Comparison of health-care utilization, costs and health-related quality of life across the subgroups defined by the Keele STarT MSK Tool.

OBJECTIVES: The aim of this study was to describe and compare health economic outcomes [health-care utilization and costs, work outcomes, and health-related quality of life (EQ-5D-5L)] in patients classified into different levels-of-risk subgroups by the Keele STarT MSK Tool. METHODS: Data on health-care utilization, costs and EQ-5D-5L were collected from a health-care perspective within a primary care prospective observational cohort study. Patients presenting with one (or more) of the five most common musculoskeletal pain presentations were included: back, neck, shoulder, knee or multi-site pain. Participants at low, medium and high risk of persistent disabling pain were compared in relation to mean health-care utilization and costs, health-related quality of life, and employment status. Regression analysis was used to estimate costs. RESULTS: Over 6 months, the mean (s.d.) total health-care (National Health Service and private) costs associated with the low, medium, and high-risk subgroups were £132.92 (167.88), £279.32 (462.98) and £476.07 (716.44), respectively. Mean health-related quality of life over the 6-month period was lower and more people changed their employment status in the high-risk subgroup compared with the medium- and low-risk subgroups. CONCLUSIONS: This study demonstrates that subgroups of people with different levels of risk for poor musculoskeletal pain outcomes also have different levels of health-care utilization, health-care costs, health-related quality of life, and work outcomes. The findings show that the STarT MSK Tool not only identifies those at risk of a poorer outcome, but also those who will have more health-care visits and incur higher costs.

A Rapid and Cost-Effective Identification of Invertebrate Pests at the Borders Using MinION Sequencing of DNA Barcodes.

The rapid and accurate identification of invertebrate pests detected at the border is a challenging task. Current diagnostic methods used at the borders are mainly based on time consuming visual and microscopic examinations. Here, we demonstrate a rapid in-house workflow for DNA extraction, PCR amplification of the barcode region of the mitochondrial cytochrome oxidase subunit I (COI) gene and Oxford Nanopore Technologies (ONT) MinION sequencing of amplified products multiplexed after barcoding on ONT Flongle flow cells. A side-by-side comparison was conducted of DNA barcode sequencing-based identification and morphological identification of both large (>0.5 mm in length) and small (<0.5 mm in length) invertebrate specimens intercepted at the Australian border. DNA barcode sequencing results supported the morphological identification in most cases and enabled immature stages of invertebrates and their eggs to be identified more confidently. Results also showed that sequencing the COI barcode region using the ONT rapid sequencing principle is a cost-effective and field-adaptable approach for the rapid and accurate identification of invertebrate pests. Overall, the results suggest that MinION sequencing of DNA barcodes offers a complementary tool to the existing morphological diagnostic approaches and provides rapid, accurate, reliable and defendable evidence for identifying invertebrate pests at the border.

Developing a framework for cash transfer programs that foster sustained economic empowerment to reduce sexual risk among adolescent girls and young women: a qualitative study.

BACKGROUND: Transactional sexual relationships contribute to a high incidence of HIV infection among adolescent girls and young women (AGYW) living in low-resource settings. Cash transfers (CT) are a structural approach to reduce sexual risk behaviors, but their positive economic effects frequently fade after the program ends. We aimed to understand AGYW's decision-making processes related to sexual, relationship, and financial decisions, in order to design a framework for a CT program that could lead to long-term financial independence and reduced transactional sex among AGYW. METHODS: We conducted qualitative research with AGYW participating in a CT program in Tanzania. Phase one was formative research to understand the context and experiences of AGYW regarding sexual behavior, relationships, and finances. Participants included 36 AGYW (15-23 years old), 15 influencers of AGYW (mothers and male partners) and 10 financially empowered women (FEW - women aged 20-30 with a sustained, reliable source of income independent of their partner). Decisions and decision-making contexts of AGYW that we identified in phase one informed the content of phase two. In phase two we simulated scenarios for decision-making and economic goals with 80 AGYW and 40 FEW, in order to identify key principles or intervention opportunities to guide development of a CT program framework. RESULTS: Through phases one and two of our research we identified three key themes in AGYW's vision of their desired future economic state: 1) positive social image, 2) power balance and respect, and 3) emotional and economic security. An important theme distinguishing AGYW from FEW was that AGYW lacked a vision to build self-agency. CONCLUSIONS: Our findings suggest that providing economic resources to AGYW through CT without ensuring self-agency is unlikely to be an effective long-term intervention for economic empowerment. Using these findings we developed a framework for CT programs with three key pillars for developing self-agency: 1) emotional efficacy, to increase AGYW's perception of rewards associated with developing self-agency; 2) social efficacy, to build constructive relationships and exit negative relationships that inhibit self-agency, and 3) economic efficacy, to help AGYW build a resilient stream of financial resources.

The challenge of pain identification, assessment, and management in people with dementia: a qualitative study.

BACKGROUND: Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia. AIM: To explore pain identification, assessment, and management for community-dwelling people with dementia. DESIGN & SETTING: A qualitative study was undertaken, set in England. METHOD: Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically. RESULTS: Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain. CONCLUSION: Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.

Analysis of Small Area Environmental, Socioeconomic and Health Data in Collaboration with Local Communities to Target and Evaluate 'Triple Win' Interventions in a Deprived Community in Birmingham UK.

The contemporary environment is a complex of interactions between physical, biological and socioeconomic systems with major impacts on public health. It is well understood that deprived communities are more exposed to negative environmental and social factors, more susceptible to the effects of those exposures, more excluded from access to positive factors, less able to change their circumstances and consequently experience worse health, economic and social outcomes compared to the more affluent. Welsh House Farm estate in Birmingham is one of the most deprived areas in Europe. An alliance between a local charity, City Council Public Health and a University in collaboration with the local community has accessed, analysed and mapped a range of health, social and economic factors at small area level, identifying areas where the community experience is unacceptably worse than other parts of Birmingham and therefore requiring targeted interventions. We make specific recommendations for coordinated action addressing the living, moving and consuming domains of residents' lives and have also identified positive aspects of life on the estate to celebrate. This pilot demonstrates the utility and cost-effectiveness of local collaboration to identify and target health, environmental and social inequalities informed by local concerns.

Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis.

OBJECTIVES: To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia. METHOD: A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted. RESULTS: Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia. CONCLUSION: This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.

Effectiveness of an Adapted Diabetes Prevention Program Lifestyle Intervention in Older and Younger Adults.

OBJECTIVES: To compare participation, self-monitoring behaviors, and weight loss outcomes in older and younger participants in an adapted Diabetes Prevention Program (DPP) lifestyle intervention. DESIGN: Pre- and postevaluation of outcomes in participants enrolled in the Montana Cardiovascular Disease (CVD) and DPP lifestyle intervention from 2008 through 2012. SETTING: Community. PARTICIPANTS: Adults at high risk for CVD and type 2 diabetes mellitus (N = 3,804). MEASUREMENTS: Number of core (16 weekly sessions) and postcore (6 monthly sessions) intervention sessions attended, weekly self-monitoring of fat intake and minutes of physical activity, weight loss outcomes and achievement of the weight loss goal, and improvements in CVD-related risk factors. RESULTS: Participants aged 65 and older were significantly more likely to attend more intervention sessions, self-monitor their fat intake, and achieve the physical activity and weight loss goals than those younger than 65. Older and younger participants experienced significant improvements in CVD-related risk factors. CONCLUSION: Older adults at high risk of CVD and diabetes mellitus participating in an adapted DPP lifestyle intervention had higher participation and self-monitoring rates than younger participants, were more likely to achieve physical activity and weight loss goals, and achieved similar CVD risk reduction.

The association of anxiety and depression with future dementia diagnosis: a case-control study in primary care.

BACKGROUND: Depression is identified as a risk factor for dementia. Little research has been carried out on the importance of anxiety, despite strong evidence of co-morbidity with depression. OBJECTIVE: To examine the association of anxiety and depression with future dementia diagnosis. METHODS: This case-control study was set in the Consultations in Primary Care Archive. Cases (n = 400), were patients aged >65 years old. About 1353 controls were matched to cases by gender, practice, age group and year of case diagnosis. Read codes of risk factors for dementia were searched in patient records. The associations of prior consultations for anxiety and depression, with future diagnosis of dementia were determined using multivariable logistic regression. RESULTS: A past anxiety diagnosis was associated with a future dementia diagnosis [odds ratio 2.76 (95% confidence interval 2.11-3.62)]. The association of depression with dementia was attenuated by the high prevalence of anxiety within those who have depression. Including an interaction of depression and anxiety showed that having only depression was associated with future dementia diagnosis but a diagnosis of depression alongside anxiety did not increase the likelihood of a dementia diagnosis compared to having just an anxiety diagnosis. CONCLUSION: Prior diagnosis of anxiety was strongly associated with dementia diagnosis after adjustment for other risk factors. The independent effect of depression was weaker compared to anxiety. Given the higher prevalence of anxiety primary care physicians should consider anxiety as well as depression as premorbid risk factors of dementia to improve early recognition and facilitate greater access to services.

The utilization of home care by the elderly in Brazil's primary health care system.

OBJECTIVES: We assessed the utilization of home care by the elderly in Brazil after implementation of the Family Health Strategy (FHS). METHODS: Data were derived from a cross-sectional study in a southern city in Brazil. Using the χ(2) test and a logistic regression with different levels of determination, we tested the hypothesis that the FHS increased the utilization of home care compared with utilization under the Traditional Primary Health Care (TPHC) system. RESULTS: We interviewed 1593 residents aged 60 years and older. Home care utilization under the FHS was 2.7 times the rate of utilization under the TPHC (95% confidence interval = 1.5, 4.7; P = .001), and utilization increased among the older group, the less educated, those with history of hospitalization, and those with functional limitations. CONCLUSIONS: Improvement in access to care resulted in greater utilization of home care. Our findings have policy implications that include expanding the coverage of the FHS throughout big cities where coverage is limited. These findings are important because the population is aging and the family strategy operates in poorer areas; thus, it can promote equity in access to home health care among the elderly.

Developing a local public health infrastructure: the Maine Turning Point experience.

This article describes the efforts of public health leaders to develop local public health capacity across Maine. More than 200 individuals representing both government and nongovernmental organizations became engaged in The Robert Wood Johnson Foundation-sponsored Turning Point project in 1999. In recent years, the state has had only two local (city) health departments, only one of substantial capacity covering an extremely small proportion of the total state population. This article describes Maine Turning Point organizational efforts, challenges, successes, and failures, from the perspective of 3 individuals involved in the process. Five years later, a new network of state-financed, community-based partnerships focused on chronic disease risk factors has been established, apparently strong enough politically to survive in an era of severe state budget cuts. Tobacco use has been reduced. Many other serious public health issues, however, from obesity to mental illness and substance abuse, remain to be successfully addressed. The development of a sustainable statewide network of local agencies providing the essential public health services remains an elusive goal.