Community Providers Research Articles

Resettlement Outcomes for People with Severe Challenging Behaviour Moving from Institutional to Community Living

Background The purpose of this study was to evaluate the quality of life consequences arising from the resettlement of adults with challenging behaviour severe enough to be deemed to require continuing healthcare from a traditional learning disability hospital to new purpose-built bungalows. The new accommodation was provided by a specialist NHS trust through special project arrangements designed to ensure that the provision of homelike accommodation in the community was coupled with ‘state of the art’ staff training. Methods There were 19 participants. Baseline data were collected on their adaptive and challenging behaviour and psychiatric status. Data on a variety of quality of care and lifestyle indicators were collected when the entire sample was in hospital (T1), when a minority had moved to the community, but the majority remained in hospital (T2), when the majority had moved to the community but a minority remained in hospital (T3) and at follow-up (T4), when all lived in the community. Results There were almost no areas of significant deterioration in quality of care or lifestyle outcome arising from moving to the community. The community provision was more homelike and associated with some improvement in working methods and staff contact received by participants, increased family contact, greater participant involvement in household activity and constructive activity generally and reduction in staff-reported challenging behaviour. Increases in the range and frequency of social and community activities over time were found but such increase also occurred while people remained in the hospital. Conclusions This evaluation has shown that the quality of care and lifestyle outcomes associated with new NHS community settings for adults with learning disabilities and severe challenging behaviour assessed as requiring continuing healthcare were generally equivalent or superior to previous hospital levels. In this, findings were similar to other more general deinstitutionalisation studies. Certain improvement over time was found within the follow-up period studied. Further follow-up may be relevant as developing the desired working culture among staff from an institutional background may take longer than was given within the length of this study.

Health geography’s voluntary turn: A view from western France

This paper examines the potential for prevailing Anglo-American perspectives on voluntarism to inform understanding of health and social care internationally. Focusing on the économie sociale et solidaire and its involvement in the secteur médico-social in France, it evaluates the transferability of a theorization about the evolving role of voluntary organizations and volunteers for the purpose of interpreting research on service provision in ageing communities. A case study of local associations is analyzed to uncover their emergence within evolving spaces of care, how they facilitate adjustment and create opportunities for resistance to the dual challenges of ageing and restructuring as well as the complexity underlying their multifaceted responses. The findings contribute to understanding the link between voluntarism, health and place, and address calls to expand the international scope of health geography within the ‘voluntary turn’ in health policy and research.

Relationship of family caregiver burden with quality of care and psychopathology in a sample of Arab subjects with schizophrenia

BackgroundAlthough the burden experienced by families of people with schizophrenia has long been recognized as one of the most important consequences of the disorder, there are no reports from the Arab world. Following the example of the five - nation European (EPSILON) study, we explored the following research question: How does the relationship between domains of caregiving (as in the Involvement Evaluation Questionnaire - IEQ-EU) and caregiver psychic distress on the one hand, and caregiver's/patient's socio-demographics, clinical features and indices of quality of care, on the other hand, compare with the pattern in the literature?MethodConsecutive family caregivers of outpatients with schizophrenia were interviewed with the IEQ-EU. Patients were interviewed with measures of needs for care, service satisfaction, quality of life (QOL) and psychopathology.ResultsThere were 121 caregivers (66.1% men, aged 39.8). The IEQ domain scores (total: 46.9; tension: 13.4; supervision: 7.9; worrying: 12.9; and urging: 16.4) were in the middle of the range for the EU data. In regression analyses, higher burden subscale scores were variously associated with caregiver lower level of education, patient's female gender and younger age, as well as patient's lower subjective QOL and needs for hospital care, and not involving the patient in outdoor activities. Disruptive behavior was the greatest determinant of global rating of burden.ConclusionOur results indicate that, despite differences in service set-up and culture, the IEQ-EU can be used in Kuwait as it has been used in the western world, to describe the pattern of scores on the dimensions of caregiving. Differences with the international data reflect peculiarities of culture and type of service. Despite generous national social welfare provisions, experience of burden was the norm and was significantly associated with patient's disruptive behavior. The results underscore the need for provision of community - based programs and continued intervention with the families in order to improve the quality of care.

Disability Sport Wales Programme: making the connections

Wales is a principality of 2.9 million people which is divided into 22 local authorities. Disability Sport Wales (DSW) has been part of the sporting landscape of Wales since 1995,...

Analysis of enhanced pharmacy services in rural community pharmacies in Western Australia

Enhanced pharmacy services (EPS) are health related services above those normally available with the supply of medicines. Rural pharmacies could provide a diversity of EPS in response to the limited access and reduced health services available in rural areas. The objective of this study was to evaluate the provision of EPS in rural Western Australian (WA) pharmacies in 2006, compared with findings extracted from a national survey conducted in 2002. Barriers to and facilitators for the provision of ETS in rural settings were also analysed. The survey was conducted in 2006, using a questionnaire developed from a 2002 Australian national survey questionnaire. The questionnaires were mailed to all 103 pharmacies in rural WA and 51 were returned (49.5%). Chi-squared tests were used to test associations between year of survey and provision of each EPS. Where significant associations were reported, logistic regression analyses that controlled for sex, age, PhARIA location (remoteness), and inclusion of a forward pharmacy area were performed. The WA rural pharmacies offered a range of EPS. There were marked increases in weight testing and weight management services. The availability of smoking cessation services increased from 52% of rural pharmacies in 2002 to 63% in 2006. Other EPS (asthma, diabetes, hypertension, hyperlipidaemia), which correspond to the Australian Government National Health Priorities Areas were offered by 20% to 50% of pharmacies and had not increased between surveys. A continued shortage in the pharmacist workforce was a major barrier to EPS provision. Provision of EPS in rural pharmacies is more important than in metropolitan pharmacies because there is often a lack of other sources for these services in rural and remote locations. A range of defined EPS were provided by 25% to 60% of rural and remote pharmacies, with other services offered in lower percentages. Significant increases were found in some important EPS, such as weight management. Additional support for EPS provision in rural and remote communities is required to increase uptake among pharmacists. Government and pharmacy bodies need to implement rural practice models to address identified pharmacist workforce barriers and improve access to EPS to rural communities.

Empowering Patient Safety Outreach Through Interprofessional Partnerships: Educating Our Communities

This article reports on an interprofessional approach to outreach and the value of partnerships for health information provision in rural underserved communities in which personnel and time is limited. The Partnering for Patient Empowerment through Community Awareness (PPECA)-II program describes how the Hardin Library for Health Sciences partnered with the University of Iowa Hospitals & Clinics to develop a patient safety education program. The authors discuss how the work complemented the library's role in provision of referral, information support, and educational services to critical access hospitals in rural Iowa. The authors discuss how the program was evaluated, provide next steps for hospital librarians to implement a similar program in their communities, and highlight the effects of partnership on a librarians' role in patient safety and other outreach work.

Carer-rated needs assessment of a cohort of people with dementia

With increasing longevity, more people will develop dementia. These people will have a wide range of needs according to their circumstances. Services in the community struggle to meet these needs. This study aimed to identify needs of dementia sufferers attending the South Dublin Old Age Psychiatry service as rated by their carers, to assess the extent of unmet need and the implication of this. The carers of 40 community-dwelling people with dementia attending the service were interviewed by one researcher using the Camberwell Assessment of Need for the Elderly (CANE). This measures a wide range of needs over 24 areas, from personal care, to social, financial and psychological care needs. Qualitative information was also obtained from carers regarding services available and their accessibility. A measure of carer stress and satisfaction with help for this was also obtained. Overall, the highest levels of need identified (both met and unmet) were in the areas of psychological functioning (memory and psychological distress), followed by social needs in the areas of managing money, daytime activities, self-care, and looking after the home. Highest unmet social needs were in the areas of daytime activities, home care and managing money. For 23/24 domains, carers were satisfied rather then unsatisfied with help received. The areas of greatest dissatisfaction to them concerned daytime activities, household skills and self-care. Over half of the carers reported psychological distress. High levels of need, both met and unmet were identified. Many identified needs related to the provision of community supports in the areas of selfcare, household skills and daytime activities, in addition to psychiatric needs. Assessment of needs is important to ensure adequate and responsive service provision, in keeping with the ethos of community care.

Effectiveness of Group Cognitive‐Behavioural Treatment for Men with Intellectual Disabilities at Risk of Sexual Offending

Background For non‐disabled men, group cognitive‐behaviour therapy is a successful form of treatment when men have committed sexual offences. However, men with intellectual disabilities and sexually abusive behaviour are rarely offered treatment for their sexual behaviour and little research data on the effectiveness of such treatment has been collected.Method Nine collaborating sites ran 13, 1‐year long cognitive‐behavioural treatment groups for men with intellectual disabilities and sexually abusive behaviour. The men came from both community and secure provision and were assessed for sexual knowledge, victim empathy and cognitive distortions before and after the group treatment. Treatment was guided by a common treatment manual.Results Forty‐six men consented to take part in the research. Most men (83%) had engaged in more than one incident of sexually abusive behaviour but only 57% of the men who came for treatment were required by law to attend. Almost all the men (92%) who began treatment (and consented to take part in the research) completed treatment 1 year later, indicating considerable motivation amongst the men to get treatment for their difficulties. Over the period of treatment, the men showed statistically significant increases in sexual knowledge and victim empathy, as well as reductions in cognitive distortions. These changes were still significant at 6‐month follow‐up for sexual knowledge and cognitive distortions. Few men showed further sexually abusive behaviour during the 1‐year period when they were attending treatment (three men) or during the 6‐month follow‐up period (four men). Only the presence of autistic spectrum disorders appeared to be related to re‐offending (though this result should be treated with caution, given the small numbers who re‐offended).Conclusions This large treatment trial provides some evidence of the effectiveness of such treatment for men with intellectual disabilities but there remains a need for a longer follow‐up period and a randomized controlled trial.

An Investigation Into the Length of Hospital Stay for Deaf Mental Health Service Users

This study looked at the average length of hospital stay for inpatients in a specialist deaf mental health service over a 10-year period, in comparison to that of a general psychiatric hearing cohort. In addition, two case studies of deaf inpatients were carried out looking specifically at the prerequisite factors governing discharge. Finally, a comparison of the types of community-based services available to deaf and hearing service users was undertaken in order to establish whether there was now a similarity of provision for both groups. The conclusion reached was that deaf inpatients are likely to remain in hospital twice as long as their hearing peers, but explanations for this difference may not necessarily be solely of a clinical nature. There is some evidence to suggest that social factors (i.e., a lack of appropriate community support, rehabilitation services, and provision) may have a negative impact on length of hospital stay. It is suggested that an increase in community-based services and provision may well shorten the length of hospital stay for deaf service users in the future. It is also recommended that further research into the relative effects of clinical versus social factors is considered.

Referrals into services for offenders with intellectual disabilities: Variables predicting community or secure provision

There is a need for research to promote an understanding among service developers on why people with intellectual disabilities (ID) are referred to offender services in order for them to receive appropriate assessment and treatment. Previous studies investigating referrals into forensic ID services have concentrated on referral sources and administrative variables such as legal status. To construct a predictive model for choice of service referral based on a comprehensive range of information about the clientele. We conducted a case record study of 336 people referred to community services and 141 to secure provision. We gathered information on referral source, demographics, diagnosis, index behaviour, prior problem behaviours and history of abuse. Comparisons revealed 19 candidate variables which were then entered into multivariate logistic regression. The resulting model retained six variables: community living at time of referral, physical aggression, being charged, referral from tertiary health care, diverse problem behaviour and IQ < 50, which correctly predicted the referral pathway for 85.7% of cases. An index act of physical aggression and a history of diversity of problem behaviours as predictors against the likelihood of community service referral suggest that professionals have similar concerns about people with ID as they do about their more average offending peers; however, the more severe levels of ID mitigated in favour of community referral, regardless. Offenders with ID tend to be referred within levels of service rather than between them, for example, form tertiary services into generic community services.

Have your say on the future

THE KEY AREAS that Professor Sir Ian Kennedy will focus on in his review of NHS children’s and young people’s services have been announced. They include community provision, transition to adult care, and safeguarding – all areas where there is concern.

Service audit of a forensic rehabilitation ward

An open forensic rehabilitation ward provides an important link bridging the gap between secure and community provisions. This paper provides an audit of such a service by examining the records of an open forensic rehabilitation ward over a five-year period from 1 June 2000 until 31 May 2005. During the audit period there were 51 admissions, involving 45 different patients, and 50 discharges. The majority of the patients came from secure unit facilities, acute psychiatric wards or home. Thirty-nine patients were discharged either into hostels (66%) or their home (12%). The majority of patients (80%) had on admission a primary diagnosis of either schizophrenia or schizoaffective disorder. Most had an extensive forensic history. The focus of their admission was to assess and treat their mental illness/disorder and offending behaviour and this was successful as the majority of patients were transferred to a community placement after a mean of 15 months. It is essential that there is a well-integrated care pathway for forensic patients, involving constructive liaison with generic services and a well-structured treatment programme which integrates the key principles of the 'recovery model' approach to care.

Can private equity deliver on equity?

In June 2009, a new Health in Africa Fund was launched by the International Finance Corporation (IFC), the branch of The World Bank group mandated with supporting and expanding the private for-profit sector. This Fund will be managed by Aureos Capital, a private equity fund manager focusing on emerging markets. Through investment in small- and medium-sized private providers, the Fund will attempt to“[help] low-income Africans gain access to affordable, high-quality health services.”1 The Fund, currently supported by the IFC, the African Development Bank, the Bill & Melinda Gates Foundation and the German development finance institution DEG, is a key component of the IFC’s US$ 1billion Africa health strategy and it targets initial commitments of US$ 100–120 million. The Fund’s establishment was inspired by the IFC’s health strategy, which entails harnessing private capital and private sector providers to improve quality and coverage of health services.2 The IFC clearly sees a potential for the private sector to improve health outcomes for the poor; less clear are the theoretical and empirical bases on which this enthusiasm is grounded. The main underlying assumptions behind a greater role of the private sector in provision of health services are: that the market can ensure optimal allocation of resources; that private firms can improve quality of care through their focus on measurable results; and that the private sector can use its flexibility to adapt to changing supply and demand factors. Market forces, however, can determine the most appropriate allocation of resources only under the assumption of perfect market conditions and in the health sector this assumption doesn’t hold. Asymmetric information between consumers (patients) and suppliers (health professionals) prevents consumers from adequately determining their own needs and making rational choices; and many key health interventions have a high propensity to positive external benefits, which tend to be under-provided by private for-profit markets.3 Economic theory also predicts that the profit-making incentive, dominant in the private sector, creates challenges to health care by segmenting access along income/quality lines. Accordingly, there is no empirical basis to argue that private providers outperform the public sector in terms of access to, quality and equity of health care.4,5 On the contrary there are concerns on the quality of privately provided care,6 as the poor generally use the lowest quality and most informal end of the private-sector spectrum.7 The new Fund is unlikely to improve access or quality of care unless it is complemented by initiatives to strengthen the public sector capacity to regulate, train, oversee and sub-contract (where appropriate) private providers, interventions that, according to a recent systematic review,8 have the potential to improve the impact of private sector provision in poor communities. In addition the Fund would also require the development of risk-pooling and subsidy mechanisms, so that privately-provided services can be offered free at the point of delivery. If it fails to do so, there is a concrete risk that the Fund, contrary to its objectives, will contribute to the entrenchment of two-tier health-care systems and to a further concentration of human and financial resources in services catering to affluent urban dwellers. The establishment of the Fund has not been accompanied by a public debate about its appropriateness and little information is available on its accountability mechanisms. A new initiative disjointed from other aid mechanisms doesn’t seem consistent with the process of streamlining the aid architecture envisaged under the International Health Partnership and related initiatives; and its focus doesn’t align with the recommendations by the High Level Taskforce on Innovative International Financing for Health Systems, which expressed caution on the role of the private for-profit sector.9 Making the private sector work equitably for the poor is no simple task: it is not immediately apparent that the fund manager, Aureos Capital,10 possesses sufficient experience in health financing and health systems to succeed in its objectives. The objectives of the health strategy of The World Bank (of which the IFC is part) include leveraging its comparative advantages in fostering better collaboration between the public and the private sectors.11 Strengthening stewardship and oversight capacity in the public sector to work more effectively with the private sector is a worthy endeavour. But the IFC’s raison d’etre is private sector growth. It is not clear whether, in case private sector provision is seen as an objective in itself, a sufficient focus can be kept on the public sector dimension of public–private collaboration. The new Fund’s progress should be monitored closely by a separately funded and independent third party evaluator, to ensure that its benefits truly accrue to the poor and that additional resources flowing to the private sector don’t exacerbate the loss of public sector health workers. ■

ATTENTION DEFICIT HYPERACTIVITY DISORDER AND THE FAMILY COURT

A major focus of the Youth at Risk Initiative is the provision of appropriate community based mental health services to help prevent unnecessary residential placement of troubled youth and thereby reduce the risk of troubled youth becoming criminal offenders. Yet, inexplicably, one of the major factors contributing to the risk of criminal offending has received scant attention. That factor is Attention Deficit Hyperactivity Disorder (ADHD). This article established the widespread prevalence of ADHD among troubled youth and hence, the critical importance of identifying and treating ADHD as an essential component for any best practices model for the Family Court. It also examined the major mechanisms whereby ADHD increases the risk for criminal offending.

Anxious provision and discourses of certainty: the sutured subject of mentally ill adult learners

This paper reports on a five‐year study which explored the engagement of a group of long‐term mentally ill adults in community provision in which they learned basic, expressive literacy. The research mapped points in the learning, writing and auto/biographic engagement where set identities were being troubled, and frisson created in the challenge of the new. This was not always sustained or managed comfortably, raising questions about the containing function of such community learning provision. The study took a critical ethnographic approach in which biographic narrative interviews with learners played a major part. The Lacanian concept of point de capiton is used here, in order to illustrate the extent to which the mentally ill learner of basic literacy is prescribed in and through current educational policy and practice. Given these constraints, the longitudinal data did, however, appear to reveal instances of both agency and defiance, with individuals making a stand regarding their learning. The paper suggests that the anxious regimes of adult learning, ironically, despite their ‘discourses of certainty’, appeared to replicate symptoms many individuals were suffering from as part of their long‐term illness. It asks whether this model of education, in which prescription, observation and quasi‐diagnosis prevail, is the most appropriate given the saturated experiences of the mentally ill, of being prescribed to, observed and diagnosed.

A Discourse Analysis of Australian Local Government Recreation and Sport Plans Provision For People with Disabilities

Public sector reforms in Australia have been promoted as ensuring efficiencies and accountability. As a response to these reform requirements, Australian local governments publically provide documented plans regarding service provision. While these documented plans may generally be perceived as value-neutral, they have the potential to imbed particular ideologies as well as ensure certain viewpoints remain entrenched in the current social realm. Using a critical discourse analysis method, this article analysed thirty-one local government sport and recreation plans publicly to assist in identifying and highlighting imbedded values and ideologies regarding community provision for people with disabilities. Results from the analysis indicate that overwhelmingly local government authorities' focus on ensuring the suitability of the built environment. As such, physical access as the problem identifies people with disabilities as a homogonous group who are immobile and as such disenfranchises many other impaired groups. This article also questions the representativeness of people with disabilities in the community consultation process.

Prevalence and age of onset of Parkinson’s disease in Cardiff: a community based cross sectional study and meta-analysis

Background:Previous prevalence studies of Parkinson’s disease (PD) in the UK have spanned a 40 year period and have predominantly been in the North of the country. These have presented rates...

Community-led infrastructure provision in low-income urban communities in developing countries: A study on Ohafia, Nigeria

The changing role of government in infrastructure provision and the need for community-based approach are widely gaining increasing recognition, but the extent to which local communities are involved in urban infrastructure provision in developing countries has not been given adequate attention in the literature. This study examines how community-based organizations are filling the gap created by partial withdrawal of the state from urban infrastructure provision in six low-income urban communities in Ohafia, Nigeria. Drawing on the role of social capital in community development, this paper reported how, and in what context situations the organizations are addressing the infrastructure challenge in their communities. Relying on the data from a survey, the study identified six organizations and three funding arrangements in urban infrastructure provision in the communities. Using this case-study, this study attempted to identify how the mobilization of resources in project initiation, design, implementation and funding influenced the type of infrastructure projects. The findings have conceptual and policy implications for understanding the socio-economic and political dynamics in harnessing local resources and integrating community-based approaches into urban development process in developing countries.

Insulin initiation in adults: evidence based or context driven?

Aim. To describe insulin initiation practices across the United Kingdom (UK) and identify factors influencing current practice.Background. The number of people commencing insulin therapy has escalated in recent years; due to increased incidence of diabetes and the evidence that improvements in glycaemic control can reduce and delay the onset of diabetic complications. However, the process of insulin initiation is not well described and the optimal way to start insulin therapy is unclear. There is currently a strong emphasis on moving diabetes care from secondary to primary care and this change in policy may also influence insulin initiation.Methods. A quantitative, cross‐sectional, nationwide survey of diabetes specialist nurses (DSNs) and practice nurses (PNs) was completed in 2006. Data were gathered using a postal questionnaire, 1310 were returned (37·7% response rate).Results. Almost all DSNs working in secondary, or across primary and secondary, care initiate insulin in people with type 1 diabetes, but only 37·7% of DSNs working in primary care or 2·5% of PNs (p &lt; 0·001). Most DSNs initiate insulin in adults with type 2 diabetes compared with only 37·7% of PNs (p &lt; 0·001). Only 23·5% of respondents initiate insulin for those with gestational diabetes (GD), most working in secondary care (p &lt; 0·001). The most commonly used insulin regimen was multiple injection in type 1 diabetes (43·9%), a twice‐daily mixture (19·2%) and night only basal insulin (17·9%) in type 2 diabetes and multiple injection in GD (46·8%). Analogue insulins were more frequently used than non‐analogues in type 1 and 2 diabetes but almost equally in those with GD.Conclusion. Despite the drive for much more diabetes care to be delivered in primary care insulin initiation remains largely the province of secondary care, and regardless of the contested nature of the evidence base, analogue insulins are widely used.Relevance to clinical practice. The focus of this study was on one aspect of diabetes care (insulin initiation), however the findings illustrate that whilst policy relating to the care of people with a long‐term condition such as diabetes may change, the practice implications in terms of community provision and availability of appropriate expertise are complex.

Family Medicine, the specialty of the future: the Portuguese situation within the European context

General Practice/Family Medicine is a specialty focused on the provision of comprehensive, continuing, and community oriented, person-centred care. The lack of prestige and the difficulty in attracting trainees to the specialty have been longstanding problems in most countries around the world. In Europe, General Practice/Family Medicine is also hampered for not being recognized as a specialty throughout Europe. As for Portugal, General Practice/Family Medicine is undergoing a massive organizational reform, as well as unprecedented levels of popularity among trainees.General Practice/Family holds tremendous latent potential, and is thus a specialty with a bright future ahead. It could well establish itself as the specialty of the future if it is able to overcome the barriers that currently make of General Practice/Family Medicine an unpopular career choice. It is important to train confident, competent and polyvalent family physicians, but it is also necessary to overhaul payment schemes, to invest in primary care infra-structure and organization, and to continue to attract more and more bright and motivated trainees.