Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing.

Background
The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.

Methods
Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs’ perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.

Results
Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: ‘Skills’, ‘Beliefs about capabilities’, ‘Beliefs about consequences’, ‘Environmental context and resources’, ‘Memory, attention and decision processes’, ‘Social/professional role and identity’, ‘Social influences’ and ‘Behavioural regulation’. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: ‘Action planning’, ‘Prompts/cues’, ‘Modelling or demonstrating of behaviour’ and ‘Salience of consequences’. An additional BCT (‘Social support or encouragement’) was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.

Conclusions
Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.

‘Running with the Fox and Hunting with the Hounds’: Social Work Tutors' Experiences of Managing Failing Social Work Students in Practice Learning Settings

The paper explores the issues raised by social work students failing in practice learning settings from the perspective of university tutors, by drawing on existing literature in this area from social work and nursing, as well as findings from a small‐scale empirical qualitative study. The qualitative study was influenced by practitioner‐researcher and practice‐near paradigms; and is based on interviews with twelve social work tutors in England. The findings reveal that tutors are able to articulate the important tasks and functions of their roles when issues of failing students in practice learning settings arise, although the process can be challenging. The challenges include: supporting practice educator and student, concerns about other tutors’ practices, the difficulties in promoting appropriate professional standards and values within higher education contexts and frustrations with practice educators and placements. Only a third of the respondents (four) however, articulated their gate keeping roles and responsibilities although this was not without its difficulties. Given the current reforms in social work education in England at this present time, with greater emphasis on threshold standards at entry level, and at key stages throughout the programme of study, the research is timely in terms of the critical consideration of the tutor role and challenges inherent in promoting appropriate standards.

Appropriateness of respiratory care: evidence-based guidelines.

PRINCIPLES: Respiratory care is universally recognised as useful, but its indications and practice vary markedly. In order to improve the appropriateness of respiratory care in our hospital, we developed evidence-based local guidelines in a collaborative effort involving physiotherapists, physicians and health service researchers. METHODS: Recommendations were developed using the standardised RAND appropriateness method. A literature search was conducted based on terms associated with guidelines and with respiratory care. A working group prepared proposals for recommendations which were then independently rated by a multidisciplinary expert panel. All recommendations were then discussed in common and indications for procedures were rated confidentially a second time by the experts. The recommendations were then formulated on the basis of the level of evidence in the literature and on the consensus among these experts. RESULTS: Recommendations were formulated for the following procedures: non-invasive ventilation, continuous positive airway pressure, intermittent positive pressure breathing, intrapulmonary percussive ventilation, mechanical insufflation-exsufflation, incentive spirometry, positive expiratory pressure, nasotracheal suctioning and non-instrumental airway clearance techniques. Each recommendation referred to a particular medical condition and was assigned to a hierarchical category based on the quality of the evidence from the literature supporting the recommendation and on the consensus among the experts. CONCLUSION: Despite a marked heterogeneity of scientific evidence, the method used allowed us to develop commonly agreed local guidelines for respiratory care. In addition, this work fostered a closer relationship between physiotherapists and physicians in our institution.

Deconstructing Evidence-Based Practice and Its Application in Children to with Mental Health Disorders

This is a mixed methodology study that uses an autoethnographic approach to combine both an autobiography and a survey of practitioners who work in children’s mental health. It is largely about the implementation of Evidence-Based Practice (EBP), and the questions, concerns, experiences that I have had, and compared them with those of my fellow practitioners. In addition, it is about my journey as a mental health professional, and how I have come to recognize that in order to achieve the goals I wanted to achieve, I needed to return to university to pursue a Master’s degree. Within the research, I identify and discuss different definitions of EBP and identify several themes. I deconstruct the implementation of EBPs through the lens of Foucault and his notions of governmentality. I offer policy and practice recommendations to improve the implementation of EBP and the services received by children facing mental health issues.

Features of the Atlantic diet and its healthiness: Theory and evidence from social science

In order to understand diets, why and how they change and can be influenced, it is important to understand how food choices are made. The has been the subject of, considerable study within many of the social science disciplines and the humanities. The paper draws on the theoretical and empirical work of psychologists, sociologists, economists, market researchers, anthropologists, geographers and historians to understand better the forces behind food choice, derive some general empirical messages from the literature, to shed light on food choice in a European context and to address the question of whether there is, or has been, a recognisably Atlantic diet. The paper proceeds to analyse the characteristics of the food consumption patterns in the Atlantic diet countries, examines whether their food consumption patterns are homogenous (i.e. similar across the countries of this group), whether they are specific (i.e. different from the ones in other country groups) and finally evaluates the nutritional composition of the Atlantic diet against the WHO/FAO recommendations for a healthy and wholesome diet.

Identifying key knowledge needs for evidence-based conservation of wild insect pollinators: a collaborative cross-sectoral exercise

In response to evidence of insect pollinator declines, organisations in many sectors, including the food and farming industry, are investing in pollinator conservation. They are keen to ensure that their efforts use the best available science. We convened a group of 32 ‘conservation practitioners’ with an active interest in pollinators and 16 insect pollinator scientists. The conservation practitioners include representatives from UK industry (including retail), environmental non-government organisations and nature conservation agencies. We collaboratively developed a long list of 246 knowledge needs relating to conservation of wild insect pollinators in the UK. We refined and selected the most important knowledge needs, through a three-stage process of voting and scoring, including discussions of each need at a workshop. We present the top 35 knowledge needs as scored by conservation practitioners or scientists. We find general agreement in priorities identified by these two groups. The priority knowledge needs will structure ongoing work to make science accessible to practitioners, and help to guide future science policy and funding. Understanding the economic benefits of crop pollination, basic pollinator ecology and impacts of pesticides on wild pollinators emerge strongly as priorities, as well as a need to monitor floral resources in the landscape.

An evidence-based review on the likely economic and environmental impact of genetically modified cereals and oilseeds for UK agriculture

An evidence-based review of the potential impact that the introduction of genetically-modified (GM) cereal and oilseed crops could have for the UK was carried out. The inter-disciplinary research project addressed the key research questions using scenarios for the uptake, or not, of GM technologies. This was followed by an extensive literature review, stakeholder consultation and financial modelling. The world area of canola, oilseed rape (OSR) low in both erucic acid in the oil and glucosinolates in the meal, was 34M ha in 2012 of which 27% was GM; Canada is the lead producer but it is also grown in the USA, Australia and Chile. Farm level effects of adopting GM OSR include: lower production costs; higher yields and profits; and ease of farm management. Growing GM OSR instead of conventional OSR reduces both herbicide usage and environmental impact. Some 170M ha of maize was grown in the world in 2011 of which 28% was GM; the main producers are the USA, China and Brazil. Spain is the main EU producer of GM maize although it is also grown widely in Portugal. Insect resistant (IR) and herbicide tolerant (HT) are the GM maize traits currently available commercially. Farm level benefits of adopting GM maize are lower costs of production through reduced use of pesticides and higher profits. GM maize adoption results in less pesticide usage than on conventional counterpart crops leading to less residues in food and animal feed and allowing increasing diversity of bees and other pollinators. In the EU, well-tried coexistence measures for growing GM crops in the proximity of conventional crops have avoided gene flow issues. Scientific evidence so far seems to indicate that there has been no environmental damage from growing GM crops. They may possibly even be beneficial to the environment as they result in less pesticides and herbicides being applied and improved carbon sequestration from less tillage. A review of work on GM cereals relevant for the UK found input trait work on: herbicide and pathogen tolerance; abiotic stress such as from drought or salinity; and yield traits under different field conditions. For output traits, work has mainly focussed on modifying the nutritional components of cereals and in connection with various enzymes, diagnostics and vaccines. Scrutiny of applications submitted for field trial testing of GM cereals found around 9000 applications in the USA, 15 in Australia and 10 in the EU since 1996. There have also been many patent applications and granted patents for GM cereals in the USA for both input and output traits;an indication of the scale of such work is the fact that in a 6 week period in the spring of 2013, 12 patents were granted relating to GM cereals. A dynamic financial model has enabled us to better understand and examine the likely performance of Bt maize and HT OSR for the south of the UK, if cultivation is permitted in the future. It was found that for continuous growing of Bt maize and HT OSR, unless there was pest pressure for the former and weed pressure for the latter, the seed premia and likely coexistence costs for a buffer zone between other crops would reduce the financial returns for the GM crops compared with their conventional counterparts. When modelling HT OSR in a four crop rotation, it was found that gross margins increased significantly at the higher levels of such pest or weed pressure, particularly for farm businesses with larger fields where coexistence costs would be scaled down. The impact of the supply of UK-produced GM crops on the wider supply chain was examined through an extensive literature review and widespread stakeholder consultation with the feed supply chain. The animal feed sector would benefit from cheaper supplies of raw materials if GM crops were grown and, in the future, they might also benefit from crops with enhanced nutritional profile (such as having higher protein levels) becoming available. This would also be beneficial to livestock producers enabling lower production costs and higher margins. Whilst coexistence measures would result in increased costs, it is unlikely that these would cause substantial changes in the feed chain structure. Retailers were not concerned about a future increase in the amount of animal feed coming from GM crops. To conclude, we (the project team) feel that the adoption of currently available and appropriate GM crops in the UK in the years ahead would benefit farmers, consumers and the feed chain without causing environmental damage. Furthermore, unless British farmers are allowed to grow GM crops in the future, the competitiveness of farming in the UK is likely to decline relative to that globally.

Factors associated with evidence-based practice among registered nurses in Sweden : a national cross-sectional study

Background: Evidence-based practice (EBP) is emphasized to increase the quality of care and patient safety. EBP is often described as a process consisting of distinct activities including, formulating questions, searching for information, compiling the appraised information, implementing evidence, and evaluating the resulting practice. To increase registered nurses' (RNs') practice of EBP, variables associated with such activities need to be explored. The aim of the study was to examine individual and organizational factors associated with EBP activities among RNs 2 years post graduation. Methods: A cross-sectional design based on a national sample of RNs was used. Data were collected in 2007 from a cohort of RNs, included in the Swedish Longitudinal Analyses of Nursing Education/Employment study. The sample consisted of 1256 RNs (response rate 76%). Of these 987 RNs worked in healthcare at the time of the data collection. Data was self-reported and collected through annual postal surveys. EBP activities were measured using six single items along with instruments measuring individual and work-related variables. Data were analyzed using logistic regression models. Results: Associated factors were identified for all six EBP activities. Capability beliefs regarding EBP was a significant factor for all six activities (OR = 2.6 - 7.3). Working in the care of older people was associated with a high extent of practicing four activities (OR = 1.7 - 2.2). Supportive leadership and high collective efficacy were associated with practicing three activities (OR = 1.4 - 2.0). Conclusions: To be successful in enhancing EBP among newly graduated RNs, strategies need to incorporate both individually and organizationally directed factors.

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

Evidence-based clinical use of insulin premixtures

Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient’s clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.

Neoliberalism, the Third Way and Social Work: the UK experience

For most of the past two decades, the notion that there is no alternative to the market as a basis for organising society has constituted a kind of global 'common sense', accepted not only by the neo-liberal Right but also by social democratic thinkers and politicians, in the form of 'the Third Way'. This paper will critically assess the central claims of neoliberalism in the light of experience in the UK and internationally, evaluate the ways in which Third Way policies are shaping social work in the UK, and in the final section, begin to explore some of the ways in which the anti-capitalist movement which has emerged in recent years might contribute to the development of a new, engaged social work, based on social justice.

Common Social Work Education Standards in the Nordic Countries - opening an issue

The article analyses the option of common Nordic Standards for social work education in these countries. The option is viewed through the lens of trends in education in the different countries. In the article the notion of an Integrated Field Model is used to indicate the starting point for a common model of education. This model covers the field characteristics of Denmark and Norway and their current move towards a more research-based education. It also covers the research characteristics of education in Finland, Iceland and Sweden and their current move towards a new field connection based on research-oriented education. Some thoughts on international requirements on comparability and compatibility in this setting are addressed in the final section.

Running Head: Social Work Developments in Lithuania

Following the end of a half-century of Soviet occupation, Lithuania, like other former Soviet republics, has been in socio-economic disorder. Now that Lithuania is free, the system of social welfare is characterized by under-funded health services and pensions, and a large number of institutions. Semi-structured interviews were conducted with students and practitioners focusing on community development, using Lofland’s model of social setting analysis.Results indicate that the collaborative efforts successfully produced a revolutionary and successful social service program, a multi-generational living facility offering full-time social services to unwed mothers, infants, and elderly residents.This article is based upon the qualitative study of social work practitioners and social work students and chronicles the successes and difficulties encountered within the process of community development.

Youth and Health as an issue of Research in Social Work - Two examples of current Research

Health issues under aspects pertaining to social work are currently being investigated in our department under two main perspectives. The study of Youth, Health, and Internet is based on experiences with a project of e-mail counseling for youths we have been running in our department for one year so far. Our thesis is that the internet has become an important platform for youngsters in general as well as concerning health issues specifically. So far, however, little is known about the ways youths address their health related problems in the net. We believe that research in this area is badly needed since future concepts of effective health improvement and prevention for youths cannot ignore this medium. Biography and Health is our second focus of investigation, addressing deficiencies in the empirical research of Aaron Antonovsky´s salutogenetic concept that has lately become quite popular in many health discussions. Drawing from biographical methods we are currently investigating the development of the so called "sense of coherence" - the center piece of salutogenesis.

Some considerations on the potential contributions of intercultural social work...

Social work at global levels, and across international and intercultural divides, is probably more important now than ever before in our history. It may be that the very form our ideas about intercultural work take need to be re-examined in the light of recent global changes and uncertainties. In this short position paper I wish to offer some considerations about how we might approach the field of intercultural social work in order to gain new insights about how we practise at both local and global levels. For me, much of the promise of an intercultural social work (and for the purposes of this paper I see aspects of international social work in much the same light) lies in its focus on the way we categorise ourselves, our ideas and experiences in relation to others. The very notion of intercultural or international social work is based on assumptions about boundaries, differences, ways of differentiating and defining sets of experiences. Whether these are deemed "cultural" or "national" is of less importance. Once we are forced to examine these assumptions, about how and why we categorise ourselves in relation to other people in particular ways, the way is opened up for us to be much more critical about the bases of our own, often very deep-seated, thinking. This understanding, about how and why notions of "difference" operate in the way they do, can potentially open our understanding to all the other ways, besides cultural or national labelling, in which we categorise and create differences between ourselves and others. Intercultural social work, taken as a potential site for understanding the creation of difference then, has the potential to help us critically examine the bases of much of our practice in any setting, since most practice involves some kind of categorisation of phenomena.