System-level Changes Research Articles

FIRST: Enhancing Agency Dementia Capability through Dementia-Specific Interventions and Supportive Services

Through the First Identify and Refer then Serve and Track (FIRST) Project, individuals and caregivers have critical connections to community organizations and resources to learn ways to handle living with memory problems. The FIRST project integrated new practices into existing programs to address gaps in service and piloted a new dementia-specific case management program. The initial intervention is a system-level change within the County of San Diego’s Aging & Independence Services (AIS) department to identify, pilot, and implement a brief Alzheimer’s Disease and Related Dementias (ADRD) screening tool. The tool was used by non-clinical personnel to identify potential ADRD cases. Individuals who screened positive for possible ADRD were referred to their physicians for an accurate diagnosis. The second intervention consisted of two components: a behavioral symptom management intervention for social workers to use in the home with caregivers and a dementia-specific case management program (including respite care) to improve quality of life and future planning for those with ADRD living alone or with a family caregiver. As of January 2021, 536 clients across several AIS programs have been screened for ADRD, of which, 60% screened positive. FIRST case management has served 196 clients, 70 who lived alone and 126 who lived with their caregiver. Respite was provided to 98 clients totaling to 3,666 hours. This poster evaluates the effectiveness of the program components in increasing dementia capability of an agency, and where applicable, its effect on caregiver burden and self-efficacy.

The Caregiver Initiative: A Model for Caregiver Health and Wellness in Age-Friendly Health Systems

Health care systems have historically relied on family caregivers to provide long-term care for older adults, often including medically complex care for which they have no medical training. Yet there are few interventions in place to assist them within health care systems. The Rush Caregiver Initiative (Rush-CGI) provides system-level and caregiver interventions. Rush-CGI’s system-level interventions focus on culture change, including modifying workflows, training, and electronic health record data. Rush-CGI caregiver interventions begin with assessment of needs and provision of resources for caregivers, offering interprofessional family-based interventions. Interventions include a Teach-Back Clinic, Family Care Planning sessions, and Goals of Medical Care meetings, all held on an outpatient basis either in person or virtually. Outcomes include decreased caregiver depression and anxiety, and increased caregiving self-efficacy. This presentation will discuss creating system level change and providing customized caregiver interventions, including how the Rush-CGI can be modified to fit a variety of patient populations.

Lessons Learned From Human Papillomavirus Vaccination to Increase Uptake of Adolescent COVID-19 Vaccination

Lessons Learned From Human Papillomavirus Vaccination to Increase Uptake of Adolescent COVID-19 Vaccination

Regenerative tourism in Aotearoa New Zealand – A new paradigm for the VUCA world

PurposeThe paper provides a summary of the findings from GOOD Awaits – The Regenerative Tourism New Zealand (NZ) Podcast and envisions a regenerative future for tourism in Aotearoa.Design/methodology/approachThis paper is based on the findings from the GOOD Awaits Podcast, a series of interviews with pioneers and practitioners of regenerative tourism. The podcast was created as a platform for the collective discovery of a new way forward for tourism in the wake of COVID-19, and the series provides a detailed summary of the regenerative tourism movement in NZ.FindingsThrough these interviews, a vision for a regenerative visitor economy in Aotearoa emerged. This new model is rooted in indigenous knowledge and living systems theory. It is a paradigm shift that allows us to see tourism as a living ecosystem and requires innovative economic models, such as social entrepreneurship, systems level changes to the way tourism operates and is governed, local tourism solutions with community thriving as the primary aim and much more collaboration both within tourism and across sectors.Originality/valueRegenerative tourism is an emerging model and one that is rapidly gaining traction in NZ and globally. The GOOD Awaits podcast is a unique, thoughtful and practical demonstration of what this model could look like in Aotearoa. It demonstrates the potential and feasibility of regenerative tourism practice, and the response has shown the desire for these conversations at a national and international scale. This paper is an accessible summary of the podcast's first season and has value for anyone interested in the regenerative tourism movement in Aotearoa.

Assessing the impact of social distancing measures implemented during COVID-19 pandemic on medications for opioid use disorder in West Virginia

IntroductionThis study evaluates if social distancing measures instituted during the novel coronavirus SARS-CoV-2 (COVID-19) pandemic were associated with a reduction in Medication for Opioid Use Disorder (MOUD) prescribing in West Virginia. The COVID-19 pandemic necessitated the quick implementation of public health interventions such as social distancing. This led to the use of telemedicine in the clinical setting however implementing telemedicine involves system level and infrastructure level changes within a healthcare environment. This could cause a barrier to MOUD delivery as it is often provided concomitantly with other face to face substance use and mental health services. The purpose of this study is to determine whether social distancing was associated with a reduction in MOUD prescribing in West Virginia, with the goal of adding to the knowledge of how COVID-19 and COVID-19-related mitigation strategies have impacted patients with OUD. MethodsPrescription monitoring data were requested from the West Virginia Board of Pharmacy. We applied interrupted time series modeling to investigate MOUD prescribing practices before and after social distancing took effect. Gabapentin prescriptions were utilized as a control for comparison. ResultsOur study assessed state-wide buprenorphine and Suboxone prescriptions as compared to a control medication and found an increase in dosage of both medications and an increase in number of buprenorphine prescriptions, but a small decrease in buprenorphine/naloxone prescription number related to the dates of implementation of social distancing. Taken together, overall this indicates an increase in prescription number of MOUD prescriptions as well as an increase in dosage. ConclusionThis study suggests that social distancing measures were associated with an increase in both the number of MOUD prescriptions and the number of doses in each prescription. Significant alterations to MOUD delivery in the clinical setting were implemented in a short timeframe with the COVID-19 pandemic. Understanding the implementation of clinical measures to accommodate social distancing measures may provide benefit to transformation of future delivery of MOUD.

Three-Decades of Research Integration—Transforming to Collaborative Aquatic Food Systems Research Partnerships in the Pacific

High-quality research to provide sustainable development solutions in aquatic food systems requires a deliberate theory for its application at scale. One frequently defined pathway in theories of change for scaling research innovation is through partnerships. Yet, despite the widespread application of partnership modalities in food-systems research, only a small proportion of published research provides original and high-quality solutions for small-scale producers. Metrics of academic success can incentivize publication regardless of end-user impact. Analogously, partnerships among national and international institutions can also lack impact because of inequity and persistent power imbalances. We describe a long-term research for development partnership between a CGIAR center (WorldFish) and a national government agency (Solomon Islands Ministry of Fisheries and Marine Resources; MFMR). We review the literature produced by, or about, the activities carried out in the name of the partnership over a 35-year period to build a time-line and to identify elements of research power, priorities and capacity by decade. The form and function of the collaboration through time form the basis of our analysis of the journey toward an increasingly equitable partnership: a theorized goal toward greater development outcome at scale in Solomon Islands. The partnership has been strongly influenced by changes in both institutions. The MFMR has undergone a significant increase in operational capacity since the partnership was first conceived in 1986. WorldFish has also undergone change and has navigated tensions between being locally impactful and globally relevant through periods of different research foci. With an increasingly competent and capable ministry, dimensions of power and practice have had to be re-visited to embed CGIAR research on aquatic food systems within national development trajectories. By focusing on a practice seeking more meaningful and respectful partnerships, WorldFish—as an international research partner—continues to evolve to be fit for purpose as a credible and effective research partner. We discuss this journey in the context of system-level change for aquatic food system sustainability and innovation.

Knowledge, Perceptions, and Attitudes Regarding Antibiotic Use for Lower Respiratory Tract Infections: Insights from Patients in Sri Lanka.

Antibiotic resistance is an emerging global public health threat. One of the main drivers of this threat is the inappropriate use of antibiotics. In Sri Lanka, antibiotic consumption is increasing, but little is known locally about how patients perceive antibiotics. We conducted a qualitative study to gain a better understanding of the knowledge, perceptions, and attitudes of patients regarding antibiotics and antibiotic resistance. Semi-structured interviews involving 18 patients with lower respiratory tract infection (LRTI) admitted to a large, public tertiary care hospital in southern Sri Lanka were conducted. Interviews were analyzed to identify themes regarding the patients' knowledge of LRTI etiology and treatment, perceptions and attitudes toward LRTI treatment, including antibiotics, and patient-physician communication. Most patients mentioned multiple care visits and the use of multiple pharmaceuticals prior to admission. Patients sought a quick resolution to their ailments and frequently visited several private physicians to obtain a satisfying answer. Self-medication was also common. Patients reused prescriptions for antibiotics, kept antibiotics for later use after prematurely stopping their course of treatment, and bought over-the-counter antibiotics. Patients' knowledge of disease etiology and antibiotics was poor. Only a few patients were aware of antibiotic resistance. Despite the desire to receive more information regarding disease and treatment, patient-provider communication was limited and mainly confined to prescription instructions. This qualitative study performed in Sri Lanka suggests that inappropriate use of antibiotics is a multifactorial problem. To improve antibiotic use, a multifactorial approach that includes educating the public, increasing awareness among physicians, and implementing systems-level changes to restrict access to antibiotics is urgently needed.

HIV care continuum interventions for Black men who have sex with men in the USA.

Disparities persist along the HIV care continuum among Black men who have sex with men (MSM) in the USA. As part of an initiative funded by the Health Resources and Services Administration's HIV/AIDS Bureau (US Department of Health and Human Services), we searched for recently published interventions focused on improving HIV care continuum outcomes among Black MSM with HIV in the USA. Our search identified 14 interventions, all of which were associated with at least one statistically significant outcome. Medication adherence was the most common outcome of interest, and linkage to care was the least common. More than half of the interventions focused on younger populations and took place in the US South. Interventions used a range of strategies to increase cultural relevance and address common barriers to optimal HIV outcomes for Black MSM. Several interventions harnessed social media, text messaging, and smartphone apps to facilitate social support, deliver HIV education, and encourage medication adherence. Interventions were delivered mostly at the individual or interpersonal level, although three made system-level changes to address structural barriers. Notably missing were interventions focused on minimising behavioural health barriers, and interventions directly addressing social determinants of health such as housing. To accelerate the pace of implementation and scale-up of interventions for Black MSM with HIV, public health entities can pilot emerging interventions in real-world settings, and use an implementation science approach to evaluate outcomes and assess the implementation strategies that drive or hinder effectiveness.

Students, Stress, and the Pandemic: An Occupational Health Perspective for Nursing Education.

Nursing students have high risk factors for stress, and the coronavirus disease 2019 pandemic underscored weaknesses in mitigating nursing student stress and supporting well-being. Occupational health uses proven frameworks and perspectives for understanding and mitigating health risks, and promoting worker wellness. Nurse educators can draw from this knowledge to implement system-level changes in support of a safe and healthy learning environment. This article describes the use of an occupational health strategy to create healthier educational environments. Applying occupational health concepts to nursing education supports honest appraisal of mental health dangers to students, offers keys to managing student health risks, and provides effective approaches for communicating risks with mitigation tactics. An occupational health and safety perspective creates a lens through which nursing stress resulting from the pandemic can be viewed and managed creatively using a holistic approach to mitigate harm from stress in the nursing educational setting. [J Nurs Educ. 2021;60(12):674-679.].

A systemic approach to transitions towards circular economy: The case of Brighton and Hove

To date, the literature on the circular economy has been dominated by closed-loop industrial practices, circular products, and business models. Lack of systemic perspective in the circularity debate limited the understanding of multi-actor and multi-pattern transitions. In this paper, we apply a co-evolutionary framework to investigate key dimensions of a socio-technical system -ecosystems, technologies, businesses, institutions, and user practices-in the city of Brighton and Hove (United Kingdom). We present the causal interaction between these systems based on the outcomes of semi-structured interviews with the local actors and documentary analysis of relevant policies and strategies. Exploring how each system evolves under own dynamics and influenced by the dynamics in the others leads us to identify the main drivers and barriers of a circular economy in the city. Our findings underline the necessity of systems-level change with a holistic vision, consideration of place-specific factors and engagement of multiple actors for a successful transition.

Burnout and Moral Injury Among Consultation-Liaison Psychiatry Trainees.

Burnout and moral injury within medicine have steadily increased over the last decades, especially among those providing care during the COVID-19 pandemic. The term burnout has been used to describe clinician distress and a syndrome of emotional exhaustion, a diminished sense of personal accomplishment, and depersonalization. Burnout has a significant impact on both job performance and patient care. Moral injury occurs when external circumstances interact with a person's cherished beliefs and standards. When the tension between them cannot be reconciled, the felt integrity of the individual is disrupted and the person experiences distress. The consultative aspect in consultation-liaison psychiatry (CLP) presents challenges that may predispose the young clinician to burnout and moral injury, especially during fellowship training. CLP psychiatrists also have a liaison role that could catalyze systemlevel change to enhance the mental well-being of their colleagues. This article reviews clinically relevant psychodynamic aspects of burnout and moral injury during CLP training. In addition, the authors propose strategies to enhance career growth and prevent and address moral injury during training to generate fulfilling professional development.

A systems approach to the exploration of research activity and relationships within a local authority

BackgroundOrganizations with responsibilities for public health are increasingly required to use evidence-based practice to inform programme delivery, requiring research to generate relevant evidence, and dissemination and use of evidence to inform decisions and practices. Understanding how relationships between organizational structures, systems and processes influence evidence-based practices is critical to improving practice at both an institutional and system level, yet how these relationships should best operate is not well understood. Understanding how to better support research within local authorities, the elected administrative bodies responsible for services including public health at a regional level in the United Kingdom, is a priority for the National Institute for Health Research (NIHR) Public Health Research. This study is based on Norfolk County Council, a local authority in the east of England. We aimed to apply a systems perspective to develop a better understanding of the structures, systems and processes that support a local authority in becoming research-active, identifying gaps in understanding and recommendations for action to address them.MethodsTaking a participatory action research approach, we applied qualitative methods to explore research activity and relationships in Norfolk County Council. We surveyed employees and used network analysis to map individuals, departments and external partners involved in research activities and the connections between them. We then applied participatory approaches to conduct a series of focus groups and semi-structured interviews to explore stakeholders’ experiences and perceptions of being involved in research at, or with, the authority, and their ideas for recommendations for future actions.ResultsA range of research activity is undertaken at the local authority, with an emphasis on applied work to improve service delivery. We identified several examples of effective practice and models of research collaboration in some departments. Challenges such as limitations in resources, capacity and knowledge exchange were evident, yet there was a readiness amongst key stakeholders to develop and implement actions that may better support the authority in becoming more research-active.ConclusionIn large complex organizations, a key challenge is how to share learning across teams and implement good practice at an organizational and system level. Our findings highlight the potential for developing improved collaborative partnership models and systems to support sustainable processes and practices for research and knowledge exchange at an institutional and interorganizational level. The insights gained and shared will support other local authorities and similar large, multilevel organizations with responsibilities for evidence-based public health to explore their own setting and implement change where needed, and provide stimulus for further research into system-level change.

Large scale healthcare facility redevelopment: A scoping review.

Internationally, organisations are undertaking large scale facility redevelopment as a strategy for the transformation of care systems. Redeveloping facilities provides a once in a generation opportunity to transform health service delivery, typically, however, system level changes are poorly understood. To address this gap, our aim was to investigate the empirical knowledge base regarding large scale redevelopment of healthcare facilities. A scoping review was undertaken, guided by the redeveloped health service management (HSM) scoping review framework (HSM-SRF). Across 17 articles, five key concepts were identified, and they form the principles for successful redevelopment. First, establish a strong governance framework integrating diverse expertise and evidence base. Second, engage with internal and external stakeholders to build effectual relationships. Third, consult with end users, including clinicians and patients, to encourage the acceptance of the redevelopment and actively manage stakeholder dynamics, including politics and power undercurrents. Fourth, commit appropriate resources, including time, workforce, technology and finance to ensure redevelopment success. Finally, reimagine workflows through consultation with end users, including staff and consumers, allowing them to conceptualise how the space will be utilised. This scoping review is the first to synthesise the empirical knowledge base of the redevelopment of healthcare facilities.

Staff and volunteers' perceptions of a Communication Enhanced Environment model in an acute/slow stream rehabilitation and a rehabilitation hospital ward: a qualitative description study within a before-and-after pilot study

Purpose A lack of social interaction during early stroke recovery can negatively affect neurological recovery and health-related quality of life of patients with aphasia following stroke. A Communication Enhanced Environment (CEE) model was developed to increase patient engagement in language activities early after stroke. This study aimed to examine staff (n = 20) and volunteer (n = 2) perceptions of a CEE model and factors influencing the implementation and use of the model. This study formed part of a broader study that developed and embedded a CEE model on two hospital wards. Materials and methods Six focus groups and one interview with hospital staff were conducted and analysed using a qualitative description approach. Feedback emailed by volunteers was included in the data set. Results Staff and volunteers perceived the CEE model benefitted themselves, the hospital system and patients. Staff identified a range of factors that influenced the implementation and use of the CEE model including individual staff, volunteer and patient factors, hospital features, the ease with which the CEE model could be used, and the implementation approach. Conclusions This study provides valuable insights into staff perceptions which may inform the implementation of interventions and future iterations of a CEE model. Implications for Rehabilitation A CEE model may promote efficiency and increased patient engagement in stroke rehabilitation. The CEE model information session and aphasia communication partner training, and the provision of resources, may be useful strategies to increase staff confidence in using communication supporting strategies with patients with aphasia. Behaviour change and implementation science strategies may provide a framework to address barriers and promote facilitators to embed hospital-based interventions that require individual, ward, cultural and systems level change to reduce the evidence-based gap in clinical practice.

Procedural Collaboration in Educational Games: Supporting Complex System Understandings in Immersive Whole Class Simulations

ABSTRACT With the current rising need for sustainability education, understanding the interconnected political, economic, ecological, and social systems that motivate (system level) change, can be uniquely addressed through immersive multiplayer games. Immersion through a mixed reality experience, face to face interactions, and game mechanics that push players to play with and against their co-learners enhances the familiar benefits of participatory simulations – where learners engage in developing parts of a complex system, and then respond to the consequences of their own decisions through interpersonal negotiation and changing strategies. Here we present City Settlers, a city management (immersive multiplayer) game that supports such learning and elicits different kinds of collaborations. We present these different collaborations as evidence for a range of complex systems understandings. We call these socially performed representations of new learning – procedural collaborations. Using a sequence of vignettes, we present cases of how game and interaction design can foster different procedural collaborations, and how City Settlers enables these procedural collaborations to represent developing understandings of a complex systems perspective on sustainable development. Through our work, we highlight the unique affordances of social immersive simulations in creating space to perform and understand concepts hard to find in many simulation and game-based learning environments.

Mental health support and training to improve secondary school teachers’ well-being: the WISE cluster RCT

Background Health and Safety Executive data show that teachers are at heightened risk of mental health difficulties, yet few studies have attempted to address this. Poor teacher mental health may impact on the quality of support provided to young people, who also report increased mental health difficulties themselves. Objective To test the effectiveness of an intervention aiming to improve secondary school teachers’ well-being through mental health support and training. Design A cluster randomised controlled trial with embedded process and economic evaluations. Setting Twenty-five mainstream, non-fee-paying secondary schools in the south-west of England and South Wales, stratified by geographical area and free school meal entitlement, randomly allocated to intervention or control groups following collection of baseline measures (n = 12, intervention; n = 13, control) between May and July 2016. Participants All teachers in the study schools at any data collection. All students in year 8 (baseline) and year 10 (final follow-up). Intervention Each intervention school received three elements: (1) a 1-day mental health first aid for schools and colleges training session delivered to 8% of all teachers; (2) a 1-hour mental health session delivered to all teachers; and (3) 8% of staff trained in the 2-day standard mental health first aid training course set up a confidential peer support service for colleagues. Control schools continued with usual practice. Main outcome measures The primary outcome was teacher well-being (using the Warwick–Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence and presenteeism, and student well-being, mental health difficulties, attendance and attainment. Follow-up was at 12 and 24 months. Data were analysed using intention-to-treat mixed-effects repeated-measures models. Economic evaluation A cost–consequence analysis to compare the incremental cost of the intervention against the outcomes measured in the main analysis. Process evaluation A mixed-methods study (i.e. qualitative focus groups and interviews, quantitative surveys, checklists and logs) to examine intervention implementation, activation of the mechanisms of change outlined in the logic model, intervention acceptability and the wider context. Results All 25 schools remained in the study. A total of 1722 teachers were included in the primary analysis. We found no difference in mean teacher well-being between study arms over the course of follow-up (adjusted mean difference –0.90, 95% confidence interval –2.07 to 0.27). There was also no difference in any of the secondary outcomes (p-values 0.203–0.964 in the fully adjusted models). The average cost of the intervention was £9103 (range £5378.97–12,026.73) per intervention school, with the average cost to Welsh schools being higher because of a different delivery model. The training components were delivered with high fidelity, although target dosage was sometimes missed. The peer support service was delivered with variable fidelity, and reported usage by teachers was low (5.9–6.1%). The intervention had high acceptability, but participants reported low support from senior leadership, and minimal impact on school culture. Limitations Participants and the study team were unblinded, self-report for the main outcome measures and inaccurate measurement of peer support service usage. Conclusions The Wellbeing in Secondary Education (WISE) intervention was not effective at improving teacher or student well-being, or reducing mental health difficulties, possibly because of contextual barriers preventing it becoming embedded in school life. Future work Identification of ways in which to achieve system-level change and sustained support from senior leaders is important for future school-based mental health interventions. Trial registration Current Controlled Trials ISRCTN95909211. Funding This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information. Intervention costs were met by Public Health Wales, Public Health England and Bristol City Council.

The Effect of Changes in the Transition to Secondary Education Systems on Mathematics Achievement

Turkey has witnessed numerous changes in the transition to secondary education systems in the 2000s. The Secondary Education Institutions Examination (OKS), the Level Specifying Examination (SBS), and the Transition from Primary to Secondary Education System (TEOG) were implemented between 2010 and 2018. Lastly, in 2018, the Transition to High School System (LGS) has been adopted as a new system. This study examines the effect of the changes in secondary education transition systems between 2010 and 2019 on students' mathematics achievement in 9th grade. The data of all students who were in 9th grade between 2010 and 2019 were analyzed through multiple linear regression methods. The parents’ education level, 8th grade mathematics achievement, age, and gender are considered as external variables and their effects are controlled statistically. The findings revealed that a significant and sharp decrease in 9th grade mathematics achievement occurs after every system-level change in the transition systems. Additionally, the largest decrease in mathematics achievement is found in TEOG. Based on the results, it is recommended to make incremental improvements instead of radical changes to alleviate the problems in secondary education transition systems.

Dairy farmers' perspectives on providing cow-calf contact in the pasture-based systems of New Zealand

Separation of the cow and calf shortly after birth is a common practice on commercial dairy farms around the world, but there are emerging concerns about this practice among citizens and other stakeholders. Continuous improvement of on-farm management practices in collaboration with dairy sector stakeholders increases the likelihood that farming systems evolve in a way that is consistent with societal expectations. Few commercial dairy farms provide extended cow-calf contact, and there is little understanding of how dairy farmers view this practice. This study examined the views of New Zealand dairy farmers toward providing cow-calf contact, particularly the barriers to adopting such a system in a seasonal-calving pasture-based dairy system. Standard farm practice in New Zealand is to remove the calf from the cow around 24 h (but could be up to 48 h) after birth. These conventional farmers (n = 63) were randomly selected from the database of all dairy farmers in New Zealand and telephone-interviewed using a semistructured interview format. Their responses to questions about providing cow-calf contact (defined as contact beyond the standard practice of 48 h) were analyzed using thematic analysis. Three major themes of concern were identified by these farmers about providing cow-calf contact as follows: (1) poor animal welfare, especially the risk of mastitis in the dam, inadequate colostrum for the calf, increased stress from delayed separation, and lack of shelter for calves while outdoors with the cow; (2) increased labor and stress on staff; and (3) system-level changes required, including infrastructure and herd management. Many of these concerns stemmed from challenges related to the nature of large-scale seasonal-calving pasture-based dairy systems, where a large number of calves are born in a short period of time and may be exposed to inclement weather in late winter in some areas. Several small-scale farmers (n = 4) providing cow-calf contact for longer than standard practice of 48 h were also interviewed; all permitted contact for at least 4 wk. These farmers also felt that animal welfare and health were important, and that this was promoted in their cow-calf contact systems. Concerns about colostrum and mastitis, for example, were not raised by these farmers, but they did agree that additional infrastructure and shelter were important considerations for cow-calf contact systems. Some conventional farmers expressed cognitive dissonance in that they theoretically preferred cow-calf contact but could not see it being realistic or practical to implement. Farmers currently providing longer cow-calf contact may be a useful resource for better understanding of how practical and economical cow-calf contact systems could be adopted on commercial pastoral dairy farms.

Treatment delay and clinical outcomes in patients with ST-elevation myocardial infarction during the COVID-19 pandemic

Abstract Background The COVID-19 pandemic negatively affected access to health-care system and timeline of treatment. The fear of contamination might potentially forbear from accessing the emergency system.mFurthermore, pandemic-specific protocols require additional time to prepare medical stuff and catheterization laboratory before procedure. Thus, patients with ST-segment elevation myocardial infarction (STEMI) might be exposed to a longer delay for revascularization and higher risk of mortality. Purpose The aim of this study was to evaluate treatment delay and clinical outcomes in COVID-19 positive and negative patients with STEMI treated with percutaneous coronary intervention (PCI) during on- and off hours. Methods All consecutive patients with STEMI treated with PCI and stent implantation between 1st March 2020 and 31st December 2020 were enrolled into analysis. To overcome potential bias related to the non-randomized design a propensity score match (PSM) was used to compare COVID-19 positive and negative patients for both working frames hours. The study group consisted of 877 matched pairs treated during regular hours (everyday 7:00AM-16:59PM) and 418 matched pairs with PCI performed during off-hours (everyday 17:00PM and 06:59AM) in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry). Results After PSM there were no differences between COVID-19 positive and negative patients in baseline characteristics during both on- and off-hours. However, patients diagnosed with COVID-19 were admitted with cardiac arrest more frequently as compared to COVID-19 negative patients during regular working hours (180 (20.5%) vs. 64 (7.30%); p=0.001). There were no differences in radiation doses and total amount of contrast between both groups. Similarly, no differences in rate of periprocedural complications were observed despite of time of intervention, including stroke, access-site-related bleeding, allergic reaction and coronary artery perforation. Furthermore, there were no differences in periprocedural mortality between both groups (on-hours: COVID-19 negative vs. COVID-19 positive: 17 (1.9%) vs. 11 (1.3%),p=0.3; off-hours: COVID-19 negative vs. COVID-19 positive: 4 (1.0%) vs. 7 (1.7%),p=0.5). However, COVID-19 positive patients were exposed to longer time from first medical contact to angiography during both on-hours (133.76 (±137.10) vs. 117.14 (±135.83) [min]; p=0.001) and off-hours (148.08 (±201.56) vs. 112.19 (±138.72) [min]; p=0.003). Time from pain to first medical contact remained similar during both working frame hours (On-hours and off-hours, respectively: p=0.7 and p=0.9). Conclusions Patients diagnosed with COVID-19 might experience a longer time from first medical contact to revascularization. There was no impact of COVID-19 diagnosis on rate of periprocedural mortality or periprocedural complication, irrespective of time of intervention. System-level changes might be crucial to improve health-care during COVID-19 pandemic. Funding Acknowledgement Type of funding sources: None.

Crisis, transformation, and agency: Why are people going back-to-the-land in Greece?

Transformations are fundamentally about agency: human intention, motivation, and power to influence and to resist. Most studies focus on deliberate system-level transformations, usually guided by a set of influential actors. However, system-level transformations may also occur as the result of the cascading effects of multiple individual transformations in response or in anticipation to various crises. Little is known about how crises foster these individual transformations, and how these may relate to different types of system-level change. This article fills this gap by looking at how crisis fosters two different types of agencies—internal and external—and how these link to individual transformations in the case of Greece’s back-to-the-land movement whereby urbanites sought to reconnect with land-based livelihoods during the economic crisis (2008 onwards). The article draws on the qualitative analysis of 76 interviews of back-to-the-landers to further understand why people are going back-to-the-land (their motivations), how these relate to the concept of agency and individual transformation, and what implications might there be for system-level social-ecological transformations. This article makes three key points. First, crises create different opportunity contexts that may lead to rapid changes in what is valued in the broader social discourse. While social values and discourses are usually considered to be “deep levers” and slow to change, we found that they can rapidly shift in times of crises, challenging notions of the role of fast vs. slow variables in system transformations. Second, agency is needed to respond to crises but is also further catalyzed and enhanced through crisis; activating one’s internal agency leads to personal transformations as well as collective transformations (linked to external agency), which are mutually co-constitutive. And third, systemic-level transformation emerges through multiple pathways including through the aggregation of multiple individual transformations that may lead to emergent system-level changes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11625-021-01043-5.