The German MultiCare-study: Patterns of multimorbidity in primary health care – protocol of a prospective cohort study

Background Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects. Methods The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed. Discussion The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines

The Evolution of Community Self-Organization in Interaction With Government Institutions: Cross-Case Insights From Three Countries

textabstractThis article deals with the evolution of community self-organization in public administration. Within the literature of interactive governance, increasing attention is being paid to how communities take initiative in dealing with societal issues. However, we know little about the factors contributing to the durability of self-organization. We analyzed three cases of community self-organization in three different countries: the United Kingdom, the United States, and the Netherlands. We found that community self-organization initiatives are strongly embedded in governmental environments, leading to different modes of interaction that change from phase to phase and in response to reciptiveness (or the lack thereof) among government counterparts. These modes of interaction strongly influence the evolution of community self-organization efforts. Moreover, we conclude that it is important that self-organized citizen initiatives represent and capture the perspectives and interests of large groups of citizens. This condition positively influences the evolution and duration of citizen initiatives. Those who manage to link with other citizens, including via community and volunteer organizations, can succeed. Those who do not can lose their legitimacy and fail

The Evolution of Community Self-Organization in Interaction With Government Institutions: Cross-Case Insights From Three Countries

This article deals with the evolution of community self-organization in public administration. Within the literature of interactive governance, increasing attention is being paid to how communities take initiative in dealing with societal issues. However, we know little about the factors contributing to the durability of self-organization. We analyzed three cases of community self-organization in three different countries: the United Kingdom, the United States, and the Netherlands. We found that community self-organization initiatives are strongly embedded in governmental environments, leading to different modes of interaction that change from phase to phase and in response to reciptiveness (or the lack thereof) among government counterparts. These modes of interaction strongly influence the evolution of community self-organization efforts. Moreover, we conclude that it is important that self-organized citizen initiatives represent and capture the perspectives and interests of large groups of citizens. This condition positively influences the evolution and duration of citizen initiatives. Those who manage to link with other citizens, including via community and volunteer organizations, can succeed. Those who do not can lose their legitimacy and fail

A Reaction Time Experiment on Adult Attachment: The Development of a Measure for Neurophysiological Settings

In the last decades, there has been an increase of experimental research on automatic unconscious processes concerning the evaluation of the self and others. Previous research investigated implicit aspects of romantic attachment using self-report measures as explicit instruments for assessing attachment style. There is a lack of experimental procedures feasible for neurobiological settings. We developed a reaction time experiment (RT) using a narrative attachment measure with an implicit nature and were interested to capture automatic processes, when the individuals’ attachment system is activated. We aimed to combine attachment methodology with knowledge from implicit measures by using a decision reaction time paradigm. This should serve as a means to capture implicit aspects of attachment. This experiment evaluated participants’ response to prototypic attachment sentences in association with their own attachment classification, measured with the Adult Attachment Projective Picture System (AAP).First the AAP was administered as the standardized interview procedure to 30 healthy participants, which were classified into a secure or insecure group. In the following experimental session, both experimenter and participants were blind with respect to classifications. 128 prototypically secure or insecure sentences related to the 8 pictures of the AAP were presented to the participants. Their response and reaction times were recorded. Based on the response (accept, reject) a continuous security scale was defined. Both the AAP classification and security scale were related to the reaction times. Differentiated study hypotheses were confirmed for insecure sentences, which were accepted faster by participants from the insecure attachment group (or with lower security scale), and rejected faster by participants form secure attachment group (or with higher security scale). The elaborating unconscious processes were more activated by insecure sentences with potential attachment conflicts.The introduced paradigm is able to contribute to an experimental approach in attachment research. The Reaction Time analysis with the narrative procedure might be of interest for a broader variety of questions in experimental and neurophysiological settings to capture unconscious processes in association to internal working models of attachment. An electrophysiological model based on preliminary research is proposed for assessing the preconscious neuronal network related to secure or insecure attachment representations