In June 2020, in the midst of the Covid-19 pandemic, Malawians went to the polls and voted to replace the incumbent government. Much like other natural disasters, the Covid-19 pandemic and ...accompanying economic and political shocks had the potential to shake voters' confidence in the government, reduce turnout, and/or reduce support for the incumbent if voters associated them with the ills of the pandemic. In this paper, we examine the extent to which the Coronavirus pandemic influenced Malawi's 2020 elections. We consider how fear of infection and economic distress affected citizens' trust and confidence in President Mutharika's government, their willingness to turn out to vote, and their choices at the polls using data collected pre- and post-Covid. We find that fears about the virus and its economic impact did influence trust and confidence in the government to handle Covid but had little to no effect on either abstention or vote choice.
Competence in any profession depends upon an understanding of the theory that underlies it. This concise and practical text for students and practitioners bridges the gap between occupational therapy ...theory and clinical practice, offering highly practical advice on using theory in practice in a wide range of settings. It considers the nature of professional practice and the need for a sound theoretical basis from which to plan, implement and justify interventions, and investigates the practical use of occupational therapy theory and the issues such use raises in health and social care settings from a European perspective. Every occupational therapy student worldwide needs to know about the underlying theory of their profession and its application to practice. The book particularly debates the nature of the theory of occupational therapy via the introduction of the concept of models of the profession as an umbrella for practice, all of which is brought to life via case studies incorporating expert advice, reflection exercises and assessment and evaluation forms.
Background
Back pain frequently affects older people. Knowledge about back pain in older people and evidence to inform clinical care was lacking, particularly for older people with neurogenic ...claudication due to spinal stenosis, which is a debilitating condition.
Objectives
To understand and reduce the burden of back pain on older people by increasing knowledge about back pain in older people and developing evidence-based treatment strategies.
Design
We completed six work packages. These were not undertaken chronologically as there was overlap between work packages.
Work package 1: Refine a physiotherapy intervention for neurogenic claudication.
Work package 2: Feasibility of the Oxford Pain Activity and Lifestyle cohort study and Better Outcomes for Older people with Spinal Trouble randomised controlled trial.
Work package 3: Development of a prognostic tool to identify when older people are at risk of mobility decline using data from the Oxford Pain Activity and Lifestyle cohort study.
Work package 4: A randomised controlled trial of physiotherapy for neurogenic claudication and nested longitudinal qualitative study (Better Outcomes for Older people with Spinal Trouble randomised controlled trial).
Work package 5: Predictors of participants’ response to treatment – prespecified subgroup analyses.
Work package 6: Implementation planning.
Setting
Primary care and National Health Service Community and Secondary Care Trusts.
Participants
Community-dwelling adults over the age of 65 years and registered with primary care practices. Better Outcomes for Older people with Spinal Trouble trial participants reported back and/or leg pain consistent with neurogenic claudication.
Interventions
The Better Outcomes for Older people with Spinal Trouble programme was a physiotherapy-delivered combined physical and psychological group intervention for older people with neurogenic claudication. The comparator was a physiotherapy assessment and tailored advice (best practice advice).
Main outcome measures
The primary outcome for the Oxford Pain Activity and Lifestyle prognostic tool was mobility decline based on the EQ-5D-5L Mobility Question.
The primary outcome for the Better Outcomes for Older people with Spinal Trouble trial was the Oswestry Disability Index at 12 months. Other outcomes included the Oswestry Disability Index walking item, 6-minute walk test and falls. The economic analyses used the EuroQol EQ-5D-5L to measure quality of life.
Results
Among Oxford Pain Activity and Lifestyle participants, 34% (1786/5304) reported back pain. A further 19.5% (1035/5304) reported back pain and associated leg pain, with 11.2% (
n
= 594/5304) reporting symptoms consistent with neurogenic claudication. Participants with back pain had worse quality of life compared to those without back pain and reported more adverse health states such as falls, frailty, low walking confidence and mobility decline. Those with neurogenic claudication were worst affected. At 2 years’ follow-up, among those reporting back pain at baseline, only 23% (489/2100) no longer reported symptoms. Recovery was lowest among participants reporting neurogenic claudication at baseline, with 90% still reporting symptoms.
At 2 years’ follow-up, 18.6% of Oxford Pain Activity and Lifestyle participants reported mobility decline. Back pain with/without leg pain was not an independent predictor of mobility decline, but lower limb pain and the report of severe pain were independent predictors. Other predictors included slow walking pace, balance difficulties, low walking confidence, walking ability worse than last year, self-reported general health and comorbidity.
In the Better Outcomes for Older people with Spinal Trouble trial, there was no significant difference in Oswestry Disability Index scores between treatment groups at 12 months (adjusted mean difference −1.4, 95% confidence interval −4.03 to 1.17), but at 6 months, scores favoured the Better Outcomes for Older people with Spinal Trouble programme (adjusted mean difference −3.7, 95% confidence interval −6.27 to −1.06). The Better Outcomes for Older people with Spinal Trouble programme resulted in greater improvements in the 6-minute walk test (mean difference 21.7 m, 95% confidence interval 5.96 to 37.38 m) and walking item (mean difference −0.2, 95% confidence interval −0.45 to −0.01) and reduced falls risk (odds ratio 0.6, 95% confidence interval 0.40 to 0.98) compared to best practice advice at 12 months. The probability that the Better Outcomes for Older people with Spinal Trouble programme is cost-effective ranged between 67% and 83% (National Health Service and Personal Social Services perspective) and between 79% and 89% (societal perspective) across cost-effectiveness thresholds between £15,000 and £30,000 per quality-adjusted life-year. From the embedded qualitative study, the Better Outcomes for Older people with Spinal Trouble programme was acceptable to participants, and enjoyable.
Limitations
Many of the data collected were self-reported and thus may be subject to recall bias or may have resulted in misclassification of participants.
Conclusions
Back pain is a substantial problem for older people, with the majority reporting persistent symptoms. We have developed an effective intervention to improve mobility and reduce falls in older people with neurogenic claudication; however, more effective interventions are needed for back pain generally. We have identified a set of self-reported questions that predict mobility decline in older people, so clinicians and their patients and families know when intervention is needed.
Future work
Develop and evaluate treatments for older people with back pain.
Optimisation of the Better Outcomes for Older people with Spinal Trouble programme to better target pain-related disability.
External validation of the Oxford Pain Activity and Lifestyle prognostic tool.
Study registration
This trial is registered as BOOST trial ISRCTN12698674.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: PTC-RP-PG-0213-20002) and is published in full in
Programme Grants for Applied Research
; Vol. 11, No. 9. See the NIHR Funding and Awards website for further award information.
Multiple long-term health conditions (multimorbidity) (MLTC-M) are increasingly prevalent and associated with high rates of morbidity, mortality, and health care expenditure. Strategies to address ...this have primarily focused on the biological aspects of disease, but MLTC-M also result from and are associated with additional psychosocial, economic, and environmental barriers. A shift toward more personalized, holistic, and integrated care could be effective. This could be made more efficient by identifying groups of populations based on their health and social needs. In turn, these will contribute to evidence-based solutions supporting delivery of interventions tailored to address the needs pertinent to each cluster. Evidence is needed on how to generate clusters based on health and social needs and quantify the impact of clusters on long-term health and costs.
We intend to develop and validate population clusters that consider determinants of health and social care needs for people with MLTC-M using data-driven machine learning (ML) methods compared to expert-driven approaches within primary care national databases, followed by evaluation of cluster trajectories and their association with health outcomes and costs.
The mixed methods program of work with parallel work streams include the following: (1) qualitative semistructured interview studies exploring patient, caregiver, and professional views on clinical and socioeconomic factors influencing experiences of living with or seeking care in MLTC-M; (2) modified Delphi with relevant stakeholders to generate variables on health and social (wider) determinants and to examine the feasibility of including these variables within existing primary care databases; and (3) cohort study with expert-driven segmentation, alongside data-driven algorithms. Outputs will be compared, clusters characterized, and trajectories over time examined to quantify associations with mortality, additional long-term conditions, worsening frailty, disease severity, and 10-year health and social care costs.
The study will commence in October 2021 and is expected to be completed by October 2023.
By studying MLTC-M clusters, we will assess how more personalized care can be developed, how accurate costs can be provided, and how to better understand the personal and medical profiles and environment of individuals within each cluster. Integrated care that considers "whole persons" and their environment is essential in addressing the complex, diverse, and individual needs of people living with MLTC-M.
PRR1-10.2196/34405.
Background
Multimorbidity is a major challenge to health and social care systems around the world. There is limited research exploring the wider contextual determinants that are important to ...improving care for this cohort. In this study, we aimed to elicit and prioritise determinants of improved care in people with multiple conditions.
Methods
A three-round online Delphi study was conducted in England with health and social care professionals, data scientists, researchers, people living with multimorbidity and their carers.
Results
Our findings suggest a care system which is still predominantly single condition focused. ‘Person-centred and holistic care’ and ‘coordinated and joined up care’, were highly rated determinants in relation to improved care for multimorbidity. We further identified a range of non-medical determinants that are important to providing holistic care for this cohort.
Conclusions
Further progress towards a holistic and patient-centred model is needed to ensure that care more effectively addresses the complex range of medical and non-medical needs of people living with multimorbidity. This requires a move from a single condition focused biomedical model to a person-based biopsychosocial approach, which has yet to be achieved.
Formation of the peptidoglycan stem pentapeptide requires the insertion of both l and d amino acids by the ATP-dependent ligase enzymes MurC, -D, -E, and -F. The stereochemical control of the third ...position amino acid in the pentapeptide is crucial to maintain the fidelity of later biosynthetic steps contributing to cell morphology, antibiotic resistance, and pathogenesis. Here we determined the x-ray crystal structure of Staphylococcus aureus MurE UDP-N-acetylmuramoyl-l-alanyl-d-glutamate:meso-2,6-diaminopimelate ligase (MurE) (E.C. 6.3.2.7) at 1.8 Å resolution in the presence of ADP and the reaction product, UDP-MurNAc-l-Ala-γ-d-Glu-l-Lys. This structure provides for the first time a molecular understanding of how this Gram-positive enzyme discriminates between l-lysine and d,l-diaminopimelic acid, the predominant amino acid that replaces l-lysine in Gram-negative peptidoglycan. Despite the presence of a consensus sequence previously implicated in the selection of the third position residue in the stem pentapeptide in S. aureus MurE, the structure shows that only part of this sequence is involved in the selection of l-lysine. Instead, other parts of the protein contribute substrate-selecting residues, resulting in a lysine-binding pocket based on charge characteristics. Despite the absolute specificity for l-lysine, S. aureus MurE binds this substrate relatively poorly. In vivo analysis and metabolomic data reveal that this is compensated for by high cytoplasmic l-lysine concentrations. Therefore, both metabolic and structural constraints maintain the structural integrity of the staphylococcal peptidoglycan. This study provides a novel focus for S. aureus-directed antimicrobials based on dual targeting of essential amino acid biogenesis and its linkage to cell wall assembly.
Background: MurE controls stereochemical incorporation of lysine or diaminopimelate into peptidoglycan stem peptides.
Results: The structure of S. aureus MurE reveals an unexpected lack of specificity for lysine within the active site.
Conclusion: Incorporation of lysine is supported by the comparatively high concentration of cytoplasmic lysine, not enzyme specificity.
Significance: This study provides new perspectives in targeting Gram-positive peptidoglycan assembly for antimicrobial discovery.
Students with disabilities face barriers to full participation in Health and Human Service (HHS) programmes. Few studies have focused on students' experiences in practice placements, an aspect of HHS ...programmes which yield unique barriers. This study aimed to understand the barriers that disabled students in HHS programmes experience during practice placements and their perspective of how to better support and accommodate them. Disabled students from 12 HHS programmes at a Canadian university and 14 Canadian occupational therapy programmes were invited to participate in a survey about their placement experiences. Eighty-two students responded to the survey. Of these, eleven volunteered to engage in follow up interviews. Results showed that students with disabilities are navigating accommodation practices that frequently lack communication, clarity, ease of use and are structured in ways that are less conducive to ever-changing practice environments. Students expressed relying on relationships with practice educators and placement coordinators to facilitate their accommodations. However, negative attitudes and stigma complicate these processes. Collaboration across HHS programmes is needed to develop clear and effective placement accommodation procedures. Those who support disabled students in placement should receive education on supporting students with disabilities and legal obligations of accommodation. Students may benefit from advocacy and disclosure skill education.
IntroductionNeurogenic claudication due to spinal stenosis is common in older adults. The effectiveness of conservative interventions is not known. The aim of the study is to estimate the clinical ...and cost-effectiveness of a physiotherapist-delivered, combined physical and psychological intervention.Methods and analysisThis is a pragmatic, multicentred, randomised controlled trial. Participants are randomised to a combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme) or best practice advice (control). Community-dwelling adults, 65 years and over, with neurogenic claudication are identified from community and secondary care services. Recruitment is supplemented using a primary care-based cohort. Participants are registered prospectively and randomised in a 2:1 ratio (intervention:control) using a web-based service to ensure allocation concealment. The target sample size is a minimum of 402. The BOOST programme consists of an individual assessment and twelve 90 min classes, including education and discussion underpinned by cognitive behavioural techniques, exercises and walking circuit. During and after the classes, participants undertake home exercises and there are two support telephone calls to promote adherence with the exercises. Best practice advice is delivered in one to three individual sessions with a physiotherapist. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the 6 Minute Walk Test, Short Physical Performance Battery, Fear Avoidance Beliefs Questionnaire and Gait Self-Efficacy Scale. Outcomes are measured at 6 and 12 months by researchers who are masked to treatment allocation. The primary statistical analysis will be by ‘intention to treat’. There is a parallel health economic evaluation and qualitative study.Ethics and disseminationEthical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials checklist. The results will be reported at conferences and in peer-reviewed publications using the Consolidated Standards of Reporting Trials guidelines. A plain English summary will be published on the BOOST website.Trial registration number ISRCTN12698674; Pre-results.
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