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ObjectiveLondon has one of the highest identified prevalence of chemsex (sexualised recreational drug use) among men who have sex with men (MSM) in Europe. We examine MSM’s patterns of chemsex and its association with HIV/STI risk behaviours, STI diagnoses and sexual healthcare-seeking behaviours, including if HIV testing behaviour met UK national guidelines (three monthly if engaging in chemsex).MethodsCross-sectional survey data from 2013 (n=905) and 2016 (n=739) were collected using anonymous, self-administered questionnaires from MSM recruited in commercial gay venues in London, UK. Descriptive and multivariable analyses, stratified by self-reported HIV status, were conducted. Adjusted prevalence ratios (aPR) with 95% CIs were calculated.ResultsComparing the 2013 and 2016 surveys, chemsex prevalence in the past year remained stable, in both HIV-negative/unknown-status MSM (20.9% in 2013 vs 18.7% in 2016, p=0.301) and HIV-positive MSM (41.6% in 2013 vs 41.7% in 2016, p=0.992). Combined 2013–2016 data showed that compared with other MSM, those reporting chemsex were more likely to report HIV/STI risk behaviours, including condomless anal intercourse with serodifferent HIV-status partners (HIV-negative/unknown-status men: aPR 2.36, 95% CI 1.68 to 3.30; HIV-positive men: aPR 4.19, 95% CI 1.85 to 9.50), and STI diagnoses in the past year (HIV-negative/unknown-status men: aPR 2.10, 95% CI 1.64 to 2.69; HIV-positive men: aPR 2.56, 95% CI 1.57 to 4.20). 68.6% of HIV-negative/unknown-status men reporting chemsex attended sexual health clinics and 47.6% had tested for HIV more than once in the past year.ConclusionsChemsex in London MSM remained stable but high, particularly among HIV-positive men. Irrespective of HIV status, chemsex was associated with engagement in HIV/STI risk behaviours. Frequency of HIV testing in the past year among HIV-negative/unknown-status men was below national recommendations. Promoting combination prevention strategies, including three monthly HIV/STI testing, access to pre-exposure prophylaxis/antiretroviral treatment and behavioural interventions among MSM reporting chemsex, remains vital to address sexual health inequalities in MSM.

Erythromelalgia is a rare hereditary channelopathy affecting the Nav1.7 sodium channel. Patients afflicted with this condition suffer from pain in their hands and feet, with vasomotor changes including flushing and redness to the distal upper and lower extremities. Current treatment modalities for this condition include pharmacological therapies (neuropathic medications), behavioural interventions, lumbar epidural infusions with local anaesthetics and sympathetic nerve blocks. Despite these treatments, many patients may have refractory pain. In these situations, there may be a role for dorsal column spinal cord stimulation for management of their pain. Here, we present the case of a 21-year-old man with 9-year history of refractory erythromelalgia successfully treated with paresthesia-free dorsal column spinal cord stimulation.

ObjectiveTo explore the perspectives of hospital staff regarding the provision of smoking cessation care.Study designA qualitative description study using focus group discussions.Study settingData were collected across metropolitan regional and rural hospitals in Victoria, Australia, between November and December 2019.ParticipantsClinical and non-clinical hospital staff.ResultsFive focus groups were conducted across four hospitals. Staff (n=38) across metropolitan regional and rural hospitals shared similar views with regards to barriers and facilitators of smoking cessation care. Four themes were present: (1) Clinical Setting wherein views about opportunity and capacity to embed smoking cessation care, relevant policies and procedures and guidelines were discussed; (2) Knowledge consisted of the need for training on the provision of pharmacotherapy and behavioural interventions, and awareness of resources; (3) Consistency represented the need for a consistently applied approach to smoking cessation care by all staff and included issues of staff smoking; and (4) Appropriateness consisted of questions around how smoking cessation care can be safely delivered in the context of challenging patient groups and different settings.ConclusionsStaff across metropolitan regional and rural hospitals experience similar views and identified shared barriers in implementing smoking cessation care. Responding to staff concerns and providing support to address smoking with patients will help to foster a consistent approach to cessation care. Clear practice guidelines for multidisciplinary clinical roles need to underpin staff training in communication skills, include priorities around smoking cessation care, and provide the authorising environment in which clinical staff actively provide smoking cessation care.

As the myopia epidemic gathers pace, with 5 billion people expected to be myopic and 1 billion predicted to have sight-threatening high myopia by 2050, there is an urgent need to identify targets for early intervention to mitigate the onset and progression of myopia among children.1 Research has suggested that insufficient time spent outdoors in childhood is one of myopia’s major modifiable risk factors,2 and public health interventions that increase time spent outdoors may therefore be the most scalable and efficacious preventative strategies. However, much of the time children spend outdoors consists of moderate-to-vigorous physical activity, and studies on the effect of time spent outdoors have typically not accounted for potentially confounding protective effects of physical activity against myopia.3 There is a noteworthy lack of research on and understanding of the independent association between myopia and physical activity, which might be measured independently of time spent outdoors by objectively studying physical activity in exclusively indoor environments or including ambient light sensors in studies on physical activity. This knowledge gap may impede the optimisation of behavioural interventions for myopia prevention. Physical activity exerts myriad positive effects on paediatric health and may protect against other eye diseases including glaucoma,4 and there are compelling reasons to expect that it may also attenuate axial elongation independently of time spent outdoors, perhaps through promotion of choroidal perfusion and thickening,5 although this has been disputed.6 A 2017 systematic review by Suhr Thykjaer and colleagues attempted to clarify the relationship between physical activity and myopia, but the authors were unable to draw strong conclusions owing …

IntroductionPatients with chronic obstructive pulmonary disease (COPD) are vulnerable to particulate matter (PM) exposure which can increase acute exacerbations and hospitalisation. Interventions to avoid PM exposure are important but evidence-based guidance is lacking. This study aims to assess the impact of PM on lung function, quality of life and exacerbations in patients with COPD using a panel design study; it will also provide evidence for interventional measures to reduce harm from PM exposure.Methods and analysisA prospective panel study of patients with COPD aged ≥40 years will be conducted. Patients will be required to have a forced expiratory volume in one second Ethics and disseminationThis study was approved by the Institutional Review Board of each site. The participants received comprehensive information and provided informed consent. The result of this study will be discussed in the form of conference presentations and peer-reviewed publications.Trial registration numberNCT04020237.

Subtle implementation details can greatly influence the effectiveness of behavioural nudges because of their inherent subjective and social nature, argue Craig Fox and colleagues

The incidence of fatal anaphylaxis is significantly higher among young people aged 15–25 compared with other age groups. Hospital admission or fatal outcome following anaphylaxis often results from failure to adhere to an agreed anaphylaxis action plan (AAP). The main barriers for adherence include lack of confidence to recognise symptoms of severe reaction, lack of confidence and skills to correctly use an adrenaline auto-injector (AAI), and not having the AAI available when needed. We describe the development of a smart phone application (app) to increase young peoples’ adherence to AAP. The development of the app was informed by information from a literature review to identify factors enhancing and impeding young peoples’ adherence to their AAP, combined with data from consultations with intended users and clinicians working with young people at risk of anaphylaxis regarding their needs and expectations with regard to the content and technical features of the app. The design process was underpinned by the novel Behavioural Intervention Technologies model. This ensured that the apps’ content is evidence based, complies with current guidelines, and responds to users’ needs and preferences in relation to content and technical characteristics. ‘Anaphylaxis’ app is the first smart phone app that comprises a comprehensive personalised AAP. Since its launch in February 2013, it has been downloaded by approximately 16 000 users worldwide. Further research is required to demonstrate its effectiveness in improving self-management of anaphylactic risk in young people.

ObjectivesDevelopment of digital biomarkers to predict treatment response to a digital behavioural intervention.DesignMachine learning using random forest classifiers on data generated through the use of a digital therapeutic which delivers behavioural therapy to treat cardiometabolic disease. Data from 13 explanatory variables (biometric and engagement in nature) generated in the first 28 days of a 12-week intervention were used to train models. Two levels of response to treatment were predicted: (1) systolic change ≥10 mm Hg (SC model), and (2) shift down to a blood pressure category of elevated or better (ER model). Models were validated using leave-one-out cross validation and evaluated using area under the curve receiver operating characteristics (AUROC) and specificity- sensitivity. Ability to predict treatment response with a subset of nine variables, including app use and baseline blood pressure, was also tested (models SC-APP and ER-APP).SettingData generated through ad libitum use of a digital therapeutic in the USA.ParticipantsDeidentified data from 135 adults with a starting blood pressure ≥130/80, who tracked blood pressure for at least 7 weeks using the digital therapeutic.ResultsThe SC model had an AUROC of 0.82 and a sensitivity of 58% at a specificity of 90%. The ER model had an AUROC of 0.69 and a sensitivity of 32% at a specificity at 91%. Dropping explanatory variables related to blood pressure resulted in an AUROC of 0.72 with a sensitivity of 42% at a specificity of 90% for the SC-APP model and an AUROC of 0.53 for the ER-APP model.ConclusionsMachine learning was used to transform data from a digital therapeutic into digital biomarkers that predicted treatment response in individual participants. Digital biomarkers have potential to improve treatment outcomes in a digital behavioural intervention.

IntroductionNAMWEZA is a novel intervention that focuses on preventing HIV and promoting sexual and reproductive health and rights by addressing underlying factors related to vulnerability of acquiring HIV, such as depression, intimate partner violence (IPV) and stigma. The goal of the study was to evaluate the effect of the NAMWEZA intervention on risk behaviour as well as factors potentially contributing to this vulnerability for people living with HIV and their network members.MethodsA stepped-wedge randomised controlled trial was conducted from November 2010 to January 2014 among people living with HIV and their network members in Dar es Salaam, Tanzania. 458 people living with HIV were randomised within age/sex-specific strata to participate in the NAMWEZA intervention at three points in time. In addition, 602 members of their social networks completed the baseline interview. Intention-to-treat analysis was performed, including primary outcomes of uptake of HIV services, self-efficacy, self-esteem, HIV risk behaviour and IPV.ResultsFor people living with HIV, a number of outcomes improved with the NAMWEZA intervention, including higher self-efficacy and related factors, as well as lower levels of depression and stigma. IPV reduced by 40% among women. Although reductions in HIV risk behaviour were not observed, an increase in access to HIV treatment was reported for network members (72% vs 94%, p=0.002).ConclusionThese results demonstrate the complexity of behavioural interventions in reducing the vulnerability of acquiring HIV, since it is possible to observe a broad range of different outcomes. This study indicates the importance of formally evaluating interventions so that policymakers can build on evidence-based approaches to advance the effectiveness of HIV prevention interventions.Trial registration numberNCT01693458.

IntroductionTourette syndrome and chronic tic disorder are common, disabling childhood-onset conditions. Guidelines recommend that behavioural therapy should be offered as first-line treatment for children with tics. However, there are very few trained behaviour therapists for tics and many patients cannot access appropriate care. This trial investigates whether an internet-delivered intervention for tics can reduce severity of symptoms.Methods and analysisThis parallel-group, single-blind, randomised controlled superiority trial with an internal pilot will recruit children and young people (aged 9–17 years) with tic disorders. Participants will be randomised to receive 10 weeks of either online, remotely delivered, therapist-supported exposure response prevention behavioural therapy for tics, or online, remotely delivered, therapist-supported education about tics and co-occurring conditions. Participants will be followed up mid-treatment, and 3, 6, 12 and 18 months post randomisation.The primary outcome is reduction in tic severity as measured on the Yale Global Tic Severity Scale total tic severity score. Secondary outcomes include a cost-effectiveness analysis and estimate of the longer-term impact on patient outcomes and healthcare services. An integrated process evaluation will analyse quantitative and qualitative data in order to fully explore the implementation of the intervention and identify barriers and facilitators to implementation. The trial is funded by the National Institute of Health Research (NIHR), Health Technology Assessment (16/19/02).Ethics and disseminationThe findings from the study will inform clinicians, healthcare providers and policy makers about the clinical and cost-effectiveness of an internet delivered treatment for children and young people with tics. The results will be submitted for publication in peer-reviewed journals. The study has received ethical approval from North West Greater Manchester Research Ethics Committee (ref.: 18/NW/0079).Trial registration numbersISRCTN70758207andNCT03483493; Pre-results.

In the USA, one in four sexually active adolescents has an STI,1 and yet sexual health education and screening in this population is inadequate.2 Factors impacting adolescent women’s access to sexual healthcare include a misunderstanding of the symptoms, stigma and fear of embarrassment, issues around cost, and conflicting clinic and school schedule.2 The purpose of our study was to identify the perceived barriers to …

Objectives Patient engagement (PE) improves patient, organisation and health system outcomes, but most research is based on primary care. The primary purpose of this study was to describe the characteristics of published empirical research that evaluated PE in hospital health service improvement. Design Scoping review. Methods Five databases were searched from 2006 to September 2016. English language studies that evaluated patient or provider beliefs, participation in PE, influencing factors or impact were eligible. Screening and data extraction were done in triplicate. PE characteristics, influencing factors and impact were extracted and summarised. Results From a total of 3939 search results, 227 studies emerged as potentially relevant; of these, 217 were not eligible, and 10 studies were included in the review. None evaluated behavioural interventions to promote or support PE. While most studies examined involvement in standing committees or projects, patient input and influence on decisions were minimal. Lack of skill and negative beliefs among providers were PE barriers. PE facilitators included careful selection and joint training of patients and providers, formalising patient roles, informal interaction to build trust, involving patients early in projects, small team size, frequent meetings, active solicitation of patient input in meetings and debriefing after meetings. Asking patients to provide insight into problems rather than solutions and deploying provider champions may enhance patient influence on hospital services. Conclusions Given the important role of PE in improving hospital services and the paucity of research on this topic, future research should develop and evaluate behavioural interventions for PE directed at patients and providers informed by the PE barriers and facilitators identified here. Future studies should also assess the impact on various individual and organisational outcomes.

Objective To assess the unmet need for comprehensive behavioural intervention for tics (CBIT) and habit reversal therapy (HRT) in adults and children with Tourette Syndrome. Method Patients with Tourette Syndrome who attended the St George’s clinic between 2004 and 2015 were selected for the study (Total 388). Basic clinical characteristics and the status of CBIT/HRT was assessed for each case. It was classified as being: (1) recommended by the clinician, (2) directly referred for therapy, (3) actually received therapy, (4) stated not suitable as not indicated for reasons such as significant learning difficulty or implied lack of availability of therapists or (5) explicitly stated to be inaccessible for the patient or (6) not mentioned at all in the notes. Results Of the 388 patients 24% were female and 76% male. 41% were adults and 56% were children of 17 years and under. In total only 111 (29%) had behavioural therapy mentioned in their clinical notes. This has increased over the years with an increase from 6% in adults in 2005 to 43% in 2015 and from 11% in children in 2005 to 78% in 2015. 23 patients (6%) were categorised as not suitable. Behavioural therapy was recommended but not eventually provided to 31 of these patients (8%). In a further 35 patients (9%), behavioural therapy was deemed inaccessible by the clinician to begin with, before any attempt was even made for a referral. Only 18 (5%) patients were actually referred for behavioural therapy and 4 (1%) patients out the total 388 received behavioural therapy (2 children and 2 adults) although missing notes may have reduced this number. Conclusion Behavioural therapies are an evidence-based treatment for Tourette syndrome. The data presented here were extracted from clinical notes and were not collected prospectively for this purpose so it was often difficult to know if clinicians omitted explicit mention of CBIT/HRT because of lack of availability or on the basis of patient selection. Increasing interest over the years is however demonstrated here by an increasing focus in the patient notes, but there is still very little access to this form of treatment, a national problem. Anecdotally, many more referrals have been made for children from this clinic to another centre in the last 12 months. Under provision in the NHS of specialised psychological services for Tourette syndrome needs to be urgently addressed.

Interventions combining diet with physical activity and behavioural change can have a small, short term effect in reducing weight among children and adolescents who are overweight or obese, report two Cochrane reviews that analysed all available studies in these age groups.12 The first review analysed evidence from 70 randomised controlled trials assessing the effects of diet, physical activity, and behavioural interventions in 8461 overweight and obese children aged 6 to 11 (median age 10). The studies included children from Europe, Canada, Japan, Malaysia, New Zealand, and the US, who …

Using a non-equivalent control group design, this report evaluated a previously studied behavioural intervention, the Stamp-in-Safety programme, which is designed to reduce the injury risk for young children on playgrounds at childcare centres by increasing the quality of adult supervision and rewarding children for safe play. In an urban, commercial childcare centre, 71 children aged 3-5 years and 15 teachers participated. Primary outcome measures were teacher verbalisations (warnings, explanations, redirects), teacher location (core, outskirt, or fringe of playground), child risk-taking behaviours (using equipment appropriately) and the number of injuries on the playground. Analyses revealed that the intervention had a modest positive effect in promoting safer teacher and child playground behaviours. This study reaffirms previous results that the Stamp-in-Safety programme is an effective method to decrease the risk of playground injuries at childcare centres.

In Brighton, we have exceptionally high rates of party drug use including chemsex among men who have sex with men (MSM) including injection drug use (slamming).1 The ever-changing landscape of drugs and legal highs pose challenges to healthcare professionals to keep up to date with current ‘trends’ and subsequently to engage in meaningful discussion to support and …

There is an urgent need for well designed randomised trials to assess the impact of behavioural interventions at both individual and community levels in developed and developing countries. The relative lack of such studies partly reflects the particular challenges of applying randomised trials in this area. Although there are obvious differences between clinical and behavioural interventions, the principles underlying successful evaluation are not fundamentally different. Experience gained from clinical trial methodology over the past two decades should be applied and further developed to tackle the demands and challenges of evaluating behavioural interventions in HIV/STI prevention.

Eleanor Barry and colleagues’ editorial relays their concerns about the NHS Diabetes Prevention Programme (DPP).1 Key concerns are dealt with here. The NHS DPP will offer people already identified as being at high risk of developing type 2 diabetes an opportunity to lower their risk through provision of an evidence based behavioural intervention. By failing to implement such a programme, people with known non-diabetic hyperglycaemia are deprived of consistent and evidence based support that would empower them to reduce their risk of type 2 diabetes, questioning our commitment to the public’s health and wellbeing. We agree that there is a need for multi-level action. Both NHS England and Public Health England (PHE) published plans last year with a focus on improving diet, increasing levels of physical activity, …

Background Intensive lifestyle change programs are utilised in cardiovascular disease prevention, but their efficacy is variable. Real-time monitoring of patients is feasible. Purpose To evaluate the efficacy of real-time adherence monitoring of patient diet and exercise, in targeting metabolic syndrome parameters of bmi, blood pressure (bp) and total cholesterol (tc), in overweight/obese (owo) individuals. Methods 28 owo (bmi >25 and 140/90), 12 elevated tc (>5 mmol/l). Baseline resting metabolic rate (rmr) and bmi was calculated. Participants had a reduced daily calorie intake (~300–500 kcal below rmr) and increased daily exercise (10 3 –12.5 3 steps). Phone app training tracked caloric intake, while a wireless weighing- scale and pedometer, enabled daily weight tracking and exercise adherence monitoring. Non-adherents received motivational emails, sms or phonecall. Participants were met weekly, face to face or via video-link. The primary aim was to assess the effects on weight loss. Secondarily, bp and tc were analysed. Results Significant weight loss was achieved at weeks 4, 8 and 12 with an average weight reduction of 5.6%, 9.6% and 10.1% (p Conclusion Intense lifestyle and behavioural intervention, coupled with real-time remote monitoring of patients diet, exercise and weight has a substantial positive effect on metabolic syndrome parameters and may have a seminal role to play in cardiovascular disease prevention.

Background In Nicaragua, 9,739 HIV cases have been reported during 1987–2014. Two Central American Behavioural Surveillance Survey (BSS) among people living with HIV (PLHIV) to estimate prevalence of STI and risk behaviour have been conducted. Since 2012, the STI Sentinel Surveillance Strategy (VICITS) has offered STI diagnosis/treatment and behavioural intervention for PLHIV in public health sites. We present socio-demographic/behavioural and STI prevalence among PLHIV from BSS (2009 and 2014) and VICITS databases. Methods For the BSS, we used a convenience sample of PLHIV seeking HIV services at Roberto Calderon Hospital (RCH) in Managua, from September–December 2009 and January–March 2014. For VICITS, PLHIV seeking services at RCH during 2014 were included. BSS information was obtained through Audio Computer-Assisted Self-Interview. VICITS data were abstracted from VICITS information system. Blood samples were collected for Syphilis testing according to national guidelines. Data were analysed using STATA v13.0. Results Each BSS survey recruited 200 PLHIV (male 53.5% BSS-2009; 74.0% BSS-2014). VICITS recruited 146 PLHIV (85.7% male). Median age was 34 years old for all three data sources. One-third reported being married/living together in BSS-2009 and VICITS (44%, BSS-2014). Alcohol use in the last month was reported by 33.2% in BSS-2009 and 50% in BSS-2014 and VICITS. Condom use in the last sex with any partner was 60.0% in BSS-2009 and 75.5% in BSS-2014 and VICITS. Prevalence of syphilis was 11.6% (95% CI: 7.5–16.8) in BSS-2009, 10.0% (95% CI: 6.2–15.0) in BSS-2014 and 16.7% (95% CI: 8.1–19.8) in VICITS. Conclusion Although socio-demographic/behavioural data of PLHIV in BSS and VICITS were similar, syphilis prevalence was higher among PLHIV enrolled in VICITS. Our results indicate that VICITS strategy can provide valuable information about sexual behaviour of PLHIV. Our findings suggest the use of programmatic data in lieu of complex and expensive surveys to monitor trends in STI prevalence and sexual behaviour. Disclosure of interest We declare that we have no conflicts of interest.

Introduction Persons with acute HIV infection (AHI) contribute disproportionately to transmission. In a pilot study, we evaluated a short-term, behavioural and biomedical intervention among persons with AHI in Malawi. Methods We enrolled persons with AHI. AHI was defined as negative or discordant antibody test (s) with detectable virus. Persons were randomised 1:2:2 to standard counselling (SC), a four-session behavioural intervention (BI), or behavioural intervention plus 12 weeks of antiretrovirals (BIA), and followed 26–52 weeks. ARV resistance was assessed at baseline and after therapy. Participants were asked to refer partners for testing. Follow-up was completed in August 2014; phylogenetic analyses were completed in May 2015. Results We identified 59 persons with AHI and enrolled 46 (9 [SC], 18 [BI], 19 [BIA]). Average age was 25; 61% were male. Median viral load (VL) was 5.9 log copies/ml (6.7 [SC]; 5.1 [BI]; 6.1 [BIA]). At week four, 64% (11/17) of BIA participants were suppressed ( Conclusion ARV quickly reduced viremia below transmissible levels and did not induce resistance; however, patients experienced rapid virological rebound after discontinuation. Sexual risk decreased rapidly in all arms. Most referred partners with available sequences were linked transmissions with the AHI index. Early diagnosis with standard AHI counselling and early ARV referral may be sufficient to reduce transmission risk. Disclosure of interest statement This study was supported by the National Institutes of Health, USA; ARVs donated by Merck and Gilead.

Behavioural interventions for HIV prevention work by encouraging people to change behaviours that may make them more susceptible to HIV infection, or more likely to infect another person. There is some evidence that such interventions have led to reductions in HIV risk behaviours, such as having multiple partners, and improvements in other outcomes, such as increased condom use, increased testing, and improved treatment adherence. Behaviour is influenced heavily by socio-cultural contexts and as such, behavioural interventions must be sensitive to these contexts in order to be effective. Examples of behavioural interventions include individual and group level counselling, and providing information and guidelines through community outreach and mass media campaigns. This paper will provide a synthesis of the evidence on the effectiveness of behavioural interventions for HIV prevention. A review of reviews methodology will be followed to identify relevant primary studies. The strength of the evidence from these reviews will be evaluated and recommendations will be made.

Merits of randomised controlled trials in behavioural and psychosocial research do not differ fundamentally from those in clinical medicine. Interventions that target behaviour are often complex and demanding, as are the requirements of good randomised controlled trials to assess their efficacy. Standardising the content and delivery of an intervention in a trial may be more challenging than justifying randomisation during informed consent. When blinding of participants and researchers to treatment allocation is impossible, it is important to minimise bias through blinded assessment of the outcome. The contribution that participant choice makes to the efficacy of an intervention is hard to measure.

Commentary on: Avery L, Flynn D, van Wersch A, et al. Changing physical activity behavior in type 2 diabetes: a systematic review and meta-analysis of behavioral interventions. Diabetes Care 2012;35:2681–9.[OpenUrl][1][Abstract/FREE Full Text][2] It is estimated that over 220 million people worldwide have diabetes.1 Aerobic and resistance-based physical activity (PA) are key components for management of type 2 diabetes (T2D),2 ,3 yet most individuals with this disease remain insufficiently active to achieve health benefits. Theoretically based, behavioural change strategies for the promotion of PA in this population have become an important clinical and public health focus in tackling the diabetes epidemic. Avery and colleagues conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) to examine (1) the effect on behavioural interventions (in comparison to usual care) on free-living PA (regular movement such as … [1]: {openurl}?query=rft.jtitle%253DDiabetes%2BCare%26rft.stitle%253DDiabetes%2BCare%26rft.issn%253D0149-5992%26rft.aulast%253DAvery%26rft.auinit1%253DL.%26rft.volume%253D35%26rft.issue%253D12%26rft.spage%253D2681%26rft.epage%253D2689%26rft.atitle%253DChanging%2BPhysical%2BActivity%2BBehavior%2Bin%2BType%2B2%2BDiabetes%253A%2BA%2Bsystematic%2Breview%2Band%2Bmeta-analysis%2Bof%2Bbehavioral%2Binterventions%26rft_id%253Dinfo%253Adoi%252F10.2337%252Fdc11-2452%26rft_id%253Dinfo%253Apmid%252F23173137%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=diacare&resid=35/12/2681&atom=%2Febmed%2F18%2F6%2F213.atom

Implications for practice and research: Behavioural interventions can reduce maternal, fetal and neonatal obstetric and weight-related risks. Good-quality research is required to inform the development of behavioural interventions to determine effectiveness and cost-effectiveness for short-term and long-term health outcomes.

Commentary on: JL Bender, A Radhakrishnan, C Diorio, et al.. Can pain be managed through the Internet? A systematic review of randomised controlled trials.Pain2011;152:1740–50.

Friedberg and Adamowicz1 make several interesting observations in their review of recovery rates reported in White et al .2 However, we disagree with them that a previous trial of an active behavioural intervention, Deale et al , which reported very similar recovery rates to White et al , ‘used similar recovery criteria’.1–3 The White et al 2 recovery criteria were: Chalder Fatigue Questionnaire (CFQ; Likert scoring) and Short Form (SF)-36 physical functioning (PF) scores in normal range (ie, ≤18 and ≥60, respectively); Oxford CFS criteria not met; and …

The definitions of recovery in chronic fatigue syndrome (CFS) are numerous, as are the amount of intervention and naturalistic studies designed to assess illness recovery.1 In a recent systematic review of 22 studies, recovery percentages ranged from 0% to 66%.1 White et al report a recovery rate of 22% to 23% in their active behavioural intervention conditions. This rate corresponds with findings of a previous intervention study in CFS that used similar recovery criteria.2

Objective To evaluate the effect of player aggression on head impact biomechanics. Design Prospective cohort. Setting Field (on-ice) study. Participants Thirty-seven volunteer ice hockey players (age=15.0±1.0 years, height=173.5±6.2 cm, mass=66.6±9.0 kg, playing experience=2.9±3.7 years). Interventions Participants were equipped with accelerometer-instrumented helmets to collect head impact biomechanics for one playing season. The Buss-Perry Aggression Questionnaire (BPAQ) was administered to all players. We collected the total number of penalties in minutes (PIM) throughout the season. Data were analysed using random intercept general mixed linear models, with each individual player as a repeating factor/cluster. Main Outcome Measurements Dependent variables included linear and rotational head accelerations, and the Head Impact Technology severity profile (HITsp), a weighted composite score factoring impact accelerations, duration, and location. Tertile aggression and PIM data were used to categorise players into high, moderate, and low aggression levels. Results The players who experienced the highest number of PIM experienced greater rotational accelerations (p=0.034) and HITsp values (p=0.046) than those with the lowest number of PIM. No differences in linear acceleration for PIM were observed (p>0.05). We did not observe any differences between the aggression levels as measured by the BPAQ (p>0.05). Conclusions Youth ice hockey players with higher PIM experienced greater head impact forces, supporting behavioural interventions designed to reduce excessive penalty taking among youth hockey players such as Fair Play in North America. Officials should more stringently assess penalties to participants who purposefully foul opponents. Our results should encourage youth ice hockey players to conform to playing rules. Acknowledgements This study was supported in part by a grant from the Ontario Neurotrauma Foundation to The University of North Carolina at Chapel Hill Injury Prevention Research Center (grant #2005-PREV-BANT-387). The USA Hockey Foundation and the National Operating Committee on Standards for Athletic Equipment (NOCSAE) also provided financial support. Competing interests None.

Objectives Rates of sexually transmitted infections (STIs) in UK young people remain high in men and women. However, the National Chlamydia Screening Programme has had limited success in reaching men. The authors explored the acceptability of various medical, recreational and sports venues as settings to access self-collected testing kits for STIs and HIV among men in the general population and those who participate in sport. Methods A stratified random probability survey of 411 (weighted n=632) men in Great Britain aged 18–35 years using computer-assisted personal and self-interviews. Results Young men engaged well with healthcare with 93.5% registered with, and 75.3% having seen, a general practitioner in the last year. 28.7% and 19.8% had previously screened for STIs and HIV, respectively. Willingness to access self-collected tests for STIs (85.1%) and HIV (86.9%) was high. The most acceptable pick-up points for testing kits were general practice 79.9%, GUM 66.8% and pharmacy 65.4%. There was a low acceptability of sport venues as pick-up points in men as a whole (11.7%), but this was greater among those who participated in sport (53.9%). Conclusions Healthcare settings were the most acceptable places for accessing STI and HIV self-testing kits. Although young men frequently access general practice, currently little STI screening occurs in this setting. There is considerable potential to screen large numbers of men and find high rates of infection through screening in general practice. While non-clinical settings are acceptable to a minority of men, more research is needed to understand how these venues could be used most effectively.

Background HIV infection continues to disproportionately affect MSM in the UK. The 2011 HPA report “Sexually Transmitted Infections in MSM in the UK” highlights the need for one-to-one behavioural interventions. Thus, identifying those at highest risk is essential. Aims To profile the sexual behaviour of younger MSM attending a dedicated clinic. To establish how MSM perceive their sexual risk and explore the use of a simple HIV Risk Assessment Tool (HIVRAT). Methods MSM attending a weekly clinic offering HIV testing self-complete a 6 question HIVRAT in addition to standard history. The HIVRAT records number of male partners in previous 12 months, and number of unprotected anal intercourse (UPAI) partners (previous 3 and 12 months). It also contains a Likert scale of perceived sexual risk. Data was collected over 6 months from June 2011. Statistical analysis was performed in Excel and correlated using Spearman9s Rank methodology. Results 138 men completed the HIVRAT (aged 18–35). Median number of sexual partners in preceding 12 months = 8 (range 1–250, 42% reported >10 partners). Median number of UPAI partners in preceding 3 months =0 (range 0–5) and 12 months =1 (range 0–8). Perceived risk was scored as 1= Very low (20.4%), 2 (44.5%), 3 (28.5%), 4 (4.4%) and 5= Very high (2.2%). There was poor correlation between sexual behaviour and perceived risk. For MSM who had UPAI with one or more partners in the previous 3 and 12 months, there was a moderately positive correlation between actual risk and perceived risk (SRCC 0.517 and 0.544 respectively). Conclusions Only 6.6% of MSM judged their personal HIV risk as high in a cohort where 36% reported UPAI with two or more partners in 12 months. Tools like HIVRAT provide valuable information which is not routinely collected. Asking about UPAI during the 12-month period prior to testing showed the strongest correlation between actual and perceived risk, and could help identify MSM who would benefit most from behavioural intervention.

Introduction Japanese government introduced behavioural approach for modifying unfavourable life styles leading to metabolic syndrome (MetS) into community health promotion in 2008. Previous studies have reported its efficacy in community settings. However, few studies examined effectiveness of work-site behavioural intervention for employees. Methods A total of 311 male workers of a health insurance company were recruited. They were classified as high risk group of Mets by measuring BMI, blood pressure, HbA1c, HDL and LDL cholesterol levels at the annual health examination in 2008. A subgroup of them were recommended to participate in a health promotion activity with behavioural approach aiming diet and physical activity modification (intervention group; 86 persons). After 1-year follow-up, prevalence of MetS and levels of the previous factors were compared between the intervention group and non-intervention group (225 persons). Results After adjusting for age, no statistically significant difference of the prevalence of MetS and levels of the previous factors was found between the group at the baseline examination. In the 2009 examination, BMI, systolic and diastolic blood pressure and LDL cholesterol levels decreased significantly in the intervention group while HbA1c level increased and HDL cholesterol level decreased in the non-intervention group. Prevalence of Mets decreased in the intervention group (−23.3%: 95% CI −34.2 to −12.2%) and also did in the non-intervention group (−16.8%: −23.5 to −10.3%). Difference in change of the prevalence in each group (6.5%: −3.7 to 16.7%) was in borderline significance. Conclusion This quasi-experimental study at worksite suggested effectiveness of work-site behavioural intervention for employees with MetS in Japan.

Over the last two and a half decades, researchers and public health agencies have invested substantial resources in developing and implementing counselling and behavioural interventions to decrease HIV transmission among men who have sex with men (MSM) in higher-income nations. Meanwhile, MSM have substantially altered their sexual risk behaviour, adapting to the HIV epidemic, as well as the technological revolution fuelled by the Internet. This presentation will review the evidence supporting the efficacy of behavioural interventions in MSM, discuss the challenges posed in bringing those interventions to scale, and suggest future research and prevention directions designed to move behavioural interventions from an efficacy to an effectiveness focus.

Background Approximately 1.1 million persons in the United States are living with HIV and for 18.5% their infections are attributable to injection drug use. In 2009 there were an estimated 5063 new HIV diagnoses attributed to injection drug use. In 2002, CDC developed the National HIV Behavioural Surveillance System (NHBS) to help state and local health departments in areas with high AIDS prevalence monitor behaviours and use of prevention services in groups at highest risk for HIV infection, including injection drug users (IDU). NHBS uses a sampling method most appropriate for each group; respondent-driven sampling (RDS) was chosen as the method for NHBS-IDU. We describe implementation and key monitoring indicators from the first two rounds of NHBS-IDU. Methods NHBS-IDU is implemented in more than 20 cities every 3 years using a standardised protocol for conducting surveys and HIV testing among persons who had injected drugs within the 12 months prior to interview. Data are analysed for each city independently and then aggregated and weighted to form national estimates. Results During the first IDU cycle (NHBS-IDU1, conducted 2005–2006), a total of 13 519 persons in 23 cities were recruited to participate, which resulted in 11 471 persons included in the final dataset. A total of 10 901 persons received 34 038 coupons to recruit others; 13 115 (62%) coupons were returned (range by city: 52.2%–75.3%). Challenges to the underlying assumptions of RDS included a somewhat high (5%) proportion of participants who reported their recruiter was “a stranger” and limited geographic cross-recruitment, suggesting IDU networks were not linked. These issues were found for some cities and were addressed in the operational guidance for NHBS-IDU2, conducted during 2009. Data from NHBS are used to monitor national progress in HIV prevention for IDU; in NHBS-IDU1, an estimated 32.8% of IDU shared syringes, and 63.4% had unprotected vaginal sex; 66.3% had been tested for HIV, and 29.7% had participated in an HIV behavioural intervention. Conclusions Use of RDS for NHBS-IDU has identified challenges in implementation and analysis that continue to further the development of this method for conducting behavioural surveillance among IDU in order to characterise the HIV epidemic in the USA.

Background To implement a randomised trial of a risk-reduction intervention consisting of small group sessions, individual counselling and support groups for African- and Mexican-American adolescent women with STI and abuse history and evaluate the effects of the intervention model vs enhanced counselling for this group on STI at 6 and 12 month follow-up. Methods Mexican- and African-American adolescent women (n=409, 13–18 years) with STI and a history of abuse (physical, psychological, sexual) were recruited from public-health clinics in a metropolitan area of the USA. Following enrolment participants received targeted physical exams including contraception counselling and interviews including assessments for abuse, sexual risk behaviour, substance use, contraceptive use and STI. Participants were encouraged to return for unscheduled visits as needed for counselling or suspected STI or pregnancy. Scheduled follow-up rates at 6 (93%) and 12 (93%) months were high Participation in risk-reduction interventions was also high (92%). Surveillance for STI and pregnancy at off-site clinic visits was conducted and documented throughout the study. Results At study entry, participants reported sexual (58.9%), physical (76.8%) and psychological (82.4%) abuse histories, ever pregnant (45%), currently pregnant (18.7%), ever used birth control (29.9%), currently in school (63.2%), previous arrest (56.2%), home runaway (54.5%), any substance use (94.1%) including marijuana (82.6%), heroin (13.4%), cigarettes (74.6%), alcohol (77.5%), cocaine (41.1%) and benzodiazepine (45%); forced sex (29.1%), sex when high/out of control (13.9%), sex with friends for benefits (36.2%), steady partner in last 3 months (77.4%) however off and on (31.4%). More workshop vs control group participants reported physical abuse (82.9% vs 71.0%), home runaway (63.1% vs 46.4%), cigarettes (78.9% vs 70.5%) and alcohol use (81.4% vs 73.8%). More control group participants were currently in school (68.1% vs 58.1%) and had used condoms (95.3% vs 86.4%). These variables plus age/ethnicity were initially included in the regression model for analysis of data from 0 to 6 and 0–12 month follow-ups. Fewer STI re-infections for intervention vs control group participants at each study interval were identified; physical abuse and substance use remained in the model. Conclusions Behavioral interventions may reduce of STI among African-and Mexican-American adolescent women with STI and a history of abuse.

Randomised controlled trials that test biomedical interventions to reduce sexually transmitted infections (STIs) have had very mixed results,1 2 as have behavioural trials.3 4 It is only in the past 10 years that the field has recognised that chlamydia resolves itself without treatment in 50% of the cases,4 although the estimates range from 13% to 60%.5–7 The length of time to clear chlamydia infection varies from 60 days in women to up to 15 months in men.5 The speed of resolution is also subject …

Rationale Obesity is a growing problem in the UK. The problem of obesity is also affecting children and with that come significant health, social and economic concerns. Lack of physical activity in children is evident. Physical activity is also beneficial for tackling obesity as well as other positive health and lifestyle outcomes. Aims We aim to investigate what children understand by the term exercise and what facilitates and prevents them from being active or taking part in sport and exercise. Subjects and methodology Qualitiative study using focus groups in 11–14 year old school children in Slough to identify their attitudes and beliefs towards exercise. Children were selected from a local slough grammar school. Results Several themes were identified which were facilatitive or perceived as barriers towards exercise. It was interesting to further discover differences in the barriers between the female and male groups and participants from ethnic minorities. Conclusion By understanding the beliefs and attitudes towards exercise of 11–14 year old children in Slough we may be able to develop and improve behavioural interventions to encourage exercise in this group. Further study into the barriers and facilitators of adolescent girls and ethnic minority children may be important to develop participation of the groups in physical activity.

The development of focal hand dystonia through repetitive tasks is a result of degradation of cortical somatosensory representation due to repetitive fast stimuli sufficient to alter the sensory-motor stimulus, harming the motor control. A sensory-motor training program can modify this disorder. A behavioural intervention focusing on movement could help reduce or eliminate these conditions.

Recently JAMA published a trial of a “get it off your chest” writing exercise.1 Seventy one patients with asthma or rheumatoid arthritis were randomised to write about the most stressful experience they had ever had or about their plans for the day for three separate 20 minute periods over a few days and then to drop their completed essay into a sealed box. The study apparently showed a significant improvement in standard measures of disease severity in both conditions four months later. An accompanying editorial exhorted readers to abandon the Cartesian split between mind and body, and acknowledge the growing evidence in support of behavioural interventions that reduce emotional stress as therapies for diseases that are mediated in part by the immune system.2 Do these results stand up, and is it therefore time to heed this call? Therapeutic writing is a hot topic on both sides of the Atlantic. In the United Kingdom the focus tends to be on descriptive accounts and somewhat speculative psychodynamic explanations for subjective improvements in health status. A recent book provides moving case studies of patients who came to terms with physical or psychological illness through creative writing and …

H Hiscock Dr H Hiscock, Royal Children’s Hospital, Parkville, Victoria, Australia; harriet.hiscock@rch.org.au Is a structured behavioural intervention (SBI) for infant sleep problems effective for maternal depression, parenting style, and child mental health and sleep outcomes at 2 years? ### Design: cluster randomised controlled trial (RCT). ### Allocation: concealed. ### Blinding: blinded {families, nurses, data collectors, and data analysts}.* ### Follow-up period: {17 months}.* ### Setting: 49 maternal and child health centres in 6 government areas in Melbourne, Victoria, Australia. ### Patients: 328 mothers (mean age 33 y) who reported infant sleep problems (mean infant age 7.4 mo, 54% boys). Infants born at < 32 weeks’ gestation and mothers who did not know sufficient English to complete questionnaires were excluded. ### Intervention: 25 centres (n = 174) were allocated to SBIs to improve infant sleep, and 24 centres (n = 154) were allocated to usual well-child care. In the SBI …

Edited by Aral SO, Douglas JM. Published by Springer, 2007, pp 578, hardcover, £53.50. ISBN 978-0-387-47863-0

Human behaviour is a major determinant of health, and a growing body of evidence shows how to make behavioural interventions effective. Theresa Marteau and colleagues explain the way forward

Appel LJ, Champagne CM, Harsha DW, et al . Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083–93. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Q In patients with above optimal blood pressure (BP), what is the relative effectiveness of 2 behavioural interventions (established lifestyle recommendations [ELR] and ELR plus the Dietary Approaches to Stop Hypertension [DASH] diet) compared with advice only? ### ![Graphic][5] Design: randomised controlled trial. ### ![Graphic][6] Allocation: concealed. ### ![Graphic][7] Blinding: blinded (data collectors). ### ![Graphic][8] Follow up period: 6 months. ### ![Graphic][9] Setting: 4 clinical centres in Maryland, Louisiana, North Carolina, and Oregon, USA. ### ![Graphic][10] Patients: 810 generally healthy adults who were ⩾25 years of age (mean age 50 y, 62% women), had above optimal BP (mean systolic BP 120–159 mm Hg and diastolic BP 80–95 mm Hg across 3 screening visits), were not taking antihypertensive medication, and had a body mass index of 18.5–45.0. Exclusion criteria: regular use of drugs affecting BP; target organ damage or diabetes; use … [1]: {openurl}?query=rft.jtitle%253DJAMA%26rft.stitle%253DJAMA%26rft.issn%253D0002-9955%26rft.aulast%253DWriting%2BGroup%2Bof%2Bthe%2BPREMIER%2BCollaborative%2BResearc%26rft.auinit1%253D%2B%26rft.volume%253D289%26rft.issue%253D16%26rft.spage%253D2083%26rft.epage%253D2093%26rft.atitle%253DEffects%2Bof%2BComprehensive%2BLifestyle%2BModification%2Bon%2BBlood%2BPressure%2BControl%253A%2BMain%2BResults%2Bof%2Bthe%2BPREMIER%2BClinical%2BTrial%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjama.289.16.2083%26rft_id%253Dinfo%253Apmid%252F12709466%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jama.289.16.2083&link_type=DOI [3]: /lookup/external-ref?access_num=12709466&link_type=MED&atom=%2Febnurs%2F7%2F1%2F18.atom [4]: /lookup/external-ref?access_num=000182374300024&link_type=ISI [5]: /embed/inline-graphic-1.gif [6]: /embed/inline-graphic-2.gif [7]: /embed/inline-graphic-3.gif [8]: /embed/inline-graphic-4.gif [9]: /embed/inline-graphic-5.gif [10]: /embed/inline-graphic-6.gif

“Does the BMJ publish studies on American datasets?” asked a researcher at a meeting in Atlanta, Georgia, last week on reporting behavioural interventions. We do, of course, although it is worrying that a scientist from the Centers for Disease Control and Prevention thinks we may not. Inevitably, there is considerable international interest in the US healthcare system, just as there is in the NHS, and studies in one setting might generalise to others. But there are more reasons for us to be interested. Our website, bmj.com, attracts about 185 000 users a week, mostly from outside …

EDITOR—Steptoe et al described the use of behavioural interventions to increase the consumption of fruit and vegetables in adults with low incomes.1 I am a doctor and an enthusiastic amateur (almost professional) apple grower. With …

(2002) British Journal of Psychiatry 180, 523; Turkington D, Kingdon D, Turner T. . Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. . June; . : . –7. . [OpenUrl][1][Abstract/FREE Full Text][2] QUESTION: Can community psychiatric nurses effectively deliver a brief cognitive behavioural therapy intervention for people with schizophrenia? Randomised controlled trial. 6 psychiatric secondary care services in England, Ireland, Scotland and Wales. 422 people with schizophrenia in secondary care (defined using ICD-10 criteria). All were aged 18–65 years (mean 40 years); 23% women; 89% white. Exclusion criteria were deterioration; need for intensive home treatment; primary diagnosis of alcohol or drug dependence; organic brain disease or severe learning disability. Brief cognitive behavioural therapy or usual care. After 10 days of training, the intervention nurses visited patients for up to 6 hour-long sessions over 2–3 months. Carers received 3 optional sessions. All phases of cognitive behavioural therapy … [1]: {openurl}?query=rft.jtitle%253DThe%2BBritish%2BJournal%2Bof%2BPsychiatry%26rft.stitle%253DBr.%2BJ.%2BPsychiatry%26rft.issn%253D0007-1250%26rft.aulast%253DTURKINGTON%26rft.auinit1%253DD.%26rft.volume%253D180%26rft.issue%253D6%26rft.spage%253D523%26rft.epage%253D527%26rft.atitle%253DEffectiveness%2Bof%2Ba%2Bbrief%2Bcognitive--behavioural%2Btherapy%2Bintervention%2Bin%2Bthe%2Btreatment%2Bof%2Bschizophrenia%26rft_id%253Dinfo%253Adoi%252F10.1192%252Fbjp.180.6.523%26rft_id%253Dinfo%253Apmid%252F12042231%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bjprcpsych&resid=180/6/523&atom=%2Febmental%2F6%2F1%2F26.atom