Community Cohesion and Social Inclusion: Unravelling a Complex Relationship

In a global context of an emphasis on identity politics and a ‘cultural turn’ in social analysis, deep concern has been expressed about multiethnic Britain becoming a broken society with many ‘sleepwalking’ into segregation and separatism. Given the close correspondence between areas of acute ethnic segregation and those of multiple deprivation, intercommunal tensions have included disputes about the equitable allocation of scarce urban resources across ethnicity. This creates the possibility that urban programmes may inadvertently accentuate intercommunal tension and confound efforts to synchronise cohesion and inclusion agendas. Following recent debates about the implications of increased diversity, influenced by arguments that multiculturalism has encouraged ‘parallel lives’, an emergent policy framework emphasises more proactive integration to promote ‘common belonging’. Criticism of this agenda includes its confusion between community and social cohesion, and its disproportionate focus on cultural aspects such as identity formation and recognition, relative to structural issues of income and class. In exploring this contested terrain in Britain, the article suggests that the longer-term debate about segregation, deprivation and community differentials in Northern Ireland can offer useful insight for Britain’s policy discourse.

Genetic testing and the relationship between specific and general self-efficacy

The study examined the extent to which variations in health-specific self-efficacy could affect general self-efficacy. In a repeated measures design, 300 participants were administered an efficacy questionnaire, before and after an alleged news report, aimed at increasing or decreasing self-efficacy over genetic-testing decision making. The results found that self-efficacy over testing was significantly reduced after reading the negative news report in those participants who felt personal efficacy over testing decisions was important. Levels of general self-efficacy were also significantly decreased. The findings suggest that being denied control over a specific area of self-efficacy can have a wider impact, with a lack of perceived efficacy over testing decision making adversely impacting on levels of general well-being. The wider implications of this generalization effect and the processes involved in efficacy generalization are discussed.

Is low self-esteem an inevitable consequence of stigma? An example from women with chronic mental health problems

It is often assumed that membership in a stigmatized group has negative consequences for the self-concept. However, this relationship is neither straightforward nor inevitable, and there is evidence suggesting that negative consequences may not necessarily occur (Psychol. Rev. 96(4) (1989) 608). This paper argues that the relationship has not been sufficiently theorized, and that a more detailed analysis is called for in order to understand the relationship between stigma and the self. The paper presents a critical examination of modified labeling theory (Am. Sociol. Rev. 52 (1987) 96), with examples from a study examining perceptions of stigma and their relationship to self-evaluation in women with chronic mental health problems. Open-ended interviews and qualitative analyses were used in preference to global measures of self-esteem. It was found that although the women were aware of society's unfavorable representations of mental illness, and the effects this had on their lives, they did not accept these representations as valid and therefore rejected them as applicable to the self. The participants did not deny their mental health problems, but their acceptance of labels was critical and pragmatic. Labels were rejected when they were perceived as carrying an unrealistic and negative stereotype, or when the women felt that their symptoms did not fit with the diagnostic criteria. The research illustrates the importance of considering people's subjective understandings of stigmatized conditions and societal reactions in order to understand the relation between stigma and the self. (C) 2002 Elsevier Science Ltd. All rights reserved.

Extension of general practice training from three to four years: experiences of a vocational training programme in Southern Ireland

The aim of this study was to evaluate the experiences of trainees taking part in an extended (four-year) general practice training programme introduced in the South Eastern region of the Republic of Ireland to replace the previous traditional (three-year) programme. In a qualitative design, eight homogeneous focus groups were held to determine the value of the additional year of training. The first cohort of trainees was interviewed towards the start and at the end of their fourth year. Trainees finishing the following year were also interviewed, as were graduates from the final three-year programme. GP trainers and the four members of the programme directing team comprised two further independent focus groups. Trainees reported that the integration of hospital posts and general practice attachments over the four years was particularly beneficial. The exposure to a variety of different general practices and the opportunity to take part in specialty clinics were considered extremely useful. The fourth year of training was felt to be less pressurised than previous years. Professional and personal development was enhanced; improved readiness to practise and confidence were noted. Perceived disadvantages of extended training included a lack of acknowledgment for doctors in their fourth year and excessive emphasis placed on research during the final year of training. The addition of an extra year of vocational training improves professional and personal development and changes the learning experience for doctors. Doctors felt more confident and ready to enter independent practice at the end of the fourth year of training.

hVps34 is a nutrient-regulated lipid kinase required for activation of p70 S6 kinase

Mammalian cells respond to nutrient deprivation by inhibiting energy consuming processes, such as proliferation and protein synthesis, and by stimulating catabolic processes, such as autophagy. p70 S6 kinase (S6K1) plays a central role during nutritional regulation of translation. S6K1 is activated by growth factors such as insulin, and by mammalian target of rapamycin (mTOR), which is itself regulated by amino acids. The Class IA phosphatidylinositol (PI) 3-kinase plays a well recognized role in the regulation of S6K1. We now present evidence that the Class III PI 3-kinase, hVps34, also regulates S6K1, and is a critical component of the nutrient sensing apparatus. Overexpression of hVps34 or the associated hVps15 kinase activates S6K1, and insulin stimulation of S6K1 is blocked by microinjection of inhibitory anti-hVps34 antibodies, overexpression of a FYVE domain construct that sequesters the hVps34 product PI(3) P, or small interfering RNA-mediated knock-down of hVps34. hVps34 is not part of the insulin input to S6K1, as it is not stimulated by insulin, and inhibition of hVps34 has no effect on phosphorylation of Akt or TSC2 in insulin-stimulated cells. However, hVps34 is inhibited by amino acid or glucose starvation, suggesting that it lies on the nutrient-regulated pathway to S6K1. Consistent with this, hVps34 is also inhibited by activation of the AMP-activated kinase, which inhibits mTOR/S6K1 in glucose-starved cells. hVps34 appears to lie upstream of mTOR, as small interfering RNA knock- down of hVps34 inhibits the phosphorylation of another mTOR substrate, eIF4E-binding protein-1 (4EBP1). Our data suggest that hVps34 is a nutrient-regulated lipid kinase that integrates amino acid and glucose inputs to mTOR and S6K1.

Socio-economic inequalities in cerebral palsy prevalence in the United Kingdom: a register-based study

Evidence is unclear as to whether there is a socio-economic gradient in cerebral palsy (CP) prevalence beyond what would be expected from the socio-economic gradient for low birthweight, a strong risk factor for CP. We conducted a population-based study in five regions of the UK with CP registers, to investigate the relationship between CP prevalence and socio-economic deprivation, and how it varies by region, by birthweight and by severity and type of CP. The total study population was 1 657 569 livebirths, born between 1984 and 1997. Wards of residence were classified into five quintiles according to a census-based deprivation index, from Q1 (least deprived) to Q5 (most deprived). Socio-economic gradients were modelled by Poisson regression, and region-specific estimates combined by meta-analysis.

The prevalence of postneonatally acquired CP was 0.14 per 1000 livebirths overall. The mean deprivation gradient, expressed as the relative risk in the most deprived vs. the least deprived quintile, was 1.86 (95% confidence interval [95% CI 1.19, 2.88]). The prevalence of non-acquired CP was 2.22 per 1000 livebirths. For non-acquired CP the gradient was 1.16 [95% CI 1.00, 1.35]. Evidence for a socio-economic gradient was strongest for spastic bilateral cases (1.32 [95% CI 1.09, 1.59]) and cases with severe intellectual impairment (1.59 [95% CI 1.06, 2.39]). There was evidence for differences in gradient between regions. The gradient of risk of CP among normal birthweight births was not statistically significant overall (1.21 [95% CI 0.95, 1.54]), but was significant in two regions. There was non-significant evidence of a reduction in gradients over time.

The reduction of the higher rates of postneonatally acquired CP in the more socioeconomically deprived areas is a clear goal for prevention. While we found evidence for a socio-economic gradient for non-acquired CP of antenatal or perinatal origin, the picture was not consistent across regions, and there was some evidence of a decline in inequalities over time. The steeper gradients in some regions for normal birthweight cases and cases with severe intellectual impairment require further investigation.

Identifying additional patients with diabetic nephropathy using the UK primary care initiative

AIMS:
The aim of this study was to use general practice data to estimate the prevalence of diabetic nephropathy within the registered diabetes patients and examine variation in practice prevalence and management performance since introduction of this initiative.
METHODS:
Reported quality indicators from the Northern Ireland General Practice Quality and Outcomes Framework were analysed for diabetes and diabetic nephropathy prevalence and management in the period 2004-2008. Variation in prevalence at practice level was assessed using multiple linear regression adjusting for age, practice size, deprivation and glycaemic control.
RESULTS:
In 2006-2007, 57,454 (4.1%) adult diabetic patients were registered in the denominator population of 1.4 million compared with 51,923 (3.8%) in 2004-2005 (mean practice range 0.5-7.7%). Diabetic nephropathy prevalence was 15.1 and 11.5%, respectively (8688 and 5955 patients). Documented diabetic nephropathy prevalence showed marked variation across practices (range 0-100%) and was significantly negatively correlated with diabetes list size, albumin creatinine ratio testing rates and renin-angiotensin-aldosterone system blockade use and positively correlated with exception reporting rates. Specifically, for every increase in 100 diabetic patients to a register, documented diabetic nephropathy prevalence reduced by 40% (P=0.003). On the positive side, median albumin-creatinine ratio testing rates doubled to 82% compared with figures in the pre-Framework era.
CONCLUSIONS:
Implementation of the Northern Ireland General Practice Quality and Outcomes Framework has positively benefitted testing for diabetic nephropathy and increased numbers of detected patients in a short space of time. Large variation in diabetic nephropathy prevalence remains and is associated with diabetes registry size, screening and treatment practices, suggesting that understanding this variation may help detect and better manage diabetic nephropathy.

The effect of essentialism in settings of historic intergroup atrocities

Three studies tested the effects of essentialist beliefs regarding the national ingroup in situations where a perpetrator group has inflicted harm on a victim group. For members of the perpetrator group, it was hypothesised that ‘essentialism’ has a direct positive association with ‘collective guilt’ felt as a result of misdeeds conducted by other ingroup members in the past. Simultaneously, it was hypothesised to have an indirect negative association with collective guilt, mediated by perceived threat to the ingroup. Considering these indirect and direct effects jointly, it was hypothesised that the negative indirect effect suppresses the direct positive effect, and that the latter would only emerge if perceived ‘ingroup threat’ was controlled for. This was tested in a survey conducted in Latvia among Russians (N?=?70) and their feelings toward how Russians had treated ethnic Latvians during the Soviet occupation; and in a survey in Germany among Germans (N?=?84), focussing on their feelings toward the Holocaust. For members of the victim group, it was hypothesised that essentialism would be associated with more anger and reluctance to forgive past events inflicted on other ingroup members. It was proposed that this effect would be mediated by feeling connected to the ingroup victims. This was tested in a survey conducted among Hong Kong Chinese and their feelings toward the Japanese and the Nanjing massacre (N?=?56). Results from all three studies supported the hypotheses.

'Murder or Mercy?' an innovative module helping UK medical students to articulate their own ethical standpoints regarding end-of-life decisions

Objectives This student selected component (SSC) was designed to equip United Kingdom (UK) medical students to respond ethically and with sensitivity to requests they might receive as qualified doctors in regard to euthanasia and assisted dying. The aim was to expose students to relevant opinions and experiences and to provide opportunities to explore and justify their own views and rehearse ethical decision making in a safe learning environment. Method The module is delivered by specialists from a number of disciplines including law, theology, medicine and nursing, each providing students with a working knowledge allowing them to actively discuss cases, articulate their own views and practise ethical reasoning through group and individual study. Visits to local intensive care units, palliative care wards and hospices are integrated effectively with theory. Student assessment comprises a dissertation, student-led debate and reflective commentary. Module impact was evaluated by analysis of student coursework and a questionnaire. Results Students found the content stimulating and relevant to their future career and agreed that the module was well-structured and that learning outcomes were achieved. They greatly appreciated the clinical context provided by the visits and opportunities to apply ethical reasoning to real cases and to debate ethical issues with peers. Students reported an increased discernment of the ethical and legal position and practical considerations and a greater awareness of the range of professional and lay viewpoints held. Student perceptions were confirmed on analysis of their submitted coursework. Many participants were less strongly in favour of euthanasia and assisted dying on module completion than at the outset but all felt better equipped to justify their own viewpoint and to respond appropriately to patient requests. Conclusions The multi-disciplinary nature of this course is helpful in preparing students to deal effectively and sensitively with ethical dilemmas they will encounter in their medical career. Use of an integrated, learner-centred approach equips students to actively engage with their peers in discussion of such issues and to formulate and defend their own position.

Design and Evaluation of a "Pharmacists in Schools" Community Outreach Programme: A Pilot Study.

Aims: To design, evaluate and pilot a novel programme that would allow school children to become “pharmacists for the day”,encouraging them to recognise the importance of science, to contribute to the Department of Health‟s Building the Community Partnership strategy and University Outreach to the community and to provide undergraduate pharmacy students with teaching experience and an opportunity to build their CV.

Methods: Concept and formulation development, branding work,schools visits,questionnaires and semi-structured interviews.

Results: Suitable formulations were developed and prepared by school children on visits to their schools. The children seemed to enjoy the experience and their teachers gave both positive and constructive feedback. Pharmacy undergraduate students felt they had gained valuable experience that will benefit their future careers.

Conclusion: The Pharmacists in Schools outreach programme has now been successfully piloted and launched and will now be fully implemented in 20 schools in the local community.

Ankle disease in juvenile idiopathic arthritis: ultrasound findings in clinically swollen ankles

The ankle joint is frequently involved in juvenile idiopathic arthritis (JIA), but it is unclear whether this is predominantly due to synovitis, tenosynovitis, or both. We performed clinic-based ultrasound examination to assess the prevalence of synovitis and tenosynovitis in children with JIA felt clinically to have active inflammatory disease of the ankle.

Children’s views on unlicensed/off-label paediatric prescribing and paediatric clinical trials.

Objectives: To explore the views and perspectives of children on the unlicensed/off-label use of medicines in children and on the participation of children in clinical trials. Methods: Focus-group discussions, involving school children, were carried out in a range of primary and secondary schools in Northern Ireland. A purposeful sample was chosen to facilitate representation of various socioeconomic groupings. Results: A total of 123 pupils, aged from 10 to 16 years, from six schools, participated in 16 focus groups. In general, pupils viewed the unlicensed/off-label use of medicines in children as unsafe and unethical and felt it is necessary to test medicines in children to improve the availability of licensed products. The majority felt that older children should be told, and that parents should be told, about the unlicensed/off-label use of medicines in children, yet they recognised some implications of this, such as potential medication non-adherence. Conclusions: This is the first study to explore the views of healthy children on unlicensed medicine use in children. Children were able to recognise potential risks associated with the unlicensed use of medicines and felt it is necessary to test and license more medicines in children. Practice implications Health care professionals should consider the views of children in decisions that affect their health.

The Geography of Conflict and Death in Belfast, Northern Ireland

The conflict known as the oTroubleso in Northern Ireland began during the late 1960s and is defined by political and ethno-sectarian violence between state, pro-state, and anti-state forces. Reasons for the conflict are contested and complicated by social, religious, political, and cultural disputes, with much of the debate concerning the victims of violence hardened by competing propaganda-conditioning perspectives. This article introduces a database holding information on the location of individual fatalities connected with the contemporary Irish conflict. For each victim, it includes a demographic profile, home address, manner of death, and the organization responsible. Employing geographic information system (GIS) techniques, the database is used to measure, map, and analyze the spatial distribution of conflict-related deaths between 1966 and 2007 across Belfast, the capital city of Northern Ireland, with respect to levels of segregation, social and economic deprivation, and interfacing. The GIS analysis includes a kernel density estimator designed to generate smooth intensity surfaces of the conflict-related deaths by both incident and home locations. Neighborhoods with high-intensity surfaces of deaths were those with the highest levels of segregation ( 90 percent Catholic or Protestant) and deprivation, and they were located near physical barriers, the so-called peacelines, between predominantly Catholic and predominantly Protestant communities. Finally, despite the onset of peace and the formation of a power-sharing and devolved administration (the Northern Ireland Assembly), disagreements remain over the responsibility and ocommemorationo of victims, sentiments that still uphold division and atavistic attitudes between spatially divided Catholic and Protestant populations.

Factors influencing patients with stage 5 chronic kidney disease to opt for conservative management: a practitioner research study

Aims and objectives. This study explored decision-making experiences of patients with stage 5 chronic kidney disease when opting for conservative management of their renal failure.

Background. Dialysis is an invasive treatment, and for some older patients, there is an associated treatment burden of dialysis-related symptoms. An alternative choice is conservative management, but little is known about those who make this decision and how they are supported through the process.

Design. Qualitative practitioner research study.

Method. Data were generated from nine patients' naturally occurring clinic consultations with a renal clinical nurse specialist between May 2010 - July 2010. Interviews were transcribed verbatim and findings fed back at three multi-disciplinary meetings to check for relevance and resonance. Common themes were identified and codes applied.

Results. Patients reported age and having to travel three times a week to hospital for dialysis as reasons not to opt for treatment. Others felt well without dialysis not wanting to upset the 'status quo' or to burden loved ones. Most felt equipped to make the decision following explanation and discussion with the clinical nurse specialist in the renal clinic.

Conclusions. Patients opting for conservative management give numerous reasons for this including old age, travel limitations, feeling well without dialysis and not wanting to be a burden, but appear content with their decision. One-to-one discussions with the clinical nurse specialist appear helpful during the decision-making process presenting an opportunity for advancing nursing roles in the chronic kidney disease service.

Relevance to clinical practice. Understanding patients' reasons for refusing dialysis assists in supporting until death. There is an opportunity for developing nursing practice to meet the multi-faceted needs of this group.

Residential segregation and health in Northern Ireland

Patterns of residential segregation in Northern Ireland reflect historic sectarian conflict as well as current animosities. A number of indices of segregation are examined in this paper and their relative merits in capturing localised societal divisions are discussed.The implications of such divisions on health as mediated through conflict-related stress are then considered. Costed datasets of hospital, community and anxiety/depression prescribing data havebeen assembled and attributed to local geographies.The association between geographical variations in these costs and levels of segregation was modelled using regression analysis.It was found that the level of segregation does not help to explain variations in costed utilisation of acute and elderly services but does explain variations in the costs of prescribing for anxiety and depression with controls for socio-economic deprivation included. Results in this paper would indicate that strategies to promote good relations in Northern Ireland have positive implications for mental health.