Adherence to antiepileptic medicines in children:a multiple-methods assessment involving dried blood spot sampling

Purpose - To evaluate adherence to prescribed antiepileptic drugs (AEDs) in children with epilepsy using a combination of adherence-assessment methods. Methods - A total of 100 children with epilepsy (≤17 years old) were recruited. Medication adherence was determined via parental and child self-reporting (≥9 years old), medication refill data from general practitioner (GP) prescribing records, and via AED concentrations in dried blood spot (DBS) samples obtained from children at the clinic and via self- or parental-led sampling in children's own homes. The latter were assessed using population pharmacokinetic modeling. Patients were deemed nonadherent if any of these measures were indicative of nonadherence with the prescribed treatment. In addition, beliefs about medicines, parental confidence in seizure management, and the presence of depressed mood in parents were evaluated to examine their association with nonadherence in the participating children. Key Findings - The overall rate of nonadherence in children with epilepsy was 33%. Logistic regression analysis indicated that children with generalized epilepsy (vs. focal epilepsy) were more likely (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.37–15.81) to be classified as nonadherent as were children whose parents have depressed mood (OR 3.6, 95% CI 1.16–11.41). Significance - This is the first study to apply the novel methodology of determining adherence via AED concentrations in clinic and home DBS samples. The present findings show that the latter, with further development, could be a useful approach to adherence assessment when combined with other measures including parent and child self-reporting. Seizure type and parental depressed mood were strongly predictive of nonadherence.

Interest groups in multiple streams:specifying their involvement in the framework

Although interests inhabit a central place in the multiple streams framework (MSF), interest groups have played only a minor role in theoretical and empirical studies until now. In Kingdon’s original conception, organized interests are a key variable in the politics stream. Revisiting Kingdon’s concept with a particular focus on interest groups and their activities—in different streams and at various levels—in the policy process, we take this argument further. In particular, we argue that specifying groups’ roles in other streams adds value to the explanatory power of the framework. To do this, we look at how interest groups affect problems, policies, and politics. The influence of interest groups within the streams is explained by linking the MSF with literature on interest intermediation. We show that depending on the number of conditions and their activity level, interest groups can be involved in all three streams. We illustrate this in case studies reviewing labor market policies in Germany and chemicals regulation at the European level.

A qualitative study of English community pharmacists’ experiences of providing lifestyle advice to patients with cardiovascular disease

Background - Cardiovascular disease (CVD) progression is modifiable through lifestyle behaviors. Community pharmacists are ideally placed to facilitate self-management of cardiovascular health however research shows varied pharmacist engagement in providing lifestyle advice. Objective - This study explored community pharmacists' experiences and perceptions of providing lifestyle advice to patients with CVD. Methods - Semi-structured interviews were conducted with fifteen pharmacists (1 supermarket; 7 multiple; 7 independent) recruited through multiple methods from community pharmacies across the Midlands, England. A thematic analysis was conducted using a Framework approach. Results - Pharmacists categorized patients according to their perceptions of the patients' ability to benefit from advice. Many barriers to providing lifestyle advice were identified. Confidence to provide lifestyle advice varied, with pharmacists most comfortable providing lifestyle advice in conjunction with conversations about medicines. Some pharmacists felt lifestyle advice was an integral part of their role whilst others questioned whether pharmacists should give lifestyle advice at all, particularly when receiving no remuneration for doing so. Conclusion - Pharmacists viewed providing lifestyle advice as important but identified many barriers to doing so. Lifestyle advice provision was influenced by pharmacists' perceptions of patients. Professional identity and associated role conflict appeared to underpin many of the barriers to pharmacists providing lifestyle advice. Pharmacists may benefit from enhanced training to: increase their confidence to provide lifestyle advice; integrate lifestyle advice with regular pharmaceutical practice and challenge their perceptions of some patients' receptiveness to lifestyle advice and behavior change. Changes to the way UK pharmacists are remunerated may increase the provision of lifestyle advice.

A mixed methods investigation of parental factors in non-attendance at general paediatric hospital outpatient appointments

Non-attendance at paediatric outpatient appointments results in delayed diagnosis and treatment, putting children at risk of avoidable ill health, and incurring considerable health service costs. Links between missed appointments and clinical, socio-demographic, and access-related factors have been indicated, but parental cognitions associated with non-attendance have yet to be investigated. The aims of this project were to evaluate the effectiveness and theoretical bases of existing interventions designed to reduce non-attendance; to consider the ways in which missed appointments are managed by healthcare providers; to explore parents’ beliefs and experiences of attending and missing appointments; and to investigate the factors underlying these beliefs. A systematic literature review focusing on non-attendance interventions was conducted Within a mixed methods framework, interviews were conducted with healthcare professionals, subsequent interviews were conducted with parents who had attended or missed a General Paediatric outpatient appointment, and a cross-sectional questionnaire study of parents’ beliefs was implemented. The systematic review revealed that text message appointment reminders are effective at reducing non-attendance rates, but that no interventions have thus far been developed using theories of behaviour. Healthcare professionals recognised both barriers and parents’ beliefs as influences on attendance, but also believed there were ‘types’ of families who miss appointments. Healthcare professionals disagreed somewhat about how non-attendance should best be managed. The parent interview study found six themes. The findings reflect parents’ perceptions about the importance of attending and of their ability to attend. The results of the questionnaire study corroborate this structure of beliefs as the analysis produced two factors, the perceived ‘worth’ of attending and anticipated ‘worry’ when attending. This thesis demonstrates an original approach to investigating non-attendance at children’s outpatient appointments, using mixed methods and adopting a psychological rather than service-use perspective. The findings contribute to Health Psychology theory and offer recommendations for healthcare providers.

Time and professional work in public sector organisations: an examination of four occupational groups in education and medicine

The aim of this thesis is to examine the experience of time of four professional occupational groups working in public sector organisations and the factors affecting this experience. The literature on time and work is examined to delineate the key parameters of research in this area. A broad organisation behaviour approach to the experience of time and work is developed in which individual, occupational, organisational and socio-political factors are inter-related. The experience of secondary school teachers, further education lecturers, general medical practitioners and hosoital consultants is then examined. Multiple methods of data collection are used: open-ended interviews, a questionnaire survey and the analysis of key documents relating to the institutional settings in which the four groups work. The research aims to develop our knowledge of working time by considering the dimensions of the experience of time at work, the contexts in wlhich this experience is generated and the constraints these contexts give rIse to. By developing our understanding of time as a key feature of work experience we also extend our knowledge of organisation behaviour in general. In conclusion a model of the factors relating the experience of time to the negotiation of time at work is presented.

Community involvement in urban nature conservation : case studies of the Urban Wildlife Group 1980-85

The effectiveness of the strategies employed by the Urban Wildlife Group (a voluntary conservation organisation) to provide and manage three urban nature parks has been evaluated, using a multiple methods methodology. Where the level of community interest and commitment to a project is high, the utilisation of the community nature park strategy (to maximise benefits to UWG and the community) is warranted. Where the level of interest and commitment of the local community is low, a strategy designed to encourage limited involvement of the community is most effective and efficient. The campaign strategy, whereby the community and UWG take direct action to oppose a threat of undesirable development on a nature park, is assessed to be a sub-strategy, rather than a strategy in its own right. Questionnaire surveys and observations studies have revealed that urban people appreciate and indeed demand access to nature parks in urban areas, which have similar amenity value to that provided by countryside recreation sites. Urban nature parks are valued for their natural character, natural features (trees, wild flowers) peace and quiet, wildlife and openness. People use these sites for a mixture of informal and mainly passive activities, such as walking and dog walking. They appear to be of particular value to children for physical and imaginative play. The exact input of time and resources that UWG has committed to the projects has depended on the level of input of the local authority. The evidence indicates that the necessary technical expertise needed to produce and manage urban nature parks, using a user-oriented approach is not adequately provided by local authorities. The methods used in this research are presented as an `evaluation kit' that may be used by practitioners and researchers to evaluate the effectiveness of a wide range of different open spaces and the strategies employed to provide and manage them.

An exploration of female leadership language:case studies of senior women in Bahrain

This is a multiple case study of the leadership language of three senior women working in a large corporation in Bahrain. The study’s main aim is to explore the linguistic practices the women leaders use with their colleagues and subordinates in corporate meetings. Adopting a Foucauldian (1972) notion of ‘discourses’ as social practices and a view of gender as socially constructed and discursively performed (Butler 1990), this research aims to unveil the competing discourses which may shape the leadership language of senior women in their communities of practice. The research is situated within the broader field of Sociolinguistics and the specific field of Language and Gender. To address the research aim, a case study approach incorporating multiple methods of qualitative data collection (observation, interviews, and shadowing) was utilised to gather information about the three women leaders and produce a rich description of their use of language in and out of meeting contexts. For analysis, principles of Qualitative Data Analysis (QDA) were used to organise and sort the large amount of data. Also, Feminist Post- Structuralist Discourse Analysis (FPDA) was adopted to produce a multi-faceted analysis of the subjects, their language leadership, power relations, and competing discourses in the context. It was found that the three senior women enact leadership differently making variable use of a repertoire of conventionally masculine and feminine linguistic practices. However, they all appear to have limited language resources and even more limiting subject positions; and they all have to exercise considerable linguistic expertise to police and modify their language in order to avoid the ‘double bind’. Yet, the extent of this limitation and constraints depends on the community of practice with its prevailing discourses, which appear to have their roots in Islamic and cultural practices as well as some Western influences acquired throughout the company’s history. It is concluded that it may be particularly challenging for Middle Eastern women to achieve any degree of equality with men in the workplace because discourses of Gender difference lie at the core of Islamic teaching and ideology.

Successful development and testing of a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS)

Objectives: To develop a tool for the accurate reporting and aggregation of findings from each of the multiple methods used in a complex evaluation in an unbiased way. Study Design and Setting: We developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) within a gastroenterology study [Evaluating New Innovations in (the delivery and organisation of) Gastrointestinal (GI) endoscopy services by the NHS Modernisation Agency (ENIGMA)]. We subsequently tested it on a different gastroenterology trial [Multi-Institutional Nurse Endoscopy Trial (MINuET)]. We created three layers to define the effects, methods, and findings from ENIGMA. We assigned numbers to each effect in layer 1 and letters to each method in layer 2. We used an alphanumeric code based on layers 1 and 2 to every finding in layer 3 to link the aims, methods, and findings. We illustrated analogous findings by assigning more than one alphanumeric code to a finding. We also showed that more than one effect or method could report the same finding. We presented contradictory findings by listing them in adjacent rows of the MATRICS. Results: MATRICS was useful for the effective synthesis and presentation of findings of the multiple methods from ENIGMA. We subsequently successfully tested it by applying it to the MINuET trial. Conclusion: MATRICS is effective for synthesizing the findings of complex, multiple-method studies.

Integrated project evaluation and selection using multiple-attribute decision-making technique

The evaluation and selection of industrial projects before investment decision is customarily done using marketing, technical and financial information. Subsequently, environmental impact assessment and social impact assessment are carried out mainly to satisfy the statutory agencies. Because of stricter environment regulations in developed and developing countries, quite often impact assessment suggests alternate sites, technologies, designs, and implementation methods as mitigating measures. This causes considerable delay to complete project feasibility analysis and selection as complete analysis requires to be taken up again and again till the statutory regulatory authority approves the project. Moreover, project analysis through above process often results sub-optimal project as financial analysis may eliminate better options, as more environment friendly alternative will always be cost intensive. In this circumstance, this study proposes a decision support system, which analyses projects with respect to market, technicalities, and social and environmental impact in an integrated framework using analytic hierarchy process, a multiple-attribute decision-making technique. This not only reduces duration of project evaluation and selection, but also helps select optimal project for the organization for sustainable development. The entire methodology has been applied to a cross-country oil pipeline project in India and its effectiveness has been demonstrated. © 2005 Elsevier B.V. All rights reserved.

When do conservation planning methods deliver? Quantifying the consequences of uncertainty

The rapid global loss of biodiversity has led to a proliferation of systematic conservation planning methods. In spite of their utility and mathematical sophistication, these methods only provide approximate solutions to real-world problems where there is uncertainty and temporal change. The consequences of errors in these solutions are seldom characterized or addressed. We propose a conceptual structure for exploring the consequences of input uncertainty and oversimpli?ed approximations to real-world processes for any conservation planning tool or strategy. We then present a computational framework based on this structure to quantitatively model species representation and persistence outcomes across a range of uncertainties. These include factors such as land costs, landscape structure, species composition and distribution, and temporal changes in habitat. We demonstrate the utility of the framework using several reserve selection methods including simple rules of thumb and more sophisticated tools such as Marxan and Zonation. We present new results showing how outcomes can be strongly affected by variation in problem characteristics that are seldom compared across multiple studies. These characteristics include number of species prioritized, distribution of species richness and rarity, and uncertainties in the amount and quality of habitat patches. We also demonstrate how the framework allows comparisons between conservation planning strategies and their response to error under a range of conditions. Using the approach presented here will improve conservation outcomes and resource allocation by making it easier to predict and quantify the consequences of many different uncertainties and assumptions simultaneously. Our results show that without more rigorously generalizable results, it is very dif?cult to predict the amount of error in any conservation plan. These results imply the need for standard practice to include evaluating the effects of multiple real-world complications on the behavior of any conservation planning method.

Data analysis methods in optometry Part 7: multiple linear regression

Multiple regression analysis is a complex statistical method with many potential uses. It has also become one of the most abused of all statistical procedures since anyone with a data base and suitable software can carry it out. An investigator should always have a clear hypothesis in mind before carrying out such a procedure and knowledge of the limitations of each aspect of the analysis. In addition, multiple regression is probably best used in an exploratory context, identifying variables that might profitably be examined by more detailed studies. Where there are many variables potentially influencing Y, they are likely to be intercorrelated and to account for relatively small amounts of the variance. Any analysis in which R squared is less than 50% should be suspect as probably not indicating the presence of significant variables. A further problem relates to sample size. It is often stated that the number of subjects or patients must be at least 5-10 times the number of variables included in the study.5 This advice should be taken only as a rough guide but it does indicate that the variables included should be selected with great care as inclusion of an obviously unimportant variable may have a significant impact on the sample size required.