How to design and evaluate interventions to improve outcomes for patients with multimorbidity

Multimorbidity is a major challenge for patients and healthcare providers. The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions. Here we present a consensus view from a group of international researchers working to improve care for people with multimorbidity to guide future studies of interventions. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems

Non-native species in floodplain secondary forests in Peninsular Malaysia.

There is an increasing concern of alien species invading our tropical ecosystems because anthropogenic land use can create conditions in which non-native species thrive. This study is an assessment of bioinvasion using a quantitative survey of non-native plant species in floodplain secondary forests in Peninsular Malaysia. The study area is known to have a long cultivation and settlement history that provides ample time for non-native species introduction. The survey results showed that introduced species constituted 23% of all the identified species, with seven species unique to riparian forest strips and eleven species unique to abandoned paddy fields and the remaining five species being shared between the two secondary forest types. There existed some habitat preferences amongst the species implying both secondary forests were potentially susceptible to bioinvasion. Fourteen species are also invasive elsewhere (PIER invasives) whereas fifteen species have acquired local uses such for traditional medicine and food products. The presence of these non-native species could alter native plant succession trajectory, and eventually leads to native species impoverishment if the exotics managed to outcompete the native species. As such, the findings of this study have a far-reaching application for the national biodiversity conservation efforts because it provides the required information on bioinvasion

Are Coping Strategies a Cop Out?

Summary Few would dispute the legitimacy of putting indigenous coping strategies firmly on the food security and famine mitigation agenda. Yet the idea of coping strategies needs to be regarded with caution, especially when used to identify famine early warning indicators. There is a tendency for ‘coping strategies’ to become shorthand for a complex web of processes at work, making for great confusion in identifying what is being talked about. With respect to famine early warning, the complexity of these processes makes for potentially huge difficulties in data collection and interpretation. In the quest to incorporate coping strategies into policy?making and planning, hard choices have to be made between operational feasibility and confronting the intricacies of ? and limitations to ? indigenous response, close to where the action is; and it is essential to be clear as to what they are. A first step is to distinguish at a conceptual level between coping and adapting. If coping strategies are to be monitored as part of early warning systems, it is the motivation for, the timing of and the effectiveness of their use which must be tracked: a formidable task. Resumé Les Stratégies D'Adaptation: Sont?Elles Tout Simplement Échappatoires? Peu de gens ne nieraient la légitimité d'inclure les stratégies autochtones adaptation aux problèmes à l'ordre du jour de tout programme de sécurité alimentaire et d'allégement de la famine. Ceci dit, il y aurait néanmoins lieu de se méfier tant soit peu de ces stratégies, surtout comme première alerte de famine. Une tendance existe par laquelle le terme stratégie d'adaptation (‘coping strategy’) est de plus en plus emprunté comme fourre?tout linguistique qui avale tout un éventail de transactions très complexes; ce qui rend l'identification exacte de ces stratégies d'autant plus compliqée. En ce qui concerne les systèmes d'alerte précoce de famine, la complexité même de ces stratégies présente de très graves difficultés au niveau du rassemblement et de l'analyse des données. Dans toute tentative d'inclure des stratégies d'adaptation dans la formulation et la mise en viguer des politiques, des choix difficiles s'imposent entre la faisabilité opérationnelle et le moyen de tenir compte des détours de la réponse autochtone et dans un même temps, de tenir compte de ses propres limites; ainsi, il est essentiel de connaitre ces détours et ces limites à fond. Un premier pas serait d'établir, au niveau conceptuel, la différence entre les stratégies d'adaptation en tant que réponses conjoncturelles face aux conditions anormales, et le processus d'adaptation permanente qui entraine des changements fondamentaux dans les systèmes de production concernés. Si l'on veut que les stratégies d'adaptation constituent un élément qui puisse être compris dans le système de'alerte précoce, il y aurait lieu de faire le suivi de la motivation, de l'incidence et de l'efficacité de leur exploitation, ce qui représenterait une tache de recherche très onéreuse. Resumen Estrategias De Solución: Una ‘Salida Fácil?’ Dentro de la agenda de soluciones para los problemas de seguridad alimentaria y mitigación del hambre, las estrategias indígenas tienan una legitimidad que muy pocos disputan. Sin embargo, esta idea de estrategias para resolver el problema del hambre debe ser abordada con precaución, especialmente cuando se usa para identificar indicadores precoces de hambre. Hay una tendencia a transformar las estrategias de solución en una versión condensada de una compleja red de procesos en acción, creando gran confusión al tratar de individualizar el asunto específico de que se trata. Con respecto a indicadores precoces, la complejidad de estos procesos ocasiona dificultades potencialmente graves en la compilación e interpretación de datos. Al tratar de incorporar estrategias dentro de la elaboración y planeamiento de programas de acción, se deben llevar a cabo elecciones muy difíciles entre la viabilidad operativa y la confrontación con la intricada ? y limitada ? respuesta local, y es esencial tener en claro qué es cada una. El primer paso es distinguir a nivel conceptual entre solución y adaptación. Para regular estas estrategias como parte del sistema de aviso precoz, se debe seguir la trayectoria de su motivación, su oportinidad y su eficacia; y ésta es una tarea formidable

Outlooks and Opinions of Practicing Physical Therapists Regarding Direct Access in Indiana

poster abstractIntroduction: Indiana is one of the remaining states that requires by state law a referral to initiate treatment by a licensed physical therapist (PT) and therefore does not allow consumers direct access to physical therapy services. In 2009, the Indiana Chapter of the American Physical Therapy Association (APTA) and Indiana University jointly funded a study to investigate the opinions of licensed physical therapists on direct access to physical therapy services. Purpose: The study investigated physical therapists opinions residing in the state of Indiana on four main issues: Direct access—desire for and willingness to achieve Scope of care—differential diagnosis and clinical skills Liability—perceived impact of direct access Manipulation practices—competence and confidence Methods: The researchers used an online program, SurveyMonkey©, to design an 18-question survey. The sample was recruited via a mailing list from the Indiana State Board of Health which included all the licensed physical therapists within the state of Indiana. A letter explaining the purpose of the study including a hyperlink to the survey and a hard copy of the survey was mailed to 3,350 physical therapists. The survey respondents could either choose to complete the survey online via the hyperlink or on the hard copy provided and return via a provided selfaddressed stamped envelope for survey return. Results: There were 1,379 respondents which accounted for a 42% return rate. APTA membership was analyzed with 39.5% of the respondents being APTA members and the remaining 60.5% being non-members. The collective responses to specific questions were reported by a five-level Likert response scale. The majority of respondents want direct access in the state of Indiana, with the average response being 4.13/5.00. However, proportionately the willingness of respondents to be actively involved is much lower, with the average response being 3.23/5.00. The majority (61%) believed their liability would increase with direct access. The terminal degrees for the respondents surveyed were varied with the majority, 48.6%, holding a Bachelor’s degree. The responses of participants were significantly influenced by their degree/level of training with higher levels of training being consistently associated with more favorable attitudes to direct access issues. Discussion /Clinical Relevance: The high return rate and passionate responses confirm these issues are important to PT’s practicing in Indiana and the majority of those surveyed are in favor of direct access to physical therapy services without compromise of the current scope of care. The results of this study may have implications for health policy regarding direct access to physical therapy services within the state of Indiana. In particular to help redirect efforts toward dispelling myths, promoting grassroots efforts and encouraging teamwork in our peers