Self-management toolkit and delivery strategy for end-of-life pain: the mixed-methods feasibility study

Background: Pain affects most people approaching the end of life and can be severe for some. Opioid analgesia is effective, but evidence is needed about how best to support patients in managing these medicines. Objectives: To develop a self-management support toolkit (SMST) and delivery strategy and to test the feasibility of evaluating this intervention in a future definitive trial. Design: Phase I – evidence synthesis and qualitative interviews with patients and carers. Phase II – qualitative semistructured focus groups and interviews with patients, carers and specialist palliative care health professionals. Phase III – multicentre mixed-methods single-arm pre–post observational feasibility study. Participants: Phase I – six patients and carers. Phase II – 15 patients, four carers and 19 professionals. Phase III – 19 patients recruited to intervention that experienced pain, living at home and were treated with strong opioid analgesia. Process evaluation interviews with 13 patients, seven carers and 11 study nurses. Intervention: Self-Management of Analgesia and Related Treatments at the end of life (SMART) intervention comprising a SMST and a four-step educational delivery approach by clinical nurse specialists in palliative care over 6 weeks. Main outcome measures: Recruitment rate, treatment fidelity, treatment acceptability, patient-reported outcomes (such as scores on the Brief Pain Inventory, Self-Efficacy for Managing Chronic Disease Scale, Edmonton Symptom Assessment Scale, EuroQol-5 Dimensions, Satisfaction with Information about Medicines Scale, and feasibility of collecting data on health-care resource use for economic evaluation). Results: Phase I – key themes on supported self-management were identified from evidence synthesis and qualitative interviews. Phase II – the SMST was developed and refined. The delivery approach was nested within a nurse–patient consultation. Phase III – intervention was delivered to 17 (89%) patients, follow-up data at 6 weeks were available on 15 patients. Overall, the intervention was viewed as acceptable and valued. Descriptive analysis of patient-reported outcomes suggested that interference from pain and self-efficacy were likely to be candidates for primary outcomes in a future trial. No adverse events related to the intervention were reported. The health economic analysis suggested that SMART could be cost-effective. We identified key limitations and considerations for a future trial: improve recruitment through widening eligibility criteria, refine the SMST resources content, enhance fidelity of intervention delivery, secure research nurse support at recruiting sites, refine trial procedures (including withdrawal process and data collection frequency), and consider a cluster randomised design with nurse as cluster unit. Limitations: (1) The recruitment rate was lower than anticipated. (2) The content of the intervention was focused on strong opioids only. (3) The fidelity of intervention delivery was limited by the need for ongoing training and support. (4) Recruitment sites where clinical research nurse support was not secured had lower recruitment rates. (5) The process for recording withdrawal was not sufficiently detailed. (6) The number of follow-up visits was considered burdensome for some participants. (7) The feasibility trial did not have a control arm or assess randomisation processes. Conclusions: A future randomised controlled trial is feasible and acceptable

Integrated care to address the physical health needs of people with severe mental illness : a rapid review

Background People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests that this discrepancy is driven by a combination of clinical risk factors, socioeconomic factors and health system factors. Objective(s) To explore current service provision and map the recent evidence on models of integrated care addressing the physical health needs of people with severe mental illness (SMI) primarily within the mental health service setting. The research was designed as a rapid review of published evidence from 2013–15, including an update of a comprehensive 2013 review, together with further grey literature and insights from an expert advisory group. Synthesis We conducted a narrative synthesis, using a guiding framework based on nine previously identified factors considered to be facilitators of good integrated care for people with mental health problems, supplemented by additional issues emerging from the evidence. Descriptive data were used to identify existing models, perceived facilitators and barriers to their implementation, and any areas for further research. Findings and discussion The synthesis incorporated 45 publications describing 36 separate approaches to integrated care, along with further information from the advisory group. Most service models were multicomponent programmes incorporating two or more of the nine factors: (1) information sharing systems; (2) shared protocols; (3) joint funding/commissioning; (4) colocated services; (5) multidisciplinary teams; (6) liaison services; (7) navigators; (8) research; and (9) reduction of stigma. Few of the identified examples were described in detail and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge from the evidence. Efforts to improve the physical health care of people with SMI should empower people (staff and service users) and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication between professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered. Limitations and future work The literature identified in the rapid review was limited in volume and often lacked the depth of description necessary to acquire new insights. All members of our advisory group were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. A conventional systematic review of this topic would not appear to be appropriate in the immediate future, although a more interpretivist approach to exploring this literature might be feasible. Wherever possible, future evaluations should involve service users and be clear about which outcomes, facilitators and barriers are likely to be context-specific and which might be generalisable

Characteristics and experiences of children and young people with severe intellectual disabilities and challenging behaviour attending 52-week residential special schools

Background: This study sought to gather information about the characteristics and experiences of children and young people with severe intellectual disabilities and severe challenging behaviour attending 52-week residential special schools. Method: Staff of nine schools completed postal questionnaires on the characteristics and experiences of 156 pupils. Results: Those attending residential schools are predominantly male, teenagers and in long-term placements. Most have limited communication skills and autistic spectrum disorders. All display high numbers of challenging behaviours, many of them serious. Children have a greater range and complexity of needs than pupils at day severe learning difficulties (SLD) schools, albeit with some overlap. Conclusions: Children at 52-week residential schools present needs that both families and local services struggle to meet. Residential placement may provide the intensity of educational input and social support that is required, but may increase the vulnerability of the children. Local alternatives to residential schools should be investigated

Beverage patterns and trends among school-aged children in the US, 1989-2008

<p>Abstract</p> <p>Background</p> <p>High intake of sugar-sweetened beverages in childhood is linked to increased risk of obesity and type II diabetes later in life. Using three nationally representative surveys of dietary intake, we investigated beverage patterns and trends among US school-aged children from 1989/91 to 2007/08.</p> <p>Methods</p> <p>3, 583 participants ages 6-11 y old were included. We reported per capita trends in beverage consumption, percent consuming, and amount per consumer for the following categories of beverages: sugar-sweetened beverages (SSB), caloric nutritional beverages (CNB) and low calorie beverages (LCB). Statistically significant differences were tested using the Student's t test in Stata 11.</p> <p>Results</p> <p>While per capita kcal contribution from total beverages remained constant over the study period, per capita consumption of SSBs increased and CNBs decreased in similar magnitude. The substantial increase in consumption of certain SSBs, such as fruit drinks and soda, high fat high sugar milk, and sports drinks, coupled with the decrease in consumption of high fat low sugar milk was responsible for this shift. The percent consuming SSBs as well as the amount per consumer increased significantly over time. Per capita intake of total milk declined, but the caloric contribution from high fat high sugar milk increased substantially. Among ethnicities, important differences in consumption trends of certain SSBs and 100% juice indicate the complexity in determining strategies for children's beverage calorie reduction.</p> <p>Conclusions</p> <p>As upward trends of SSB consumption parallel increases in childhood obesity, educational and policy interventions should be considered.</p

DOs and DON'Ts for using climate change information for water resource planning and management: guidelines for study design

Water managers are actively incorporating climate change information into their long- and short-term planning processes. This is generally seen as a step in the right direction because it supplements traditional methods, providing new insights that can help in planning for a non-stationary climate. However, the continuous evolution of climate change information can make it challenging to use available information appropriately. Advice on how to use the information is not always straightforward and typically requires extended dialogue between information producers and users, which is not always feasible. To help navigate better the ever-changing climate science landscape, this review is organized as a set of nine guidelines for water managers and planners that highlight better practices for incorporating climate change information into water resource planning and management. Each DOs and DON'Ts recommendation is given with context on why certain strategies are preferable and addresses frequently asked questions by exploring past studies and documents that provide guidance, including real-world examples mainly, though not exclusively, from the United States. This paper is intended to provide a foundation that can expand through continued dialogue within and between the climate science and application communities worldwide, a two-way information sharing that can increase the actionable nature of the information produced and promote greater utility and appropriate use

The predicament of primary physical education: a consequence of 'insufficient' ITT and 'ineffective' CPD?

Background: Research on primary physical education (PE) in England and other countries has shown that it is an aspect of the curriculum that has suffered from sparse initial teacher training (ITT). As a consequence of ‘insufficient’ time spent on PE in ITT (PE-ITT), primary teachers often have low levels of confidence and competence with respect to teaching the subject. Evidence also points to inadequacies in traditional forms of professional development in PE (PE-CPD), leading to calls for more effective ways of developing teachers' competence to deliver high quality PE. Purpose: To explore primary school teachers' experiences of PE during ITT and the PE context in their schools prior to them engaging in a national PE-CPD programme, and their perceptions of the immediate and longer-term effects of this programme. Setting and participants: Primary school teachers in five local education authorities in England. Research design and data collection: A combination of quantitative and qualitative methodological approaches were adopted, including: pre-course audits, course evaluations, focus groups and semi-structured interviews. The pre-course audits captured information about the teachers' experiences of PE-ITT and the PE context in their schools prior to them engaging in the CPD. The course evaluations focused on initial impressions of the PE-CPD, and the focus groups and interviews captured the teachers' perceptions of its longer-term effects. Findings: For up to half of the teachers, their PE-ITT was ‘insufficient’ in terms of the time dedicated to it and the breadth of coverage of the subject. The PE-CPD programme, which was designed in the light of ‘insufficient’ PE-ITT, demonstrated features of ‘effective’ CPD in that it was considered relevant to classroom practice and partially addressed some of their many needs (especially in relation to content ideas and inclusive practice). However, its effectiveness was undoubtedly limited due to: its short time span and minimal engagement with teachers; a heavy reliance on resources; and the absence of follow-up support. In addition, it did not adequately address known areas of development for primary PE (such as medium to long-term planning and assessment) and was challenged in meeting the diverse needs of primary teachers of 5–11 year olds. Furthermore, inadequate PE time and reduced opportunities to teach PE in some schools limited implementation of learning from the PE-CPD. Conclusions: The findings of this study confirmed that PE-ITT continues to be ‘insufficient’ for many primary teachers and that the PE-CPD in question, whilst partially ‘effective’, was not, and could never have been, the panacea for the inherent issues within and predicament of primary PE. In effect, this PE-CPD programme with its limited duration and engagement with teachers, a heavy reliance on resources, and no planned follow-up support was not sufficiently different to forms of CPD described in the literature as ‘ineffective’; consequently, it could not hope to compensate for long-term systemic weaknesses such as inadequate primary PE-ITT. These weaknesses need to be addressed through a dual approach of ‘sufficient’ PE-ITT followed by ‘effective’ PE-CPD which engages teachers and their colleagues in long-term collaborative endeavours that support transformative practice

Social justice and leadership development

The revised professional standards for the teaching profession in Scotland are underpinned by a set of values which includes a detailed articulation of social justice for education covering rights, diversity and sustainability. There is a future orientation in these standards that privileges the contribution of teachers and leaders to realizing a wider social aspiration for social justice. This expectation on leaders to contribute to this wider aspiration for social justice raises questions about the practice of leaders and their development. This article considers the implications of the articulation of social justice in the professional standards for career-long leadership development. The article explores some of the issues related to social justice and the role of leadership in school. The article then focuses on the context of Scottish education, looking firstly at the professional standards and secondly at the issues related to social justice leadership. From this discussion the implications for career-long leadership development are considered. The article concludes with a framework for social justice leadership development identifying key aspects of values, knowledge and understanding, inclusive practice, policy, issues of equity and equality that can be developed progressively across a leadership development continuum

Physical activity and nutrition program for seniors (PANS): protocol of a randomized controlled trial

Background Along with reduced levels of physical activity, older Australian's mean energy consumption has increased. Now over 60% of older Australians are considered overweight or obese. This study aims to confirm if a low-cost, accessible physical activity and nutrition program can improve levels of physical activity and diet of insufficiently active 60-70 year-olds. Methods/Design This 12-month home-based randomised controlled trial (RCT) will consist of a nutrition and physical activity intervention for insufficiently active people aged 60 to 70 years from low to medium socio-economic areas. Six-hundred participants will be recruited from the Australian Federal Electoral Role and randomly assigned to the intervention (n = 300) and control (n = 300) groups. The study is based on the Social Cognitive Theory and Precede-Proceed Model, incorporating voluntary cooperation and self-efficacy. The intervention includes a specially designed booklet that provides participants with information and encourages dietary and physical activity goal setting. The booklet will be supported by an exercise chart, calendar, bi-monthly newsletters, resistance bands and pedometers, along with phone and email contact. Data will be collected over three time points: pre-intervention, immediately post-intervention and 6-months post-study. Discussion This trial will provide valuable information for community-based strategies to improve older adults' physical activity and dietary intake. The project will provide guidelines for appropriate sample recruitment, and the development, implementation and evaluation of a minimal intervention program, as well as information on minimising barriers to participation in similar programs