Health literacy practices in social virtual worlds and the influence on health behaviour

This study explored how health information accessed via a 3D social virtual world and the representation of ‘self’ through the use of an avatar impact physical world health behaviour. In-depth interviews were conducted in a sample of 25 people, across 10 countries, who accessed health information in a virtual world (VW): 12 females and 13 males. Interviews were audio-recorded via private in-world voice chat or via private instant message. Thematic analysis was used to analyse the data. The social skills and practices evidenced demonstrate how the collective knowledge and skills of communities in VWs can influence improvements in individual and community health literacy through a distributed model. The findings offer support for moving away from the idea of health literacy as a set of skills which reside within an individual to a sociocultural model of health literacy. Social VWs can offer a place where people can access health information in multiple formats through the use of an avatar, which can influence changes in behaviour in the physical world and the VW. This can lead to an improvement in social skills and health literacy practices and represents a social model of health literacy

Hand hygiene techniques:Still a requirement for evidence for practice?

Introduction Two hand hygiene techniques are promoted internationally: the World Health Organisation’s 6 step and the Centre for Disease Control’s 3 step techniques; both of which may be considered to have suboptimum levels of empirical evidence for use with alcohol based hand rub (ABHR). Objectives The aim of the study was to compare the effectiveness of the two techniques in clinical practice. Methods A prospective parallel group randomised controlled trial (RCT) was conducted with 1:1 allocation of 6 step versus the 3 step ABHR hand hygiene technique in a clinical setting. The primary outcome was residual microbiological load. Secondary outcomes were hand surface coverage and duration. The participants were medical and nursing participants (n=120) in a large teaching hospital. Results The 6 step technique was statistically more effective at reducing the bacterial count 1900cfu/ml (95% CI 1300, 2400cfu/ml) to 380cfu/ml (95% CI 150, 860 cfu/ml) than the 3 step 1200cfu/ml (95% CI 940, 1850cfu/ml) to 750cfu/ml (95% CI 380, 1400cfu/ml) (p=0.016) but even with direct observation by two researchers and use of an instruction card demonstrating the technique, compliance with the 6 step technique was only 65%, compared to 100% compliance with 3 step technique. Further those participants with 100% compliance with 6 step technique had a significantly greater log reduction in bacterial load with no additional time or difference in coverage compared to those with 65% compliance with 6 step technique (p=0.01). Conclusion To our knowledge this is the first published RCT to demonstrate the 6 step technique is superior to the 3 step technique in reducing the residual bacterial load after hand hygiene using alcohol based hand rub in clinical practice. What remains unknown is whether the residual bacterial load after the 3 step technique is low enough to reduce risk of transmission from the hands and whether the 6 step technique can be adapted to enhance compliance in order to maximise reduction in residual bacterial load and reduce duration

Urinary incontinence in hospital in-patients: a nursing perspective

Urinary incontinence is a common health problem with not only physical, but also far-reaching psychological and social implications for the sufferer, her family and carers. Assisting patients with meeting their eliminatory needs is a fundamental part of nursing care. Incontinence is encountered in almost every sphere of clinical practice and is a problem with which nurses are often directly concerned. Nurses, in association with other members of the health care team, have considerable potential to help patients regain continence, or when this is not possible, to ensure that the individuals concerned, and their relatives or carers, can cope effectively with the problem, both physically and psychologically. This is an area of nursing care, however, which to date has attracted little research. The studies undertaken in this thesis sought to examine the nursing assessment and management of the care of patients with urinary incontinence in acute medical and care of the elderly wards. The research comprises of a sequence of studies which examined the problem from a number of perspectives. Methods of data collection included nurse and patient self-, reports, the examination of nursing and medical documentation, direct observation and self-completed questionnaires. Findings indicated that urinary incontinence was common in acute medical and care of the elderly wards, and that a considerable proportion of patients had indwelling catheters to manage the problem. Nurses were not always aware of patients' incontinence problems and their assessments concerning important aspects of the symptom were frequently unreliable. Further inadequacies in nurses' assessments, as well as in the management of the care of patients with incontinence, were identified from an examination of the nursing and medical records, and observations of verbal hand-over reports. Qualified nurses and learners appeared ill-informed about the causes of incontinence, and the majority had little knowledge of the range of factors which need to be considered to ensure that a systematic assessment of the problem is carried out. Despite considerable scope for the provision of rehabilitative care for incontinence sufferers, many nurses appeared to have a limited appreciation of their potential for initiating such care. Evidence collected from the nursing and medical records, the verbal hand-over reports and nurses' questionnaires, suggested that the management of patients with incontinence still focuses predominantly on measures which aim to contain the problem with little attention being given to rehabilitative interventions. A considerable proportion of the charge nurses, and the majority of the other qualified nursing staff, stated they had not received any continuing in-service education relevant to the promotion of continence or management of incontinence since their basic training. Nurses exhibited positive attitudes, overall, towards the management of incontinence but their responses indicated that a number of common misconceptions surrounding the problem persist. The enrolled nurses demonstrated significantly less positive attitudes towards the management of patients with incontinence than other grades of nurses. Similarly, the nursing staff who worked in the slow-stream rehabilitation care of the elderly wards showed significantly less positive attitudes towards incontinence than the nurses working in other types of wards. The implications of the findings of these studies for nursing practice, education and further research are discussed

Urinary incontinence in hospital in-patients: a nursing perspective

Urinary incontinence is a common health problem with not only physical, but also far-reaching psychological and social implications for the sufferer, her family and carers. Assisting patients with meeting their eliminatory needs is a fundamental part of nursing care. Incontinence is encountered in almost every sphere of clinical practice and is a problem with which nurses are often directly concerned. Nurses, in association with other members of the health care team, have considerable potential to help patients regain continence, or when this is not possible, to ensure that the individuals concerned, and their relatives or carers, can cope effectively with the problem, both physically and psychologically. This is an area of nursing care, however, which to date has attracted little research. The studies undertaken in this thesis sought to examine the nursing assessment and management of the care of patients with urinary incontinence in acute medical and care of the elderly wards. The research comprises of a sequence of studies which examined the problem from a number of perspectives. Methods of data collection included nurse and patient self-, reports, the examination of nursing and medical documentation, direct observation and self-completed questionnaires. Findings indicated that urinary incontinence was common in acute medical and care of the elderly wards, and that a considerable proportion of patients had indwelling catheters to manage the problem. Nurses were not always aware of patients' incontinence problems and their assessments concerning important aspects of the symptom were frequently unreliable. Further inadequacies in nurses' assessments, as well as in the management of the care of patients with incontinence, were identified from an examination of the nursing and medical records, and observations of verbal hand-over reports. Qualified nurses and learners appeared ill-informed about the causes of incontinence, and the majority had little knowledge of the range of factors which need to be considered to ensure that a systematic assessment of the problem is carried out. Despite considerable scope for the provision of rehabilitative care for incontinence sufferers, many nurses appeared to have a limited appreciation of their potential for initiating such care. Evidence collected from the nursing and medical records, the verbal hand-over reports and nurses' questionnaires, suggested that the management of patients with incontinence still focuses predominantly on measures which aim to contain the problem with little attention being given to rehabilitative interventions. A considerable proportion of the charge nurses, and the majority of the other qualified nursing staff, stated they had not received any continuing in-service education relevant to the promotion of continence or management of incontinence since their basic training. Nurses exhibited positive attitudes, overall, towards the management of incontinence but their responses indicated that a number of common misconceptions surrounding the problem persist. The enrolled nurses demonstrated significantly less positive attitudes towards the management of patients with incontinence than other grades of nurses. Similarly, the nursing staff who worked in the slow-stream rehabilitation care of the elderly wards showed significantly less positive attitudes towards incontinence than the nurses working in other types of wards. The implications of the findings of these studies for nursing practice, education and further research are discussed

Structure and agency attributes of residents’ use of dining space during mealtimes in care homes for older people

Research stresses that mealtimes in care homes for older people are vital social events in residents’ lives. Mealtimes have great importance for residents as they provide a sense of normality, reinforce individuals’ identities and orientate their routines. This ethnographic study aimed to understand residents’ use of dining spaces during mealtimes, specifically examining residents’ table assignment processes. Data were collected in summer 2015 in three care homes located in England. The research settings looked after residents aged 65+, each having a distinct profile: a nursing home, a residential home for older people and a residential home for those with advanced dementia. Analyses revealed a two-stage table assignment process: 1. Allocation – where staff exert control by determining residents’ seating. Allocation is inherently part of the care provided by the homes and reflects the structural element of living in an institution. This study identified three strategies for allocation adopted by the staff: (a) personal compatibilities; (b) according to gender and (c) ‘continual allocation’. 2. Appropriation – it consists of residents routinely and willingly occupying the same space in the dining room. Appropriation helps residents to create and maintain their daily routines and it is an expression of their agency. The findings demonstrate the mechanisms of residents’ table assignment and its importance for their routines, contributing towards a potentially more self-fulfilling life. These findings have implications for policy and care practices in residential and nursing homes

Randomised cluster trial to support informed parental decision-making for the MMR vaccine

Background In the UK public concern about the safety of the combined measles, mumps and rubella [MMR] vaccine continues to impact on MMR coverage. Whilst the sharp decline in uptake has begun to level out, first and second dose uptake rates remain short of that required for population immunity. Furthermore, international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children. Together, this work suggests that effective interventions are required to support parents to make informed decisions about MMR. This trial assessed the impact of a parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on informed parental decision-making for MMR. Methods This was a two arm, cluster randomised trial. One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations. The intervention arm received an MMR information leaflet and participated in the intervention (parent meeting). The control arm received the leaflet only. The primary outcome was decisional conflict. Secondary outcomes were actual and intended MMR choice, knowledge, attitude, concern and necessity beliefs about MMR and anxiety. Results Decisional conflict decreased for both arms to a level where an 'effective' MMR decision could be made one-week (effect estimate = -0.54, p < 0.001) and three-months (effect estimate = -0.60, p < 0.001) post-intervention. There was no significant difference between arms (effect estimate = 0.07, p = 0.215). Heightened decisional conflict was evident for parents making the MMR decision for their first child (effect estimate = -0.25, p = 0.003), who were concerned (effect estimate = 0.07, p < 0.001), had less positive attitudes (effect estimate = -0.20, p < 0.001) yet stronger intentions (effect estimate = 0.09, p = 0.006). Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73%, p = 0.04). Conclusions Whilst both the leaflet and the parent meeting reduced parents' decisional conflict, the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake

The importance of detecting and managing comorbidities in people with dementia?

Dementia is a debilitating condition characterised by global loss of cognitive and intellectual functioning, which gradually interferes with social and occupational performance. It is a common worldwide condition with a significant impact on society. There are currently 36 million people worldwide with Alzheimer's disease (AD) and other dementias [1]. This is expected to more than double by 2030 (65 million) and reach ∼115 million in 2050, unless a major breakthrough is made. The worldwide societal costs were estimated at USD 604 billion in 2010 and rising [2]. To date research on the specific physical healthcare needs of people with dementia has been neglected. Yet, physical comorbidities are reported as common in people with dementia [3] and have been shown to lead to increased disability and reduced quality of life for the affected person and their carer [4]. Dementia is most frequently associated with older people who often present with other medical conditions, known as co-morbidities. Such co-morbidities include diabetes, chronic obstructive pulmonary disorder, musculoskeletal disorders and chronic cardiac failure and are common, 61% of people with

A Pragmatic Randomized Controlled Trial of 6-Step vs 3-Step Hand Hygiene Technique in Acute Hospital Care in the United Kingdom.

OBJECTIVE To evaluate the microbiologic effectiveness of the World Health Organization's 6-step and the Centers for Disease Control and Prevention's 3-step hand hygiene techniques using alcohol-based handrub. DESIGN A parallel group randomized controlled trial. SETTING An acute care inner-city teaching hospital (Glasgow). PARTICIPANTS Doctors (n=42) and nurses (n=78) undertaking direct patient care. INTERVENTION Random 1:1 allocation of the 6-step (n=60) or the 3-step (n=60) technique. RESULTS The 6-step technique was microbiologically more effective at reducing the median log10 bacterial count. The 6-step technique reduced the count from 3.28 CFU/mL (95% CI, 3.11-3.38 CFU/mL) to 2.58 CFU/mL (2.08-2.93 CFU/mL), whereas the 3-step reduced it from 3.08 CFU/mL (2.977-3.27 CFU/mL) to 2.88 CFU/mL (-2.58 to 3.15 CFU/mL) (P=.02). However, the 6-step technique did not increase the total hand coverage area (98.8% vs 99.0%, P=.15) and required 15% (95% CI, 6%-24%) more time (42.50 seconds vs 35.0 seconds, P=.002). Total hand coverage was not related to the reduction in bacterial count. CONCLUSIONS Two techniques for hand hygiene using alcohol-based handrub are promoted in international guidance, the 6-step by the World Health Organization and 3-step by the Centers for Disease Control and Prevention. The study provides the first evidence in a randomized controlled trial that the 6-step technique is superior, thus these international guidance documents should consider this evidence, as should healthcare organizations using the 3-step technique in practice. Infect Control Hosp Epidemiol 2016;37:661-666

Systematic review investigating the reporting of comorbidities and medication in randomized controlled trials of people with dementia

Objectives: dementia is a debilitating condition characterised by global loss of cognitive and intellectual functioning, which reduces social and occupational performance. This population frequently presents with medical co-morbidities such as hypertension, cardiovascular disease and diabetes. The CONSORT statement outlines recommended guidance on reporting of participant characteristics in clinical trials. It is, however, unclear how much these are adhered to in trials assessing people with dementia. This paper assesses the reporting of medical co-morbidities and prescribed medications for people with dementia within randomised controlled trial (RCT) reports. Design: a systematic review of the published literature from the databases AMED, CINAHL, MEDLINE, EMBASE and the Cochrane Clinical Trial Registry from 1 January 1997 to 9 January 2014 was undertaken in order to identify RCTs detailing baseline medical co-morbidities and prescribed medications . Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) RCT appraisal tool, and descriptive statistical analyses were calculated to determine point prevalence. Results: nine trials, including 1474 people with dementia, were identified presenting medical co-morbidity data. These indicated neurological disorders ( prevalence 91%), vascular disorders (prevalence 91%), cardiac disorders ( prevalence 74%) and ischaemic cerebrovascular disease ( prevalence 53%) were most frequently seen. Conclusions: published RCTs poorly report medical co-morbidities and medications for people with dementia. Future trials should include the report of these items to allow interpretation of whether the results are generalisable to frailer older populations

Assessing fidelity to complex interventions: the icons experience

Background Assessing fidelity to complex healthcare interventions in clinical trials is a challenging area. ‘ICONS' is a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP), incorporating bladder training and prompted voiding, to promote post-stroke continence. Here we describe feasibility of one aspect of fidelity assessment: the day-to-day implementation of the SVP through analysis of clinical logs. Methods Nurses completed clinical logs daily, which included documenting: the toileting interval, proposed toileting times and times toileted. Clinical logs were sampled across trial sites. The original intention was to assess fidelity by exploring the degree of concordance between proposed times and times toileted. Initial analysis revealed the unfeasibility of this method due to documentation errors in toileting intervals and proposed times. Consequently, the planned method was changed to identification of key ‘quality indicators' (QIs) for documentation of practice. Results The need to revise the method of measurement demonstrates the difficulty in assessing fidelity. Assessment of clinical logs revealed low levels of adherence to key quality indicators. However, it is unclear whether this indicates poor fidelity or an imprecise method of fidelity assessment. Conclusion This study highlights challenges of assessing fidelity to complex interventions. Lessons learned will inform the measurement of fidelity in a future trial. Researchers should be aware that the practical implementation of complex healthcare interventions may not be exactly as intended. For ICONS, clinical logs constituted a proxy measure of day-to-day fidelity to the intervention: identification of alternative methods could be considered