Exploring the prevalence of and factors associated with pain: a cross-sectional study of community-dwelling people with dementia

Few pain studies have made community-dwelling people with dementia (PWD) their focus. The aim of this study was to determine the prevalence of pain among this patient population and to explore medication use. Moreover, we sought to investigate patient and caregiver variables associated with the presence of pain. Community-dwelling PWD and their caregivers were recruited between May 2009 and July 2012 from outpatient memory clinics in Northern Ireland to take part in a face-to-face structured interview with a researcher. Patients' cognitive status and presence of depression were established. A full medication history was taken. Both patients and caregivers were asked to rate patients' pain, at the time of the interview and on an average day, using a 7-point verbal descriptor scale. From the 206 patients who were eligible to take part, 75 patient-caregiver dyads participated in the study (participation rate = 36.4%). The majority of patients (92.0%) had dementia classed as mild or moderate. Pain was commonly reported among the sample, with 57.3% of patients and 70.7% of caregivers reporting patient pain on an average day. Significant differences were found between patients' and caregivers' reports of pain. Two-fifths of patients (40.0%) were prescribed analgesia. Antipsychotic, hypnotic and anxiolytic drug use was low, whereas antidepressant drugs were prescribed more commonly. Presence of pain was unaffected by dementia severity; however, the use of prescribed analgesic medication was a significant predictor of the presence of pain in these patients, whether reported by the patient or their caregiver 'right now' or 'on an average day' (P < 0.001). Patient and caregiver recruitment was challenging, and remains a barrier to research in this area in the future.

‘Plugging the Gap’: Shared Education and the promotion of community relations through schools in Northern Ireland

Although there is no consensus amongst educationalists as to the role schools play as drivers of hostilities in divided societies, there is broad agreement that they can facilitate more positive intergroup relations. In Northern Ireland the promotion of school based inter-group contact has been offered as a means through which this can happen. Until 2007, the approach was twofold, reflected on the one hand in short-term contact opportunities for pupils in predominantly Catholic and Protestant schools, and on the other, in support for integrated schools which educate Catholics and Protestants together. In 2007 the Shared Education Programme was introduced to ‘bridge the gap’ between short-term opportunities for contact, and ‘full immersion’ integrated schools. Informed by contact theory, shared education offers curriculum based interaction between pupils attending all school types, aimed at promoting the type of contact likely to reduce negative social attitudes and ultimately contribute to social harmony. In this paper, we examine the impact of shared education thus far. Our analysis suggests that whilst shared education is generally effective in promoting positive assessments of other group members, there is a danger that programme impact may be inhibited by the foregrounding of educational over reconciliation priorities. Appreciating that the downplaying reconciliation objectives may have been necessary when the programme was established in order to maximize recruitment to it, we argue that if the full potential of shared education is to be realized, moving forward, it is important for schools to engage with issues of group differences.

A qualitative study of community pharmacists’ awareness of and involvement with intermediate care facilities

Rationale, aims and objectives: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery and maximising independence. The introduction of IC has created a new interface between primary and secondary care. Older people are known to be at an increased risk of medication-related problems when transferring between healthcare settings and pharmacists are often not included as part of IC multidisciplinary teams. This study aimed to explore community pharmacists’ (CPs) awareness of IC services and to investigate their views of and attitudes towards the medicines management aspects of such services, including the transfer of medication information.

Method: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with CPs practising in the vicinity of IC facilities in Northern Ireland, UK.

Results: Interviews were conducted with 16 CPs. Three themes were identified and named ‘left out of the loop’, ‘chasing things up’ and ‘closing the loop’. CPs felt that they were often ‘left out of the loop’ with regards to both their involvement with local IC services and communication across the healthcare interfaces. As a result, CPs resorted to ‘chasing things up’ as they had to proactively try to obtain information relating to patients’ medications. CPs viewed themselves as ideally placed to facilitate medicines management across the healthcare interfaces (i.e., ‘closing the loop’), but several barriers to potential services were identified.

Conclusion: CPs have limited involvement with IC services. There is a need for improvement of effective communication of patients’ medication information between secondary care, IC and community pharmacy. Increasing CP involvement may contribute to improving continuity of care across such healthcare interfaces, thereby increasing the person-centeredness of service provision.

The Effect of Community-Based Specialist Palliative Care Teams on Place of Care

BACKGROUND: Prior research on community-based specialist palliative care teams used outcome measures of place of death and/or dichotomous outcome measures of acute care use in the last two weeks of life. However, existing research seldom measured the diverse places of care used and their timing prior to death.

OBJECTIVE: The study objective was to examine the place of care in the last 30 days of life.

METHODS: In this retrospective cohort study, patients who received care from a specialist palliative care team (exposed) were matched by propensity score to patients who received usual care in the community (unexposed) in Ontario, Canada. Measured was the percentage of patients in each place of care in the last month of life as a proportion of the total cohort.

RESULTS: After matching, 3109 patients were identified in each group, where 79% had cancer and 77% received end-of-life home care. At 30 days compared to 7 days before death, the exposed group's proportions rose from 33% to 41% receiving home care and 14% to 15% in hospital, whereas the unexposed group's proportions rose from 28% to 32% receiving home care and 16% to 22% in hospital. Linear trend analysis (proportion over time) showed that the exposed group used significantly more home care services and fewer hospital days (p < 0.001) than the unexposed group. On the last day of life (place of death), the exposed group had 18% die in an in-patient hospital bed compared to 29% in usual care.

CONCLUSION: Examining place of care in the last month can effectively illustrate the service use trajectory over time.

The design and implementation of a study to investigate the effectiveness of community vs hospital eye service follow-up for patients with neovascular age-related macular degeneration with quiescent disease

Introduction
Standard treatment for neovascular age-related macular degeneration (nAMD) is intravitreal injections of anti-VEGF drugs. Following multiple injections, nAMD lesions often become quiescent but there is a high risk of reactivation, and regular review by hospital ophthalmologists is the norm. The present trial examines the feasibility of community optometrists making lesion reactivation decisions.

Methods
The Effectiveness of Community vs Hospital Eye Service (ECHoES) trial is a virtual trial; lesion reactivation decisions were made about vignettes that comprised clinical data, colour fundus photographs, and optical coherence tomograms displayed on a web-based platform. Participants were either hospital ophthalmologists or community optometrists. All participants were provided with webinar training on the disease, its management, and assessment of the retinal imaging outputs. In a balanced design, 96 participants each assessed 42 vignettes; a total of 288 vignettes were assessed seven times by each professional group.The primary outcome is a participant's judgement of lesion reactivation compared with a reference standard. Secondary outcomes are the frequency of sight threatening errors; judgements about specific lesion components; participant-rated confidence in their decisions about the primary outcome; cost effectiveness of follow-up by optometrists rather than ophthalmologists.

Discussion
This trial addresses an important question for the NHS, namely whether, with appropriate training, community optometrists can make retreatment decisions for patients with nAMD to the same standard as hospital ophthalmologists. The trial employed a novel approach as participation was entirely through a web-based application; the trial required very few resources compared with those that would have been needed for a conventional randomised controlled clinical trial.

The Well London program - a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results

Background The Well London programme used community engagement, complemented by changes to the physical and social neighbourhood environment, to improve physical activity levels, healthy eating and mental wellbeing in the most deprived communities in London. The effectiveness of Well London is being evaluated in a pair-matched cluster randomised trial (CRT). The baseline survey data are reported here. Methods The CRT involved 20 matched pairs of intervention and control communities (defined as UK census lower super output areas; ranked in the 11% most deprived LSOAs in London by Index of Multiple Deprivation) across 20 London boroughs. The primary trial outcomes, sociodemographic information and environmental neighbourhood characteristics were assessed in three quantitative components within the Well London CRT at baseline: a cross-sectional, interviewer-administered adult household survey; a self-completed, school-based adolescent questionnaire; a fieldworker completed neighbourhood environmental audit. Baseline data collection occurred in 2008. Physical activity, healthy eating and mental wellbeing were assessed using standardised, validated questionnaire tools. Multiple imputation was used to account for missing data in the outcomes and other variables in the adult and adolescent surveys. Results There were 4107 adults and 1214 adolescent respondents in the baseline surveys. The intervention and control areas were broadly comparable with respect to the primary outcomes and key sociodemographic characteristics. The environmental characteristics of the intervention and control neighbourhoods were broadly similar. There was greater between cluster variation in the primary outcomes in the adult population compared to the adolescent population. Levels of healthy eating, smoking and self-reported anxiety/depression were similar in the Well London population and the national Health Survey for England. Levels of physical activity were higher in the Well London population but this is likely to be due to the different measurement tools used in the two surveys. Conclusions Randomisation of social interventions such as Well London is acceptable and feasible and in this study the intervention and control arms are well balanced with respect to the primary outcomes and key sociodemographic characteristics. The matched design has improved the statistical efficiency of the study amongst adults but less so amongst adolescents. Follow-up data collection will be completed 2012.

Cape Verde coastal ecosystem: a study of community structure, trophic interactions and exploitation pattern

Tese de dout., Ciências e Tecnologia das Pescas, Faculdade de Ciências do Mar e do Ambiente, Universidade do Algarve, 2005

Transformation or bureaucratisation?: the changing role of community representation in local strategic partnerships in England

The debate about the need to build social capital and to engage local communities in public policy has become a central issue in many advanced liberal societies and developing countries. In many countries new forms of governance have emerged out of a growing realisation that representative democracy by itself is no longer sufficient. One of the most significant public policy trends in the UK has been the involvement of community organisations and their members in the delivery of national policy, mediated through local systems of governance and management. One such policy area is urban regeneration. Central government now requires local authorities in England to set up Local Strategic Partnerships (LSPs) to bring together stakeholders who can prepare Community Strategies and deliver social and economic programmes which target areas of deprivation. This paper reviews the key institutional processes which must be addressed, such as representation, accountability and transformation.

The role, organisation and contribution of community enterprise to urban regeneration policy in the UK

This monograph investigates the organisation, constitution and delivery of community-based organisations which are normally called community enterprises in the UK. These are organisations which emerge from local communities at the neighbourhood level, work in partnership with the public and private sectors, and provide a range of services to meet social, economic and environmental needs. The main focus of the paper is to explore how these organisations contribute to local regeneration strategies, generate social capital and contribute towards the promotion of civil society in general. The main emphasis is on organisations in England and Wales but comparisons are made with the USA and other countries where relevant literature is available. The key questions to be answered relate to the organisation and management of these bodies; the extent to which they engage with and contribute to local regeneration strategies; and the impact they have particularly in acquiring and managing assets. The diversity of the sector, and the range, scale and level of benefits it can deliver is illustrated through five detailed case studies of community enterprises established at different times, in different geographical locations and with different objectives and funding regimes. But, whilst the UK political economy is moving towards less state intervention and more community self-help, the community development corporations in the USA provide an indication of the future direction community enterprises might take in the UK as part of a broad trend towards civic capacity building.

Wellspring: an intrinsic case study of community-based education for adults living with cancer /

This paper presents education research as vital to addressing the issues faced by adults living with cancer. This qualitative study looked at philosophies of practice for cancer patient education. It was about understanding how values and beliefs shape the way program planners and managers operationalize their knowledge of adult education and how this has significant impact on meeting the needs of those touched by cancer. Improved technology has extended life expectancy, so that Canadians living with cancer, or even dying with cancer now spend less time in direct medical care. The notion of cancer as simply a medical concern is outdated. This study found that informational and support needs of adults living with cancer are often unmet, ignored or unknown. This research investigated a community-based education initiative that is inviting, accessible, and promotes a sense of hope. More specifically, this case study uncovered factors contributing to the success of Wellspring, a grass-roots cancer patient support centre which has been recognized nationally for its ability to effectively meet the diverse non-medical supportive care needs of as many cancer patients and caregivers as possible. Therefore, Wellspring was selected as a case study. Educating people to take charge of their own lives and supporting them in making informed decisions about their lifestyle choices made Wellspring part of a social action movement that focused on improving social attitudes toward people living with cancer. Results of this descriptive inquiry and philosophical inquiry evolved into data that was used to devise an organic model of community-based education that encompasses Adler's (1993) four dimensions of philosophy within a socio-cultural context.

An Exploration Into Doctoral Students' Sense of Community and its Influence on the Formation of Informal Mentoring Relationships

This exploratory mixed method research project was designed to investigate an area of doctoral education that has received little attention in the past. This research focused specifically on the non-intellectual, hoped-for by-products of doctoral education; the dynamic processes of developing and maintaining both a sense of community and informal mentoring relationships. The design of the study captured the experiences of doctoral students and alumni at various time periods in the doctoral program. Participants represented a diverse group of students with differences in professional and academic backgrounds and life stages. A pilot study for this research suggested that the presence of a sense of community and informal mentoring may provide the necessary relationships to support this diversity. The primary question at the forefront of this study was: Do doctoral students feel connected to one another? Five subquestions were developed to address this research topic: Does a sense of community already exist and flourish in doctoral education? Are the programs and resources of the doctoral program organized to nurture the creation and maintenance of a sense of community? Is a sense of community a foundational element in the formation of naturally occurring relationships among doctoral students? What educational and socio-emotional benefits are associated with informal mentoring relationships during the doctoral experience? and Do doctoral students perceive a change in their development as stewards of their discipline over time? The principal methods used to investigate these research questions combined both quantitative and qualitative techniques in a concurrent time sequence. The quantitative portion of the study involved a questionnaire, while the qualitative portion involved two approaches; face-to-face interviews and an open-ended question at the end of the questionnaire. Findings from the study indicated that the presence of both sense of community and informal mentoring enhance the overall quality of doctoral education. Program elements that enhanced or hindered connection between students were identified. Both the dynamics and the emotional, social, and academic benefits of informal mentoring were elucidated. Over time participants perceived changes in their development of the qualities assqciated with stewardship. This study brought the "hoped-for by-products" associated with doctoral education from the background shadows to an illuminated position at the forefront of inquiry.