Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention.

BACKGROUND: Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. METHODS: A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. RESULTS: Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. CONCLUSIONS: The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. TRIAL REGISTRATION: ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.

The organisation of federal Veterinary Services in Canada: the Canadian Food Inspection Agency.

The organisational design of a national Veterinary Service is critical to the overall quality and integrity of its animal health and veterinary public health infrastructure. It is well recognised that the diversity of political, economic and social situations which exist in and between countries dictates that no one model of organisational structure can be applied to all circumstances. In Canada, a re-organisation of the approach of the federal government to food inspection in 1997 resulted in the transfer of the veterinary administration to a newly created agency called the Canadian Food Inspection Agency (CFIA). The authors provide a short background on the impetus for the creation of the CFIA and an overview of its organisational structure and responsibilities in animal and veterinary public health and food safety. Also included are the logic models that were developed for the federal Veterinary Services as part of their quality and performance management framework. Integrating all federally mandated food inspection systems under the CFIA has had concrete benefits in clarifying roles and responsibilities, reducing overlap and duplication of programme functions, improving service delivery and facilitating federal-provincial collaboration. Moreover, the strength of the organisation lies in the ability of the Canadian Veterinary Services to adhere to the fundamental principles of quality which are recommended by the OIE (World organisation for animal health) for the evaluation of Veterinary Services. No single organisational structure can guarantee a highly effective or competent Veterinary Service. Common challenges exist that may or may not be addressed in whole or in part by the organisational structure. The challenges highlighted in this paper provide further thoughts on the management of shared jurisdiction, meeting public health objectives, balancing science and political accountability, and defining the role and jurisdiction of veterinarians.

Gender constancy judgments in children with gender identity disorder: evidence for a developmental lag.

Gender constancy judgments in children referred for problems in their gender identity development (N = 206) and controls (N = 95) were compared. On Slaby and Frey's (1975) gender constancy interview, the gender-referred children performed more poorly than the controls at three stage levels: gender identity, gender stability, and gender consistency. On the Boy-Girl Identity Task, a second measure of gender constancy (Emmerich et al., 1977), the gender-referred children also performed more poorly. Gender-referred children who had not attained gender consistency engaged in significantly less same-sex-typed play on a free-play task than the gender-referred children who had, but there were no gender consistency effects for the controls. Two other measures of sex-typed behavior were unrelated to gender consistency. In the gender-referred group alone, children who "failed" the gender identity or gender stability stages were more likely to draw an opposite-sex person first on the Draw-a-Person test and to evince more affective gender confusion on the Gender Identity Interview (Zucker et al., 1993) than children who had "passed." It is concluded that children referred for problems in their gender identity development have a developmental lag in gender constancy acquisition. Possible reasons for the lag are discussed.

Radiation-induced superior vena cava syndrome.

A 59-year-old man developed superior vena caval obstruction 20 years after receiving a radiation treatment for primary germinal cell tumor of the mediastinum. Venous decompression was achieved by anastomosing a 10-mm ringed polytetrafluoroethylene graft from the left internal jugular vein to the right atrium, which yielded immediate relief of symptoms. A left internal jugular venogram demonstrated graft patency 11 months post-operatively, and the patient remained free of symptoms of superior vena caval obstruction 29 months postoperatively.

Sex-typed responses in the Rorschach protocols of children with gender identity disorder.

A coding system was developed to measure sex-typed responses in the Rorschach protocols of children with gender identity disorder (n = 79). Their responses were compared to that of sibling (n = 25), psychiatric (n = 26), and normal (n = 28) controls. Results show that children with gender identity disorder gave significantly more cross-sex responses than same-sex responses, whereas the psychiatric and normal controls gave significantly more same-sex responses than cross-sex responses. The siblings did not differ in the number of same-sex and cross-sex responses. Results are discussed with regard to various assessment issues in the study of children with gender identity disorder.

Effects of neutral toys on sex-typed play in children with gender identity disorder.

This study assessed the relative influences of approach and avoidance behaviors toward same-sex and cross-sex toys in the play of children with gender identity disorder and in normal boys, normal girls, and psychiatric controls. Three forced-choice situations with toys and three forced-choice situations with dress-up apparel were presented that paired same-sex and cross-sex stimuli, same-sex and neutral stimuli, and cross-sex and neutral stimuli. In the same-sex/cross-sex situation, the gender-disordered group played a significantly shorter time with the same-sex stimuli and a significantly longer time with the cross-sex stimuli than the normal boys and the psychiatric controls, whereas the play patterns of the normal girls fell in between that of the gender-disordered group and the two control groups. Within-groups analyses showed that the normal boys and the psychiatric controls preferred the same-sex toys, whereas the gender-disordered group and the normal girls showed no preference. When the neutral toys were the alternative, avoidance of cross-sex toys appeared to be stronger than the attraction to same-sex toys in the normal boys and in the psychiatric controls. The relative influence of approach-avoidance tendencies was more equivocal in the gender-disordered group, though they appeared to have a weaker attraction to same-sex toys and less avoidance of cross-sex toys in comparison with the normal boys and the psychiatric controls. The approach-avoidance patterns of the normal girls fell in between that of the gender-disordered group and the other two control groups.

Two subgroups of gender-problem children.

Gender-referred children who met the DSM-III diagnostic criteria for gender identity disorder of childhood (n = 21) and gender-referred children who did not meet these criteria (n = 15) were compared with regard to demographic, gender role, and behavioral disturbance information. As judged by parental questionnaires and behavioral tests, the cross-gender role behavior of gender-referred children who met the DSM-III criteria was generally more extreme than that of their non-DSM-III counterparts. These two diagnostically defined subgroups did not, however, differ in the degree of their behavioral and emotional disturbance. The DSM-III children were significantly younger than the non-DSM-III children, but the extent to which the disparity in age accounted for the gender role differences appeared equivocal. The implications of these findings for the diagnosis and assessment of gender-referred children are discussed.

Human figure drawings of gender-problem children: a comparison to sibling, psychiatric, and normal controls.

The Draw-a-Person test was used to evaluate a number of questions regarding children referred for potential problems in their gender-identity development (N = 36). Sibling (N = 31), psychiatric (N = 23), and normal (N = 30) children served as comparison groups. The major results included the following: (1) The gender-referred children were more likely to draw an opposite-sex person when requested to "draw a person" than were the other three groups; (2) the gender-referred children who drew an opposite-sex person were more likely to play with opposite-sex toys and dress-up apparel on a free-play task than were the gender-referred children who drew a same-sex person; (3) the gender-referred children drew taller opposite-sex persons than same-sex persons; (4) using Koppitz's (1968) criteria, the normal children had a smaller proportion of emotional disturbance indicators in their same-sex drawings than did the other three groups. These findings were discussed with regard to psychometric and interpretive issues in the assessment of children with atypical gender-role behavior.

Sex-typed play in gender-disturbed children: a comparison to sibling and psychiatric controls.

Gender-disturbed children (n = 14) were compared to their preadolescent siblings (n = 16) and psychiatric controls (n = 13) on a sex-typed free-play task previously shown to differentiate gender-disturbed boys from normal boys. On three separate trials totaling 20 minutes, the gender-disturbed children played for a significantly longer period of time with cross-sex toys and for a significantly shorter period of time with same-sex toys than did the two control groups. The gender-disturbed children also showed greater trial-to-trial consistency in their play preferences than the other two groups. The utility of this task in the assessment of childhood gender disturbance is discussed. In addition, the results are discussed in relation to a number of perspectives regarding both typical and atypical gender identity development in childhood.

Patterns of intellectual functioning and spatial ability in boys and gender identity disorder.

Preadolescent boys with Gender Identity Disorder (N = 13), their brothers (N = 8) and boys referred for psychiatric assessment (N = 10) were administered age-appropriate Wechsler intelligence scales. Four hypotheses regarding patterns of intellectual functioning and spatial ability were tested. A previous suggestion that the development of boyhood femininity is associated with higher than average IQ was not supported, since the IQs of the feminine boys and their brothers did not differ. A report of enhanced verbal ability as compared with perceptual organization also was not replicated in these feminine boys. On Kaufman's "Freedom from Distractibility" factor, the feminine boys and their brothers obtained scores as low as the psychiatric controls; that is, all three groups were equally distractible. It was suggested that anxiety contributed to poor performance on this factor. Unlike the control groups, the feminine boys obtained low scores on a test of spatial ability (Block Design) as compared to their scores on a verbal task (Vocabulary). The association between a feminine gender role and relatively poor spatial ability was discussed.

Gender identity problems of children and adolescents: the establishment of a special clinic.

Theoretical accounts of the origins of gender identity disturbance are reviewed and then followed by a description of the establishment of a child and adolescent gender identity clinic. Clinical impressions of 16 gender disturbed patients are presented and the position is taken that most patients manifested a confused, as opposed to fixed, core gender identity.