Homecare and the informal information grapevine: implications for the electronic record in social care

Cooper, J. & Urquhart, C. (2008). Homecare and the informal information grapevine: implications for the electronic record in social care. Health Informatics Journal, 14(1), 59-69. Sponsorship: AHRC

Collaboration on procurement of e-content between the National Health Service and higher education in the UK

Urquhart, C. J., Cox, A. M.& Spink, S. (2007). Collaboration on procurement of e-content between the National Health Service and higher education in the UK. Interlending & Document Supply, 35(3), 164-170. Sponsorship: JISC, LKDN

Sedentariness and physical inactivity in diabetes: a case for home-based exercise prescription

Increasing proportions of the global population are being diagnosed with diabetes. It is anticipated that by 2030, 10% of the adult population worldwide will be living with this condition. Lifestyle factors can impact on the development, management and progression of diabetes. Obesity and sedentary living are contributory factors to the increased volume of diabetes. Physical activity offers those living with diabetes the opportunities to keep well and attain potentially more stable blood glucose control reducing the level of medical intervention required and delaying or preventing some of the life-changing complications that can derive from a diabetes diagnosis. Exercise interventions are effective in preventing and treating type-II diabetes. However, maintaining regular exercise routines, especially home-based exercises may provide a key for sustaining the health benefits.

Workplace sedentary health risks and exercise interventions

Sedentary lifestyle and physical inactivity are causes of major health risks including cardiovascular disease (CVD), diabetes and cancer. Workplace is an ideal setting to understand both the prevalence of these risks and for devising and implementing effective intervention strategies. It is now possible to perform direct workplace assessments to identify the sedentary prevalence and assess the sedentary related health risks, which can include assessing the risks of atherosclerosis, hypertension, hypercholesterolemia, hyperglyaemia and reduced cardiorespiratory capacity. Based on evaluating the workplace health risks, it is possible to identify individuals who may be at higher CVD risk so they can be targeted with a risk-reduction intervention that can also be tailored towards improving healthy behaviours, especially towards physical activity activity and exercise. This chapter explains workplace sedentary risks, and provides examples of CVD risk prevalence, particularly within the university campus workplace, and presents examples of an exercise based targeted interventions aimed at reducing CVD risks amongst high risk sedentary employees.

Household Health and Cocoa Production: A Baseline Survey of Smallholder Farming Households in Western Region, Ghana

Background Chronic illness and premature mortality from malaria, water-borne diseases, and respiratory illnesses have long been known to diminish the welfare of individuals and households in developing countries. Previous research has also shown that chronic diseases among farming populations suppress labor productivity and agricultural output. As the illness and death toll from HIV/AIDS continues to climb in most of sub-Saharan Africa, concern has arisen that the loss of household labor it causes will reduce crop yields, impoverish farming households, intensify malnutrition, and suppress growth in the agricultural sector. If chronic morbidity and premature mortality among individuals in farming households have substantial impacts on household production, and if a large number of households are affected, it is possible that an increase in morbidity and mortality from HIV/AIDS or other diseases could affect national aggregate output and exports. If, on the other hand, the impact at the household farm level is modest, or if relatively few households are affected, there is likely to be little effect on aggregate production across an entire country. Which of these outcomes is more likely in West Africa is unknown. Little rigorous, quantitative research has been published on the impacts of AIDS on smallholder farm production, particularly in West Africa. The handful of studies that have been conducted have looked mainly at small populations in areas of very high HIV prevalence in southern and eastern Africa. Conclusions about how HIV/AIDS, and other causes of chronic morbidity and mortality, are affecting agriculture across the continent cannot be drawn from these studies. In view of the importance of agriculture, and particularly smallholder agriculture, in the economies of most African countries and the scarcity of resources for health interventions, it is valuable to identify, describe, and quantify the impact of chronic morbidity and mortality on smallholder production of important crops in West Africa. One such crop is cocoa. In Ghana, cocoa is a crop of national importance that is produced almost exclusively by smallholder households. In 2003, Ghana was the world’s second-largest producer of cocoa. Cocoa accounted for a quarter of Ghana’s export revenues that year and generated 15 percent of employment. The success and growth of the cocoa industry is thus vital to the country’s overall social and economic development. Study Objectives and Methods In February and March 2005, the Center for International Health and Development of Boston University (CIHD) and the Department of Agricultural Economics and Agribusiness (DAEA) of the University of Ghana, with financial support from the Africa Bureau of the U.S. Agency for International Development and from Mars, Inc., which is a major purchaser of West African cocoa, conducted a survey of a random sample of cocoa farming households in the Western Region of Ghana. The survey documented the extent of chronic morbidity and mortality in cocoa growing households in the Western Region of Ghana, the country’s largest cocoa growing region, and analyzed the impact of morbidity and mortality on cocoa production. It aimed to answer three specific research questions. (1) What is the baseline status of the study population in terms of household size and composition, acute and chronic morbidity, recent mortality, and cocoa production? (2) What is the relationship between household size and cocoa production, and how can this relationship be used to understand the impact of adult mortality and chronic morbidity on the production of cocoa at the household level? The study population was the approximately 42,000 cocoa farming households in the southern part of Ghana’s Western Region. A random sample of households was selected from a roster of eligible households developed from existing administrative information. Under the supervision of the University of Ghana field team, enumerators were graduate students of the Department of Agricultural Economics and Agribusiness or employees of the Cocoa Services Division. A total of 632 eligible farmers participated in the survey. Of these, 610 provided complete responses to all questions needed to complete the multivariate statistical analysis reported here.

An empirical examination of risk equalisation in a regulated community rated health insurance market

Despite universal access entitlements to the public healthcare system in Ireland, over half the population is covered by voluntary private health insurance. The market operates on the basis of community rating, open enrolment and lifetime cover. A set of minimum benefits also exists, and two risk equalisation schemes have been put in place but neither was implemented. These schemes have proved highly controversial. To date, the debate has primarily consisted of qualitative arguments. This study adds a quantitative element by analysing a number of pertinent issues. A model of a community rated insurance market is developed, which shows that community rating can only be maintained in a competitive market if all insurers in the market have the same risk profile as the market overall. This has relevance to the Irish market in the aftermath of a Supreme Court decision to set aside risk equalisation. Two reasons why insurers’ risk profiles might differ are adverse selection and risk selection. Evidence is found of the existence of both forms of selection in the Irish market. A move from single rate community rating to lifetime community rating in Australia had significant consequences for take-up rates and the age profile of the insured population. A similar move has been proposed in Ireland. It is found that, although this might improve the stability of community rating in the short term, it would not negate the need for risk equalisation. If community rating were to collapse then risk rating might result. A comparison of the Irish, Australian and UK health insurance markets suggests that community rating encourages higher take-up among older consumers than risk rating. Analysis of Irish hospital discharge figures suggests that this yields significant savings for the Irish public healthcare system. This thesis has implications for government policy towards private health insurance in Ireland.

The utility of survey and administrative data to generate information for research and outcomes-based oral health services development

The aim of this research, which focused on the Irish adult population, was to generate information for policymakers by applying statistical analyses and current technologies to oral health administrative and survey databases. Objectives included identifying socio-demographic influences on oral health and utilisation of dental services, comparing epidemiologically-estimated dental treatment need with treatment provided, and investigating the potential of a dental administrative database to provide information on utilisation of services and the volume and types of treatment provided over time. Information was extracted from the claims databases for the Dental Treatment Benefit Scheme (DTBS) for employed adults and the Dental Treatment Services Scheme (DTSS) for less-well-off adults, the National Surveys of Adult Oral Health, and the 2007 Survey of Lifestyle Attitudes and Nutrition in Ireland. Factors associated with utilisation and retention of natural teeth were analysed using count data models and logistic regression. The chi-square test and the student’s t-test were used to compare epidemiologically-estimated need in a representative sample of adults with treatment provided. Differences were found in dental care utilisation and tooth retention by Socio-Economic Status. An analysis of the five-year utilisation behaviour of a 2003 cohort of DTBS dental attendees revealed that age and being female were positively associated with visiting annually and number of treatments. Number of adults using the DTBS increased, and mean number of treatments per patient decreased, between 1997 and 2008. As a percentage of overall treatments, restorations, dentures, and extractions decreased, while prophylaxis increased. Differences were found between epidemiologically-estimated treatment need and treatment provided for those using the DTBS and DTSS. This research confirms the utility of survey and administrative data to generate knowledge for policymakers. Public administrative databases have not been designed for research purposes, but they have the potential to provide a wealth of knowledge on treatments provided and utilisation patterns.

The role of the IL-1 type 1 receptor in the life, death and differentiation of adult hippocampal neural precursor cells

Neurogenesis occurs in two distinct regions of the adult brain; the subgranular zone (SGZ) of the dentate gyrus (DG) in the hippocampus, and the subventricular zone (SVZ) lining the lateral ventricles. It is now well-known that adult hippocampal neurogenesis can be modulated by a number of intrinsic and extrinsic factors e.g. local signalling molecules, exercise, environmental enrichment and learning. Moreover, levels of adult hippocampal neurogenesis decrease with age, at least in rodents, and alterations in hippocampal neurogenesis have been reported in animal models and human studies of neuropsychiatric and neurodegenerative conditions. Neuroinflammation is a common pathological feature of these conditions and is also a potent modulator of adult hippocampal neurogenesis. Recently, the orphan nuclear receptor TLX has been identified as an important regulator of adult hippocampal neurogenesis as its expression is necessary to maintain the neural precursor cell (NPC) pool in the adult DG. Likewise, exposure of animals to voluntary exercise has been consistently demonstrated to promote adult hippocampal neurogenesis. Lentivirus (LV)- mediated gene transfer is a useful tool to elucidate gene function and to explore potential therapeutic candidates across an array of conditions as it facilitates sustained gene expression in both dividing and post-mitotic cell populations. Both intrinsic and extrinsic factors are important regulators of adult hippocampal neurogenesis. Examining how these factors are affected by an inflammatory stimulus, and the subsequent effects on adult hippocampal neurogenesis provides important information for the development of novel treatment strategies for neuropsychiatric and neurodegenerative conditions in which adult hippocampal neurogenesis is impaired. The aims of the series of experiments presented in this thesis were to examine the effect of the pro-inflammatory cytokine interleukin-1β (IL-1β) on adult hippocampal NPCs both in vitro and in vivo. In vitro, we have shown that IL-1β reduces proliferation of adult hippocampal NPCs in a dose and time-dependent manner. In addition, we have demonstrated that TLX expression is reduced by IL-1β. Blockade of IL-1β signalling prevented both the IL-1β-induced reduction in cell proliferation and TLX expression. In vivo, we examined the effect of short term and long term exposure to LV-IL-1β in sedentary mice and in mice exposed to voluntary running. We demonstrated that impaired hippocampal neurogenesis is only evident after long term exposure to IL-1β. In mice exposed to voluntary running, hippocampal neurogenesis is significantly increased following short-term but not long-term exposure to running. Moreover, short-term running effectively prevents any IL-1β-induced effects on hippocampal neurogenesis; however, no such effects are seen following long-term exposure to running.

An assessment of health in post-medieval Ireland: ‘One vast Lazar house filled with famine, disease and death’

Three indicators of health and diet were selected to examine the health status in three socioeconomic groups in post-medieval Ireland. The aim was to examine the reliability of traditional skeletal markers of health in highly contextualised populations. The link between socio-economic status and health was examined to determine if traditional linking of poor health with poverty was evident in skeletal samples. The analysis indicated that this was indeed the case and that health was significantly compromised in populations of low socio-economic status. Thus it indicated that status intimately influences the physical body form. Sex was also found to be a major defining factor in the response of an individual to physiological stress. It was also evident that contemporary populations may suffer from different physiological stresses, and their responses to those stresses may differ. Adaptation was a key factor here. This has implications for studies of earlier populations that may lack detailed contextual data in terms of blanket applications of interpretations. The results also show a decline in health from the medieval through to the post-medieval period, which is intimately linked with the immense social changes and all the related effects of these. The socio-economic structure of post-medieval Ireland was a direct result of the British policies in Ireland. The physical form of the Irish may be seen to have occurred as a result of those policies, with the Irish poor in particular suffering substantial health problems, even in contrast to the poor of Britain. This study has enriched the recorded historical narrative of this period of the recent past, and highlights more nuanced narratives may emerge from the osteoarchaeological analysis when sound contextual information is available. It also examines a period in Irish history that, until very recently, had been virtually untouched in terms of archaeological study.

Assessment of dietary background exposure of the Irish adult population to dioxins and PCBs particularly taking into account additional exposure due to the 2008 Irish dioxin food contamination incident

Irish monitoring data on PCDD/Fs, DL-PCBs and Marker PCBs were collated and combined with Irish Adult Food Consumption Data, to estimate dietary background exposure of Irish adults to dioxins and PCBs. Furthermore, all available information on the 2008 Irish pork dioxin food contamination incident was collated and analysed with a view to evaluate any potential impact the incident may have had on general dioxin and PCB background exposure levels estimated for the adult population in Ireland. The average upperbound daily intake of Irish adults to dioxins Total WHO TEQ (2005) (PCDD/Fs & DLPCBs) from environmental background contamination, was estimated at 0.3 pg/kg bw/d and at the 95th percentile at 1 pg/kg bw/d. The average upperbound daily intake of Irish adults to the sum of 6 Marker PCBs from environmental background contamination ubiquitous in the environment was estimated at 1.6 ng/kg bw/d and at the 95th percentile at 6.8 ng/kg bw/d. Dietary background exposure estimates for both dioxins and PCBs indicate that the Irish adult population has exposures below the European average, a finding which is also supported by the levels detected in breast milk of Irish mothers. Exposure levels are below health based guidance values and/or Body Burdens associated with the TWI (for dioxins) or associated with a NOAEL (for PCBs). Given the current toxicological knowledge, based on biomarker data and estimated dietary exposure, general background exposure of the Irish adult population to dioxins and PCBs is of no human health concern. In 2008, a porcine fat sample taken as part of the national residues monitoring programme led to the detection of a major feed contamination incidence in the Republic of Ireland. The source of the contamination was traced back to the use of contaminated oil in a direct-drying feed operation system. Congener profiles in animal fat and feed samples showed a high level of consistency and pinpointed the likely source of fuel contamination to be a highly chlorinated commercial PCB mixture. To estimate additional exposure to dioxins and PCBs due to the contamination of pig and cattle herds, collection and a systematic review of all data associated with the contamination incident was conducted. A model was devised that took into account the proportion of contaminated product reaching the final consumer during the 90 day contamination incident window. For a 90 day period, the total additional exposure to Total TEQ (PCDD/F &DL-PCB) WHO (2005) amounted to 407 pg/kg bw/90d at the 95th percentile and 1911 pg/kg bw/90d at the 99th percentile. Exposure estimates derived for both dioxins and PCBs showed that the Body Burden of the general population remained largely unaffected by the contamination incident and approximately 10 % of the adult population in Ireland was exposed to elevated levels of dioxins and PCBs. Whilst people in this 10 % cohort experienced quite a significant additional load to the existing body burden, the estimated exposure values do not indicate approximation of body burdens associated with adverse health effects, based on current knowledge. The exposure period was also limited in time to approximately 3 months, following the FSAI recall of contaminated meat immediately on detection of the contamination. A follow up breast milk study on Irish first time mothers conducted in 2009/2010 did not show any increase in concentrations compared to the study conducted in 2002. The latter supports the conclusion that the majority of the Irish adult population was not affected by the contamination incident.

Diphtheria, the public health response and the origins of the childhood immunisation programme in Ireland

In common with most countries, the childhood immunisation programme in Ireland was founded on a successful public health response to diphtheria. The success of the antidiphtheria public health intervention in Ireland has meant that no case of the disease has been recorded in the state for almost fifty years. This is a significant achievement considering that diphtheria continues to appear annually in many European states, albeit in much reduced numbers on former years. For parents and children of nineteenth, and early twentieth-century Ireland, diphtheria represented the ‘most dreaded disease of childhood’, however, for their modern day counterparts diphtheria is no more than an obscure disease mentioned in leaflets promoting the benefits of childhood immunisation. In Ireland, diphtheria has been consigned to history, and so too have the horrors and mass fatalities once associated with it. But how was this achieved? Was active immunisation received with open arms by public health authorities, the wider medical community, and the general public? This study tackles these questions by undertaking the first historical examination of the issues which underpin the origins of active immunisation in Ireland. It explores the driving forces that shaped the national childhood immunisation programme, and those that opposed them. In addition, it examines the complex social implications attendant on the introduction of this mass public health intervention in an Irish context.

Evolving perspectives on business and books: practitioner implications

The research subject of this Portfolio of Essays is my ‘apparatus of thought’ in the context of my professional development. I have examined theory and the application of theory to a professional life. I analyse how my use of theory has changed and enabled my professional development. Each of the three Essays takes a different perspective and applies the theories of adult mental development, business and firm growth as an analytical framework. Using Kegan’s theories of Adult Mental Development as an ‘apparatus of thought’, Essay One is my reflection on my professional development in the light of my training, education, and development. I describe how changes in my ‘apparatus of thought’, my meaning-making system, have enabled me to develop my professional practice. Exposure to the theories of Adult Mental Development have also enabled me to understand how my development has precipitated and necessitated my career changes. In Essay Two, moving from military aviation to book publishing was a major career change for me, enabled by a change in my meaning-making system. In the context of my professional development, I sought to change my practice so that I could make a more meaningful contribution to the firm. To achieve this, I directed my reading towards a deeper understanding of the nature of the firm and the impact of industrial change on the firm. Using the context of my professional environment in Essay Three, I show how my use of theory has developed. I describe how I sought to change working practices in the firm and discuss the impact this initiative had on my professional self. I use the ‘data of my experience’ to examine my theory of the business from a Penrosian perspective. The Penrosian perspective coupled with my exposure to theories of Adult Mental Development and the effects of a transformational education process enabled me to transition to a leadership role with an international online publisher.

Cancer associated malnutrition: prevalence of cachexia, sarcopenia and impact on treatment outcomes, survival and health related quality of life

Malnutrition, sarcopenia and cancer cachexia (CC) are prevalent among cancer patients and can have detrimental effects on clinical outcomes such as quality of life (QoL) and overall survival. Cachexia is associated with lower tolerance for chemotherapy, which limits the total dose that can be delivered, the number of symptomatic responses and any survival advantage that might be accrued. Moreover, for the majority who do not respond, cachexia may be exacerbated by systemic chemotherapy, thus increasing the net symptom burden experienced by patients. The multitude of interactions between cancer location, treatments, nutritional status and QoL has never been thoroughly explored in an Irish cancer cohort. The objectives of this thesis were to further understand nutritional status, especially body composition in ambulatory cancer patients and determine the relationship between nutritional status using different assessment criteria and QoL, chemotherapy toxicity and survival among cancer patients undergoing chemotherapy. Results aimed to identify baseline factors that may be predictive of poor outcome, toxicities to chemotherapy and disease-free and overall survival. This thesis broadly divides into two sections. The first section (Chapters 3 & 4) focuses on improving our knowledge of the nutritional status of Irish cancer outpatients using a cross sectional study design. A study of 517 patients referred for chemotherapy was conducted using computed tomography (CT) imaging (body composition) and a survey that documented oncologic data, weight loss (WL) data and QoL data. We revealed that a significant proportion of Irish cancer patients undergoing chemotherapy experience unintentional WL over the previous 6 months (62%), sarcopenia (45%) and CC (43%), and the distribution of WL and nutritional risk were associated with site of primary tumour and treatment intent. Patients that had sarcopenia, nutritional risk, or CC had significantly reduced functional abilities, more symptoms and adverse global QoL. In the second section of this thesis (Chapters 5 & 6) the potential link between developing toxicity to antineoplastic regimens in patients with sarcopenia was conducted by way of retrospective studies. A retrospective serial CT analysis defined the prevalence of sarcopenia in patients with metastatic renal cell carcinoma (mRCC) and metastatic castrate resistant prostate cancer (mCRPC), which was then correlated with dose limiting toxicities of sunitinib and docetaxel respectively. Sarcopenia was prevalent in patients with mRCC and mCRPC, was an occult condition in patients with normal/high BMI, was associated with less treatment days, was a significant predictor of DLT in patients receiving sunitinib and a significant predictor of neutropenia and neurosensory toxicities in patients receiving docetaxel. This thesis attempted to address the underlying research deficiencies in Irish oncology nutritional data at national level. The findings from this thesis have implications for the planning of cancer care interventions and indicate that further research is required to improve nutritional screening, in particular for CC and sarcopenia, in the hope that timely intervention can improve both patient-centered and oncologic outcomes.

Self-neglect: a case study and implications for clinical practice

Self-neglect is a worldwide and serious public health issue that can have serious adverse outcomes and is more common in older people. Cases can vary in presentation but typically present as poor self-care, poor care of the environment and service refusal. Community nurses frequently encounter self-neglect cases and health and social care professionals play a key role in the identification, management and prevention of self-neglect. Self-neglect cases can give rise to ethical, personal and professional challenges. The aim of this article is to create a greater understanding of the concept of self-neglect among community nurses.

Randomized, controlled trial investigating short-term health-related quality of life with doxorubicin and paclitaxel versus doxorubicin and cyclophosphamide as first-line chemotherapy in patients with metastatic breast cancer: European Organization for Research and Treatment of Cancer Breast Cancer Group, Investigational Drug Branch for Breast Cancer and the New Drug Development Group Study.

PURPOSE: To compare health-related quality of life (HRQOL) in patients with metastatic breast cancer receiving the combination of doxorubicin and paclitaxel (AT) or doxorubicin and cyclophosphamide (AC) as first-line chemotherapy treatment. PATIENTS AND METHODS: Eligible patients (n = 275) with anthracycline-naive measurable metastatic breast cancer were randomly assigned to AT (doxorubicin 60 mg/m(2) as an intravenous bolus plus paclitaxel 175 mg/m(2) as a 3-hour infusion) or AC (doxorubicin 60 mg/m(2) plus cyclophosphamide 600 mg/m(2)) every 3 weeks for a maximum of six cycles. Dose escalation of paclitaxel (200 mg/m(2)) and cyclophosphamide (750 mg/m(2)) was planned at cycle 2 to reach equivalent myelosuppression in the two groups. HRQOL was assessed with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and the EORTC Breast Module at baseline and the start of cycles 2, 4, and 6, and 3 months after the last cycle. RESULTS: Seventy-nine percent of the patients (n = 219) completed a baseline measure. However, there were no statistically significant differences in HRQOL between the two treatment groups. In both groups, selected aspects of HRQOL were impaired over time, with increased fatigue, although some clinically significant improvements in emotional functioning were seen, as well as a reduction in pain over time. Overall, global quality of life was maintained in both treatment groups. CONCLUSION: This information is important when advising women patients of the expected HRQOL consequences of treatment regimens and should help clinicians and their patients make informed treatment decisions.