Despite the ubiquity of guided self-help (GSH) interventions in Primary Care psychological services, there have been no previous studies of the relationship between the competence of qualified practitioners and treatment outcomes. This study compared competence-outcome associations in two types of GSH. Competence and clinical outcome measures were drawn from a clinical trial comparing the efficacy of two types of GSH for anxiety disorders, based on cognitive behaviour therapy (CBT-GSH) or cognitive analytic therapy (CAT-GSH). These interventions were delivered over the telephone by qualified and supervised practitioners. Audio-recordings of GSH sessions (n=94) were rated using a validated competence measure. Clinical outcomes were anxiety, depression and functioning. Secondary outcomes were attendance and need for further intervention after GSH. Competence ratings were highly reliable. No significant associations were found between competence and clinical outcomes, treatment engagement or need for further intervention. In this clinical trial, GSH competence ratings were not associated with clinical outcomes. Directions for future competence-outcome research are provided for GSH interventions.

Key learning aims

1. (1) Become familiar with the current empirical literature on therapist competence and associations with clinical outcome.

2. (2) Raise awareness of a recently developed alternative form of guided self-help based on the theory and principles of cognitive analytic therapy.

3. (3) Enhance understanding of the relationship between practitioner competence and clinical outcome in guided self-help for anxiety disorders.

This scoping review addresses gaps in the existing literature on dietary guidelines for pregnant and lactating women globally. The study delves into adherence levels, identifies influencing factors and examines outcomes associated with these guidelines. Analysing food-based dietary guidelines (FBDG) from around the world, the review reveals that half of the countries lack FBDG, with only 15% providing tailored advice for pregnant and lactating women. Utilising data extracted from forty-seven articles across MEDLINE and EMBASE, the study highlights a scarcity of adherence studies, particularly in low- or middle-income countries (LMIC), and emphasises the lack of research during lactation. Overall adherence to dietary guidelines is low, with disparities in fruit, vegetable, whole grain and fish consumption. Positive correlations with adherence include age, education, employment, social class and certain medical histories, while negative correlations involve smoking, alcohol consumption, metropolitan residence and elevated BMI. The study documented significant associations between adherence and reduced risks of gestational complications but calls for further exploration of intermediate nutritional outcomes such as micronutrient deficiencies and child growth. Emphasising the urgency for globally standardised guidelines, especially in LMIC, this review provides a foundational call for prioritised studies and strategies to enhance dietary practices for pregnant and lactating women worldwide.

Our systematic review aims to synthesise the evidence on interventions targeting improvement in patient adherence to psychological treatments for common mental disorders. A search was conducted on six electronic databases using search terms under the following concepts: common mental disorders, adherence, psychological treatments and controlled trial study design. Due to the heterogeneity in intervention content and outcomes evaluated in the included studies, a narrative synthesis was conducted. Risk of bias was assessed using the Cochrane Risk of Bias Version 2 tool for randomised controlled trials and the Cochrane ROBINS-I tool for non-randomised controlled trials. The search yielded 23 distinct studies with a total sample size of 2,779 participants. All studies were conducted in high-income or upper-middle-income countries. Interventions to improve patient adherence to psychological treatments included reminders and between-session engagement (e.g., text messages), motivational interviewing, therapy orientation (e.g., expectation-setting) and overcoming structural barriers (e.g., case management). Interventions from 18 out of 23 studies were successful in improving at least one primary adherence outcome of interest (e.g., session attendance). Some studies also reported an improvement in secondary outcomes – six studies reported an improvement in at least one clinical outcome (e.g., depression), and three studies reported improvements in at least one measure of well-being or disability (e.g., days spent in in-patient treatment). By incorporating these interventions into psychological treatment services, therapists can better engage with and support their patients, potentially leading to improved mental health outcomes and overall well-being.

The aim of this systematic mixed-studies review is to summarise barriers/facilitators to adherence to and/or consumption of oral nutritional supplements (ONS) among patients with disease-related malnutrition. In March 2022, the Cochrane CENTRAL, PUBMED, PsycINFO (Ovid) and CINAHL were searched for articles with various study designs, published since 2000. Articles were identified on the basis of ‘population’ (patients ≥18 years with malnutrition/at nutritional risk), ‘intervention’ (ONS with ≥2 macronutrients and micronutrients), ‘comparison’ (any comparator/no comparator) and ‘outcome’ (factors affecting adherence or consumption) criteria. A sequential exploratory synthesis was conducted: first, a thematic synthesis was performed identifying barriers/facilitators; and second, the randomised controlled trials (RCTs) were used to support these findings. The five WHO dimensions of adherence guided the analysis. Study inclusion, data extraction, analysis and risk-of-bias assessment (MMAT 2018) were carried out independently by two researchers. From 21 835 screened articles, 171 were included with 42% RCTs and 20% qualitative studies. The two major populations were patients with malignancies (34%) and older adults (35%). In total, fifty-nine barriers/facilitators were identified. Patients’ health status, motivation, product tolerance and satisfaction as well as well-functioning healthcare routines and support were factors impacting ONS consumption. Few barriers/facilitators (n = 13) were investigated in RCTs. Two of those were serving a small ONS volume and integrating ONS into ward routines. Given the complexity of ONS adherence, non-adherence to ONS should be addressed using a holistic approach. More studies are needed to investigate the effect of different approaches to increase adherence to ONS.

Maternal malnutrition is pervasive throughout the world, notably in sub-Saharan Africa, including Ethiopia. This study examined the effect of community-based iron-folic acid supplementation (IFAS) nutrition education on IFAS knowledge and attitude among pregnant women in urban settings in South Ethiopia. A community-based quasi-experimental study was conducted among 198 randomly selected pregnant women attending antenatal care (ANC) (99 intervention and 99 control). We used a multistage sampling technique followed by systematic sampling to select the pregnant women. Pregnant women who participated in the intervention arm received six nutrition education sessions and counselling using a health belief model (HBM), while the control group received only routine ANC services. Baseline and endline data were collected during the ANC and compared. The data was analysed using statistical package for social sciences. Analyses of the effect of the intervention were done using difference-in-difference and generalised estimation equation to allow correlation of repeated observations over time. The results indicated a significant effect of intervention on maternal knowledge towards IFAS; with intervention, group levels increased by 35 percentage points (P < 0.001). The odds of being knowledgeable at the endpoint in the intervention group were 2.6 times higher than baseline (OR = 2.67, 95% CI 1.88–3.80). There was a significant (P = 0.001) change in proportion with a favourable attitude towards IFAS between the two time points. The community-based nutrition education intervention approach has significantly improved maternal knowledge and a favourable attitude towards IFAS among pregnant women. The HBM is effective in improving knowledge and attitude among pregnant women.

Obesity is a significant health issue in Aotearoa; effective and pragmatic strategies to facilitate weight loss are urgently required. Growing recognition of the circadian rhythm’s impact on metabolism has popularised diets like time-restricted eating (TRE)(1). The 16:8 TRE method involves limiting food intake to an 8-hour daily eating window and can lead to weight loss without other substantial changes to diet(2). Nonetheless, TRE requires accountability and tolerating hunger for short periods. Continuous glucose monitors (CGM) are small wearable biofeedback devices that measure interstitial glucose levels scanned via smartphones. By providing immediate feedback on the physiological effects of eating and fasting, CGM use may promote adherence to TRE(3). This pilot study aimed to 1) investigate how CGM affects adherence to TRE and 2) assess the feasibility of CGM use while undertaking TRE. This two-arm randomised controlled trial enrolled healthy adults from Dunedin, assigning them to TRE-only or TRE+CGM groups for 14 days. Successful adherence to TRE was defined a priori as maintaining an 8-hour eating window on 80% of days. CGM feasibility was defined a priori as scanning the glucose monitor thrice daily on 80% of days. Secondary outcomes included well-being, anthropometry, glucose levels, and overall TRE and CGM experiences via semi-structured interviews. Twenty-two participants were randomised into two groups: TRE-only (n = 11) and TRE+CGM (n = 11, with n = 2 excluded from analysis post-randomisation for medical reasons). Participants had a diverse range of ethnicities, the mean age was 32 (+/-14.9) years, and 55% were female. The TRE+CGM group adhered to the 8-hour eating window for an average of 10.0 days (range 2-14) compared with 8.6 days (range 2-14) in the TRE-only group. Both groups had similar mean eating window durations of 8.1 hours. Five (56%) participants in the TRE+CGM group achieved the a priori criteria for TRE adherence, compared to 3 (27%) in the TRE-only group. Participants in the TRE+CGM group performed an average of 8.2 (+/-5.6) daily scans, with n = 7 (78%) of participants meeting the a priori CGM feasibility criteria. Neither group reported consistent adverse psychological impacts in DASS-21 and WHO-5 scores. Interviews highlighted that CGM increased hunger tolerance during fasting as participants felt reassured by their normal glucose levels. CGM aided TRE accountability by acting as a biological tracker of food intake. Participants reported that TRE led to improved energy and self-efficacy, a more productive daily routine, and healthier food choices. Promisingly, 72% of participants would use CGM and undertake TRE in future. This study demonstrates that using CGM while undertaking TRE is feasible and can improve adherence by enhancing hunger tolerance and accountability. Overall, participants experienced increased awareness of eating habits and physiological mechanisms. Over the longer term, this simple and synergistic approach may be a helpful weight loss strategy.

Nutrition intervention trials play a key role in informing clinical and dietary guidelines. Within these trials, we need participants to change their behaviours; however, researchers seldom systematically consider how to support participants with these changes, contributing to poor adherence. Here we evaluate how using a behaviour change framework to develop support within a dietary intervention impacts young adults’ adherence to required trial behaviours. In the Protein Diet Satisfaction (PREDITION) trial, 80 young adults were randomised to a flexitarian or vegetarian diet for 10-weeks to investigate the psychological and cardiometabolic effects of moderate lean red meat consumption as part of a balanced diet(1). To understand these outcomes, it was key that participants within the trial (i) ate a healthy, basal vegetarian diet (excluding meat, poultry, and fish not provided by research team) and (ii) reported their dietary intake daily on a smartphone application (required to evaluate intervention compliance). To enhance adherence to these behaviours the Nine Principles framework was used to develop behaviour change support (BCS)(2). Key components of the BCS included access to a dietitian-led Facebook group, text reminders, and food delivery. Effectiveness was measured using the following analyses of the 78 participants who completed the study: pre-post change in targeted dietary habits over time using a subscore of the Healthy Diet Habits Index, adherence score to reporting over 10-weeks, Facebook group engagement, and impact evaluation. Analysis included linear imputation modelling, t-tests, and chi-square analysis. The total Healthy Diet Habits Index subscore out of 16 significantly increased from baseline to week 10 (10.6 ± 2.6 to 11.2 ± 2.6, p = 0.011), demonstrating maintenance of a healthy diet. Overall adherence to reporting was high across the 10 weeks, with the total population mean reporting score 90.4 ± 14.6 out of a possible 100. This strengthens study validity, allowing us to confidently report if participants complied with study requirements of consuming the intervention protein (red meat or plant-based meat alternatives) on top of a basal vegetarian diet. Although relatively low active Facebook engagement was observed (on average <1 ‘react’ per post), most participants agreed the text messages and Facebook groups supported them to adhere to recording (63%) and eating healthily (60%), respectively. This is the first study to provide an example of how a framework can be used to systematically develop, implement, and assess BCS within a nutrition trial. This appears to be a promising way to enhance adherence to study-related behaviours, including the burdensome task of reporting dietary intake. We believe this has great potential to improve research validity and decrease resource waste, not only for the PREDITION trial but in future dietary intervention trials.

Flexitarian, vegetarian and vegan diets are increasingly popular, particularly amongst young adults. This is the first randomised dietary intervention to investigate the health, wellbeing, and behavioural implications of consuming a basal vegetarian diet that additionally includes low-to-moderate amounts of red meat compared to one containing plant-based meat alternatives (PBMAs) in young adults (NCT04869163)(1). The objective for the current analysis is to measure adherence to the intervention, nutrition behaviours, and participants’ experience with their allocated dietary group. Eighty healthy young adults participated in this 10-week dietary intervention as household pairs. Household pairs were randomised to receive approximately three serves of beef and lamb meat (average of 390 g total cooked weight per person per week, flexitarian group) or PBMAs (350–400 g, vegetarian group) on top of a basal vegetarian diet. Participants were supported to adopt healthy eating behaviours, and this intervention was developed and implemented using a behaviour change framework(2). Diet adherence (eating allocated meat or PBMA, abstaining from animal-based foods not provided by researchers) was monitored daily, with total scores calculated at the end of the 10-week intervention period. Eating experiences were measured by the Positive Eating Scale and a purpose-designed exit survey, and a food frequency questionnaire measured dietary intake. Analyses used mixed effects modelling taking household clustering into account. The average total adherence score was 91.5 (SD = 9.0) out of a possible 100, with participants in the flexitarian group scoring higher (96.1, SD = 4.6, compared to 86.7, SD = 10.0; p < 0.001). Those receiving meat were generally more satisfied with this allocation compared to those receiving the PBMAs, even though a leading motivation for participants joining the study was an opportunity to try plant-based eating (35% expressed that that interest). Participants in both intervention groups had increased vegetable intake (p < 0.001), and reported more positive eating experiences (p = 0.020) and satisfaction with eating (p = 0.021) at the end of the 10-week intervention relative to baseline values. Behavioural methods to encourage engagement with the trial were successful, as participants demonstrated excellent adherence to the intervention. The flexitarian and vegetarian diets elicited different responses in adherence and eating experience. This holds relevance for the inclusion of red meat and PBMAs in healthy, sustainable dietary patterns beyond this study alone.

Adherence to post-exposure prophylaxis and post-exposure vaccination (PEV) is an important measure to prevent rabies. The purpose of this study was to explore the adherence to the vaccination protocol and its influencing factors among rabies-exposed patients in Shenzhen, China. A cross-sectional survey was conducted in a tertiary hospital in Shenzhen, China, to obtain epidemiological characteristics of patients; knowledge, attitude, and practice scores of rabies prevention; and medical records. A total of 326 patients requiring full rabies PEV were included in this study, and only 62% (202) completed the full course of vaccination according to the norms of the vaccination guidelines. After multifactor logistic regression, the factors influencing adherence to vaccination were as follows: age 31 to 40 years, time spent to reach the nearest rabies prevention clinic was >60 min, the time of injury was at night to early morning, the place of injury was a school/laboratory, the animal causing injury was a cat, the health status of the animal causing injury could not be determined, and patients with higher practice scores (all p<0.05). Understanding the factors influencing rabies vaccination adherence among rabies-exposed patients in urban areas of China and promote changes in patients’ practice toward rabies prevention is essential for rabies elimination by 2030.

The Constitutional Convention in Chile, like other constitution-making mechanisms in democracies, carried out its work within the democratic institutional framework. In a democracy, the success of a constitution-making process depends not only on internal factors, such as its capacity for representation and the procedural rules by which it is governed, but also on external factors such as participation, the government’s role and other contingent factors. When the process – including both internal and external factors – fails to produce adherence to the new constitution, institutional resistance to changes is very likely to occur. This article argues that the manner in which the political and social spectrum was represented in the Chilean Convention, combined with the way participation was implemented and the rules governing the Convention, insulated it from society and the rest of the democratic institutions. As a result, party and public adherence to the proposal made by the Convention was low and its contents generated institutional resistance from outside.

Financial incentives for medication adherence have been controversial in mental healthcare. Much of the debate, however, may be based on a misconception of what financial incentives are and what their purpose is. Financial incentives are not meant to influence informed consent about treatment decisions, but to bridge the gap between intentions and behaviour and help patients achieve adherence to a treatment that they have agreed to. In this context, patients’ positive views may reflect that the use of financial incentives can support a good therapeutic relationship rather than undermine it.

Clozapine dose assessment in treatment-refractory schizophrenia is complicated. There is a narrow margin between an effective and a potentially toxic dose and wide inter-individual variation in clozapine metabolic capacity. Moreover, factors such as changes in smoking habit, infection/inflammation, co-prescription of certain drugs, notably fluvoxamine, and age alter the dose requirement within individuals. Therapeutic drug monitoring (TDM) of plasma clozapine and N-desmethylclozapine (norclozapine) can help assess adherence, guide dosage and guard against toxicity. This article gives an overview of clozapine pharmacokinetics and factors affecting clozapine dose requirements. It then outlines the procedures and processes of clozapine TDM, from taking the blood sample for laboratory assay or point-of-contact (finger-prick) testing (POCT) to interpreting and acting on the results.