Addressing potentially inappropriate prescribing in older patients: development and pilot study of an intervention in primary care (the OPTI-SCRIPT study)

Background: Potentially inappropriate prescribing (PIP) in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. The prevalence of PIP in Ireland is estimated at 36% with an associated expenditure of over [euro sign]45 million in 2007. The aim of this paper is to describe the application of the Medical Research Council (MRC) framework to the development of an intervention to decrease PIP in Irish primary care.

Methods: The MRC framework for the design and evaluation of complex interventions guided the development of the study intervention. In the development stage, literature was reviewed and combined with information obtained from experts in the field using a consensus based methodology and patient cases to define the main components of the intervention. In the pilot stage, five GPs tested the proposed intervention. Qualitative interviews were conducted with the GPs to inform the development and implementation of the intervention for the main randomised controlled trial.

Results: The literature review identified PIP criteria for inclusion in the study and two initial intervention components - academic detailing and medicines review supported by therapeutic treatment algorithms. Through patient case studies and a focus group with a group of 8 GPs, these components were refined and a third component of the intervention identified - patient information leaflets. The intervention was tested in a pilot study. In total, eight medicine reviews were conducted across five GP practices. These reviews addressed ten instances of PIP, nine of which were addressed in the form of either a dose reduction or a discontinuation of a targeted medication. Qualitative interviews highlighted that GPs were receptive to the intervention but patient preference and time needed both to prepare for and conduct the medicines review, emerged as potential barriers. Findings from the pilot study allowed further refinement to produce the finalised intervention of academic detailing with a pharmacist, medicines review with web-based therapeutic treatment algorithms and tailored patient information leaflets.

Conclusions: The MRC framework was used in the development of the OPTI-SCRIPT intervention to decrease the level of PIP in primary care in Ireland. Its application ensured that the intervention was developed using the best available evidence, was acceptable to GPs and feasible to deliver in the clinical setting. The effectiveness of this intervention is currently being tested in a pragmatic cluster randomised controlled trial.

Trial registration: Current controlled trials ISRCTN41694007.© 2013 Clyne et al.; licensee BioMed Central Ltd.

The making of a void sovereignty: political implications of the military checkpoints in the West Bank

Research on the Israeli checkpoints in the West Bank has emphasized not only that these checkpoints have dire implications for the Palestinians living there, at the personal, familial, and communal levels, and devastating eff ects on the Palestinian economy, but also that they have far-reaching consequences for the ability of the Palestinians to establish an independent political entity. At the same time, analysis of the Israeli forms of domination over the Palestinians has also stressed the role of a Palestinian governing authority in sustaining the Israeli rule, since the former relieves the latter of its responsibility to care for the occupied Palestinian population. This paper aims to address this apparent contradiction claiming that a comprehensive analysis of Israeli forms of domination requires a spatial examination of the operation of sovereignty with an assessment of governmentalizing arrays. This combined analysis suggests that a Palestinian sovereignty, but one which is emptied of its actual ruling power, is construed at the checkpoints as an epiphenomenon of Israeli apparatuses of control. © 2013 Pion and its Licensors.

Between Imaginary Lines: Violence and its Justifications at the Military Checkpoints in Occupied Palestine

Looking at one site, the Israeli checkpoints in the occupied Palestinian territory, this article seeks to understand the mechanisms by which violence can present itself as justifiable (or justified), even when it materializes within frames presumably set to annul it. We look at the checkpoints as a condensed microcosmos operating within two such frames. One is the prolonged IsraeliPalestinian ‘peace process’ (the checkpoints became a primary technology of control in the period following the beginning of the peace process), and the other is regulatory power (disciplinary and biopower), which in the Foucauldian framework presumably sidelines the violent form which sovereign power takes. We argue that the checkpoints, which dissect the Palestinian occupied territories into dozens of enclaves and which are one of the most effective and destructive means of control within the current stage of occupation, can be seen as more than obstacles in the way of Palestinian movement; we suggest that they also function as corrective technologies that are meant to fail. It is with this failure that violence can appear as justified. In order to show the operation of this embedded failure, we examine one mechanism operating within the checkpoints: ‘the imaginary line’. The imaginary line is both a component within, and an emblem of a mode of control that constantly undoes itself in order to summon violence. Since it is never visibly marked in the physical space, the imaginary line is bound to be unintentionally crossed, thereby randomly rendering Palestinians as ‘transgressors’ of the rule and thus facilitating eruptions of violence by the soldiers stationed at the checkpoints. This article proposes an analysis of this hidden demarcation of space in order to question the different relations between subjects and power which it both assumes and constitutes.

A lesson in business: cost-effectiveness analysis of a novel financial incentive intervention for increasing physical activity in the workplace

Background: Recently both the UK and US governments have advocated the use of financial incentives to encourage healthier lifestyle choices but evidence for the cost-effectiveness of such interventions is lacking. Our aim was to perform a cost-effectiveness analysis (CEA) of a quasi-experimental trial, exploring the use of financial incentives to increase employee physical activity levels, from a healthcare and employer’s perspective.

Methods: Employees used a ‘loyalty card’ to objectively monitor their physical activity at work over 12 weeks. The Incentive Group (n=199) collected points and received rewards for minutes of physical activity completed. The No Incentive Group (n=207) self-monitored their physical activity only. Quality of life (QOL) and absenteeism were assessed at baseline and 6 months follow-up. QOL scores were also converted into productivity estimates using a validated algorithm. The additional costs of the Incentive Group were divided by the additional quality adjusted life years (QALYs) or productivity gained to calculate incremental cost effectiveness ratios (ICERs). Cost-effectiveness acceptability curves (CEACs) and population expected value of perfect information (EVPI) was used to characterize and value the uncertainty in our estimates.

Results: The Incentive Group performed more physical activity over 12 weeks and by 6 months had achieved greater gains in QOL and productivity, although these mean differences were not statistically significant. The ICERs were £2,900/QALY and £2,700 per percentage increase in overall employee productivity. Whilst the confidence intervals surrounding these ICERs were wide, CEACs showed a high chance of the intervention being cost-effective at low willingness-to-pay (WTP) thresholds.

Conclusions: The Physical Activity Loyalty card (PAL) scheme is potentially cost-effective from both a healthcare and employer’s perspective but further research is warranted to reduce uncertainty in our results. It is based on a sustainable “business model” which should become more cost-effective as it is delivered to more participants and can be adapted to suit other health behaviors and settings. This comes at a time when both UK and US governments are encouraging business involvement in tackling public health challenges.

Evaluation of a Psychoeducational intervention for patients with Advanced Cancer who have Cachexia and their lay Carers (EPACaCC): study protocol

Aim: To evaluate a psychoeducational intervention for patients with advanced cancer who have cachexia and their lay carers.

Background: Cachexia is a frequent and devastating syndrome of advanced cancer. It has an impact on patients biologically, psychologically and socially and has profound impact on their lay carers. Prior research has predominately focused on the biological components of cachexia and associated potential treatment modalities. At present, there is no standardized supportive healthcare intervention in current practice that targets the psychosocial impact of this syndrome.

Design: A pragmatic multicentre randomized controlled trial.

Methods: Patient/carer dyads (n = 200) will be recruited into a randomized controlled trial of a DVD intervention for cachexia management. The sample will be recruited from two urban hospices in the UK. The primary outcome measure will be the General Health Questionnaire-12. Additional questionnaires focusing on distress, readiness to give care and coping skills will be used as secondary outcome measures. In addition, lay carers in the intervention group will be asked to participate in semi-structured interviews following the death of their loved one. Both Office for Research Ethics Committee approval and local governance approval at both hospices have been obtained as of February 2013.

Discussion: This is the first time that a psychoeducational DVD has been tested in a randomized controlled trial in this population. Dissemination of findings will make a significant contribution to international knowledge and understanding in this area. Findings will inform education, practice and policy.

Cooperative learning in science:Intervention in the secondary school

The use of cooperative learning in secondary school is reported - an area of considerable concern given attempts to make secondary schools more interactive and gain higher recruitment to university science courses. In this study the intervention group was 259 pupils aged 12-14 years in nine secondary schools, taught by 12 self-selected teachers. Comparison pupils came from both intervention and comparison schools (n = 385). Intervention teachers attended three continuing professional development days, in which they received information, engaged with resource packs and involved themselves in cooperative learning. Measures included both general and specific tests of science, attitudes to science, sociometry, self-esteem, attitudes to cooperative learning and transferable skills (all for pupils) and observation of implementation fidelity. There were increases during cooperative learning in pupil formulation of propositions, explanations and disagreements. Intervened pupils gained in attainment, but comparison pupils gained even more. Pupils who had experienced cooperative learning in primary school had higher pre-test scores in secondary education irrespective of being in the intervention or comparison group. On sociometry, comparison pupils showed greater affiliation to science work groups for work, but intervention pupils greater affiliation to these groups at break and out of school. Other measures were not significant. The results are discussed in relation to practice and policy implications. © 2011 Taylor & Francis.

A pilot study of a family focused, psychosocial intervention with war-exposed youth at risk of attack and abduction in north-eastern Democratic Republic of Congo

Rural communities in the Haut-Uele Province of northern Democratic Republic of Congo live in constant danger of attack and/or abduction by units of the Lord's Resistance Army operating in the region. This pilot study sought to develop and evaluate a community-participative psychosocial intervention involving life skills and relaxation training and Mobile Cinema screenings with this war-affected population living under current threat. 159 war-affected children and young people (aged 7-18) from the villages of Kiliwa and Li-May in north-eastern DR Congo took part in this study. In total, 22% of participants had been abduction previously while 73% had a family member abducted. Symptoms of post-traumatic stress reactions, internalising problems, conduct problems and pro-social behaviour were assessed by blinded interviewers at pre- and post-intervention and at 3-month follow-up. Participants were randomised (with an accompanying caregiver) to 8 sessions of a group-based, community-participative, psychosocial intervention (n=79) carried out by supervised local, lay facilitators or a wait-list control group (n=80). Average seminar attendance rates were high: 88% for participants and 84% for caregivers. Drop-out was low: 97% of participants were assessed at post-intervention and 88% at 3 month follow-up. At post-test, participants reported significantly fewer symptoms of post-traumatic stress reactions compared to controls (Cohen's d=0.40). At 3 month follow up, large improvements in internalising symptoms and moderate improvements in pro-social scores were reported, with caregivers noting a moderate to large decline in conduct problems among the young people. Trial Registration clinicalTrials.gov, Identifier: NCT01542398.

Adaption and adjustment of military spouses to overseas postings: An online forum study

Little research has examined the impact of being an accompanying spouse on British military foreign postings. The aim of this qualitative study was to investigate the experiences of 13 military spouses from 11 different overseas locations. Data were collected via an online forum and thematic content analysis was conducted. Key findings revealed that, regardless of the location, reactions to overseas posting varied considerably and were related to the military spouse's personality and personal circumstances, as well as their relationship with family, husband and their support networks. Spouses experienced a loss of control over their lives that was in some cases psychologically distressing. The findings corroborate and extend the findings from a previous study that was limited to one location, further highlighting the need for pre-established support resources from the military and healthcare professionals to be readily accessible for all military spouses. Importantly, such support provision may also facilitate the military spouse in regaining some control over their everyday life, enhancing their well-being and the experience for the family.