Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions.

OBJECTIVES: This evidence review was conducted to understand how and why workforce development interventions can improve the skills and care standards of support workers in older people's services. DESIGN: Following recognised realist synthesis principles, the review was completed by (1) development of an initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce; (3) 'testing out' the synthesis findings to refine the programme theories, and establish their practical relevance/potential for implementation through stakeholder interviews; and (4) forming actionable recommendations. PARTICIPANTS: Stakeholders who represented services, commissioners and older people were involved in workshops in an advisory capacity, and 10 participants were interviewed during the theory refinement process. RESULTS: Eight context-mechanism-outcome (CMO) configurations were identified which cumulatively comprise a new programme theory about 'what works' to support workforce development in older people's services. The CMOs indicate that the design and delivery of workforce development includes how to make it real to the work of those delivering support to older people; the individual support worker's personal starting points and expectations of the role; how to tap into support workers' motivations; the use of incentivisation; joining things up around workforce development; getting the right mix of people engaged in the design and delivery of workforce development programmes/interventions; taking a planned approach to workforce development, and the ways in which components of interventions reinforce one another, increasing the potential for impacts to embed and spread across organisations. CONCLUSIONS: It is important to take a tailored approach to the design and delivery of workforce development that is mindful of the needs of older people, support workers, health and social care services and the employing organisations within which workforce development operates. Workforce development interventions need to balance the technical, professional and emotional aspects of care. TRIAL REGISTRATION NUMBER: CRD42013006283.

Effect of socioeconomic deprivation on uptake of measles, mumps and rubella vaccination in Liverpool, UK over 16 years: a longitudinal ecological study.

Suboptimal uptake of the measles, mumps and rubella (MMR) vaccine by certain socioeconomic groups may have contributed to recent large measles outbreaks in the UK. We investigated whether socioeconomic deprivation was associated with MMR vaccine uptake over 16 years. Using immunization data for 72,351 children born between 1995 and 2012 in Liverpool, UK, we examined trends in vaccination uptake. Generalized linear models were constructed to examine the relative effect of socioeconomic deprivation and year of birth on MMR uptake. Uptake of MMR1 by age 24 months ranged between 82·5% in 2003 [95% confidence interval (CI) 81·2-83·7] and 93·4% in 2012 (95% CI 92·7-94·2). Uptake of MMR2 by age 60 months ranged between 65·3% (95% CI 64·4-67·4) in 2006 and 90·3% (95% CI 89·4-91·2) in 2012. In analysis adjusted for year of birth and sex, children in the most deprived communities were at significantly greater risk of not receiving MMR1 [risk ratio (RR) 1·70, 95% CI 1·45-1·99] and MMR2 (RR 1·36, 95% CI 1·22-1·52). Higher unemployment and lower household income were significantly associated with low uptake. Contrary to concerns about lower MMR uptake in affluent families, over 16 years, children from the most socioeconomically deprived communities have consistently had the lowest MMR uptake. Targeted catch-up campaigns and strategies to improve routine immunization uptake in deprived areas are needed to minimize the risk of future measles outbreaks.

Rural-urban differences in the effects on mental well-being of caring for people with stroke or dementia.

BACKGROUND: Rural and urban differences in the effects of care-giving are not well documented. This paper reports data on 122 carers for people with stroke or dementia living in rural and urban settings in Wales. METHOD: Carers completed a postal questionnaire, including the SF-12v2 Health Survey. Definitions of rural and urban were based on the Urban/Rural Indicator from the Office of National Statistics (ONS) All Fields Postcode Directory 2004. RESULTS: Carers' mean Mental Component Summary (MCS) score (adjusted for age and sex) was one standard deviation below the population mean (-12.03). Male carers living in urban areas reported better mental health than male carers in rural areas (p<0.05) and female carers in both settings (p<0.05). A full model and a parsimonious model were developed, using MCS scores as outcome variables. In the full model sitting service provision in rural and urban locations was linked to better carer mental health, while support from friends and family was linked to better mental health for urban carers only. CONCLUSION: Our findings indicate the existence of both gender and location differences in carer experiences.

Guidelines for gynecological cancer-an audit of current network documents in England and Wales.

The objective of this study was to assess the adequacy of network cancer guidelines paying particular attention to referral criteria, referral routes, tumor diagnosis, staging, and suggested management and care pathways for ovarian and endometrial cancer. Guidelines from 15 regions in England and Wales were analyzed quantitatively and qualitatively as a prospective audit of predefined data items and subsequently agreed management recommendations. Details of unit and center clinicians were included in a minority of documents (2 to 5/15). Multidisciplinary team membership was not usually offered (6/15). Among the least reported data items were histopathology minimum dataset for endometrial cancer and an algorithm for management or summary and clinical symptoms and signs for both cancers. Among the most reported data items were hysteroscopy and ultrasound scanning for endometrial cancer and CA125 and chemotherapy for ovarian cancer. Qualitative analysis revealed differing criteria for the use of endometrial biopsy and radiotherapy in endometrial cancer, for lymphadenectomy and management of recurrent disease in ovarian cancer, and for referral pathways and the use of computed tomography/magnetic resonance (MR) scanning in the assessment of either disease. This study concludes that consideration should be given to the development of national guidelines or templates to ensure consistency of management for gynecological malignancy in England and Wales.

The experience of caring for older people with dementia in a rural area: using services.

This paper reports findings from the carer component of the Gwynedd Dementia Study. It is based on carer interviews, using quantitative and qualitative data. It confirms earlier findings that carers for people with dementia are typically female and older than other carers, although it notes that caring husbands are amongst the oldest carers. The problems that are most common are those that cause psychological stress to carers. Carers were found to receive both help and appreciation from their families and to perceive neighbours to be helpful if needed. In Gwynedd, as elsewhere, levels of formal service inputs are low, but most of the carers appeared to receive the services they needed. Problems are primarily associated with crisis support and long-term care is accepted reluctantly. It is suggested that community care dementia specialists could play a supporting role for carers.

Carers of older people with dementia: assessment and the Carers Act.

The Carers (Recognition and Services) Act 1995 came into force on 1 April 1996. It entitles carers who are providing substantial amounts of care on a regular basis to an assessment of their needs and ability to care. Local authorities are required to take the results of this assessment into account when making decisions about services. This paper reports the key findings of a two-year study, conducted in Wales, that evaluated the process and outcomes of assessments carried out under the auspices of the Carers Act. The findings offer insights to policy makers and practitioners and profile how care managers assess carers' needs. In addition, the paper describes carers' qualitative experiences of the assessment process and the difficulties care managers encounter in translating into practice the policy emphasis on supporting carers. It is suggested that separate carer assessments are not an established feature of care management practice and that care managers lack an explicit framework to direct the assessment of carers' needs.

Political economy of tobacco control in low-income and middle-income countries: lessons from Thailand and Zimbabwe. Global Analysis Project Team.

Crucial to the success of the proposed Framework Convention on Tobacco Control will be an understanding of the political and economic context for tobacco control policies, particularly in low-income and middle-income countries. Policy studies in Thailand and Zimbabwe employed the analytical perspective of political economy and a research strategy that used political mapping, a technique for characterizing and evaluating the political environment surrounding a policy issue, and stakeholder analysis, which seeks to identify key actors and to determine their capacity to shape policy outcomes. These policy studies clearly revealed how tobacco control in low-income and middle-income countries is also being shaped by developments in the global and regional political economy. Hence efforts to strengthen national control policies need to be set within the context of globalization and the international context. Besides the transnational tobacco companies, international tobacco groups and foreign governments, international agencies and nongovernmental organizations are also playing influential roles. It cannot be assumed, therefore, that the tobacco control strategies being implemented in industrialized countries will be just as effective and appropriate when implemented in developing countries. There is an urgent need to expand the number of such tobacco policy studies, particularly in low-income and middle-income countries. Comprehensive guidelines for tobacco policy analysis and research are required to support this process, as is a broader international strategy to coordinate further tobacco policy research studies at country, regional and global levels.

HIV-AIDS in Nepal: the coming crisis.

The number of officially reported cases of HIV infection and of AIDS in Nepal remains low in comparison with numbers in many other Asian countries. But Nepal's open border with India (where HIV infection rates are rapidly rising) and the high level of physical mobility within Nepal and abroad, associated with widespread labor migration and encouraged by the recent development of road transport, means that there is a real danger of a rapid spread of HIV within Nepal. The major means of infection is through heterosexual encounters involving male clients and female sex workers, but other sections of the population are also at risk from infection. Media attention has focused on female sex workers, particularly those who have worked in India, but the issue is far broader than this. Social and economic factors forcing or encouraging young men and women to seek employment away from home underlie the widespread growth of ¿the sex industry¿ and the ¿trafficking¿ of girls and young women. The state's capacity to respond effectively is limited, in part through lack of resources; international agencies are supporting local nongovernmental organizations in a variety of activities designed to ¿educate¿ and to ¿support¿ those at risk; but in the last analysis, it is the local communities from which young men and women migrate and to which they return that are obliged to find ways of coping. Sometimes these communities are supportive of the victims, sometimes not. The spread of HIV-AIDS is not just a ¿health¿ issue, but an issue of economic and social development, of gender relations and of human rights.

Data quality in population-based cancer registration: an assessment of the Merseyside and Cheshire Cancer Registry.

Merseyside and Cheshire Cancer Registry (MCCR) data quality was assessed by applying literature-based measures to 27,942 cases diagnosed in 1990 and 1991. Registrations after death (n = 8535) were also audited (n = 917) to estimate death certificate only (DCO) case accuracy and the proportion of registrations notified by death certificate (DC). Ascertainment appeared to be high from the registration/mortality ratio for lung [1.01:1] and to be low from capture-recapture estimates (59.4%), varying significantly with site from oesophagus [92.2% (95% CI 88.5-95.9)] to breast [47.5 (95% CI 41.8-53.2)]. The estimated DC-dependent proportion was 20% (5601 out of 27 942) with successful traceback in 3533 out of 5601 (63.1%) cases. DCO flagging (2497 out of 27,942, 8.9%) overestimated true DCO cases (2068 out of 27,942, 7.4%). The proportion of cases of unknown primary site was low (1.5%), varying significantly with age [0-4.2%, (95% CI 2.5-5.9)] and district [0.8% (95% CI 0.3-1.3) to 2.2% (95% CI 1.8-2.6)]. The median diagnosis to registration interval appeared to be good (10 weeks), varying significantly with site (P < 0.0001), age (P < 0.0001) and district (P < 0.0001). The proportion with a verified diagnosis was 77.3%, varying significantly with site [lung 55.2% (95% CI 53.7-56.7) to cervix 96.9% (95% CI 96.3-97.5)], age [45.2% (95% CI 40.9-49.5) to 97.5% (95% CI 96.4-98.6)] and district [71.8% (95% CI 69.9-73.8) to 82.5% (95% CI 80.7-84.3)]. The DCO percentages varied similarly by site [non-melanoma skin 0.4% (95% CI 0.2-0.6) to lung 22.6% CI (95% 19.9-25.3)], age [0.7(95% CI 0.1-1.4) to 23.0 (95% CI 19.4-26.6)] and district [6.9% (95% CI 5.7-8.1) to 13.9% (95% CI 12.9-15.0)]. MCCR data quality varied with age, site and district - inviting action - and apparently compares favourably with elsewhere, although deficiencies in published data hampered definitive assessment. Putting quality assurance into practice identified shortcomings in the scope, definition and application of existing measures, and absent standards impeded interpretation. Cancer registry quality assurance should henceforward be within an explicit framework of agreed and standardized measures.

Measurement of lung tissue mass in interstitial lung disease.

A gamma camera and 99m Technetium were used to obtain transmission and emission scans of the thorax in order to estimate transthoracic tissue thickness, and volumes of blood and interstitial tissue in each pixel of the gamma camera image. This technique has been applied to six patients with stage 2/3 pulmonary sarcoidosis and eight with cryptogenic fibrosing alveolitis and age and sex-matched control groups without lung disease. In both conditions transthoracic tissue thickness was significantly increased: mean values (SD) were 14.6 (1.8) cm in cryptogenic fibrosing alveolitis and 12.3 (2.2) cm in stage 2/3 sarcoidosis. This was partially accounted for by an increase in the interstitial fluid compartment. Blood volume was unaffected. Measurement of transthoracic tissue thickness involves minimal radiation exposure and may be of value in monitoring these diseases; measurement of interstitial fluid volume may give information on disease activity.

Estimation of lung oedema in humans by transmission-emission scintigraphy with 99Tcm.

UNLABELLED: We have used a combination of transmission and emission gamma camera techniques to scan the thorax in the anteroposterior plane in 21 patients with partially treated cardiogenic pulmonary oedema and have compared their results with those from 20 age-matched normal subjects who were scanned previously. For transmission scanning, an external 99Tcm flood source was used; for emission scanning we labelled sequentially the vascular compartment with 99Tcm autologous erythrocytes and the interstitium with 99Tcm diethylenetriaminepentaacetic acid (99Tcm-DTPA). From the transmission scans we derived the transthoracic tissue thickness (Tt) and from the emission scans, after correction for attenuation, the regional blood and interstitial volumes. In the lower zone of the right lung, mean (S.D.) Tt in normal subjects was 10.9 (S.D. 3.1) cm and in subjects with lung oedema was 12.5 (S.D. 3.1) cm (P = 0.07). There was a weak correlation between Tt and a radiographic numerical score of oedema severity (r = 0.47, P less than 0.05). In eight subjects with lung oedema, lung tissue thickness (T1) was estimated (by subtraction from Tt of radiographically estimated chest wall thickness). The T1 correlated closely with the radiographic score (r = 0.78, P less than 0.01). There was no significant change in blood or interstitial volumes in oedema. IN CONCLUSION: (1) transmission scanning gives an indication of oedema severity if an allowance is made for chest wall thickness; (2) 99Tcm-DTPA fails to equilibrate fully with oedema liquid during an equilibration period of 5 min.

Thoracic tissue thickness measured by transmission scintigraphy with 99Tcm.

A flood source containing 25 mCi of technetium-99m (99Tcm) was used to measure thoracic tissue thickness (Tt) in 20 healthy subjects, 14 patients with cardiogenic pulmonary oedema, 8 patients with biopsy proven cryptogenic fibrosing alveolitis (CFA) and 10 subjects with radiographic evidence of severe, widespread emphysema. Unattenuated counts from the flood source were acquired first, and then with the subject seated between the flood source and the gamma camera, a second scan of transmitted counts was acquired. Assuming a constant linear attenuation coefficient of 0.135 cm-1, we calculated Tt per pixel of the gamma camera image, thus creating a profile of Tt throughout the length of the thorax. In normal subjects mean (S.D.) Tt at the base of the right lung was 10.8 (2.4) cm. In patients with pulmonary oedema, CFA and emphysema, mean (S.D.) values for Tt, in cm, were 12.9 (2.7) p less than 0.05, 14.4 (1.9) p less than 0.001 and 6.0 (1.1) p less than 0.0001 respectively. This simple, quick and inexpensive technique could be used to give regional measurements of Tt.

Carcinoma of the bronchus in young adults.

Thirty patients with bronchial carcinoma, aged 45 or less, were identified as having attended this or other local chest clinics. In four cases the diagnosis was reached after four or more months of investigations. In two of these cases, pulmonary tuberculosis was incorrectly suspected to be responsible for the illness of the patient. Compared with the disease as it affects all age groups, there appeared to be no greater incidence of any particular presenting symptom. In the group of patients studied, there was an excess of small cell carcinoma compared with that expected.

Spontaneous fracture of the ulna complicating tuberculous osteomyelitis.

A 63 year old Asian woman presented with tuberculous osteomyelitis of the right ulna and a large subcutaneous cold abscess. During the course of her treatment the midshaft of the ulna sustained a spontaneous transverse fracture. Aspects of her case are reviewed.

Measurement of lung tissue mass in Pneumocystis carinii pneumonia.

Transmission-emission scanning of the thorax with a flood source of technetium-99m (99mTc), autologous 99mTc labelled red blood cells, and diethylenetriaminepenta-acetic acid (99mTc DTPA) allows measurement of thoracic tissue thickness and blood and interstitial volume per pixel of the gamma camera image. Volume of blood or interstitium per pixel divided by pixel area gives the thoracic tissue thickness for these two compartments. A measure of lung tissue thickness may be obtained by subtracting chest wall thickness as measured on a lateral chest radiograph. As part of the evaluation of this technique 13 patients were scanned before treatment for proved or presumed pneumocystis pneumonia and their results were compared with those of 12 normal young men, approximately matched for age. In the patients with pneumocystis pneumonia lung tissue thickness at the base of the right lung averaged 3.4 cm (71%) more than that in the normal subjects, and interstitial thickness was 1.2 cm (150%) more than in the normal subjects. After treatment 10 of the patients with pneumocystis pneumonia were scanned again. Lung tissue thickness remained greater than the control value by 1.2 cm and interstitial tissue thickness by 0.5 cm. Blood thickness remained unchanged. Lung tissue and interstitial tissue thickness was correlated with a numerical score of the changes in the chest radiograph. The changes in the properties of the lung tissue compartments in the patients presumably reflect the mural and intra-alveolar inflammation found in pneumocystis pneumonia. Transmission scanning alone measures the increase of lung tissue thickness as well as transmission-emission scanning. It may be of value in monitoring the progress of this condition during treatment.

Long term survival after treatment of disseminated T cell lymphoma presenting with tracheal obstruction in a patient with coeliac disease.

A 46 year old man with coeliac disease and upper airway obstruction was thought to have undifferentiated carcinoma of the trachea. Subsequent immunohistological examination showed that the neoplasm was a T cell lymphoma. He had combination chemotherapy and is alive and well seven years after diagnosis.

Surgical management of pneumothorax in cystic fibrosis.

Twenty seven adults with cystic fibrosis who had had either a surgical pleurodesis or pleurectomy for the management of pneumothorax were studied. There were no significant differences in postoperative respiratory function, incidence of recurrent pneumothorax, or incidence of major postoperative complications between the two groups.