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Abstract Background The pragmatic randomised controlled trial is widely regarded as the gold standard method for evaluating the effectiveness of health care interventions. Successful conduct of trials and generalisation of findings depends upon efficient recruitment of representative samples, which often requires the collaboration of 'gatekeepers' who mediate access to potential participants. Effective negotiation of gatekeeping is thus vital to process and outcomes of trials and the quality of evidence. Whilst relevant literature contains discussion of the problems of recruitment and gatekeeping, little is known about how recruitment can be optimised and factors leading to successful recruitment. Discussion As practised researchers with first-hand experience of gatekeeping, we were aware that some researchers recruit more effectively than others and curious about the ingredients of success. With the goal of developing practical guidance, we conducted a series of workshops with 19 expert researchers to investigate and map successful recruitment. Workshops were digitally recorded and transcribed. Analysis of discussion supported modelling of effective recruitment as a process involving three phases, each comprising two key tasks. Successful negotiation of set-up, alliance, and exchange require judicious deployment of interpersonal skills in an appropriately assertive manner. Researcher flexibility and credibility are vital for success, such that a foundation for rapprochement between the worlds of research and practice is established. Our model provides a framework to support design and implementation of recruitment activities and will enable trouble shooting and support recruitment, supervision and training of effective researchers. This, in turn will support delivery of trials on time and on budget, maximising return on investment in the production of evidence. Summary Pragmatic trials are central to development of evidence based health care but often failure to recruit the necessary sample in a timely manner means many fail or require costly extensions. Gatekeeping is implicated in this. Drawing on the knowledge of 19 expert researchers, we argue that successful researchers are resourceful and personable, judiciously deploying interpersonal skills and expertise to engage with gatekeepers and establish a shared objective. We propose that understanding recruitment as a phased process can enhance design and conduct of trials, supporting completion on time, on budget.

Abstract Background Art Therapy has been promoted as a means of helping people who may find it difficult to express themselves verbally engage in psychological treatment. Group Art Therapy has been widely used as an adjunctive treatment for people with schizophrenia but there have been few attempts to examine its effects and cost effectiveness has not been examined. The MATISSE study aims to evaluate the clinical and cost effectiveness of group Art Therapy for people with schizophrenia. Method/Design The MATISSE study is a three-arm, parallel group, pragmatic, randomised, controlled trial of referral to group Art Therapy plus standard care, referral to an attention control 'activity' group plus standard care, or standard care alone. Study participants were recruited from inpatient and community-based mental health and social care services at four centres in England and Northern Ireland. Participants were aged over 18 years with a clinical diagnosis of schizophrenia, confirmed by an examination of case notes using operationalised criteria. Participants were then randomised via an independent and remote telephone randomisation service using permuted stacked blocks, stratified by site. Art Therapy and activity groups were made available to participants once a week for up to 12 months. Outcome measures were assessed by researchers masked to allocation status at 12 and 24 months after randomisation. Participants and care givers were aware which arm of the trial participants were allocated to. The primary outcomes for the study are global functioning (measured using the Global Assessment of Functioning scale) and mental health symptoms (measured using the Positive and Negative Syndrome Scale) assessed at 24 months. Secondary outcomes were assessed at 12 and 24 months and comprise levels of group attendance, social function, satisfaction with care, mental wellbeing, and costs. Discussion We believe that this is the first large scale pragmatic trial of Art Therapy for people with schizophrenia. Trial registration Current Controlled Trials ISRCTN46150447

Objective: To identify motivation, capabilities and opportunities that enable psychiatrists and registrars to seek help for mental health problems and to inform design of interventions. Method: Data collected in qualitative semi-structured interviews were analysed using a framework approach with the COM-B model of behaviour as a theoretical frame. Results: Accounts of the eight participants show help-seeking to be a complex process requiring cognitive and emotional capability to recognise a problem or goal, acceptance of vulnerability, and facilitated by access to professional networks. Help-seeking was enabled by openness about mental health problems in workplace culture. Conclusions: Interventions to enable help-seeking should focus on normalising the experience of mental health problems among doctors and challenge the notion that difficulties represent characterological flaws. Greater understanding of the mandatory reporting requirements is also required. [ABSTRACT FROM AUTHOR]

Aims: This study investigated the commissioning and delivery of advocacy for problem drug users. We aimed to quantify provision, describe the commissioning of advocacy services in Drug Action Teams (DATs) and to identify factors influencing advocacy provision. Methods: A cross-sectional survey of a randomly selected sample of 50 English DATs. The purpose-designed questionnaire comprising a mix of closed and open questions was completed through a telephone interview. Findings: An 86% response rate was achieved. Informants understood "advocacy" as encompassing a range of activities including user involvement and peer support. A range of approaches classified as formal, informal and ad hoc were described. Whilst advocacy was identified as a need in 29 DATs (67%), formal, independent advocacy was commissioned in only four (9%). In eight DATs (19%), there was no advocacy provision of any kind. Conclusions: Advocacy is described by the National Treatment Agency as an essential element of effective drug treatment systems. However, provision in English DATs is inconsistent, poorly integrated with treatment systems and characterized by the absence of strategic planning. Clarification of the concept and purpose of advocacy as either a right adhering to citizenship or a means to achieve treatment targets is an essential first step towards systematic and meaningful integration of advocacy within the treatment system. (Contains 2 tables.)

The oral health of people with severe mental illness is severely compromised. Rates of premature total tooth loss and tooth decay are substantially higher than in the general population. Causation is complex, restricted access to treatment a major contributing factor. To examine factors enabling people with complex problems related to severe mental illness to attend scheduled dental appointments. Qualitative semi-structured interviews were conducted with 15 service users who attended no-cost treatment at a university clinic, following oral health screening at an inner-city community mental health service. Analysis used a framework approach informed by a theoretical model of behaviour (COM-B). Complex individual motivations, related variously to function, pain and/or self or social appraisal, were also influenced by expectations of treatment. Capabilities included managing "messy" life circumstances; participants overcame various psychological and physical challenges to attend treatment, enabled by opportunities of social and instrumental support. Genuine partnerships between agencies to provide access opportunities, in addition to individual support responsive to personal motivators and adapted to capabilities can enable access to services and improve the lives of people with severe mental illness. [ABSTRACT FROM AUTHOR]

Interventions that promote exercise and a healthy diet can improve quality of life and may promote recovery for people with mental health issues. The aim of this study was to evaluate a community-based lifestyle program for adults with mental health issues to inform the design of such interventions, and assess its impact on quality of life and recovery. Mixed methods were used to evaluate 8-week interventions involving weekly group gym-based exercise sessions and nutritional education. Programs were delivered by personal trainers and chefs at a charitable community organization. Acceptability was evaluated using qualitative focus groups and procedural statistics (rates of referral, attendance, and withdrawal). Primary outcomes were quality of life and recovery assessed at baseline and post-intervention; other outcomes included metabolic indicators (weight, waist, blood pressure and fasting glucose, cholesterol, triglycerides) and functional capacity (walk test). Of the 100 adults referred, 58 began the program and 38 (66%) completed, attending a median of 75% of sessions. Participants indicated that their appraisal of the program environment (related to venue, social group, and staff), and the realization of benefits, were essential to their experiences with the program. Quality of life (mental health, coping, relationships, senses and self-worth), and recovery (hope) significantly improved. Exercise and nutrition interventions have diverse benefits for quality of life and recovery. Programs should be implemented within contexts that promote positive experiences and inclusive social environments to foster self-worth, personal confidence and hope. Recovery-oriented lifestyle interventions should be utilized routinely in mental health care. [ABSTRACT FROM AUTHOR]

Exercise has diverse benefits for physical and mental health in people with mental illness; however, it is unclear how to effectively promote exercise motivation in this group. The aim of this study is to evaluate the effectiveness of interventions utilising exercise instruction or behavioural counselling with people with mental illness to improve self‐determined motivation for exercise, and physical and mental health. Participants were adults (aged 18+ years) receiving mental health services. Participants could choose from two 8‐week programs comprising weekly group‐based sessions delivered by an exercise physiologist: (a) exercise instruction in a gym (GYM) or (b) behavioural counselling (MOT). Self‐determined motivation was measured using the Behaviour Regulations for Exercise Questionnaire (BREQ3). Physical health indicators included waist circumference, blood pressure, leg strength (sit‐to‐stand test), physical capacity (six‐minute walk test) and self‐reported exercise. Mental health was assessed using the Kessler‐6 scale of psychological distress. Most of the 95 participants chose exercise instruction (GYM = 60; MOT = 35). At baseline, participants who chose MOT had higher external motivation, body mass index, waist circumference and psychological distress, and a higher proportion had multiple physical comorbidities than those who chose GYM. More self‐determined motivation was associated with meeting physical activity guidelines. Post‐intervention, GYM participants had significant improvements in self‐determined motivation, psychological distress and sit‐to‐stand test; MOT participants had significant improvements in integrated regulation, self‐reported exercise and physical functioning. In conclusion, exercise instruction can improve self‐determined motivation; however, more intensive behavioural counselling support may be needed to improve self‐determined motivation. Counselling programs can increase exercise behaviour and may appeal more to people with poorer health and more external motivation. Findings have high ecological validity and applicability to real‐world implementation of exercise interventions. To accommodate people with diverse conditions and motivations, motivational counselling should be combined with practical exercise support, and participants afforded the autonomy to decide their level of involvement. [ABSTRACT FROM AUTHOR]

Janet Soskice's book 'Metaphor and Religious Language' is flawed by basing its argument almost entirely on linguistic, not theological, grounds, and never succeeds in linking the two. Her argument and assumptions must be reworked from the theological perspective. Metaphor does serve a dual role, permitting figures of speech and informing religious thought. In fact, it implicitly or explicitly mediates God as Truth, revealing Truth as a gift from God through Grace.