ABSTRACT
Background: Dementia is associated with frailty leading to increased risks of falls and hospitalisations. Interventions are required to maintain functional ability, strength and balance. Design: Multi-centre parallel group randomised controlled trial, with embedded process evaluation. Procedures were adapted during the COVID-19 pandemic. Participants: People with mild dementia or mild cognitive impairment (MCI), living at home, and a family member or carer. Objectives: To determine the effectiveness of an exercise and functional activity therapy intervention compared to usual care. Intervention: A specially-designed dementia-specific rehabilitation programme focussing on strength, balance, physical activity and performance of ADL, which was tailored, progressive, addressed risk and the psychological and learning needs of people with dementia, providing up to 50 therapy sessions over 12 months. The control group received usual care plus a falls risk assessment. Main outcome measure: The primary outcome was the informant-reported Disability Assessment for Dementia (DAD) 12 months after randomisation. Secondary outcomes were: self-reported ADL, cognition, physical activity, quality of life, frailty, balance, functional mobility, fear of falling, mood, carer strain and service use (at 12 months) and falls (between months 4 and 15). Results: 365 people were randomised, 183 to intervention and 182 to control. Median age of participants was 80 years (range 65-95), median Montreal Cognitive Assessment score 20/30 (range 13-26), 58% were men. Participants received a median of 31 (IQR = 22-40) therapy sessions out of a possible maximum of 50. Participants reported completing a mean 121 minutes/week of PrAISED activity outside of supervised sessions. Primary outcome data were available for 149 (intervention) and 141 (control) participants. There was no difference in DAD scores between groups: adjusted mean difference -1.3/100, 95% Confidence Interval (-5.2 to +2.6); Cohens d effect size -0.06 (-0.26 to +0.15); p=0.5. Upper 95% confidence intervals excluded small to moderate effects on any of the range of secondary outcome measures. Between months 4 and 15 there were 79 falls in the intervention group and 200 falls in the control group, adjusted incidence rate ratio 0.78 (0.5 to 1.3); p= 0.3. Conclusion: The intensive PrAISED programme of exercise and functional activity training did not improve ADLs, physical activity, quality of life, reduce falls or improve any other secondary health status outcomes even though uptake was good. Future research should consider alternative approaches to risk reduction and ability maintenance. Trial registration: ISRCTN15320670 . Funding: National Institute for Health and Care Research
Subject(s)
COVID-19 , Dementia , Cognition DisordersABSTRACT
Background Uncertainty around the risk of COVID-19 to pregnant women and their babies prompted precautionary restrictions on their health and care during the pandemic. Maternity services had to adapt to changing Government guidance. Coupled with the imposition of national lockdowns in England and restrictions on daily activities, women’s experiences of pregnancy, childbirth and the postpartum period, and their access to services, changed rapidly. This study was designed to understand women’s experiences of pregnancy, labour and childbirth and caring for a baby during this time. Methods This was an inductive longitudinal qualitative study, using in-depth interviews by telephone with women in Bradford, UK, at three timepoints during their maternity journey (18 women at timepoint one, 13 at timepoint two and 14 at timepoint three). Key topics explored were physical and mental wellbeing, experience of healthcare services, relationships with partners and general impact of the pandemic. Data were analysed using the Framework approach. A longitudinal synthesis identified over-arching themes. Results Three longitudinal themes captured what was important to women: (1) women feared being alone at critical points in their maternity journey, (2) the pandemic created new norms for maternity services and women’s care, and (3) finding ways to navigate the COVID-19 pandemic in pregnancy and with a baby. Conclusions Modifications to maternity services impacted significantly on women’s experiences. The findings have informed national and local decisions about how best to direct resources to reduce the impact of COVID-19 restrictions and the longer-term psychological impact on women during pregnancy and postnatally.
Subject(s)
COVID-19ABSTRACT
Objective Organizational responses that support healthcare workers (HCWs) and mitigate health risks are necessary to offset the impact of the COVID-19 pandemic. We aimed to understand how HCWs and key personnel working in healthcare settings in Melbourne, Australia perceived their employing organizations' responses to the COVID-19 pandemic. Method In this qualitative study, conducted May-July 2021 as part of the longitudinal Coronavirus in Victorian Healthcare and Aged Care Workers (COVIC-HA) study, we purposively sampled and interviewed HCWs and key personnel from healthcare organizations across hospital, ambulance, aged care and primary care (general practice) settings. We also examined HCWs' free-text responses to a question about organizational resources and/or supports from the COVIC-HA Study's baseline survey. We thematically analyzed data using an iterative process. Results We analyzed data from interviews with 28 HCWs and 21 key personnel and free-text responses from 365 HCWs, yielding three major themes: navigating a changing and uncertain environment, maintaining service delivery during a pandemic, and meeting the safety and psychological needs of staff . HCWs valued organizational efforts to engage openly and honesty with staff, and proactive responses such as strategies to enhance workplace safety (e.g., personal protective equipment spotters). Suggestions for improvement identified in the themes included streamlined information processes, greater involvement of HCWs in decision-making, increased investment in staff wellbeing initiatives and sustainable approaches to strengthen the healthcare workforce. Conclusions This study provides in-depth insights into the challenges and successes of organizational responses across four healthcare settings in the uncertain environment of a pandemic. Future efforts to mitigate the impact of acute stressors on HCWs should include a strong focus on bidirectional communication, effective and realistic strategies to strengthen and sustain the healthcare workforce, and greater investment in flexible and meaningful psychological support and wellbeing initiatives for HCWs.
ABSTRACT
This inaugural special issue of ‘Beyond the Text’ brings together a collection of visual arts (animation, creative and fine art, film, photographs, and zines) produced by children, young people, families, artists, and academics as part of co-created research during the 2020–2021 coronavirus pandemic. Our aim, in making these pieces available in this new publication format, is to illustrate the potential of visual arts as a form of co-creation and knowledge exchange which can transcend the challenges of researching ‘at a distance’, enable participants and co-researchers to share their stories, and support different ways of knowing for academic, policy, and public audiences. This is not to suggest that such methods offer transparent windows into participants’ worlds. As the reflections from the contributing authors consider, visual arts outputs leave room for audience interpretations, making them vulnerable to alternative readings, generating challenges and opportunities about how much it is possible to know about another and what is ethical to share. It is to these issues of ethics, representation, and voice that this special issue attends, reflecting on the possibilities of arts-based approaches for knowledge generation and exchange in and beyond the coronavirus pandemic.
ABSTRACT
‘Our Voices’ is an animation co-created with children aged 9–11 during the 2020–2021 global pandemic. A short, stop-start animation of children’s visual, audio and textual representations of their experiences offers a visceral account of the pandemic in England from their perspectives. In making available the animation in this inaugural issue of ‘Beyond the Text’, we have two key aims. The first is to enable children, who have been barely seen and little heard during the pandemic, to voice their experiences in accordance with their aspirations. The second is to reflect upon the process of transforming creative data made by and with children into an animation that is representative of children’s diverse experiences and acknowledges their contributions in ways which enable audiences to engage through ‘seeing’. Accordingly, our accompanying text explores how, through a feminist ethics of care, we sought to co-produce an animation with children which delivers key messages from them and acknowledges their role as co-researchers while maintaining their anonymity. In describing our methodological and ethical practices, we aspire to make visible the relational, dialogic processes inherent in co-production, offering viewers a way of seeing the complexity of children’s experiences through the multi-layered affordances of participatory animation.
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IntroductionIn May 2020, subcutaneous (SC) vedolizumab was approved for use in Inflammatory Bowel Disease (IBD). Patients with IBD have a number of risk factors for a poor outcome from SARS-CoV-2 infection and managing this risk by reducing hospital visits is crucial. Currently there is no information on the process or outcomes of transitioning patients established on intravenous (IV) vedolizumab to SC.MethodsThis is a prospective service evaluation of adult patients who are either stable on IV vedolizumab or have been newly started and opted for SC administration. Between October and December 2020, all suitable patients attending our infusion centre for vedolizumab were offered the option to switch to SC. Initially, the aim was to offer a SC dose to patients in place of their IV infusion with injection training by IBD specialists. This proved to be a challenge as it left a narrow window of time for homecare deliveries to be arranged for subsequent doses. Therefore, the remaining patients who agreed to the switch received an IV infusion at their baseline review, with the aim of administering the first SC dose in place of the next scheduled IV dose.Outcomes include reasons for consenting or declining to switch, patient experience with using SC injections and time saved by not needing to travel to the infusion centre. Data on factors associated with poor outcomes from SARS-CoV-2 infection were collected, including co-morbidities, smoking status, concomitant medication and age.Clinical baseline data collected as part of routine care included disease activity (modified Harvey-Bradshaw Index or Simple Clinical Colitis Activity Index), biochemical results including C-reactive protein, albumin, haemoglobin and platelet count, faecal calprotectin and quality of life using IBD-Control. Trough vedolizumab levels were measured in patients who had had at least 3 IV doses previously. Patients will be reviewed after 12 weeks as part of the switching programme.Results179 patients were offered the opportunity to change to SC vedolizumab (54.2% CD, 44.1% UC, 1.7% IBDU), of which 125 (70%) (64 (51.2%) CD, 58 (46.4%) UC and 3 (2.4%) IBDU) agreed to the switch. The mean age (SD) was 55 (19.4). 11 patients were new to vedolizumab or reloading. The median time taken by patients (leaving home to returning home) to receive their infusions was 180 minutes (IQR 45 to 360).The main reasons for agreeing to switch were patient preference to manage their treatment at home (70.4%), concerns about contracting an infection at the infusion centre (15.7%) and difficulty attending the infusion centre (15.7%). Reasons for patients declining included not wanting to self-inject (28.3%), needle phobia (15.2%), and current instability of symptoms (15.2%). There have been no major adverse events to date.ConclusionsThis is a description of a service evaluation design to monitor outcomes in patients who have consented to transition from IV to SC vedolizumab at one IBD tertiary referral centre.
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BackgroundA large proportion of front-line paediatric healthcare in Zambia is delivered by staff with no specialist paediatric training, and training this group could significantly reduce preventable child deaths. In 2019–2020, the Tropical Health and Education Trust undertook a 6-month paediatric capacity building project in Lusaka, Zambia, funded by Health Education England.ObjectivesThe aim of the project was to improve paediatric skills of front-line healthcare workers.MethodsThree volunteers were recruited (2 paediatric registrars and 1 programme and evaluation consultant) to work with first (district) level hospitals in Lusaka. A needs analysis found that there was an under-utilisation of the structured approach to the recognition and stabilisation of unwell children on the front line.The initial suggestion of embedding the Emergency Triage and Treatment (ETAT) course was not an option due to insufficient resources and funding for a five-day course. The volunteers worked with local and international colleagues to design a one-day alternative based on local data, priorities and available resources. The Paediatric Assessment and Stabilisation (PAS) course is based on national Zambia Paediatric Association and international protocols (including ETAT, APLS and WHO).A ‘teach the teacher’ approach was used with instructors nominated from four first level hospitals and University Teaching Hospital (the local tertiary referral hospital). Two half-day sessions were held to train instructors on course teaching methods, and encourage them to be local ‘PAS Champions’ to embed their new knowledge and skills amongst their own hospital teams post-course.The pilot was funded by Lusaka Provincial Health Office, with participants recruited from the same four first level hospitals as the instructors. The course was delivered in small groups using Peyton’s four stage approach and simulation. A simulation test scenario was used at the end of the course to ensure credibility. Impact of the course was measured using a Likert scale questionnaire to assess participant confidence in managing critically ill children before and after the course.ResultsThe pilot ran four separate PAS courses. These were attended by 91 participants (including clinical officers, medical officers and nurses) of which 88 passed. Pre and post course questionnaires showed participant confidence scores increased by 19% in assessment of unwell children, and by 22% in treatment of unwell children. Free text by participants showed a positive impact on individual clinical practice. 25 instructors were trained to teach on the PAS course, as well as 2 course directors and 1 course administrator. Instructors also fed back that critically unwell children were more effectively managed within their facilities after the course. Ownership of the course was handed back to the ZPA and Ministry of Health at the end of the pilot. Unfortunately, the COVID-19 pandemic prevented any further impact analysis, and any further PAS courses were put on hold.ConclusionsAt a time where national resources are limited to fund internationally recognised paediatric courses (e.g. ETAT), it is hoped that the structured approach learned on the PAS course can benefit front line paediatric care in Zambia at present, and become an effective ‘stepping-stone’ to these courses.
ABSTRACT
Introduction: Seasonal malaria chemoprevention (SMC) is a WHO-recommended intervention for children aged 3-59 months living in areas of high malaria transmission to provide protection against malaria during the rainy season. Operational guidelines were developed, based on WHO guidance, to support countries to mitigate the risk of coronavirus disease 2019 (COVID-19) transmission within communities and among community distributors when delivering SMC.MethodsA cross-sectional study to determine adherence to infection prevention and control measures during two distribution cycles of SMC in Nigeria, Chad and Burkina Faso. Community distributors were observed receiving equipment and delivering SMC. Adherence across six domains was calculated as the proportion of indications in which the community distributor performed the correct action. Focus group discussions were conducted with community distributors to understand their perceptions of the infection prevention and control measures and barriers and facilitators to adherence.ResultsWe observed community distributors in Nigeria (n=259), Burkina Faso (n=252) and Chad (n=266) receiving infection prevention and control equipment and delivering SMC. Adherence to infection prevention and control indications varied. In all three countries, adherence to mask use was the highest (ranging from 73.3% in Nigeria to 86.9% in Burkina Faso). Adherence to hand hygiene for at least 30 seconds was low (ranging from 3.6% in Nigeria to 10.3% in Burkina Faso) but increased substantially when excluding the length of time spent hand washing (ranging from 36.7% in Nigeria to 61.4% in Burkina Faso). Adherence to safe distancing in the compound ranged from 5.4% in Chad to 16.4% in Nigeria. In Burkina Faso and Chad, where disinfection wipes widely available compliance with disinfection of blister packs for SMC was low (17.4% in Burkina Faso and 16.9% in Chad). Community distributors generally found the infection prevention and control measures acceptable, however there were barriers to optimal hand hygiene practices, cultural norms made social distancing difficult to adhere to and caregivers needed assistance to administer the first dose of SMC.ConclusionAdherence to infection prevention and control measures for SMC delivery during the COVID-19 pandemic varied across domains of infection prevention and control, but was largely insufficient, particularly for hand hygiene and safe distancing. Improvements in provision of equipment, early awareness raising and adaptations to make infection prevention and control measures more feasible to implement could increase adherence.
Subject(s)
COVID-19 , MalariaABSTRACT
BackgroundDuring the COVID-19 pandemic, the Ministry of Health asked Singapore’s private general practitioners (GPs) to perform swab testing in their clinics, but some GPs had concerns about swabber protection. Our aim was to develop a swabbing booth to address these concerns.MethodsWe developed a prototype with potential GP users using a human-centred design approach and piloted it with 10 GP clinics. The pilot was then extended to 170 GP clinics around Singapore. These GPs were then surveyed on user satisfaction.Results93 GPs (54%) responded. The majority (75%) practiced in public residential estates in small practices (mean 1.93 doctors). 86% requested the booth to enhance swabber protection. 74% “would recommend” or “would strongly recommend” the booth to colleagues. 79% continue to use the booth to conduct swab tests. 92% liked that it offered swabber protection. 71% liked that the booth created a separate space for swabbing and 64% liked its ease of disinfection. 47% started swabbing only after receiving the booth and 58% said the booth was “important” or “very important” to their decision to participate in swab testing. However, 34% disliked that it took up too much space and the most frequently critiqued area was the gloves.ConclusionThe human-centred design approach generated a product that had high user satisfaction, addressed GPs’ concerns of swabber protection and increased GPs’ participation in swab testing. The booth may be useful where GPs are concerned about swabber protection and space is limited.