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Background: Clinical guideline recommendations for addressing modifiable risk factors are not routinely implemented into preconception and antenatal care. This review assessed the effectiveness of implementation strategies in improving health professional provision of preconception and antenatal care addressing tobacco smoking, weight management and alcohol consumption., Methods: A systematic review of randomised and non-randomised studies with a parallel comparison group was conducted. Eligible studies used implementation strategy/ies targeted at health professionals to improve at least one element of preconception and/or antenatal care (smoking: ask, advise, assess, assist, arrange; weight/alcohol: assess, advise, refer) compared to usual practice/control or alternative strategies. Eligible studies were identified via CENTRAL, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL and other sources. Random-effects meta-analyses were conducted where appropriate, with other findings summarised using the direction of effect. The certainty of the pooled evidence was assessed using the GRADE approach., Results: Fourteen studies were included in the review. Thirteen were in the antenatal period and 12 tested multiple implementation strategies (median: three). Meta-analyses of RCTs found that implementation strategies compared to usual practice/control probably increase asking (OR: 2.52; 95% CI: 1.13, 5.59; 3 studies; moderate-certainty evidence) and advising (OR: 4.32; 95% CI: 3.06, 6.11; 4 studies; moderate-certainty evidence) about smoking and assessing weight gain (OR: 57.56; 95% CI: 41.78, 79.29; 2 studies; moderate-certainty evidence), and may increase assessing (OR: 2.55; 95% CI: 0.24, 27.06; 2 studies; low-certainty evidence), assisting (OR: 6.34; 95% CI: 1.51, 26.63; 3 studies; low-certainty evidence) and arranging support (OR: 3.55; 95% CI: 0.50, 25.34; 2 studies; low-certainty evidence) for smoking. The true effect of implementation strategies in increasing advice about weight gain (OR: 3.37; 95% CI: 2.34, 4.84; 2 non-randomised studies; very low-certainty evidence) and alcohol consumption (OR: 10.36; 95% CI: 2.37, 41.20; 2 non-randomised studies; very low-certainty evidence) is uncertain due to the quality of evidence to date., Conclusions: Review findings provide some evidence to support the effectiveness of implementation strategies in improving health professional delivery of antenatal care addressing smoking and weight management. Rigorous research is needed to build certainty in the evidence for improving alcohol and weight gain advice, and in preconception care., Trial Registration: PROSPERO-CRD42019131691., (© 2022. The Author(s).)

Introduction: This paper aimed to document alcohol use during pregnancy and determine predictors of ongoing use, including knowledge and agreement with national alcohol guideline recommendations., Methods: Pregnant women (n = 1179) attending public antenatal services in a Local Health District in NSW, Australia, were surveyed about their alcohol use before pregnancy and after pregnancy recognition, and awareness of, and agreement with, national alcohol guidelines and health-related statements. Respondent characteristics, drinking behaviour and predictors of ongoing drinking during pregnancy were assessed., Results: Most women consumed alcohol before pregnancy (79.3%) but the majority (82.0%) stopped following pregnancy recognition. Half the ongoing drinkers only drank on special occasions. Most (63.6%) women were aware of the national guidelines: 78.1% knew the recommendation that consuming no alcohol in pregnancy is safest, 4.6% thought some alcohol was safe and 17.3% were unsure. Predictors [OR (95%CI)] of ongoing drinking were older age [1.11 (1.07, 1.15)]; medium [2.42 (1.46, 4.00)] or high-risk drinking pre-pregnancy [3.93 (2.35, 6.56)]; and agreement that: avoiding alcohol in pregnancy is safest [0.05 (0.006, 0.47)]; avoiding alcohol is important for baby's health [0.14 (0.06, 0.31)] and pregnancy is a good time to change alcohol use for mother's health [0.29 (0.13, 0.63)]., Discussion and Conclusions: Results emphasise the importance of asking about special occasion drinking, the link between pre-pregnancy drinking and ongoing drinking during pregnancy, and the need to understand why women disagree with the national guideline. To ensure guidelines have their intended benefit, interventions to promote behaviour change relating to alcohol consumption during pregnancy are warranted., (© 2021 Australasian Professional Society on Alcohol and other Drugs.)

Background: Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women., Methods: Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form., Discussion: The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children., Systematic Review Registration: PROSPERO CRD42018095315.

Introduction and Aims: People who use substances have a high prevalence of modifiable chronic disease health risk behaviours. Preventive care to address such risks has not traditionally been provided during substance use treatment. This study aimed to assess clinicians' attitudes towards preventive care and their association with care provision., Design and Methods: A cross-sectional study utilising computer-assisted telephone interviews was undertaken with clinicians (n = 54) of community-based substance use treatment services in one health district, Australia. Clinicians indicated their agreement with 10 attitudinal statements regarding their perceived role and self-efficacy in providing preventive care and perceptions of client interest in modifying behaviours. Logistic regression analyses examined the association between clinician attitudinal items and self-reported care provision., Results: Fifty-four clinicians (74%) agreed to participate. The most positive attitudes were preventive care being part of their role (100%), and they have the knowledge and skills to provide preventive care (100%). The least favourable attitude was clients were interested in changing their health risk behaviours (60%). Clinicians who reported that preventive care left little time to undertake acute care were more likely to assess for smoking (OR 8.06 [95% CI 1.31, 49.46]) and less likely to provide brief advice for all risks combined (OR 0.11 [95% CI 0.02, 0.63])., Discussion and Conclusions: Overall, clinicians reported positive attitudes regarding the preventive care provision for modifiable health risk behaviours in substance use treatment settings. Further research is required to investigate why, despite such positive attitudes, clinicians in substance use treatment settings do not routinely provide preventive care., (© 2020 Australasian Professional Society on Alcohol and other Drugs.)

People who use substances have a high prevalence of other modifiable health risk behaviours such as tobacco smoking which contribute to an increased mortality and morbidity. Preventive care can reduce the prevalence of such behaviours and is recommended by clinical practice guidelines. This review describes the prevalence of preventive care delivery by substance use treatment healthcare providers and examines differences by treatment setting. Five databases were searched for studies published between 2005 and 2017. Eligible studies reported levels of preventive care (assessment, brief advice and/or referral/follow-up) in substance use treatment services for tobacco smoking, nutrition or physical activity. Two reviewers independently conducted article screening, data extraction and methodological quality assessment. Sixteen studies were included and all except one investigated care provision for tobacco smoking only. Four studies reported care levels as a proportion and 12 studies reported care as a score-based mean. Client-reported receipt of smoking cessation care ranged from: 79-90% for assessment; 15-79% for brief advice; 0-30% for referral/follow-up. Meta-regression analyses of 12 studies found clinician-reported preventative care for tobacco smoking was more frequently reported in studies assessing care occurring across multiple substance use treatment settings, compared to studies reporting provision in inpatient only. This review indicated that, compared to smoking cessation care, little is known about the level of preventive care for nutrition or physical activity. Overall, the delivery of smoking cessation care reported was sub-optimal. High levels of assessment relative to brief advice and low levels of referral to ongoing assistance were indicated., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Despite existing best practice care recommendations for addressing tobacco smoking, alcohol consumption and weight management in preconception and antenatal care, such recommendations are often not implemented into routine practice. Effective strategies that target known barriers to implementation are key to reducing this evidence to practice gap. The aim of this review is to synthesise the evidence on the effectiveness of implementation strategies in improving the provision of preconception and antenatal care for these modifiable risk factors., Methods: Randomised and non-randomised study designs will be eligible for inclusion if they have a parallel control group. We will include studies that either compare an implementation strategy to usual practice or compare two or more strategies. Participants may include any health service providing preconception or antenatal care to women and/or the health professionals working within such a service. The primary outcome will be any measure of the effectiveness of implementation strategies to improve preconception and/or antenatal care for tobacco smoking, alcohol consumption and/or weight management (including care to improve nutrition and/or physical activity). Secondary outcomes will include the effect of the implementation strategy on women's modifiable risk factors, estimates of absolute costs or cost-effectiveness and any reported unintentional consequences. Eligible studies will be identified via searching Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, ProQuest Dissertations and Theses and other sources (e.g. contacting experts in the field). Study selection, data extraction and risk of bias will be assessed independently by two review authors and differences resolved by a third reviewer. If data permits, we will conduct fixed-effects or random-effects meta-analysis where appropriate. If studies do not report the same outcome or there is significant heterogeneity, results will be summarised narratively., Discussion: This review will identify which implementation strategies are effective in improving the routine provision of preconception and antenatal care for tobacco smoking, alcohol consumption and weight management. Such a review will be of interest to service providers, policy makers and implementation researchers seeking to improve women's modifiable risk factors in preconception and antenatal care settings., Systematic Review Registration: PROSPERO CRD42019131691.

Primary healthcare services are recommended to provide preventive care to address chronic disease risk behaviours. However, all care elements are infrequently provided, and there is a need to understand the impact of partial care provision on behaviour change. This study examined the association between variable levels of preventive care receipt from primary care clinicians on short-term behaviour change for four risk behaviours. A survey was undertaken with 5639 Australian community health service clients (2009-2014). Clients self-reported: engagement in risk behaviours (tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption, physical inactivity) in the month prior to and four week post their community health service appointment; receipt of preventive care during appointments (assessment, advice, referral/follow-up) for each behaviour. Univariate regression models explored the association between change in risk status and preventive care received. The odds of behaviour change for those receiving all three care elements was significant for all behaviours, compared to no care, ranging from 2.02 (alcohol consumption, 95% CI 1.16-3.49) to 4.17 (inadequate fruit and/or vegetable consumption, 95% CI 2.91-5.96). Receipt of both assessment and advice increased the odds of behaviour change, compared to no care, for all behaviours except smoking, ranging from 2.32 (physical inactivity, 95% CI 1.60-3.35) to 2.83 (alcohol consumption, 95% CI 1.84-4.33). Receipt of 'assessment only' increased the odds of behaviour change, compared to no care, for inadequate fruit and/or vegetable consumption (OR = 2.40, 95% CI 1.60-3.59) and physical inactivity (OR = 2.81, 95% CI 1.89-4.17). Results highlight the importance of primary care clinicians providing best practice preventive care to maximise client behaviour change., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Despite clinical guideline recommendations, implementation of antenatal care addressing alcohol consumption by pregnant women is limited. Implementation strategies addressing barriers to such care may be effective in increasing care provision. The aim of this study is to examine the effectiveness, cost and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women., Methods: The study will be a randomised, stepped-wedge controlled trial conducted in three sectors in a health district in New South Wales, Australia. Stepped implementation of a practice change intervention will be delivered to sectors in a random order to support the introduction of a model of care for addressing alcohol consumption by pregnant women. A staged process was undertaken to develop the implementation strategies, which comprise of: leadership support, local clinical practice guidelines, electronic prompts and reminders, opinion leaders, academic detailing (audit and feedback), educational meetings and educational materials, and performance monitoring. Repeated cross-sectional outcome data will be gathered weekly across all sectors for the study duration. The primary outcome measures are the proportion of antenatal appointments at 'booking in', 27-28 weeks gestation and 35-36 weeks gestation for which women report (1) being assessed for alcohol consumption, (2) being provided with brief advice related to alcohol consumption during pregnancy, (3) receiving relevant care for addressing alcohol consumption during pregnancy, and (4) being assessed for alcohol consumption and receiving relevant care. Data on resources expended during intervention development and implementation will be collected. The proportion of women who report consuming alcohol since knowing they were pregnant will be measured as a secondary outcome., Discussion: This will be the first randomised controlled trial to evaluate the effectiveness, cost and cost-effectiveness of implementation strategies in improving antenatal care that addresses alcohol consumption by pregnant women. If positive changes in clinical practice are found, this evidence will support health service adoption of implementation strategies to support improved antenatal care for this recognised risk to the health and wellbeing of the mother and child., Trial Registrations: Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Objectives: To evaluate the potential effectiveness of a practice change intervention in increasing preventive care provision in community-based substance use treatment services. In addition, client and clinician acceptability of care were examined., Design: A pre-post trial conducted from May 2012 to May 2014., Setting: Public community-based substance use treatment services (n=15) in one health district in New South Wales (NSW), Australia., Participants: Surveys were completed by 226 clients and 54 clinicians at baseline and 189 clients and 46 clinicians at follow-up., Interventions: A 12-month multistrategic clinician practice change intervention that aimed to increase the provision of preventive care for smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity., Primary and Secondary Outcome Measures: Client and clinician reported provision of assessment, brief advice and referral for three modifiable health risk behaviours: smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity. Clinician-reported optimal care was defined as providing care to 80% of clients or more. Client acceptability and clinician attitudes towards preventive care were assessed at follow-up., Results: Increases in client reported care were observed for insufficient fruit and/or vegetable consumption including: assessment (24% vs 54%, p<0.001), brief advice (26% vs 46%, p<0.001), and clinicians speaking about (10% vs 31%, p<0.001) and arranging a referral (1% vs 8%, p=0.006) to telephone helplines. Clinician reported optimal care delivery increased for: assessment of insufficient fruit and/or vegetable consumption (22% vs 63%, p<0.001) and speaking about telephone helplines for each of the three health risk behaviours. Overall, clients and clinicians held favourable views regarding preventive care., Conclusion: This study reported increases in preventive care for insufficient fruit and/or vegetable consumption; however, minimal increases were observed for smoking or insufficient physical activity. Further investigation of the barriers to preventive care delivery in community substance use settings is needed., Trialregistration Number: ACTRN12614000469617., Competing Interests: Competing interests: None decalred., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the effect of universal, school-based, resilience-focused interventions on mental health problems in children and adolescents., Method: Eligible studies were randomized controlled trials (RCTs) of universal, school-based interventions that included strategies to strengthen a minimum of 3 internal resilience protective factors, and included an outcome measure of mental health problems in children and adolescents aged 5 to 18 years. Six databases were searched from 1995 to 2015. Results were pooled in meta-analyses by mental health outcome (anxiety symptoms, depressive symptoms, hyperactivity, conduct problems, internalizing problems, externalizing problems, and general psychological distress), for all trials (5-18 years). Subgroup analyses were conducted by age (child: 5-10 years; adolescent: 11-18 years), length of follow-up (short: post-≤12 months; long: >12 months), and gender (narrative)., Results: A total of 57 included trials were identified from 5,984 records, with 49 contributing to meta-analyses. For all trials, resilience-focused interventions were effective relative to a control in reducing 4 of 7 outcomes: depressive symptoms, internalizing problems, externalizing problems, and general psychological distress. For child trials (meta-analyses for 6 outcomes), interventions were effective for anxiety symptoms and general psychological distress. For adolescent trials (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. For short-term follow-up, interventions were effective for 2 of 7 outcomes: depressive symptoms and anxiety symptoms. For long-term follow-up (meta-analyses for 5 outcomes), interventions were effective for internalizing problems., Conclusion: The findings may suggest most promise for using universal resilience-focused interventions at least for short-term reductions in depressive and anxiety symptoms for children and adolescents, particularly if a cognitive-behavioral therapy-based approach is used. The limited number of trials providing data amenable for meta-analysis for some outcomes and subgroups, the variability of interventions, study quality, and bias mean that it is not possible to draw more specific conclusions. Identifying what intervention qualities (such as number and type of protective factor) achieve the greatest positive effect per mental health problem outcome remains an important area for future research., Systematic Review Protocol and Registration: Systematic Review of Universal Resilience Interventions Targeting Child and Adolescent Mental Health in the School Setting; http://dx.doi.org/10.1186/s13643-015-0172-6; PROSPERO CRD42015025908., (Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Although clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours., Methods: A three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009-May 2014). Segmented logistic regression models were developed to assess intervention effectiveness., Results: A total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes (smoking OR 1.53; fruit and/or vegetable intake OR 2.18; alcohol consumption OR 1.69; all risks combined OR 1.78) and two of five brief advice outcomes (fruit and/or vegetable intake OR 2.05 and alcohol consumption OR 2.64). No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity., Conclusions: The implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision., Trial Registration: Australian Clinical Trials Registry ACTRN12611001284954 . Registered 15 December 2011. Retrospectively registered.

Introduction and Aims: Health risk behaviours, such as smoking, nutrition and physical inactivity, are significant contributors to chronic disease for people with substance use disorders. This study reports the prevalence of these behaviours amongst substance use treatment clients, their attitudes towards modifying such behaviours and the acceptability of receiving support to do so. Client characteristics associated with risk status and interest in modifying behaviours were examined., Design and Methods: A cross-sectional survey was undertaken with clients of 15 community substance use treatment services within in New South Wales, Australia. Data for the study were collected via computer assisted telephone interviews., Results: Of those contactable and eligible, 386 (71%) clients completed the survey. Clients reported a high prevalence of smoking (80%), insufficient fruit and/or vegetable consumption (89%) and insufficient physical activity (31%). Overall, 51-69% of clients reported considering modifying their health risk behaviours and 88-97% thought it was acceptable to be provided preventive care to address such behaviours. Younger clients were more likely to smoke (18-34 years (odds ratio [OR] = 4.6 [95% confidence interval [CI] = 1.9, 11.3]); 35-54 years (OR = 2.6 [95% CI = 1.2, 5.7])) and be interested in increasing vegetable consumption (18-34 years (OR = 4.4 [95% CI = 1.3, 14.8]); 35-54 years (OR = 8.0 [95% CI = 2.5, 25.4])) than older clients (≥55 years)., Discussion and Conclusions: There is a high prevalence of health risk behaviours amongst clients of community substance use treatment services. However, contrary to commonly cited barriers to care provision, clients are interested in modifying their risk behaviours and report that receiving preventive care to address these behaviours is acceptable. [Tremain D, Freund M, Wolfenden L, Wye P, Bowman J, Dunlop A, Gillham K, Bartlem K, McElwaine K, Gow B, Wiggers J. Modifiable health risk behaviours and attitudes towards behaviour change of clients attending community-based substance use treatment services. Drug Alcohol Rev 2017;36:369-377.]., (© 2016 The Authors Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: People with substance use problems have a higher prevalence of modifiable health risk behaviors. Routine clinician provision of preventive care may be effective in reducing such health behaviors. This study aimed to examine clinician provision of preventive care to clients of community substance use treatment services., Methods: A cross-sectional survey was undertaken with 386 clients and 54 clinicians of community substance use treatment services in one health district in New South Wales, Australia. Client- and clinician-reported provision of three elements of care (assessment, brief advice and referral) for three health risk behaviors (tobacco smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity) was assessed, with associations with client characteristics examined., Results: Provision was highest for tobacco smoking assessment (90% client reported, 87% clinician reported) and brief advice (79% client reported, 80% clinician reported) and lowest for fruit and vegetable consumption (assessment 23%, brief advice 25%). Few clients reported being offered a referral (<10%). Assessment of physical activity and brief advice for all behaviors was higher for clients residing in rural/remote areas., Conclusion: Assessment and brief advice were provided to the majority of clients for smoking, but sub-optimally for the other behaviors. Further investigation of barriers to the provision of preventive care within substance use treatment settings is required, particularly for referral to ongoing support., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Repair behaviors (a speaker's attempts to make a message understood when the listener indicates a breakdown in communication has occurred) of children with and without mental retardation, ages 8 to 13, were compared as they responded to stacked sequences of requests for clarification (the child's response to a request for clarification is followed by a second and then a third request for clarification). A picture description task with a barrier between the child and examiner was the repair-evoking context. Significant differences were observed in the use of repairs by the two groups. Children with mental retardation did not respond as often as did the children without mental retardation, who also more frequently used details to expand their utterances. Differences were also observed as the request sequence progressed. Evaluation of repair behaviors of children with mental retardation may provide direction for the development of conversational skills.