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The investigation of Islamic archaeology in Ethiopia has until recently been neglected. Excavations at Harlaa, a large urban centre in eastern Ethiopia, are now beginning to redress this lack of research attention. By establishing occupation and material sequences, and by assessing the chronology and material markers of Islamisation, recent work provides important new insight on the presence and role of Muslims and Islamic practice at Harlaa, and in the Horn of Africa more generally. The results challenge previous assumptions of cultural homogeneity, instead indicating the development of cosmopolitanism. They also suggest a possible historical identity for Harlaa: as Hubät/Hobat, the capital of the Hārlā sultanate.
Even though the intention is to offer the whole population services of comparable quality regardless of where they live, there are some challenges with living in rural areas…. (Kirkevold and Kristiansen, from Chapter 4 in this book)
Drawing across the material in this book, in this chapter we raise and discuss the emergent themes as highlighted by the contributions of leading experts and commentators from around the world. In terms of policy we consider systems issues and between-countries similarities and differences; for practice, we examine the relevance of culture and the importance of heeding the central human experience of dementia within the current healthcare system; and in respect of key emergent research topics, we feature the relevance of place-based planning and the role of technology. We end with a collated research agenda, drawing from topics suggested by authors across the chapters.
Policy and systems
Dementia is a costly issue for governments as people with dementia can live for a long time following their diagnosis, variably requiring different health and social care inputs (Prince et al, 2015). The World Health Organization (WHO) has taken a lead in establishing the need for coordinated national policy and planning approaches (2018), and has provided a toolkit for planning, education and community engagement (WHO, 2017), an online training programme for dementia carers (iSupport for Dementia) (WHO, 2020), and a knowledge exchange platform with access to key dementia data and indicators so that progress in meeting global dementia targets can be evaluated (Global Dementia Observatory) (WHO, 2019). The mhGAP toolkit can be adopted by individual countries and adapted to local systems and contexts.
The chapters in this book highlight the relevance of countries’ health systems and the contexts in which services are provided, as well as the characteristics of such services. By one interpretation, chapters depict health systems with features across a wide spectrum, from those with atomised services provided by a mixture of public, private and nongovernmental organisations (in Australia), through those that have become depleted (in Ireland), to apparently more coordinated and adaptive social welfarist models (such as those in Austria and Norway).
This book is the first edited collection to focus on dementia in remote and rural areas. Drawing on examples of research studies and innovative practice from remote and rural locations globally, it highlights the implications of living with dementia in remote and rural areas for dementia policy, practice and future research. The chapters represent countries with considerable experience and expertise in developing support and services for their rural and remote populations, such as Canada, Australia, the UK, Ireland and Austria. However, many other countries have rural geographies and ageing populations, and are likely to face similar challenges of meeting the needs of people living with dementia in remote and rural areas. To promote knowledge translation, the book's contributors share ideas from their countries to help practitioners working in challenging geographical landscapes anywhere as they strive to provide the highest standards of support for those living with dementia. The book draws on research conducted in different countries with longstanding histories of conducting remote and rural dementia research, and as such it is a resource for academics who teach or research rurality and dementia. The edited structure allows international examples of innovative research/practice in the remote and rural dementia field to be showcased with the implications of such national examples to be considered in relation to research, policy and practice globally. In this way, we hope that you, the reader, will find this edited collection to be a resource, whether you are a student, practitioner, policy influencer or academic, to assist you in enhancing the experience of living with dementia in remote and rural areas in the future.
Dementia has been defined by the World Health Organization as:
… an umbrella term for several diseases that are mostly progressive, affecting memory, other cognitive abilities and behaviour, and that interfere significantly with a person's ability to maintain the activities of daily living. (WHO, 2017c: 5)
Although the symptoms of dementia may be similar, how these are experienced and the impact on individuals’ lives can vary significantly. The experience of dementia is one that is fraught with challenges for the person diagnosed with dementia, and for families, friends and communities. It may require coming to terms with new identity and functionality and may require significant adaptation and resilience at individual, family and community levels (Innes et al, 2011).
As the number of people affected by dementia continues to rise, this is the first in-depth examination of related services dedicated to the unique demands of remote and rural settings. Contributors from the UK, Australia, North America and Europe explore the experiences and requirements of those living with dementia and those caring for them in personal and professional capacities in challenging geographical locations. For practitioners, researchers, academics and policy makers, this book is an essential review of evidence and strategies to date, and a guide to future research needs and opportunities for improvements in rural dementia practice.
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