Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design

BACKGROUND:At least 100,000 patients with schizophrenia receive care from community mental health teams (CMHTs) in England. These patients have regular meetings with clinicians, who assess them, engage them in treatment and co-ordinate care. As these routine meetings are not commonly guided by research evidence, a new intervention, DIALOG, was previously designed to structure consultations. Using a hand-held computer, clinicians asked patients to rate their satisfaction with eight life domains and three treatment aspects, and to indicate whether or not additional help was needed in each area, with responses being graphically displayed and compared with previous ratings. In a European multicentre trial, the intervention improved patients’ quality of life over a 1-year period. The current programme builds on this research by further developing DIALOG in the UK. RESEARCH QUESTIONS:(1) How can the practical procedure of the intervention be improved, including the software used and the design of the user interface? (2) How can elements of resource-oriented interventions be incorporated into a clinician manual and training programme for a new, more extensive ‘DIALOG+’ intervention? (3) How effective and cost-effective is the new DIALOG+ intervention in improving treatment outcomes for patients with schizophrenia or a related disorder? (4) What are the views of patients and clinicians regarding the new DIALOG+ intervention? METHODS:We produced new software on a tablet computer for CMHTs in the NHS, informed by analysis of videos of DIALOG sessions from the original trial and six focus groups with 18 patients with psychosis. We developed the new ‘DIALOG+’ intervention in consultation with experts, incorporating principles of solution-focused therapy when responding to patients’ ratings and specifying the procedure in a manual and training programme for clinicians. We conducted an exploratory cluster randomised controlled trial with 49 clinicians and 179 patients with psychosis in East London NHS Foundation Trust, comparing DIALOG+ with an active control. Clinicians working as care co-ordinators in CMHTs (along with their patients) were cluster randomised 1 : 1 to either DIALOG+ or treatment as usual plus an active control, to prevent contamination. Intervention and control were to be administered monthly for 6 months, with data collected at baseline and at 3, 6 and 12 months following randomisation. The primary outcome was subjective quality of life as measured on the Manchester Short Assessment of Quality of Life; secondary outcomes were also measured. We also established the cost-effectiveness of the DIALOG intervention using data from the Client Service Receipt Inventory, which records patients’ retrospective reports of using health- and social-care services, including hospital services, outpatient services and medication, in the 3 months prior to each time point. Data were supplemented by the clinical notes in patients’ medical records to improve accuracy. We conducted an exploratory thematic analysis of 16 video-recorded DIALOG+ sessions and measured adherence in these videos using a specially developed adherence scale. We conducted focus groups with patients (n = 19) and clinicians (n = 19) about their experiences of the intervention, and conducted thematic analyses. We disseminated the findings and made the application (app), manual and training freely available, as well as producing a protocol for a definitive trial. RESULTS:Patients receiving the new intervention showed more favourable quality of life in the DIALOG+ group after 3 months (effect size: Cohen’s d = 0.34), after 6 months (Cohen’s d = 0.29) and after 12 months (Cohen’s d = 0.34). An analysis of video-recorded DIALOG+ sessions showed inconsistent implementation, with adherence to the intervention being a little over half of the possible score. Patients and clinicians from the DIALOG+ arm of the trial reported many positive experiences with the intervention, including better self-expression and improved efficiency of meetings. Difficulties reported with the intervention were addressed by further refining the DIALOG+ manual and training. Cost-effectiveness analyses found a 72% likelihood that the intervention both improved outcomes and saved costs. LIMITATIONS:The research was conducted solely in urban east London, meaning that the results may not be broadly generalisable to other settings. CONCLUSIONS:(1) Although services might consider adopting DIALOG+ based on the existing evidence, a definitive trial appears warranted; (2) applying DIALOG+ to patient groups with other mental disorders may be considered, and to groups with physical health problems; (3) a more flexible use with variable intervals might help to make the intervention even more acceptable and effective; (4) more process evaluation is required to identify what mechanisms precisely are involved in the improvements seen in the intervention group in the trial; and (5) what appears to make DIALOG+ effective is that it is not a separate treatment and not a technology that is administered by a specialist; rather, it changes and utilises the existing therapeutic relationship between patients and clinicians in CMHTs to initiate positive change, helping the patients to improve their quality of life. FUTURE RESEARCH:Future studies should include a definitive trial on DIALOG+ and test the effectiveness of the intervention with other populations, such as people with depression. TRIAL REGISTRATION:Current Controlled Trials ISRCTN34757603. FUNDING:The National Institute for Health Research Programme Grants for Applied Research programme

A seamlessly coupled GIS and distributed groundwater flow model

Abstract There are three approaches for coupling groundwater models with GISs, i.e. loose, tight, and seamless. In seamless coupling a model code is written into, and run from within, a GIS. We implemented {BGS} {GISGroundwater} in a {GIS} in this way for the first time. It facilitates the construction and simulation of the model, and the visualisation of the results all within the {GIS} environment. The model consists of a 2D finite-difference groundwater flow model and a simple user-interface. It can represent heterogeneous aquifers, variably confined and unconfined conditions, and distributed groundwater recharge and abstraction. It offers benefits in terms of ease of use and in streamlining the model construction and application process. {BGS} {GISGroundwater} has been validated against analytical solutions to groundwater-head profiles for a range of aquifer configurations. This model lowers barriers to entry to groundwater flow modelling for a wider group of environmental scientists

Parametrisation of the orographic enhancement of precipitation and deposition in a long-term, long-range transport model

International audienceOrographic enhancement of wet deposition arising from the 'seeder-feeder' effect is, by necessity, highly parametrised in long-range transport models of acid deposition that are long-term (i.e. annual average) and spatially resolved at tens of kilometres. Here, we describe a mechanistic approach to the incorporation of these mechanisms into such a model. The model formulation required the following: precipitation rate by direction and quantification of the fractions that are orographic and non-orographic; treatment of the fast oxidation of sulfur dioxide in clouds; the directionality of the seeder-feeder process; and a quantitative basis for increasing wet deposition factors to account for the seeder-feeder process. The directionality of non-orographic precipitation was determined from meteorological data at 47 sites across the UK. Orographic precipitation varies on a much finer scale than can be interpolated from measurements, and thus a modelling approach was adopted. The directionality of the seeder-feeder effect was taken from measurements. The enhancement factor of the orographic component of precipitation, assumed to represent feeder-rain, was determined from a review of measurements. Fast oxidation of sulfur dioxide is an observed phenomenon in cap-cloud, but limited in duration. An adjustment was made to the sulfur dioxide oxidation rate in the model in locations where cap-cloud was assumed to be present. The results from the model were compared with UK deposition budgets and enhanced wet deposition maps. The revised parametrisation underestimated the UK wet deposition budgets of oxidised N and S, but spatial patterns of deposition were improved for much of the UK. It was concluded that this was a satisfactory outcome given the constraints of the statistical approach of weighting of deposition at receptors utilising straight line trajectories. The sensitivity of the model to directional constraints of seeder-feeder enhancement was tested and it was concluded that a fairly narrow constraint resulted in similar estimations to a broader one, and the broader constraint was thus adopted as frontal conditions which result in the process arrive from a fairly broad band of directions. When enhancement was allowed to occur from all directions, UK wet deposition of oxidised N and S was increased by 10%. The sensitivity to the enhancement factor on wet deposition was tested and found to be relatively robust. An increase in the enhancement factor from 2 to 6 resulted in increases in UK wet deposition of oxidised N and S of 9 and 6%, respectively.Key words: Atmospheric composition and structure (pollution ? urban and regional) ? Meteorology and atmospheric dynamics (precipitation

Nonprofit-public collaborations: understanding governance dynamics

As many of the challenges facing society are too complex to be addressed by single organizations working alone, nonprofit organizations are increasingly working in collaboration with public authorities. The governance of nonprofit–public collaborations is important for their effectiveness, yet it remains poorly understood. Drawing on case study research, this article examines and develops an extant conceptual model developed by Takahashi and Smutny that seeks to explain the formation and demise of nonprofit collaborations in terms of “collaborative windows” and the inability to adapt initial governance structures. The research finds that while initial governance structures are an important constraint on development, they can be adapted and changed. It also suggests that the development of collaborations is not only influenced by changes in the collaborative window but also by how key actors in the collaboration respond to important internal tensions

Quantifying water requirements of African ungulates through a combination of functional traits

Climate and land use change modify surface water availability in African savannas. Surface water is a key resource for both wildlife and livestock and its spatial and temporal distribution is important for understanding the composition of large herbivore assemblages in savannas. Yet, the extent to which ungulate species differ in their water requirements remains poorly quantified. Here, we infer the water requirements of 48 African ungulates by combining six different functional traits related to physiological adaptations to reduce water loss, namely minimum dung moisture, relative dung pellet size, relative surface area of the distal colon, urine osmolality, relative medullary thickness, and evaporation rate. In addition, we investigated how these differences in water requirements relate to differences in dietary water intake. We observed strong correlations between traits related to water loss through dung, urine and evaporation, suggesting that ungulates minimize water loss through multiple pathways simultaneously, which suggests that each trait can thus be used independently to predict water requirements. Furthermore, we found that browsers and grazers had similar water requirements, but browsers are expected to be less dependent on surface water because they acquire more water through their diet. We conclude that these key functional traits are a useful way to determine differences in water requirements and an important tool for predicting changes in herbivore community assembly resulting from changes in surface water availability

Emission-line Helium Abundances in Highly Obscured Nebulae

This paper outlines a way to determine the ICF using only infrared data. We identify four line pairs, [NeIII] 36\micron/[NeII] 12.8\micron, [NeIII]~15.6\micron /[NeII] 12.8\micron, [ArIII] 9\micron/[ArII] 6.9\micron, and [ArIII] 21\micron/[ArII] 6.9\micron, that are sensitive to the He ICF. This happens because the ions cover a wide range of ionization, the line pairs are not sensitive to electron temperature, they have similar critical densities, and are formed within the He$^+$/H$^+$ region of the nebula. We compute a very wide range of photoionization models appropriate for galactic HII regions. The models cover a wide range of densities, ionization parameters, stellar temperatures, and use continua from four very different stellar atmospheres. The results show that each line pair has a critical intensity ratio above which the He ICF is always small. Below these values the ICF depends very strongly on details of the models for three of the ratios, and so other information would be needed to determine the helium abundance. The [Ar III] 9\micron/[ArII] 6.9\micron ratio can indicate the ICF directly due to the near exact match in the critical densities of the two lines. Finally, continua predicted by the latest generation of stellar atmospheres are sufficiently hard that they routinely produce significantly negative ICFs.Comment: Accepted by PASP. Scheduled for the October 1999 issue. 11 pages, 5 figure

How much flower-rich habitat is enough for wild pollinators? Answering a key policy question with incomplete knowledge.

In 2013, an opportunity arose in England to develop an agri-environment package for wild pollinators, as part of the new Countryside Stewardship scheme launched in 2015. It can be understood as a 'policy window', a rare and time-limited opportunity to change policy, supported by a narrative about pollinator decline and widely supported mitigating actions. An agri-environment package is a bundle of management options that together supply sufficient resources to support a target group of species. This paper documents information that was available at the time to develop such a package for wild pollinators. Four questions needed answering: (1) Which pollinator species should be targeted? (2) Which resources limit these species in farmland? (3) Which management options provide these resources? (4) What area of each option is needed to support populations of the target species? Focussing on wild bees, we provide tentative answers that were used to inform development of the package. There is strong evidence that floral resources can limit wild bee populations, and several sources of evidence identify a set of agri-environment options that provide flowers and other resources for pollinators. The final question could only be answered for floral resources, with a wide range of uncertainty. We show that the areas of some floral resource options in the basic Wild Pollinator and Farmland Wildlife Package (2% flower-rich habitat and 1 km flowering hedgerow), are sufficient to supply a set of six common pollinator species with enough pollen to feed their larvae at lowest estimates, using minimum values for estimated parameters where a range was available. We identify key sources of uncertainty, and stress the importance of keeping the Package flexible, so it can be revised as new evidence emerges about how to achieve the policy aim of supporting pollinators on farmland.LVD was funded by NERC (NE/K015419/1), CC by Defra and Natural England (flower density data); MB and CC by BBSRC Defra, NERC, the Scottish Government and the Wellcome Trust under the Insect Pollinators Initiative (BB/I000925/1 and Agriland - BB/H014934/1).This is the final version of the article. It first appeared from Wiley via http://dx.doi.org/10.1111/een.1222

Government support for faith-based organizations: the case of a development programme for faith leaders

A government initiative to train faith leaders usefully extended existing provision, but will require continuing support for some years. Broader community leadership is not always expected from those holding religious positions. The challenges involved in bridging linguistic and cultural differences highlight some of the reasons why initiatives like this are needed