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The majority of self-management interventions are designed with a narrow focus on patient skills and fail to consider their potential as “catalysts” for improving care delivery. A project was undertaken to develop a patient self-management resource to support evidence-based, person-centered care for cancer pain and overcome barriers at the levels of the patient, provider, and health system.
The project used a mixed-method design with concurrent triangulation, including the following: a national online survey of current practice; two systematic reviews of cancer pain needs and education; a desktop review of online patient pain diaries and other related resources; consultation with stakeholders; and interviews with patients regarding acceptability and usefulness of a draft resource.
Findings suggested that an optimal self-management resource should encourage pain reporting, build patients’ sense of control, and support communication with providers and coordination between services. Each of these characteristics was identified as important in overcoming established barriers to cancer pain care. A pain self-management resource was developed to include: (1) a template for setting specific, measureable, achievable, relevant and time-bound goals of care, as well as identifying potential obstacles and ways to overcome these; and (2) a pain management plan detailing exacerbating and alleviating factors, current strategies for management, and contacts for support.
Significance of results
Self-management resources have the potential for addressing barriers not only at the patient level, but also at provider and health system levels. A cluster randomized controlled trial is under way to test effectiveness of the resource designed in this project in combination with pain screening, audit and feedback, and provider education. More research of this kind is needed to understand how interventions at different levels can be optimally combined to overcome barriers and improve care.
The second year of life is a period of nutritional vulnerability. We aimed to investigate the dietary patterns and nutrient intakes from 1 to 2 years of age during the 12-month follow-up period of the Growing Up Milk – Lite (GUMLi) trial. The GUMLi trial was a multi-centre, double-blinded, randomised controlled trial of 160 healthy 1-year-old children in Auckland, New Zealand and Brisbane, Australia. Dietary intakes were collected at baseline, 3, 6, 9 and 12 months post-randomisation, using a validated FFQ. Dietary patterns were identified using principal component analysis of the frequency of food item consumption per d. The effect of the intervention on dietary patterns and intake of eleven nutrients over the duration of the trial were investigated using random effects mixed models. A total of three dietary patterns were identified at baseline: ‘junk/snack foods’, ‘healthy/guideline foods’ and ‘breast milk/formula’. A significant group difference was observed in ‘breast milk/formula’ dietary pattern z scores at 12 months post-randomisation, where those in the GUMLi group loaded more positively on this pattern, suggesting more frequent consumption of breast milk. No difference was seen in the other two dietary patterns. Significant intervention effects were seen on nutrient intake between the GUMLi (intervention) and cows’ milk (control) groups, with lower protein and vitamin B12, and higher Fe, vitamin D, vitamin C and Zn intake in the GUMLi (intervention) group. The consumption of GUMLi did not affect dietary patterns, however, GUMLi participants had lower protein intake and higher Fe, vitamins D and C and Zn intake at 2 years of age.
Since 1985, land retirement has been the primary approach used by the federal government for environmental protection of agricultural landscapes, but increasingly it is being supplemented by conservation initiatives on working lands. This shift logically supports agroforestry and other multifunctional approaches as a means to combine production and conservation. However, such approaches can be complex and difficult to design, contributing to the limited adoption in the USA. To understand and improve the integration of multifunctional landscapes into conservation programs, we worked with 15 landowners in a collaborative design process to build unique conservation plans utilizing agroforestry. We interviewed participants before and after the design process to examine the utility of a personalized design process, applicability of agroforestry to conservation programs and pathways to improve conservation policy. We found that landowners strongly preferred working in person for the design process, and being presented a comparison of alternative designs, rather than a single option, especially for novel systems. Agroforestry was seen as a viable method of generating conservation benefits while providing value to the landowners, each of whom stated they were more inclined to adopt such practices irrespective of financial assistance to do so. For conservation programs, landowners suggested reducing their complexity, inflexibility and impersonal nature to improve the integration of multifunctional practices that appeal directly to the practitioner's needs and preferences. These findings are valuable for conservation policy because they complement previous research theory suggesting the value of working collaboratively with landowners in the design of multifunctional landscapes. Personalized solutions that are developed based on the unique characteristics of the local landscape and the preferences of the individual landowner may be retained beyond a specified payment period, rather than being converted back into annual crop production.
Telephone cognitive–behaviour therapy (TCBT) may be a cost-effective method for improving access to evidence-based treatment for obsessive–compulsive disorder (OCD) in young people.
Economic evaluation of TCBT compared with face-to-face CBT for OCD in young people.
Randomised non-inferiority trial comparing TCBT with face-to-face CBT for 72 young people (aged 11 to 18) with a diagnosis of OCD. Cost-effectiveness at 12-month follow-up was explored in terms of the primary clinical outcome (Children's Yale-Brown Obsessive-Compulsive Scale, CY-BOCS) and quality-adjusted life-years (QALYs) (trial registration: ISRCTN27070832).
Total health and social care costs were higher for face-to-face CBT (mean total cost £2965, s.d. = £1548) than TCBT (mean total cost £2475, s.d. = £1024) but this difference was non-significant (P = 0.118). There were no significant between-group differences in QALYs or the CY-BOCS and there was strong evidence to support the clinical non-inferiority of TCBT. Cost-effectiveness analysis suggests a 74% probability that face-to-face CBT is cost-effective compared with TCBT in terms of QALYs, but the result was less clear in terms of CY-BOCS, with TCBT being the preferred option at low levels of willingness to pay and the probability of either intervention being cost-effective at higher levels of willingness to pay being around 50%.
Although cost-effectiveness of TCBT was sensitive to the outcome measure used, TCBT should be considered a clinically non-inferior alternative when access to standard clinic-based CBT is limited, or when patient preference is expressed.
Declaration of interest
D.M.-C. reports research grants from the Swedish Research Council (Vetenskapsrådet), the Swedish Research Council for Health, working life and welfare (Forte), the US National Institute of Mental Health (NIMH), the UK National Institute of Health Research (NIHR), as well as royalties from Wolters Kluwer Health and Elsevier, all unrelated to the submitted work.
We develop a political history of Wards Cove v. Atonio (1989) to show how Robert Cover's concepts of jurisgenesis and jurispathy can enrich the legal mobilization framework for understanding law and social change. We illustrate the value of the hybrid theory by recovering the Wards Cove workers’ own understanding of the role of litigation in their struggle for workplace rights. The cannery worker plaintiffs exemplified Cover's dual logic by articulating aspirational narratives of social justice and by critically rebuking the Supreme Court's ruling as the “death throe” for progressive minority workers’ rights advocacy. The cannery workers’ story also highlights the importance of integrating legal mobilization scholars’ focus on extrajudicial political engagement into Cover's judge‐centered analysis. Our aim is to forge a theoretical bridge between Cover's provocative arguments about law and the analytical tradition of social science scholarship on the politics of legal mobilization.
Jeannine Bell's Hate Thy Neighbor: Move In Violence and the Persistence of Racial Segregation in American Housing provides an account of racist violence as a tool for maintaining housing segregation that challenges perceptions of rising tolerance and demonstrates the importance of understanding racism as a structural feature of social organization. Bell shows how some perpetrators of move in violence deploy claims about “property values” as a defense against charges of racism. The use of such claims starkly illustrates how colorblind racism allows assertions of racial privilege to resonate as neutral articulations of rational self-interest. The desire to defend racial privileges persists as a significant practical barrier to racial equality even when tolerance increases.
Coastal ecosystems have been degraded by human activity over centuries, with loss of memory about past states resulting in shifted baselines. More recently conservation efforts have resulted in localized recoveries of species and ecosystems. Given the dynamism of ecosystem degradation and recovery, understanding how communities perceive long-term and recent changes is important for developing and implementing conservation measures. We interviewed stakeholders on three Caribbean islands and identified a shifted baseline with respect to the extent and degree of long-term declines in marine animal populations; stakeholders with more experience identified more species as depleted and key species as less abundant than those with less experience. Notably, the average respondent with < 15 years of experience listed no species as depleted despite clear evidence of declines. We also identified a phenomenon we call the policy placebo effect, in which interviewees perceived some animal populations as recently recovering following passage of new conservation legislation but in the absence of evidence for actual recovery. Although shifted baselines have a negative effect on conservation as they can lower recovery goals, the outcomes of a policy placebo effect are unclear. If the public prematurely perceives recovery, motivation for continued conservation could decline. Alternatively, perception of rapid success could lead communities to set more ambitious conservation goals.
Collaborative care can support the treatment of depression in people with long-term conditions, but long-term benefits and costs are unknown.
To explore the long-term (24-month) effectiveness and cost-effectiveness of collaborative care in people with mental-physical multimorbidity.
A cluster randomised trial compared collaborative care (integrated physical and mental healthcare) with usual care for depression alongside diabetes and/or coronary heart disease. Depression symptoms were measured by the symptom checklist-depression scale (SCL-D13). The economic evaluation was from the perspective of the English National Health Service.
191 participants were allocated to collaborative care and 196 to usual care. At 24 months, the mean SCL-D13 score was 0.27 (95% CI, −0.48 to −0.06) lower in the collaborative care group alongside a gain of 0.14 (95% CI, 0.06-0.21) quality-adjusted life-years (QALYs). The cost per QALY gained was £13 069.
In the long term, collaborative care reduces depression and is potentially cost-effective at internationally accepted willingness-to-pay thresholds.
We report the results of Long Baseline Array observations made in 2001 of ten southern sources proposed by Mattox et al. as counterparts to EGRET >100 MeV gamma-ray sources. Source structures are compared with published data where available and possible superluminal motions identified in several cases. The associations are examined in the light of Fermi observations, indicating that the confirmed counterparts tend to have radio properties consistent with other identifications, including flat radio spectral index, high brightness temperature, greater radio variability, and higher core dominance.
Despite policy and practice mandates for patient involvement, people with serious mental illness often feel marginalised in decisions about antipsychotic medication.
To examine stakeholder perspectives of barriers and facilitators to involving people with serious mental illness in antipsychotic prescribing decisions.
Systematic thematic synthesis.
Synthesis of 29 studies identified the following key influences on involvement: patient's capability, desire and expectation for involvement, organisational context, and the consultation setting and processes.
Optimal patient involvement in antipsychotic decisions demands that individual and contextual barriers are addressed. There was divergence in perceived barriers to involvement identified by patients and prescribers. For example, patients felt that lack of time in consultations was a barrier to involvement, something seldom raised by prescribers, who identified organisational barriers. Patients must understand their rights to involvement and the value of their expertise. Organisational initiatives should mandate prescriber responsibility to overcome barriers to involvement.
More than half of all cancer patients experience unrelieved pain. Culture can significantly affect patients’ cancer pain-related beliefs and behaviors. Little is known about cultural impact on Chinese cancer patients’ pain management. The objective of this review was to describe pain management experiences of cancer patients from Chinese backgrounds and to identify barriers affecting their pain management.
A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported pain management experiences of adult cancer patients from Chinese backgrounds. Five databases were searched for peer-reviewed articles published in English or Chinese journals between1990 and 2015. The quality of included studies was assessed using Joanna Briggs Institution's appraisal tools.
Of 3,904 identified records, 23 articles met criteria and provided primary data from 6,110 patients. Suboptimal analgesic use, delays in receiving treatment, reluctance to report pain, and/or poor adherence to prescribed analgesics contributed to the patients’ inadequate pain control. Patient-related barriers included fatalism, desire to be good, low pain control belief, pain endurance beliefs, and negative effect beliefs. Patients and family shared barriers about fear of addiction and concerns on analgesic side effects and disease progression. Health professional–related barriers were poor communication, ineffective management of pain, and analgesic side effects. Healthcare system–related barriers included limited access to analgesics and/or after hour pain services and lack of health insurance.
Significance of results
Chinese cancer patients’ misconceptions regarding pain and analgesics may present as the main barriers to optimal pain relief. Findings of this review may inform health interventions to improve cancer pain management outcomes for patients from Chinese backgrounds. Future studies on patients’ nonpharmacology intervention-related experiences are required to inform multidisciplinary and biopsychosocial approaches for culturally appropriate pain management.
The greatest thrill that any researcher can experience is coming across, quite unforeseen, priceless documents long given up as lost. In the case of myself and two close colleagues, Wendy Kramer and Christopher H. Lutz, the documents that have come to light and that have so delighted us include Libros de Cabildo numbers two and three of the city of Santiago de Guatemala, the capital of Spanish Central America. Libro Segundo is a register of events that took place between 1530 and 1541; Libro Tercero is a log spanning the years 1541 to 1553. Our incredulity at learning the whereabouts of these two volumes was matched, if not surpassed, by the anticipation of verifying their existence and thereafter consulting them, something that has not occurred (as best we can determine) in over a century. Far more than the minutes of mundane municipal affairs, these two Libros de Cabildo contain valuable information about Spanish conquest and colonization, and indigenous resistance to it, that will enhance considerably our understanding of the early colonial period, not only in Guatemala but throughout Central America. Furthermore, the Libros de Cabildo have proven to be the proverbial tip of the iceberg, for the cache of which they form part contains other treasures perhaps not quite so unique but nonetheless of significant historical worth.
The International Celestial Reference Frame suffers from significantly less observations in the southern hemisphere compared to the northern one. One reason for this is the historically low number of very long baseline interferometry radio telescopes in the south. The AuScope very long baseline interferometry array with three new telescopes on the Australian continent and an identical antenna in New Zealand were built to address this issue. While the overall number of observations in the south has greatly improved since then, a closer look reveals that this improvement is only true for strong radio sources (source flux densities >0.6 Jy). The new array of small very long baseline interferometry antennas has a relatively low baseline sensitivity so that only strong sources can be observed within a short integration time. A new observing strategy, the star scheduling mode, was developed to enable efficient observations of weak sources during geodetic sessions, through the addition of a single more sensitive antenna to the network. This scheduling mode was implemented in the Vienna very long baseline interferometry Software and applied in four 24-h sessions in 2016. These observations provide updated positions and source flux densities for 42 weak southern radio sources and significantly reduce the formal uncertainties for these sources. The star scheduling mode now allows the AuScope very long baseline interferometry array to undertake greater responsibility in monitoring sources in the southern sky, without significantly weakening the session for geodetic purposes.
The in vivo determination of methane (CH4) production requires specialist equipment which is costly to maintain. Whilst the in vitro gas production technique has been demonstrated to show potential to rank diets for their methanongenic potential at maintenance planes of nutrition (Moss and Givens, 1997) no study has investigated this relationship when feedstuffs are fed ad libitum. The objective of this study was to assess the ability of the technique to predict in vivo CH4 production and animal performance from six diets differing in their chemical composition.
The relationship between diversification and labor productivity is a pressing issue for diversified farming systems (DFS), which must compete with the high labor productivity of specialized and mechanized industrial farming systems. Synergies between multiple production systems represent an alternative pathway for enhancing labor productivity, contrasting with the economies of scale achieved by industrial farming. Facing a lack of technical and institutional support for managing diversified systems, DFS turn to grassroots agroecological networks for support. Permaculture is a grassroots network with an emphasis on diversified production that—despite its international scope and high public profile—has received little scholarly attention. In this exploratory study we assessed the relationship between diversification, labor productivity and involvement with permaculture, using data from 196 enterprises (i.e., distinct sources of income or aspects of a farm business) on 36 permaculture farms in the USA. We characterized diversification in two ways: by income at the level of the whole farm, and by labor for production enterprises only. By fitting a multilevel model of labor productivity (enterprises nested within farms) we assessed the evidence for synergies in production, i.e., positive relationships between diversification and returns to labor. Results indicated that both production diversity and level of involvement in the permaculture network had significant positive effects on labor productivity. This effect disappeared, however, when both diversity and participation were at their highest levels. Results also indicate that high levels of diversification shift tree crops from the lowest labor productivity of any type of production enterprise to the highest. Through this first ever (to our knowledge) systematic investigation of permaculture farms, our results provide support for the presence of production synergies in DFS, and for the role of permaculture in helping farmers achieve these synergies.