if they anticipated the news. Participants wanted frank, open conversations with their healthcare providers that both acknowledged that they were at end of life but did not remove all hope.

The concept of trust is essential for high-functioning general practice teams during a pandemic.

This study explores factors that affect the people of low socioeconomic status regarding food choices after diagnosis with cardiovascular disease. Qualitative approach was used to identify the important factors associated with dietary changes as a result of their disease. Twenty-four participants were interviewed from two cardiac facilities in Karachi, the largest metropolitan city of Pakistan. Data were analyzed to identify the themes using the interpretative description approach. While most participants understood the need for dietary changes, few were able to follow recommended diets. Their food choices were primarily influenced by financial constraints as well as cultural, familial, and religious values and practices. The challenge for health care providers lies in understanding the economical, sociocultural, and religious factors that influence behavioral changes which, in turn, affect dietary choices. It is apparent that cardiovascular risk and disease outcomes for the people of low socioeconomic status are likely to escalate. Thus, it is necessary to address the sociocultural, religious, and behavioral factors affecting dietary choices. Achieving this imperative requires an intersectorial, multilevel intervention for the prevention of cardiovascular diseases in people of low socioeconomic status., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Background: Patients' values are everywhere and nowhere in nursing: frequently invoked and associated with effective nursing care but seldom explicitly defined or subject to dedicated analysis. Clarification of the concept of patients' values is pivotal because respecting and supporting patients' values are widely recognized as crucial for ethical nursing care. Despite this and the pervasive employment of the term patients' values in theories, approaches, and clinical guidelines, the concept remains ambiguous., Purpose: We sought to understand the key elements of the concept by investigating its use in theoretical and empirical literature., Method: This study used Rodgers' evolutionary concept analysis approach., Findings: We found that values are core individual beliefs that function in hierarchical systems; however, in the context of disease, the priority assigned to values by the individual may change. This is important, given that values play a foundational role in health-related decisions, such as in the context of chronic diseases., Discussion: Values are influenced by both individual intrinsic needs and the social context, but importantly, are involved in guiding decision-making. The attributes of the values may vary according to the context of the disease, the type of disease, and the decision at hand., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Coronary heart disease (CHD) is a major cause of death worldwide. Cardiac rehabilitation, an evidence-based CHD secondary prevention programme, remains underutilized. Telehealth may offer an innovative solution to overcome barriers to cardiac rehabilitation attendance. We aimed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and/or usual care for patients with CHD., Methods: Relevant randomized controlled trials evaluating telehealth interventions in CHD patients with at least three months' follow-up compared with cardiac rehabilitation and/or usual care were identified by searching electronic databases. We checked reference lists, relevant conference lists, grey literature and keyword searching of the Internet. Main outcomes included all-cause mortality, rehospitalization/cardiac events and modifiable risk factors. (PROSPERO registration number 77507.)., Results: In total, 32 papers reporting 30 unique trials were identified. Telehealth was not significant associated with a lower all-cause mortality than cardiac rehabilitation and/or usual care (risk ratio (RR)=0.60, 95% confidence interval (CI)=0.86 to 1.24, p=0.42). Telehealth was significantly associated with lower rehospitalization or cardiac events (RR=0.56, 95% CI=0.39 to 0.81, p<0.0001) compared with non-intervention groups. There was a significantly lower weighted mean difference (WMD) at medium to long-term follow-up than comparison groups for total cholesterol (WMD= -0.26 mmol/l, 95% CI= -0.4 to -0.11, p <0.001), low-density lipoprotein (WMD= -0.28, 95% CI = -0.50 to -0.05, p=0.02) and smoking status (RR=0.77, 95% CI =0.59 to 0.99, p=0.04]., Conclusions: Telehealth interventions with a range of delivery modes could be offered to patients who cannot attend cardiac rehabilitation, or as an adjunct to cardiac rehabilitation for effective secondary prevention.

Background: The role of exercise training modality to attenuate left ventricular (LV) remodeling in heart failure patients with reduced ejection fraction (HFrEF) remains uncertain. The authors performed a systematic review and meta-analysis of published reports on exercise training (moderate-intensity continuous aerobic, high-intensity interval aerobic, and resistance exercise) and LV remodeling in clinically stable HFrEF patients., Methods: We searched MEDLINE, Cochrane Central Registry of Controlled Trials, CINAHL, and PubMed (2007 to 2017) for randomized controlled trials of exercise training on resting LV ejection fraction (EF) and end-diastolic and end-systolic volumes in HFrEF patients., Results: 18 trials reported LV ejection fraction (LVEF) data, while 8 and 7 trials reported LV end-diastolic and LV end-systolic volumes, respectively. Overall, moderate-intensity continuous training (MICT) significantly increased LVEF (weighted mean difference, WMD = 3.79%; 95% confidence interval, CI, 2.08 to 5.50%) with no change in LV volumes versus control. In trials ≥6 months duration, MICT significantly improved LVEF (WMD = 6.26%; 95% CI 4.39 to 8.13%) while shorter duration (<6 months) trials modestly increased LVEF (WMD = 2.33%; 95% CI 0.84 to 3.82%). High-intensity interval training (HIIT) significantly increased LVEF compared to control (WMD = 3.70%; 95% CI 1.63 to 5.77%) but was not different than MICT (WMD = 3.17%; 95% CI -0.87 to 7.22%). Resistance training performed alone or combined with aerobic training (MICT or HIIT) did not significantly change LVEF., Conclusions: In clinically stable HFrEF patients, MICT is an effective therapy to attenuate LV remodeling with the greatest benefits occurring with long-term (≥6 months) training. HIIT performed for 2 to 3 months is superior to control, but not MICT, for improvement of LVEF., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background and Objectives: Obesity is a common chronic condition, and general practitioners are seeking more effective strategies for assisting their patients. The therapeutic relationship between patients and practitioners is increasingly recognised as a fundamental part of intervention effectiveness. The influence of therapeutic relationships in obesity interventions in primary care has not been systematically studied. We plan to undertake a systematic review and meta-analysis to identify the influence of the therapeutic alliance on the effectiveness of obesity interventions in primary healthcare. The aim of this article is to outline the study protocol., Method: A systematic review of primary care interventions for patients with obesity will be undertaken. Using Bordin's framework for the therapeutic alliance, interventions will be categorised as to whether they incorporate the alliance or not. A meta‑analysis will be performed if studies of sufficiently homogenous primary outcome data are found., Discussion: Understanding the role of the therapeutic alliance on interventions for obesity management will have implications for both future intervention development and the translation of current interventions from trial settings to the real world.

Background: The mechanisms contributing to the success of cardiac rehabilitation (CR) are poorly understood and may include assessment, monitoring and review activities enabled by continuity of care and this is investigated in this study., Objectives: To identify active assessment components of CR., Methods: A qualitative study using focus groups and individual interviews. CR staff (n = 39) were recruited via professional association email and network contacts and organised into major themes., Results: CR staff assessment strategies and timely actions undertaken provided a sophisticated post-discharge safety net for patients. Continuity of care enabled detection of adverse health indicators, of which medication issues were prominent. Interventions were timely and personalised and therefore likely to impact outcomes, but seldom documented or reported and thus invisible to audit., Conclusion: CR staff assessment and intervention activities provide an unrecognised safety net of activities enabled by continuity of care, potentially contributing to the effectiveness of CR., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In summer 2015, a Saudi 1000-bed tertiary care hospital experienced a serious outbreak among patients of Middle Eastern Respiratory Syndrome (MERS); during which, some healthcare providers contracted the virus, but none died. The outbreak provoked not only fear and stress; but also professional, emotional, ethical, and social conflicts and tension among healthcare providers and patients alike. Therefore, this study aims to explore what healthcare providers, who survived coronavirus infection, have experienced as a MERS patient and how the infection affected their relationship with their colleagues. Semi-structured, face-to-face interviews were conducted individually with seven survivors (healthcare providers). Each interview lasted up to 90min, and the data were analyzed using the thematic analysis technique. Within the participants' rich and illuminating experiences, four themes were identified: caring for others in the defining moments, perceived prejudice behaviours and stigmatization, lived moments of traumatic fear and despair, and denial and underestimation of the seriousness of the disease at the individual and organizational levels. Survivors still suffered as a result of their traumatic experiences, which might negatively influence their performance. As these survivors are vulnerable, it is their organization's responsibility to provide a system that embraces HCPs during and after disastrous events., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation., Objectives: 1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event)., Search Methods: We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied., Selection Criteria: 1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD., Data Collection and Analysis: Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables., Main Results: This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains., Authors' Conclusions: We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.

A challenge that speech-language pathologists (SLPs) face is the translation of research into clinical practice. While randomised controlled trials (RCTs) are often touted as the "gold standard" of efficacy research, much valuable information is lost through the process; RCTs by nature are designed to wash out individual client factors and contexts that might influence the outcome in order to present the "true" impact of the intervention. However, in the area of behavioural interventions, the interaction of client factors and contexts with the treatment agent can substantially influence the outcome. This paper provides an overview of the theoretical background and methods involved in critical realistic evaluation (CRE) and discusses its current and potential application to speech-language pathology. CRE is based on the premise that a behavioural intervention cannot be evaluated without considering the context in which it was provided. While the ways in which contextual aspects and treatment mechanisms interact may seem endless, CRE methodology attempts to operationalise them into hypotheses to be empirically tested. Research based on these principles has the potential to support clinical translation of research outcomes and reduce the costs of unsuccessful treatment attempts for SLPs, clients and the service provider.

Cardiovascular disease exerts an enormous burden on women's health. The intake of a healthy diet may reduce this burden. However, social norms and economic constraints are often factors that restrain women from paying attention to their diet. Underpinned by critical realism, this study explores how gender/sex influences decision-making regarding food consumption among women of low socioeconomic status (SES). The study was carried out at two cardiac facilities in Karachi, Pakistan, on 24 participants (male and female from different ethnic backgrounds), who had received health education. Using an interpretive descriptive approach, the study identified major barriers to a healthy diet: proscribed gender roles and lack of women's autonomy, power, male domination, and abusive behaviours. Cardiovascular risk and disease outcomes for the Pakistani women of low SES are likely to further escalate if individual and structural barriers are not reduced using multifactorial approaches., (© 2016 John Wiley & Sons Ltd.)

Background: Cognitive impairment is prevalent in heart failure (HF) with severe consequences, including increased risk of mortality and reduced ability to self-manage HF symptoms. Identifying cognitive impairment through screening would assist clinicians in managing HF and comorbid cognitive impairment. However, the accuracy of cognitive screening instruments for HF has not been adequately determined., Objective: The aim of this study was to determine the diagnostic accuracy of cognitive screening instruments in screening for mild cognitive impairment (MCI) in HF patients., Methods: A systematic review of major electronic bibliographic databases was searched from January 1999 to June 2013. Inclusion criteria were as follows: primary studies examining cognitive impairment in HF, administration of a cognitive screening instrument and neuropsychological test battery, and cognitive impairment indicated by performance on neuropsychological tests 1.5 SDs less than that of normative data. Methodological rigor of included publications was evaluated using 2 bias risk instruments: QUality Assessment of Diagnostic Accuracy Studies and STAndards for the Reporting of Diagnostic accuracy studies. The precision, accuracy, and receiver operating characteristic curves of the Mini Mental State Examination were computed., Results: From 593 citations identified, 8 publications met inclusion criteria. Risk of bias included selective HF patient samples, and no study examined the diagnostic test accuracy of the cognitive screening instruments. The Mini Mental State Examination had low sensitivity (26%) and high specificity (95%) with a score of 28 or less as the optimal threshold for MCI screening., Conclusions: Screening for cognitive impairment in HF is recommended; however, future studies need to establish the diagnostic accuracy of screening instruments of MCI in this population.

Background: Values are central to ethical and effective nursing and health care. However, in relation to heart failure, an extremely common and burdensome syndrome, the role that patients' values have in influencing self-care is poorly understood., Methods: A mixed methods systematic review was conducted using a critical meta-narrative synthesis approach to synthesizing qualitative and qualitized data. Nine databases were searched (14 March 2014). To be included in the review, studies had to contain data on heart failure patients' values and self-care behaviors, include adults aged ≥18 years with symptomatic heart failure, and be published ≥2000 as full articles or theses. Study quality was assessed using a mixed-methods appraisal tool., Findings: Of 6467 citations identified, 54 studies were included (30 qualitative, 8 mixed methods, and 16 quantitative; 6045 patients, 38 lay caregivers, and 96 health care professionals). The synthesis identified multiple bi-directional interactions between heart failure, patients' values, and self-care. Patients are motivated by self-related and other-related values. Self-related values are tied directly to intimate personal feelings (self-direction, pleasure, and being healthy) or related to individuals' life circumstances (maintaining a healthy lifestyle and financial balance). Other-related values, which are fundamentally socially-based, are related to benefits received from society (social recognition and socialization) and social obligations (responsibility, observing traditions, and obedience). For each decision, several values are involved; some are incompatible and some are in conflict. Patients make their self-care decision based on the values they prioritize and those that are blocked., Conclusion: Values are integral to how patients approach and undertake HF self-care. These values both affect and respond to this self-care and the severity of HF symptoms. Values extend to those relating to the self and others and incorporate a range of personal, life, and social dimensions. Values cannot be assumed to be fixed, normative or similar to those held by nurses and other health professionals. Future interventions to improve HF self-care must address and respond to the complexity of patients' values and how they influence patient behavior in undertaking heart failure self-care., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To identify the main mechanisms of heart failure (HF) disease management programmes based in hospitals, homes or the community., Methods: Systematic review of qualitative and quantitative studies using realist synthesis. The search strategy incorporated general and specific terms relevant to the research question: HF, self-care and programmes/interventions for HF patients. To be included, papers had to be published in English after 1995 (due to changes in HF care over recent years) to May 2014 and contain specific data related to mechanisms of effect of HF programmes. 10 databases were searched; grey literature was located via Proquest Dissertations and Theses, Google and publications from organisations focused on HF or self-care., Results: 33 studies (n=3355 participants, mean age: 65 years, 35% women) were identified (18 randomised controlled trials, three mixed methods studies, six pre-test post-test studies and six qualitative studies). The main mechanisms identified in the studies were associated with increased patient understanding of HF and its links to self-care, greater involvement of other people in this self-care, increased psychosocial well-being and support from health professionals to use technology., Conclusion: Future HF disease management programmes should seek to harness the main mechanisms through which programmes actually work to improve HF self-care and outcomes, rather than simply replicating components from other programmes. The most promising mechanisms to harness are associated with increased patient understanding and self-efficacy, involvement of other caregivers and health professionals and improving psychosocial well-being and technology use., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)