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Australia has a large and expanding population of people from a refugee background – referred to as ‘refugees’. Refugees in general, and refugee women in particular, have distinctive and diverse health needs which require complex and conscientious responses from nurses and health systems. In the context of nursing refugee women in Australia, this paper will explore the need for cultural safety in nursing. It will then analyse the negative impacts of culturally unsafe nursing practices and health systems in Australia on refugees and refugee women. Finally, it will discuss how culturally safe nursing practice can (and should) be achieved in Australia to improve the health outcomes of refugee women and others of diverse backgrounds.

The Nursing Council of New Zealand (2002: p. 7), which developed the concept of cultural safety, defines it as “the effective nursing … [care] of a person or family from another culture, [as] determined by that person or family”. Fundamentally, culturally safe nursing practice focuses on supporting diverse people to effectively access and engage with mainstream ‘biomedical’ health systems, and so reducing the high rates of poor physical and psychological mental health outcomes in these populations (Johnstone & Kanitsaki, 2007). Culturally safe nursing practice achieves this by attempting to deconstruct the inequitable power relationships between patients and health providers and systems, which are a significant barrier to health access and engagement for socio-culturally vulnerably groups (Anderson et al., 2003; Woods, 2010). This is achieved through a focus on culture. However, culturally safe practice does not involve nurses learning others’ cultures; indeed, diversity both between and among cultures is too significant to allow a nurse to do this meaningfully (Woods, 2010). Instead, culturally safe nursing involves a nurse reflecting on their own culture and on the legitimacy of others’ cultures in the context of the nursing care they provide (Mortensen, 2010). Belfrage (2007) notes that ‘cultural safety’ underpins the provision of the most effective health practice and systems for diverse groups in Australia. This is particularly true in the context of refugee health.

The United Nations’ 1951 Refugee Convention, Article 1(A)2, defines a refugee as any person residing outside their country of nationality or residence due to fear of persecution (UNHCR, 2015). As a signatory to this Convention Australia has an obligation to assist with the resettlement of refugees, including a special category of refugees referred to ‘women at risk’ (Australian Law Reform Commission, 2015; Parliament of Australia, 2015b). In 2013-14, Australia resettled a total of 6500 refugees, approximately 3.2% of its total migrant intake (Parliament of Australia, 2015b). The majority of these refugees were from Afghanistan (39%), with significant numbers also from Myanmar (18%) and Iraq (13%) (Parliament of Australia, 2015b). In response to the Syrian refugee crisis, in 2015-16 Australia will significantly increase its intake of refugees within existing humanitarian quotas (Parliament of Australia, 2015a). Under the Migration Regulation 1994 Australia allocates 12% of its humanitarian quota to ‘women at risk’, and in 2013-14 granted over 1000 visas to women at risk (Parliament of Australia, 2015b). This program highlights the fact that refugee women are particularly vulnerable to the effects of conflict and persecution (Federal Minister for Women, 2014).

Refugees in general, and refugee women in particular, have “unique and diverse health profiles” (Hadgkiss & Renzaho, 2014: p. 157). Though refugees make up a very small part of the overall Australian population, it is essential that nurses are aware of refugees’ health needs and their complex sociocultural determinants if culturally safe health care is to be provided. In a seminal work on refugee health in Australia (examining the health of refugee children specifically), Davidson et al. (2004) report that a significant number of refugees arrive in Australia with complex health needs. The psychological issues experienced by refugees are well-recognised. Exposure to trauma leaves many refugees – up to 60% in one Australian study – with complex psychological sequelae, including impairments to memory function and debilitating dissociative reactions (Alvin Tay et al., 2013). Nickerson et al. (2014) reports that up to 25% of refugees receive a psychological diagnosis of Post-Traumatic Stress Disorder (PTSD), and 16% of these people also have disorders related to grief. Costa (2007) highlights that refugee women in particular face an increased risk of psychological morbidity related to trauma underpinned by conflict, persecution and forced resettlement. For example, one study found that the gender discrimination experienced by a large number of refugee women is positively correlated with increased incidence of traumatic disorders (including PTSD) and increased risk of suicidality (Kira et al., 2010). It is important to note that issues related to gender, including roles and access, may also limit a refugee woman’s health-seeking behaviours related to mental illness (O’Mahony & Donnelly, 2013).

In addition to mental illness, a large number of refugees – up to 77% in some reports – also experience physical illness; indeed, Hadgkiss and Renzaho (2014) note that poor mental health is strongly correlated with poor physical health in refugee populations. Physical illnesses which are particularly prevalent in refugee populations include dental disease, non-specific migraine, musculoskeletal pain and disorders of the integumentary, respiratory and gastrointestinal systems (Hadgkiss & Renzaho, 2014). There is also a high prevalence of infectious disease in refugee populations, including human immunodeficiency virus (HIV), active tuberculosis, Hepatitis B and C and chronic gastrointestinal infections (Hadgkiss & Renzaho, 2014). Costa (2007) notes that refugee women are disproportionately affected by nutritional deficiencies and anaemia, and a sequelae of physical and psychological issues related to gender-based violence. Refugee women experience higher rates of complex gynaecological and obstetric conditions, are more likely to have been sexually assaulted and are more likely to have had an unwanted pregnancy and / or abortion than other women in host countries (Goosen et al., 2009; Kurth et al., 2010).

The myriad of complex health issues faced by refugees highlights the importance of host countries’ health systems being responsive to refugees’ health needs through the provision of culturally safe care and services. However, there is evidence to suggest this is not being achieved in the Australian context; indeed, Johnstone and Kanitsaki (2007) conclude that cultural safety is both poorly understood and lacks currency in Australia’s mainstream health contexts (Johnstone & Kanitsaki, 2007). This leads to culturally unsafe nursing practices. The Nursing Council of New Zealand (2002: p. 7) define this as “compris[ing] any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual”, either overtly and intentionally or otherwise.

There are many examples of culturally unsafe practice relating to refugees in the Australian context. For example, many refugees, both in Australia and elsewhere, perceive themselves to be discriminated against by health staff in their host countries – a key aspect of culturally unsafe practice. Multiple studies report on such issues – including refugees’ perceptions of denial or provision of poorer-quality care on the basis of race and / or immigration status (Bhatia & Wallace, 2007; O’Donnell et al., 2007; O’Donnell et al., 2008; Wahoush, 2009; Bernardes et al., 2010; Kokanovich & Stone, 2010; Asgary & Segar, 2011). This is particularly problematic in terms of the provision of mental health services for refugees in Australia; indeed, Newman et al. (2008) highlight that Australian health workers frequently devalue and deligitimise refugees’ experiences of mental illness – for example, by dismissing the self-harm behaviours of refugees in immigration detention as being politically-motivated. Hadgkiss and Renzaho (2014) report a high level of ‘medical mistrust’ among refugee populations, underpinned by issues such as a fear of financial exploitation and that health information will be used to inform decisions about asylum status (Kokanovic & Stone, 2010; Asgary & Segar, 2011). Covert institutional racism is recognised to be a significant problem in Australian health settings, and this is underpinned by the prejudicial and discriminative attitudes towards refugees which are pervasive in wider Australian society (Henry et al., 2004; Davidson et al., 2008; Johnstone & Kanitsaki, 2008). This ‘systemic trauma’ compounds the health issues of refugees settled in Australia, and is a particular problem for women. Indeed, one Australian study found that women with vulnerabilities related to social adversity were substantially more likely to experience inequalities in health access (in this study, in the context of perinatal care specifically) (Yelland et al., 2012).

In addition to culturally unsafe nursing practices, the provision of culturally unsafe health services is a particular problem for refugees in Australia. As noted by Renzaho et al. (2013) the health systems in host countries are often poorly-equipped to manage the complex health, linguistic and cultural needs of refugee populations (Renzaho et al., 2013). It is well-recognised that Australia’s mainstream biomedical health system is highly Eurocentric, disempowering because of its exclusivity and repressive of the fundamental social dimensions of health (Willis & Elmer, 2007). Additionally, the biomedical model of health may be incompatible with refugees’ diverse perceptions of health, focusing instead on a limited ‘pathological’ definition of disease and a reductionist distinction between physical and mental health (Willis & Elmer 2007). Again, this is particularly problematic in terms of the provision of refugee mental health services; for example, Savy & Sawyer (2008) present evidence for the considerably limited culturally safe treatment options in Australia for refugees suffering acute mental illness. These issues may result in refugees’ exclusion from or disengagement with health services (Correa-Velez et al., 2013). Indeed, there is evidence to suggest that refugees’ engagement with health services is poor; in a European study, Bischoff et al. (2009) found that refugees attend far fewer than the average number of consultations, and that their cost to the health system of their host country was just half that of others in host countries. There is minimal current data available on the engagement of refugee women specifically with health services; however, one study suggests that refugee women are 40% less likely than other women in host countries to attend health screening (in this case for Papanicolaou testing, a common screen for cervical cancer) (Rogstad & Dale, 2004). Refugees’ exclusion from and disengagement with health services feeds into the cycle of poor physical and mental health outcomes in this population.

Woods (2010) notes that nurses have a critical role to play in deconstructing the power imbalances which exist between patients and health providers, and which often result in the provision of culturally unsafe care – thereby promoting refugees’ access to and engagement with health services in a culturally safe way. The Nursing Council of New Zealand (2002: p. 7) highlights that culturally safe nursing practice is underpinned by nurses “hav[ing] undertaken a process of reflection on [their] cultural identity and … recognis[ing] the impact that [their] personal culture has on [their] professional practice”. Here, the notion of ‘culture’ extends beyond the traditional definition of the term as a system of worldviews, value systems and lifestyles based on shared race or ethnicity, and instead ‘culture’ is considered as a complex, changing concept underpinned by factors such as individual experiences, gender and social position, etc. (Woods, 2010). It is important to note that achieving culturally safe nursing is an ongoing process of continuous reflection (Ogunsiji et al. 2007). Given the covert but pervasive negative views of refugees in Australian health systems and wider society (Henry et al., 2004; Davidson et al., 2008; Johnstone & Kanitsaki, 2008), reflecting on one’s own culture in this way is a particularly important aspect of providing culturally safe health care to refugees.

In addition to reflecting on their own culture, a nurse must also reflect on the cultures of others – but should do so in the context of cultural relativism. Cultural relativism is a sociological theory which posits that all cultures are, and therefore must be recognised as, equally valid and legitimate forms of human expression (Kottak, 2004). Cultural relativism is particularly important when caring for refugees, including refugee women, who engage in unfamiliar and challenging health practices, one example of which is ritualised genital cutting (also referred to as ‘female genital mutilation’). Many refugee women from parts of Africa and the Middle East perceive genital cutting to be an important cultural practice and fundamental to their identity, role and beliefs, however the mainstream biomedical health system in Australia denounces and reproves the practice (Ogunsiji et al. 2007). If such issues are not dealt with sensitively and approaches – from both nurses and the health system – balanced through the application of principles of cultural relativism, refugee women may disengage from health services (Ogunsiji et al. 2007). As noted, disengagement drives the cycle of poor physical and mental health outcomes for refugees in Australia.

Australia has a large refugee population which is predicted to increase significantly in the coming years. Refugees in general, and refugee women in particular, have distinctive and diverse health needs which require complex and conscientious responses from nurses and health systems. In the context of nursing refugee women in Australia, this paper has explored the need for cultural safety in nursing. It has also analysed the negative impacts of culturally unsafe nursing practices and health systems in Australia on refugees, with a focus on refugee women. Finally, it was discussed how culturally safe nursing practice can (and should) be achieved in Australia to improve the health outcomes of refugee women and others of diverse backgrounds.

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This work was produced by one of our professional writers as a learning aid to help you with your studies

The National Health Service is the universal medical care provider for residents of the UK. The principles it was originally developed upon ensured the service was provided free to meet everyone’s clinical need (NHS, 2013). This ethos is still at the core of its delivery, but additional principles have been added to its constitution to improve quality standards and to provide the public with rights as an NHS patient (Department of Health, 2012). Thus, for health professionals and the wider NHS workforce to achieve these principles, the patient needs to be central to the delivery of their healthcare. Therefore, the focus of this essay will be to explore the relationship between a positive NHS culture and increased quality of patient care. In this essay the phrase ‘positive NHS culture’ has two definitions: 1) its internal organisational structure and the working environments of staff 2) the public and patients’ perception and experiences of the NHS as service users. Due to the limited word count of this essay, the following factors will only be discussed: multi-disciplinary working, patient engagement and the role of the media.

Within an organisation, a positive work culture is the key to successful delivery to its customers, clients, service users or patients. An inclusive workplace is constantly promoted by governing bodies, trade unions and human resource professionals because it allows for greater happiness to be achieved at work through the creation of a positive working environment (Equality and Human Rights Commission, 2010). This is because when professionals are respected and their skills are valued, they feel a sense of autonomy and purpose (West et al, 2011). Furthermore, this supportive environment can create trusting relationships amongst colleagues, which can result in a positive internal work culture. Oppositely, within an organisation where there is a lack of respect and trust, the service of the quality being delivered can become compromised. For example, cases have been identified where clinicians did not trust the medical judgments of fellow clinicians and this resulted in clinical assessments being repeated on patients (NHS Institute for Innovation and Improvement, 2010). This mistrust can result in creating more worry for the patient, a negative relationship between clinicians, an increased waiting time for the result of the assessment and possibly delaying NHS services to another patient and wasting NHS money.

It can be argued that this critical approach by one clinician can ensure the diagnosis of a patient is correct; however as the UK has a high standard in its medical education progammes, the knowledge of another clinician should be respected. Also, there are other processes to ensure the diagnosis and treatment/care of the patient is suitable and of a high quality through regular discussions with allied health professionals who have been trained in a varied way to meet specific service areas. This allows alternative methods and treatments to be discussed and leads to better quality decisions on patient care (Borrill et al, 2002).

Multi-disciplinary working is essential for a large organisation like the NHS, who aim to provide healthcare for everyone regardless of what health and well-being support or treatment is needed by the patient (NHS Institute for Innovation and Improvement, 2010). It allows professionals to efficiently manage their times and reduce patient waiting times, and more importantly it ensures the patient is receiving care from the relevant expert. Multi-disciplinary working could in the future challenge the entrenched feature of ‘waiting times’ in the NHS healthcare system. It is often accepted by NHS professionals that it is normal for a patient to wait to be seen: this indirectly disrespects the status and clinical need of the patient, suggesting that their time is less valuable than the healthcare professional’s time (Leape et al, 2012).

Over time, a blame culture has developed within the NHS when poor quality of care has been delivered, or more extremely when a number of fatal cases have been reported within one trust. Multi-disciplinary working is used to promote a team effort in high quality care and it is also used to challenge and prevent poor quality care (Berwick and Department of Health, 2013). To ensure poor standards are not accepted, patient partnerships need to be created to allow patients to participate in planning future NHS care improvements. Furthermore, if healthcare professionals communicate with patients in a method which allows them to understand jargon and medical information related to their health condition, this can then empower them to make suitable decisions in regards to their healthcare (Leape et al, 2012). Furthermore, the patient may become confident enough to comment on their healthcare and also feel respected and comfortable in the medical environment which they are being treated within, hence positively influencing their perception of the NHS.

To further support the comfort patients’ feel when using the NHS services, practitioners need to have a level of emotional intelligence as well as the intellectual ability to provide high quality care. This is because ‘good health’ is a combination of mental, physical and social well-being (WHO, 1946). Intellectual ability is usually identified and revisited often in a practitioner’s healthcare training because it is thoroughly assessed. However, emotional intelligence differs within training depending on the role of the practitioner. Also, trainers of technical skills would argue it is not easy to teach emotional intelligence because it is often connected to an individual’s personality/character and the events they have experienced throughout their own personal life (Tapia and Hyter, 2015). Nursing staff initially deal with difficult patient situations where emotional intelligence is essential to solve or ease the patient’s situation. Therefore, showing care and compassion towards the patient often shows the patient they are being supported, hence improving the patient’s satisfaction towards the support offered by the nurse (Ruddick, 2015).

Media are used globally to reach a mass audience. Therefore, the NHS uses the mass media to reach a national audience for their health campaigns. Cutting down the number of smokers in the country is still a high priority to improve public health (NICE, 2015). The NHS using media campaigns for smoking cessation services, and the advice these provide has resulted in an overall positive effect for the incentive, due to the campaign reaching a mass audience (NHS Institute for Innovation and Improvement, 2013). This has been due to the development of diverse and creative advertisements being produced and made available freely to healthcare professionals, organisations and the public (NHS, 2015). These advertisements are not for online or television use only: they are often displayed or given in physical environments where patients and practitioners are present, hence making the delivery of patient care more interesting and more effective in tackling negative habits such as smoking. The extent of influence that the media has on its audience, and their thoughts and beliefs on specific topics, depend on a variety of factors; hence one single theory cannot sum up the impact of media.

Using the media to acknowledge successful NHS services is important because often the media report investigations or organisational changes. For example, the BBC reported that over 40% of NHS investigations are not carried out adequately (BBC, 2015). This suggests that the culture of the NHS is one that fails to handle a large number of patient complaints appropriately; the complaint of a patient often suggests that there was a negative event when receiving healthcare within the NHS such as medical negligence. Therefore, failing to acknowledge this can further deteriorate the perception of the NHS to the patient. Furthermore, due to the NHS being a healthcare provider it is expected by society to have a high standard service, yet the demands on the staff to provide this service is often forgotten (Griffin, 2014).

The NHS Practitioner Health Programme Team received the ‘Innovation in Mental Health in Primary Care’ award in 2014; this recognition of high quality practice was reported by various forms of media (NHS, 2014). The public were shown that these practitioners were successful and passionate individuals who were working to improve the Mental Health service within the NHS. Despite this not having a direct impact on the quality of patient care, it positively promoted the NHS and it also recognised that the mental health service in primary care was being recognised as innovative. Healthcare professionals can further promote the NHS culture as positive by using social media to engage with a larger public audience and also to connect with other healthcare professionals by increasing their participation in discussions on healthcare knowledge and alternative techniques (Cooper and Craig, 2013). This engagement can promote self-help techniques to patients and support them to manage their conditions. Self-help and self-care of conditions can reduce hospital admissions, hence directly impacting the number of patients waiting in Accident and Emergency departments, which can then allow clinicians to have more time with patients (The King’s Fund, 2010).

To summarise, patient experience is central to the quality of patient care. It seems a positive NHS culture is at the core of positive patient experience because it supports the development of relationships between the patient and the healthcare professional: this then can allow the patient to express their thoughts on the healthcare being delivered to them. In addition to this, trusting and respectful relationships can be created between professionals, who can then apply successful multi-disciplinary working to make the quality of care sufficient to meet service demands yet of a high personalised standard for each patient. Sadly, there are constraints in creating a highly positive NHS culture due to the demands put on the NHS service, diverse training of staff and the influence of the media.

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Since the pioneering experiments of allograft heart transplantation by Christiaan Barnard in 1967, there have been significant advances in the development of human organ transplantation. Indeed, over 35,000 patients in both the US and Europe benefit annually from organ transplantation (Hampton, 2005). Through the transplantation and engraftment of these organs, not only can biological function of organs be restored, but also the quality of life of recipients can be greatly increased. As a result the number of transplantation operations carried out each year has increase exponentially over the past decades. Despite improvements in surgical techniques, the hurdle of immunological rejection by the host of transplanted organs still remains a current obstacle. This represents a challenge both scientifically and clinically and, as a result, is a focus of both the medical and scientific communities.

Over the past 60 years, there has been an exponential increase in the development of immunosuppressive drugs in order to treat organ rejection, as well as autoimmune diseases (Gummert et al. 1999). These drugs seek to suppress various components of the immune system in order to prevent rejection in the context of organ transplantation. This essay seeks to examine the broad immunology of transplantation as well as the different classes of immunosuppressive drugs and their associated benefits and side effects.

Transplantation is broadly defined as the act of transferring cells, tissues, or organs from one site to another. In the context of organ transplantation, this is generally from one person to another, with transplantation classed as either from a living donor or cadaveric. Although less common, there has been some attempt to transplant organs from other animals, known as xenografts. This was initially attempted given the lack of availability of human donor organs. However, as transplantation occurs between two immunologically distinct persons, a degree of immunological mismatch occurs. Due to this mismatch, the host immune system recognises the donor organ as ‘foreign’ and, as a result, activates various arms of the immune system.

Several types of immune rejection can occur in individuals undergoing organ transplantation. Hyperacute rejection occurs when pre-existing antibodies within the host against donor antigens attack the graft and result in rapid rejection of the graft, typically within a few hours (Murphy et al. 2010). This results in rapid declining function of the graft and is often non-reversible, thereby causing the recipient to lose the graft. In contrast, acute rejection occurs within six months following transplantation and is the result of activated T cells against donor antigens (Murphy et al. 2010). The third type of rejection is known as chronic rejection and, as the name suggests, occurs years after transplantation and is mediated by both antibodies and T cells. In order to encourage graft survival, and prevent the aforementioned from occurring, effective regimes in order to suppress these immune responses have been developed, although as outlined, they often come with significant side effects.

Glucocorticoids, such as prednisone, are commonly used in immunosuppressive regimes. These drugs seek to prevent rejection by suppressing various arms of the immune system including T cells, B cells, macrophages, granulocytes and monocytes (Steiner and Awdishu, 2011). These drugs are, therefore considered to be relatively non-specific and highly potent leading to a range of side effects. Glucocorticoids exert their effects by regulating the activity and expression of various cytokines through inhibition of intracellular signalling pathways such as NF-kB. Through modulation of this complex signalling pathway, the production of pro-inflammatory cytokines such as IL-1, IL-6 and TNF-alpha are greatly reduced (Schacke et al. 2002). Although these drugs feature heavily in clinical practice, they are associated with a significant number of side effects. Prolonged glucocorticoid use can lead to Cushing’s syndrome: a constellation of symptoms characterised by increased central adiposity, ‘buffalo hump’, osteoporosis and a round face (Schacke et al. 2002). These symptoms are due to excess exogenous cortisol within the body and therefore have multiple endocrinological effects on various physiological processes. The concentration of such drugs are therefore closely monitored and patients are encouraged to monitor for symptoms suggestive of Cushing’s syndrome.

As well as glucocorticoids, drugs known as antimetabolites are frequently used in immunosuppressive regimes. These drugs, such as azathioprine and mercaptopurine, amongst others, were originally developed in the 1950s, but remain used to this day. Azathioprine is commonly used for liver and kidney transplantation (Germani et al. 2009), as well as for the treatment of autoimmune conditions such as rheumatoid arthritis (Whisnant and Pelkey, 1982). Antimetabolites exert their immunosuppressive effects by blocking the synthesis of purine within cells (Murphy et al. 2010). Through the blockage of purine synthesis, DNA replication is unable to take place, thereby preventing expansion of rapidly dividing cells within the immune system. Through the blockade of T and B cell expansion, the level of rejection against organ transplants can be controlled.

One considerable side effect associated with the use of azathioprine is the increased risk of skin cancer. A relatively recent review by Ulrich and Stockfleth (2006) has shown that sunlight exposure, pre and post transplantation in patients using azathioprine, correlates with an increased incidence of skin cancer. As exposure to UVA light damages skin cells: these cells are unable to undergo repair following damage, due to inhibition of DNA replication from azathioprine. In the long term, this accumulation of damage results in the increased propensity for patients to develop skin cancer. Current clinical guidelines suggest that clinicians discourage patients in spending prolonged periods of time in the sun following transplantation (Perrett et al. 2008).

Along with these classes, of drugs, another category of immunosuppressive medications, known as calcineurin inhibitors, also work efficaciously in organ transplantation. These drugs, which include tacrolimus and cyclosporine, act by inhibiting the protein calcineurin. Calcineurin in activated following the presentation of an antigen by an antigen presenting cell, such as a dendritic cell or macrophage, to a T cell, resulting from an increase in the concentration of intracellular calcium (Reynolds and Al-Daraji, 2002). Following the activation of calcineurin, there is an increase in the production of interleukin 2 (IL-2), which causes the activation of T cells. As a result, this further propagates an immune response. Calcineurin inhibitors are, therefore, useful in dampening an immune response, preventing the activation of T cells against a transplanted organ. Calcineurin inhibitors are popular drugs used in renal transplantation. However, evidence over the past decade has suggested that drugs such as tacrolimus may induce renal failure in some patients (Ponticelli, 2000). Obviously this a key consideration when considering patients who already have poor renal function to being with. As a result, these drugs are often combined with other immunosuppressive agents and tailored to the lowest dosage possible.

The understanding into the way in which the immune system functions has been exploited over the past thirty years with the development of monoclonal antibodies. Monoclonal antibodies were first developed in the 1970s through the fusion of rapidly proliferative myeloma cells with B cells to produce hybridomas (Liu, 2014). Antibodies are protein molecules that have a specific antigen-binding region enabling them to have a high degree of specificity. Antibodies have, therefore, been exploited therapeutically in order to target pathogenic molecules within the body.

Recently, monoclonal antibodies have been developed to target various components of the immune responses in order to modulate organ rejection seen in patients. In particular, monoclonal antibodies have been developed to target T and B cells. Some examples of these therapeutics are discussed below.

Muromonab is a monoclonal antibody, which is specific for cluster of differentiation 3 (CD3), a molecule found primarily on T cells (Murphy et al. 2010). By targeting T cells and preventing their activation against the transplanted organ, there is considerable evidence to show that this can significantly prolong the survival of the organ following transplantation, compared to glucocorticoid steroids (Authors not listed, 1985). However, despite the success of anti-CD3 therapy, there are substantial side effects associated with clinical use. Use of anti-CD3 has been associated with severe fever in patients, as well as the unwanted release of pro-inflammatory cytokines (Norman et al. 2000). As a result the use of anti-CD3 has declined in clinical practice and is reserved for treatment resistant cases of organ rejection.

As well as muromonab, another mainstay treatment for organ rejection are antibodies directed against cluster of differentiation number 25 (CD25). Organ rejection is heavily mediated by T cells, in combination with other arms of the immune system (Ingulli, 2010). When activated, T cells produce large amounts of IL-2, a cytokine that acts in an autocrine fashion to further expand T cells via the IL-2 receptor CD25. Therefore, blockade of CD25 with a monoclonal antibody was hypothesised to offer a novel target in treating immunological rejection by T cells. As a result, daclizumab was developed and was shown by Vincenti et al. in 1998 to be a successful tool in treating renal transplantation compared to using a combination therapy of cyclosporine, azathioprine and corticosteroids. Furthermore, more long term studies have examined the function of renal transplants and concluded that patients on daclizumab showed improved renal function, as established by estimated glomerular filtration rate (GFR) (Ferran et al. 1990). However, like other pharmacological treatments, daclizumab has also been shown to cause a significant number of side effects such as hypertension and insomnia (EPAR for Zenapax).

More recently, the scientific community has sought to develop more refined immunological tools in order to modulate rejection. Through the development of monoclonal antibodies targeting cluster of differentiation 52 (CD52), clinicians are able to target lymphocytes for destruction, sparing the destruction of resident haematopoetic stem cell populations (Flynn and Byrd, 2000). Anti-CD52 drugs were originally developed for multiple sclerosis (Coles et al. 2008) and trials are currently being undertaken to establish their efficacy in organ transplantation.

The overarching side effect with immunosuppressive regimes is the relatively blanket level of immunosuppression which they cause. Although immunosuppression is required to maintain organ survival, immunosuppression also results in a reduced ability to fight infections. In particular, pulmonary infections are common in organ transplant patients, with Hoyo et al. (2012) detailing that around 1 in 5 patients in their study developed pulmonary infections. It is clear that clinicians dealing with organ transplantation patients must remain vigilant for infections. It is similarly clear, therefore, that a fine balance of the level of immunosuppression should be reached: a heavily weighted level will pre-dispose to opportunistic infections, and, conversely, a lightly weighted level will result in organ rejection.

With respect to future outlooks in transplantation immunology, the development of pluripotent stem cells has been hypothesised to overcome immunological issues associated with organ transplantation. Through the use of induced pluripotent stem cells (iPS cells) developed by Takahashi et al. (2006) it has been shown that it is possible to differentiate nearly all existing cell types. As these cells are derived from the patient, they are immunologically matched to the individual and, as a result, patients would not require harsh immunosuppressive regimes. Although this technology has not been tested clinically in patients extensively yet, it is hoped that within the next twenty years this method will provide an unlimited source of organ replacement for patients. Use of such cells is currently being explored for regeneration of certain organs such as the heart (Masumoto, 2014). Use of these cells will require a significant amount of clinical testing to determine their immunological properties, as well as their propensity to develop into tumours. It is likely, therefore, that the clinical applications of stem cells are still many years away.

In conclusion, despite significant improvements in targeted immunosuppressive regimes, significant side effects are associated with current pharmacological treatments. Clearly, as patients treated with these agents are often susceptible to opportunistic infections, their progress must be monitored closely by a clinician who is familiar with such patients, and the complications they can present with. Through our increased understanding of the immune system, alongside new technologies such as stem cell replacement therapy, it is hoped that the immunological issues associated with organ transplantation will in the near future be overcome.

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Identify a patient, stating the reason for admission/appointment. It must be on diabetes. Describe a specific problem that has been highlighted through the assessment process. Explore factors that may have led to their hospital admission/appointment. This could include physical psychological and social aspects.

Case details

In this essay we shall discuss the case of Mrs Singh. She is an elderly lady of 76 yrs. old. Who lives in warden assisted accommodation. She has done so for the last ten years since her husband died. She has had Type II diabetes mellitus for the last 17 years, and copes reasonably well considering her age and her comparative infirmity. She has been able to go out and get her shopping from the nearby shops and is otherwise self-caring, clean and tidy.

According to the referral letter from her General Practitioner, who arranged this admission to hospital, a number of people had recently commented that she looked ill and was not caring for herself as well as she used to do. Her family live a considerable distance away from her and, although they see her about once or twice a month, they do not stay for long as they have a business to run.

When she was admitted she was found to be lucid and coherent but her family told us that she had had a number of episodes of confusion recently. She was occasionally very sleepy and had left the gas burning on one occasion. She had a large infected ulcer on her left shin, which had clearly been there for a matter of weeks, but because of her habit of wearing long skirts, no one had noticed it. She had a degree of ankleoedema, but her physical examination was otherwise unremarkable, apart from the fact that she had a BMI in excess of 29. She is a moderate smoker.

Discussion

Mrs Singh as an individual is clearly unique, but sadly, she also represents a great many elderly diabetic patients who live in similar conditions. The thrust of this particular discussion will be the aetiology and management of her condition with particular relevance to her leg ulcer.

Diabetes Mellitus, an overview

Diabetes is a comparatively common disease process in the UK. In children it is the commonest major illness (after childhood infections). There are approximately 1.5 million diabetic patients in the UK at present and the number is relentlessly increasing. (Devendra et al 2004).

The 1.5 million are not equally spread across all segments of the population. People from the Asian and Afro-Caribbean ethnic backgrounds have a markedly increased risk of developing Diabetes Mellitus (UKPDSG 1998) with one in four of all Afro-Caribbean women over the age of 55 being diabetic. (Nathan 1998).

Increasing age and BMI also are both independent risk factors for Diabetes Mellitus (James 1997). Of this number, it is expected that about 10% will develop some form of lower limb ulceration while they are diabetic. (Amos et al 1997). To some extent, it is statistically more likely that those patients who have poor control of their diabetic state will develop ulceration (and other complications) than those patients who have good control.

The other factor that is relevant in the aetiology of leg ulceration is the length of time a person is diabetic. Chronicity of the disease process is an independent variable for leg ulceration. (Simon P et al 2004).

A number of authorities have estimated the burden of cost of Diabetes Mellitus to the NHS. A recent study by Newrick (et al 2000) considered that 9% of the total NHS budget was spent on diabetes and diabetic related issues. By far the biggest single portion of that amount (over half) was on the treatment of complications and the commonest clinically relevant complication is that of venous ulceration (Ellison et al2002)

We can start by considering the pathophysiology of Diabetes Mellitus

Pathophysiology

This is a huge subject in its own right and we shall therefore present a brief overview as far as it is relevant to Mrs Singh. In broad terms Diabetes Mellitus is a condition where the body loses the ability to metabolise carbohydrates in general and glucose in particular.

Glucose is absorbed from the gut, transported to the liver where is can be stored as glycogen, and then transported through the bloodstream to the cells in the periphery of the body, where it is one of the main metabolic substrates. It is absorbed from the blood into the cells by a specific molecular carrier system and this is totally insulin dependent.

If there is a failure of insulin production, then the circulating level of insulin falls and the glucose is not transported into the cells. This leads, initially to hyperglycaemia and finally to ketosis and metabolic failure. This is the situation of Type I diabetes mellitus.

The alternative is Type II diabetes mellitus where the cells lose the ability to respond to the circulating insulin levels. This also results in hyperglycaemia and eventual metabolic failure but is characterised by high levels of circulating insulin. In general terms, Type I diabetes mellitus is a comparatively acute illness whereas Type 1 diabetes mellitus tends to be far more chronic, sometimes taking many months or even years to become clinically apparent. (after Donnelly et al 2000)/

The complications of Diabetes Mellitus are many. The largest group are the micro- and macro vascular group of the cardiovascular complications.

(Stratton I et al 2000). The macro vascular group are usually related to the process of atherosclerosis and present with either degrees of myocardial is chaemia or as peripheral impairment such as intermittent claudication or ulceration. In general terms the incidence of this type of complication is directly associated with the average levels of HbA1 (which is a long term indicator of diabetic control) (HSG 1997).

Nursing interventions

The major nursing intervention to discuss here is the management of the leg ulcer. In any medical intervention its important to establish a sound evidence base (Sackett, 1996). We shall therefore quote the literature relevant to each point.

The first, and arguably most important consideration is whether the ulcer is primarily venous, arterial or (more rarely) neuropathic in origin. This is comparatively easily determined by an assessment of the ankle/brachial pressure ratio. This is measured by means of a Doppler measure and the ratio is easily calculated. If it is less than the critical level of 0.8 it is likely that an significant arterial element is present.(Partsch H. 2003).

Mrs Singh was treated with a 4 layer bandage. Her ratio was significantly above the 0.8 threshold and the main aetiology of her ulcer was therefore judged to be venous.

The composition and construction of a 4-layer bandage is very specific but it can be individually modified to suit the demands of the individual patient. The first layer is a cotton wool based bandage with the primary purpose of absorbing the copious amounts of exudates that are common with this type of ulcer. It also has the secondary purpose of spreading the pressure evenly across the underlying tissues the second layer is a crepe bandage which has the prime function of holding the lower layer in place. The third layer is a compressive layer, usually an elastic type of bandage is then applied and this is covered by a final binding layer. (Nelsonet al. 2004).

The rationale behind the bandage is that in the typical diabetic venous ulcer there is an increased pressure at the venous end of the capillary bed which translates into stagnation in the capillary blood flow which renders the tissues less viable because of poor oxygenation. By exerting physical pressure of about 40 mm Hg on the tissues, this increase of venous pressure is negated and the circulation improved.(Thomas S. 2003).

Clearly it follows that in an arterial ulcer, as there is a reduction in the arterial pressure at the arterial end of the capillary bed, any increase in physical pressure could further reduce the blood flow across the capillary bed, which is why it is vital to differentiate between the two types before applying the bandage.(Marston W et al. 2003).

The second main nursing intervention, and possibly more beneficial in the longer term, would be the Health Promotion aspects of the nursing relationship. Mrs Singh is overweight. Her BMI is about 29 which means that her weight is not only contributing to the reduction in venous return, and thereby contributing to both the aetiology and the persistence of her ulcer, but the obesity is also a major factor in the aetiology of her Type II diabetes mellitus. If Mrs Singh can be persuaded to reduce her weight, her need for hypoglycaemic medication may well lessen. It is possible that it may reduce to the point that she could manage her condition on diet alone. (Terry T-K et al 2003).

Smoking is not only an independent risk factor for Type II diabetes mellitus, but it is also a risk factor for cardiovascular disease. A major health promotion measure would therefore be to help Mrs Singh to give up smoking. This is not a short term measure, so is not particularly suited for hospital intervention, although the nursing staff spent a considerable amount of time with Mrs Singh to explain the problems associated with smoking. (Marks-Moran & Rose 1996).

On discharge she was referred to, and seen by, the smoking cessation nurse at the local primary healthcare team. The whole concept of patient empowerment and education is most important in this field. If a patient understands why they are being asked to do something, they are much more likely to comply with the request from the healthcare professional (Marinker M.1997).

The weight reduction needs to be carefully managed if it is to be successful. She was referred to the dietician who prescribed a low fat, carbohydrate regulated, 1,200 cal. per day diet. Because this is clearly going to be a long term intervention, arrangements were made for Mrs Singh to be followed up in the community dietetic clinic.

Mrs Singh was in hospital for seven days when the multidisciplinary discharge team were able to arrange her discharge. This involved the assistance of an occupational therapist to assist with minor home modifications and the community nurses who continued the treatment with the 4 layer bandage.

(Harrison, I. D et al 2005) The diabetic specialist nurse was also involved. As Mrs Singh’s weight slowly reduced she was able to reduce and finally come off her hypoglycaemic medication.

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In the Australian tertiary health care system, ‘best practice’ in the care of a terminally-ill neonate and the neonate’s family centres on the provision of ‘holistic care’. Neonates and their families are considered an interdependent system; therefore, holistic care involves the complete physical and psychological care of both the neonate and the family. However, quality holistic care can be challenging for nurses to achieve, particularly in a complex palliative model of care. This paper discusses the best practice holistic care of a terminally ill neonate and the neonate’s family in the context of the Australian tertiary health care system.

The term ‘palliative care’ refers to the withholding and / or withdrawal of life sustaining treatment in patients with terminal illness, to prevent or relieve suffering and allow death to occur (World Health Organisation, 2015). In all patients, and children in particular, the World Health Organisation (2015: n.p.) highlights that palliative care must be a holistic process, one which provides “active total care of the child’s body, mind and spirit, and [which] also involves giving support to the family”. Palliative care is concerned with providing a terminally ill neonate with the best conditions in which to live and with facilitating a comfortable death (Ahern, 2013; Bergstraesser, 2013). As parents are fundamental in the decision-making processes around neonatal palliation and as it is they who will be the most significantly affected by these decisions (Branchett & Stretton, 2012; Larcher, 2013), neonatal palliative care places a particular focus on caring for parents. There is consensus in the academic literature for palliation as the best model of care for neonates who are terminally ill; indeed, both the Australian College of Neonatal Nurses (2010) and the Royal Australian College of General Practitioners (2014) highlight palliative care as a best-practice option for terminally ill neonates in the Australian context.

It is accepted that the parents of a terminally-ill neonate in palliative care require significant emotional support from neonatal nurses and other members of the health care team. Parents of palliated neonates often experience a complex emotional reaction to their situation, typically one of grief, shock and confusion (Badenhorst & Hughes, 2007; Gardner & Dickey, 2011). They may also experience feelings of profound loss, related not only to the impending loss of their child but also to a loss of their expectations, aspirations, role as parents and family dynamic, etc. (Gardner & Dickey, 2011). Additionally, it is not uncommon for parents to feel indecisiveness, shame or guilt about the decision to palliate their neonate (Reid et al., 2011), particularly when the outcome of the neonate’s condition is uncertain. There is evidence from one early Australian study to suggest that women who experience neonatal loss have significantly higher rates of psychological distress and a greater risk of clinical depression than other mothers (Boyle et al., 1996). Thus, it is essential for neonatal nurses to validate the complex emotions the parents of a palliated neonate experience as being part of a normal and healthy psychological process (Badenhorst & Hughes, 2007). The provision of a clinical environment where parents’ complex emotions can be expressed and explored is also important.

Best-practice models of neonatal palliative care recommend that parents take a lead role in the care of their infant, both in terms of decision-making and practical care (PSANZ, 2009; Australian College of Neonatal Nurses, 2010). Whilst some parents may resist providing care for and thus becoming attached to a palliated neonate, fearing that this will increase the degree and duration of their grief following the child’s death, there is evidence to suggest this is not the case for many parents (Gardner & Dickey, 2011). There is also evidence which indicates that many parents regret not spending more time with their deceased neonate, both prior to and following death (Williams et al., 2008). Thus, the literature recommends that parents should be treated by neonatal nurses as ‘welcome partners’ in the care of their baby (Griffin, 2013). Parents should also be encouraged and supported to be involved in the care of their baby to the extent that they feel comfortable doing so (PSANZ, 2009).

So that parents may be meaningfully and safely involved in the care of their palliated baby, it is important that neonatal nurses provide them with the information they require to make informed decisions – and this may begin in the palliation planning phase. Developing a flexible, transparent and family-centred palliation plan is essential, and so that their preferences are met, parents should take a key role in this process (Williamson et al., 2009). The palliation plan must focus on enabling ‘open caregiving policies’, highlight parents’ wishes for their neonate and be legally documented (Breeze et al., 2007; Wiliamson et al., 2009; Gardner & Dickey, 2011). Whilst most parents wish to be involved in decisions and planning around end-of-life care for their neonate, they may find this responsibility overwhelming (Williams et al., 2008). Parents will be exposed to a range of options and opinions which they must synthesise in order to make the best decisions for their family; however, it is important for neonatal nurses to realise that highly emotive situations can often cause significant deficits in parents’ ability to comprehend and process such information (Williams et al., 2008). Evidence suggests that repetition printed literature is important in the provision of information to parents in situations involving neonatal death (PSANZ, 2009). The timing and delivery of the information provided by neonatal nurses should also be carefully planned to ensure maximal uptake (PSANZ, 2009).

Australian guidelines recommend that when supporting the parents of a palliated neonate, neonatal nurses focus on the normalcy of parenthood wherever possible (PSANZ, 2009). Neonatal nurses should assist parents to engage in normal parenting opportunities – including holding, changing and bathing their baby, and routine interactions such as reading cues and providing comfort – if they feel able to do so (PSANZ, 2009). For babies with longer palliative periods and where the baby’s condition permits, feeding – including breastfeeding or the feeding of expressed breast milk – is also an important consideration. Normal rituals associated with infancy, such as naming ceremonies and baptism, should also be followed if the family consider these to be important (PSANZ, 2009; Weidner et al., 2011).

A palliated neonate’s relationship with extended family may also be an important consideration for many families. Though visiting in intensive care nurseries is often restricted to parents, photographs and videos of the baby may be shared with extended family members and these relatives may be encouraged to send toys, clothing and nursery decorations, etc. for the baby in return (PSANZ, 2009). Research suggests that the support of family is a significant factor in the recovery of parents from the death of a neonate; indeed, the grief of parents may be enhanced when there is a lack of familial engagement with a palliated neonate (Gardner & Dickey, 2011). Grief of the family itself is also essential to consider; for example, there is evidence to suggest that better outcomes are achieved when grandparents and siblings are engaged with parents in the process of bereaving a deceased neonate (Roose & Blanford, 2011).

The literature suggests that the creation of tangible memories is fundamentally important to the parents of a palliated neonate, and this is included as a recommendation in Australian perinatal mortality guidelines (Capitulo, 2005; PSANZ, 2009). Memories collected may include photographs and videos, prints or casts of the hands and feet, locks of hair, identification bracelets or cards, toys and gifts, nursery decorations, and blankets, hats or clothing, etc. (De Lisle-Porter & Podruchny, 2009; PSANZ, 2009). It is important to note that many parents, and particularly those in denial of their baby’s palliative state, may resist collecting such memories; in this case, it is recommended that hospitals do so and hold these with the baby’s clinical documentation until such time as the family is ready to receive them (PSANZ, 2009).

So that parents may maximise the quality time they spend with their neonate, it is important for neonatal nurses consider the wider social factors which may affect them and their families (Ahern, 2013). Issues related to finances, employment commitments, accommodation, transport and the care of other children should be referred to a hospital social worker. Where required, postnatal medical attention in a clinical area where the mother will not be in close proximity to other healthy neonates, in addition to the suppression of lactation, are important (Badenhorst & Hughes, 2007). The environment in which the palliative care takes place must also be considered; Australian guidelines suggest that this environment should be private, comfortable, peaceful and supportive (Kain, 2006; PSANZ, 2009).

Once the decision has been made to palliate a neonate, all treatment which is not essential to the baby’s comfort must be withheld and withdrawn. This includes removing all inessential intravenous lines, invasive ventilation, monitors and pharmaceutical treatment. As the neonate begins to decline physiologically and the activity of the gastrointestinal system reduces, nasogastric feeding and hydration should also be ceased (Porta & Frader, 2007). Administering an appropriate dose of narcotic analgesia to relieve discomfort and sedate the respiratory drive may be useful (Williams et al., 2008; Carter & Jones, 2013); however, parents should be assured that this does not constitute euthanasia, which is illegal in Australia. At this stage, the end-of-life rituals should be conducted according to parental preference (Ahern, 2013). As the neonate progressively declines, it is essential that neonatal nurses prepare parents with information about how the baby’s death will likely occur. This includes the possibility of the neonate rapidly decompensating and displaying distressing signs such as hypoxic agitation, gasping, intercostal recession, pallour and temperature loss (Brosig et al., 2007; Williams et al., 2008; Carter & Jones, 2013). Information provided should also include the fact that timing to death cannot be predicted (Williams et al., 2008). Parents should be given a choice as to whether they remain with the neonate during death.

Following death, parents should be provided with the opportunity to hold, change or bathe their baby if they wish to do so (PSANZ, 2009). Whilst many parents are reluctant to or even fear engaging with their deceased baby, there is evidence to suggest that no parent regrets this experience and that many find it valuable (Capitulo, 2005). The policies of most maternity services in Australia allow parents to view their neonate as many times they wish, and some may also provide parents with the option of taking the baby home for a short period (PSANZ, 2009). Once the parents are ready, neonatal nurses should assist them to complete death registration and autopsy documents, as appropriate. Nurses should also support parents to organise a funeral through a company of their choice; in Australia, a funeral is legally required for all neonates born at or over 20 weeks gestation. A funeral is particularly important for many parents in terms of achieving closure (Williams et al., 2008).

Most literature recommends that the parents who have experienced a neonatal death receive ‘early supported discharge’ from hospital (Gardner & Dickey, 2011). Referral to support services in the parents’ own community – including general practitioners, counsellors and peer support groups, etc. – are essential considerations. Follow-up is also important; for example, if an autopsy was performed, neonatal nurses should communicate these results to parents in a timely manner (PSANZ, 2009; Reid et al., 2011). Additionally, many parents find personal follow-up, including telephone calls and cards, from the neonatal nurses who cared for their baby to be meaningful (Weidner et al., 2011), reinforcing that their child was important and will be remembered.

In the Australian tertiary health care system, ‘best practice’ in the care of a terminally-ill neonate and the neonate’s family centres on the provision of ‘holistic care’. As they are an interdependent system, holistic care involves the complete physical and psychological care of both the neonate and the family. This paper has discussed the best practice holistic care of a terminally ill neonate and the neonate’s family in the context of the Australian tertiary health care system. It has demonstrated that whilst holistic care may be challenging to achieve, it is essential in delivering the best positive outcomes in a complex situation such as neonatal palliation.

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Aboriginal and Torres Strait Islander people, referred to as ‘Indigenous Australians’, experience significantly poorer health outcomes than non-Indigenous Australians. This is particularly true for Indigenous women. The difference in life expectancy between Indigenous and non-Indigenous women is some 9.5 years, and Indigenous mothers are three times as likely as non-Indigenous mothers to die during childbirth (AIHW, 2014a; AIHW, 2014b). There are many complex, interrelated social factors which impact the health of Indigenous people. This paper provides a critical analysis of the social determinants of health for Indigenous mothers in particular.

Education is one of the most fundamental social determinants of health, and this is particularly true for Indigenous Australians. Education enables Indigenous women to access and interpret health-related information to prevent ill health, and it also improves their capacity to engage effectively with the health care system when necessary (Jones et al., 2014). In Indigenous women, higher levels of education are directly linked with positive health outcomes; for example, an Indigenous woman is less likely to smoke if she completes secondary schooling (Australian Government Department of Health & Ageing, 2012; Biddle & Cameron, 2012). However, Indigenous women have poor rates of formal education attainment; just 29% of Indigenous people complete Year 12 compared with a national average of 73% (ABS, 2012). Indigenous women with a lower standard of education are more likely to bear a child in their adolescent years, a particular problem for Indigenous women generally, and are also more likely to have a child with a low birthweight (Comino et al., 2009; Osborne et al., 2013). Additionally, Indigenous mothers with lower standards of education are more likely to children with poor educational outcomes; this highlights the significant problems associated with the intergenerational transfer of health and social risk in Indigenous communities (Benzies et al., 2011).

Education is related directly to an Indigenous woman’s level of economic participation – specifically, her ability to gain employment and earn an adequate income, both of which are key predictors of health (Osborne et al., 2013). Research suggests that an Indigenous person’s chance of gaining employment increases by 40% if they complete Year 10 and by 53% if they complete Year 12 (New South Wales Government Department of Education & Training, 2004). However, as with low education, low employment is a significant problem for Indigenous women; indeed, rates of unemployment for Indigenous women are above 16%, compared with a national average of just 4% (ABS, 2013). Economic disadvantage resulting from unemployment is a significant predictor of poor health. Booth and Carrol (2008) suggest that economic variables can explain up to 50% of the disparity in health between Indigenous and non-Indigenous Australians. Additionally, and demonstrating the cyclical nature of socioeconomic disadvantage and poor health in Indigenous communities, research also suggests that poor health may explain 60% of the disparity in employment participation between Indigenous and non-Indigenous women (Kalb et al., 2011).

Unemployment and socioeconomic disadvantage may affect the health of Indigenous women in a range of ways. Primarily, limited disposable income – in combination with a lack of food storage and cooking facilities within households and, particularly within remote communities, lack of access to fresh food itself – means indigenous women have reduced access to nutritionally-appropriate foods and lower food security (Osborne et al., 2013; Browne et al., 2014). Indeed, the diets of Indigenous people in many regions are characterised by a high intake of saturated fats, refined carbohydrates and salt, and little to no intake of fresh fibre-rich foods (ABS, 2006). In Indigenous women, as in all women, nutrition is fundamental to health in the ante-, intra- and post-partum periods (Browne et al., 2014). Poor dietary intake leads to high rates of gestational diabetes mellitus among Indigenous mothers – 5.1%, compared with a national average of 4.5% (2000-2009 estimate) (Chamberlain et al., 2014). Poor nutritional status also underpins the burden of chronic disease evident in Indigenous women and particularly chronic diseases related to obesity, which are a significant problem in Indigenous communities (Liaw et al., 2011). Around 60% of Indigenous women aged 25-55 years have a body mass index which indicates they are ‘obese’ (ABS, 2006). Because of the risks posed by chronic disease, Indigenous mothers are significantly more likely than non-Indigenous mothers to require antenatal hospital admission (Badgery-Parker et al., 2012). Additionally, maternal chronic disease means that around 11% of indigenous neonates have a low birthweight (ABS, 2014). This is an important marker for increased risk of chronic disease, again demonstrating the cyclical nature of socioeconomic disadvantage and poor health outcomes in Indigenous communities.

Socioeconomic disadvantage has a variety of other impacts on Indigenous mothers. For example, lack of employment and poverty mean that many Indigenous women have reduced access to appropriate housing. Up to 28% of Indigenous people live in housing which is severely overcrowded and where basic facilities – including showers, toilets and stoves – are not available or do not work (Osborne et al., 2013). Compounding the issue of poor housing is the fact that Indigenous Australians, and particularly those living in regional and remote communities, have disproportionate access to essential health infrastructure such as safe drinking water, rubbish collection services, sewerage systems and a reliable supply of power (Australian Human Rights Commission, 2007; Osborne et al., 2013). Indeed, lower standards of housing health infrastructure in Australian communities contribute directly to the high rates of parasitic and bacterial infection and increased rates of physical injury – for example, from house fires – among Indigenous women (Bailie & Wayte, 2006).

Inappropriate, overcrowded housing has had other impacts on Indigenous mothers. Specifically, it has led to breakdowns in traditional, complex social structures, norms and spiritual practices in Indigenous communities (Osborne et al., 2013). This has resulted in increases in the rates violence, including domestic violence, perpetrated against Indigenous women; indeed, Indigenous women are 40 times more likely than non-Indigenous women to experience violence, and are 35 times more likely to experience intra-familial violence which results in hospitalisation (Osborne et al., 2013). Indigenous people are also significantly more likely than non-Indigenous people to experience sexual assault (Phillips & Park, 2006; ABS, 2009). The Australian Human Rights Commission (2007) notes that a combination of unemployment, the receipt of welfare payments and a lower standard of education also predispose Indigenous women to an increased risk of poor health outcomes due to violence.

In Indigenous women in particular, social capital – including a connection with community, country and culture, is positively correlated with wellbeing (Brough et al., 2004; Biddle, 2012; Osborne et al., 2013). The relationship between social capital and mental wellbeing, particularly in Indigenous people, is well-established, however the correlation between social capital and physical wellbeing is now also acknowledged. For example, a number of Australian studies have demonstrated that Indigenous people who are connected to their community, country and culture are less likely to be diagnosed with a range of chronic health conditions including obesity, diabetes mellitus, hypertension and renal disease (Burgess et al., 2009; Campbell et al., 2011). Where there are declines in social capital, therefore, the mental and physical health of Indigenous women also decline.

Shepherd et al. (2012) report on the growing body of knowledge which suggests that Indigenous peoples’ social environment may significantly affect their mental health. Rates of mental illness among Indigenous women are high; indeed, Indigenous women are 2.6 times as likely as non-Indigenous women to report experiencing psychological distress and are also more likely to engage in self-harm and / or suicide (Australian Human Rights Commission, 2007; Burns et al. 2015, np). Mental illness is also strongly correlated with poverty; for example, Australian research suggests that people in poverty lack a sense of control over their lives and so experience higher levels of psychological stress (Australian Human Rights Commission, 2007). In addition to poor mental health, psychological stress can also lead to poor physical health outcomes – specifically, via negative effects on the immune and cardiovascular systems and metabolic function (Australian Human Rights Commission, 2007; Shepherd et al., 2012). Mental illness is not only underpinned by social health determinants, it is also problematic in terms of modifying the social factors which underpin poor health outcomes in Indigenous communities. For example, Marmot (2011) suggests that, in Indigenous communities, marginalisation results in disempowerment which in turn leads many Indigenous women to perceive little value in efforts to make health-related changes.

Social dysfunction and high rates of mental illness in Indigenous communities is driven by – and, indeed, drives – the high rate of substance abuse in these communities (Osborne et al., 2013). Indigenous women are twice as likely as non-Indigenous women to smoke on a daily basis, and three times as likely to smoke during pregnancy (Osborne et al., 2013; Passey et al., 2013). Approximately 50% of Indigenous people report consuming alcohol at least once per week, 28% report current regular use of illicit substances including cannabis and other drugs, and 15% engage in ‘risky’ behaviours related to substance use (ABS, 2006). Substance abuse is an important social determinant of health; the correlation between substance use and poor outcomes in terms of both physical and mental health in adults is well-established. Whilst the prevalence of Indigenous mothers who use alcohol and illicit substances is unknown, rates of fetal alcohol spectrum disorder and neonatal abstinence syndrome are high among Indigenous neonates (AIHW, 2015). Additionally, Indigenous mothers who abuse substances are at greater risk of losing custody of their children; because of the relationship between social capital and health in Indigenous communities, this can itself be perceived as a poor health outcome (Australian Human Rights Commission, 2007; Osborne et al., 2013).

As noted by the Australian Government Department of Health and Ageing (2013), poverty limits the access of many Indigenous people to health care services. This is particularly true in regional and remote communities – and approximately 46% of Indigenous women live in an area classified as ‘regional’ or ‘remote’ (ABS, 2010). Though many regional and remote Indigenous communities are supported by ‘fly-in fly-out’ health services, research suggests that fragmented services and discontinuity of care can contribute to poor health outcomes for Indigenous women (Bar-Zeev et al., 2012). Many communities have no health services at all, and to receive medical attention Indigenous women are often required to travel long distances to regional centres. Although the federal government subsidises the transport and accommodation expenses associated with such trips, general living costs borne by Indigenous women are often significant (Kildea et al., 2010). Additionally, the costs for those accompanying a woman are often not subsidised, so women may be required to travel without support (Kildea et al., 2010). These issues affect Indigenous mothers disproportionately; for example, in comparison to non-Indigenous women, Indigenous women tend to access antenatal care both less frequently and later in their pregnancy, and this is underpinned by lack of access to care (Osborne et al., 2013).

Further complicating these issues is the fact that the ‘risk-prevention’ paradigm evident in many medicalised health services is incompatible with the holistic perception of health held by many Indigenous women (Ireland et al., 2011). Additionally, historic protectionist and paternalist attitudes directed towards Indigenous people continue to pervade many medicalised health services in Australia. Durey and Thompson (2012) suggest that racism, both covert and overt, towards Indigenous women in Australian health services remains a significant problem; indeed, the Australian Human Rights Commission (2007) notes that systematic discrimination is a key factor underpinning the lack of opportunity for Indigenous Australians achieve a health status equitable to that of non-Indigenous Australians. These issues associated with ‘culturally-safe’ service provision often culminate in Indigenous mothers disengaging from medicalised health services. This is a significant problem considering a lack of antenatal and intrapartum care in particular, and health care in general, is fundamental to the high maternal morbidity and mortality rates in Indigenous communities (AIHW, 2014a).

This paper has provided a critical analysis of the many social determinants of health for Australia’s Aboriginal and Torres Strait Islander peoples – and, particularly, Indigenous mothers. It has demonstrated that social factors underpin the health of Indigenous mothers in both the physical and mental domains. It has also provided evidence for the complex relationship between health and social determinants in Indigenous mothers.

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Palliative care can vary significantly in its effectiveness according to condition, location, and type of patient (WHO, 2011; Gomes et al., 2013). This has long been recognised as an issue: Higginson et al. (2003) suggested that it has been difficult to prove the effectiveness of palliative care given the broad range of providers and the diverse nature of the clients. The World Health Organisation (WHO, 2011) has argued that palliative care has generally been unduly focused on the needs of cancer patients and is unsuited for the increase in older patients with diverse needs that are more common in many parts of the world. Part of this variation is the differences between the type of care required for various conditions and the fact that sometimes specialised care for a variety of conditions is required (Preston et al. 2014). There are also challenges posed to meeting patients’ wishes for palliative care through patient-centred care, and Gomes et al. (2013) suggest that the desire of most patients to die at home can stretch resources or result in palliative care provision not reaching the wishes of their clients. Likewise, the extent to which palliative care can be effectively provided through interaction with other care providers, and the role of family or informal carers is often unclear (Hanson et al., 2012). This has led to a range of views on the effective provision of palliative care. In this essay, first the challenges posed by an aging population and the challenge of providing specialist care to specific population groups will be considered. Second, the challenge of providing home-based palliative care will be discussed. Third, the challenges of developing effective communication between caregivers and the family will be evaluated. Fourth, ways in which informal caregivers may be involved in palliative care will be discussed. Finally, the arguments for earlier intervention in some cases will be evaluated.

The World Health Organisation argues that an important factor impacting upon the effectiveness of palliative care is the aging population in most countries that is coupled with a lack of attention to their complex needs (WHO, 2011). Older people more commonly experience multiple health problems, resulting in the need for such complex health needs to be more effectively supported (WHO, 2011). The model for palliative care traditionally focuses upon support for single diseases such as cancer, whereas people aged over 85 years are more likely to die from cardiovascular disease. There are also multiple debilitating diseases, such as dementia, osteoporosis and arthritis, and may require palliative care at any point in their illness trajectory (Gardiner et al., 2011). WHO (2011) indicate that palliative care does not usually form a part of traditional disease management, and with a combination of diseases the point at which palliative care is needed may become increasingly difficult to determine. The need for integration between different agencies is also cited as an important factor affecting older people (WHO, 2011). As such, palliative care for older adults must take into account the increasing variety of conditions that may develop, which is something that is not yet common amongst many care providers.

Solutions to these issues proposed by WHO (2011) include the need for palliative and primary care providers to receive more effective training in the needs of older people, and to gain a clearer understanding of the syndromes that affect this population group. This also includes a more effective understanding of the pharmacokinetics of opiates for pain management, and issues that are caused by comorbidity (Gardiner et al., 2011). Palliative physicians also need to improve their understanding of long-term care, including the administrative and clinical issues that are associated with older people dying in care homes. Likewise, inter-agency collaboration in palliative care is required to ensure that diverse needs are met through carers with different specialisms (Neilson et al., 2013). This means that palliative care needs to adopt a more personalised approach that takes into account the specific needs of clients, making collaborative approaches more common (Vitillo & Puchalski, 2014). As such, partnership working is likely to play an increasingly prominent role in palliative care provision in the future.

Similar concerns involving the specialised care for specific groups is identified by Vollenbroich et al. (2012), who investigate the potential for providing home care for children. These results suggested that where a specialised paediatric care team was used, there were high improvements in the children’s symptoms and quality of life. Additional benefits were seen as the reduction of the administrative barriers and improvement in aspects of communication between the care teams and the family. This supports arguments made by WHO (2011) which suggests greater specialisation is required to take into account the different diversities of patients who need palliative care. However, one aspect that is not identified by Vollenbroich et al. (2012) is the challenge posed by whether the condition should be considered as of greatest importance or whether the demographic considerations are needed (Gardiner et al., 2011). This suggests that perceptions of the age at death can significantly affect the patients’ needs in palliative care, and further research may be required to investigate the extent to which such suppositions are borne out in practice.

The place in which palliative care is provided is also a significant factor when considering how far the care meets the wishes of the patients. The extent to which people can opt for their place of death is an important factor affecting the effectiveness of palliative care. In the European Union, most people do not die at home (WHO, 2011). However, this is the preferred place of death for most people. In England, 58% of deaths occur in NHS hospitals, 18% at home, 4% in hospices, and 3% in other places. There is clearly an interest amongst many patients for dying at home. Jordhoy et al. (2010) report on an intervention programme staged by the University Hospital of Trondheim, Norway, which was intended to enable patients to spend more time at home and for them to die there should they prefer. This demonstrates that in order to achieve this end, close cooperation was necessary with the community health-care providers, and a multidisciplinary consultant team was needed to coordinate the care provision. This research demonstrated that intervention patients spent a smaller proportion of the last month of life in nursing homes than was possible for the control sample (Jordhoy et al. 2010). This illustrated that to increase the proportion of patients who were able to die at home, a significant investment of resources would be needed. This manifested itself in the need for greater levels of training in palliative care for community care staff, thus increasing the costs associated with the provision of care (Jordhoy et al. 2010).

Similar considerations were made by Gomes et al. (2013), who argue that providing palliative care at home increases the chances of dying at home, while reducing symptom burden that people experience as a part of an advanced illness. This also reduces the intensity of grief for family members if the patient dies (Gomes et al., 2013). However, Gomes et al. (2013) suggest that it is possible to provide home palliative care without significantly raising costs, but this is challenged by reports such as WHO (2011) who argue that for many patients, the complexity of the conditions experienced undermine the potential for home care to be effectively provided. Smith et al. (2014) suggest, however, that the context of increasing costs of healthcare means that the potential for palliative care to be provided in the home environment should be more closely investigated. In particular, this outlines that the quality of care can be significantly improved for home-based care, and in some cases the costs may be reduced by the fact that they may be spread between existing caregivers.

Communication between the patients and family members is often cited as an important factor leading to improved palliative care. Hannon et al. (2012) suggest that in contexts where family members are taken into account and given a role, family meetings can account for a significant improvement to the weekly workload for staff members. The study suggested that such meetings improved the particular areas of concern and worry for family members (Hannon et al., 2012). This demonstrates that such meetings can play an important role improving the experience of palliative care and indicate that one of the important roles of caregivers lies in the support that is given to the families of the patients as well as to the patients themselves (Hannon et al., 2014). However, although such meetings are considered appropriate and effective they may be undermined by the time constraints, the availability of appropriate staff, and the limitations of resources (Hannon et al., 2014). This may lead to less emphasis being placed on such aspects of palliative care, particularly where the benefit is not directed wholly towards the patient. Nevertheless, against this criticism is the extent to which such issues may result in the needs of the patient being better identified by consultation with family members (Gomes et al., 2013). It can be argued that this would represent an area of particular benefit to the provision of palliative care.

Harding et al. (2011) point out that informal caregivers are of significance in providing effective palliative care. Given the diversity of the care provided by this group, there is a need for a range of intervention strategies to provide appropriate support, depending on the needs of the patient. However, Harding et al. (2011) suggest that the range of models that are available to meet caregivers’ needs. Likewise, Harding et al. (2012) emphasise the significant costs to informal caregivers in terms of the emotional, physical and financial demands that informal caregiving places upon them. The conclusions of these studies indicate that support should be provided specifically to the caregiver and tailored closely to their needs, and the drawback of many existing approaches was the fact that interventions were not tailored to the caregivers’ needs. This is an important aspect for improving palliative care, as many patients prefer the services of informal caregiving, and this can also reduce the burden on professional healthcare if appropriate (Aslakson et al., 2014). The potential for providing support that is tailored to the needs of the informal caregivers would seem an important and effective means by which the quality of palliative care can be improved (Brandstatter et al., 2014).

Zimmerman et al. (2014) identify that there are limitations to the provision of palliative care in home settings that depend upon the condition of the patient. In their study, patients with advanced cancer tend to have a much lower quality of life that worsens as their condition progresses. This suggests that for some patients, palliative care should be provided at an earlier stage than is usually the case. However, such developments would depend upon the prognosis, and in such cases it is important to avoid premature judgment. Yoong et al. (2013) also suggest that early palliative care can prove beneficial in situations where patients have advanced lung cancer. This suggests that the benefits allow the palliative care teams to focus on fostering relationships with patients and their families, and improving illness understanding amongst patients and caregivers. The potential for adopting a comprehensive approach in this case provided psychosocial benefits, such as improving the coping mechanisms for patients alongside the management of medical treatment (Bajwah et al., 2012). The research thus indicates that the involvement of palliative care teams at an earlier stage in the treatment may be appropriate for some conditions and may provide significant benefits to the quality and effectiveness of care.

In conclusion, many of the arguments discussed suggest that there is an important case to be made for a greater diversity in approaches to palliative care. The need to take into account the diversity in the psychosocial needs of different population groups illustrate the importance of a more personalised approach to palliative care. Likewise, the challenge in meeting patients’ wishes to die at home requires significant attention as this can clearly provide significant benefits to patients. The research also indicates that greater engagement with family members can help support patients and prove of wider benefit to the carers. This also indicates that the involvement of informal caregivers is also a significant area of development, given the wide-ranging role they can play in the provision of palliative care. The introduction of palliative care at an earlier stage may allow benefits to the care process, particularly where the patient is cared for at home, as it helps foster an effective working relationship between different parties. Thus far, the key deficiencies of palliative care are largely that it appears to be focused on particular conditions and specific locations; the challenge is to broaden the type of patient that can be cared for, provide greater support to informal carers and family members, and be more responsive to the wishes of the patient.

References

Aslakson, R., Cheng, J., Vollenweider, D., Galusca, D., Smith, T. J., & Pronovost, P. J. (2014). Evidence-based palliative care in the intensive care unit: a systematic review of interventions. Journal of Palliative Medicine, 17(2), 219-235.

Brandstatter, M., Kogler, M., Baumann, U., Fensterer, V., Kuchenhoff, H., Borasio, G. D., & Fegg, M. J. (2014). Experience of meaning in life in bereaved informal caregivers of palliative care patients. Supportive Care in Cancer, 22(5), 1391-1399.

Bajwah, S., Higginson, I. J., Ross, J. R., Wells, A. U., Birring, S. S., Patel, A., & Riley, J. (2012). Specialist palliative care is more than drugs: a retrospective study of ILD patients. Lung, 190(2), 215-220.

Bruera, E., & Yennurajalingam, S. (2012). Palliative care in advanced cancer patients: How and when?. The Oncologist, 17(2), 267-273.

Gardiner, C., Cobb, M., Gott, M., & Ingleton, C. (2011). Barriers to providing palliative care for older people in acute hospitals. Age and Ageing, 40(2), 233-238.

Gomes, B., Calanzani, N., Curiale, V., McCrone, P., & Higginson, I. J. (2013). Effectiveness and costaˆ?effectiveness of home palliative care services for adults with advanced illness and their caregivers. The Cochrane Library. http://www.update-software.com/BCP/WileyPDF/EN/CD007760.pdf

Hannon, B., O’Reilly, V., Bennett, K., Breen, K., & Lawlor, P. G. (2012). Meeting the family: measuring effectiveness of family meetings in a specialist inpatient palliative care unit. Palliative and Supportive Care, 10(1), 43-49.

Hannon, B., Swami, N., Pope, A., Rodin, G., Dougherty, E., Mak, E., … & Zimmermann, C. (2014). The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer. Supportive Care in Cancer, 23(4), 1073-1080.

Harding, R., Epiphaniou, E., Hamilton, D., Bridger, S., Robinson, V., George, R., … & Higginson, I. J. (2012). What are the perceived needs and challenges of informal caregivers in home cancer palliative care? Qualitative data to construct a feasible psycho-educational intervention. Supportive Care in Cancer, 20(9), 1975-1982.

Hanson, L. C., Rowe, C., Wessell, K., Caprio, A., Winzelberg, G., Beyea, A., & Bernard, S. A. (2012). Measuring palliative care quality for seriously ill hospitalized patients. Journal of Palliative Medicine, 15(7), 798-804.

Harding, R., List, S., Epiphaniou, E., & Jones, H. (2011). How can informal caregivers in cancer and palliative care be supported? An updated systematic literature review of interventions and their effectiveness. Palliative Medicine, 26(1), 7-22.

Higginson, I. J., Finlay, I. G., Goodwin, D. M., Hood, K., Edwards, A. G., Cook, A., … & Normand, C. E. (2003). Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?. Journal of Pain and Symptom Management, 25(2), 150-168.

Jordhoy, M. S., Fayers, P., Saltnes, T., Ahlner-Elmqvist, M., Jannert, M., & Kaasa, S. (2010). A palliative-care intervention and death at home: a cluster randomised trial. The Lancet, 356(9233), 888-893.

Neilson, S. J., Kai, J., McArthur, C., & Greenfield, S. (2013). Using social worlds theory to explore influences on community nurses’ experiences of providing out of hours paediatric palliative care. Journal of Research in Nursing, 18(5), 443-456.

Preston, N., Dunleavy, L., Rigby, J., Griggs, A., Salt, S., Parr, A., & Payne, S. (2014). Overcoming barriers to research in palliative care: results from a consensus exercise. Palliative Medicine, 28(6), 745-745.

Smith, S., Brick, A., O’Hara, S., & Normand, C. (2014). Evidence on the cost and cost-effectiveness of palliative care: A literature review. Palliative Medicine, 28(2), 130-150.

Vitillo, R., & Puchalski, C. (2014). World Health Organization authorities promote greater attention and action on palliative care. Journal of Palliative Medicine, 17(9), 988-989.

Vollenbroich, R., Duroux, A., Grasser, M., Brandstatter, M., Borasio, G. D., & Fuhrer, M. (2012). Effectiveness of a pediatric palliative home care team as experienced by parents and health care professionals. Journal of Palliative Medicine, 15(3), 294-300.

Yoong, J., Park, E. R., Greer, J. A., Jackson, V. A., Gallagher, E. R., Pirl, W. F., … & Temel, J. S. (2013). Early palliative care in advanced lung cancer: a qualitative study. JAMA Internal Medicine, 173(4), 283-290.

Zimmermann, C., Swami, N., Krzyzanowska, M., Hannon, B., Leighl, N., Oza, A., … & Lo, C. (2014). Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. The Lancet, 383(9930), 1721-1730.

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Deathography Reflective Essay

In life nothing is more inevitable than death, it simply cannot be avoided. Despite advances in medical sciences and increased longevity in the Western world, human life remains fragile as death can occur at any age in a myriad of circumstances. Grief follows the death of a loved one, is often cited as being a ‘universal’ response to loss (Davidson, 1988) and can be defined as ‘intense sorrow’ (Oxford English Dictionary, 2013). Each bereaved person will experience and respond to grief in a unique way, underpinned by social, cultural and religious factors, further influenced by the individual’s personality and coping mechanisms. Grief reactions are widely acknowledged to vary in length and severity and to have physical, emotional, cognitive, behavioural and spiritual components (Rosenblatt, 1993: Archer, 1999: Parkes, 2001).

On the 18th September 1989 I gave birth to a beautiful, healthy baby girl weighing 8lbs and 11 ounces. As a parent I had such high hopes and expectations for the future but on 23rd February 2002, aged 12 years, her life was drastically cut short following a tragic accident. She was excited as she set off for her first ever sleep over at her best friend’s house, I was anxious as this was the first time she had been away from home without me.

On that cold, damp Saturday afternoon they had decided to go out for a bike ride (my daughter had borrowed an old bike belonging to her friend’s brother).Whilst out riding the chain came off, as she fell to the ground the bike landed on top of her abdomen causing her liver to rupture. My daughter died within minutes from a massive internal haemorrhage, in severe pain and all alone at the road side as her friend had gone to get help. Oblivious to what had happened; I received a telephone call from her friend’s mother stating that Gemma had been in an accident and to meet her at the Birmingham Children’s Hospital. Assuming that she had experienced relatively minor injuries (I was told not to worry), I was ill prepared for the scene that unfolded before me as I entered the Multiple Injuries Unit in Accident and Emergency. Gemma lay motionless on a trolley, her body covered with a white sheet. The room was full of nurses and doctors who had attempted to resuscitate her, all of whom appeared shaken and emotional but no one was able to provide an explanation or answer my questions as there were no signs of injury or trauma to her body. It was only after the post mortem that the cause of her death was identified. I left the hospital that evening with a carrier bag containing her personal possessions and a leaflet explaining ‘what to do when a child dies in hospital’, barely able to comprehend what had just happened or the magnitude of my loss.

The loss of a child is the most devastating loss of all. It defies the natural order of events as parents do not expect to mourn their children, causing heartbreak and trauma like no other. Parental grief is different from other losses in both intensity and length. Sudden death robs the bereaved of preparatory grief, is more common in young people and often occurs in clinical environments.

There is a well-established theory base relating to issues of loss. Early theories include Freud’s (1917) grief work perspective and Bowlby’s (1969) early attachment model. Freud’s work led to grief being conceptualised as both a pathological condition requiring psychological intervention and a linear process. The individual must ‘work through’ it in order to detach the memories and thoughts associated with the deceased love one. Both Bowlby (1980) and Parkes and Brown (1972) suggest that grief follows a predictable pattern. A well-known five stage grief model developed by Kubler-Ross (1969) depicts grief as passing through phases of shock and denial, anger, depression, bargaining and eventual resolution and acceptance. Terms such as ‘normal’ and ‘complicated’ grief (Engel, 1961) were developed as a way of distinguishing grief that had not resolved within a given time frame.

Recent years have seen the development of a number of new theories and approaches to loss and grief. Stroebe and Schut (1999) explain grief reactions in terms of two concurrent processes or ‘orientations’ (also known as the dual process model). Loss orientation is described as a traditional grief reaction, characterised by despair, sadness and anger, whilst restoration orientation is characterised by attempting to rebuild one’s life and move on. Klass et al (1996) emphasises the importance not of letting go but of holding on even after the loss has occurred to maintain continuing bonds. Worden (1991) described four overlapping stages and tasks which the bereaved work through in order to relocate the deceased by redefining the relationship in the new context of the loss to invest in the future.

People who are suddenly bereaved often require more support and counselling than those who have the time to prepare for the death of a loved one. Without such support, unresolved grief reactions may occur along with a life time risk for psychiatric diagnosis (Keyes et al, 2014).Unexpected death is associated with Post Traumatic Stress Disorder (PTSD), panic disorder and depression regardless of when the death occurred in the life of the bereaved person. The incidence of generalised anxiety disorder, social phobia, mania and alcohol abuse is greater if the death occurred after the age of 40 in the bereaved person’s life. Thus, whilst extreme sadness and despair are normal reactions to loss which usually dissipate over time, some grief reactions are so severe they give rise to psychiatric disorders requiring medical intervention (Worden, 2003).

On that fateful day in 2002, my whole life’s purpose changed and everything that I had lived for now ceased to be. Neimeyer (2000) maintained that major losses challenge a person’s sense of identity. In the immediate days and months that followed I strongly identified with the initial stages outlined by Kubler – Ross of shock and denial. As a mental health professional I was familiar with the model and knew the predicted pattern that my grief would likely follow. I would ask myself over and over again, how could my only child be dead? How can someone die falling off a bicycle?

Catapulted into the depths of despair, no longer a mother, all my hopes and plans for the future had become futile and irrelevant. A major task of grief requires refocusing one’s life story to rebuild and maintain a semblance of continuity between what has gone before and what lies ahead (Neimeyer, 2006). The foundations of my belief system had been called into question; why Lord did you have to take my daughter who had so much to live for when there is so much human suffering in the world. I was consumed with anger whilst having to support my husband, parents and other family members alongside coping with returning to work. My colleagues would avoid me in the corridor, not knowing how to approach me or what to say.

Barely able to function, I felt lost, alone, hopeless and worthless. Overwhelmed by guilt, I felt that I should be blamed for failing to protect my daughter as I had not fulfilled my duty as a mother. The months turned to years, my frustration grew as I waited for the time that I would achieve resolution and acceptance. I lost motivation and became anxious, living in fear that I would lose another family member in such sudden and dreadful circumstances. I experienced flashbacks and actively avoided seeing friends and family as their children reached major milestones such as learning to drive or graduation. Loss orientation and concurring loss restoration would have been incomprehensible for me at this time. Instead, I chose to keep her memory alive by raising money for the Birmingham Children’s Hospital, publishing a diary of a bereaved mother, sponsoring an award in her name at the school she had previously attended, making frequent visits to her grave and commissioning a large portrait of her to hang in the lounge (continuing bonds).

Five years on, I was still unable to contemplate resolution and the trajectory of my grief wasn’t following a staged or linear process but zig zagged erratically back and forth between stages. This was unsettling and uncomfortable and went against everything that I had been taught as a mental health professional. Not only had the prescriptive linear and staged models been unhelpful (Sheehy, 2013) but had led professionals to conclude that I experienced a complicated grief reaction as resolution didn’t come within a given time frame. I gave up engaging with health care professions as I felt the template they were adhering to didn’t fit my unique situation. I still felt the physical pain of losing her as I acknowledged that my loss had pervaded every area of my life and completely changed my personality. Finally, I knew that it was up to me to find meaning in my life in order to have a future. That meaning came six years later when I became the mother of a baby boy in 2008.

The experience of losing Gemma was devastating and remains immensely painful but I now accept that the pain is an intrinsic part of me. I have simply learnt to live with it. The loss and trauma I have experienced has defined the person I am today, however, it must be stated that it has also positively influenced my attitudes and beliefs about life in many ways. Over the thirteen years, I have gained inner strength and I now appreciate just how precious life is. I take nothing for granted, knowing only too well how quickly a life can be taken away. I don’t plan for next year or too far into the future but I prefer to live in the moment and try to find something positive in each day. I am more tolerant and forgiving of others, whilst making a conscious effort to regularly remind relatives and friends how important they are to me and how much they are loved. If something is wrong in my life, I now have the courage to change it. I am not afraid of my own mortality, my faith has now been fully restored and I believe that one day I will be with her again when it is my turn to cross to the other side. Furthermore, the way in which I interact with bereaved people as a mental health professional has changed, shaped by my own experiences and the need to understand each individual in the context of their reality.

The hardest thing to do was to forgive myself and to realise that I am not to blame for her death. I have survived life’s cruellest blow and although life will never be the same, I am now able to experience happiness again. Gemma will always have a presence in my life as she is spoken about lovingly and frequently as a household name, her portrait remains over the fire place as a reminder of her wonderful contribution to my life.

In conclusion, whilst models and theories offer helpful frameworks and insights into the grieving process an individual’s unique response cannot be overstated. Many factors influence how an individual grieves, the dominance of linear or staged processes are too prescriptive. In supporting the bereaved, the task of the health care professional is not to favour or propose one model over another but to challenge assumptions and listen to the bereaved in order to facilitate an accurate reconstruction of the individual’s inner self and outer world. Thus, adopting broad concepts facilitates a more holistic understanding of the needs of the individual. Failure to do so will result in a continued theory/practice gap and those bereaved individuals who do not come through may remain prone to a range of long lasting psychiatric disorders. Further research is required into bereavement related contextual factors and the development of effective interventions in helping the bereaved to cope and such an approach is relevant in a wide variety of situations.

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Sheehy, L (2013) Understanding Factors that Influence the Grieving Process. End of Life Journal.3 (1)

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Can breastfeeding in the first six months prevent childhood obesity?

‘Obesity’ is defined as a body mass index (BMI) of ?25kg/m2 (World Health Organisation 2015). In the past decade, throughout much of the world, the rates of obesity in children in particular have increased to epidemic proportions (Lefebvre & John 2012, p. 386). The World Health Organisation (2015) estimates that 42 million children under the age of 5 years are overweight or obese worldwide and in Britain, overweight and obesity affects nearly one-third of children aged 2 to 15 years (Health and Social Care Information Centre 2009). Since obesity in childhood is strongly correlated with serious disease and increased risk of mortality throughout life (Yan et al. 2014, p. 3), and because of the significant direct costs of obesity on health services and societies globally (Department of Health 2011), strategies to prevent childhood obesity are of paramount importance. Research has suggested that breastfeeding for the first six months may be protective against and, therefore, prevent obesity in childhood (Lefebvre & John 2012, p. 386). Through a critical evaluation of this research, this paper will answer the question of whether breastfeeding in the first six months can prevent childhood obesity.

The beneficial effects of breastfeeding for children are well-established in the literature. High-quality studies have demonstrated that children who are breastfed have a reduced risk of ear infections (Duncan et al. 1993, p. 867), respiratory infections (Bachrach, Schwarz & Bachrach 2003, p. 237), necrotizing enterocolitis (Lucas & Cole 1990, p. 1519), gastroenteritis (Chien 2001, p. 69), diabetes (Owen et al. 2006, p. 1043), atopic dermatitis (Gdalevich et al 2001, p. 520) and sudden infant death syndrome (SIDS) (Vennemann et al. 2005, p. 655). Breast milk is not only rich in protective antibodies and beneficial bacteria, it is nutritionally-balanced and adapts to meet an infant’s changing needs (National Health Service 2015). Research has therefore suggested that another significant benefit of breastfeeding may be that is acts as a protective factor against obesity in childhood.

Kramer was the first to report that breastfeeding may result in a “significantly reduced” risk of obesity in children (1981, p. 4). In the next two decades, a number of similar studies also suggested an association between breastfeeding and a reduction in the risk of childhood obesity. In the mid-2000s this research was collated into three seminal meta-analyses which concluded that, overall, breastfeeding for the first six months did reduce the risk of childhood obesity. For example, Arenz et al. (2004, p. 1247) found that obesity had a “small but consistent” protective effect against obesity in children. This was supported by Owen et al. (2005, p. 1367), who demonstrated a small positive correlation between breastfeeding and a reduction in the risk of childhood obesity. Harder et al. (2005, p. 397) also found that the duration of breastfeeding was inversely associated with the risk of childhood obesity. These meta-analyses suggested an overall 15% to 30% reduction in odds of overweight from breastfeeding. However, they were widely criticised for major methodological problems, including a failure to deal appropriately or consistently with confounding variables such as parental BMI. As a result, the evidence they presented on the relationship between breastfeeding and reduced childhood obesity risk was not widely accepted.

However, the potential for a correlation between breastfeeding and a reduction in the risk of childhood obesity continued to be discussed and researched. In the past decade, a small number of high-quality studies have investigated this potential relationship. Evidence from this research is largely conflicting, with results varying depending on the study design used. For example, two large randomised-controlled trials found breastfeeding had no impact on the prevalence of obesity in children aged 6 or 11 years (Kramer et al., 2007, p. 1717; Martin et al., 2013, p. 1005). Similarly, several studies in siblings found no differences in the BMI of breastfed versus non-breastfed children (Evenhouse & Reilly 2005, p. 1781; Gillman et al. 2006, p. 112; Colen & Ramsey 2014, p. 55). Likewise, two high-quality American studies reported either no (Jiang & Foster 2013, p. 628) or small and inconsistent (Jenkins & Foster 2014, p. S128) effects of breastfeeding on childhood BMI. Conversely, multiple studies have reported a positive relationship between breastfeeding and a reduction in the risk of childhood obesity. For example, a large UK study concluded that breastfeeding reduced the overall risk of childhood obesity to a degree considered statistically-significant. These findings are supported in high-quality studies from Germany (Grube e tal. 2015, p. 1), Brazil (Assuncao et al. 2015, p. 1) and Japan (Jwa et al. 2015, p. 1527). Furthermore, these studies demonstrate that the length of time a child is breastfeed is proportional to the degree of their reduction in obesity risk, and that the inverse association between breastfeeding and overweight appears to be sustained over time.

Part of the problem underpinning these marked differences in study results can be explained by the quality of the studies themselves. Randomised-controlled trials – the gold standard of research trials – investigating the effects of breastfeeding are rare, because the well-established benefits of breastfeeding means allocating children into ‘breastfeeding’ and ‘non-breastfeeding’ cohorts would raise justifiable ethical concerns (Grube et al. 2015, p. 2). In studies where groups are not randomised, a spurious relationship between breastfeeding and reduced risk of obesity may result as a result of confounding if, for example, mothers who breastfeed also adopt a healthier lifestyle involving a nutritious diet and adequate physical activity for themselves and their children (Centers for Disease Control 2007, p. 3).

Reasons for these marked differences in study results can also be explained by the diverse sociocultural context in which both breastfeeding and obesity are grounded. Essentially, sociocultural factors have a significant impact on both breastfeeding and obesity which confounds the relationship between these two variables. For example, a cohort study examining the correlation between breastfeeding and childhood obesity in groups of English and Brazilian children found that breastfeeding was associated with reduced risk of childhood obesity in the English cohort but not in the Brazilian cohort (Brion et al., 2011, p. 670). This study suggests that sociocultural factors have a significant impact on the relationship between breastfeeding and childhood obesity in cohorts with different sociocultural characteristics. Another similar cohort study confirmed that breastfeeding in particular is a ‘socially-patterned’ phenomena, and that as a result the relationship between breastfeeding and childhood obesity may differ between cohorts in low- to middle-income and high-income countries (Fall et al., 2007, p. 47). Furthermore, a high-quality meta-analysis found that evidence for the relationship between breastfeeding and childhood obesity is primarily derived from studies conducted in high-income countries where the correlation between breastfeeding and socioeconomic status is a significant source of confounding in this relationship (Horta & Victora 2013). It is apparent, therefore, that the question of whether breastfeeding in the first six months can prevent childhood obesity is largely dependent on sociocultural factors.

The sociocultural-dependent nature of the relationship between breastfeeding and childhood obesity is also revealed in studies which have adjusted statistically for other covariates, such as sociodemographic factors and variables concerning birth, pregnancy and parental atopy, etc. For example, in one adjusted study on a German cohort, Grube et al. (2015, p. 1) conclude that breastfeeding might help to prevent childhood obesity. However, in another adjusted study on a Chinese cohort Jing et al. (2015, p. 55) found no statistically significant effect of breastfeeding on reducing the risk of childhood obesity. Because these studies both adjust for a range of sociodemographic and other covariates, sociocultural differences are an important explanation for the differences observed in results.

It is exceedingly difficult, perhaps impossible, to control for the diversity of sociocultural variables evident in different populations. The best that can be done is to control for as many other variables, such as sociodemographic factors, as possible. When this is done, the evidence overwhelmingly suggests that breastfeeding in the first six months can reduce the risk of childhood obesity. For example, a meta-analysis by Horta and Victora (2013) concluded that, if only studies which control for confounding are considered, breastfeeding leads to a reduction in childhood obesity of around 10%. This is supported by another large meta-analysis by Yan (2014) which, after examining only studies controlling for confounding, concluded that the risk of childhood obesity was lower in breastfed children by 22%.

It is worth noting that no Cochrane Systematic Review – the gold standard of meta-analysis – has been completed on the relationship between breastfeeding and childhood obesity. However, a Cochrane Systematic Review on evidence for the optimal duration of breastfeeding did conclude that breastfeeding did not confer any protection against obesity in children to the age of 6 years (Kramer & Kakuma 2012, p. 5) – a surprising finding, given the conclusions drawn in the previous paragraphs. However, this Cochrane Systematic review looked at obesity in terms of weight gain rather than BMI, the standard measure for obesity. It also did not exclude studies which failed to adjust for confounding. Thus, it is not accurate to compare its results with those of the meta-analyses discussed previously.

It is now generally accepted that breastfeeding in the first six months can reduce the risk of childhood obesity. However, complicating this conclusion is the complexity surrounding differences in the concepts of childhood obesity prevention versus risk reduction. The literature widely accepts that breastfeeding reduces the risk of childhood obesity; however, no studies claim that breastfeeding prevents obesity. Thus, in direct answer to the research question it must be concluded that breastfeeding in the first six months does not prevent childhood obesity. However, breastfeeding does reduce the risk of childhood obesity. Moreover, the length of time a child is breastfeed is proportional to the degree of their reduction in obesity risk and the inverse association between breastfeeding and overweight appears to be sustained as the child grows (Centers for Disease Control 2007, p. 4).

A variety of research is now being undertaken to further explain the relationship between breastfeeding and a reduction in the risk of childhood obesity. It has been suggested that, due to more normalised concentrations of the hormone leptin, breastfed children may have a more well-developed recognition of satiety and an improved ability to self-regulate their energy intake in both early and later childhood (Gillman 2011, p. 681). Hormones in human breast milk may influence this learned self-regulation of energy intake (Savino et al. 2009, p. 397). Additionally, breast fed children have a lower plasma insulin concentration and a shorter insulin response resulting in more regulated body fat deposition (Dietz 2001, p. 2506). Furthermore, the higher protein intake of formula-fed infants may stimulate the secretion of insulin and result in the dysregulation of body fat deposition (Dietz 2001, p. 2506).

The conclusion that breastfeeding reduces the risk of childhood obesity is widely accepted by global peak bodies on child health. These peak bodies include the World Health Organisation’s (2015) UNICEF, whose Baby Friendly Initiative is widely endorsed by maternity hospital and health service in the UK. The relationship between breastfeeding and a reduction in the risk of childhood obesity is also reflected in the policy statements and guidelines of most major paediatric bodies worldwide, including the Royal College of Paediatrics and Child Health (2011) and the American Academy of Pediatrics (2012).

Obesity in childhood is a significant problem globally. This paper has concluded that whilst breastfeeding in the first six months does not prevent childhood obesity, there is evidence to suggest that breastfeeding does reduce the risk of childhood obesity. Moreover, the length of time a child is breastfeed is proportional to the degree of their reduction in obesity risk and the inverse association between breastfeeding and overweight appears to be sustained over time. However, it must be remembered that both breastfeeding and obesity are grounded in a range of sociocultural determinants which may confound this relationship. However, since obesity in childhood is strongly correlated with serious disease and increased risk of mortality throughout life, and because of the significant direct costs of obesity health services and societies globally, a relationship between breastfeeding and a reduction in the risk of childhood obesity is a significant finding.

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This work was produced by one of our professional writers as a learning aid to help you with your studies

Introduction

A group of young men who had been in music for some while by the name” The rolling Stones” placed a claim that they were the greatest Rock & Roll band in the whole world in the later part of 1960s. Most people disputed the claim and little did they know the group had actually raised to a world class musicians. Since then, the Rolling Stones’ music which is mainly based on Rhythms and Blues has continued to sound vital pieces through the decades.

During the period of British invasion in 1964, the members of this group were called the bad boys instead of the world’s best band. What was viewed initially as a gimmick later led to a world image that many people especially their critics could not believe. One of their comrades Brian Jones met his death in 1969 which is up to date a mystery. This tragic year also saw violent murder during their set towards the end of the year at Altamont (Regina, 1980).

This band pioneered the famous ridiculing tone of British rock’s detachment and they did this through the music they composed. They wrote songs about offhand brutality, implied sex as a source of power among other compositions that were according to British community then, a taboo.

This group did not act as per the norms of its community. Mike Jagger in his music and social controversies as a musician in this band was perceived to be evil and was as a result branded the name ‘Lucifer’. He released ‘sympathy for the devil’ which, to many, was like an admission that what he and his group were doing was devilish.

The Rolling Stones Band

Dartford Maypole County Primary School is legendry to Jagger and Richards for this was their first meeting place. Afterwards in1960 the duo discovered one familiar thing concerning themselves which was love for R&B. They managed to develop a reciprocal friendship with Dick Taylor, who was a guitarist and was pursuing economic studies in a London school. Jagger and Richards teamed up with Taylor and this also saw Richards becoming a second guitarist when they formed the Little Boy Blue and the Blue Boys band.

This formation was disastrous for Richards as he was debarred from Dartford Technical College for absenteeism. Interestingly, Brian Jones started playing bebop alto sax and clarinet while in Cheltenham. One of the most awful things, at the age of sixteen Brian Jones had to flee briefly to Scandinavia for he had been a father to two illegitimate kids. Immediately after Jones returned back to Cheltenham, they teamed up with Ramrods prior to proceeding to London. Once he settled in London he joined Alexis Korner in his band which played blues.

This did not stop him from organizing his own band of which he incorporated Ian Stewart who was a renowned pianist in London (Sandford & Richards, 2004). Just as his colleague Elmo Lewis, Jones started to work at Ealing Blues Club and later joined other groups in singing blues. With this new group, he met and played with drummer Charlie Watts. While at one side Richards and Jagger started jamming with playing Blues music, these two together with Jones started going in to private music practice while Jagger became the most famous and featured singer of the time with blues, Inc. while in the city of London, the three friends and blues musicians Jones, Jagger and Richards rented a tiny apartment.

Together with Tony Chapman who was a drummer, they cut a demo tape which to their disappointment did not meet the standards of EMI and was therefore rejected. Taylor left his colleagues to join the royal college of arts after which he started ‘Pretty Things’. The genesis of the name The Rolling Stones can be traced to this period when Taylor left. It is after his leaving when they did the song ‘Muddy Waters’.

It is this particular song that earned them the name of their band which they were to use to rise to fame and be universally recognized as the best Rock music in the whole world. Life was a little bit a challenge to the group but when one of their colleagues Ian Stewart got a job with a chemical company in London, the rest of the group could not starve to death because there was something to eat, at least (Regina, 1980).

July 1962, the band; ‘The Rolling Stones was made up of its veterans Jagger, Jones, Richards together with bass voice singer Taylor Dick and drummer Mick Avory. The latter was to join the Kinks group later. This band staged their first work at the Marquee on the 12 th of July, 1962 (Sandford &Richards, 2004). Two guys from the Clifton’s band namely Chapman and Bill Wyman soon replaced Avory and Taylor respectively after their departure from the Rolling Stones band.

According to Jagger, Jones and Richards, Chapman did not fit well in his new position. To avoid a mistake in appointing a person to replace Mr. Chapman, they decided to take their time, actually several months, to recruit Charlie Watts. They took much caution in executing this exercise because they simply wanted the best person to take that role satisfactorily. Charlie Watts previously worked in Blues.

He was an employee to an advertising agency. At one time, the Blues’ schedule would get too busy and it made his job difficult, he had decided to leave the group and concentrate on his advertising job. Recruiting Mr. Watts who was an advertiser is felt to have been a strategic approach for the members of the Rolling Stones band. First, Mr. Watts was a famous man in the city and he could appear in company advertisements for brands.

Such a famous person being associated with the band and actively participating in the Rolling Stones made the group feel proud. Most of their fans would come to see the man they saw in television adverts perform live. This contributed positively in getting more fans and more cash in that case (Sandford & Richards, 2004).

In January 1963, Mr. Watts officially joined, thus completing the band. Their fortune began when Mr. Gomelsky Giorgio, who was a local businessman, signed a deal with the Rolling Stones where they were to perform at his Crawdaddy club for eight months. This residency was most successful for the band. The owner of this club remained the manager of the Stones, although unofficially, they were signed as clients to Andrew Loog Oldham who obtained finances from Eric Easton.

Their sponsorship by Oldham was meant to raise their status so that they may out-compete the Beatles who were then the sensation of Britain. This kind of promotion was an easy way out for Mr. Stewart, who despite being mild-mannered was the band’s popular pianist both on tour and road within the residence (Sandford& Richards, 2004).

The Rolling Stones released their first track single in June 1963, known as ‘Come on’ by Chuck Berry. When the Stones first played on the British TVs ‘Thank Your Lucky Stars’ Program, the producer of that program reportedly advised the groups sponsor and manager to get rid of Stewart because he was ‘vile-looking singer with the tire thread lips’ (Mick et al. 2003).

Despite this criticism, that single reached number twenty one on the British best music chart. The same year, the Rolling Stones for the first time participated in the London based National Jazz and Blues Festival which was held annually.

In September 1963, the Rolling Stones band was short listed among other bands that were to participate in a package of tour entertaining their fans while promoting the business of their sponsors. Included in the tour were other bands such as Everly brothers, Little Richard and Bo Diddley. In December 1962, the Rolling Stones band released their second single track known as ‘I wanna be your man’ which was entirely written by John Lennon and Paul McCartney. This track brought much fame to the band and it featured in the top 15 hits in Britain.

In January 1964, The Rolling Stones band for the first time headlined a tour in Britain with the Ronettes. They jointly released a version of ‘Not fade away’ which had earlier been done by Buddy Holly. This track rose up the chart and unbelievably was rated third. The track did not only bring fame to the Rolling Stones in Britain but also crosses borders as far as the US where it was rated No. 48 in the US singles charts.

Meanwhile, the band had actually attained the dreams of their sponsors and manager because it was a real sensation in Britain. At times, the press would report things like members of the band had been spotted urinating in public which was a show of ill manners but at same time a proof of sensation in the city (Obrecht 1980).

In April 1964, Rolling Stones band released their first album in United Kingdom which was followed by an American tour barely two months later in June 1964. They covered the song ‘it’s all over now’ which had earlier been as collaboration between Valentinos and Bobby Womack. This song had been rated the British number 1 and had been one of their own (Stephen 2006).

In their tour to America in June 1964, they stopped at the city of Chicago based Chess Records, to record ‘five by five’ EP. Their recording was a success although there was a challenge when riots broke out when the band members attempted to address the press. Meanwhile, the band’s version of the blues standard track ‘little red rooster’ which had been rated number 1 on Britain’s chart was banned in the US market and media for claims that it had “objectionable” lyrics (Sandford & Richards, 2004).

At this time, both Jagger and Richards had already started the composition of their own tunes initially using ‘Nanker Phelge’ for compositions which they made jointly. In August 1964, one of Jagger and Richards piece “Tell me (you are coming back home) was one of the joint composition tracks which was accepted in the US and rated in the top forty (Regina 1980).

In November 1964, another composition by Jagger and Richards which was original, “Time is on my side” was rated number 6 on the top hit chart in US. Since then, very few of the songs that were performed by the Rolling Stones band were a joint-composition of Richards and Jagger (Nico 2008).

The year 1965 was a good year for the group because they recorded success. Their hit “The late time” became number one on the UK charts while it appeared in the top ten hits in the US in that spring. The stones next single release was “I can’t get no satisfaction” which consecutively remained number 1 for four weeks in the summer of 1965 and it is perceived to have been the most famous song.

The talented and creative duo (Jagger & Richards) continued to write songs but with time, their composition became more sophisticated. Their work was worth their effort because each of their composition appeared in the top hit charts either in the UK or the US. Some of their most famous tracks include ‘get off my cloud’ which was No. 1 in 1965, ‘as tears go by’ rated position 6 in 1965, ’19^th nervous breakdown rated second in 1966, ‘mother’s little helper’ rated 8 in 1966 and ‘have you seen your mother, baby, standing in shadow?” which was rated ninth in 1966.

The Rolling Stones released their primary LP 1966 and it was a set of purely original material (Sandford & Richards, 2004). Although it was expected to bring much impact in the music industry and market, the impact was significantly minimized because the Beatles released their ‘Revolver’ while Dylan Bob released his ‘Blonde on Blonde’ almost at the same time. This resulted in steep competition in the market because despite these three simultaneous releases by industry foes, the Middle Eastern had produced ‘paint it black’ in 1966 and the ballad “ruby Tuesday” which had remained the number 1 hits in the US (Obrecht 1980). They were simply unbeatable.

In January 1967, there was a stir up of another sensation in Ed Sullivan show when the stones performed their ‘let’s spend the night together’ which was side B of Ruby Tuesday. In this show, Jagger instead of singing the words in the title line mumbled because there was a threat of censorship after some people made claims that the first line of the track had been censored. Many people anticipated that Jagger sung the phrase ‘let’s spend some time together with clarity and audibly (Mick et al. 2003).

In February 1967, Jagger and Richards faced a major challenge when the two were arrested while in Britain in connection to crime of possessing drugs (Stephen 2006).May 1967, another challenge faced the Rolling Stones band with the arrest of Brian Jones. Luckily, the heavy jail sentences which had been made upon the three artistes were eventually put in to suspension following an appeal by their lawyer.

As a result of this drawback, the Rolling Stone band members decided to refrain from making public appearances whether performing or in private business but this were a temporary measure and a strategy to recollect and reflect on their plight. Jagger with his love, singer Marianne Faithfull, flew to India in the company of Beatles to meet star Maharishi Yogi. Following this episode, the Rolling Stones did not release another single until much later in the fall when they released the hit ‘Dandelion’ which was ranked number 14 while its side B ‘we love you’ was rated 50. In this last hit, both J. Lennon and P. McCartney sang back-up voices and the aim of this hit was to thank all fans of the Rolling Stones

(Sandford & Richards, 2004).

December 1967, the Stones released their ‘Satanic Majesties Request’ which was their psychedelic response to ‘Sgt. Pepper’ by the Beatles which was perceived to be an ambitious mess (Regina 1980). It took some time for ‘she is a rainbow’ which was a lone single track in their album featured in the top 25 chart. By the time it entered the chart, management of the group had been put under the responsibility of Allen Klein (Obrecht 1980).

In May 1968, a hit track named ‘Jumping Jack Flash’ was released and it was placed position 3 in the charts. In this month, basic rock and roll returned. Again, the electric ‘Beggars Banquet’ was in market after a 5- month delay which resulted from some sleeve photos which were in the controversial package. Critics of the band claimed that this album had been the best piece of work the Stones had ever made (Mick et al. 2003).

On June 9^th 1969, the greatest setback to the band struck. One of the most reliable and adventurous members by the name Brian Jones left the band. Jones had lent to the band a marimba, sitar and dulcimer. He had also been to Morocco where he recorded nomadic musicians who belonged to the Joujouka community. The explanation he gave for his quitting was that he did not see eye-to eye with other band members over the discs they were jointly cutting any more. Jones had made public his intentions to start his own band. The group reacted to this withdrawal swiftly and within a week, his position was taken up by Mick Taylor who was a former guitarist in the John Mayall band (Obrecht 1980).

On July 3^rd 1969, Brian Jones was found dead in his own swimming pool. Reports cited it as “death by misadventure”. It was revealed that Jones had been beset by drug problems and it had clearly come to him that the Rolling Stones band was owned by Jagger and Richards who made him barely participate in the various sessions of Beggars Banquet. A Few days after death of Jones, the Stones performed in open at Hyde Park (Mick et al. 2003).

A day after burial of Brian Jones, on July 11^th 1969, the Stones released ‘Honkey Tonk Women’, and another classic. At this time, every one of their album was in high demand including “Let it Bleed” (Regina 1980).

Immediately after Jagger’s return from Australia where he was a celebrity in the film Ned Kelly, he started the band’s massive tour to America in 1969, after 3 years of not be able to visit the US (Mick et al. 2003). Their performance at Altamont Speedway, California turned tragic and portrayed the satanic image they had adopted earlier when the Hell’s Angels motorcycle gang who had been hired by Stones to provide security stabbed a boy to death. This incident led to Stones dropping their stage shows for the following 6 years. The fall of 1970, after a long break from stage, they released a live album named ‘Get Yer Ya-Yas out. Later that year, the band founded the Rolling Stones Records (Obrecht 1980).

References

Mick, J. Richards, K. & Wood, C. (2003). Rolling Stones: Chronicle Books. ISBN 0-8118-4060

Nico, Z. (2008). The Complete Works of the Rolling Stones.New York: Sage Publication.

Obrecht, Jas. (1980). Mick Taylor: Ex-Rolling Stones on His Own, Guitar World,p.20.

Regina, R. (1980). Criminal Cases: Canada Law Book. p. 518.

Sandford, C. and Richards K. (2004). Satisfaction.New York: Caroll & Graf.

Stephen, T. (2006). Some Girls AMG: All music. London: Longman Publishers.