text:
On the situation of short-term rentals and tourism in southern Europe
By Jaime Jover (@JaimeJover)
Few people that had heard about Airbnb in southern Europe 10 years ago. The San Francisco-based holiday rentals company had just started its expansion in the continent. During the first years of the 2010s, short-term leases' growth was still slow in a context where the World –particularly southern European economies– struggled to recover from the 2008 financial crisis. However, the Airbnb business began to accelerate in larger urban areas by 2014, increasing exponentially in the following years. Rooms and, especially, single houses and apartments skyrocketed across southern Europe reaching a peak in 2019, right before the COVID-19 crisis broke out. European capitals such as Barcelona, Madrid, Milano, Lisbon, or Rome had listed up to 20,000 listings by then (more than 25,000 in the case of the Italian capital). The situation was worse in southern European second-tier cities, particularly those branding themselves as cultural tourism destinations. Athens, Florence, Porto, Seville, or Valencia accumulated between 8,000 and 12,000 listings before the pandemic (data form InsideAirbnb). Even nowadays, with international tourism arrivals at the lowest level in decades, there are still thousands of short-term rentals available in these destinations. In some of them, the Airbnb accommodation offer surpassed that of hotels. Numbers are not the only issue, but also concentration. Airbnb listings have colonized central locations with a vivid cultural and leisure offer appealing to visitors as well as surrounding neighbourhoods, which had never been touristic before.
According to InsideAirbnb data, between 75% and 85% of the Airbnb offer in cities are single properties, i.e., a good part of housing has lost is residential use to host commercial activities permanently. Short-term rentals are no longer an alternative activity, the one you do when you go abroad on holidays and decide to rent your place to visitors for a few weeks. Rather, it has become business as usual. Thousands of housing units have been deprived of the market –usually long-term leases–, turning into tourism. Higher revenues are usually behind this trend, which has alternatively attracted investors of all sizes and nationalities. In southern European cities, the majority of Airbnb hosts are no longer people with second-homes, but individual and institutional buy-to-let investors, from a couple of apartments to entire buildings. Intermediaries have also sprung up: short-term rental management agencies have given birth to a business that is closer to a horizontal hotel than to a peer-to-peer activity. The sharing economy is not about sharing anymore (if it ever were).
The housing shortage has had different consequences. In the long-term rental market, there are fewer options, and usually more expensive. Lower-income residents, families who have traditionally rented in the central locations and surroundings neighbourhoods have been forced to move out. In Portugal and Spain, the concept of 'invisible evictions' has risen to define the foreclosure of (usually long-term) tenants because the landlord would not renovate a lease, or he would but increasing the price abusively, knowing their tenants could never afford it. Even for those who own an apartment, sharing their building's common spaces with unknown people have caused distressed, and decided to leave to other neighbourhoods. Impacts are also noted daily in the neighbourhood's public spaces, with noise, dirtiness, and overcrowding being the most common disruptions. Tourism congestion in streets and squares results in a reduction of meeting places and translates into the loss of community and social bonds. Culture facilities or monuments commonly suffer from saturation, modifying how locals spend their free time. Excluding neighbours from their neighbourhood is also seen in retail habits and the transformation of shops, as many cater now almost exclusively to tourists. One would think about business opportunities and employment if it were not for tourism being the sector that concentrates the lowest wages and precarious labour conditions in southern Europe. Tourism, and especially Airbnb, has largely disrupted urban living in many cities across the Mediterranean; concepts such as touristification or overtourism have emerged to explain the nature of these rapid transformations.
Under such circumstances, governments' response has been generally slow and insufficient to cope with the new challenges tourism is bringing over cities. In Italy and Portugal, national governments have passed legislation to assimilate short-term leases to tourism accommodation standards and taxation, by which there is a public compulsory registration, although leaving all the pressure of specific measures to municipalities. On the one hand, for instance, Milano or Torino have done nothing about it despite existing evidence of tourism-related problems. On the other hand, Venice decided not to control short-term rentals but visitors in general and started charging from 3 to 10 euros to tourists entering the city. In Portugal, registration entails symbolizing in the street the condition of a house or building as a short-term rental, which allows the public to identify them. Lisbon and Porto have also zoned central areas where short-term rentals are not allowed. However, criteria are lax, and its enforcement has been delayed. Greece has passed a similar bill with a peculiarity: short-term rentals must be listed only when their activity surpasses 90 days a year, following the steps of Amsterdam or Vienna. In Spain, government action varies depending on the regions, but almost all of them have also agreed to have public compulsory registration. In cities, Barcelona and San Sebastián have both zoned central locations as saturated, meaning it is not only impossible to open a new short-term rental or other accommodation business, but there is the need to decrease. Madrid has also zoned areas; however, spatial criteria are less restrictive, focusing on accommodation: only short-term rentals to street access are allowed. All these measures have been taken to court on the grounds of limiting the right to property or the municipalities not having the capacity to regulate tourist activities, and rules are expected in the following months.
Most of the measures taken by municipalities are the result of social mobilization. Right-to-housing movements such as Habita or La PAH in Portugal and Spain respectively have joined neighbourhood associations, tenants' unions, or radical trade unions to denounce the situation. These alliances and coalitions have sprung up across the Mediterranean, alternatively coming together in the SET net: the Southern Europe facing Touristification network. At local as well as transnational scales, efforts have focused on analysing each situation, sharing experiences, and agreeing on discourses aiming at the tourist model rather than tourism because visitors are the last to blame: large hospitality corporations, airlines, tourists' agencies, or governments must be held responsible. Therefore, proposals have generally had two lines of action: institutional- and activist-related. First, institutional activities have consisted of writing reports (by activist themselves or in collaboration with academics) with zoning, housing-related, or tourism-degrowth proposals, engaging in media conversation with appearances on press or radio stations, and having meetings with city officials, especially where there are (or have been) left-wing governments (Barcelona, Madrid or Rome). However, not all SET net members have followed this collaboration strategy. Second, activist-related activities have been common, especially raise-awareness campaigns and direct actions. The former includes handing out leaflets to residents and tourists or workshops with other social actors, while the latter encompasses demonstrations and satirical performances. Among these, for example, we could highlight counter-tourist routes (taking pictures of tourists visiting not touristic neighbourhoods) or the burial of the neighbour (carrying a coffin to make visible the exile of residents, and how it means neighbourhoods are dying).
Despite public outcry and mobilization, and the Covid-19 crisis, states and cities have continued to foster tourism-oriented strategies to attract visitors and real estate capital. Instead of analysing the urban economic structure or recognizing the tourism dependency and its volatile character in the pandemic context, governments across southern Europe insist on deploying tourism policies to reactivate local economies. State and local resources are still flowing to tax exemptions to building construction or renovation for tourism purposes or to international city-marketing campaigns, while public discourses shield on austerity to deny public housing projects or the implementation of rent controls –grassroots organization for such policies come, by the way, because of tourism-driven increasing pressure in housing markets in central locations–. Ruling-classes' incapacity to imagine another urban context in southern Europe is outstanding. That is why we need to keep organizing and fighting against the monopoly of tourism economies that increase social and spatial inequalities between wealthy individuals and the working classes.
Jaime Jover is a Post-Doctoral Fellow at the Graduate Center of the City University of New York (CUNY), studying social geography, with specializations in critical theory, historic preservation, and urban tourism.
Cover photo credit: Jaime Jover
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The Jingle Jubilee event is hosted by A Helicopter Mom, About A Mom, The Kids Fun Review, Sunshine and Sippy Cups, and The Adventures of J-Man and MillerBug. My prize for the hop is provided by Logitech! You can see a video about it here.
In order to win a giveaway of the Logitech Ultrathin Keyboard Cover answer the question, "What is your favorite logitech gadget?" The Logitech Ultrathin Keyboard Cover is the perfect companion to the iPad—super sleek, magnetically connected, reliable (six months of battery life) and practical, giving you smooth and quiet typing.
Loving the Logitech Broadcaster Wi-Fi Webcam! Thank you for the chance!
I love the Wireless Trackball mouse. That's exactly what I need for using my computer from my couch and TV. Awesome.
The Wireless Trackball mouse. I use my couch and TV with my computer, and I always seem to go just alittle to far and slid the mouse off the armrest. I didn't even know they made that. Awesome.
my favorite is their webcams!
I really like the Logitech Wireless Gaming Headset G930!
Like the Logitech keyboards & mouse!
I use a laser mouse from the with my laptop and a headset as well. I haven't tried any other products.
I TRULY LOVE ALL THEIR PRODUCTS. MY MOM HAS THE ROLLER BALL MOUSE, I USE IT AND IT IS FAST FOR GAMING:) THANKS AND PRAYING!
My favorite Logitech gadget is their Harmony Remotes! I have one and I will never use anything else EVER again.
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I like the Logitech G19 Keyboard for Gaming.
I like the Z506 speakers or the Z623.
I love the Harmony remotes! Especially like the Harmony 1100 Advanced Universal Remote.
I like the Washable Keyboard K310.
solar keyboard folio for ipad.
I like the m500 mouse I'm using.
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I really like Logitech's mice…the gaming ones with the ergonomic shape. Our mouse is crazy old and we need to get a new one, but it is Logitech and we like it the best (even after trying other ones out, we always went back to this one)!!
I like the The Logitech Ultrathin Keyboard Cover.
my favorite is this keyboard cover!!
definiitely the Laptop Cooling Pad N200! i neeed one!
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Logitech Solar Keyboard Folio for iPad just went on my list to Santa.
I like the white paisley m325 mouse. Thanks for the chance.
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my favorite Logitech product is Logitech Cooling Pad N200!!
I like the keyboard/mouse combinations, but MY favorite gadget is my mouse. I only use logitech.
My favorite Logitech device is always a mouse. They make the best mice as far as I'm concerned.
The Logitech Touch Mouse T620.
My son would love the Logitech Wireless Gaming Headset G930.
I like the Logitech® Speaker Lapdesk N700.
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My favorite Logitech gadget is the Logitech Ipad. I love that there is an ultra-thin cover for it.
I like the ultra thin keyboard cover for the iPad.


text:
The Hot Mess and the Heartthrob by Pippa Grant
by Pippa Grant
Levi Wilson, aka an international pop sensation who thinks a steak lunch is about to be the best part of his day
For my thirteenth birthday, I talked my big brother into helping me sneak out of the house to take the bus downtown so we could see Seven Knobs perform. They were a local indie rock group with a wicked sound, and for that summer, they were my heroes.
Not that I had high standards for heroes. If a band had a good sound and I could see them locally, they qualified.
I had many, many heroes.
Tripp and I both knew I'd go with or without him there to watch over me, which is the only reason he agreed.
Older brothers.
They're the pains in the ass you love to love.
After the show, we got turned around outside the arena on our way back to the bus stop and ended up with a police escort home at two in the morning, where our mother, who was raising us solo, had called every other mom in the neighborhood and was about to send out a search party.
Mom's no dummy. She'd known where we were going. She knew when we were supposed to be home. And she knew something had happened.
I took ten years off her life that night.
That's the last time I ever got lost sneaking around in downtown Copper Valley.
Until today.
At least this time, I'm lost in broad daylight where the worst thing that could go wrong is missing lunch.
Okay, second-worst thing.
It's highly unlikely I'd have a repeat of that incident in San Francisco when I was taking the scenic route to a late breakfast and got spotted by a field trip from an all-girls' school who got so excited that my security detail shoved me out of sight and into the nearest open door, which led directly into a full mani-pedi spa.
Let's just say you shouldn't startle people having their toes painted by other people holding full bottles of nail polish.
Especially not on a week when you're on the cover of both People and Entertainment Weekly, which is basically when you're most recognizable as a celebrity.
Related: Nail polish is weirdly difficult to get out of your eyebrows.
But I'm sure that won't happen today. Especially since I'm only a pop-out picture on the cover of The National Enquirer.
Apparently I have six toes and one writes all my songs for me.
It's a good sign the world's forgotten me this week, so I can go anywhere without being recognized.
Or maybe not.
But optimism is important, right?
"This corner, G. This is the one," I tell my lead protection agent as we hustle down the street, buffeted by the fall wind howling through the corridor between the fifteen- and twenty-story buildings on the outskirts of Copper Valley's warehouse district. Rain's on the agenda for today, and Mother Nature isn't playing. She's as serious as Giselle, who stays straight-faced, eyes perpetually scanning the random people passing us by who haven't noticed me.
Ball cap, sunglasses, and someone else's old letterman jacket for the win.
For the moment.
"You're not issuing orders about parking garages next time," Giselle informs me.
"I like that parking garage. Good memories."
"You're thinking of the garage on Seventeenth and Sunshine. And no one has good memories of that garage except you."
Ah, hell.
She's right.
No wonder she argued when I told her to park two blocks back and that we'd walk the rest of the way. I don't know where I thought we were, but it's not where we are. "Just because you didn't want to wear a parking cone as a hat and be in my video—"
"Giselle, don't let me shoot a video riding a contact high ever again," she replies, completely falsetto and sounding nothing like me, even though I do vaguely recall saying something like that the day after the parking lot shoot.
"Still a fan-favorite collaboration."
"And you still don't know your parking lots here anymore."
My stomach growls, and I swear she hears it. She's five-six, dark-haired, about a decade older than me, which you wouldn't know since age is terrified to touch her face. She's built like a badass and has the skills of a ninja, thanks to being head cheerleader in high school and spending decades honing her skills ever since. At least, that's her story.
"Let me know when you want me to steer you in the right direction."
"I think I can find my favorite steak restaurant in my own hometown."
Real Fake Love (Copper Valley Fireballs #2)
Kiss Me Now (A Billionaire Boss Romance) by Pippa Grant Glint by Pippa Grant Blood Metal Bone by Pippa Grant Angelview Academy: A Dark High School Romance (The Complete Series) by Pippa Grant O-Men: Liege's Legion - Merc by Pippa Grant Guilty Pleasure (Redemption #4) by Pippa Grant Off the Cuff by Pippa Grant Twelve Months of Kristal 50 Loving States, Maine by Pippa Grant The Spinster (Emerson Pass Historicals #2) by Pippa Grant Haunted by Shadows (Demons of New Chicago #2) by Pippa Grant The Last Thing to Burn by Pippa Grant Mr. Hired Boss (Alphalicious Billionaires Boss #4) by Pippa Grant

redpajama_set_name: RedPajamaCommonCrawl


text:
Charles Brun (16 February 1866 in Copenhagen – 28 January 1919) was a Danish politician, representing the Venstre Reform Party in Parliament (Folketinget). He served as Finance Minister of Denmark in the Cabinet of Niels Neergaard I from October 12, 1908 to August 16, 1909.

References

1866 births
1919 deaths
Danish Finance Ministers
Members of the Folketing
Politicians from Copenhagen
Brun family

redpajama_set_name: RedPajamaWikipedia


text:
Mon-Friday: 7am - 2pm
Sat-Sunday: 9am - 2pm
12 S Main St, Memphis, TN 38103
Hold the Press
Bar Keough
Cafe Keough
In the afternoon around three, as the low sun floats in, Café Keough takes on a soft glow. At this time of day jazz wafts from the speakers, jiving with the light tap dance of the law school laptops. Soon enough the banker ambles around the corner for a chat. The newspaper publisher comes in to hash out river city politics. And then the lawyers - can't seem to get away from them. Even married one. The Brazilian interpreter says this place is Buenos Aries. The Parisians say it's Paris. The Germans say it's Vienna and I just smile and say welcome to Memphis.
Café Keough is owned by Kevin Keough and his investment partners. The general manager is Terry Jenkins and Brent McAfee is the chef de cuisine. The Café is open throughout the week and mid-day Sunday for brunch.
Kevin Keough's restaurant experience began in gritty Memphis blues joints tracking down the wandering musicians on Beale Street so they could finish the next set. He next created a synergy with Karen Carrier's culinary originality and design to make Automatic Slims the Downtown Memphis scene of the 1990s. The two partnered up in 2005 to create The Beauty Shop Restaurant, a highly successful and award winning restaurant anchoring the City's vibrant Cooper-Young District.
Kevin opened Café Keough at the tail end of 2013. Situated on Main Street between the fourth and fifth presidential streets, Madison and Monroe, the Café is around the corner from the University of Memphis law school and down the street from the historic Peabody Hotel. It occupies part of the ground floor in an upscale residential tower known as "10 South Main".
At about 3,000 square feet, the mood of Café Keough undulates throughout the day from lively breakfast to quiet work/study time, exploding at noon in a bustling lunch crowd and settling into the evening wind down with drinks and tapas.
The atmosphere of the Café reflects Kevin's desire to create an old Memphis café from scratch using bits and pieces of remembered images from trips around Nice, Prague, New York and New Orleans – crystalizing that wonderful sense of being in a special place. Kevin's fingerprint is literal, honed into the plaster of the ceiling and the paint on the kitchen floors. He worked alongside the contractors and tradesmen to tease the whispers out of the historic walls of the 100 year old Commerce Title Building. Now the aroma of the panini press wafts up to those old beams and the fragrant coffee warms the belly.
Café Keough is a beautiful place with a simple café design that honors the existing architecture by using the original granite, recreating the Corinthian capitals and repurposing the old Commerce Title Building sign as community table tops. New but old touches include a long custom bar, crisp white subway tiles, and benches reminiscent of the train station at the more southern end of South Main.
A soft light filters in beautifully during the long afternoons and at night the chandeliers and sconces collected from basements and dusty antique store backrooms give off a warm glow. The deep window seats provide a front row view of the trolleys and horse and carriages that rumble past on the cobblestones outside.
The menu is designed to tickle every taste bud, including inventive paninis and salads that use fresh ingredients in clever tasty ways. The day begins with the signature Bavarian Breakfast of black bread, fresh fruit, soft cheese & a boiled egg, or perhaps a bacon, onion & gruyere quiche. Alternatively, one can choose organic oats with Vermont maple syrup, freshly made local granola & yogurt, or a variety of croissants and Danishes.
At lunch, the smoked turkey with cranberry jam, provolone, sweet onion & tomato is a favorite as is the roast beef with horseradish crème fraiche, sweet onions, mushrooms & arugula. A side of the French onion soup with a generous dollop of gruyere is a must, and the red beet and French feta salad competes with the Nicoise for most popular. In the evening, a crisp glass of chilled wine with Meze platter of hummus, olives, quinoa, feta, domas and pita provides the base for languorous conversation.
Café Keough boasts a full bar and a growing selection of locally brewed beer. General Manager, Terry Jenkins, known to all as TJ, creates fun social events where tourists, young professionals, Downtown denizens and law students can gather and play.
Kevin Keough never intended to put his name on the place, even though his entrepreneurial great-grandfather's name marks a road east of the City. Surrounded by so much of historic Downtown Memphis he thought for sure he could tie the name into the Spanish and French explorers or the cotton traders, rascals and personalities that make Memphis so great. He tried a million names in his mind before settling on the most obvious one of them all. In the end, he is just another Memphis man trying to make his mark doing what he loves. It is a café run by a Keough.
Mimosa Sundays - $3 Mimosas, Every Sunday, Open to Close!


Complete Your Responsible Service of Alcohol (RSA) Course Online From The Comfort and Convenience of Home. Only $19.90!
Is this RSA course valid in my State?
QLD – The OLGR approved National SITHFAB201 or SITHFAB002 course is required. We currently offer SITHFAB002: Responsible Service of Alcohol.
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TAS – Must be a National SITHFAB201 or SITHFAB002 course, the RTO must meet the AQTF in relation to continuing registration, it must be customised for the State, and RTO's must have measures in place to verify the ID of the student and that it is them doing the course. We currently offer SITHFAB002: Responsible Service of Alcohol online only and meet all of the additional, Tasmania-specific requirements.
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text:
\section{Introduction}
A central goal of the Learning Assistant (LA) model is to improve students' learning of science through the transformation of instructor practices \citep{Otero2016LearningNetworks}. Specifically, the LA model aims to leverage the additional in-class and planning supports that LAs provide to increase science instructors' uses of research-based pedagogies. To support LA and faculty collaboration, the LA model trains LAs in pedagogy courses and creates opportunities for instructors and LAs to co-plan for class each week. These structures support instructors to reexamine and refine their pedagogical practices and increase their effectiveness. This study sets out to examine whether instructor's prior experience teaching courses with LAs is associated with improved student learning.
\par 	The impact that K-12 teachers prior experiences have on their effectiveness, as measured by students' learning, has been the focus of significant discussion within the education policy communities \citep{StephenSawchuk2015,Ladd2015,Kini2016}. Researchers have repeatedly found strong links between teacher experience and improved student standardized test scores in math and reading \citep{Ladd2015,Kini2016}. The assumption that teachers' experiences improve their effectiveness has strongly influenced the creation of the K-12 salary schedules and is a significant source of inequity across school settings \citep{Rice2010}. While the impact of K-12 teacher experience on student learning of math and reading has been well documented, the impact of college instructor experience on student learning of physics (or science more generally) has received little attention.

\section{Background}
Increases in K-12 teacher effectiveness vary substantially across educational environments. The general trend within these settings is that teacher experience positively correlates with improved student performance on standardized math and reading tests \citep{Kini2016}. The effects of increasing teachers' experience is strongest over the first several years but continued throughout their careers. Teacher effectiveness was also found to improve most quickly when the teachers were in a supportive environment that facilitated peer collaboration \citep{Kini2016}. The impact of teacher experience on student math test performance was only half as strong in grades 6-8 than in grades 4 and 5 (Rice, 2010). Teacher experience was also associated with larger shifts on tests scores in math than in reading \citep{Kini2016}. Some studies have found that teaching effectiveness can decline over time, particularly in high school settings \citep{Rice2010}. These findings show that teacher experience can be an important factor in student learning, but there is considerable variability in how teacher experience relates to teacher effectiveness. Given the variation in impacts of teacher experience within K-12 educational environments and the substantial differences across K-12 and college systems, it is unclear how predictive the findings are of the impacts of instructor experience in college physics courses.

\par 	In one of the few examinations of physics instructor experience, Pollock and Finkelstein \citep{Pollock2012ImpactsPhysics} tracked eight years of student performance in first and second semester physics courses utilizing Peer Instruction \citep{Mazur1997PeerInstruction} and LAs. They categorized each of the 27 instructors in the study as Inexperienced, Experienced, or Physics Education Researcher (PER) based on their teaching and research backgrounds. Students in classes with Experienced and PER instructors outperformed their peers in classes with Inexperienced instructors. The three instructors initially identified as Inexperienced but who subsequently taught the course multiple times saw significant improvements in their students' performance. The three instructors identified as PER and who taught the course multiple times began with higher student performance but failed to show consistent improvement in student performance as they became more experienced. While the study was exploratory and did not have a control group of instructors not using LAs, it indicated that college physics instructor experiences may impact student performance and that these impacts may vary across instructor groups.

\par	In an examination of the impact of LAs on instructor practices, Otero et al. \citep{Otero2010AModel} found that the 11 instructors interviewed reported that collaborating with LAs on planning lessons was instrumental in increasing their attention to student learning. The investigation, however, did not measure shifts in instructor effectiveness over time. While the support and collaborative aspects of the LA model align with the recommendations made in the K-12 literature \citep{Kini2016}, there are no large-scale studies that have empirically tested the impact of these practices on college physics instructors.

\section{Research Questions}
\par 	To investigate how interactions with LAs relates to physics instructor effectiveness over time, we investigated two questions:
\begin{enumerate}
\item What is the impact of instructor experience teaching introductory physics courses on student learning, if any?
\item Does an instructor's history of using LAs alter the impact of their teaching experience on student learning?
\end{enumerate}

\section{Methods}
The Learning About STEM Student Outcomes (LASSO) platform hosts, administers, scores, and analyzes student pre- and posttest assessments online to provide instructors with objective feedback on their courses. Instructors receive a report on their student performance and can access their students' responses. Data from participating courses are added to the LASSO database where they are anonymized, aggregated with similar courses, and made available to researchers with approved IRB protocols. This study used three years of introductory physics courses data from the LASSO database. We examined data from courses that used the Force Concept Inventory (FCI) \citep{Hestenes1992ForceInventory} or Force and Motion Conceptual Evaluation (FMCE) \citep{Thornton1998Fmce}. We did not differentiate between the FCI and FMCE in the models presented in this paper because our preliminary analysis indicated that doing so did not meaningfully change the model.

\par	To clean our data, we removed assessment scores for students if they took less than 5 minutes on the assessment or were less than 80\% complete. We removed entire courses if they had less than 40\% student participation on either the pre- or posttest. After filtering our data was  missing 15\% of the pretest scores and 30\% of the posttest scores. To address missing data, we used Hierarchical Multiple Imputation (HMI) with the hmi and mice packages in R. HMI addresses missing data by (1) imputing each missing data point \emph{m} times to create \emph{m} complete data sets, (2) independently analyzing each data set, and (3) combining the  \emph{m} results using standardized methods \citep{Drechsler2015MultipleSimplicity}. The analysis used 10 imputed datasets. HMI is preferable to using matched data because it maximizes statistical power by using all available data \citep{Drechsler2015MultipleSimplicity}. After cleaning and imputation, our dataset included pre- and posttest scores for 4,365 from 93 courses.

\par 	 When setting up a course in LASSO, each instructor answered a pair of questions on the number of times they had previously taught the course with LAs and the number of times they had taught the course without LAs. The majority (83\%) of the instructors reported having prior experience teaching their courses (Figure 1). Many of the instructors reported having always taught the course either with (24\%) or without (32\%) LAs.

\begin{figure}
\includegraphics[width=1\columnwidth]{color_graph.png}
\caption{Instructor's prior experience teaching their course with and without LAs. Sixteen courses were taught by instructors with no prior experience in that course.}
\end{figure}

\par	To identify factors associated with differences in student performance, we developed 2-level HLM models using the HLM 7.01 software. These models nested student data (level 1) within course data (level 2). The multi-level nature of our models allowed us to quantify the impact of teacher experience in courses taught with and without LAs while accounting for inherent and unknown course-level variations (e.g. the time of day of a class and instructor backgrounds, which can lead to unforeseeable differences in student performance).

\par	We developed our HLM models through a series of incremental additions of variables. In this paper we show the results from three models. Model 1 is the unconditional model, which predicts the student performance without level-1 or level-2 variables. Model 2 builds on Model 1 by including the student (level-1) variables (student prescore). Model 3 builds on Model 2 by including the course (level-2) variables and is shown below. Postscore is the outcome variable and is in level 1 because it was measured for each student. Level 1 also includes a coefficient for the intercept ($\beta_{0j}$), for the student prescore ($\beta_{1j}$), and for a random effects variable ($r_{0j}$). Each coefficient in level 1 has an associated level 2 equation. In the level 2 equation, the intercept is $\gamma_{i0}$, there is an associated coefficient ($\gamma_{ij}$) for each variable in the equation and $u_{ij}$ represents the random effect for the level 2 equations.
\\
\par
\textbf{Level-1 Equation}
\begin{eqnarray*}
(\text{Postscore})_{ij} & = & \beta_{0j} + \beta_{1j}*(\text{Student Prescore})_{ij} +r_{ij}
 \end{eqnarray*}

\textbf{Level-2 Equations}
\begin{eqnarray*}
\beta_{0j}& = & \gamma_{00}+\gamma_{01}*(\text{Times Taught With LAs})_{j} +\\
& & \gamma_{02}*(\text{Times Taught Without LAs})_{j}+\\
& & \gamma_{03}*(\text{LA Supported})_{j}+\\
& &  \gamma_{04}*(\text{Class Mean Prescore})_{j}+u_{0j}\\
\beta_{1j}& = & \gamma_{10}+u_{1j}\\
\end{eqnarray*}

\par 	We do not include LA-support in the level-2 equation for student prescore because the interaction between the variables is not of interest in our analysis. For ease of interpretation, student prescore is group mean centered, class mean prescore is grand mean centered, and all other variables are uncentered. These centerings simplify interpreting the model by shifting the model to predict posttest scores for average performing students in average performing classes. We included pretest scores in the model because they are strong predictors of student performance and improved the model's fit. Pretest scores are not the focus of this investigation so we will not substantively discuss them in our interpretation of the models.

\par To interpret the models we will first discuss the variance across the three models then we will look at the coefficients for each variable of interest. In discussing the variance, first we will discuss the Intraclass Correlation Coefficient (ICC) for the unconditional model (model 1) to compare the amount of variance in the data at the student versus course level. The ICC is a good indicator of the need for using HLM. Second, we will calculate the variance that the additional variables in each model explained by comparing the variances between the three models. Then we will discuss the model coefficients.

\begin{table}
\caption{Hierarchical Linear Models}
\begin{tabular}{p{2cm}ccp{.05cm}ccp{.05cm}cc}
\hline \hline

\rule{0pt}{3ex}&\multicolumn{8}{c}{Fixed Effects with Robust SE}\\ \cline{2-9}
\rule{0pt}{3ex} &\multicolumn{2}{c}{\underline{Model 1}}&&\multicolumn{2}{c}{\underline{Model 2}}&&\multicolumn{2}{c}{\underline{Model 3}}\\
			&$\beta$&\emph{p}&&$\beta$&\emph{p}&&$\beta$&\emph{p}\\

For Intercept	&&&&&&&&\\
~~Intercept		&55.05&\textless0.001	&&55.04&\textless0.001	&&55.97&\textless0.001	\\
~~With LAs		&-&-&			&-&-&			&0.02&0.974\\
~~W/o LAs	&-&-&			&-&-&			&-1.18&0.01\\
~~LA Sup. 		&-&-&			&-&-&			&3.10&0.171\\
~~Class Pre.	&-&-&			&-&-&			&1.05&\textless0.001\\
\multicolumn{4}{l}{For Student Prescore}	&&&&&\\
~~Intercept		&-&-&		&0.55&\textless0.001	&&0.54&\textless0.001	\\
\hline
\rule{0pt}{3ex}&\multicolumn{8}{c}{Random Effect Variance}\\ \cline{2-9}
Intercept		&\multicolumn{2}{c}{12.81}	&&\multicolumn{2}{c}{12.98}	&&\multicolumn{2}{c}{8.08}	\\
Prescore		&\multicolumn{2}{c}{-}	&&\multicolumn{2}{c}{0.10}	&&\multicolumn{2}{c}{0.10}	\\
Level-1		&\multicolumn{2}{c}{20.14}	&&\multicolumn{2}{c}{17.47}	&&\multicolumn{2}{c}{17.43}	\\

\hline \hline

\end{tabular}
\end{table}

\section{Findings}
The ICC shows that 39\% of the variability in student performance is between students within courses and 61\% of the variability is within students. This shows  that course features are meaningfully related to student performance and HLM is an appropriate method of analysis. The reduction in level-1 variance (\textit{r}) from Model 1 to Model 2 (Table 1) shows that our student-level variable (Student Prescore) explains 13\% of the within-class variance in student performance. The reduction in level-2 intercept variance (\textit{u\textsubscript{0j}}) from Model 1 to Model 3 shows that our final model explains 37\% of the variance in mean performance across classes. This amount of explained variance indicates that Model 3 has strong explanatory power. As Model 3 is our most robust model, we will focus solely on it in the remainder of our findings.

\begin{figure}
\includegraphics[width=1\columnwidth]{ribbon_plot_rev1.png}
\caption{Predicted posttest scores for average students with instructors who habitually teach with or without LAs (95\% confidence interval).}
\end{figure}

 \par	Model 3 shows that as the number of times instructors have taught a course without LAs increases their posttest scores are predicted to reliably (p=0.01) decrease by 1.2\%/term (Table 1). This decline in instructor effectiveness is absent in LA-supported courses as instructor experience using LAs is not a reliable (p=0.974) predictor of student posttest scores. Figure 2 illustrates the longitudinal impacts of repeated teaching with and without LAs on predicted posttest scores for average students. When instructors have no prior experience teaching that course, our model predicts that the students in LA-supported courses will outperform their peers in courses without LAs by 3.1\%. As the instructors  gain experience the predicted gap in student posttest scores grows. When instructors have 6 terms of experience teaching their respective courses (either with or without LAs), the students in LA-supported courses are predicted to outperform their peers by 10.3\% on their posttests.
\section{Discussion}
Prior research into the impact of experience on teacher effectiveness has primarily focused on K-12 settings. Existing research has found that teacher experience has differential impacts across grades and disciplines. Our investigation extends this work by examining the impact of teaching experience on college introductory physics instructor effectiveness. In answering research question 1, our analysis found a general decline in effectiveness over time for instructors who were not using LAs. In contrast, in answering research question 2, instructors who were teaching with LAs maintained their effectiveness. While the decline in student posttest performance associated with each term of instructor teaching experience without LAs (1.2\%) may not sound substantial, the losses are cumulative. Students in courses with instructors who have taught without LAs for 6 terms are predicted to underperform their peers in LA-supported courses by 10.3\% (7.2\% loss due to instructor experience and 3.1\% loss due to current lack of LA-support). Given that in our dataset the average student raw gains from pretest to posttest are approximately 20\%, losing 10.3\% of that gain represents losing approximately half of the student learning.
\par 	While our models cannot provide a causal mechanism for these observed declines in effectiveness we hypothesize that the shift may come from the lack of resources allocated to improving instructor pedagogical practices. In contrast to K-12 schools, the structures in colleges (e.g. incentives and funding) tend to value faculty's scholarly productivity over teaching effectiveness. Given the general lack of resources that colleges commit to supporting and improving faculty's instructional practices, it is not entirely surprising that college instructors do not improve their effectiveness in the same way as K-12 teachers do. In contrast to typical college instructors, instructors who use LAs have an entire network of resources (e.g. LAs, weekly LA co-planning meetings, LA pedagogy courses, LA program directors, and the LA Alliance) designed to support them in reflecting on and improving their teaching effectiveness. We propose that the additional resources provided by LA programs may help to fill the gap created by the colleges and preventing the decline in instructor effectiveness.

\section {Limitations and future work}
The LASSO platform was originally promoted to faculty in the LA Alliance, which likely skewed the courses to be ones that use research-based pedagogical practices whether they were LA-supported or not. Thus, the shifts in instructor effectiveness without LAs may not represent the shifts in traditional lecture-based courses. We expect that increased adoption of the LASSO platform will improve the generalizability of our findings. In our future work, we will use a meta-analysis of published results to further inform our analysis. This work was funded in part by NSF-IUSE Grant No. DUE-1525338 and is Contribution No. LAA-046 of the Learning Assistant Alliance.

redpajama_set_name: RedPajamaArXiv


text:
Pharmacist-led adherence support in general practice: a qualitative interview study of adults with asthma
General practice / Family practice
http://orcid.org/0000-0002-8048-7239Marissa Ayano Mes1,
Caroline Brigitte Katzer1,
Vari Wileman1,
Amy Hai Yan Chan1,
Robert Horne1,
Stephanie Jane Caroline Taylor2
1 Centre for Behavioural Medicine, Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
2 Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
Correspondence to Professor Stephanie Jane Caroline Taylor; s.j.c.taylor{at}qmul.ac.uk
Objectives The National Health Service (NHS) in England recently introduced general practice pharmacists (GPPs) to provide medication-focused support to both patients and the general practice team. This healthcare model may benefit people with asthma, who currently receive suboptimal care and demonstrate low medication adherence. This study aimed to explore the perspectives of adults with asthma on the potential for pharmacist-led adherence support delivered in general practice, with a focus on how these perspectives are formed.
Design and setting The study was conducted in the United Kingdom (UK) utilising a qualitative interview methodology. Participants were invited to partake in a telephone-based semistructured interview, followed by an online questionnaire for demographic details and asthma history. Qualitative data were analysed using thematic analysis.
Participants Participants (n=17) were adults with asthma in the UK with a prescription for an inhaled corticosteroid. Participants did not have previous experience with GPPs and were asked to provide their views on a proposed GPP-led service.
Results Participant perspectives of GPPs were determined by trust in pharmacists, perceived gaps in asthma care and the perceived strain on the NHS. Trust was based on pharmacists' perceived clinical competency, established over time, and gauged through a 'benchmarking' process. GPP's fit in current asthma care was assessed based on potential role overlap with other healthcare professionals, continuity of care and medication-related support needs. Participants navigated the NHS based on a perceived hierarchy of healthcare professionals (general practitioners on top, nurses, then pharmacists), and this influenced their perspectives of GPPs.
Conclusion While the GPP scheme shows promise based on the perspectives of people with asthma, the identified barriers to optimal patient engagement and service implementation will need to be addressed for the service to be effective.
pharmaceutical services
The use of qualitative methodology captured the complex processes behind people's perspectives of general practice pharmacists (GPPs), including how lived experiences shaped opinions of new pharmacist-led services.
Telephone-based interviews enabled recruitment across the UK and increased study accessibility for people with severe asthma and travel limitations.
The study may not have captured the full variation in views among adults with asthma in the UK because participants primarily had self-reported mild asthma and were recruited through an asthma charity.
Participants had no experience with GPP-led consultations and therefore represented the general population with asthma that would initially need to be convinced to engage with the service.
The pressure on primary care to deliver core services is increasing rapidly worldwide due to a growing and ageing population, the prevalence of long-term conditions and significant resource constraints. Primary care systems are being reshaped, and new models of care are emerging to cope with growing demand.1
One such model is the general practice pharmacist (GPP) model, which was introduced in England as part of the NHS General Practice Forward View initiative.2–4 These pharmacists support both the patients and the general practice team with medication-related issues, with the aim of expanding the general practice workforce, reducing practice burden and increasing patient access to appointments.4 Initial qualitative feedback from general practitioners (GPs) and pharmacists in a pilot study in England suggests that GPPs can have positive impacts on medication safety, medication adherence, healthcare access and patient satisfaction across a variety of long-term conditions.3
People with asthma may benefit from GPP support. Research shows that adherence to inhaled corticosteroids (ICS), an essential medication for asthma, is low.5 6 Furthermore, only 35% of people with asthma in the UK receive basic care (ie, annual reviews, inhaler technique checks and a written asthma action plan).7 Previous research suggests that pharmacist-led interventions can increase medication adherence and support asthma self-management among people with asthma.8 However, most of the previous research in the UK has been limited to community rather than GPPs and focused on their impact across a range of long-term conditions rather than asthma specifically.9 10
Understanding the specific perspectives of people with asthma regarding GPPs is an important first step in establishing the potential benefits of this new service for this specific patient group, as well as identifying any potential issues in its future uptake and effectiveness.11 The aim of this study was to explore the perspectives of adults with asthma on the potential of pharmacist-led asthma adherence support delivered in general practice, with a focus on how these perspectives are formed.
This study is reported according to the Standards for Reporting Qualitative Research.12 It was a telephone-based semistructured interview study, using an interpretivist approach to understand how adults with asthma construct their initial opinions of GPP-led asthma adherence support. Demographic details and asthma history were collected using a brief online questionnaire.
Participants were adults (≥18 years old) living in the UK and proficient in English, with a self-reported asthma diagnosis, a prescription for ICS and access to a telephone and e-mail account. People with respiratory comorbidities (eg, Chronic Obstructive Pulmonary Disease) and/or those in hospital or nursing homes were excluded, as the adherence behaviour and support needs of these individuals were hypothesised to be different.
Several recruitment channels were used to ensure that participants varied in age, gender and self-reported asthma severity. A flyer with study information and researchers' contact details was circulated by researchers, the Asthma UK Centre for Applied Research (AUKCAR) and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames via social media. The study was advertised in two electronic newsletters: the Asthma UK volunteer bulletin and the University College London student newsletter. Printed flyers were handed directly to potential participants by a respiratory consultant at a London hospital and pharmacists at two hospitals in Wales.
People who contacted the researchers were e-mailed an information sheet, consent form and eligibility criteria to review. If they were eligible and willing to participate, they were booked in for a 1-hour telephone interview. In preparation for the call, participants were asked to read a description of a GPP-led adherence support consultation, sent to them via e-mail (see online supplementary appendix A). This description was based on the work of a clinical respiratory pharmacist working in general practice in London. Participants gave verbal consent over the telephone before the interview began. The consent procedure and interview were audio-recorded with their permission. All participants received a £20 online shopping voucher to thank them for their time.
One researcher (MAM) conducted the interviews. Participants were informed that the researcher had a background in Health Psychology and an interest in adherence and pharmacist-led care for asthma.
The interview topic guide had two sections (see online supplementary appendix B). The first section focused on participants' previous experiences of asthma, asthma care and pharmacists. The second section focused on how these lived experiences informed participants' opinions of GPP-led adherence support, with questions based on previous research on interpersonal/institutional trust in healthcare professionals,13 14 perceptions of the pharmacist role15–17 and pharmacist-led care for asthma.10 18–20
Participants also completed an online questionnaire on demographic details (gender and age) and asthma history (self-reported asthma severity, hospitalisations and GP visits). An online questionnaire was used because participants may have felt uncomfortable disclosing personal information (eg, age) directly to a researcher during the telephone call. The self-report method was chosen because recruitment to the study may have been difficult if access to participants' medical records was required.
All interviews were professionally transcribed, with transcripts checked for accuracy by MAM. Data were analysed using NVivo (QSR, V.11). Thematic analysis was used to identify themes at the semantic level using a deductive approach, based on their relevance to the study aim.21 Continuous iterative analyses were conducted to establish when thematic saturation had been reached. Recruitment was set for 30 participants or thematic saturation, whichever was attained first. The study ran from October 2017 to February 2018. All transcripts were analysed by MAM, and four transcripts (representing 25% of the total transcripts) were independently second-coded by another researcher (CBK), as recommended by MacPhail et al.22 Discrepancies were resolved through consensus discussion.
All study materials (recruitment flyer, participant information sheet, consent form, interview topic guide, GPP consultation example and online questionnaire) were reviewed by the AUKCAR Patient Advisory Group (PAG) prior to study commencement. Members of the PAG were adults with asthma. Their feedback, often regarding word choice and text length, was incorporated into the study materials.
Thematic saturation was reached with 17 participants (table 1). The median interview length was 42 min (ranging from 30 to 58 min). The participant sample was 59% female, with most participants (41%) aged 30 to 39 years and recruited through the Asthma UK newsletter (41%). The sample included participants with self-reported mild (53%), moderate (24%) and severe asthma (17%). Three overarching themes (with seven subthemes) were identified from the data: building trust in pharmacists, filling gaps in current asthma care and navigating a strained healthcare system.
Demographic characteristics and asthma history
Theme 1: building trust in pharmacists
Trust in healthcare professionals involves the optimistic acceptance of being in a vulnerable situation, knowing that one's interests will be cared for.14 For participants, opinions of the new service were based on the level of trust they placed in pharmacists. Trust was built over time, based on perceived clinical competency and through a benchmarking process, which form the subthemes discussed below.
Building trust over time
Participants highlighted that trust in any healthcare professional builds through consistent contact over time. Some participants felt hesitant about the new service because it meant deviating from their usual trusted healthcare professional, suggesting a preference for usual care over new initiatives to maintain the quality of their asthma care.
'I don't really know, I think I'd prefer a doctor (to talk to about my asthma). It's the way it's always been.'
– P15, male, 30–39 years, mild asthma
Building trust based on perceived clinical competency
When asked about specific criteria for trust, participants discussed pharmacists' clinical competency. This included pharmacists' asthma-specific and broad clinical knowledge. Support for the new service was high when pharmacists were viewed as knowledgeable.
'So I know that in the pharmacy role they're very knowledgeable. So if (adherence support for asthma) is something they want to do then why not? I have a lot of faith in somebody who's got a lot of knowledge in something.'
– P8, female, 30–39 years, severe asthma
Some participants believed that pharmacists would need extensive additional training to develop the knowledge needed for the new service. Their main concern was that pharmacists were too medication-focused and therefore lacked broader clinical skills.
'…it could be that the (medication) side-effects are something else entirely. So (pharmacists) would be kind of completely thinking down the asthma route, 'it might just be that you're taking an inhaler that you feel side-effects'…but what if it turns out you actually have cancer?'
Building trust through a benchmarking process
None of the participants had previous experiences with GPPs, with some participants questioning the differences between GPPs and community pharmacists. Many participants engaged in a benchmarking process: using their trust and previous experiences of other healthcare professionals to gauge how much they could trust a GPP. Common reference points included community pharmacists, respiratory consultants, nurses, GPs and paramedics.
'…I know (pharmacist support) is there but I still don't understand it with (brittle) asthma because I still get wary. If paramedics have never heard of it and don't know what they're doing, how's a pharmacist going to hear of it?'
'I would much rather go to a pharmacist than to a nurse to discuss the medication issues that I was having… I can see an asthma nurse to discuss medication, and I was like 'Really? What do nurses know about…not to be rude, but what do they know about medication more than my specialist who prescribed it?'
– P4, female, 30–39 years, mild asthma
Theme 2: filling gaps in current asthma care
Participants' opinions of GPPs were also informed by perceived gaps in their current asthma care. Participants evaluated the new service's place in their current care based on potential role overlap between GPPs and other healthcare professionals, continuity of care and medication-specific support.
Potential role overlap
Participants that saw potential role overlap between GPPs and other healthcare professionals were more sceptical of the new service.
'I think if I was having an annual asthma review I wouldn't need to use the pharmacist's service as well, but it might be an alternative to the annual asthma review…'
– P3, male, 70+years, mild asthma
However, other participants clearly delineated the GPP role, and these participants often recommended ways to integrate pharmacists into their care.
'If you're asking a GP, you've got maybe five, ten minutes… If you know you've got another ten or fifteen minutes with this pharmacist… for asking all these questions…with the GP you can concentrate on the problem and get that sorted, and then go see the pharmacist and discuss the medication.'
– P5, female, 60–69 years, moderate asthma
Continuity of care
Participants with self-reported severe asthma often had multiple healthcare professionals involved in their care (eg, respiratory consultants, GPs and asthma nurses). When asked about the new service, some participants felt concerned about involving an additional healthcare professional in their care. This was unrelated to their views on pharmacist competency and was usually influenced by previous experiences of inadequate continuity of care due to a lack of communication between healthcare professionals.
'(Pharmacists) always say speak to your GP but then the GP tells you to speak to the pharmacist because they're supposed to know more about drugs than what they are…and then you're somewhere in the middle…'
Medication-specific support
Other participants with severe asthma who spoke about being on multiple medications and/or having other health concerns welcomed the service. This enthusiasm came from the fact that they identified gaps in their current care that they believed could be filled by pharmacists as medication experts.
'…just having contact with someone who actually…knows about the medication, like they know how they work and what the potential side effects are going to be and interactions…it's that knowledge that a GP wouldn't necessarily have time to tell you all about…'
'…I'm trying to conceive at the moment so…and I thought I don't want to be taking anything that's unnatural or steroid-y…I did ask the respiratory consultant (about asthma medications and In Vitro Fertilisation) but he didn't know…'
–P8, female, 30–39 years, severe asthma
Some participants felt that GPPs should have an independent prescribing qualification to fulfil their role as medication experts. They worried that the new service might contribute to the burden on patients and/or the healthcare system and that independent pharmacist prescribers would minimise the risk of this happening.
'For me, it would just be down to whether or not (pharmacists) are able to prescribe. I don't imagine that they wouldn't have the knowledge that was required…It's just if I had to then see a doctor to be prescribed a different medication, I'd rather just go to see the doctor instead.'
– P10, female, 40–49 years, mild asthma
Theme 3: navigating a strained healthcare system
Participants were acutely aware of the limited resources within general practice. They often expressed guilt and frustration about booking appointments for asthma. Participants never booked appointments just for medication-related questions, and their medication-related concerns were frequently left unaddressed because other topics took priority in a consultation, particularly if the participant had multiple comorbidities. The pharmacist-led service was welcomed by these participants because they felt pharmacists would have more time to focus on their medication.
'…come Monday morning I wouldn't want to call the GP because I know on Monday morning they're very, very busy…I'll just sort of crack on at home, multi-dosing salbutamol and seeing what happens.'
'(GPs) just want you in and out… 'oh yes, I wanted to ask you something else' but too late now, you're away. That's how you feel.'
–P1, female, 30–39 years, mild asthma
The hierarchy of healthcare professionals
Many participants constructed a hierarchy of healthcare professionals with GPs at the top, followed by nurses and finally pharmacists. This hierarchy determined the importance of each healthcare professional's time. Severe health concerns justified booking a GP appointment, while non-urgent concerns were viewed as more suitable for pharmacists.
The hierarchy of healthcare professionals affected opinions of GPPs in both directions. Some participants were enthusiastic about the new service because they believed it would lessen the workload of GPs and nurses. For these participants, seeing a pharmacist (the healthcare professional further down the hierarchy) felt less intimidating and formal, slightly easing concerns about taking up valuable appointment time.
'…to be honest, GPs have bigger problems to deal with…[they're] dealing with people with, you know, life threatening illnesses, then actually seeing the standard case of asthma or an asthma check-up isn't the best use of (their) time.'
– P16, male, 18–29 years, moderate asthma
'It feels less formal, I think, when you're with a pharmacist than when you're in the doctor's…sometimes when you go to the doctor's, you're kind of clock watching…'
Others felt that pharmacists could not extend into a clinical role similar to GPs and nurses, with some suggesting a triage-like function to safeguard GP time.
'I never feel as though a pharmacist is a nurse, if you see what I mean. A nurse has practical hands-on experience of trying to make people better. The pharmacist is one who deals with the theory of medication.'
–P9, male, 60–69 years, undisclosed asthma severity
'… the pharmacist has seen you and if there's communication between the pharmacist and the GP, so that I guess it would help the GPs prioritise who they saw…'
–P11, female, 40–49 years, moderate asthma
However, pharmacists themselves were also viewed as a limited resource. Many participants supported moving pharmacists from community pharmacies to general practice because they experienced inadequate care in busy community pharmacies. Others were concerned that pharmacist-led adherence support with a wide scope (ie, for multiple long-term conditions) would limit access for people with asthma.
'If (pharmacists) weren't running a community pharmacy, if they were linked in, if they worked within the GP surgery with a lot of time, then yes, I don't see how (a lack of time) would be an issue'
'…my worry is if a pharmacist has to do (adherence support in general practice) for asthma, what other long-term conditions will they have to do it for?'
This is the first in-depth exploration of the perspectives of adults with asthma on pharmacist-led adherence support in general practice. This focused exploration identified potential barriers to service uptake and has the potential to help further refine and tailor the GPP service as it is rolled out.
Interpretation of findings
Trust played an important role in participants' initial perspectives of GPP-led care—it was an essential component of the patient-pharmacist relationship and it informed participants' views of pharmacists' role in asthma care. These findings suggest that general awareness of the existence of pharmacist-led services is insufficient to encourage service uptake.
Participants based their trust in pharmacists on perceived clinical competency and comparisons with other trusted healthcare professionals (eg, GPs and nurses), guided by perceptions of pharmacists' position in the hierarchy of healthcare professionals. These findings may suggest that explicit endorsement of GPP-led care by other trusted healthcare professionals might improve service uptake among adults with asthma. Reassurance and support from GPs and nurses may address some of the concerns raised by study participants, including those about fragmented care, pharmacists' clinical competency and potential role overlap.
Support for GPP-led care did not seem to differ based on participants' age, gender or self-reported asthma severity—there was a variety of views in each group of participants. However, participants who spoke about being on multiple medications and/or having additional health concerns seemed to be more open to pharmacist input, perhaps because they felt current asthma care was unable to meet these additional needs. Targeting this group of adults with asthma may improve service uptake in the future.
The qualitative method in this study captured the complex processes behind people's initial opinions of GPPs. The combination of recruitment channels produced variation in the sample in terms of age, self-reported asthma severity and healthcare utilisation. Telephone-based interviews enabled recruitment across the UK without increasing participant burden, thus increasing study accessibility for participants with severe asthma and limited travel capacity. In addition, telephone-based interviews can produce data of higher quality compared with face-to-face interviews when sensitive topics (eg, long-term conditions) are discussed.23
The participant sample may however not have captured the views of all adults with asthma because it consisted primarily of people with self-reported mild asthma (53%) and people recruited through Asthma UK (41%). Thematic saturation may have been reached due to the relative homogeneity of the participant sample. The participants recruited through Asthma UK may have had a stronger interest in asthma care or pharmacist-led support and may therefore have been more supportive of the new service compared with the general population with asthma. However, if scepticism of the new service exists among people who are more engaged in their care, then the findings may be amplified in the general population with asthma who may have less interest in asthma care.
A major drawback of the study is that none of the participants had experienced a GPP consultation directly, with some participants recruited from Scotland and Northern Ireland where the GPP scheme does not exist. While the consultation description that participants were asked to read was based on real work by a clinical respiratory pharmacist working in general practice, study findings can only be used to understand patients' initial views of a GPP-led service. These participants represent the general population with asthma who would initially need to be convinced to engage with the service. Addressing some of the concerns identified by participants may help improve the uptake of existing GPP-led care among adults with asthma. However, participants' views may change over time and could potentially be influenced by direct personal experience with a GPP consultation.
Comparison with existing literature
There is limited research on patient perspectives of GPPs because the care model is relatively new. However, findings from this study align with those from community pharmacy-based research, suggesting that people with asthma may not differentiate between pharmacy sectors.
Findings align with work by Gidman et al,13 who found that people were hesitant about deviating from their usual trusted care model (often a GP). However, two of the older participants in this study were open to GPP-led care, in contrast to previous research that suggests that older patients may be less likely to accept an expanded pharmacist role.24
In line with the present study's findings, previous research with general members of the public and people with asthma found that other trusted healthcare professionals (eg, GPs and nurses) were used as benchmarks to inform opinions of community pharmacist-led services.13 20 Similarly, Naik Panvelkar et al 20 found that previous positive experiences with community pharmacists raised expectations for other pharmacist-led services in a population of people with asthma.
Participants' views of the gaps in their current asthma care shaped their perspectives of GPPs. Similarly, Boyd et al 25 found that recipients of the New Medicine Service welcomed pharmacists' recommendations if they addressed a concern directly raised by the patient. While asthma care guidelines recommend a multidisciplinary approach in treating difficult asthma, the present study suggests that some people with self-reported severe asthma were hesitant to include another healthcare professional due to issues with continuity of care.26 In line with previous research, the hierarchy of healthcare professionals influenced perspectives of pharmacists expanding further into clinical roles.13 15 However, this study also found that the hierarchy increased support for pharmacist-led care to reduce the burden on GPs/nurses.
Implications for research and practice
As the GPP model is rolled out, future studies could be conducted using in-depth interviews with people with asthma after they have experienced a GPP-led consultation. These interviews could establish if interpersonal factors (ie, rapport with the pharmacist) have an impact on patient perspectives. Ethnographic observations of pharmacist-led consultations and the general practice team will help assess pharmacists' integration and its effect on continuity of care for asthma patients. Future recruitment should aim for greater variation in participants (eg, self-reported asthma severity) through various recruitment channels, with additional efforts to look for discordant voices when thematic saturation is reached.
Findings from this study could be implemented in efforts to increase service uptake among people with asthma. Given the benchmarking process used to establish trust in pharmacists, comparisons between GPPs and other healthcare professionals could be used to inform and engage the public. For example, public campaigns highlighting the differences and similarities between GPs and GPPs may help the public differentiate the pharmacist role and understand the added value of the new service within asthma care.
Participants wanted GPPs to have broad clinical skills and a prescribing qualification. Encouragingly, the Centre for Pharmacy Postgraduate Education has already included these components in their GPP training pathways.27
Although the hierarchy of healthcare professionals sometimes prevented pharmacists from being perceived as clinicians, it also made GPP appointments appear less formal and intimidating to access. Participants felt more comfortable making an appointment with a pharmacist for medication-related questions. This is encouraging because the new service may encourage people with asthma to address medication-related concerns that may be barriers to medication adherence.28
While the perspectives of people with asthma explored in this study show that the GPP model has promise, they identified several barriers to optimal patient engagement and service implementation that will need to be addressed for the service to be effective. Meeting patient expectations will be the first crucial step in ensuring the programme's long-term benefit and reducing the pressure on general practice in England.
We would like to thank the Asthma UK Centre for Applied Research (AUKCAR) Patient Advisory Group for their feedback and support for this study.
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OpenUrlCrossRefWeb of Science
Twitter @marissames1
Contributors The study was designed by MAM, RH and SJCT. All interviews were conducted by MAM. Data was analysed by MAM and CBK. The manuscript was written by MAM, AHYC and VW, with input from RH and SJCT.
Funding The research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust.
Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
Patient and public involvement statement All study materials were reviewed by the AUKCAR Patient Advisory Group
Ethics approval The research was approved by the NHS London-Harrow Research Ethics Committee (12 October 2017, Ref: 17/LO/1565) and Cwm Taf University Health Board (17 November 2017, Ref: CT/831/205928/17).
Data availability statement No data are available.


Reads a single e-mail message from the standard input, and writes the commit log message in <msg> file, and the patches in <patch> file. The author name, e-mail and e-mail subject are written out to the standard output to be used by git am to create a commit. It is usually not necessary to use this command directly. See git-am instead.


text:
Top 10 places for a fish and chip as voted for by our Ulster Star readers
Seat Leon e-Hybrid review: family hatchback makes the switch to a plug-in future
Fourth generation of Golf and Focus rival adds hybrid options
By Matt Allan
Seat Leon e-Hybrid
Say hola to the fourth generation of the Seat Leon
First launched in 1999, the family hatchback has proved a huge hit for the Spanish brand and remains its best seller even in this age of the SUV. But time marches on and so does the competition, so 2020 saw a brand new version launched to help it stay relevant.
On the surface it looks like a case of evolution rather than revolution, with a designer's scalpel taken to the old shape to add some sharper edges and more defined lines. Underneath, though, there's more passenger space than before, along with more advanced connectivity and an updated engine range that runs the full gamut from straight petrol or diesel to mild hybrid and the plug-in e-Hybrid you see before you.
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The Leon's almost buttonless interior looks good but isn't user-friendly
Driving the e-Hybrid is a combination of a 1.4-litre turbocharged petrol engine and a single electric motor. Even on its own the engine's 148bhp is respectable but with the motor spinning as well, the Leon offers a healthy 201bhp. That's enough to get the Leon to 62mph in 7.5 seconds and the setup feels responsive and punchy in almost any situation. Although it's capable of haring around rapidly, the car will usually start in electric mode, offering around 115bhp, and stick there until a heavy foot prompts the engine into action, at which point the transition is pleasantly slick.
Consult Seat's website and you'll see outlandish claims of more than 200 miles per gallon. That might be what the official tests say but don't expect anything like that on an actual road with an actual human at the wheel. That's not to say the Leon's economy isn't impressive. Some lead-footed individuals had managed to get our test car's long-term economy below 50mpg but I saw an effortless 67mpg on a fairly demanding cross-country run. Keep the battery topped up - which takes just under four hours on a home wallbox - and you should enjoy diesel-like economy without the societal shame.
At 12.8kWh, the battery is a useful size for the sort of short urban hops that make up much of many families' regular motoring. I didn't see near the claimed 40 miles of range but mid-20s during a particularly cold snap should translate into 30+ in better conditions. That's enough for a few school runs and trips to the supermarket without using the petrol motor, although having to manage the hybrid/EV modes via the touchscreen rather than a physical button could take a bit of getting used to.
The lack of any drive mode button, or pretty much any other button is part of Seat's effort to smooth out the car's interior. Most functions are now controlled via either the steering wheel buttons or the 10-inch touchscreen. While this certainly makes for a clear, slick interior look, it means the infotainment system is overloaded with menus and isn't always the easiest to use. Unfortunately, Seat has also seen fit to go down the same route as the new Golf and use unlit haptic "sliders" for heating control. Positioned flat beneath the touchscreen they're easy to hit accidentally but hard to operate accurately.
Digital instruments are standard on all hybrid cars, while even entry-level models get keyless entry, cruise control and lane keep assist. Our FR spec adds three-zone climate control and auto dipping LED headlights along with wireless phone, charging 17-inch alloys and sportier styling touches.
Don't be fooled by the flat-bottomed steering wheel, deeper bodykit and twin exhausts, though, at more than 1,600kg, the Leon is no lightweight and despite our FR spec car's "sports" suspension it never felt particularly dynamic. Quick in a straight line, yes, but not involving in the way that a Focus is. However, that's a criticism that can be levelled at pretty much any car in the segment and if you just need a comfortable and sharply styled family hatch, then the Leon has the space and comfort you'd hope for, although the battery robs the boot of 110 precious litres.
That makes it slightly less practical than either a regular petrol Leon or some of its rivals but the impressive hybrid drivetrain makes up for that somewhat. If you can live with its smaller boot, buttonless interior and slightly inert handling, the Leon is a stylish, smooth and frugal option for the family.
Seat Leon FR e-Hybrid
Price: £30,970 (£31,115 as tested); Engine: 1.4-litre, four-cylinder, turbo, petrol with 85kW electric motor; Power: 201bhp; Torque: 258lb/ft; Transmission: Six-speed DSG automatic; Top speed: 137mph; 0-62mph: 7.5 seconds; Economy: 217.3-235.4mpg; CO2 emissions: 27g/km
Seat LeonSeatGolf


text:
Blindman
Roger Ebert January 14, 1972
Now streaming on:
Sometimes a movie comes along with a title so perfect you're afraid to see it because that might spoil everything. Such a work is "Crimson Bat, Blind Swordswoman," which plays every now and then in the Japanese film series up at Francis W. Parker School. I've always been under the impression that Ms. Bat was alone in her specialty, but no.
"Blindman" stars Tony Anthony as a blind gunman. And just when I was thinking that was fairly original, I found out that "Blindman" was inspired by still another Japanese movie, "Zatoichi," about a blind samurai warrior. By a coincidence too marvelous to explain, "Zatoichi" happens to be playing this very weekend at Francis Parker; the program notes promise, somewhat unnecessarily, "swords flashing faster than the eye can see."
Westerns inspired by samurai dramas are nothing new, of course. "The Seven Samurai" gave us "The Magnificent Seven," and "A Fistful of Dollars" launched Clint Eastwood into orbit via a story borrowed from Japan. The neat thing about "Blindman," though, is that Tony Anthony operates with a rifle instead of a sword, and that can get tricky. One good sweep of a room with a sword is likely to kill, wound or at least nick everyone within range of Crimson Bat. But a rifleman has got to aim.
Anthony does pretty well, all things considered. All he needs is to be pointed in the direction of the church and he hits the bell nine times in a row. Later on, he kills four bad guys before they can even get a shot off. He is helped somewhat, to be sure, by a rifle that never runs out of ammunition, no matter how many times he fires. But you figure that he and Crimson Bat must have something going for them. Radar, maybe.
The movie itself is a greasy bill of goods about Blindman's lonely quest for 50 women he was supposed to deliver to the lust-crazed miners of Lost Fork, Tex. Blindman himself never misses a fork because he has a map burned into a piece of leather. At one point, he halts his horse and lets his fingers trace the leather map. They spell out the word Oklahoma." Satisfied, he rides ahead. Later, his fingers spell out "Texas," and he nods again. I guess the knack with a map like this is to know when to pull it out.
Blindman gets a little help from his horse, too. When he whistles, the horse comes running to his side. This is some horse. It is always saddled, complete with gear like Blindman's rifle, blanket, change of duds, canteen and hat. When Blindman talks to the horse, the horse whinny's and, tosses its head and stamps its feet and does everything but type.
The 50 women are handled interestingly. There aren't actually 50 women in most of the scenes, see, because that could get expensive. So in most of the scenes, we see the first 12 women from the front, and then the last 12 women bringing up the rear, so that all you need are 12 women and two camera placements.
Speaking of the horse, I seem to remember that there was a wonder horse in Kentucky about 20 years ago who could type answers to questions asked by newspapermen. An ability like that is rare, especially in election years. Dolphins are said to be particularly smart, of course. No reading has been made on the IQ of a turtle, but what kind of cowboy would ride into town on a turtle, anyway? The movie raises all sorts of intriguing questions, as you can see. I wonder whether we won't get all kinds of imitations, like "Blind Angels on Wheels," where the greasers never have to worry because the Harley knows the way.
Roger Ebert was the film critic of the Chicago Sun-Times from 1967 until his death in 2013. In 1975, he won the Pulitzer Prize for distinguished criticism.
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It was bitterly cold and getting colder in Lola Prentiss Park in downtown Southampton Sunday afternoon, but, all afternoon long, a crowd of advocates for immigration reform kept growing.
More than 120 strong by mid-afternoon, they came from Hampton Bays and East Hampton and they walked up the street from down in Southampton Village, but many of the ralliers' journeys had initially spanned the world, from Colombia, from Chilé, from Costa Rica and Guatemala.
Their purpose was simple: to ask the U.S. House of Representatives to put the Comprehensive Immigration Reform bill, which passed the Senate in June, up to a vote.
With just four days left of Congressional sessions this year, ralliers accepted the fact that immigration reform likely won't be on their agenda this year. But many said their hope, this Christmas, is that it will be put up for a vote early in 2014.
Jahayra Naranja of Hampton Bays said that, while working in the United States, she and many people she knows have not been able to say goodbye to loved ones who have died at home, and only know the babies that have been born since they left through photographs.
The stretch of Southampton near where the ralliers gathered has long been a hot spot for immigration confrontations on the East End. For the better part of a decade, anti-immigration protesters stood outside the 7-Eleven on the corner of County Road 39 and North Sea Road, where many day laborers gather to find work each morning.
Nearly a decade ago, plans to build a hiring hall in Southampton Village were met with severe opposition from neighbors.
But organizers said Sunday's rally was the first time they'd seen such momentum for immigrant rights on the East End.
They said they had come from New York City as part of the group New Yorkers for Immigration Control and Enforcement, and handed out flyers stating "The American people don't want the 20 million illegal invaders in our country legalized." They added that the reform would benefit ultra-rich Silicon Valley billionaires "who want the cheap labor that an army of the newly legalized would provide." They stood quietly, holding their signs, throughout the rally.
Eastern Long Island NAACP President Lucius Ware lent his support to the ralliers.
He said comprehensive immigration reform is one of the cornerstone issues the NAACP is currently working on.


text:
After "Alleged" Rocket Attacks, DPA Reports "So-Called" Burning Balloons
By: Tamar Sternthal June 18, 2019
A month after correcting photo captions which had originally referred to hundreds of Palestinian rockets "allegedly" fired at Israel, the German Deutsche Presse-Agentur (DPA) wire service published new photo captions Friday which called incendiary devices launched by Palestinians in Gaza "so-called" burning balloons. The misleading captions dismissively referred to airborne arson attacks launched from the Gaza Strip against southern Israel as "so-called four burning balloons . . . creating small fires in southern Israel" (Emphasis added). A sampling of the numerous photographs which carry the tendentious captions follows:
14 June 2019, Palestinian Territories, Gaza City: Palestinian fishing boats anchored in Gaza port and fish shops empty. According to media reports, Israel closed the fishing area of Gaza fishermen until further notice in response to the so-called four burning balloons that emerged from the coastal enclave creating small fires In southern Israel. Photo by: picture-alliance/dpa/AP Images
14 June 2019, Palestinian Territories, Gaza City: A Palestinian stands in his empty fish shop. According to media reports, Israel closed the fishing area of Gaza fishermen until further notice in response to the so-called four burning balloons that emerged from the coastal enclave creating small fires In southern Israel. Photo by: picture-alliance/dpa/AP Images
Why does DPA qualify these burning balloons as "so-called" burning balloons? That is, in fact, what they are.
The AFP reported on last Wednesday, June 12, when the fishing ban was imposed:
The Israeli government said late Wednesday that the fishing zone off the coast of Gaza had been closed, in retaliation for the launch of incendiary balloons from the Palestinian enclave.
"Due to the continuous launching of incendiary balloons and kites from the Gaza Strip towards Israel, it has been decided tonight (Wednesday) not to allow access to Gaza's maritime space until further notice," a spokesperson for COGAT, a unit of Israel's defence ministry, said in a statement. . . .
A spokesman for the Israeli fire service said incendiary balloons from Gaza caused seven fires just on Tuesday.
In the past year, Palestinians have succeeded in setting fire to large areas of farmland in southern Israel.
Indeed, in the past year, such Palestinian arson attacks have destroyed tens of thousands of dunums of agricultural land and nature reserves.
According to latest figures from Israel's Ministry of Foreign Affairs, more than 35,000 dunums of agricultural and park lands in southern Israel have been destroyed in Palestinian arson attacks in the last year, resulting in 13 million shekels of damage.
Moreover, Times of Israel reported that on Wednesday, June 12, the day the fishing ban was imposed, Gazans launched a balloon-borne bomb into Israel, which exploded over an Israeli town. The Times of Israel also reported that "the local fire department report[ed] six fires were started Wednesday in southern Israel as a result of incendiary and explosive devices flown from Gaza."
CAMERA has contacted DPA editors to request they amend the unjustified reference to "so-called" burning balloons. As of this writing, they have yet to correct.
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Deutsche Presse-Agentur (DPA)