Are Population-Level Approaches to Dementia Risk Reduction Under-Researched? A Rapid Review of the Dementia Prevention Literature.

Dementia is forecast to become increasingly prevalent, particularly in low- and middle-income countries, and is associated with high human and economic costs. Primary prevention of dementia -preventing risk factors leading to disease development - is an emerging global public health priority. Primary prevention can be achieved in two ways: individual-level or population-level. In this rapid review, we quantify the proportion of contributing interventional evidence to the dementia primary prevention literature that is concerned with either approach. We searched Medline, the National Institute for Health and Care Excellence, Cochrane, the World Health Organization, and Google to identify systematic reviews that described primary prevention interventions for dementia. We used search terms related to dementia risk reduction, intervention/policy, and review. We analysed reference lists of included dementia prevention reviews to identify contributing primary prevention evidence, and categorised these as either individual-level or population-level. Additionally, we examined search strategies to investigate the likelihood of reviews identifying available population-level interventions. We included twelve of the 527 articles retrieved. Population-level evidence was summarised by only two reviews. In these two reviews, <2.5% of the interventions described where population-level interventions. Most search strategies were weighted towards identifying individual-level evidence. Existing systematic reviews of dementia primary prevention interventions include almost no population-level evidence. Correction of this imbalance is needed to ensure that dementia prevention policies can achieve meaningful reductions in the prevalence of, and inequalities in, dementia.

What is a population-level approach to prevention, and how could we apply it to dementia risk reduction?

The World Health Organisation's 2022 'blueprint for dementia research' highlights the need for more research into population-level risk reduction. However, definitions of population-level prevention vary, and application to dementia is challenging because of its multi-factorial aetiology and a maturing prevention evidence base. This paper compares and contrasts key concepts of 'population-level prevention' from the literature, explores related theoretical models and policy frameworks, and applies this to dementia risk reduction. We reach a proposed definition of population-level risk reduction of dementia, which focusses on the need to change societal conditions such that the population is less likely to develop modifiable risk factors known to be associated with dementia, without the need for high-agency behaviour change by individuals. This definition, alongside identified policy frameworks, can inform synthesis of existing evidence and help to co-ordinate the generation of new evidence.

Whole systems approach to diet and healthy weight: a longitudinal process evaluation in East Scotland.

AIMS: Obesity contributes to morbidity and early mortality, affecting people of all ages and sociodemographic backgrounds. Despite attempts to address obesity, efforts to date have only had limited success. Adopting a whole systems approach (WSA) may potentially address obesity and emphasise complex inter-relating factors beyond individual choice. This study aimed to assess implementation of WSA to diet and healthy weight in two council areas of Scotland, longitudinally exploring enablers and barriers. One area followed a Leeds Beckett WSA model (LBM) of implementation, while the other used a hybrid model incorporating existing working systems. METHODS: To assess the process of implementing a WSA, interviews and focus groups were conducted after initiation and 1 year later. RESULTS: Main enablers included: belief in WSA effectiveness; positive relationships between key personnel; buy-in at community and national levels; funding availability; the working group responsible for coordinating the system development comprising individuals with diverse expertise; good communication; and existing governance structures. Barriers included: insufficient funding; high staff turnover; inadequate training in WSA methodology; engaging all relevant stakeholders and reverting to 'old ways' of non-WSA working. The LBM provided a framework for system setup and generating an action plan. CONCLUSION: This study provides the first independent longitudinal process evaluation of WSAs that have incorporated Leeds Beckett methodology, and offers insights into how a WSA can be implemented to address diet and healthy weight.

Prehistoric deforestation at Chaco Canyon?

Ancient societies are often used to illustrate the potential problems stemming from unsustainable land-use practices because the past seems rife with examples of sociopolitical "collapse" associated with the exhaustion of finite resources. Just as frequently, and typically in response to such presentations, archaeologists and other specialists caution against seeking simple cause-and effect-relationships in the complex data that comprise the archaeological record. In this study we examine the famous case of Chaco Canyon, New Mexico, during the Bonito Phase (ca. AD 860-1140), which has become a prominent popular illustration of ecological and social catastrophe attributed to deforestation. We conclude that there is no substantive evidence for deforestation at Chaco and no obvious indications that the depopulation of the canyon in the 13th century was caused by any specific cultural practices or natural events. Clearly there was a reason why these farming people eventually moved elsewhere, but the archaeological record has not yet produced compelling empirical evidence for what that reason might have been. Until such evidence appears, the legacy of Ancestral Pueblo society in Chaco should not be used as a cautionary story about socioeconomic failures in the modern world.

Parental perceptions regarding healthy behaviours for preventing overweight and obesity in young children: a systematic review of qualitative studies.

Evidence is increasingly pointing towards the importance of early life strategies to prevent childhood overweight and obesity. This systematic review synthesizes qualitative research concerning parental perceptions regarding behaviours for preventing overweight and obesity in young children. During May and June 2008, a range of electronic databases were searched and together with lateral searching techniques 21 studies were identified for review. Data extraction and synthesis using thematic content analysis revealed six organizing and 32 finer level themes. These related to child factors, family dynamics, parenting, knowledge and beliefs, extra-familial influences and resources and environment. Themes were mapped to a socioecological model which illustrated how factors at individual, interpersonal, community, organizational and societal levels interact in complex ways to impact on parental perceptions about healthy behaviours for preventing child overweight. Although parents suggested several ideas to promote healthy child weight-related behaviours, many of their views concerned perceived barriers, some of which may be amenable to practical intervention. Furthermore, intergenerational influences on parental health beliefs and knowledge suggest that health promotion strategies may be more effective if directed at the wider family, rather than parents alone. Significantly, many parents believed strategies to promote healthy weight should start early in a child's life.

Exploring the limitations of an adult-led agenda for understanding the health behaviours of young people.

Public health and health promotion agendas are usually determined by adults, even when the 'target' population is children and young people. Adult-centred frameworks for health maintenance and the promotion of well-being risk ignoring young people's conceptualizations and experiences of health and health-relevant behaviours. However, the current policy emphasis in the UK and elsewhere apparently seeks to position young people at the centre of their own health-related decisions. Building on the United Nations Convention on the Rights of the Child, this paper examines and critiques policies relating to young people in UK, European and worldwide contexts. This paper then introduces data from two qualitative studies conducted in the UK. These studies illustrate that young people's definitions of health often run counter to prevailing public health and health promotion discourses. Young people do, however, often exhibit strategies for managing their health, even though they are frequently restricted by the perceptions that adults have about their lives and behaviour. This paper argues that the new policy discourse is not yet being systematically turned into action to give all young people a voice. This is important to begin to understand young people's perspectives about what matters to them and what really influences their health behaviours.

The influence of the secondary school setting on the food practices of young teenagers from disadvantaged backgrounds in Scotland.

In this paper, we explore the secondary school environment as an important context for understanding young teenagers' eating habits and food practices. We draw on data collected during semi-structured interviews with 36 young teenagers (aged 13/14 years) living in disadvantaged circumstances in Scotland. We found that the systems inherent in school had an impact on what, where and when participants ate their lunch. Each school had rules governing use of the school dining hall and participants sometimes chose to leave this environment to buy food outside school premises. Our interviews showed that parents determined how much money young people took to school and, therefore, had some control over their food choices. Participants rarely spoke of giving priority to food and eating during the non-curriculum parts of the school day, preferring to spend time 'hanging out' with friends. Eating with friends was sometimes reported as a cause of anxiety, particularly when participants had concerns about body image, appetite or appearance. We suggest that young teenagers' dislike for queuing for food, their ability to budget for food at school and their desire to maximize time spent with friends influence food choices; therefore, these are issues which have implications for health education and will be of interest to those responsible for school meal provision.

Arbovirus surveillance in South Carolina, 1996-98.

Arboviruses isolated and identified from mosquitoes in South Carolina (USA) are described, including new state records for eastern equine encephalitis virus (EEE), St. Louis encephalitis virus (SLE), Flanders virus, Tensaw virus (TEN), and a variant of Jamestown Canyon virus (JC). Mosquitoes were collected at 52 locations in 30 of 46 South Carolina counties beginning in June 1996, and ending in October 1998, and tested for arboviruses. Of 1,329 mosquito pools tested by virus isolation (85,806 mosquitoes representing 34 mosquito species or complexes), 15 pools were positive. Virus isolations included EEE from 1 pool each of Anopheles crucians complex and Culex erraticus; a variant of JC from 1 pool of An. crucians complex; a California serogroup virus from 1 pool of Aedes atlanticus/tormentor; TEN from 5 pools of An. crucians complex and 1 pool each of Culex salinarius and Psorophora ciliata; Flanders virus from 1 pool of Culiseta melanura; and Potosi virus from 1 pool each of Aedes vexans, Coquillettidia perturbans, and Psorophora columbiae. Of 300 mosquito pools tested by antigen-capture assay for EEE and SLE (14,303 mosquitoes representing 16 mosquito species or complexes), 21 were positive for EEE and I was positive for SLE. Positive EEE mosquito pools by antigen-capture assay included An. crucians complex (14 pools), Anopheles punctipennis (1 pool), Anopheles quadrimaculatus (1 pool), Cq. perturbans (4 pools), and Cs. melanura (1 pool). One pool of Cx. salinarius was positive for SLE by antigen-capture assay. Arbovirus-positive mosquito pools were identified from 12 South Carolina counties, all located in the Atlantic Coastal Plain, and from 4 of 8 Carolina bays surveyed.

The fleas (Siphonaptera) of South Carolina with an assessment of their vectorial importance.

We document 25 species of fleas from South Carolina including new state records for two species, the ctenophthalmids Epitedia cavernicola and Rhadinopsylla orama. Host and other collection data, by county, are provided, including many new records amassed from 1992-1998 and some older records gleaned from the Clemson University Arthropod Collection. One flea species, the rhopalopsyllid Polygenis gwyni, is especially common and widespread in South Carolina, particularly on the cotton rat (Sigmodon hispidus) in coastal plain habitats. The largest number of flea species (8) from a single host species was recorded from the cotton mouse, Peromyscus gossypinus. Several flea species of potential medical or veterinary importance were recorded, some of which are potential vectors of pathogens, such as the agents of murine typhus, murine typhus-like disease, sylvatic epidemic typhus, cat scratch disease, and rodent bartonellosis. A host-flea list for South Carolina is included.

Ticks of South Carolina (Acari: Ixodoidea).

County and host records are reported for 19 species of ticks from South Carolina: Amblyomma americanum, Amblyomma maculatum, Amblyomma tuberculatum, Aponomma latum, Boophilus annulatus, Boophilus microplus, Dermacentor albipictus, Dermacentor variablis, Haemaphysalis leporispalustris, Ixodes affinis, Ixodes brunneus, Ixodes cookei, Ixodes marxi, Ixodes minor, Ixodes scapularis, Ixodes texanus, Ixodes woodi, Rhipicephalus sanguineus, and Ornithodoros capensis. Ixodes woodi is recorded from South Carolina for the first time. Boophilus annulatus and Boophilus microplus probably no longer exist in South Carolina, and Aponomma latum is an exotic species that is not established in South Carolina. Brief notes follow each species.

The Taps Project 40: quality of care provisions for the elderly mentally ill--traditional vs alternative facilities.

The study evaluates some aspects of care reprovision for psychogeriatric patients. Seven hospital wards are compared with four community settings, established as part of the reprovision programme for Friern Hospital in London. Each facility was assessed for policy and programme, social climate and physical characteristics; staff attitudes in regard to their tasks, training needs and job satisfaction were also explored. Community settings were superior to hospital wards in providing more privacy for the residents and were better equipped with physical amenities and safety features. There were relatively small differences between the way staff perceived the social climate in community homes and in hospital. The former were regarded as encouraging greater independence. Care staff in the hospital were more likely to express dissatisfaction with pay, working conditions and social status, while community staff were more dissatisfied with the quality of cooperation between staff members. Clients transferred to Social Services facilities had a higher level of functioning and needed less on-site medical care. This was further reflected by the lower frequency of nursing care tasks being performed by staff in community facilities. Overall, the shift towards a less medical model of care in community-based homes appears to be beneficial to psychogeriatric patients, provided that current and prospective physical needs of the residents are adequately addressed.

TAPS project 28: does reprovision benefit elderly long-stay mental patients?

A survey of all inpatients aged 70 years or more was conducted in one of London's mental hospitals in 1989. Baseline measures of cognitive and behavioural disabilities were established for each of the 130 functionally-ill long-stay patients. Three years later 71 patients were still alive, being equally distributed between hospital and community facilities. The study examines the outcomes of patients who had left hospital in comparison with a similar group who remained there. The results indicate that behaviour of patients who were settled in the community was stable and even improved slightly over time, as opposed to those who remained in hospital, who became more disturbed. Direct examinations demonstrate that while those who remained in hospital markedly deteriorated in their cognitive function, patients who left hospital had also declined, but to a much lesser extent. When considering the overall outcomes, we come to recognise the potential for stabilization and even improvement in the condition of ageing schizophrenics being moved from hospital to the community.

Quality of life of long-stay patients discharged from two psychiatric institutions.

OBJECTIVE: The study compared the quality of life of long-stay psychiatric patients after they had been discharged to community residences for one year with that of long-stay patients who remained hospitalized. METHODS: Long-stay patients (that is, those with stays of at least one year) who were discharged from two psychiatric hospitals in London were closely matched with patients likely to stay in the hospital for another year. Baseline (in-hospital) and one-year follow-up assessments were conducted using six instruments to measure factors related to quality of life such as problems in social functioning and size of the social network. RESULTS: A total of 494 discharged patients were compared with 279 patients who remained in the hospital. The death rate did not differ between the two groups. Only six discharged patients became vagrants, and only two were imprisoned, one briefly. Discharged patients were living under much less restrictive conditions, they preferred their life in the community, and the number of their friends increased, as did the number of acquaintances in the community such as neighbors. No adverse effects of discharge on mental state or social behavior were noted. CONCLUSIONS: The results indicate that community care is a beneficial alternative to long-term care in psychiatric hospitals for the majority of patients, provided it is well planned and adequate resources are available.

The TAPS Project. 10: The long-stay populations of Friern and Claybury hospitals. The baseline survey.

As part of the TAPS project, the baseline long-stay populations of Friern and Claybury Hospitals were compared using the TAPS assessment schedules. Each hospital has reduced bed numbers by two-thirds, and although the two have been subjected to different influences, their remaining long-stay patients were similar, and characterised by severe problems with hygiene, florid psychotic symptoms, a high prevalence of negative symptoms, and impoverished social networks.

The TAPS Project. 13: Clinical and social outcomes of long-stay psychiatric patients after one year in the community.

The first prospective, controlled study of a large, long-stay, in-patient population as their hospital services were reprovided in the community is reported. Two-hundred-and-seventy-eight patients were matched individually with similar patients who remained in hospital. Clinical and social outcomes over a one-year follow-up are presented for the first three years of the reprovision process. Compared with matches, the leavers at follow-up had more diverse social networks that contained a higher proportion of contacts named as friends. The care facilities in the community allowed more opportunities for patient autonomy than the hospitals across all aspects of the environments measured. At follow-up, more leavers than matches wanted to remain in their current placement, while fewer leavers than matches said there was nothing they liked about their current placement. More leavers than matches found their medication helpful.

The TAPS Project. 4: An observational study of the social life of long-stay patients.

Observations of long-stay patients in a club in a psychiatric hospital were carried out unobtrusively over several months. Much of the social activity that went on was stimulated by an economy based around the purchase and exchange of tea and cigarettes, and the borrowing and lending of small change. Most patients could be fitted into one of four social categories: helpers, friends, nuisances, and the asocial. The inter-rater reliability of the observations was found to be 0.95. A close correspondence emerged between the observations of patients' social behaviour and material reported by patients when interviewed with the Social Network Schedule.

The TAPS Project. 5: The structure of social-network data obtained from long-stay patients.

The Social Network Schedule was successfully completed on 489 (64%) of 770 long-stay patients in Friern and Claybury Hospitals and the data on 3774 social contacts of the patients subjected to log-linear modelling. This showed that the category 'confidant' was salient in understanding the data. Latent-class analysis highlighted the importance of the nature of the social interaction between patients and their contacts. In particular, non-verbal exchanges of goods and services emerged as important in creating social bonds.

The TAPS project. 3: Predicting the community costs of closing psychiatric hospitals.

The planning of long-term care in the community as an alternative to in-patient care requires accurate information on the likely expense of altering the balance of provision. Unfortunately, as very few long-stay psychiatric hospitals have yet closed, the planning of these resource requirements has had to proceed in a vacuum. By examining the costs of community reprovision for the first 136 people to leave Claybury and Friern Hospitals, a prediction equation has been estimated from existing data which links the hospital-assessed characteristics (including psychiatric symptoms and behavioural problems) of these people to the subsequent cost of community care. About a third of the observed variation in these costs can be explained statistically by these 'baseline' characteristics. However, the first cohorts exhibit fewer behavioural problems and other symptoms of mental illness, they have been in hospital for shorter lengths of time, and they are younger. The prediction equation for the leavers is thus used to extrapolate community costs for those hospital residents yet to leave. It is found that community costs are lower than hospital costs, not just for the first cohorts of leavers, but for the full populations of the two hospitals scheduled to close.

Which patients first: a study from the closure of a large psychiatric hospital.

The decision to close down large psychiatric hospitals has led to many districts determining current patient dependency levels by conducting surveys of their hospital inpatient populations. This paper reports on the Claybury Hospital survey, which used Baker and Hall's REHAB scale to measure the level of patient functioning. The 641 patients assessed comprised the total long-stay and elderly, mentally-ill population of the hospital, excluding only patients on admission wards. Of these, 403 (63%) patients were in the 'severe handicap' category. In contrast, only 97 (15%) had 'potential for discharge'. A comparison of Claybury scores with those from other hospitals suggests that Claybury patients function at a lower level. Evidence is presented of 'creaming off' with respect to how one particular district has chosen patients, and this leaves behind an increasingly disabled hard core of patients. These findings are discussed and compared with other similar studies, and with respect to the Government's care in the Community policy.