Self-identified culturally related stressors that influence self-care in older adults with multiple chronic conditions: A qualitative study.

AIM: To identify culturally related stressors that influence self-care in Chinese older adults with multiple chronic conditions. BACKGROUND: Effective self-care can improve health outcomes for chronic conditions, but implementing self-care is challenging. Individuals with multiple chronic conditions face even more self-care complexity than those with single chronic conditions, generating additional stressors. Although stressors have been found to negatively influence self-care in multiple chronic conditions, the role of culture in generating stressors has been neglected. DESIGN: This paper reports on the qualitative component of a larger mixed-methods study. Two free-response items in a survey were used to identify culturally related stressors that influence self-care. This report adhered to the SRQR guideline checklist. METHODS: Data were collected between January and April 2022. One hundred and thirty-eight free text responses asking participants to identify stressors that influenced their self-care effectiveness were analysed sequentially using deductive content analysis and thematic analysis. RESULTS: Findings from deductive content analysis largely confirmed published work in Western literature on stressors complicating self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. CONCLUSION: Chinese older adults with multiple chronic conditions identified a wide range of stressors that impacted their day-to-day self-care. This study provided valuable insights into culturally related stressors in older adults with multiple chronic conditions. Findings deepened our knowledge of cultural influences on the success of self-care in older adults with multiple chronic conditions, suggesting the potential for reaching populations across different cultures and regions. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Stressors that might influence self-care ability are important for nurses to assess in people with multiple chronic conditions. The design of self-care interventions should take a culturally tailored intergenerational family-centred approach to help mitigate the impact of stressors and ultimately improve patient outcomes. IMPACT: What problem did the study address? Stressors documented in older adults with MCCs have all been generated from research with Western populations. China is now home to the largest population of older people in the world. Understanding the influence of culturally relevant stressors on self-care in Chinese older adults with MCCs is lacking. What were the main findings? Findings from deductive content analysis largely confirmed published work in Western literature on stressors that complicated self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors in older adults with MCCs in China: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. Where and on whom will the research have an impact? The research will have an impact on guiding nurses' assessment of culturally relevant stressors' impact on self-care for older adults with MCCs. In addition, findings could inform research and policy development to aim at mitigating the impact of culturally based stressors on self-care. REPORTING METHOD: This study adhered to the Standards for Reporting Qualitative Research (SRQR) guideline checklist. PATIENT OR PUBLIC CONTRIBUTION: During the member-checking process, the validation of findings for accuracy was carried out by 10 participants, who also found resonance between these findings and their own experiences.

Wisconsin's Lifecourse Initiative for Healthy Families: application of the maternal and child health life course perspective through a regional funding initiative.

National experts are calling for more integrated approaches such as the life course perspective to reduce health disparities and achieve greater health equity. The translation and application of the life course perspective is therefore of great interest to public health planners, policy makers and funders to promote community-wide improvements in maternal and child health. However, few organizations have applied the life course perspective in designing strategic funding initiatives. For over three decades, Wisconsin has observed persistent racial disparities in birth outcomes. This complex public health issue led to the development of the Lifecourse Initiative for Health Families, a regional multi-million dollar funding initiative created and supported by the Wisconsin Partnership Program of the University of Wisconsin School of Medicine and Public Health (Created by the UW SMPH from an endowment following the conversion of Blue Cross Blue Shield United of Wisconsin, the Partnership Program makes investments in research, education, and public health and prevention initiatives that improve health and reduce health disparities in the state.). Over a 2-year period, the program funded four collaboratives to adopt a life course perspective and develop strategic plans for improving African American birth outcomes. The Twelve-point plan to close the black-white gap in birth outcomes provided the framework for the planning process. Despite the conceptual challenges, the life course perspective was embraced by the collaboratives, challenged community assumptions on the root causes of poor birth outcomes and provided a unifying funding construct for organizing and planning complementary individual-level interventions with social and physical environmental change strategies. These integrated and complimentary approaches provide a long-term opportunity to address the persistent racial birth outcome disparity in Wisconsin.

Qualitative Analysis of Implementation Factors of an Embedded Caregiver Support Intervention into Adult Day Services.

Background: Adult day services (ADS) are an important and often underutilized support resource for older adults. For persons living with dementia (PLWD), ADS is an optimal access point to not only receive therapeutic and rehabilitative activities, but as a vehicle for respite/relief for dementia caregivers. Yet, there is currently a lack of research on integrating caregiver interventions into home and community-based services such as ADS. Objective: This paper reports on qualitative findings from the Improving Outcomes for Family Caregivers of Older Adults with Complex Conditions: The Adult Day Plus (ADS Plus) Program Trial. Methods: Drawing from semi-structured interviews conducted with family caregivers and ADS site staff, we conducted a thematic analysis to examine the implementation process of ADS Plus. Results: Themes address the relational nature of the intervention, learning, influence of the administrative infrastructure, and receptivity of ADS Plus. Conclusions: Our analysis determined that implementation of ADS Plus was feasible and accepted by site staff and dementia caregivers but also calls for additional evaluation of embedded caregiver support interventions across different contexts (e.g., staff size, limited technology environments) to further identify and test implementation mechanisms across settings.

Experiences of in-hospital care among dementia caregivers in the context of high neighborhood-level disadvantage.

BACKGROUND: Persons living with dementia (PLWD) experience high rates of hospitalization and rehospitalization, exposing them to added risk for adverse outcomes including delirium, hastened cognitive decline, and death. Hospitalizations can also increase family caregiver strain. Despite disparities in care quality surrounding hospitalizations for PLWD, and evidence suggesting that exposure to neighborhood-level disadvantage increases these inequities, experiences with hospitalization among PLWD and family caregivers exposed to greater levels of neighborhood disadvantage are poorly understood. This study examined family caregiver perspectives and experiences of hospitalizations among PLWD in the context of high neighborhood-level disadvantage. METHODS: We analyzed data from the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) study, an in-depth, multisite qualitative study examining hospitalization and rehospitalization of PLWD in the context of high neighborhood disadvantage, to identify caregiver perspectives and experiences of in-hospital care. Data were analyzed using rapid identification of themes; duplicate transcript review was used to enhance rigor. RESULTS: Data from N = 54 individuals (47 individual interviews, 2 focus groups with 7 individuals) were analyzed. Sixty-three percent of participants identified as Black/African American, 35% as non-Hispanic White, and 2% declined to report. Caregivers' experiences were largely characterized by PLWD receiving suboptimal care that caregivers viewed as influenced by system pressures and inadequate workforce competencies, leading to communication breakdowns and strain. Caregivers described poor collaboration between clinicians and caregivers with regard to in-hospital care delivery, including transitional care. Caregivers also highlighted the lack of person-focused care and the exclusion of the PLWD from care. CONCLUSIONS: Caregiver perspectives highlight opportunities for improving hospital care for PLWD in the context of neighborhood disadvantage and recognition of broader issues in care structure that limit their capacity to be actively involved in care. Further work should examine and develop strategies to improve caregiver integration during hospitalizations across diverse contexts.

Dementia Caregivers' Experiences Engaging Supportive Services While Residing in Under-Resourced Areas.

BACKGROUND: Family caregivers of people living with dementia benefit from supportive service use to address care needs associated with caregiving. Yet, research consistently demonstrates low rates of service use. Existing research has focused on barriers and facilitators to service use, with few studies examining the influence of caregivers' environmental context which often patterns social advantage and health services accessibility. OBJECTIVE: To describe the perspectives of caregivers residing in socially disadvantaged areas have in regards to utilizing supportive services. METHODS: Ten informal caregivers residing in socially disadvantaged areas participated in in-depth interviews that were analyzed using thematic analysis. RESULTS: Across all interviews, caregivers spontaneously described common precedents of service use (crisis or accumulation of unmet needs) and a distinct sequence of stages (seeking, initiating, and utilizing) surrounding service engagement. Major themes characterizing caregivers' experiences throughout service engagement highlight the varied influence of personal, familial, health, and social system-related factors. Findings demonstrate that caregivers may have different service needs as dementia progresses and that gerontological social work practice can facilitate service use. CONCLUSION: While preliminary, these findings provide important insights into new domains that can be further examined in future research and intervention efforts to improve supportive service use in socially disadvantaged and underserved communities.

A Case Study on A University-Community Partnership to Eliminate Racial Disparities in Infant Mortality: Effective Strategies and Lessons Learned.

This case study discusses the implementation framework, effective strategies, and lessons learned of a university-community partnership addressing racial disparities in infant mortality. The partnership was successful at enhancing coordination within service delivery systems for maternal and child health programs. Results: the elimination of waiting list for services, maximizing federal and state reimbursement, the adoption of culturally-appropriate intervention practices, increasing racial diversity in the workforce, diffusing silos, and facilitating healthier relationships among service providers. Key lessons: activating the collective strengths among a network of diverse community stakeholders with shared interests, prioritizing black voices in the change process, and capacity building opportunities.

Loss of angiotensin II receptor expression in dopamine neurons in Parkinson's disease correlates with pathological progression and is accompanied by increases in Nox4- and 8-OH guanosine-related nucleic acid oxidation and caspase-3 activation.

BACKGROUND: In rodent models of Parkinson's disease (PD), dopamine neuron loss is accompanied by increased expression of angiotensin II (AngII), its type 1 receptor (AT1), and NADPH oxidase (Nox) in the nigral dopamine neurons and microglia. AT1 blockers (ARBs) stymie such oxidative damage and neuron loss. Whether changes in the AngII/AT1/Nox4 axis contribute to Parkinson neuropathogenesis is unknown. Here, we studied the distribution of AT1 and Nox4 in dopamine neurons in two nigral subregions: the less affected calbindin-rich matrix and the first-affected calbindin-poor nigrosome 1 of three patients, who were clinically asymptomatic, but had nigral dopamine cell loss and Braak stages consistent with a neuropathological diagnosis of PD (prePD). For comparison, five clinically- and neuropathologically-confirmed PD patients and seven age-matched control patients (AMC) were examined. RESULTS: AT1 and Nox4 immunoreactivity was noted in dopamine neurons in both the matrix and the nigrosome 1. The total cellular levels of AT1 in surviving dopamine neurons in the matrix and nigrosome 1 declined from AMC>prePD>PD, suggesting that an AngII/AT1/Nox4 axis orders neurodegenerative progression. In this vein, the loss of dopamine neurons was paralleled by a decline in total AT1 per surviving dopamine neuron. Similarly, AT1 in the nuclei of surviving neurons in the nigral matrix declined with disease progression, i.e., AMC>prePD>PD. In contrast, in nigrosome 1, the expression of nuclear AT1 was unaffected and similar in all groups. The ratio of nuclear AT1 to total AT1 (nuclear + cytoplasmic + membrane) in dopamine neurons increased stepwise from AMC to prePD to PD. The proportional increase in nuclear AT1 in dopamine neurons in nigrosome 1 of prePD and PD patients was accompanied by elevated nuclear expression of Nox4, oxidative damage to DNA, and caspase-3-mediated cell loss. CONCLUSIONS: Our observations are consistent with the idea that AngII/AT1/Nox4 axis-mediated oxidative stress gives rise to the dopamine neuron dysfunction and loss characteristic of the neuropathological and clinical manifestations of PD and suggest that the chance for a neuron to survive increases in association with lower total as well as nuclear AT1 expression. Our results support the need for further evaluation of ARBs as disease-modifying agents in PD.

Shoulder disorders related to work organization and other occupational factors among supermarket cashiers.

The study was designed to examine, in 210 supermarket cashiers, the cross-sectional relationships between shoulder disorders according to location and chronicity of pain as well as personal and occupational factors and store and workstation characteristics. The factors associated with shoulder disorders differed for the right and left sides. Age and psychological disorders were significant risk factors. Among occupational factors, duration of employment, job control, wage dependence on efficiency, exposure to cold, movements and postures such as stooping, working with arms above shoulder level and holding heavy loads in position, and using a laser scanner were associated with shoulder disorders, especially on the left. These results confirm the multifactorial origin of shoulder disorders, and show the importance of psychosocial work factors, movements and postures, and the laser scanner as occupational risk factors, and the need to consider right and left shoulder disorders in cashiers separately.

Dorsal locking of the metacarpophalangeal joint.

Many causes for metacarpophalangeal joint locking have been documented. However nearly all are from volar entrapment of periarticular structures. The following case, unlike those previously reported in the literature, was one with locking caused by dorsal entrapment. The differences in presentation and its importance to subsequent treatment are highlighted.

Comparison of 1% lignocaine with 0.5% bupivacaine in digital ring blocks.

In a randomised double-blind trial comparing 1% lignocaine with 0.5% bupivacaine in digital ring block, the mean time of onset of complete anaesthesia was 5.8 minutes (range 5 to 10 minutes) for lignocaine and 11.2 minutes (range 8 to 20 minutes) for bupivacaine. The duration of action was 59.6 minutes (S.D. +/- 28.7 minutes) for lignocaine and 476 minutes (S.D. +/- 277 minutes) for bupivacaine. We describe how these differences can be exploited in clinical practice.

Digital prostheses for single finger amputations.

After amputation digital prostheses are infrequently used. With modern methods of fabrication both cosmetic and functional use are now possible. We have assessed the use of single digit prostheses in a district general hospital setting.

Clenched fist human bite injuries.

A prospective study has been made of 29 human bite injuries caused by the clenched fist, 27 over M.P. joints and two over P.I.P. joints. All were treated by surgical exploration, within 24 hours in 84% of cases. In 62% the wound had entered the underlying joint and in 58% the bone was injured. Significantly less morbidity was noted in those cases where there was no joint injury (P less than 0.001). Early surgical exploration to identify and to treat the joint injury is recommended.

Dorsal fracture subluxation of the proximal interphalangeal joints treated by extension block splintage.

In a prospective study, 27 consecutive patients with dorsal fracture subluxation of the PIP joint were treated conservatively using an extension block splint, with good results in 70%. The percentage surface involved with the fracture varied considerably (19-77%) the average being 55%. Three patients initially managed with splintage proceeded to surgery because the splint failed to hold the joint in reduction. These patients had a less favourable outcome. We feel that all such fractures can be treated by splintage, provided that early reduction is maintained in the splint and checked by serial radiology.

Dorsal fracture subluxation of the distal interphalangeal joint of the finger and the interphalangeal joint of the thumb treated by extension block splintage.

In a prospective study six patients with dorsal fracture subluxation of the IP joint of the thumb or the DIP joint of the finger were treated conservatively using an extension block splint. The fracture size varied from 22% to 47% of the articular surface of the volar base of the terminal phalanx. Good or excellent results were reported in all cases except for one, which was fair. Only one case in the study complained of any pain, and this was minimal. Conservative treatment using extension block splintage for this injury is as good as a surgical approach.

Transcutaneous electrical nerve stimulation in acute hand infections.

Twenty-six patients with severe hand infections requiring operative drainage and admission to hospital were entered into a prospective, randomised, placebo-controlled trial. This was to test the use of a functioning transcutaneous electrical nerve stimulator and a non-functioning transcutaneous electrical nerve stimulator for pain relief in the first three postoperative days. Those patients with a functioning transcutaneous electrical nerve stimulator required significantly less analgesia. They also demonstrated highly significant improvement in their range of total active movement over those patients with a non-functioning transcutaneous electrical nerve stimulator. We recommend the use of transcutaneous electrical nerve stimulator after operation to reduce pain and improve mobility.

Early mobilisation of acute middle slip injuries.

After operative repair, the conventional management of open injuries to the middle slip of the extensor tendon involves prolonged immobilisation of the P.I.P. joint. We report our results using controlled mobilisation with a Capener splint after two weeks rigid splintage. In a series of 99 patients seen soon after injury, 88% had excellent or good results after six months. Poor results were more common in patients with complex joint injuries and in patients who did not comply with the treatment. We advocate early mobilisation following repair of the middle slip.

The conservative management of volar avulsion fractures of the P.I.P. joint.

A retrospective study was made of 74 volar avulsion fractures of the P.I.P. joint in which there was no radiological evidence of subluxation. Overall, 96% of those reviewed achieved good results but morbidity was increased by immobilisation. Providing the joint is stable, simple neighbour strapping is recommended for these injuries.

Ulnar collateral ligament repair of the metacarpo-phalangeal joint of the thumb: a study comparing two methods of repair.

25 patients were assessed following repair of an acutely ruptured ulnar collateral ligament of the thumb metacarpo-phalangeal joint. The patients were divided into two groups, repaired by either a horizontal mattress suture using 4/0 polybutylate (nine patients), or a pre-fashioned steel wire (16 patients). Assessment included a physical examination and functional testing at a mean of 12.9 months (range 4-36 months) after the operation. Both techniques were equally effective, and the use of the more expensive steel wire, while technically satisfying and easy to perform, offers no clinical advantage over simple suture. This pre-fashioned steel wire is, however, recommended in those cases with an avulsion fracture or where distal avulsion of the ligament is associated, since the technique allows easy secure reduction.

A controlled trial of pentoxifylline (Trental 400) in intermittent claudication: clinical, haemostatic and rheological effects.

A formulation of pentoxifylline (Trental 400) has been claimed to increase claudication distance by improving red cell deformability and decreasing blood viscosity and platelet aggregation. In order to test this claim 30 stable claudicants recruited from one population took part in a double-blind randomised trial of placebo versus pentoxifylline. Both placebo and pentoxifylline treated patients improved subjectively and increased their claudication distance over the study period. Analysis of the blood results showed that the only apparent change was a tendency towards increased red cell filtration in the group treated with pentoxifylline; but no significant difference was found between claudicants and normal controls in the degree of red cell filterability nor did red cell filterability correlate with claudication distance. Pentoxifylline did not affect claudication distance or have any useful effect on blood flow properties, calling into question both its efficacy and suggested mode of action.