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1.  Alcohol dependent patients have weak negative rather than strong positive implicit alcohol associations 
Psychopharmacology  2013;228(4):603-610.
Rationale
Alcohol dependence is characterised by motivational conflict (or ambivalence) in controlled cognitive processes, but it is unclear if ambivalence also exists within automatic cognitive processes, and if ambivalence operates between controlled and automatic processes.
Objective
To investigate ambivalence operating within and between controlled and automatic processes in alcohol dependence.
Method
Alcohol-dependent patients who had recently completed inpatient alcohol detoxification (N = 47) and social drinking controls (N = 40) completed unipolar implicit association tests and self-report measures of alcohol approach and avoidance motivation and alcohol outcome expectancies.
Results
As predicted, both positive and negative alcohol outcome expectancies were stronger in alcohol-dependent patients compared to controls, indicative of ambivalence. Groups did not differ on implicit alcohol-positive associations, but alcohol-dependent participants had significantly weaker alcohol-negative associations than controls. Regression analyses revealed that implicit negative associations accounted for unique variance in group membership after controlling for alcohol outcome expectancies.
Conclusions
Our findings demonstrate that alcohol dependent patients possess weak automatic alcohol-negative associations but not strong automatic alcohol-positive associations, and they suggest the presence of conflict between controlled and automatic processes with regard to negative alcohol cognitions.
Electronic supplementary material
The online version of this article (doi:10.1007/s00213-013-3066-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s00213-013-3066-0
PMCID: PMC3726926  PMID: 23503702
Alcohol dependence; Outcome expectancies; Implicit associations; Unipolar implicit association test
2.  Integrating telecare for chronic disease management in the community: What needs to be done? 
Background
Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community.
Methods
Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers.
Results
Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice.
Conclusion
Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care.
doi:10.1186/1472-6963-11-131
PMCID: PMC3116473  PMID: 21619596
3.  The effectiveness and cost effectiveness of a national lay‐led self care support programme for patients with long‐term conditions: a pragmatic randomised controlled trial 
Objective
Supporting patients' self care could have a major effect on the management of long‐term conditions, which has led to worldwide interest in effective self care interventions. In England, self care support is being developed through the “Expert Patients Programme”, which provides lay‐led generic courses to improve patients' self care skills. However, the clinical and cost effectiveness of such courses remains unclear.
Methods
Two‐arm pragmatic randomised controlled trial design with waiting list control in community settings in England. 629 patients with a wide range of self‐defined long‐term conditions were studied. The lay‐led self care support group involved 6‐weekly sessions to teach self care skills. Primary outcomes were self‐efficacy, reported energy and routine health services utilisation at 6 months. A cost‐effectiveness analysis was also conducted.
Results
Patients receiving immediate course access reported considerably greater self‐efficacy and energy at 6‐month follow‐up, but reported no statistically significant reductions in routine health services utilisation over the same time period. The cost‐effectiveness analysis showed that patients receiving immediate course access reported considerably greater health related quality of life, and a small reduction in costs. If a quality adjusted life year was valued at £20 000 ($39 191; €30 282), there was a 70% probability that the intervention was cost effective.
Conclusions
Lay‐led self care support groups are effective in improving self‐efficacy and energy levels among patients with long‐term conditions, and are likely to be cost effective over 6 months at conventional values of a decision‐maker's willingness to pay. They may be a useful addition to current services in the management of long‐term conditions.
doi:10.1136/jech.2006.053538
PMCID: PMC2652924  PMID: 17325405
4.  Creating 'good' self-managers?: Facilitating and governing an online self care skills training course 
Background
In chronic disease management, patients are increasingly called upon to undertake a new role as lay tutors within self-management training programmes. The internet constitutes an increasingly significant healthcare setting and a key arena for self-management support and communication. This study evaluates how a new quasi-professional health workforce – volunteer tutors – engage, guide and attempt to manage people with long-term conditions in the ways of 'good' self-management within the context of an online self-management course.
Methods
A qualitative analysis of postings to the discussion centre of 11 online classes (purposively selected from 27) run as part of the Expert Patients Programme. Facilitators (term for tutors online) and participants posted questions, comments and solutions related to self-management of long-term conditions; these were subjected to a textual and discursive analysis to explore:
a) how facilitators, through the internet, engaged participants in issues related to self-management;
b) how participants responded to and interacted with facilitators.
Results
Emergent themes included: techniques and mechanisms used to engage people with self-management; the process facilitators followed – 'sharing', 'modelling' and 'confirming'; and the emergence of a policing role regarding online disclosure. Whilst exchanging medical advice was discouraged, facilitators often professed to understand and give advice on psychological aspects of behaviour.
Conclusion
The study gave an insight into the roles tutors adopt – one being their ability to 'police' subjective management of long-term conditions and another being to attempt to enhance the psychological capabilities of participants.
doi:10.1186/1472-6963-9-93
PMCID: PMC2699343  PMID: 19505302
5.  Predicting who will benefit from an Expert Patients Programme self-management course 
Background
In England, the Expert Patients Programme, a lay-led chronic disease self-management course, was developed to improve self-care support and skills. The course is designed for anyone with a self-defined long-term condition, and attracts a heterogeneous group of patients. A randomised controlled trial has demonstrated effectiveness in improving subjective health. However, it is not known whether particular patient characteristics predict the impact of the course.
Aim
To determine whether baseline characteristics predict clinical outcomes from attendance at a chronic disease self-management course; and to assess whether identification of such characteristics assists in targeting the course to individuals most likely to benefit.
Design of study
A post-hoc subgroup analysis of data from a randomised controlled trial to explore predictors of three trial outcomes: self-efficacy, energy, and health-related quality of life.
Setting
Participants with self-defined long-term conditions (n = 629) were recruited from community settings in all 28 strategic health authorities in England.
Method
Multiple regression was used to examine interactions between baseline variables and trial outcomes.
Results
The predictors demonstrating significant interactions were: age and general health, and baseline values for self-efficacy, energy levels, and health-related quality of life.
Conclusion
Participants with lower self-efficacy and health-related quality of life at baseline demonstrated more positive health outcomes. The Expert Patients Programme may have a protective effect on health-related quality of life for patients with poor health and low confidence. Younger people benefited substantially more than older people. Results suggest that positive outcomes associated with the course will be demonstrated with a wide variety of patients, although it may be worthwhile encouraging attendance of younger patients, those lacking confidence, and those coping poorly with their condition.
doi:10.3399/bjgp08X277320
PMCID: PMC2249796  PMID: 18318974
chronic disease; outcome studies; randomised controlled trial; self-care
6.  A qualitative study of GPs' attitudes to self-management of chronic disease 
Background
Improving the quality of care for patients living with a chronic illness is a key policy goal. Alongside systems to ensure care is delivered according to evidence-based guidelines, an essential component of these new models of care is the facilitation of self-management. However, changes to the way professionals deliver care is complex, and it is important to understand the key drivers and barriers that may operate in the primary care setting.
Aim
To explore GPs' perspectives on their involvement in the facilitation of chronic disease self-management.
Design of study
Qualitative study.
Setting
General practices located in two primary care trusts in northern England.
Method
Data were collected through in-depth, semi-structured interviews with a purposive sample of GPs. During analysis, categories of response were organised into themes that relate to Howie's theoretical model for understanding general practice consultations: content, values, context.
Results
The GPs' responses highlighted tensions and trade-offs regarding their role in facilitating self-management. Although GPs valued increased patient involvement in their health care, this was in conflict with other values concerning professional responsibility. Furthermore, contextual factors also limited the degree to which they could assist in encouraging self-management.
Conclusions
Providing GPs with training in consultation skills is required in order to encourage the delivery of effective self-management. In addition, the context in which GPs work also needs to be modified for this to be achieved.
PMCID: PMC1839014  PMID: 16762121
chronic disease; family practice; self-care

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