Enhancing Capacity of Community-Academic Partnerships to Achieve Health Equity: Results From the CBPR Partnership Academy.

Community-based participatory research (CBPR) is an equitable partnership approach that links academic researchers, community organizations, and public health practitioners to work together to understand and address health inequities. Although numerous educational materials on CBPR exist, few training programs develop the skills and knowledge needed to establish effective, equitable partnerships. Furthermore, there are few professional development opportunities for academic researchers, practitioners, and community members to obtain these competencies in an experiential co-learning process. In response, the Detroit Community-Academic Urban Research Center developed the CBPR Partnership Academy, an innovative, yearlong capacity-building program facilitated by experienced community and academic partners, involving an intensive short course, partnership development, grant proposal preparation and funding, mentoring, online learning forums, and networking. Three diverse cohorts (36 teams) from 18 states and 2 tribal nations have participated. We describe the rationale and components of the training program and present results from the first two cohorts. Evaluation results suggest enhanced competence and efficacy in conducting CBPR. Outcomes include partnerships established, grant proposals submitted and funded, workshops and research conducted, and findings disseminated. A community-academic partner-based, integrated, applied program can be effective for professional development and establishing innovative linkages between academics and practitioners aimed at achieving health equity.

Reconciling Autonomy and Beneficence in Treatment Decision-Making for Companion Animal Patients.

This article explores how the concept of consent to medical treatment applies in the veterinary context, and aims to evaluate normative justifications for owner consent to treatment of animal patients. We trace the evolution of the test for valid consent in human health decision-making, against a backdrop of increased recognition of the importance of patient rights and a gradual judicial espousal of a doctrine of informed consent grounded in a particular understanding of autonomy. We argue that, notwithstanding the adoption of a similar discourse of informed consent in professional veterinary codes, notions of autonomy and informed consent are not easily transferrable to the veterinary medicine context, given inter alia the tripartite relationship between veterinary professional, owner and animal patient. We suggest that a more appropriate, albeit inexact, analogy may be drawn with paediatric practice which is premised on a similarly tripartite relationship and where decisions must be reached in the best interests of the child. However, acknowledging the legal status of animals as property and how consent to veterinary treatment is predicated on the animal owner's willingness and ability to pay, we propose that the appropriate response is for veterinary professionals generally to accept the client's choice, provided this is informed. Yet such client autonomy must be limited where animal welfare concerns exist, so that beneficence continues to play an important role in the veterinary context. We suggest that this 'middle road' should be reflected in professional veterinary guidance.

Contextualised care: faddish or foundational?

Members of Veterinary Humanities UK argue that contextualised care should be considered as foundational to morally and economically sustainable veterinary practice in today's changing world.

Supporting the case for 'progressive universalism' in health visiting: Scottish mothers and health visitors' perspectives on targeting and rationing health visiting services, with a focus on the Lothian Child Concern Model.

AIMS AND OBJECTIVES: To explore parents and professionals' experience of family assessment in health visiting (public health nursing), with a focus on the Lothian Child Concern Model. BACKGROUND: Health visitors currently assess families as requiring core, additional or intensive support, and offer support at a corresponding level. The majority of families are assessed as core and receive no pro-active support beyond the early days. Previous assessment tools, consisting of checklists, have been criticised as being ineffective in identifying a range of health needs and unacceptable to parents and health visitors. The Lothian Child Concern Model was developed and introduced in the study area to promote a partnership approach with parents and assess strengths as well as difficulties in parents' capacity to care for their child. METHODS: Qualitative methods were used. Ten mothers and 12 health visitors took part in individual semi-structured interviews. RESULTS: Most mothers were aware of the assessment process but some felt that they were not involved in the decision-making process. Explaining the assessment process to parents is problematic and not all health visitors do so. The assessment process was stressful for some mothers. Health visitors find the model useful for structuring and documenting the assessment process. Many believe that most families benefit from some support, using public health approaches. Health visitors said that families are often assessed as core because there are insufficient resources to support all those who meet the criteria of the additional category and that managers assess caseloads in terms of families with child protection concerns. CONCLUSIONS: The study findings significant the concept of 'progressive universalism' that provides a continuum that intensity of support to families, depending on need. Mothers would like better partnership working with health visitors. RELEVANCE TO CLINICAL PRACTICE: The study endorses proposed policy changes to re-establish the public health role of health visitors and to lower the threshold for families to qualify for support.

Building the foundation for equitable and inclusive research: Seed grant programs to facilitate development of diverse CBPR community-academic research partnerships.

Introduction: The effectiveness of community-based participatory research (CBPR) partnerships to address health inequities is well documented. CBPR integrates knowledge and perspectives of diverse communities throughout the research process, following principles that emphasize trust, power sharing, co-learning, and mutual benefits. However, institutions and funders seldom provide the time and resources needed for the critical stage of equitable partnership formation and development. Methods: Since 2011, the Detroit Urban Research Center, collaborating with other entities, has promoted the development of new community-academic research partnerships through two grant programs that combine seed funding with capacity building support from community and academic instructors/mentors experienced in CBPR. Process and outcomes were evaluated using mixed methods. Results: From 2011 to 2021, 50 partnerships received grants ranging from $2,500 to $30,000, totaling $605,000. Outcomes included equitable partnership infrastructure and processes, innovative pilot research, translation of findings to interventions and policy change, dissemination to multiple audiences, new proposals and projects, and sustained community-academic research partnerships. All partnerships continued beyond the program; over half secured additional funding. Conclusions: Keys to success included participation as community-academic teams, dedicated time for partnership/relationship development, workshops to develop equity-based skills, relationships, and projects, expert community-academic instructor guidance, and connection to additional resources. Findings demonstrate that small amounts of seed funding for newly forming community-academic partnerships, paired with capacity building support, can provide essential time and resources needed to develop diverse, inclusive, equity-focused CBPR partnerships. Building such support into funding initiatives and through academic institutions can enhance impact and sustainability of translational research toward advancing health equity.

Erratum: Building the foundation for equitable and inclusive research: Seed grant programs to facilitate development of diverse CBPR community-academic research partnerships - CORRIGENDUM.

[This corrects the article DOI: 10.1017/cts.2022.495.].

Using electronic health records to explore negotiations around euthanasia decision making for dogs and cats in the UK.

BACKGROUND: End-of-life decision making for animals happens daily in veterinary practice. However, access to such discussions as they happen is difficult, in view of the highly emotional circumstances of end-of-life consultations. Despite the expanding literature on euthanasia, few studies have explored the circumstances of euthanasia disagreement or delay. METHODS: To explore euthanasia discussions in veterinary practice, consultations recorded in electronic health records in a UK veterinary surveillance database (SAVSNET) were examined. From a sample of 2000 identified consultations, 69 canine and 76 feline consultations were purposively sampled for detailed thematic analysis. Specifically, consultations were selected if they involved a decision to delay euthanasia, including disagreement about the timing of euthanasia. RESULTS: Reasons identified for euthanasia refusal or delay included client-related factors (e.g., allowing other family members to say goodbye, differing opinions on the quality of life) and veterinary surgeon-related factors (eg, the wish to carry out further investigations or to try a new treatment). In the instance of refusal or delay, palliative treatment was commonly provided to preserve animal welfare. CONCLUSION: This study illustrates some of the processes used to negotiate end-of-life decision making in dogs and cats. Its findings shed light on the importance of palliative care in providing owners with time to decide.

Effectiveness of a Web-Based Provider Communications Platform in Reducing Hospital Readmissions Among Patients Receiving Dialysis: A Pilot Pre-Post Study.

Rationale & Objective: Suboptimal care coordination between dialysis facilities and hospitals is an important driver of 30-day hospital readmissions among patients receiving dialysis. We examined whether the introduction of web-based communications platform ("DialysisConnect") was associated with reduced hospital readmissions. Study Design: Pilot pre-post study. Setting & Participants: A total of 4,994 index admissions at a single hospital (representing 2,419 patients receiving dialysis) during the study period (January 1, 2019-May 31, 2021). Intervention: DialysisConnect was available to providers at the hospital and 4 affiliated dialysis facilities (=intervention facilities) during the pilot period (November 1, 2020-May 31, 2021). Outcomes: The primary outcome was 30-day readmission; secondary outcomes included 30-day emergency department visits and observation stays. Interrupted time series and linear models with generalized estimating equations were used to assess pilot versus prepilot differences in outcomes; difference-in-difference analyses were performed to compare these differences between intervention versus control facilities. Sensitivity analyses included a third, prepilot/COVID-19 period (March 1, 2020-October 31, 2020). Results: There was no statistically significant difference in the monthly trends in the 30-day readmissions pilot versus prepilot periods (-0.60 vs -0.13, P = 0.85) for intervention facility admissions; the difference-in-difference estimate was also not statistically significant (0.54 percentage points, P = 0.83). Similar analyses including the prepilot/COVID-19 period showed that, despite a substantial drop in admissions at the start of the pandemic, there were no statistically significant differences across the 3 periods. The age-, sex-, race-, and comorbid condition-adjusted, absolute pilot versus prepilot difference in readmissions rate was 1.8% (-3.7% to 7.3%); similar results were found for other outcomes. Limitations: Potential loss to follow-up and pandemic effects. Conclusions: In this pilot, the introduction of DialysisConnect was not associated with reduced hospital readmissions. Tailored care coordination solutions should be further explored in future, multisite studies to improve the communications gap between dialysis facilities and hospitals.

A Web-Based, Provider-Driven Mobile App to Enhance Patient Care Coordination Between Dialysis Facilities and Hospitals: Development and Pilot Implementation Study.

BACKGROUND: We piloted a web-based, provider-driven mobile app (DialysisConnect) to fill the communication and care coordination gap between hospitals and dialysis facilities. OBJECTIVE: This study aimed to describe the development and pilot implementation of DialysisConnect. METHODS: DialysisConnect was developed iteratively with focus group and user testing feedback and was made available to 120 potential users at 1 hospital (hospitalists, advanced practice providers [APPs], and care coordinators) and 4 affiliated dialysis facilities (nephrologists, APPs, nurses and nurse managers, social workers, and administrative personnel) before the start of the pilot (November 1, 2020, to May 31, 2021). Midpilot and end-of-pilot web-based surveys of potential users were also conducted. Descriptive statistics were used to describe system use patterns, ratings of multiple satisfaction items (1=not at all; 3=to a great extent), and provider-selected motivators of and barriers to using DialysisConnect. RESULTS: The pilot version of DialysisConnect included clinical information that was automatically uploaded from dialysis facilities, forms for entering critical admission and discharge information, and a direct communication channel. Although physicians comprised most of the potential users of DialysisConnect, APPs and dialysis nurses were the most active users. Activities were unevenly distributed; for example, 1 hospital-based APP recorded most of the admissions (280/309, 90.6%) among patients treated at the pilot dialysis facilities. End-of-pilot ratings of DialysisConnect were generally higher for users versus nonusers (eg, "I can see the potential value of DialysisConnect for my work with dialysis patients": mean 2.8, SD 0.4, vs mean 2.3, SD 0.6; P=.02). Providers most commonly selected reduced time and energy spent gathering information as a motivator (11/26, 42%) and a lack of time to use the system as a barrier (8/26, 31%) at the end of the pilot. CONCLUSIONS: This pilot study found that APPs and nurses were most likely to engage with the system. Survey participants generally viewed the system favorably while identifying substantial barriers to its use. These results inform how best to motivate providers to use this system and similar systems and inform future pragmatic research in care coordination among this and other populations.

Cyclic CINE-balanced steady-state free precession image intensity variations: implications for the detection of myocardial edema.

PURPOSE: To evaluate the dependence of CINE-balanced steady-state free precession (bSSFP) image intensities on spatial location, cardiac phase, and disease state. MATERIALS AND METHODS: Eight subjects with recent myocardial infarctions and eight age- and sex-matched normal volunteers were studied using CINE-bSSFP imaging to describe cyclic image intensity variations as a function of the cardiac cycle and to optimize and assess the ability of CINE-bSSFP imaging to depict myocardial edema. Signal intensities of the left ventricular (LV) bloodpool and myocardium were measured using region-of-interest analysis across the cardiac cycle. The magnitude and time course of the cyclic variations were evaluated. Mixed-model analysis of variance was used to examine the influence of physical location, cardiac phase, and presence of myocardial infarction. RESULTS: The LV bloodpool and myocardial CINE-bSSFP signal intensities varied significantly with spatial location, cardiac phase, and disease (P < 0.001). Cardiac phase had a significant effect on the signal intensities after adjustments for spatial location. The LV bloodpool signal decreased slowly during systole and rose sharply during LV filling. There were two distinct myocardial intensity peaks, one occurring at peak systole and the other at the end of the LV rapid inflow phase. Myocardial edema was seen as a hyperintense region. Image contrast with adjacent myocardium was the greatest at the end of systole. CONCLUSION: Detection of myocardial edema using the conventional CINE-bSSFP technique is feasible, but is complicated by normal cyclic changes in myocardial image intensities during the cardiac cycle.

Problems presented by medical students seeking support: a possible intervention framework.

BACKGROUND: Academically bright and ambitious medical students must cope with a combination of curriculum, assessment, career choice, personal, family and social pressures. Many seek support, and some present complex problems that consume substantial resources. A few continue unresolved into postgraduate life and may affect future professional performance. Early intervention may be helpful in minimising the impact on both individual students and school resources. AIM: To develop a broad classification framework for personal problems presented by medical students to student support services. METHODS: We report a study of more complex student problems presenting to student support services. A three stage iterative process, involving student support faculty from several international medical schools, discussed case scenarios based on pooled experience and developed a framework for categorising and considering management. RESULTS: Seven profiles of student problems were developed, based on composites of unidentified cases drawn from participants' experiences, reflecting: immaturity; learning skills; organisational skills; health or personal issues and poor insight. Broad characteristics and brief prognostic comments are provided for each profile. DISCUSSION: While profiles may overlap and each student may have a unique set of issues, there appears to be similarities that allow some categorisation for management strategies and prognostic features in both undergraduate and postgraduate medical education. Further work is needed to develop 'diagnostic' assessments that might guide intervention. CONCLUSION: This classification may assist early intervention into personal problems presented by medical students to student support services.

Professional boundary work in the face of change to generalist working in community nursing in Scotland.

AIM: The present study explored how community nurses and managers constituted changes towards generalist working. BACKGROUND: Following international trends moving from acute care towards community care, changes within community nursing in the United Kingdom have been subject to debate in recent years. Sociological insights into 'boundary work' in professional disciplines are informative for understandings about proposed new roles in community nursing. Recently, radical changes to the role of the community nurse from specialist disciplines to a generalist community health nurse model were proposed in Scotland and tested in four health boards. METHODS: Focus group discussions were held with 27 community nurses and semi-structured interviews with three managers during January-March 2009 in a purposive sample from one health board. Discussions were audio-recorded and transcribed verbatim. Initial thematic analysis was used to highlight key themes from the data and later a discursive analysis focused on the rhetorical strategies used by participants. FINDINGS: Four key themes were identified along with the rhetorical devices associated with these including: the undermining of the generalist model through the 'jack of all trades, master of none' metaphor through associations of loss of specialisms; how the re-establishment of specialist discipline boundaries occurred; how current roles were validated and how managers and nurses accounted for future changes to the profession. CONCLUSION: The qualitative study explored here has implications for discussions about future role change debates within community nursing as well as the specialist-generalist debate internationally. Managers and policy-makers involved in organizational changes are required to give greater credence to the perceived professional status of community nursing.

'Gold standard care' is an unhelpful term.

Members of Veterinary Humanities UK argue that the vet professions should move away from using the term 'gold standard care' and instead adopt 'contextualised care', which acknowledges that different treatment pathways are able to offer equally acceptable patient journeys in different contexts.

Proportion and risk factors for death by euthanasia in dogs in the UK.

The loss of a pet can be particularly distressing for owners, whether the method of death is euthanasia or is unassisted. Using primary-care clinical data, this study aimed to report the demographic and clinical factors associated with euthanasia, relative to unassisted death, in dogs. Method of death (euthanasia or unassisted) and clinical cause of death were extracted from a random sample of 29,865 dogs within the VetCompass Programme from a sampling frame of 905,544 dogs under UK veterinary care in 2016. Multivariable logistic regression modelling was used to evaluate associations between risk factors and method of death. Of the confirmed deaths, 26,676 (89.3%) were euthanased and 2,487 (8.3%) died unassisted. After accounting for confounding factors, 6 grouped-level disorders had higher odds in euthanased dogs (than dogs that died unassisted), using neoplasia as the baseline. The disorders with greatest odds included: poor quality of life (OR 16.28), undesirable behaviour (OR 11.36) and spinal cord disorder (OR 6.00). Breed, larger bodyweight and increasing age were additional risk factors for euthanasia. The results highlight that a large majority of owners will face euthanasia decisions and these findings can support veterinarians and owners to better prepare for such an eventuality.

Role of the consent form in UK veterinary practice.

BACKGROUND: Informed consent from the client is required before veterinary professionals may administer treatment or perform surgery on an animal patient, except in an emergency. This study investigates the potential role(s) of the consent form in the consent process in the UK. METHODS: Thematic analysis was carried out on the text contained in 39 blank consent forms sourced from veterinary practices in the UK. Analysis was conducted at the levels of topical survey and thematic summary. RESULTS: Consent forms were used to authorise procedures, to define proposed treatment, to offer or recommend additional procedures, to convey the risks of treatment and to document the client's financial obligations. None of the forms analysed provided sufficient space to document the accompanying conversation. Notable omissions from the submitted forms included options for treatment and benefits of treatment. CONCLUSIONS: The consent form acts as a record of the procedure to be performed, the associated costs and the status of the person giving consent. However, from this analysis, it often fails to record the detail of the consent discussion, an essential part of the consent process. A proposal for an improved version of a veterinary consent form is provided.

Legal and Ethical Aspects of 'Best Interests' Decision-Making for Medical Treatment of Companion Animals in the UK.

Medical decisions for young children are made by those with parental responsibility, with legal involvement only if the decision is potentially detrimental to the child's welfare. While legally classified as property, some argue that animals are in a similar position to children; treatment decisions are made by their owners, posing a legal challenge only if the proposed treatment has the potential to cause harm or unnecessary suffering, as defined by animal protection legislation. This paper formulates the approach to a 'best interests' calculation, utilising the factors included in the United Nations Convention on the Rights of the Child and relying on exchange of information between the human parties involved. Although this form of decision-making must primarily protect the animal from unnecessary suffering, it recognises that the information provided by the owner is critical in articulating the animal's non-medical interests, and hence in formulating what is in the animal's best overall welfare interests. While statute law does not mandate consideration of 'best interests' for animals, this approach might reasonably be expected as a professional imperative for veterinary surgeons. Importantly, this version of a 'best interests' calculation can be incorporated into existing ethical frameworks for medical decision-making and the humane treatment of animals.

Applying Experiential Action Learning Pedagogy to an Intensive Course to Enhance Capacity to Conduct Community-Based Participatory Research.

Community-based participatory research (CBPR) is widely recognized as an effective approach to understand and address health inequities. Opportunities for public health practitioners and researchers to engage jointly with community partners in intensive colearning processes can build capacity for CBPR. Using active learning approaches that engage diverse partners can enhance partnership development, competence, and equity. Examination of such pedagogical approaches can strengthen understanding of their contributions to the effectiveness of CBPR capacity-building programs. This article describes a weeklong intensive course carried out by the Detroit Urban Research Center as the foundation for a yearlong training program to build the capacity of community-academic partnership teams to engage in CBPR in their own communities. The in-person CBPR course was developed and implemented by expert academic and community instructors and used an experiential action learning model that integrated CBPR principles and processes. We describe the course content and application of our collaborative, experiential action learning model to course design; present results from participant evaluation of course effectiveness, CBPR competence, and equitable partnership development; and examine the contributions of the pedagogical approach to outcomes central to successful CBPR. The participatory, formative course evaluation used multiple methods that included closed- and open-ended questionnaires to assess instructional effectiveness, participant competence on 12 core components of CBPR, and course impact on partner relationships. Evaluation findings suggest that an experiential action learning approach with attention to colearning, collaboration among diverse instructors and participants, and an environment that fosters and models equitable and trusting relationships can be effective in building CBPR capacity.