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The emergence and spread of extensively multidrug-resistant organisms is a public health crisis, and long-term care settings have been identified as a reservoir for the cultivation of these organisms. Long-term care settings are now taking on increasingly ill residents with complicated medical problems, indwelling devices, and significant healthcare exposure, all of which are considered risk factors selecting for resistant organisms. Despite this, guidelines addressing infection prevention procedures in long-term care remain vague, and implementation of these guidelines is challenging, largely due to staff turnover, limited resources, knowledge gaps, and lack of organizational support. Human factors engineering approaches have emerged as an important innovation to address patient safety issues and develop interventions in the healthcare work system (ie, tools and technologies, tasks, organization, physical environment) that support human performance, which, in turn, lead to improvements in processes (eg, compliance with infection prevention guidelines) and outcomes (eg, reduced infection rates). We propose the concept of using the methods and approaches from the scientific field of human factors engineering to address the unique challenges of implementing infection prevention in the long-term care setting.
In recent years, several initiatives have sought to encourage redemption of food assistance benefits at direct-to-consumer (DTC) market venues such as community supported agriculture programs and farmers’ markets in the USA, with the dual goal of increasing access to healthy foods for low-income families and sales of locally-grown foods for farmers. Proponents of these interventions assert that these programs have a positive impact on local economies yet there is limited evidence to validate this argument. This research project used a customized input-output model to simulate potential economic impacts of programs and policies that enable Supplemental Nutrition Assistance Program (SNAP) recipients to shift purchases from traditional food retailers to DTC venues in four states. Two different scenarios were explored: (1) increased outreach to low-income consumers and (2) financial support for using SNAP benefits at DTC market channels. We found a positive, though modest, economic impact at the state level under both scenarios when accounting for (a) business losses in the food retail and wholesale sectors, (b) a shift in acreage from commodity to specialty crops and (c) the cost to taxpayers. Since most of the increased economic activity would be in the produce farming sector, we discuss the opportunities and challenges for this sector along with potential policy implications.
To examine perspectives on food access among low-income families participating in a cost-offset community-supported agriculture (CO-CSA) programme.
Farm Fresh Foods for Healthy Kids (F3HK) is a multicentre randomized intervention trial assessing the effect of CO-CSA on dietary intake and quality among children from low-income families. Focus groups were conducted at the end of the first CO-CSA season. Participants were interviewed about programme experiences, framed by five dimensions of food access: availability, accessibility, affordability, acceptability and accommodation. Transcribed data were coded on these dimensions plus emergent themes.
Nine communities in the US states of New York, North Carolina, Washington and Vermont.
Fifty-three F3HK adults with children.
CSA models were structured by partner farms. Produce quantity was abundant; however, availability was enhanced for participants who were able to select their own produce items. Flexible CSA pick-up times and locations made produce pick-up more accessible. Despite being affordable to most, payment timing was a barrier for some. Unfamiliar foods and quick spoilage hindered acceptability through challenging meal planning, despite accommodations that included preparation advice.
Although CO-CSA may facilitate increased access to fruits and vegetables for low-income families, perceptions of positive diet change may be limited by the ability to incorporate share pick-up into regular travel patterns and meal planning. Food waste concerns may be particularly acute for families with constrained resources. Future research should examine whether CO-CSA with flexible logistics and produce self-selection are sustainable for low-income families and CSA farms.
The Pediatric Heart Network designed a career development award to train the next generation of clinician scientists in paediatric-cardiology-related research, a historically underfunded area. We sought to identify the strengths/weaknesses of the programme and describe the scholars’ academic achievements and the network’s return on investment.
Survey questions designed to evaluate the programme were sent to applicants – 13 funded and 19 unfunded applicants – and 20 mentors and/or principal investigators. Response distributions were calculated. χ2 tests of association assessed differences in ratings of the application/selection processes among funded scholars, unfunded applicants, and mentors/principal investigators. Scholars reported post-funding academic achievements.
Survey response rates were 88% for applicants and 100% for mentor/principal investigators. Clarity and fairness of the review were rated as “clear/fair” or “very clear/very fair” by 98% of respondents, but the responses varied among funded scholars, unfunded applicants, and mentors/principal investigators (clarity χ2=10.85, p=0.03; fairness χ2=16.97, p=0.002). Nearly half of the unfunded applicants rated feedback as “not useful” (47%). “Expanding their collaborative network” and “increasing publication potential” were the highest-rated benefits for scholars. Mentors/principal investigators found the programme “very” valuable for the scholars (100%) and the network (75%). The 13 scholars were first/senior authors for 97 abstracts and 109 manuscripts, served on 22 Pediatric Heart Network committees, and were awarded $9,673,660 in subsequent extramural funding for a return of ~$10 for every scholar dollar spent.
Overall, patient satisfaction with the Scholar Award was high and scholars met many academic markers of success. Despite this, programme challenges were identified and improvement strategies were developed.
As attention to emergency preparedness becomes a critical element of health care facility operations planning, efforts to recognize and integrate the needs of vulnerable populations in a comprehensive manner have lagged. This not only results in decreased levels of equitable service, but also affects the functioning of the health care system in disasters. While this report emphasizes the United States context, the concepts and approaches apply beyond this setting.
This report: (1) describes a conceptual framework that provides a model for the inclusion of vulnerable populations into integrated health care and public health preparedness; and (2) applies this model to a pilot study.
The framework is derived from literature, hospital regulatory policy, and health care standards, laying out the communication and relational interfaces that must occur at the systems, organizational, and community levels for a successful multi-level health care systems response that is inclusive of diverse populations explicitly. The pilot study illustrates the application of key elements of the framework, using a four-pronged approach that incorporates both quantitative and qualitative methods for deriving information that can inform hospital and health facility preparedness planning.
The conceptual framework and model, applied to a pilot project, guide expanded work that ultimately can result in methodologically robust approaches to comprehensively incorporating vulnerable populations into the fabric of hospital disaster preparedness at levels from local to national, thus supporting best practices for a community resilience approach to disaster preparedness.
KreisbergD, ThomasDSK, ValleyM, NewellS, JanesE, LittleC. Vulnerable Populations in Hospital and Health Care Emergency Preparedness Planning: A Comprehensive Framework for Inclusion. Prehosp Disaster Med. 2016;31(2):211–219.
The current study sought to examine the utility of intra-individual variability (IIV) in distinguishing participants with prodromal Huntington disease (HD) from nongene-expanded controls. IIV across 15 neuropsychological tasks and within-task IIV using a self-paced timing task were compared as a single measure of processing speed (Symbol Digit Modalities Test [SDMT]) in 693 gene-expanded and 191 nongene-expanded participants from the PREDICT-HD study. After adjusting for depressive symptoms and motor functioning, individuals estimated to be closest to HD diagnosis displayed higher levels of across- and within-task variability when compared to controls and those prodromal HD participants far from disease onset (FICV(3,877)=11.25; p<.0001; FPacedTiming(3,877)=22.89; p<.0001). When prodromal HD participants closest to HD diagnosis were compared to controls, Cohen’s d effect sizes were larger in magnitude for the within-task variability measure, paced timing (−1.01), and the SDMT (−0.79) and paced tapping coefficient of variation (CV) (−0.79) compared to the measures of across-task variability [CV (0.55); intra-individual standard deviation (0.26)]. Across-task variability may be a sensitive marker of cognitive decline in individuals with prodromal HD approaching disease onset. However, individual neuropsychological tasks, including a measure of within-task variability, produced larger effect sizes than an index of across-task IIV in this sample. (JINS, 2015, 21, 8–21)
Aetiological mechanisms underlying ethnic density associations with
psychosis remain unclear.
To assess potential mechanisms underlying the observation that minority
ethnic groups experience an increased risk of psychosis when living in
neighbourhoods of lower own-group density.
Multilevel analysis of nationally representative community-level data
(from the Ethnic Minorities Psychiatric Illness Rates in the Community
survey), which included the main minority ethnic groups living in
England, and a White British group. Structured instruments assessed
discrimination, chronic strains and social support. The Psychosis
Screening Questionnaire ascertained psychotic experiences.
For every ten percentage point reduction in own-group density, the
relative odds of reporting psychotic experiences increased 1.07 times
(95% CI 1.01–1.14, P = 0.03 (trend)) for the total
minority ethnic sample. In general, people living in areas of lower
own-group density experienced greater social adversity that was in turn
associated with reporting psychotic experiences.
People resident in neighbourhoods of higher own-group density experience
‘buffering’ effects from the social risk factors for psychosis.
To establish prevalence of domestic violence among female psychiatric
patients, including risk factors, health professional attention and
acceptability of routine enquiry. Participants were 70 adult women in an
inner-city community mental health team who received questionnaire and
case-note review. Main outcome measures were: lifetime/point prevalence
of domestic violence; attitudes to routine enquiry; past disclosure and
recording in psychiatric records; clinical and demographic risk
Lifetime prevalence was 60% for physical violence from partners, 27%
during pregnancy and 40% receiving injuries. Point prevalence was not
reported, as an insufficient number of participants were currently in a
relationship. As many as 82% regarded routine enquiry as acceptable, but
only 24% had ever been questioned. Logistic regression analysis showed
prediction by presence of children, previous overdose, and experience of
Domestic violence in female psychiatric patients is common but
undetected. Enquiry should be routine, but would require staff
To (i) identify and describe prevailing infant feeding policy documents in five diverse European countries; (ii) analyse types of health outcomes for the infant that are associated with feeding breast milk rather than formula milk in the documents of different countries; and (iii) assess the extent to which documents reflect the WHO global recommendation of exclusive breast-feeding for 6 months.
Documentary review and analysis.
Five geographically dispersed countries of Europe (England, Finland, Germany, Hungary and Spain).
Policy documents on infant feeding were identified; statements that linked choice between breast- and formula-feeding to a health outcome for the infant were extracted.
Twenty-six documents (varied authorships, dates, length and character) were identified: four from England; two from Finland; nine from Germany; six from Hungary; and five from Spain. There was no consistency in the way in which health outcomes were cited as factors in the recommendations for breast- rather than formula-feeding. Seven documents contained no reference to the health implications of infant feeding choice. Of 203 statements in remaining documents citing health outcomes, 24·1 % mentioned general health effects, 32·5 % protection against infections, 31·5 % long-term conditions (e.g. diabetes, CVD) and 11·8 % mentioned allergy. Health outcomes were linked to exclusive breast-feeding in only 25 % of statements.
Policy documents in the study countries varied in the extent to which they reflect the health outcomes for the baby of breast-feeding, and this may limit effective promotion by health professionals. There is scope to improve the process of bringing evidence and recommendations into policy documents.
Grey matter and other structural brain abnormalities are consistently
reported in first-onset schizophrenia, but less is known about the extent
of neuroanatomical changes in first-onset affective psychosis
To determine which brain abnormalities are specific to (a) schizophrenia
and (b) affective psychosis
We obtained dual-echo (proton density/T2-weighted) magnetic resonance
images and carried out voxel-based analysis on the images of 73 patients
with first-episode psychosis (schizophrenia n=44,
affective psychosis n=29) and 58 healthy controls
Both patients with schizophrenia and patients with affective psychosis
had enlarged lateral and third ventricle volumes. Regional cortical grey
matter reductions (including bilateral anterior cingulate gyrus, left
insula and left fusiform gyrus) were evident in affective psychosis but
not in schizophrenia, although patients with schizophrenia displayed
decreased hippocampal grey matter and increased striatal grey matter at a
more liberal statistical threshold
Both schizophrenia and affective psychosis are associated with volumetric
abnormalities at the onset of frank psychosis, with some of these evident
in common brain areas
To describe feeding patterns and mothers' perceptions of desirable feeding practices in low-birth-weight (LBW) infants after hospital discharge in England and to test for the association of inappropriate practices/perceptions with identifiable demographics.
Postal questionnaires from 198 mothers of LBW infants in London, Liverpool and Winchester were analysed regarding infant demographics, mothers' demographics, infant milks used, solid feeding practices and mothers' perceptions of infant feeding practices.
At birth, the median weight, independent of gestational age, was 1.80 kg (range 0.6–2.50 kg) and 37.1% of infants received breast milk exclusively; 83.7% were breast-fed at some stage, a practice favoured more by first-time mothers (90.2%) than multiparous mothers (73.4%) (P = 0.004) as well as by mothers of higher social groups (P> = 0.019). The median age of solid food introduction was 17 postnatal weeks (range 8–36 weeks); the timing correlated strongly with infant birth weight (P < 0.001). A high-fibre diet and a low-fat diet were incorrectly considered important for their infants by 67.1% and 51.6% of mothers, respectively. Regarding a high-fibre diet as important was associated with being a multiparous mother (P = 0.006), while regarding a low-fat diet as important was associated with low social group (P = 0.018). A quarter of mothers did not consider 'plenty of calories' to be important for their infants, reflecting similar attitudes in 1990 for mothers of term infants; this incorrect attitude exhibited an association with being a first-time mother (P = 0.047).
Infant feeding practices were very variable, showing poor concordance with national and international recommendations for term infants. In selecting foods for their infants, many mothers appeared to be applying principles more appropriate to planning a healthy diet for adults. There is an urgent need to develop and implement evidence-based guidelines for feeding LBW infants after hospital discharge, with special attention given to multiparous mothers as well as mothers from lower social groups.
Background. The incidence of schizophrenia in the African-Caribbean population in England is reported to be raised. We sought to clarify whether (a) the rates of other psychotic disorders are increased, (b) whether psychosis is increased in other ethnic minority groups, and (c) whether particular age or gender groups are especially at risk.
Method. We identified all people (n=568) aged 16–64 years presenting to secondary services with their first psychotic symptoms in three well-defined English areas (over a 2-year period in Southeast London and Nottingham and a 9-month period in Bristol). Standardized incidence rates and incidence rate ratios (IRR) for all major psychosis syndromes for all main ethnic groups were calculated.
Results. We found remarkably high IRRs for both schizophrenia and manic psychosis in both African-Caribbeans (schizophrenia 9·1, manic psychosis 8·0) and Black Africans (schizophrenia 5·8, manic psychosis 6·2) in men and women. IRRs in other ethnic minority groups were modestly increased as were rates for depressive psychosis and other psychoses in all minority groups. These raised rates were evident in all age groups in our study.
Conclusions. Ethnic minority groups are at increased risk for all psychotic illnesses but African-Caribbeans and Black Africans appear to be at especially high risk for both schizophrenia and mania. These findings suggest that (a) either additional risk factors are operating in African-Caribbeans and Black Africans or that these factors are particularly prevalent in these groups, and that (b) such factors increase risk for schizophrenia and mania in these groups.
Background. There is a common assumption that Black patients with a psychotic mental illness experience longer treatment delays during a first episode. We sought to investigate this issue in a large cohort of patients with a first episode of psychosis.
Method. All patients with a first episode of psychosis presenting to secondary mental health services within tightly defined catchment areas in south-east London and Nottingham over a 2-year period were included in the study. Data relating to duration of untreated psychosis (DUP) and clinical and sociodemographic characteristics were collected from patients, relatives and case-notes.
Results. There was no evidence that African-Caribbean or Black African patients experienced longer periods of untreated psychosis than White British patients prior to first contact with services. There was evidence that Black African patients experienced shorter periods of untreated psychosis than White British patients.
Conclusions. Contrary to what is commonly assumed, our study suggests that Black patients with a psychotic mental illness do not experience longer treatment delays prior to first contact with services than White British patients. This suggests that strategies to reduce treatment delays targeted specifically at Black patients will be of limited value.
Many studies have found high levels of compulsory admission to psychiatric hospital in the UK among African–Caribbean and Black African patients with a psychotic illness.
To establish whether African–Caribbean and Black African ethnicity is associated with compulsory admission in an epidemiological sample of patients with a first episode of psychosis drawn from two UK centres.
All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (ÆSOP) study. For this analysis we included all White British, other White, African–Caribbean and Black African patients from the ÆSOP sampling frame. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.
African–Caribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. African–Caribbean men were the most likely to be compulsorily admitted.
These findings suggest that factors are operating at or prior to first presentation to increase the risk of compulsory admission among African–Caribbean and Black African patients.
Previous research has found that African–Caribbean and Black African patients are likely to come into contact with mental health services via more negative routes, when compared with White patients. We sought to investigate pathways to mental health care and ethnicity in a sample of patients with a first episode of psychosis drawn from two UK centres.
We included all White British, other White, African–Caribbean and Black African patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.
Compared with White British patients, general practitioner referral was less frequent for both African–Caribbean and Black African patients and referral by a criminal justice agency was more common. With the exception of criminal justice referrals for Black African patients, these findings remained significant after adjusting for potential confounders.
These findings suggest that factors are operating during a first episode of psychosis to increase the risk that the pathway to care for Black patients will involve non-health professionals.
Experiencing life-threatening events often contributes to the onset of such psychiatric conditions as post-traumatic stress disorder (PTSD). Children can develop PTSD; however, there is controversy over whether PTSD symptoms decrease or persist over time.
To examine the long-term effects of surviving the 1966 Aberfan disaster in childhood.
Survivors (n=41) were compared with controls (n=72) matched for age and background. All were interviewed using the Composite International Diagnostic Interview, measures of current health and social satisfaction, and the General Health Questionnaire. The survivor group also completed the Impact of Event Scale to assess current levels of PTSD.
Nineteen (46%; 95%CI 31–61) survivors had had PTSD at some point since the disaster, compared with 12 (20%; 95% CI 10–30) controls (OR=3.38 (95% CI 1.40–8.47)). Of the survivors, 12 (29%; 95% CI 15–43) met diagnostic criteria for current PTSD. Survivors were not at a significantly increased risk of anxiety, depression or substance misuse.
Trauma in childhood can lead to PTSD, and PTSD symptoms can persist for as long as 33 years into adult life. Rates of other psychopathological disorders are not necessarily raised after life-threatening childhood trauma.