because they are dramatic and in complications of epilepsy (eg, gingival hypertrophy following phenytoin use or intellectual disability). 8 Stigma scores are highest in the poorest people, in children with unemployed parents, and in urban areas. Stigma scores might be higher in older children, who have more awareness of stigma. Other context-specific devalued statuses might add com plexities to epilepsy stigma in children (eg, race and gender issues in India or HIV-orphanage residence and poor economic status in Africa). 9 Stigma affects the quality of life of children with epilepsy, but few studies formally assess this interaction. A child with epilepsy might be refused admission to school, with Guinean children citing embarrassment due to seizures as reason for nonschool attendance. 10 However, school attendance can also be affected by other epilepsy-related factors (eg, intellectual disability). Stigma exacerbates psychiatric comorbidities in children with epilepsy, and in a survey of parents of children with epilepsy in India psychological stress due to fear of shame and rejection was cited if they divulged their child's diagnosis. 4 Epilepsy stigma might deter parents from seeking care for their children for fear of being discriminated against by the community. Stigma is associated with poor self-efficacy management in children with epilepsy by their parents and can persist even after seizures are controlled by anti-seizure medication.Interventions for epilepsy stigma should be multicomponent, cost-effective, scalable, and directed towards tackling forces that engender and sustain stigma (self, the public, and institutions) and to those stigmatised (child and family or caregivers). Most intervention studies in LMICs are fraught with bias, and criteria for evaluation of efficacy should be robustly defined. Peer support groups have reduced internalised stigma in adolescents, and traditional health practitioners offer psychosocial support to victims of stigma in LMICs. Epilepsy stigma should be addressed by joint efforts of epilepsy stakeholders, such as National Epilepsy Coordinating Committees, whose role includes awareness creation, advocacy for policy change and practice, and promotion of responsible journalism.We declare no competing interests.
IntroductionCare home residents are at increased risk of infections and antibiotic prescription. Reduced antibiotic use from fewer infections would improve quality of life. TheProbiotics toReduceInfections iN CarEhome reSidentS(PRINCESS) trial aims to determine the efficacy and investigate mechanisms of daily probiotics on antibiotic use and incidence of infections in care home residents.Methods and analysisPRINCESS is a double-blind, individually randomised, placebo-controlled trial that will assess the effect of a daily oral probiotic combination ofLactobacillus rhamnosus,GG (LGG) andBifidobacterium animalissubsp.lactis, BB-12 (BB-12) on cumulative antibiotic administration days (CAADs) (primary outcome) for infection in up to 330 care home residents aged ≥65 years over up to 12 months. Secondary outcomes include:Infection:Total number of days of antibiotic administration for each infection type (respiratory tract infection, urinary tract infection, gastrointestinal infection, unexplained fever and other); number, site, duration of infection; estimation of incidence and duration of diarrhoea and antibiotic-associated diarrhoea;Stool microbiology:Clostridium difficileinfection; Gram-negative Enterobacteriaceae and vancomycin-resistant enterococci; LGG and BB-12.Oral microbiology: Candidaspp.Health and well-being:Self and/or proxy health-related quality of life EQ5D (5 L); self-and/or proxy-reported ICEpop CAPability measure for older people.Hospitalisations:number and duration of all-cause hospital stays.Mortality:deaths.Mechanistic immunology outcomes:influenza vaccine efficacy (haemagglutination inhibition assay and antibody titres); full blood count and immune cell phenotypes, plasma cytokines and chemokines; cytokine and chemokine response in whole blood stimulatedex vivoby toll-like receptor 2 and 4 agonists; monocyte and neutrophil phagocytosis ofEscherichia coli; serum vitamin D.Ethics and disseminationEthics approval is from the Wales Research Ethics Committee 3. Findings will be disseminated through peer-reviewed journals and conferences; results will be of interest to patient and policy stakeholders.Trial registration numberISRCTN16392920; Pre-results.
Background Social connections have been linked to the genesis and amelioration of mental health problems and thus have potential therapeutic value. Purpose To identify the current evidence base, assess risk of bias and synthesise findings on the effectiveness of social network interventions for people with mental health problems. Methods Electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science, Scopus) and grey literature databases were systematically searched from inception to October 2021 using free text syntax combining synonyms for ‘mental health problems’ and ‘social network interventions’. Articles were eligible for inclusion if they reported data from randomised controlled trials on the effectiveness of interventions designed to improve social networks for adults (18+) with mental health problems. Papers were independently reviewed for inclusion with conflicts resolved through consensus. Included papers were quality assessed and data extracted and synthesized narratively. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Results Nine studies randomising 2226 participants were included. Four focused on those with a diagnosis of schizophrenia or psychosis, one on major depressive disorder and four included all types of mental health diagnoses. The current evidence base is of unclear quality. However, interventions which focused on supporting social activities appear to hold the most promise for enhancing social networks. Data on cost-effectiveness and research acceptability were limited, but suggest the potential economic feasibility of and acceptability for evaluating these interventions. Conclusion There is emerging evidence that social network interventions can be effective in improving social connections for people with mental health problems. However, further evaluations with robust methodological approaches are required to inform evidence-based recommendations for health services.
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