This paper explores the qualitative outcomes as part of a larger feasibility study which was developed to test a Cultural Health Check toolkit designed to assist healthcare workers and organisations ...in the provision of safe, dignified and compassionate quality care for older people. For the qualitative part of this project, 11 healthcare workers agreed to participate in a one-to-one semi-structured interview. The primary aim of the research was to identify the experiences of staff in relation to the different factors they feel contribute to the culture of the organisation. These data were analysed using Attride-Stirling thematic analysis. The data were coded and four global themes were evident: professional practice, support, workforce and service delivery. Professional practice included organisational themes of quality, communication and collaboration and how these impact on a health worker’s ability to carry out their role and the impact on the delivery of compassionate quality care. Support included organisation themes of personal and professional development, and facilitation by leaders and managers to access the available support. Workforce centred on the importance of having adequate levels of all staffing groups to be able to deliver safe, quality person-centred care and services. Service delivery identified the organisational themes of care, person-centred care and communication where staff have the desire, determination and enthusiasm to deliver safe, high quality compassionate person-centred care and services. These themes are key in the impact analysis relating to the delivery of compassionate quality care.
Background
Child and adolescent overweight and obesity has increased globally, and can be associated with significant short‐ and long‐term health consequences. This is an update of a Cochrane review ...published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages.
Objectives
To assess the effects of diet, physical activity and behavioural interventions (behaviour‐changing interventions) for the treatment of overweight or obese children aged 6 to 11 years.
Search methods
We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases.
Selection criteria
We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour‐changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow‐up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity.
Data collection and analysis
Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta‐analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.
Main results
We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty‐five trials compared a behaviour‐changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour‐changing intervention. Sixty‐four trials were parallel RCTs, and four were cluster RCTs. Sixty‐four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.
Primary analyses demonstrated that behaviour‐changing interventions compared to no treatment/usual care control at longest follow‐up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was ‐0.53 kg/m2 (95% confidence interval (CI) ‐0.82 to ‐0.24); P < 0.00001; 24 trials; 2785 participants; low‐quality evidence. MD in BMI z score was ‐0.06 units (95% CI ‐0.10 to ‐0.02); P = 0.001; 37 trials; 4019 participants; low‐quality evidence and MD in weight was ‐1.45 kg (95% CI ‐1.88 to ‐1.02); P < 0.00001; 17 trials; 1774 participants; low‐quality evidence.
Thirty‐one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour‐changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health‐related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI ‐12.88 to ‐0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all‐cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta‐analysed.
As the meta‐analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post‐intervention follow‐up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post‐intervention was no longer evident at follow‐up at less than six months, which has to be investigated in further trials.
Authors' conclusions
Multi‐component behaviour‐changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short‐term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour‐changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour‐changing interventions on health‐related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer‐term follow‐up and further research on the most appropriate forms of post‐intervention maintenance in order to ensure intervention benefits are sustained over the longer term.
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