Improving primary palliative care – a Delphi consensus study on measures for general practice in Germany

Background The majority of severely ill and dying people in Germany can be administered primary palliative care (PPC) by general practitioners (GP). However, the current provision of PPC does not match the needs of the population. Although several public health strategies aim at strengthening the role of GPs in PPC provision, it remains challenging for GP teams to integrate PPC into their daily routines. Aim A Delphi study with GPs was conducted to achieve consensus on specific measures for improving the integration of PPC into everyday GP practice. Methods The study is part of the junior research project “Primary Palliative Care in General Practice” (ALLPRAX). After having developed, tested and evaluated 26 practical measures for GP practices to improve their PPC, a Delphi consensus study among GPs took place. In 2020, 569 GPs were asked to rate the relevance and feasibility of the measures on a 4-point Likert scale via an anonymous online questionnaire. Consensus was defined as a sum percentage of ‘strongly agree’ and ‘somewhat agree’ responses ≥75% after two rounds. Between these rounds, measures that were not consented in the first round were adapted in light of respondents’ free text comments and suggestions. Results The response rate was 11.3% in round 1 (n = 64) and 53.1% in round 2 (n = 34). From the initial n = 26 measures, n = 20 measures achieved consensus and were included in the final intervention package. The consented measures pertained to four main topics: advance care planning with patients, consulting and informing patients and family caregivers, GP office organisation and continuing education. N = 6 measures did not achieve consensus, predominantly due to time and workload constraints. Conclusion The consented measures provide valuable support to improve the provision of PPC by GPs. They can be used freely and flexibly, according to the needs of individual GP teams, and are thus suitable for implementation nationwide. Trial registration The study was registered in the German Clinical Trials Register (Registration N° DRKS00011821; 4 December 2017; https://apps.who.int/trialsearch/) and the German Register of Health Care Research (Registration N° VfD_ALLPRAX_16_003817; 30 March 2017).

Fit for purpose. Co-production of complex behavioural interventions. A practical guide and exemplar of co-producing a telehealth-delivered exercise intervention for people with stroke

Background Careful development of interventions using principles of co-production is now recognized as an important step for clinical trial development, but practical guidance on how to do this in practice is lacking. This paper aims (1) provide practical guidance for researchers to co-produce interventions ready for clinical trial by describing the 4-stage process we followed, the challenges experienced and practical tips for researchers wanting to co-produce an intervention for a clinical trial; (2) describe, as an exemplar, the development of our intervention package. Method We used an Integrated Knowledge Translation (IKT) approach to co-produce a telehealth-delivered exercise program for people with stroke. The 4-stage process comprised of (1) a start-up planning phase with the co-production team. (2) Content development with knowledge user informants. (3) Design of an intervention protocol. (4) Protocol refinement. Results and reflections The four stages of intervention development involved an 11-member co-production team and 32 knowledge user informants. Challenges faced included balancing conflicting demands of different knowledge user informant groups, achieving shared power and collaborative decision making, and optimising knowledge user input. Components incorporated into the telehealth-delivered exercise program through working with knowledge user informants included: increased training for intervention therapists; increased options to tailor the intervention to participant’s needs and preferences; and re-naming of the program. Key practical tips include ways to minimise the power differential between researchers and consumers, and ensure adequate preparation of the co-production team. Conclusion Careful planning and a structured process can facilitate co-production of complex interventions ready for clinical trial. Graphical Abstract

Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk

Anesthetics and adjunct agents have a long history of being associated with patients engaging in delirious or agitated behavior in a perioperative setting. Prior to this study, few have explored the topic with a focus on safety for both the patient and staff. We explored the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports to identify bouts of delirium/ agitation associated with anesthetics and/or adjunct agents that occurred during the pre-, intra-, or postoperative period. We identified 97 event reports from 63 healthcare facilities over a two-year period. Patients’ ages ranged from 1 to 91 years and 66% of the patients were reported as male. Also, 8% of the delirium/agitation occurred preoperatively, 8% intraoperatively, and 84% postoperatively. Across all three operative periods, 62% of the reports described dangerous/nonviolent behavior and 26% described dangerous/violent behavior. Additionally, 40% of the event reports described one or more patient injuries (e.g., cardiopulmonary arrest, asphyxiation, hematoma, prolapse/dehiscence, progressive ischemia) and 36% of the patients required additional healthcare services or monitoring (e.g., intra- or interfacility transfer, additional surgical procedure). Finally, 54% of the event reports described patient behavior that created an immediate and high risk of staff harm. Overall, the current study provides novel insight into how delirium/agitation has varying safety implications depending on the operative period. We encourage readers to review Table 5, which proposes a four-phase intervention package to prevent, treat, and de-escalate bouts of delirium/agitation.

Effectiveness of Water, Sanitation and Hygiene (WASH) Intervention for School going Children on Hygiene Practices, Absenteeism, Diarrhea, and Respiratory Infection: An Interventional Study Protocol

Introduction: Safe drinking water, sanitation and hygiene beyond the household, and particularly in the school setting, are crucial to the health and education of children. Ashram schools where children from tribal community are taking education in India are mostly ignored. Thus, inclusion of water, sanitation and hygiene (WASH) in schools as part of the SDG, necessitates assessing the coverage and utilization in all types of schools; Government, private, funded including Ashram (residential) schools. Hence, we plan this research to study the effectiveness of proposed WASH in Ashram school with regards to hygiene practices, diarrheal diseases, respiratory infection and school absenteeism. Methods: Interventional study will be conducted in all eight Ashram schools of Wardha district. Baseline data regarding WASH practices and absenteeism, diarrhea, and respiratory infection will be collected. Intervention model for adopting safe WASH practices will be developed implemented in randomly selected four ashram schools. Survey and interview questionnaire will be adopted from UNICEF monitoring package modules. Children of forth, fifth and sixth classes (460), teachers, and Principles(8) will be interviewed; and school environment will be reviewed. After collection of post intervention data in ODK tool, descriptive statistics, two-sample t-tests and unadjusted mean percentages for all outcome variables were calculated by aggregating individual-level data to the school level. Conclusion: The intervention package is based on community mobilization and participation; life skill education, capacity building of school staff related to WASH. This will contribute to bring long term changes and improvement in health status and academic performance of school children.

Pathways to Improving Nutrition among Upland Farmers through Nutrition-Sensitive Agriculture Interventions: A Case from Northern Laos

While there is an increased awareness of the role of nutrition-sensitive agriculture (NSA) interventions on nutrition, the studies that investigate holistic pathways from interventions to nutrition outcomes are inadequate. We aimed to understand these pathways to improved nutrition from the Enhancing Nutrition of Upland Farming Families (ENUFF) Project implemented in northern Laos. We applied an embedded case study design by recruiting 101 participants representing implementers, school and private sector representatives, and beneficiaries, of which 34 participated in interviews and 68 participated in 11 FGDs. This was supplemented by a desk review of project documents. We analyzed the data using a directed content analysis across five pathways using a published framework on impact pathways from NSA interventions to nutrition outcomes. The project contributed to nutrition mainly through three core pathways-food production, nutrition and WASH-related knowledge, and agricultural income, supported by strengthening local institutions within the project’s scope. While it is evident that the project contributed to empowering women by saving their time and increasing income, further study is needed to investigate the translation of these aspects to nutrition-related practices. We also suggest the need to sustain the capacity of local institutions and their engagement beyond the project cycle. To enhance the effectiveness of NSA interventions on nutrition, there is a need to design and implement intervention package with multiple pathways and tailored strategies based on nutrition outcomes, the envisaged pathways, geographical context, and factors affecting these.

Coping and Caregiver Burden and Depression Among Chinese Caregivers of Older Adults With Cognitive Impairment

Coping strategies are important factors that influence caregivers’ mental health outcomes. The purpose of this study is to examine the association between coping strategies and caregiver burden and depression among Chinese caregivers of older adults with cognitive impairment. Data came from structured interviews with 300 primary family caregiver-care recipient dyads in Wuhan, China. We used OLS to examine the association between coping strategies and caregiver burden and depression. More positive reframing and acceptance were associated with lower caregiver burden, whereas more self-distraction was associated with higher caregiver burden. More positive reframing was associated with lower caregiver depression, whereas higher self-distraction and religion were associated with higher caregiver depression. Findings of this study suggest that a psychosocial intervention package that emphasizes on enhancing positive reframing skills and affirming acceptance may be effective in reducing caregiver burden and depression among Chinese caregivers of older adults with cognitive impairment.

Teaching and Promoting Generalization of Peer Imitation With Preschoolers With Disabilities

Researchers have identified effective instructional strategies for teaching peer imitation, including embedded classroom-based interventions. However, there is a dearth of strategies that have been effective for teaching generalization of imitation skills to novel contexts. Building on previous research, we examined the use of progressive time delay to increase peer imitation in the context of a play activity for four preschoolers with disabilities. We conducted preference and reinforcer assessments to identify effective reinforcers for each child prior to intervention. We conducted a multiple baseline across participants design meeting contemporary single case standards and used visual analysis to identify a functional relation: the intervention package was associated with an increase in the participants’ peer imitation in training contexts. The intervention also led to levels of peer imitation comparable to those of typically developing peers, as measured by a normative peer sample, and generalization to novel contexts.

Using Errorless Learning and Discrimination Training to Teach Early Literacy Skills in a Pre-School Setting

This case study investigates the effects of using an intervention package of errorless learning and discrimination trial training to teach a 4-year old preschool student to read Consonant-Vowel-Consonant (CVC) words. A single case multiple baseline design across three equal instructional sets was used to evaluate the effects of the intervention package. Each set contained six CVC words incorporating words with each of the five vowels. The results of this study indicate that utilizing both errorless learning and discrimination training to teach a preschool student how to read CVC words was effective. In addition, generalization assessments post-intervention showed an increase in (a) mastering new unknown CVC words, as well as (b) book text reading.