Search

Patients who achieve smoking cessation following a cancer diagnosis can experience an improvement in treatment response and lower morbidity and mortality compared to individuals who continue to smoke. It is therefore imperative for publicly funded cancer centres to provide appropriate training and education for healthcare providers (HCP) and treatment options to support smoking cessation for their patients. However, system-, practitioner-, and patient-level barriers exist that hamper the integration of evidence-based cessation programs within publicly funded cancer centres. The integration of evidence-based smoking cessation counselling and pharmacotherapy into cancer care facilities could have a significant effect on smoking cessation and cancer treatment outcomes. The purpose of this paper is to describe the elements of a learning health system for smoking cessation, implemented and scaled up in community settings that can be adapted for ambulatory cancer clinics. The core elements include appropriate workflows enabled by technology, thereby improving both practitioner and patient experience and effectively removing practitioner-level barriers to program implementation. Integrating the smoking cessation elements of this program from primary care to cancer centres could improve smoking cessation outcomes in patients attending cancer clinics.

Coronavirus disease 2019 (COVID-19)-related stressors and restrictions, in the absence of social and institutional support, have led many individuals to either increase their substance consumption or relapse. Consequently, treatment programs for substance use disorders (SUDs) made a transition from in-person to remote care delivery. This review discusses the following evidence regarding changes prompted by the COVID pandemic to the clinical care of individuals with SUDs: (1) reduction in availability of care, (2) increase in demand for care, (3) transition to telemedicine use, (4) telemedicine for treatment of opioid use disorders, and (5) considerations for use of telemedicine in treating SUDs.

Background Women experience greater difficulty achieving smoking abstinence compared to men. Recent evidence suggests that hormonal fluctuations during different phases of the menstrual cycle can contribute to lower smoking abstinence rates following a quit attempt among women. However, these findings are limited by small sample sizes and variability among targeted smoking quit dates. This clinical trial aims to clarify whether targeting the quit date to the follicular or luteal phase of the menstrual cycle can improve smoking abstinence. Methods Participants will enroll in an online smoking cessation program providing nicotine replacement therapy (NRT) and behavioral support. We will randomize 1200 eligible individuals to set a target quit date: (1) during the mid-luteal phase, (2) during the mid-follicular phase, or (3) 15–30 days after enrollment with no regard to the menstrual cycle phase (usual practice). Participants will receive a 6-week supply of combination NRT consisting of a nicotine patch plus their choice of nicotine gum or lozenge. Participants will be instructed to start using NRT on their target quit date. Optional behavioral support will consist of a free downloadable app and brief videos focusing on building a quit plan, coping with cravings, and relapse prevention, delivered via e-mail. Smoking status will be assessed via dried blood spot analysis of cotinine concentration at 7 days, 6 weeks, and 6 months post-target quit date. Discussion We aim to overcome the limitations of previous studies by recruiting a large sample of participants and assigning target quit dates to the middle of both the follicular and luteal phases. The results of the trial can further elucidate the effects of the menstrual cycle on smoking cessation outcomes and whether it is beneficial to combine menstrual cycle phase timing strategies with accessible and low-cost NRT. Trial registration ClinicalTrials.gov NCT05515354. Registered on August 23, 2022.

Les groupes marginalisés sont touchés de manière disproportionnée par la pandémie actuelle. Parmi les effets directs, notons des taux d’infection supérieurs associés à une morbidité et à une mortalité accrues, les effets indirects découlant quant à eux de la réponse sociétale visant à limiter la propagation du virus. Ces groupes présentent également des taux de tabagisme nettement plus élevés que ceux de la population générale. Dans cet article, nous examinons, au moyen du cadre syndémique, la façon dont la pandémie a contribué à exacerber les méfaits du tabac chez ces groupes. Cette approche nous permet d’étudier les facteurs qui favorisent le cumul des méfaits du tabac et des méfaits de la COVID 19, en particulier une aggravation de la détresse psychologique, une augmentation potentielle du tabagisme, une exposition accrue à la fumée secondaire et un accès réduit aux services d’arrêt du tabac. Nous proposons ensuite des stratégies d’atténuation destinées à protéger les groupes défavorisés contre les méfaits du tabac, pendant et après la pandémie de COVID-19 : des services d’arrêt du tabac abordables, une approche proactive du traitement du tabagisme à l’aide des technologies de l’information, un dépistage et un traitement de la dépendance au tabac au moment où les personnes vont se faire vacciner contre la COVID-19, la prise de mesures pour instaurer une couverture universelle de la pharmacothérapie de sevrage du tabac, des politiques d’interdiction totale de fumer et une réglementation de la densité des points de vente au détail de tabac. Aujourd’hui plus que jamais, les cliniciens, les systèmes de soins de santé, les organismes de santé publique et les responsables des politiques de santé doivent agir de manière coordonnée pour protéger les groupes vulnérables contre les méfaits du tabac.

Marginalized populations are being disproportionally affected by the current pandemic. Direct effects include higher infection rates with greater morbidity and mortality; indirect effects stem from the societal response to limit the spread of the virus. These same groups also have smoking rates that are significantly higher than the general population. In this commentary, we discuss how the pandemic has been acting to further increase the harm from tobacco endured by these groups by applying the syndemic framework. Using this approach, we elaborate on the factors that promote clustering of harms from tobacco with harms from COVID-19. These include the worsening of psychological distress, a potential increase in smoking behaviour, greater exposure to second-hand smoke and less access to smoking cessation services. Then, we offer mitigation strategies to protect disadvantaged groups from tobacco-related harm during and following the COVID-19 pandemic. These strategies include affordable smoking cessation services, a proactive approach for smoking treatment using information technology, opportunistic screening and treatment of tobacco dependence among individuals presenting for COVID-19 vaccination, policy interventions for universal coverage of cessation pharmacotherapy, comprehensive smoke-free policies and regulation of tobacco retail density. Now more than ever, coordinated action between clinicians, health care systems, public health organizations and health policy makers is needed to protect vulnerable groups from the harm of tobacco.

Les groupes marginalisés sont touchés de manière disproportionnée par la pandémie actuelle. Parmi les effets directs, notons des taux d’infection supérieurs associés à une morbidité et à une mortalité accrues, les effets indirects découlant quant à eux de la réponse sociétale visant à limiter la propagation du virus. Ces groupes présentent également des taux de tabagisme nettement plus élevés que ceux de la population générale. Dans cet article, nous examinons, au moyen du cadre syndémique, la façon dont la pandémie a contribué à exacerber les méfaits du tabac chez ces groupes. Cette approche nous permet d’étudier les facteurs qui favorisent le cumul des méfaits du tabac et des méfaits de la COVID 19, en particulier une aggravation de la détresse psychologique, une augmentation potentielle du tabagisme, une exposition accrue à la fumée secondaire et un accès réduit aux services d’arrêt du tabac. Nous proposons ensuite des stratégies d’atténuation destinées à protéger les groupes défavorisés contre les méfaits du tabac, pendant et après la pandémie de COVID-19 : des services d’arrêt du tabac abordables, une approche proactive du traitement du tabagisme à l’aide des technologies de l’information, un dépistage et un traitement de la dépendance au tabac au moment où les personnes vont se faire vacciner contre la COVID-19, la prise de mesures pour instaurer une couverture universelle de la pharmacothérapie de sevrage du tabac, des politiques d’interdiction totale de fumer et une réglementation de la densité des points de vente au détail de tabac. Aujourd’hui plus que jamais, les cliniciens, les systèmes de soins de santé, les organismes de santé publique et les responsables des politiques de santé doivent agir de manière coordonnée pour protéger les groupes vulnérables contre les méfaits du tabac.

BACKGROUND For individuals living with diabetes and its psychosocial comorbidities (eg, depression, anxiety, and distress), there remains limited access to interprofessional, integrated care that includes mental health support, education, and follow-up. Health technology, broadly defined as the application of organized knowledge or skill as software, devices, and systems to solve health problems and improve quality of life, is emerging as a means of addressing these gaps. There is thus a need to understand how such technologies are being used to support, educate, and help individuals living with co-occurring diabetes and mental health distress or disorder. OBJECTIVE The purpose of this scoping review was to (1) describe the literature on technology-enabled integrated interventions for diabetes and mental health; (2) apply frameworks from the Mental Health Commission of Canada and World Health Organization to elucidate the components, type, processes, and users of technology-enabled integrated interventions for diabetes and mental health; and (3) map the level of integration of interventions for diabetes and mental health. METHODS We searched 6 databases from inception to February 2022 for English-language, peer-reviewed studies of any design or type that used technology to actively support both diabetes and any mental health distress or disorder in succession or concurrently among people with diabetes (type 1 diabetes, type 2 diabetes, and gestational diabetes). Reviewers screened citations and extracted data including study characteristics and details about the technology and integration used. RESULTS We included 24 studies described in 38 publications. These studies were conducted in a range of settings and sites of care including both web-based and in-person settings. Studies were mostly website-based (n=13) and used technology for wellness and prevention (n=16) and intervention and treatment (n=15). The primary users of these technologies were clients and health care providers. All the included intervention studies (n=20) used technology for clinical integration, but only 7 studies also used the technology for professional integration. CONCLUSIONS The findings of this scoping review suggest that there is a growing body of literature on integrated care for diabetes and mental health enabled by technology. However, gaps still exist with how to best equip health care professionals with the knowledge and skills to offer integrated care. Future research is needed to continue to explore the purpose, level, and breadth of technology-enabled integration to facilitate an approach to overcome or address care fragmentation for diabetes and mental health and to understand how health technology can further drive the scale-up of innovative integrated interventions.

Levels of smoking and smoking initiation have been found to increase during the transition to adulthood. Symptoms of depression and anxiety may both precede or follow smoking behavior, yet there is equivocal evidence regarding the direction of this relationship. The aim of the current study was to examine the direction of this relationship in a group of young adult backpackers who traveled to social environments which are permissive of smoking. The current study involved a quasi-experimental design examining 199 (52% men, mean age 24.27, SD = 1.05 years at time 1) young adults, before, during and following a backpacking experience of at least six months. Regression analyses was used to examine the association between smoking and symptoms of depression and anxiety over time. Relative to smoking levels before the journey, a significant transient increase in smoking was found during the journey. The increase in smoking during the journey predicted increases in both depressive and anxiety symptoms following the journey. The reverse direction models were not significant. Our study suggests that social contexts which are permissive of smoking, such as backpacking, increase young adult smoking behavior. Mood symptoms did not contribute to the observed increase in smoking behavior but, inversely, increases in smoking contributed to heightened mood symptoms. Additional longitudinal studies are needed to explore the role that smoking behavior plays in young adults' mental health.

The COVID-19 pandemic disproportionately disrupts the daily lives of marginalized populations. Persons with substance use disorders are a particularly vulnerable population because of their unique social and health care needs. They face significant harm from both the pandemic itself and its social and economic consequences, including marginalization in health care and social systems. Hence, we discuss: (1) why persons with substance use disorders are at increased risk for infection with COVID-19 and a severe illness course; (2) anticipated adverse consequences of COVID-19 in persons with substance use disorders; (3) challenges to health care delivery and substance use treatment programs during and after the COVID-19 pandemic; and (4) the potential impact on clinical research in substance use disorders. We offer recommendations for clinical, public health, and social policies to mitigate these challenges and to prevent negative outcomes.

Public health reports document an increase in rates of smoking among emerging adults. This study examines environmental influences and temperament as predictors of this increase. One hundred ninety-nine emerging adults were followed from before embarking on a journey outside of Israel and on their return. Participants reported their levels of daily smoking (before, during, and after the journey), novelty seeking, harm avoidance, depressive symptoms, and sociodemographics. Overall, an increase in smoking levels was observed during the backpacking experience. Latent profile analysis showed three separate trajectories of smoking: stable low (70% of participants), experimental increasing (22%), and stable high (8%). In comparison with the stable low group, the experimental increasing group was characterized by higher levels of novelty seeking, while the stable high group was characterized by higher levels of depressive symptoms. Findings highlight the interplay between smoking, temperament, and a permissive environment to explain emerging adult smoking trajectories.

BACKGROUND People who smoke also have other risk factors for chronic disease such as sedentary behaviours and poor diet. Usual practice is to address smoking with the exclusion of these other behaviours. Clinical decision support systems (CDSS) are a promising resource to effectively support health care practitioners integrate interventions for diet and physical activity as part of their smoking cessation programming. OBJECTIVE The aims of this study are to: (1) assess whether adding a CDSS for physical activity and diet to a smoking cessation program affects smoking cessation outcomes, and (2) assess the implementation of the study. METHODS We conducted a pragmatic, hybrid type I effectiveness/implementation trial with 232 team-based primary care practices in Ontario Canada from November 2019 to May 2021. We measured the effectiveness of the CDSS using a two-arm randomized control trial comparing a CDSS for addressing physical activity and diet as part of a smoking cessation program with treatment as usual, and used the RE-AIM Framework to measure implementation outcomes. RESULTS In total, 5331 smokers did not meet the recommended Canadian guidelines for physical activity and/or fruit/vegetable consumption were enrolled in this study). We randomized 2599 people to the control group and 2732 to the intervention group. At the six month follow-up, 552 of 2020 respondents (27.3%) in the control arm and 634 of 2137 respondents (29.7%) in the intervention arm reported abstinence from tobacco. After multiple imputation, these proportions were 25.9% (95% CI = 24.2%, 27.6%) and 28.0% (95% CI = 26.1%, 29.8%), respectively, corresponding to an absolute group difference of 2.1% (95% CI = -0.5%, 4.6%). This difference did not meet our threshold for significance (F(1, 1000.42)=2.43, p=0.12). From baseline to six month follow-up, mean exercise minutes changed from 32 to 113 in the control arm and from 32 to 110 in the intervention arm (group effect: B = -3.7 minutes, 95% CI = -17.8, 10.4, p=0.61). For servings of fruit and vegetables, group means changed from 2.52 at baseline to 2.45 at six month in the control group and from 2.64 to 2.42 in the intervention group (incidence rate ratio for intervention group = 0.98, 95% CI = 0.93, 1.02, p=0.35). CONCLUSIONS Our study findings illustrate that the introduction of a CDSS that guides health care practitioners to address multiple health behaviours among their patients did not negatively affect smoking cessation outcomes and did not have a significant impact on participants’ physical activity nor fruit/vegetable consumption. Although there are still challenges that need to be addressed, thoughtful implementation of CDSS could transform the smoking cessation program into a more holistic program in primary care. CLINICALTRIAL ClinicalTrials.gov (NCT04223336). https://clinicaltrials.gov/ct2/show/NCT04223336 INTERNATIONAL REGISTERED REPORT RR2-10.2196/19157

The COVID-19 pandemic is associated with increased levels of stress, anxiety and depression in the population. These are associated with unhealthy eating patterns and sedentary behaviour. In turn, this may increase risk of obesity or aggravate it. This narrative review discusses the link between adverse mental health states and weight related behaviours. We present emerging evidence for this phenomenon during the COVID-19 pandemic in individuals with and without pre-existing obesity.A sizeable proportion of the population exhibits deterioration in mental health during the pandemic and those affected often report unhealthy weight-related behaviours such as "junk food" consumption and physical inactivity. Women, individuals with obesity, and those with pre-existing mental health conditions seem to be particularly at risk for overeating in response to stress (i.e. emotional eating). A number of psychological interventions including cognitive behavioural therapy and self-compassion may be effective in improving mental health and emotional eating patterns among the general population and particularly in individuals living with obesity. There is a need to complement efforts to improve mental health in the general population during the COVID-19 pandemic with targeted action to improve physical activity levels and healthy eating particularly among groups at-risk. This may be achieved by reducing disruptions to specialist and primary healthcare services and facilitating access to psychological interventions that address stress-related eating behaviours. Additional studies that examine such interventions, especially those that are delivered remotely, are urgently needed.

Background Given the harms associated with tobacco use, continuing the provision of smoking cessation treatment during the COVID-19 pandemic is critical. The aim of this study was to examine pandemic-related changes in enrolment, total treatment use and participant characteristics in a large, publicly funded smoking cessation program in Ontario, Canada. Methods We conducted a secondary data analysis of patients who enrolled in the program between Jan. 1, 2018, and Dec. 7, 2020. We used descriptive statistics to examine changes in treatment use. To test for differences in sociodemographic and health variables, we used segmented mixed-effects regression with a break point on Mar. 17, 2020, when Ontario declared a state of emergency. We tested 25 variables, using Holm's correction for multiplicity. Results We analyzed 60 373 enrolments. In the month after the break point, enrolments fell 69% and total visits fell 42% relative to previous years. After Mar. 17, 2020, those who enrolled were less likely to report employment in the previous week (absolute expected difference -12.4%, 95% confidence interval [CI] -15.0% to -9.8%); were more likely to be occasional (1.3%, 95% CI 0.6% to 1.9%) or noncurrent smokers (1.7%, 95% CI 0.8% to 2.6%); were less likely to have set a target quit date (-4.8%, 95% CI -7.0% to -2.6%); and were more likely to have a physical health (6.6%, 95% CI 4.0% to 9.2%), mental health (4.6%, 95% CI 1.9% to 7.2%) or substance use diagnosis (3.5%, 95% CI 1.3% to 5.6%). Interpretation Sharp decreases in new enrolments and subsequent visits to smoking cessation programs were seen when pandemic restrictions were implemented in Ontario, but the characteristics of the people who accessed the programs did not change markedly. Incorporating an equity perspective is essential when new models of care for smoking cessation are developed.

Objective: Antipsychotic use among youth is common and is associated with metabolic side effects such as weight gain. Guidelines recommend periodic screening of metabolic measures in youth prescribed antipsychotics; however, a guideline-to-practice gap exists. We systematically reviewed the literature to synthesize the knowledge from interventions that aim to improve antipsychotic metabolic screening. We described the interventions' effect on screening rates, the strategies used for improvement, and study quality. Methods: We conducted a systematic review of studies that attempted to improve antipsychotic metabolic risk screening practices among pediatric populations published between 2004 and August 2019. We included studies with an improvement intervention that compared screening rates before and after the intervention. We extracted data about study characteristics, screening rates in pre- and postintervention groups, strategies used to influence screening practices, and assessed studies' risk of bias. This review was prospectively registered with PROSPERO #CRD42018088241. Results: We identified six studies that demonstrated modest improvements in median metabolic screening rates for waist circumference (0%-16%), glucose (9%-39%), and lipids (11%-37%). Median postintervention screening rates were higher for weight and blood pressure (84% and 72.5%) compared with glucose and lipids (39% and 37%). Interventions used a variety of improvement strategies to address patient-, provider-, and organization-level barriers for screening, including increasing patient and provider knowledge regarding antipsychotic side effects, fostering social clinical environments that promote screening, and organizational commitment for screening antipsychotic-treated youth. All interventions were deemed at high risk of bias due to uncontrolled design and lack of adjustment for confounders. Conclusions: Included studies reported partial success in improving antipsychotic screening rates but were of poor methodological quality. Common improvement strategies may affect provider behavior to conduct metabolic screening, but these need to be tailored to local resources and organization structure. Future studies need to use rigorous methodology and theory-informed improvement strategies aligned with organizational actions to prioritize safe and judicious practice of antipsychotics among pediatric populations.

Background Modifiable risk factors such as tobacco use, physical inactivity, and poor diet account for a significant proportion of the preventable deaths in Canada. These factors are also known to cluster together, thereby compounding the risks of morbidity and mortality. Given this association, smoking cessation programs appear to be well-suited for integration of health promotion activities for other modifiable risk factors. The Smoking Treatment for Ontario Patients (STOP) program is a province-wide smoking cessation program that currently encourages practitioners to deliver Screening, Brief Intervention, and Referral to treatment for patients who are experiencing depressive symptoms or consume excessive amounts of alcohol via a web-enabled clinical decision support system. However, there is no available clinical decision support system for physical inactivity and poor diet, which are among the leading modifiable risk factors for chronic diseases. Objective The aim of this study is to assess whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcomes. Methods This study is designed as a hybrid type 1 effectiveness/implementation randomized controlled trial to evaluate a web-enabled clinical decision support system for supporting practitioners in addressing patients’ physical activity and diet as part of smoking cessation treatment in a primary care setting. This design was chosen as it allows for simultaneous testing of the intervention, its delivery in target settings, and the potential for implementation in real-world situations. Intervention effectiveness will be measured using a two-arm randomized controlled trial. Health care practitioners will be unblinded to their patients’ treatment allocation; however, patients will be blinded to whether their practitioner receives the clinical decision support system for physical activity and/or fruit/vegetable consumption. The evaluation of implementation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results Recruitment for the primary outcome of this study is ongoing and will be completed in November 2020. Results will be reported in March 2021. Conclusions The findings of the study will provide much needed insight into whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcome. Furthermore, the implementation evaluation would provide insight into the feasibility of online-based interventions for physical activity and diet in a smoking cessation program. Addressing these risk factors simultaneously could have significant positive effects on chronic disease and cancer prevention. Trial Registration ClinicalTrials.gov NCT04223336; https://clinicaltrials.gov/ct2/show/NCT04223336 International Registered Report Identifier (IRRID) DERR1-10.2196/19157

COVID-19 can worsen the physical health of individuals with serious mental illness, a vulnerable group already facing physical health disparities. COVID-19 is further reducing access to physical health care due to shutdown of services deemed "non-urgent" and overcrowding of emergency services. Management of chronic diseases, highly prevalent in this group, is undermined due to exacerbation of psychiatric disorders, reduction in availability of social support, and worsening of negative social determinants of health. In this commentary, we discuss the challenges experienced by this group and offer mitigation strategies to reduce: (1) inequalities in access to physical health care; and (2) disruptions to the management of chronic physical conditions in the face of COVID-19. Recommendations include coordinated efforts by health authorities, primary and mental health care organizations, researchers, policymakers, and other stakeholders. These efforts should ensure equitable access to physical health care and implementation of innovative programs to protect the physical health of people with serious mental illness during and following the pandemic.

The COVID-19 pandemic disproportionately disrupts the daily lives of marginalized populations. Persons with substance use disorders are a particularly vulnerable population because of their unique social and health care needs. They face significant harm from both the pandemic itself and its social and economic consequences, including marginalization in health care and social systems. Hence, we discuss: (1) why persons with substance use disorders are at increased risk for infection with COVID-19 and a severe illness course; (2) anticipated adverse consequences of COVID-19 in persons with substance use disorders; (3) challenges to health care delivery and substance use treatment programs during and after the COVID-19 pandemic; and (4) the potential impact on clinical research in substance use disorders. We offer recommendations for clinical, public health, and social policies to mitigate these challenges and to prevent negative outcomes.

Aim Individuals with psychotic disorders have poorer health outcomes and die earlier due to cardiovascular diseases when compared to healthy populations. Contributing factors include low levels of physical activity, poor nutrition and tobacco smoking. Currently, patients navigate a fragmented health-care system to seek physical and mental health services, often without access to evidence-based health promotion interventions, especially in non-academic settings or rural areas, increasing client barriers at the individual and provider level. To address these gaps, we wish to test the feasibility and impact of a Technology-Enabled Collaborative Care for Youth (TECC-Y) model to improve healthy behaviours among youth with early psychosis. The model addresses geographical barriers and maldistribution of physical and mental health care. Methods A randomized controlled trial, including youth (ages of 16-29) with early psychosis (diagnosed in the past 5 years) residing in Ontario, Canada. Our primary outcome is client engagement. Secondary outcomes include smoking status, physical health and nutrition. Participants are randomly assigned to either a health coach supervised by a virtual care team, or a self-directed learning group (e-platform with psychoeducational materials). Assessments are conducted at baseline, 6, 12 and 24 weeks. Results This paper presents the protocol of the study. Recruitment commenced in August 2018. This study was registered on 16 July 2018 on clinicaltrials.gov (Registry ID: NCT03610087). Conclusions TECC-Y will determine if a technology-based collaborative care model engages youth with early psychosis, and whether this will be associated with changes in smoking, physical health and nutrition.

BackgroundSmoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation.The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome.MethodsThis realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis.ResultsOf the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.’s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant’s capability or motivation to make a behaviour change was only successful within certain contexts.ConclusionIn order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from ‘individualistic epidemiology’ and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment).Trial registrationPROSPERO registration number:CRD42017064430

Background Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about what components of these interventions help to promote successful smoking cessation . The aim of this rapid realist review was to identify possible mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with effectively changing tobacco use. Methods This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis. Results Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.’s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant’s capability or motivation to make a behaviour change was only successful within certain contexts. Conclusion In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from ‘individualistic epidemiology’ and invest resources into modifying factors that exist outside of the individual (i.e. creating a supportive environment). Study registration PROSPERO registration number: CRD42017064430

Antipsychotic use is associated with elevated cardiometabolic risk. Guidelines for metabolic risk screening of individuals taking antipsychotics have been issued, but with little uptake into clinical practice. This review systematically assessed interventions that address this guideline-to-practice gap and described their quality, improvement strategies, and effect on screening rates.Studies of interventions that addressed metabolic risk screening of adult patients taking antipsychotics, published from inception to July 2018, were selected from MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Reviews databases. Information was extracted on study characteristics; improvement strategies at the provider, patient, and system levels; and screening rates in the intervention and comparison groups.The review included 30 complex interventions that used between one and nine unique improvement strategies. Social influence to shift provider and health organization culture to encourage metabolic risk screening was a common strategy, as were clinical prompts and monitoring tools to capture provider attention. Most studies were deemed at high risk of bias. Relative to comparison groups, the interventions were associated with an increase in median screening rates for glucose (28% to 65%), lipids (22% to 61%), weight (19% to 67%), and blood pressure (22% to 80%).This knowledge synthesis points to shortcomings of current interventions to improve antipsychotic metabolic risk screening, both in quality and in outcomes. Findings may be used to inform the design of future programs. Additional interventions are needed to address the current guideline-to-practice gap, in which approximately one-third of patients are unscreened for metabolic risk.

Objective: Individuals with severe mental illness (SMI) are disproportionally affected by medical comorbidities, resulting in poor physical health and premature death. Despite this, care for chronic medical conditions is suboptimal, and there is limited research that explores this phenomenon from the patient’s perspective. The aim of this study was to identify barriers and facilitators of engagement with a physical health service experienced by individuals with SMI. Methods: Adults with SMI were recruited from a large psychiatric hospital and offered referral to a physical health service focused on the prevention and treatment of obesity and diabetes. Interviews were conducted at referral, 3, and 6 months. Data from 56 interviews of 24 participants were analyzed using the framework method to identify factors influencing engagement. Results: Barriers to engagement were identified at individual, medical program, and health system levels. Factors influencing the individual experience included difficulty in care coordination, affective symptomatology, and ability to bond with providers. Factors at the program level included difficulty adjusting to the clinic environment and the inability to achieve treatment goals. Factors at the system level included challenges in attending multiple appointments in a fragmented health system, lack of social support, and financial constraints. Conclusions: This qualitative study suggests that traditional models of medical care for chronic conditions pose challenges for many individuals with SMI and contribute to health disparities. Adaptation of medical care to populations with SMI and close collaboration between medical and mental health services are necessary to improve medical care and, subsequently, health outcomes.

Background Health behaviors directly impact the health of individuals, and populations. Since individuals tend to engage in multiple unhealthy behaviors such as smoking, excessive alcohol use, physical inactivity, and eating an unhealthy diet simultaneously, many large community-based interventions have been implemented to reduce the burden of disease through the modification of multiple health behaviors. Smoking cessation can be particularly challenging as the odds of becoming dependent on nicotine increase with every unhealthy behavior a smoker exhibits. This paper presents a protocol for a rapid realist review which aims to identify factors associated with effectively changing tobacco use and target two or more additional unhealthy behaviors. Methods An electronic literature search will be conducted using the following bibliographic databases: MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, Social Science Abstracts, Social Work Abstracts, and Web of Science. Two reviewers will screen titles and abstracts for relevant research, and the selected full papers will be used to extract data and assess the quality of evidence. Throughout this process, the rapid realist approach proposed by Saul et al., 2013 will be used to refine our initial program theory and identify contextual factors and mechanisms that are associated with successful multiple health behavior change. Discussion This review will provide evidence-based research on the context and mechanisms that may drive the success or failure of interventions designed to support multiple health behavior change. This information will be used to guide curriculum and program development for a government funded project on improving smoking cessation by addressing multiple health behaviors in people in Canada. Systematic review registration PROSPERO CRD42017064430 Electronic supplementary material The online version of this article (10.1186/s13643-018-0702-0) contains supplementary material, which is available to authorized users.

To assess the level of anticoagulation control achieved in patients with atrial fibrillation (AF) receiving routine medical care within a large managed care organization and to explore patient factors that influence control.Retrospective cross-sectional study of all patients with AF treated in Clalit Health Services (CHS) community clinics in central Israel between November 1, 2006, to October 31, 2007.Using the CHS computerized database, we identified 906 patients with a diagnosis of AF who were treated with warfarin for at least 6 months. Data included patient demographics, comorbidities, and international normalized ratio (INR) values as well as managing physician certification. Anticoagulation control was assessed by measurement of time within therapeutic range (TTR) (INR 2-3). Univariate and multivariate analyses were performed to explore the association of patient variables with anticoagulation control.Roughly two-thirds of patients had poor anticoagulation control, as evidenced by TTR of60%; the mean TTR was 48.6%. Poor control was significantly associated with female sex, advancing age, and comorbid conditions. Heart failure and having a non-board-certified physician were found to be independent predictors of poor control (odds ratio [OR] = 1.63; 95% confidence interval [CI] = 1.20-2.22; and OR = 1.41; 95% CI, 1.05-1.88, respectively).Quality of anticoagulation in patients with AF receiving routine medical care was suboptimal, with nearly half the time spent outside the therapeutic range. Ways to improve anticoagulation control among patients with AF should be sought.

To examine how family physicians identify and document obesity.Prospective cross-sectional study of 289 patients in 7 family practice clinics of Clalit Health Services in Israel.Two hundred eighty-nine patients from 7 family practice clinics had their body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) determined by the study staff and subsequently compared with the data retrieved from the family practices' database regarding physicians' BMI documentation and obesity diagnosis. Demographic variables, comorbidities, and medication use were also extracted. Multivariate odds ratios (ORs) and 95% confidence intervals (CIs) were obtained to determine the predictors of BMI documentation.Seventy-eight of 289 patients (27.0%) were obese (BMI,or =30.0), and 126 (43.6%) were overweight (BMI range, 25.0 toor =29.9). Body mass index was documented in 39 of 78 obese patients (50.0%) and in 49 of 126 overweight patients (38.9%) (P.001). Diagnosis of obesity was recorded in 19 of 78 obese patients (24.4%). Older patients (OR, 2.77; 95% CI, 1.39-5.49) and obese patients (OR, 2.04; 95% CI, 1.04-3.99) were more likely to have their weight and height measured and BMI calculated by their physician. Patients with comorbid conditions such as diabetes mellitus (OR, 4.35; 95% CI, 2.20-8.62) and hypertension (OR, 3.20; 95% CI, 1.71-5.99) and patients taking chronic medications (OR, 3.44; 95% CI, 1.20-9.83) were also more likely to have their BMI documented.Family physicians failed to identify most obese and overweight patients, as seen by lack of BMI documentation and concordant diagnoses in the medical problem list. Determination of BMI by physicians in family practice is of utmost importance, and its incorporation into medical care should be optimized.

Background The COVID-19 pandemic disrupted the delivery of diabetes care and worsened mental health among many patients with type 2 diabetes (T2D). This disruption puts patients with T2D at risk for poor diabetes outcomes, especially those who experience social disadvantage due to socioeconomic class, rurality, or ethnicity. The appropriate use of communication technology could reduce these gaps in diabetes care created by the pandemic and also provide support for psychological distress. Objective The purpose of this study is to test the feasibility of an innovative co-designed Technology-Enabled Collaborative Care (TECC) model for diabetes management and mental health support among adults with T2D. Methods We will recruit 30 adults with T2D residing in Ontario, Canada, to participate in our sequential explanatory mixed methods study. They will participate in 8 weekly web-based health coaching sessions with a registered nurse, who is a certified diabetes educator, who will be supported by a digital care team (ie, a peer mentor, an addictions specialist, a dietitian, a psychiatrist, and a psychotherapist). Assessments will be completed at baseline, 4 weeks, and 8 weeks, with a 12-week follow-up. Our primary outcome is the feasibility and acceptability of the intervention, as evident by the participant recruitment and retention rates. Key secondary outcomes include assessment completion and delivery of the intervention. Exploratory outcomes consist of changes in mental health, substance use, and physical health behaviors. Stakeholder experience and satisfaction will be explored through a qualitative descriptive study using one-on-one interviews. Results This paper describes the protocol of the study. The recruitment commenced in June 2021. This study was registered on October 29, 2020, on ClinicalTrials.gov (Registry ID: NCT04607915). As of June 2022, all participants have been recruited. It is anticipated that data analysis will be complete by the end of 2022, with study findings available by the end of 2023. Conclusions The development of an innovative, technology-enabled model will provide necessary support for individuals living with T2D and mental health challenges. This TECC program will determine the feasibility of TECC for patients with T2D and mental health issues. Trial Registration ClinicalTrials.gov NCT04607915; https://clinicaltrials.gov/ct2/show/NCT04607915 International Registered Report Identifier (IRRID) DERR1-10.2196/39724