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This chapter describes Psychosis Identification and Early Referral (PIER), a clinical and public health system for identifying, treating, and rehabilitating young people at risk for major psychosis and psychotic disorders. A specialized clinical team educates key sectors of the community in identifying very early signs and symptoms of a likely psychosis in youth ages 10–25. The team then rigorously assesses those referred and found at risk and provides family-aided assertive community treatment. This model was originally developed for schizophrenia in young adults, and it has been adapted for the much younger and less seriously symptomatic and disabled at-risk population. The model includes flexible, in-vivo clinical treatment, family psychoeducation, cognitive-behavioral therapy, occupational therapy, supported education and supported employment, and psychiatric and nursing care. PIER has been tested across six population-representative sites in the United States; within testing periods, very few participating youths have experienced psychosis and about 90 percent are in school or working. It has been replicated widely enough that it is available to over 15 percent of the US population.
Early intervention in psychosis (EIP) services improve outcomes for young people, but approximately 30% disengage.
Aims
To test whether a new motivational engagement intervention would prolong engagement and whether it was cost-effective.
Method
We conducted a multicentre, single-blind, parallel-group, cluster randomised controlled trial involving 20 EIP teams at five UK National Health Service (NHS) sites. Teams were randomised using permuted blocks stratified by NHS trust. Participants were all young people (aged 14–35 years) presenting with a first episode of psychosis between May 2019 and July 2020 (N = 1027). We compared the novel Early Youth Engagement (EYE-2) intervention plus standardised EIP (sEIP) with sEIP alone. The primary outcome was time to disengagement over 12–26 months. Economic outcomes were mental health costs, societal costs and socio-occupational outcomes over 12 months. Assessors were masked to treatment allocation for primary disengagement and cost-effectiveness outcomes. Analysis followed intention-to-treat principles. The trial was registered at ISRCTN51629746.
Results
Disengagement was low at 15.9% overall in standardised stand-alone services. The adjusted hazard ratio for EYE-2 + sEIP (n = 652) versus sEIP alone (n = 375) was 1.07 (95% CI 0.76–1.49; P = 0.713). The health economic evaluation indicated lower mental healthcare costs linked to reductions in unplanned mental healthcare with no compromise of clinical outcomes, as well as some evidence for lower societal costs and more days in education, training, employment and stable accommodation in the EYE-2 group.
Conclusions
We found no evidence that EYE-2 increased time to disengagement, but there was some evidence for its cost-effectiveness. This is the largest study to date reporting positive engagement, health and cost outcomes in a total EIP population sample. Limitations included high loss to follow-up for secondary outcomes and low completion of societal and socio-occupational data. COVID-19 affected fidelity and implementation. Future engagement research should target engagement to those in greatest need, including in-patients and those with socio-occupational goals.
Millions of people visit US national parks annually to engage in recreational wilderness activities, which can occasionally result in traumatic injuries that require timely, high-level care. However, no study to date has specifically examined timely access to trauma centers from national parks. This study aimed to examine the accessibility of trauma care from national parks by calculating the travel time by ground and air from each park to its nearest trauma center. Using these calculations, the percentage of parks by census region with timely access to a trauma center was determined.
Methods:
This was a cross-sectional study analyzing travel times by ground and air transport between national parks and their closest adult advanced trauma center (ATC) in 2018. A list of parks was compiled from the National Parks Service (NPS) website, and the location of trauma centers from the 2018 National Emergency Department Inventory (NEDI)-USA database. Ground and air transport times were calculated using Google Maps and ArcGIS, with medians and interquartile ranges reported by US census region. Percentage of parks by region with timely trauma center access—defined as access within 60 minutes of travel time—were determined based on these calculated travel times.
Results:
In 2018, 83% of national parks had access to an adult ATC within 60 minutes of air travel, while only 26% had timely access by ground. Trauma center access varied by region, with median travel times highest in the West for both air and ground transport. At a national level, national parks were unequally distributed, with the West housing the most parks of all regions.
Conclusion:
While most national parks had timely access to a trauma center by air travel, significant gaps in access remain for ground, the extent of which varies greatly by region. To improve the accessibility of trauma center expertise from national parks, the study highlights the potential that increased implementation of trauma telehealth in emergency departments (EDs) may have in bridging these gaps.
To identify the efficacy of group-based nutrition interventions to increase healthy eating, reduce nutrition risk, improve nutritional status and improve physical mobility among community-dwelling older adults.
Design:
Systematic review. Electronic databases MEDLINE, CINAHL, EMBASE, PsycINFO and Sociological Abstracts were searched on July 15, 2020 for studies published in English since January 2010. Study selection, critical appraisal (using the Joanna Briggs Institute’s tools) and data extraction were performed in duplicate by two independent reviewers.
Setting:
Nutrition interventions delivered to groups in community-based settings were eligible. Studies delivered in acute or long-term care settings were excluded.
Participants:
Community-dwelling older adults aged 55+ years. Studies targeting specific disease populations or promoting weight loss were excluded.
Results:
Thirty-one experimental and quasi-experimental studies with generally unclear to high risk of bias were included. Interventions included nutrition education with behaviour change techniques (BCT) (e.g. goal setting, interactive cooking demonstrations) (n 21), didactic nutrition education (n 4), interactive nutrition education (n 2), food access (n 2) and nutrition education with BCT and food access (n 2). Group-based nutrition education with BCT demonstrated the most promise in improving food and fluid intake, nutritional status and healthy eating knowledge compared with baseline or control. The impact on mobility outcomes was unclear.
Conclusions:
Group-based nutrition education with BCT demonstrated the most promise for improving healthy eating among community-dwelling older adults. Our findings should be interpreted with caution related to generally low certainty, unclear to high risk of bias and high heterogeneity across interventions and outcomes. Higher quality research in group-based nutrition education for older adults is needed.
Chapter 1 introduces the book’s main theme, namely the growing global contest over the future of coal. Three main aspects are identified – the changing world-historical status of coal as the fuel of development, the shifting significance of the coal commodity in economic growth, and its impact as a central driver of climate change and ecological exhaustion. Government-led development ideology remains closely bound up with the extraction of coal as a source of energy security, yet is increasingly exposed and contested. Increased populist rejection of climate policy in the name of fossil fuel reliance reflects the growing intensity of this contest. Pro-coal political forces gain most traction where they are most threatened, in high-income coal-producing countries such as in the US, Canada and Australia, as well as in the EU. In newly industrialising contexts with lower emissions targets, such as in India, coal is challenged by new low-cost renewable energy, and by immediate health imperatives.
Chapter 8 develops a series of comparative themes from the experience of coal and climate change in India, Australia and Germany. In each country, we find that coal’s legitimacy crisis has created sharp contradictions in wider society, as well as within state institutions, and that local contests over new mines are rapidly undermining the social value of coal. Coal’s value to ‘development’ reflects its cultural narration as a valuable commodity and source of energy and in concluding we chart the way these narratives are contested, and are changing. In particular the chapter shows how anti-coal groups have gained strategic traction in the context of growing contradictions in national climate and energy policy. In this we return to the book’s initial provocation, expressed in the coal conundrum of increased coal extraction coupled with climate instability, arguing the conundrum is on the way to being resolved, for a post-coal future.
Chapter 4 focusses on proposed brown coal mines for Lusatia, a region of Eastern Germany on the Polish border. The mines aimed to extend existing concessions, supplying coal for the nearby power generators. They were owned by the Swedish state-owned corporation Vattenfall, which sold them to a Czech conglomerate in 2016. The developmentalist argument for the mining is addressed first, especially in terms of its strategic value for German ‘energy security’. We examine the debates about coal’s economic necessity as a ‘transition fuel’ in Germany’s Energiewende, and its environmental or climate impacts. These themes are then developed in analysing the governance framework for the mine approval and opposition to it. The chapter shows how local opponents mobilise established conceptions of home or ‘heimat’ against the mining. These scripts, centred on local values of belonging in place, are integrated with concerns about impacts on livelihood and environment, and with concerns about climate change. The direct contradiction between Germany’s post-industrial ‘green economy’ and its determination to expand emissions-intensive brown coal is particularly powerful, not least as it destabilises technocratic authority.
Chapter 7 takes the historical analysis into the present day and charts a significant unravelling in the coal-industrial complex. Investor uncertainty about the future viability of energy installations has shifted into a dramatic (and long-awaited) process of capital flight from coal to renewables. Perhaps most revealing, the coal sector itself has begun hedging its losses by investing in renewables. The chapter discusses the reasons for this shift. The Paris Agreement’s 2050 deadline for ‘net-zero carbon’, which, at the time of writing in 2019, was well within the investor horizon for coal-fired power plants, has imposed a growing perception of risk associated with coal facilities. It has also precipitated an unexpected realignment of low-income economies to seek new industrial strategies linked to the renewables sectors, creating a new state-renewables nexus to rival coal.
The Introduction to the book defines coal as a key driver of climate change and outlines the urgent need for a global transition to renewable energy. It discusses theapproach taken in the book, of comparinghow new coal mines are contested, and justifies the focus on India, Australia and Germany. It outlines the book's research questions, its inter-disciplinary method and its chapter-by-chapter structure.
Chapter 2 investigates the proposal for a new thermal coal mine in Chhattisgarh, Central India. The proposed mine is located in an emerging coal-mining region that feeds power stations mainly for industry. The mine would destroy forested lands and displace a large number of villages populated by Indian indigenous Adivasi people. The proponent for the mine, Adani, is a major privately owned industrial conglomerate seeking the coal to fuel its industrial concerns. The national government strongly favours expanded coal extraction, and the mine forms part of its privatization effort, designed to stimulate the sector. Within civil society there is strong village-level opposition to the mine, with concerns centred on land and livelihood. Alliances of villages opposing the mine find allies at the regional level and are able to disrupt regional politics; they also are able to make legal claims at the national level, and link with national and international environmental NGOs. Arguments for sustainable energy gain momentum especially when there are viable renewable alternatives. The struggle is skewed by coercion, with anti-mine campaigners subjected to surveillance and arbitrary detention by Indian state security.
Chapter 6 investigates the contradiction between expanded coal use and the climate policy regimes that emerged after the adoption of the UN Framework Convention on Climate Change (UNFCCC) in 1992, and the subsequent Kyoto Protocol. During this period coal mines and coal-fired power remained ‘locked in’ as the key foundation for energy security, and for economic growth. Struggles over climate policy in support of renewable energy did secure some changes, especially in Germany, but overall there was a steep increase in aggregate emissions from the coal sector. During this period, ‘business as usual’ entrenched the primacy of coal: international agencies such as the IEA predicted that climate policy would fail and coal would remain dominant. Yet coal was now in direct collision with climate stability, and this was profoundly disruptive of coal’s hegemony.
Chapter 5 charts the post-1945 history of energy policy in India, Australia and Germany, focussing on the strengthened state-corporate ‘coal-industrial complex’. All three, in their different ways, highlight the centrality of national development models in conditioning outcomes. The present-day dynamics, in the face of climate change, reflect historically sedimented tendencies. Across the three countries coal-centred fossil fuel developmentalism became deeply entrenched in the aftermath of the Second World War. The national state was a key agent in this process, which saw coal maintain and extend its role in power generation. The task of capitalising coal reserves, as a critical asset for economic development and energy security, was taken up by a range of newly formed state agencies. The state-led push for coal was later was accelerated by the 1970s’ Oil Crisis, which again positioned coal as the fossil fuel of choice into the 1980s. The neoliberal revolution from the 1980s brought more transformations, privatizing an already highly concentrated and entrenched industry, strengthening its influence over climate policy. The chapter outlines these shared themes at the global and national state level that entrenched a relatively durable ‘coal-industrial complex’ in each of the three countries.