The key values and factors identified by older adults to promote physical activity and reduce sedentary behaviour using co-production approaches: a scoping review.

BACKGROUND: Inactivity and sedentary behaviour in older adults adversely impacts physical function, reduces social networks, and could contribute to population healthcare costs. To encourage and support the planning and uptake of physical activity by older adults, it is important to understand what physical activity means to older adults. Therefore, the aim of this scoping review was to collate what older adults have self-identified as the key factors for sustaining and increasing their physical activities. METHODS: Arksey and O'Malley's Scoping Review framework was used to guide the review process. SCOPUS, ASSIA, PsychINFO and MEDLINE databases were searched. Studies were eligible for inclusion if they were peer-reviewed, the target population were older adults (aged 55 and above), co-production related research approaches were explicitly stated in the methods and there was a focus on design of physical activity interventions or products to support or enhance physical activity. Assets and values important for physical activity were first extracted from included studies and were subsequently thematically analysed. Themes are presented to provide an overview of the literature synthesis. RESULTS: Sixteen papers were included in the analysis. Data from these papers were gathered via designing interventions or services (n = 8), products (n = 2), 'exergames' (n = 2) or mobile applications (n = 4). Outcomes were varied but common themes emerged across papers. Overarching themes identified by older adults were associated with a desire to increase activity when it was accessible, motivational, and safe. In addition, older adults want to enjoy their activities, want independence and representation, want to stay connected with families and friends, be outdoors, familiarity, activities to be tailored and resulting in measurable/observed progress. CONCLUSIONS: Population demographics, personal attributes, and life experiences all affect preferences for physical activity. However, the key factors identified by older adults for increasing physical activity were common-even in separate co-production contexts. To promote physical activities in older adults, activities must fundamentally feel safe, provide a sense of social connectedness, be enjoyable and be accessible in terms of cost and ability.

Implementation of a medicine management plan (MMP) to reduce medication-related harm (MRH) in older people post-hospital discharge: a randomised controlled trial.

BACKGROUND: Medication-related harm (MRH) is an escalating global challenge especially among older adults. The period following hospital discharge carries high-risk for MRH due to medication discrepancies, limited patient/carer education and support, and poor communication between hospital and community professionals. Discharge Medical Service (DMS), a newly introduced NHS scheme, aims to reduce post-discharge MRH through an electronic communication between hospital and community pharmacists. Our study team has previously developed a risk-prediction tool (RPT) for MRH in the 8-weeks period post discharge from a UK hospital cohort of 1280 patients. In this study, we aim to find out if a Medicines Management Plan (MMP) linked to the DMS is more effective than the DMS alone in reducing rates of MRH. METHOD: Using a randomized control trial design, 682 older adults ≥ 65 years due to be discharged from hospital will be recruited from 4 sites. Participants will be randomized to an intervention arm (individualised medicine management plan (MMP) plus DMS) or a control arm (DMS only) using a 1:1 ratio stratification. Baseline data will include patients' clinical and social demographics, and admission and discharge medications. At 8-weeks post-discharge, a telephone interview and review of GP records by the study pharmacist will verify MRH in both arms. An economic and process evaluation will assess the cost and acceptability of the study methods. DATA ANALYSIS: Univariate analysis will be done for baseline variables comparing the intervention and control arms. A multivariate logistic regression will be done incorporating these variables. Economic evaluation will compare the cost-of-service use among the study arms and modelled to provide national estimates. Qualitative data from focus-group interviews will explore practitioners' understanding, and acceptance of the MMP, DMS and the RPT. CONCLUSION: This study will inform the use of an objective, validated RPT for MRH among older adults after hospital discharge, and provide a clinical, economic, and service evaluation of a specific medicines management plan alongside the DMS in the National Health Service (UK).

Towards an Understanding of Population Health Data in a Single NHS Trust during COVID-19.

The objective of this study was to determine the further care needs of people discharged from the hospital following a COVID-19 illness from April-September 2020. Methods: In partnership with an NHS trust in the UK, data analysis was undertaken by linking data from the Trust, to facilitated a triage process. The intention was to provide information in a format that enabled an examination of the population data and highlight any inequality in provision. Data were mapped onto the indices of multiple deprivation, and a range of text and graphical methods were used to represent the population data to the hospital leadership. The visual representation of the demographics and deprivation of people discharged during a critical period of the pandemic was intended to support planning for community services. The results demonstrated that just under half of those discharged were from the poorest fifth of the English population and that just under half were aged 75 or older. This reflected the disproportional effect of COVID-19 on those who were poorer, older or had pre-existing multiple morbidities. Referral to community or outpatient services was informed by the analysis, and further understanding of the diversity of the population health was established in the Trust. Conclusion: By identifying the population and mapping to the IMD, it was possible to show that over half of discharged patients were from deprived communities, and there was significant organisational learning bout using data to identify inequalities.. The challenge of planning services that target underserved communities remains an important issue following the pandemic, and lessons learnt from one health system are being shared.

Thermal Sensation in Older People with and without Dementia Living in Residential Care: New Assessment Approaches to Thermal Comfort Using Infrared Thermography.

The temperature of the indoor environment is important for health and wellbeing, especially at the extremes of age. The study aim was to understand the relationship between self-reported thermal sensation and extremity skin temperature in care home residents with and without dementia. The Abbreviated Mental Test (AMT) was used to discriminate residents to two categories, those with, and those without, dementia. After residents settled and further explanation of the study given (approximately 15 min), measurements included: tympanic membrane temperature, thermal sensation rating and infrared thermal mapping of non-dominant hand and forearm. Sixty-nine afebrile adults (60-101 years of age) were studied in groups of two to five, in mean ambient temperatures of 21.4-26.6 °C (median 23.6 °C). Significant differences were observed between groups; thermal sensation rating (p = 0.02), tympanic temperature (p = 0.01), fingertip skin temperature (p = 0.01) and temperature gradients; fingertip-wrist p = 0.001 and fingertip-distal forearm, p = 0.001. Residents with dementia were in significantly lower air temperatures (p = 0.001). Although equal numbers of residents per group rated the environment as 'neutral' (comfortable), resident ratings for 'cool/cold' were more frequent amongst those with dementia compared with no dementia. In parallel, extremity (hand) thermograms revealed visual temperature demarcation, variously across fingertip, wrist, and forearm commensurate with peripheral vasoconstriction. Infrared thermography provided a quantitative and qualitative method to measure and observe hand skin temperature across multiple regions of interest alongside thermal sensation self-report. As an imaging modality, infrared thermography has potential as an additional assessment technology with clinical utility to identify vulnerable residents who may be unable to communicate verbally, or reliably, their satisfaction with indoor environmental conditions.

Remote Assessment of Functional Mobility and Strength in Older Cancer Survivors: Protocol for a Validity and Reliability Study.

BACKGROUND: Older cancer survivors, faced with both age- and treatment-related morbidity, are at increased and premature risk for physical function limitations. Physical performance is an important predictor of disability, quality of life, and premature mortality, and thus is considered an important target of interventions designed to prevent, delay, or attenuate the physical functional decline. Currently, low-cost, valid, and reliable methods to remotely assess physical performance tests that are self-administered by older adults in the home-setting do not exist, thus limiting the reach, scalability, and dissemination of interventions. OBJECTIVE: This paper will describe the rationale and design for a study to evaluate the accuracy, reliability, safety, and acceptability of videoconferencing and self-administered tests of functional mobility and strength by older cancer survivors in their own homes. METHODS: To enable remote assessment, participants receive a toolkit and instructions for setting up their test course and communicating with the investigator. Two standard gerontologic performance tests are being evaluated: the Timed Up and Go test and the 30-second chair stand test. Phase 1 of the study evaluates proof-of-concept that older cancer survivors (age ≥60 years) can follow the testing protocol and use a tablet PC to communicate with the study investigator. Phase 2 evaluates the criterion validity of videoconference compared to direct observation of the two physical performance tests. Phase 3 evaluates reliability by enrolling 5-10 participants who agree to repeat the remote assessment (without direct observation). Phase 4 enrolls 5-10 new study participants to complete the remote assessment test protocol. Feedback from participants in each phase is used to refine the test protocol and instructions. RESULTS: Enrollment began in December 2019. Ten participants completed the Phase 1 proof-of-concept. The study was paused in mid-March 2020 due to the COVID-19 pandemic. The study is expected to be completed by the end of 2020. CONCLUSIONS: This validity and reliability study will provide important information on the acceptability and safety of using videoconferencing to remotely assess two tests of functional mobility and strength, self-administered by older adults in their homes. Videoconferencing has the potential to expand the reach, scalability, and dissemination of interventions to older cancer survivors, and potentially other older adults, especially in rural areas. TRIAL REGISTRATION: ClinicalTrials.gov NCT04339959; https://clinicaltrials.gov/ct2/show/NCT04339959. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20834.

Potential for Digital Monitoring to Enhance Wellbeing at Home for People with Mild Dementia and Their Family Carers.

Digital technologies have the potential to assist people with dementia to monitor day to day activities and mitigate the risks of living independently. This purposive pilot study surveyed participants for frailty, wellbeing, and perceived carer burden using the 3Rings™ digital plug. 30 paired participants used the digital device for four months. People with dementia reported a decline in wellbeing and increased frailty. Family carers reported a decline in wellbeing but 18 reported a reduction in burden. The use of digital monitoring by family carers demonstrated a reduction in their perceived burden and the device was acceptable to people with mild dementia living alone.

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review.

BACKGROUND: Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medication adherence amongst older, community dwelling adults. METHODS: A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers were searched between May and December 2017. Results were double screened in accordance with pre-defined inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was performed in accordance with the PRISMA reporting statement. RESULTS: A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13 countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners (GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was reported as a secondary outcome in all but one study. CONCLUSIONS: There is insufficient evidence to show that deprescribing improves medication adherence. Only 13 studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend further study into the efficacy and outcomes of medicines management interventions. A consensus on priority outcome measurements for prescribed medications is indicated. TRIAL REGISTRATION: PROSPERO number CRD42017075315.

Who attends out-of-hours general practice appointments? Analysis of a patient cohort accessing new out-of-hours units.

OBJECTIVES: This report describes the patients who used additional out-of-hours (OOH) appointments offered through a UK scheme intended to increase patient access to primary care by extending OOH provision. DESIGN: Cohort study and survey data. SETTING: OOH appointments offered in four units in one region in England (October 2015 to November 2016). METHODS: Unidentifiable data on all patients were abstracted from a bespoke appointment system and the responses to a patient opinion questionnaire about this service. Descriptive analysis of the appointment data was conducted. Multivariate analysis of the opinion survey data examined the characteristics of the patients who would have gone to the emergency department (ED) had the OOH appointments not been available. RESULTS: There were 24 448 appointments for 19 701 different patients resulting in 29 629 service outcomes. Women dominated the uptake and patients from the poorest fifth of the population used nearly 40% of appointments. The patient survey found OOH appointments were extremely popular-93% selecting 'extremely likely' or 'likely' to recommend the service. Multivariate analysis of patient opinion survey data on whether ED would have been an alternative to the OOH service found that men, young children, people of Asian heritage and the most deprived were more likely to have gone to ED without this service. CONCLUSIONS: The users of the OOH service were substantially different from in-hours service users with a large proportion of children under age 5, and the poor, which support the idea that there may be unmet need as the poor have the least flexible working conditions. These results demonstrate the need for equality impact assessment in planning service improvements associated with policy implementation. It suggests that OOH need to take account of patients expectations about convenience of appointments and how patients use services for urgent care needs.

Factors affecting decisions to extend access to primary care: results of a qualitative evaluation of general practitioners' views.

OBJECTIVES: To report general practitioners' (GPs') views and experiences of an Enhanced Primary Care programme (EPCP) funded as part of the Prime Minister's Challenge Fund (second wave) for England which aimed to extend patient access to primary care. SETTING: Primary care in Sheffield, England. PARTICIPANTS: Semi-structured interviews with a purposive sample of GPs working in 24 practices across the city. RESULTS: Four core themes were derived: GPs' receptivity to the aims of the EPCP, their capacity to support integrated care teams, their capacity to manage urgent care and the value of some new community-based schemes to enhance locality-based primary care. GPs were aware of the policy initiatives associated with out-of-hours access that aimed to reduce emergency department and hospital admissions. Due to limited capacity to respond to the programme, they selected elements that directly related to local patient demand and did not increase their own workload. CONCLUSIONS: The variation in practice engagement and capacity to manage changes in primary care services warrants a subtle and specialist approach to programme planning. The study makes the case for enhanced planning and organisational development with GPs as stakeholders within individual practices and groups. This would ensure that policy implementation is effective and sustained at local level. A failure to localise implementation may be associated with increased workloading in primary care without the sustained benefits to patients and the public. To enable GPs to become involved in systems transformation, further research is needed to identify the best methods to engage GPs in programme planning and evaluation.

Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial.

PURPOSE: This randomized trial compared 6- and 12-month outcomes of a home-based psychoeducational program to mailed information provided to 159 survivors of stroke (SS) and their spousal caregivers (CG). METHODS: SS (age 50+) and CG were recruited as dyads post-discharge from inpatient rehabilitation. All dyads received mailed information for 12 months. Dyads randomized to the home-based group received an average of 36.7 h of psychoeducation over 6 months. Health status, depression, stress, burden, coping, support, mutuality and function were obtained on all dyads. Repeated measures analysis with linear mixed models was used to compare the groups for change over time in the outcome variables. RESULTS: Both groups demonstrated less depression and stress over time. Compared to the mailed information group, SS in the home-based group demonstrated significantly improved self-reported health and cognitive function; CG demonstrated significantly improved self-reported health and coping strategies. Mutuality and social support decreased in both groups. CONCLUSIONS: The home-based intervention was effective in improving self-reported health, coping skills in CG and cognitive functioning in SS. However, the finding that dyads in both groups demonstrated decreased depression and stress suggests that providing repeated doses of relevant, personalized information by mail may result in positive changes. IMPLICATIONS FOR REHABILITATION: A stroke affects both the stroke survivor and the spousal caregiver, so nurses and therapists should use multicomponent strategies to provide education, support, counseling and linkages to community resources to ease the transition from hospital to home. Stroke may have a negative impact on the dyad's relationship with each other and also on the availability of support people in their lives during the 12 months after hospital discharge. Comprehensive stroke programs should encourage dyads to attend support groups and to seek individual and group counseling, as needed. Establishing an ongoing relationship with stroke survivors and their spouses and providing relevant and engaging information by mail can reduce stress and depression over 12 months post-discharge at a minimal cost. Nurses and therapists should consider home visits post-discharge to reinforce education and skills taught in the hospital, increase self-reported health in stroke survivors and spousal CG, increase coping skills and to link the couple to community resources.

Health Impact Assessment, Physical Activity and Federal Lands Trail Policy.

OBJECTIVES: The objectives of this paper are to describe the application of Health Impact Assessment (HIA) to inform trail decisions affecting a rural, under-resourced community and propose the routine integration of HIAs to enhance NEPA environmental assessments and environmental impact statements for trail decisions on federal lands. METHODS: Screening, scoping, assessment, recommendations, reporting, monitoring and evaluation are being used to examine the health impact of trail location and design. RESULTS: HIA recommendations are being integrated into the public lands National Environmental Protection Act process for planning access to a new segment of the Continental Divide National Scenic Trail. Potential users from a nearby rural New Mexico community and a region of almost one million may benefit from this HIA-informed planning. CONCLUSIONS: HIA can be integrated into the policy and decision-making process for trails on public lands.

Introducing service improvement to the initial training of clinical staff.

BACKGROUND: It is well recognised in healthcare settings that clinical staff have a major influence over change in how services are provided. If a culture of systematic service improvement is to be established, it is essential that clinical staff have an understanding of what is required and their role in its application. METHODS: This paper describes the development of short educational interventions (a module of 6-8 contact hours or a longer module of 18-30 h) for inclusion in the initial training of future clinical staff (nursing, medicine, physiotherapy, occupational therapy, dietetics, social work, operating department practice, public health and clinical psychology) and presents the results of an evaluation of their introduction. Each module included teaching on process/systems thinking, initiating and sustaining change, personal and organisational development, and public and patient involvement. RESULTS: Over 90% of students considered the modules relevant to their career. Nearly 90% of students felt that they could put their learning into practice, although the actual rate of implementation of changes during the pilot period was much lower. The barriers to implementation most commonly cited were blocks presented by existing staff, lack of time and lack of status of students within the workforce. CONCLUSION: This pilot demonstrates that short educational interventions focused on service improvement are valued by students and that those completing them feel ready to contribute. Nevertheless, the rate of translation into practice is low. While this may reflect the status of students in the health service, further research is needed to understand how this might be enhanced.

Integrating formative assessment and participatory research: Building healthier communities in the CHILE Project.

BACKGROUND: The need to conduct formative assessment to inform the development of interventional studies has been increasingly recognized in community-based health research. While this purpose alone may provide sufficient justification to conduct formative assessment, researchers are also recognizing the importance of such efforts with regard to partnership building. PURPOSE: This article reports a formative assessment process in a large scale randomized controlled trial in New Mexico aimed at preventing obesity in rural American Indian and Hispanic children in Head Start programs. METHODS: We interviewed Head Start staff and conducted observations to understand the context of food service and physical activity in these sites. We also collected data from other community partners, including grocery store managers and primary care providers, to assess appropriate strategies regarding their engagement in the study. RESULTS: Formative assessment findings helped modify the planned intervention while allowing for variation relevant to cultural and Head Start organizational conditions in each community. Rather than view formative assessment only as a planning phase of the research, our experience illustrates the need to conceptualize these activities more broadly. DISCUSSION: Integrating formative assessment and participatory research raises the need to address the challenge of ensuring standardization and consistency across varied community settings, the evolving nature of initial formative relationships and the need to build trust in academic/community partnerships. TRANSLATION TO HEALTH EDUCATION PRACTICE: In our work with American Indian and Hispanic communities in New Mexico, formative assessment represents a partnership building opportunity.

Societal drivers in the applications of telehealth.

The application of telemedicine and e-health tools and the integration of these tools in healthcare is no longer a demonstration, pilot project, or idea. The changing landscape of humanity dictates that new solutions be implemented to address old problems. The landscape is changing with diminishing resources of fossil fuels, aging population, a shortage of skilled labor in healthcare (doctors, nurses, and allied health professionals), and emerging technologies for the personal space, culture, and consumer demand. All are key drivers in altering healthcare delivery, access, and education. The very foundation of medicine needs to change to meet these demands. Access using telehealth will widen and enable our ability to respond to public health issues. This paper addresses the many societal issues facing healthcare delivery and demonstrates how telehealth solutions are key components of the future of healthcare delivery across the globe.

Dissemination of physical activity promotion interventions in underserved populations.

Achieving minimum physical activity levels of 30 or more minutes per day will require a variety of intervention strategies to engage each segment of an aging and increasingly ethnically diverse U.S. population. This article presents a focused review of the sparse literature on the diffusion of evidence-based physical activity interventions that are culturally appropriate for underserved populations. Related literature and experiential insights inform this discussion, because so few published studies report outcome data beyond the first diffusion phase of intervention development and evaluation. Three brief case studies are presented to further illustrate and exemplify key concepts and processes at several different stages in diffusing physical activity interventions. Successful engagement of underserved populations reflects a delicate balance between embracing group customs and values and recognizing the nonmonolithic nature of any sociodemographically defined group. The costs of failing to promulgate effective physical activity interventions in these groups continue to mount, in dollars, health, and lives. Researchers, practitioners, decision makers, and policymakers must partner to bridge the evidentiary gap so that the physically active lifestyle choices become the easier choices.

Medications, comorbidities, and medical complications in stroke survivors: the CAReS study.

Stroke survivors enter rehabilitation units with many medical comorbidities and often experience significant complications during their stays. The 97 stroke survivors discharged home in this study received prescriptionsfor a mean of 11.3 medications from 5.4 different drug classifications. There were significant correlations between the number of comorbidities and after stroke complications and the number of different classifications of drugs that were ordered. This article (1) identifies the types of medications prescribed for stroke survivors who are being discharged home from rehabilitation, (2) explores correlations between medication prescriptions and the number of stroke-related comorbidities and medical complications, (3) identifies the cost of medications and the potential effect of medication costs on stroke survivors, and (4) discusses the nurse's role in preparing stroke survivors and their caregivers for medication use after discharge. Rehabilitation nurses bear the major responsibility for teaching stroke survivors and their caregivers about their discharge medications.

Environmental, policy, and cultural factors related to physical activity in sedentary American Indian women.

Focus group interviews were conducted to explore sociocultural, environmental, and policy-related determinants of physical activity among sedentary American Indian women. Thirty women aged 20 to 50 years (mean = 37.4 +/- 10.6 years) participated. Three sessions were conducted with women aged 20 to 34 years and three with women aged 35 to 50 to evaluate response differences by age. Because no obvious age differences were observed, data were pooled. Barriers to physical activity included inadequate support for household and child care responsibilities and difficulties balancing home-related and societal expectations with physical activity. In addition, women reported little support from their communities and work sites to be physically active. Environmental barriers included lack of safe outdoor areas and accessible walking trails. Weather and stray dogs were also commonly mentioned. Sociocultural barriers included giving family obligations priority above all other things, being expected to eat large portions of high-fat foods, and failing to follow a traditionally active lifestyle. Enablers of physical activity included support from family and coworkers and participation in traditional community events. Suggested intervention approaches included accessible and affordable programs and facilities, community emphasis on physical activity, and programs that incorporated the needs of larger women and of families. Participants emphasized a preference for programs that were compatible with the role expectations of their families and communities, and they expressed the desire for acceptance and encouragement to be physically active from the family, the community, the worksite, and their tribal leaders.

Food Perceptions and Dietary Behavior of American-Indian Children, Their Caregivers, and Educators: Formative Assessment Findings from Pathways.

Dietary findings from a school-based obesity prevention project (Pathways) are reported for children from six different American-Indian nations. A formative assessment was undertaken with teachers, caregivers, and children from nine schools to design a culturally appropriate intervention, including classroom curriculum, food service, physical education, and family components. This assessment employed a combination of qualitative and quantitative methods (including direct observations, paired-child in-depth interviews, focus groups with child caregivers and teachers, and semistructured interviews with caregivers and foodservice personnel) to query local perceptions and beliefs about foods commonly eaten and risk behaviors associated with childhood obesity at home, at school, and in the community. An abundance of high-fat, high-sugar foods was detected in children's diets described by caregivers, school food-service workers, and the children themselves. Although children and caregivers identified fruits and vegetables as healthy food choices, this knowledge does not appear to influence actual food choices. Frequent high-fat/high-sugar food sales in the schools, high-fat entrees in school meals, the use of food rewards in the classroom, rules about finishing all of one's food, and limited family resources are some of the competing factors that need to be addressed in the Pathways intervention.