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Part 1: Management Style
Description and feelings

This essay aims to reflect on my experience when working with a group of seven students tasked to critically analyse a case study and develop a group presentation. The Gibbs (1988) model of reflection will be used to discuss and analyse the lessons gained from my experience. At the start of our group meeting, a leader was selected and helped the group in planning and implementing the task. However, my experience with the group was marked with difficulties and challenges. In the first stages of our group formation, or the norming stage, we had difficulties meeting as a group due to differences in university schedule. During the meetings, some of the members chose not to participate while others were more demanding and tried to dominate the discussions. The leader tried to create some sense of order in our first meetings and demonstrated the authoritarian leadership style. Throughout our team meetings, some of the members were absent, while others who were present continued to depend on the more dominant members to accomplish the tasks. I was frustrated in the beginning of our meetings and felt that we could have been successful in our presentation if we managed to work more effectively. Our team presentation was not what I expected. I was disappointed with our overall team performance.

Discussion and Analysis

Management is described as a process where leaders govern and make decision-making within an organisation (Bach and Ellis, 2011). This also involves planning of tasks, organising work, staffing, directing activities and controlling (Belbin, 2010). The main aim of management is for managers to influence or encourage team members to accomplish a task (Belbin, 2010). On reflection, my team leader demonstrated the authoritarian leadership style. This type of leadership is described as one where the leader provides the direction of the team and gives specific instructions and directives on how to achieve the team goal (Daly et al., 2015). An authoritarian leader also supervises the activities of the subordinates and strongly discourages members to validate or question his or her directives (Bach and Elllis, 2011). This type of leadership is appropriate in workplaces where there is a highly-structured setting with routine operations (Bishop, 2009). Autocratic leadership is also favourable for activities that are simple and of shorter duration (Marquis and Huston, 2012). On evaluation of my experience in the team, we had very little interaction and cohesion during the first few stages of the team working.

According to Tuckman’s model of team development, there are four stages of group formation (Clark et al., 2007). These include the following: forming, norming, storming and performing. Our lack of cohesion and difficulties in conducting team meetings may reflect the first stage of group formation, which is the establishing stage. In this this step, Clark et al. (2007) has explained that team members are still beginning to form their team roles and tend to be polite and diplomatic. At this stage, a team leader was chosen, who in turn reflected the authoritarian leadership style. Since most team members were reluctant to accept a task, our leader decided to assign team roles and ensured that each team member would attend the team meetings. The leader also supervised the entire group. On reflection, the authoritarian leadership style was appropriate in the first few stages of our team working since this ensured that tardiness and absenteeism were prevented (Belbin, 2010). Further, the authoritarian leadership style was also appropriate since our assigned task was not complex and was of shorter duration (Bishop, 2009). Our group leader was able to make follow-ups on our assigned task. However, as we progressed towards the second stage, which is the storming stage, conflicts soon arose.

There were members who tended to dominate the discussion and did not agree with our leader on our assigned team roles and how the case study should be presented. Although Goodman and Clemow (2010) argue that conflicts in teams are natural and may not always have a negative impact on the function and development of the team, in my experience, the conflicts had negative impact on our team development. Members who disagreed with our team leader on how the case study should be presented chose not to participate in our succeeding meeting and role-playing. Since the authoritarian leadership style was adopted, our team leader did not consider the team member’s suggestions. Morgan et al. (2015) reiterate that conflicts could help in the development of a team if each team member acknowledges the differences of the team members and learn to adjust to their individual roles. On reflection, most of my team members chose not to adjust to our individual differences. In turn, this created a discordant team, which also reflected on our final presentation. I felt that our presentation was chaotic and reflected poorly on our role as team members. On consideration, our team would have benefitted with the transformational leadership style. This type of leadership encourages members to actively participate in decision-making and is associated with achievement of goals and objectives (Bach and Ellis, 2010).

Conclusion

The authoritarian leadership style was not the most appropriate style in managing our team since this failed to encourage team members to participate in decision-making. This type of leadership is also not applicable in actual healthcare settings since patient-centred care is promoted and team working and participation highly encouraged.

Action Plan

When managing a team in the future, I will ensure that I am aware of my own team role. Conflicts should be used to develop and not destroy teams. I will also adopt a leadership style that allows teams members to actively participate in decision-making. Specifically, I will develop the transformational leadership style since this ensures that all members have opportunities to be actively involved and valued during achievement of a task (Bishop, 2009).

References:
Bach, S. & Ellis, P. (2011) Leadership, Management and Team Working in Nursing. Exeter: Learning Matters.
Belbin, R. (2010) Management of teams: why they succeed or fall. London: Butterworth-Heinemann.
Bishop. V. (2009) Leadership for nursing and allied healthcare professionals. Open University Press: Milton Keynes.
Clark, P., Cott, C. & Drinka, T. (2007) ‘Theory and practice in interprofessional ethics: a framework for understanding ethical issues in health care teams’, Journal of Interprofessional Care, 21(6), pp. 591-603.
Daly, J., Speedy, S. & Jackson, D. (2015) Leadership and Nursing. Contemporary Perspectives. 2nd ed. Chatswood: Elsevier.
Gibbs, G. (1988) Learning by doing: A guide to teaching and learning methods, Oxford: Further Educational Unit, Oxford Polytechnic.
Goodman, B. & Clemow, R. (2010) Nursing and collaborative practice: A guide to interprofessional learning and working. Exeter: Learning Matters, Ltd.
Marquis. B. & Huston. C. (2012) Leadership and management tools for the new nurse. A case study approach. Lippincott: Philadelphia.
Morgan, S., Pullon, S. & McKinlaey, E. (2015) ‘Observation of interprofessional collaborative practice in primary care teams: An integrative literature review’, International Journal of Nursing Studies, doi: 10.1016/j.ijnurstu.2015 03.008 [Online]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25862411 (Accessed: 15 May 2015).
Part 2: Leadership, Management and Change
Description and Feelings

In our team meetings, the concept of change management surfaced since our team leader struggled in influencing team members to assume different team roles. I also realised that I used to complete tasks individually and not as a team. Although I was not the team leader, I also have to learn how to reflect an appropriate leadership style that will be used in future team working. During our team meetings, I was frustrated since we were accomplishing little, but in the end, I felt that I have developed my ability to work in a team.

Discussion and Analysis

Change is described as a transition that involves movement from the present state of an organisation to a desired, future state (Marquis and Huston, 2012). Changes often occur in healthcare settings and require change management. During the role-play and team meetings, collaborative team working was encouraged to achieve the goals of the team. This represented a change in how I accomplish tasks. From completing assigned tasks individually, I have to learn how to complete tasks as a group. Apart from changes on how to complete tasks, there was also a suggested change on leadership style from authoritarian to the transformational leadership style. On evaluation, change management was necessary in our group since this could have addressed the factors that caused our poor performance and increased the factors that would lead to a successful group performance.

Practising change management is crucial since this would help prepare myself in my future role as a registered nurse and as a nurse leader. At least three theories have been proposed in managing change. These include the Plan, Do, Study, Act cycle (PDSA), Kotter’s Model and Lewin’s change model (Bach and Ellis, 2010; Appelbaum et al., 2012; Reed and Card, 2016). The PDSA cycle is often used in the NHS and allows nurse leaders and other healthcare practitioners to create a plan on how to implement a change while the ‘do’ stage constitutes the actual performance of the plan. In the third or ‘study’ phase, nurse leaders and team members analyse the performance and whether this needs to be enhanced or changed (Reed and Card, 2016). In the ‘act’ phase, the proposed changes in the action plan and performance are implemented. The entire process is then repeated until change has been integrated within an organisation. A critique of the PDSA is the difficulty in repeating this cycle, with Reed and Card (2016) noting that only 20% of healthcare groups using PDSA actually repeat the cycle. The applicability of the PDSA is limited with some healthcare settings not benefitting from this type of change management (Taylor et al., 2013).

Meanwhile, the Kotter Model of change adopts the top-down approach and is often used in corporate settings (Appelbaum et al., 2012). It is difficult to use this model of change in actual healthcare settings since the NHS encourages all team members and patients to actively participate in planning and implementation of a change initiative (NHS Leadership Academy, 2011). However, a reflection of my own group would show that the Kotter Model of change was demonstrated as our team leader exercised the authoritarian leadership style. The change came from the leader and trickled down to the team members. Finally, the Lewin’s model of change proposes three stages of change: unfreezing, change and refreezing (Gopee and Galloway, 2013). This model is often used in healthcare settings since it takes into account the factors that enable or deter change in actual practice. Force-field analysis is done and factors that enable change are increased while factors that deter change are reduced (Gopee and Galloway, 2013).

On reflection, employing this type of change management is crucial in my future role as a registered nurse leading a multidisciplinary team. In the NHS, it is recognised that there are several factors that deter or promote change in practise. For instance, the perception that a proposed change initiative only increases paperwork could deter the uptake of change in practice (Bach and Ellis, 2011). This perception is supported in literature with the Royal College of Nursing (2013) reporting that nurses spend an average of 2.5 million hours per week completing clerical tasks. Hence, I have to be aware of factors that deter or enable change. On reflection, the autocratic leadership style, coupled with the top-down approach to change did not lead to a successful performance of my group. The Lewin’s model of change would have been more appropriate in helping my team members accept their individual roles and in changing their own way of completing tasks. This model would have helped our team leader investigate the factors that lead to poor attendance to our team meetings and the team members’ refusal to resolve conflicts.

Conclusion

Effective leadership and change management are crucial when implementing a change initiative and in completing group tasks. Using the Lewin’s model of change would have helped the team leader identify the factors that enable and deter change. Successful use of this model would lead to achievement of the goals of the team.

Action Plan

I will develop my leadership skills and abilities to carry out Lewin’s change model. I will find opportunities to practice change management skills in my own healthcare setting and report regularly to my mentor and colleagues on my progress. I will ask feedback from my mentor and colleagues if I have achieved leadership and change management skills.

References:
Appelbaum, S., Habashy, S., Malo, J. & Shafiz, H. (2012) ‘Back to the future: revisiting Kotter’s 1996 change model’, Journal of Management Development, 31(8), pp. 764-782.
Bach, S. & Ellis, P. (2011) Leadership, Management and Team Working in Nursing. Exeter: Learning Matters.
Gopee, N. & Galloway, J. (2013) Leadership and Management in Healthcare. 2^nd ed. London: Sage.
Marquis. B. & Huston. C. (2012) Leadership and management tools for the new nurse. A case study approach. Lippincott: Philadelphia.
NHS Leadership Academy (2011) Clinical Leadership Competency Framework. Coventry: NHS Institute for Innovation and Improvement.
Reed, J. & Card, A. (2016) ‘The problem with Plan-do-study-act cycles’, British Medical Journal Quality and Safety, 25(3), pp. 147-152.
Royal College of Nursing (2013) Nurses spend 2.5 million hours a week on paperwork- RCN Survey [Online]. Available at: https://www2.rcn.org.uk/newsevents/press_releases/uk/cries_unheard_-_nurses_still_told_not_to_raise_concerns (Accessed: 10 May, 2017).
Taylor, M., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. & Reed, J. (2013) ‘Systematic review of the application of the plan-do-study-act method to improve quality in healthcare’, British Medical Journal Quality and Safety, doi: 10.1136/bmjqs-2013-001862.
Part 3: Leadership, Management and Decision Making
Description and Feelings

In our group work, our team leader did not make a decision to identify the factors that deterred participants from resolving conflicts and adjusting to team roles. There was also no decision to reflect on why team members were reluctant to accept the assigned tasks and the reasons for poor attendance to the team meetings. I felt that these non-decisions heavily influenced our team performance. As a group, we made the erroneous conclusion that our team leader can handle all the required tasks. This group conclusion might have also contributed to our failed group presentation. During our meetings, I was anxious and apprehensive that we were not accomplishing our tasks with the given time frame.

Discussion and Analysis

The indecision to identify factors that deterred the group from participating in meetings and accepting tasks had a negative impact on our team performance. The ability to make decisions is crucial when completing tasks as a student nurse and in preparation for my role as a registered nurse or a nurse leader. Marriner-Tomey (2009) has argued that decision-making is crucial in healthcare organisations and within teams. In actual healthcare settings, decisions are made constantly and range from decision on whether to admit a patient to decisions on which interventions to use for a specific healthcare condition. These decisions are influenced by legislations, policies, leadership styles and the practice of patient-centred care (NHS Leadership Academy, 2011). On analysis, it is crucial to make decisions within groups. However, it is cautioned that collective decisions might reflect ‘groupthink’ and lead to failure instead of success (Marriner-Tomey, 2009). The theory of groupthink is described as faulty decision made by a group that represents deterioration in reality testing, mental efficiency and moral judgment (Wilcox, 2010). Groups who demonstrate groupthink often do so without realising the impact of their decisions on other groups and in the process, ignore alternatives or actions (Cooke and Young, 2002). It is important to note that groupthink often occurs when members have similar background, when rules for decision-making are not clear and when members do not consider the opinions of others (Wilcox, 2010). In my experience, we were not able to make a decision or demonstrate groupthink despite the similarities of our background. I felt that our lack of cohesion prevented us from also making faulty decisions, which are common when a team ‘groupthinks’.

An analysis of our group revealed that we were not able to examine the power relations within the group. Power relations could have an impact on who make the decisions and whether these decisions are followed (Bach and Ellis, 2010). Power is described according to who has the formal authority to make decisions for the group and according to who has access to resources (McDonald et al., 2012). Power is also described according to who has less ability to control ideas (McDonald et al., 2012). In teams, there may be power imbalance especially when professional systems, social and cultural factors reinforce these imbalances (Martin-Rodriguez et al., 2005). This power imbalance may be more evident in hospital settings where medical dominance is seen. For example, medical doctors have traditionally retained their independence and professional autonomy and status when collaborating with other groups of healthcare workers (Hudson, 2002). This may create power imbalance as doctors tend to have more power in decision-making compared to the rest of the group. This is in contrast with what is often seen in community healthcare settings where each member of a healthcare team tends to share power and make decisions according to what is best for the patient (Hudson, 2002).

Meanwhile, Weir-Hughes (2011) asserts that in order for a therapeutic relationship to develop, there is a need to consider the power relationships between healthcare practitioners and patients. It is suggested that power may be used negatively (i.e. through coercion and force) or positively (i.e. through encouragement and empowerment). On analysis, my ability to understand power relations through my experiences in team working will be essential when caring for actual patients. In our team, power was used negatively since our team leader had to force our team members to accept assignments. However, I realised that in actual settings, it is important to encourage and empower patients and my colleagues to improve patient care. It has been shown that patient empowerment tends to improve the quality of care and patient outcomes (Sullivan and Garland, 2010). On analysis, there was power imbalance in our group since the team leader made all the decisions and the top-down approach to change was followed.

Conclusion

Making decisions is crucial in team working and when caring for patients. However, the ability to make decisions would depend on one’s power. Those with more access to resources and power have greater ability to influence decisions. In healthcare settings, it is crucial to use power positively and empower patients and other members of the healthcare team to make decisions. Positive use of power is also important in preventing ‘groupthink’, a phenomenon that tends to result to negative consequences for the group.

Action Plan

When faced with a similar situation in the future, I will ensure that I actively participate in decision-making. However, I need to empower others and myself to make good decisions. Empowerment is necessary to prevent power imbalance. I will continue to engage in training on how to practice effective leadership and management skills in order to empower others to actively engage in decision-making.

References:
Bach, S. & Ellis, P. (2011) Leadership, Management and Team Working in Nursing. Exeter: Learning Matters.
Cooke, M. & Young A. (2002) Managing and Implementing Decisions in Healthcare. London: Healthcare Balliere Tindall/RCN.
Marriner-Tomey (2009) Guide to Nursing Management and Leadership. St. Louis: Mosby Elsevier.
Martin-Rodriguez, L., Beaulieu, M., D’Amour, D. & Ferrada-Videla, M. (2005) ‘The determinants of successful collaboration: a review of theoretical and empirical studies’, Journal of International Care, 19(2), pp. 132-147.
McDonald, J., Jayasuriya, R. & Harris, M. (2012) ‘The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus’, BMC Health Services Research, 12(63). Doi: 10.1186/1472-6963-12-63.
NHS Leadership Academy (2011) Clinical Leadership Competency Framework. Coventry: NHS Institute for Innovation and Improvement.
Sullivan E., Garland G. (2010) Practical Leadership and Management in Nursing. Pearson Education, Harlow.
Wilcox, C. (2010) Groupthink: An impediment to success. USA: Xlibris Corporation.
Part 4: Reflection on Development of Skill
Description and Feelings

I participated in a second group activity where I was chosen as the leader. In the second group, I was able to practice leadership skills such as effective communication, motivation, change management and integrity. During one of our discussions, I assigned a group member to search for evidence-based interventions for a specific healthcare condition. Following some research, my team member decided to use the case of a real patient to explain the interventions. However, she identified the name of the patient and the context of her care, including the names of the nurses who were involved in her care. I talked to my colleague privately after our discussion and informed her of the NMC (2015) code of conduct on patient autonomy and the need to observe the privacy of the patient. I asked her to use a pseudonym instead when discussing the case of a patient. My colleague accepted my suggestion and protected the identity of the patient during succeeding discussions. On reflection, I felt that my decision to inform my colleague on how to discuss patient care was based on the ethics principles of patient autonomy.

Discussion and Analysis

From my participation in teams/groups throughout the module, I was able to develop effective communication skills. Specifically, I learned how to listen and show compassion to my colleagues and my patients during placement when they converse with me. Kourkouta and Papathanasiou (2014) have emphasised that effective communication skills is crucial in healthcare settings and when working in teams. These communication skills include recognising both verbal and non-verbal messages (Johnston, 2013). Patients who feel that their nurses are listening intently tend to report higher patient satisfaction with the care they receive (Kourkouta and Papathanasiou, 2014). Effective communication skills are also necessary in resolving conflicts in teams and understanding the perspectives of others (Craig and Moore, 2015). In nursing teams or when working with patients, it is recognised that conflicts in ideas also occur. Hence, the ability to communicate effectively and resolve conflicts will be necessary in preparing myself in my future role as a registered nurse (Craig and Moore, 2015).

Apart from effective communication, I also learned how to motivate my fellow team members. Motivation is crucial in team working since this would help team members to complete tasks. In my experience with my first group, team motivation was not practiced. In contrast, my second team was able to use motivation to help team members accept and carry out tasks. I realised that the main difference was the support that my team members received in the succeeding group. Craig and Moore (2015) state that team support is critical in team working since the absence of support could create dissatisfaction and loss of motivation. In addition to the skills on motivation, I also saw the importance of change management in our team. In my first group, change management was not practised. Managing change is critical in healthcare practice. Thorpe (2015) has stated that planned change, which is described as purposeful, requires collaborative effort and the presence of a change agent. The NMC (2015) has emphasised that nurses must deliver quality care that is based on evidence, suggesting that nurses have to continually update their skills and practice. This also means that changes in practice have to be made. However, in practice, implementing change is challenging. It is suggested that almost 70% of change projects do not succeed (Mitchell, 2013).

In my experience with the group, I also realised the necessity of recognising factors that influence or deter change. Mitchell (2013) suggests that advances in science, shortages of the nursing workforce, an ageing population, the need to increase patient satisfaction and rising cost of treatment all influence change. Inappropriate leadership, poor communication and under-motivated staff also deter the uptake of change in practice (O’Neal and Manley, 2007). In my future practice, I have to identify factors that promote change in practice. On reflection, I was not able to promote change in our first group. I could have assisted the team leader in my first group in analysing the factors that deter my colleagues from accepting their assigned tasks.

Integrity was also practiced in the succeeding groups that I was involved in. Specifically, power was not misused as all team members in these groups had equal chances to participate in decision-making. In addition, the team leader and group members exercised honesty and transparency in the decisions made. Finally, ethics in decision-making was observed. For instance, all personal information of patients discussed during case studies was not mentioned and patient autonomy was observed. The NMC (2015) has reiterated the importance of protecting the privacy and autonomy of the patients.

Conclusion

Practising effective leadership skills and ethical decision-making are important when working as teams and in providing quality care to the patients. Inability to work effectively could result to poor performance, which in turn could affect the quality of care that my future patients will receive. Developing these leadership skills early in my undergraduate years would help prepare me in my role as a registered nurse.

Action Plan

As part of my action plan, I will continue to engage in training on how to develop effective communication skills. Specifically, I will refine my skills on how to show empathy when listening to my patients and colleagues. The ability to demonstrate empathy is crucial since this would help my patients feel that they matter to the team (Fowler, 2015).

References:
Craig. M. & Moore. A. (2015) ‘Providing support for teams in difficulty’, Nursing Times. 111(16), pp. 21 – 23.
Fowler. J. (2015) ‘What makes a good leader?’, British Journal of Nursing, 24(11), pp. 598 – 599.
Johnston, B. (2013) ‘Patient satisfaction and its discontents’, Journal of the American Medical Association, 173(22), pp. 2025-2026.
Kourkouta, L. & Papathanasiou, I. (2014) ‘Communication in nursing practice’, Materia Socio Medica, 26(1), pp. 65-67.
Mitchell, G. (2013) ‘Selecting the best theory to implementing planned change’, Nursing Management, 20(1), pp. 32-37.
Nursing and Midwifery Council (NMC, 2015) The Code: Professional Standards of practice and behaviour for nurses and midwives [Online]. Available from: http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmc-code.pdf (Accessed: 12 May, 2015).
O’Neal, H. & Manley, K. (2007) ‘Action planning: making change happen in clinical practice’, Nursing Standard, 21(35), pp. 35-39.
Thorpe. R. (2015) ‘Planning a change project in mental health nursing’, Nursing Standard, 30(1), pp. 38 – 44.

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

Choose one gender group and critically discuss how their health outcomes can be improved in regards to ageing.

Introduction

Wound infection post-surgery, now preferably known as Surgical Site Infection (SSI) refers to infections at or near a surgical site within 30 days after surgery or within one year, if the procedure involved insertion of an implant (Illingworth et al., 2013; Owens and Stoessel 2008). While definite statistics of the incidence of SSI are complicated given the gamut of surgical procedures, environment and patients, available data indicate that SSI contributes to more than 15% of reported Hospital-acquired infections (HAI) for all patients and about 38% for surgical patients (Campbell et al., 2013; Owens and Stoessel, 2008; Reichman and Greenberg, 2009). Also, data from across Europe indicate that, depending on surgical procedure and/or surveillance methods used, incidence of SSI may be as high as 20% for all surgical procedures (Leaper et al., 2004). Although, HAIs generally, and SSI are relatively less common in Orthopaedic surgery, compared with other surgical procedures (Johnson et al., 2013), however, when they do occur, osteo-articular infections for example, can be very difficult to treat, with significant risk of lifelong recurrence (Faruqui and Choubey, 2014). SSI leads to significantly higher costs of care from longer hospital stays; it poses a major burden on healthcare providers and the healthcare system, jeopardises the health outcomes of patients and remains a major cause of morbidity and mortality despite improvements in surgical procedures and infection control techniques (Owens and Stoessel, 2008; Tao et al., 2015). Consequently, understanding evidenced-based approaches to reduce/prevent incidence of SSI has attracted significant interests from researchers, healthcare administrators and policy-makers. This essay intends to review current best-practices in prevention of SSIs and to offer recommendations for future practice within orthopaedic settings.

Rationale

This review of best practices in the prevention of SSI following orthopaedic surgery is underpinned by two major reasons. One, despite the considerable improvement in surgical procedures and techniques in most orthopaedic settings, SSI negatively impact on patient outcomes and imposes significant cost on the healthcare system. According to a case-control study reported by Owens and Stoessel (2008), patients who suffer SSI are more likely to require readmission to hospital and have more than double the risk of death compared to patients without SSI. In addition, the median duration of hospitalisation required due to SSI was put at 11 days and the extra cost to the healthcare system estimated at ˆ325 per day (Owens and Stoessel, 2008). Two, the prevention of SSI is hardly straightforward. Given the wide range of factors that modify the risk of SSI, a ‘bundle’ approach with ‘systematic attention to multiple risk factor’ is required for any effective prevention of SSI (Uckay et al., 2013). Thus, by undertaking a state-of-the-art review of orthopaedic SSI prevention techniques/processes, this essay may contribute towards better orthopaedic surgery outcomes for patients and providers.

Prevention of SSI in orthopaedic surgery: Best Practices

According to the Health Protection Agency (2011), the most common pathogenic organisms responsible for surgical wound infections in orthopaedic surgery include methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), Coagulate negative Staphylococci (CoNS), Enterobacteriaceae, Enterococcus spp, Pseudomonas spp, Stretococcus spp as well as occasional cases of unspecified diphtheroids’ of the Corynebacterium spp. and other gram-positive organisms. Moreover, SSIs can be categorised into superficial incisional, deep incisional and organ space SSI (Reichman and Greenberg, 2009). Superficial incisional SSI refers to infection that involves only skin and subcutaneous tissue at the point of incision; deep incisional SSI refers to infection of the underlying soft tissues, while organ space SSI refers to infection involving organs or organ spaces that were opened or manipulated during the surgical procedure. Since the risk of ending up with SSI and the specific type of SSI suffered are determined by factors related to the patient, procedure and hospital environment, current best-practices and guidelines for preventing SSI can be broadly elaborated under these categories.

Patient-related Practices

Existing patient conditions like diabetes mellitus, obesity and/or rheumatoid arthritis have been associated with increased risk of SSI (Illingworth et al., 2013; Johnson et al., 2013). As part of effective patient management, pre-operatively, current body of evidence recommends aggressive glucose control for diabetes patient to reduce the heightened risk of infection due to hyperglycaemia pre or post-surgery. In patients with rheumatoid arthritis, corticosteroids and anti-tumour necrosis factor (TNF) therapy have been argued to delay wound healing and increase risk of infection. However, the British Society for Rheumatology (BSR) recommends that in deciding whether to cease these medications for such patients, pre-surgery, the potential benefits of preventing post-surgery infection should be balanced with the risk of disease flare, pre-surgery (Dixon et al., 2006; Luqmani et al., 2006). In addition, orthopaedic surgery for patients who currently smoke or are obese (BMI above 30kg/m2) should be delayed (until smoking cessation/loss of weight) to reduce the risk of SSI. For example, a randomised, controlled study reported that smoking cessation for just 4 weeks significantly reduced the odds of incisional SSI (Sorensen et al., 2003), while Namba et al. (2005) reported significantly higher odds of SSI in obese patients (>35kg/m2) undergoing total hip and knee replacement surgery, compared with patients that were not obese.

Screening patients for presence of MSSA and MRSA and subsequent decolonisation is one of the most recommended techniques for preventing SSI. Staphylococcus aureus colonisation is reportedly found in the nares of about 30% of healthy individuals (Kalmeijer et al., 2002). This nasal carriage of both methicillin sensitive/resistant S. aureus have been demonstrated as a significant risk factor for SSI. Kelly et al. (2012) reported a significant drop in SSI from 2.3% to 0.3% with the use of intranasal mupirocin and triclosan showers to decolonise patients before orthopaedic surgery. Also, a review of eight randomised controlled trial by van Rijen et al. (2008) reported that the use of mupirocin significantly reduced the incidence of MRSA and MSSA associated SSI. However, guidelines from the National Institute for Health and Care Excellence (NICE, 2008) recommends a combination of nasal mupirocin and chlorhexidine showers for patient decolonisation while Uckay et al. (2013) indicated that available evidence from orthopaedic literature suggests that S. aureus screening, decolonisation and shower constitute a cost-saving, effective strategy to reduce the incidence of SSI in orthopaedic surgeries.

Surgical Procedure-related Practices

Preoperative preparation of skin before incision is one of the major avenues to prevent SSI (Kelly et al., 2012). However, there is no consensus on what antiseptic agent offers the most effective protection against SSI. While NICE (2008) guidelines suggest that both aqueous and alcohol based preparations e.g. povidone-iodine or chlorhexidine are suitable for skin preparation, Darouiche et al. (2010) and Milstone et al. (2008) have raised concerns about the development of bacterial resistance to chlorhexidine. These studies report the relative superiority of 2% chlorhexidine mixed with 70% isopropyl alcohol, while some experts have suggested increasing the chlorhexidine concentration to 4% or the use of 10% povidone-iodine (Uckay et al., 2013). Nevertheless, povidone-iodine or chlorhexidine still remain the gold standard for preoperative skin preparation.

Also as part of skin preparation, NICE recommends that hair should only be removed if necessary, should be done immediately before surgery and with electronic clippers, not razor blades. Recent evidence suggests that use of razor blades can sometimes result in microscopic skin cuts that may act as foci for micro-organisms colonisation, thus increasing the risk of infection (Owens and Stoessel, 2008).

Preoperative administration of antibiotic prophylaxis to reduce the risk of surgical wound infection is widely accepted for surgery in orthopaedic settings, including bone trauma. Several large scale studies have demonstrated that antibiotic prophylaxis, when administered properly, help reduce tissue contamination, during surgery, to levels that do not overwhelm the patient’s immune system, and thus, can reduce the risk of SSI by up to 75% (Chen et al., 2013; Faruqui and Choubey, 2014; Illingworth et al., 2013; Uckay et al. 2013). However, NICE (2008) recommends that potential adverse effects, optimal dosage and most effective time for administration pre-operatively should be carefully considered to maximize the benefit of antibiotic prophylaxis. Uckay et al. (2013) believe that first or second generation parenteral cephalosporins are sufficient in most cases, except in cases of skin colonisation with MRSA, in which case glycopeptide antibiotics may be more effective. However, this should be considered in relation to individual patients’ allergy history. Uckay et al. (2013) also recommend that 30mins – 1hr before incision is the idea time to administer prophylaxis. While this is generally accepted, NICE (2008) recommends that prophylaxis may be given earlier in procedures where a tourniquet is used.

In addition to minimising the risks from the skin and endogenous flora of the patient, the surgical team must also strive to reduce chances of contamination from either their person, the tools used or the procedure itself. NICE (2008) recommends that every member of the surgical team must thoroughly scrub before wearing surgical gown and gloves. There is growing support for double-gloving and frequent glove-changing to reduce the risk of contamination from tiny punctures in surgical gloves that often go unnoticed during surgery. While evidence in support of double-gloving and/or frequent glove-changing intra-operatively as a strategy for reducing risk of SSI remain inconclusive, Widmer et al. (2010) conclude that the practice is supported by expert opinion, especially for lengthy procedures. Moreover, excellent surgical techniques are crucial in preventing SSI. For example, maintaining effective haemostasis while preserving adequate blood supply, removal of devitalized tissues, eradication of dead space(s), gentle handling of tissue and effective management of surgical wound postoperatively can all help reduce the chance of SSI (Uckay et al., 2013).

Hospital Environment-related Practices

The CDC and World Health Organization recommend that doors to the operating room should be kept closed and traffic kept to a minimum to reduce potential contamination of surgical sites (Tao et al., 2015). To achieve this, essential equipment and tools should be stored in the operating room. In fact, Health Protection Agency (2011) suggest that frequency of operating room door opening is a positive predictor of increased bacterial count in the operating room. Airflow in the operating room is another modifier of SSI risk. Vertical or horizontal laminar-flow ventilation systems have been advocated for orthopaedic surgery to achieve ultra-clean air within the operating room and reduce airborne contaminants. Although evidence supporting the effect of laminar airflow systems on SSI risk remains inconclusive, the reduction in airborne contaminants is perhaps an added advantage (Owens and Stoessel, 2008; Reichman and Greenberg, 2009).

Lastly, constant surveillance is an important part of preventing SSI. By following up on patients post-operatively and reporting appropriate data to the surgical team, surgical decisions can be improved upon based on historical records (Skramm et al., 2012). Moreover, surveillance ensures that cases of SSI are identified early and treated before complications arise. Data from surveillance could also form the basis of evidenced-based decision making on facility specific service improvements to reduce incidences of SSI and improve outcomes for all concerned (Skramm et al., 2012).

Recommendations

This essay have reviewed current knowledge on surgical site infection and strategies to reduce its incidence. It is pertinent to state that despite the various precautions elaborated above, complete eradication of surgical site contamination is almost impossible as some endogenous micro-organisms always remain and environmental factors cannot be totally eliminated. To reduce incidence of SSI to the barest minimum, the following are recommended:

It is crucial to adopt a ‘bundle’ approach that ensures that patient, procedure and facility related factors are controlled for as much as possible.
While improving surgical and care delivery is always crucial, surveillance and data collection should also promoted to ensure that changes/improvements in procedures and facility practices are evidenced-based
New technologies and strategies are continually been developed to reduce complications like SSI and improve outcomes for patients, it is important to always stay on top of these developments to ensure that orthopaedic surgeries are not only evidenced-based but contemporary, achieving the best outcome possible for all parties.
Conclusion

Surgical site infection (SSI) poses a significant challenge to patients undergoing orthopaedic surgeries, the surgical team as well as the healthcare system in general. SSI negatively impact patient outcomes and imposes unnecessary demand on healthcare resources. Fortunately, much of the burden associated with SSI can be avoided. This review identifies the multitude of patient and procedure-related factors that modify SSI risk and highlights various evidence-based strategies to mitigate these risks. The paper demonstrates that there is consensus in the literature that by screening and subsequent decolonisation of patients, administering antibiotic prophylaxis, ensuring that surgical tools, equipments and garments are properly sterilised and the operating room is free of airborne contaminants, cases of surgical wound infection in orthopaedic surgeries can be effectively prevented.

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Literature Review
1.0 Introduction

This chapter provides a comprehensive critical literature review of a small number of sources that are considered to be particularly useful in exploring the two key themes of this dissertation. The first of these themes is the impact of drug abuse on the health of the teenagers aged 13-19 in London, while the second is the impact of governmental strategies in tackling drug abuse amongst teenagers aged 13-19 in London. These themes are discussed using the resources selected, and the quality, methodological approach, relevance and ethical and anti-oppressive practices are all part of the critical review. The chapter finishes with a short summary bringing these key ideas together.

1.1 The Impact of Drug Abuse on the Health of Teenagers Aged 13 – 19 in London

The first theme investigates the impact of drug abuse on specific aspects of health on teenagers in London. There are two key sources that form the core of this critical review for this theme. Even so, neither of these relate solely to the target population, and in each case some extrapolation of findings is made in order to describe the likely characteristics of 13 – 19 years’ olds in London.

The first is source is the case-controlled study carried out by Di Forti et al (2015:1), and briefly discussed in Chapter Two above. Looking more closely at this study, and reviewing it critically, it still remains a useful article, as it focuses on the mental health impacts of cannabis and shows a clear association between the use of the drug in its high potency form (skunk) and psychosis. It might not at first appear that the study is relevant given that it started in 2005. However, it continued recruiting for over 6 years, and amassed a wealth of data on those individuals abusing drugs – specifically high potency and easily available cannabis.

The research study used a primary research methodology. For the recruitment of cases, the authors approached all patients (18 – 65 years) with first episode psychosis presenting at the inpatient units of the South London and Maudsley Hospital. They invited people to participate in the study only if they met the International Classification of Diseases 10 criteria for a diagnosis of non-affective (F20–F29) or affective (F30–F33) psychosis, which they validated by administering the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (Di Forti et al, 2015:2). For the controls, the authors used internet and newspaper adverts and also distributed leaflets on public transport and in shops and job centres. The controls were given the Psychosis Screening Questionnaire and were excluded if they met the criteria for a psychotic disorder. While the two groups only included the last two years of the target population group for this study i.e. 18 and 19 year olds, it was a study located in London, and on analysis appeared to indicate a number of characteristics that were felt to be useful for providing information that would also be useful for younger teenagers.

All participants (cases and controls) included in the study gave written informed consent under the ethical approval obtained from the Institute of Psychiatry Local Research Ethics Committee. There did not appear to be any unethical practices, but the study had the potential to be oppressive as by the nature of the patients presenting at the clinics, and by the nature of their access to skunk, being more likely to be of certain ethnic groups – especially of black West Indian origin – it could be argued that the study to some extent misrepresented the populations of south west London, and more specifically, the West Indian communities found there. In other words, the inclusion of participants from these origins might be likely to give observers an unjust view of the ethnic group or of the population of that area of London as a whole.

The method used with the participants was quantitative and involved questionnaire assessments, specifically socioeconomic data and the Cannabis Experience Questionnaire modified version (CEQmv) which included data on history of use of alcohol. tobacco, alcohol, any other use of recreational drugs, and detailed information on cannabis use (i.e. first use age, use duration, frequency of use, type of cannabis used) (Di Forti et al, 2015:2). Between 2005 and 2011, the researchers approached 606 patients of which 145 (24%) refused to participate, therefore 461 patients with first-episode psychosis were recruited. Using a range of statistical tests, and adjusting for a number of variables including the variables for frequency of cannabis use and the type of cannabis used, and in combining these the authors found that controls were more likely to be occasional users of hash, whilst the frequent users were more likely to be using skunk. They also found, using logistic regression, that those people who had started using cannabis at a younger age had a greater risk of developing psychotic episodes (Di Forti et al, 2015:5).

The second resource to be analysed was the study by McCardle (2004). This was a literature review focusing on the impacts of substance abuse by children and young people. Although this did not use primary research, it provided a useful analysis of a number of other studies. Although the age of this study meant that it might have had limited relevance to teenagers in 2017, in fact the study related directly to the findings of the later Di Forti et al study. This was because McCardle (2004:1) found that cannabis was becoming stronger than it had been in the past – just as Di Forti et al found that skunk use was increasing and that it was of a much higher potency than previously. McCardle (2004:2) also found that there was a range of mental health issues resulting from the use of cannabis, including an increased risk of suicide, and an increase in aggressive, disassociated behaviours, anxiety, depression and other similar problems (McCardle, 2004:2). Another useful aspect of this research was that it identified the problems of terminology relating to the gathering and analysis of data – so many different terms are used that it is often difficult to ascertain accurate trends and outcomes (McCardle, 2004:3). While it would have been preferred to have used a London based source or one that engaged participants of the target age group though a primary method, the lack of sources of academic literature meant that this study was valuable in that it analysed other studies, and also existing datasets from the UK government. The article also focused on the social impacts of cannabis, for example, looking at the developmental impacts, and the negative effects on education, both of which could lead to poor outcomes in terms of quality of life and attainment in later life.

The findings from these two articles provided valid evidence of the relationship between the use of cannabis and mental, emotional, social and physical health of teenagers and young people. Although there was limited focus on the population age target group for the dissertation specifically, both articles provided relevant points of interest, and it is possible to extrapolate from them to state that teenagers in London engaged in cannabis abuse are very likely to be at risk of experiencing the various health effects identified above.

3.2 The Impact of Government Strategies in Tackling Drug Abuse Amongst Teenagers Aged 13-19 in London

Finding academic research sources that focused on recent government strategies aimed at the target group based in London was very challenging. For the most recent strategy – the Troubled Families Programme, Lambert and Crossley (2017:1) get to the very heart of the ethical and oppressive practices issue, as they argue that this government strategy is one of a wider spectrum of policies that locates problems within the family itself, and which emphasises behaviour as the target for action irrespective of the socio-economic influences that exist. This is a review study – critically reviewing a strategy – and is very current, as the TFP has recently been revisited by the Government, who are considering an extension, despite evidence that it has not met its targets or expected outcomes. While this article is not based on a piece of primary data, the authors have conducted primary data about this issue through interviews in the very recent past, and the article refers to these. They have found that TFP has continued the view of target families as an ‘underclass’, as ‘neighbours from hell’ and as expensive and very difficult to ‘treat’. While the TFP took a holistic approach, using one individual or team to work with families on all of their problems, Lambert and Crossley (2017:4), and others (Bonell et al, 2016) argue that the underlying attitude of the Government and of the strategy meant that its approach was unlikely to succeed.

3.3 Summary

This chapter showed that there were clearly associated health impacts with the use of cannabis; some of these impacts were severe, and often included mental illness and behavioural change, especially where high potency cannabis was used. It also showed that despite many years of government strategies and policies, there still does not appear to be a solution that can reduce the use or impacts of cannabis and other drugs. The final chapter provides a reflection on the research undertaken for this dissertation, and provides some brief conclusions and recommendations.

CHAPTER FOUR – REFLECTIONS, CONCLUSIONS AND RECOMMENDATIONS
4.0 Introduction

In this final chapter, three tasks are completed. First, a reflective account of the research is undertaken. In research and practice, reflection on a task and outcome is very important because it provides the author with the opportunity to look back and learn from their actions. There are in fact two types of reflection, both of which might be applicable to this work. The first definition is that of ‘reflection’ which is considered to be a ‘process or activity’ that involves thinking and is judged to include cognitive processes of problem finding and problem solving (Leitch and Day, 2000:180). The second type of reflection is that of ‘reflective practice’. This is the use of reflection and reflective skills to transfer learnt knowledge i.e. theories to the application of those theories to the everyday practices of an individual. It has been shown to be very important for individual practitioners as it aids their ability to learn from their actions and associated outcomes, and enables them to develop improvements based on experience and theoretical knowledge (White et al, 2016:9).

There are two main models of reflection that can be used to support the reflective researcher or the reflective practitioner. These are Kolb’s model of experiential learning (Kolb, 1984) and Gibbs’ reflective cycle (Gibbs, 1988). Gibbs developed his model as a refinement of the earlier Kolb model, and it is Gibbs’ model that is used in this dissertation.

Figure 1: Gibbs’ Model of Reflection (Park and Son, 2011:2)

The Gibbs Model provides a researcher with the opportunity to gain a deep understanding of what they have learned (Park and Kastanis, 2009:11) and the strengths and weaknesses of their work, their underlying values, the insufficiency of their approach, and areas of improvement (Park and Son, 2012:3). For these reasons the Gibbs Model will be applied below.

4.1 Reflection on the Process of the Research

4.1.1 The Experience

The process of writing the dissertation was both challenging and enjoyable. It was enjoyable because any research activity is one of problem solving and of searching for information, and these two activities can be very satisfying when they result in finding out something new. While primary research is often seen as the most valid form of activity, in fact secondary research, based as it is on the gathering of existing data, and the synthesis of that data to suggest new outcomes or findings, can be just as valid, and just as difficult as carrying out processes that collect new or primary data.

4.1.2 The Challenges and the Achievements

As alluded to a number of times throughout this dissertation there were a number of difficulties or challenges. The choice of the topic was in retrospect a good one because it focussed on a population group in a particular location, London, that had clearly received little research focus previously. While there has been substantial data gathered on drug use and abuse more generally in the UK and more generally across age ranges, very little has been done in relation to the 13 – 19 year old age group. In fact, it was this aspect that caused the greatest difficulty in completing the dissertation – the lack of resources and data available that were relevant to this age group, in London, for any kind of drug abuse other than newspaper articles that often used the issue of drug abuse in relation to crime, ethnic minorities or deprivation, meant that the data that was available had to be used carefully. For example, it was possible to obtain academic resources such as that of Di Forti et al, that looked at drug abuse, specifically, cannabis, in London, but only two years of respondents in that study (18 and 19 year olds) fit into this dissertation, whilst the study by McCardle (2004) provided relevance to the wider age group (15 – 24) but was not based in London, so could point to some useful outcomes but did not have specific locational knowledge. In relation to the strategies developed to address the issue, again the resources of an academic nature were very limited, made even more challenging because the most recent strategies, i.e. those that had occurred in the past five years, have yet to undergo much academic analysis, but as they are a very different approach from those used a decade or so ago, there is little point in trying to evaluate those older approaches.

Despite the difficulties outlined above, it was felt that there were a number of positives obtained from the research. As there was such a dearth of resources available, this dissertation appears to provide new research and new analysis of data for this group of the population in this location. As a result, the author felt that the validity of their choice of topic and their research approach was justified to some extent. In terms of time management, it was felt that the research was planned well, and even though the search for data and resources took longer than expected, it was still possible to incorporate the timing required into the overall research schedule. The research also challenged the overall beliefs and judgements held by the author at the start of the process. Whilst it was felt that some degree of knowledge was held about these issues, there were some preconceptions held about the type of teenagers that participated in drug abuse. The gathering of the data enabled the author to begin to challenge those preconceptions especially in relation to the factors that cause people of this age to start abusing drugs. This new understanding allowed the author to start to view the issues differently.

4.1.3 Changes Required

There are a number of changes that could be implemented to make the research easier and to address the question of limited resources. Firstly, the age range would be extended to include children from the age of 0 years to 24 or 25 years, as this would enable a greater number of data sources to be used, and they could be more easily analysed and extrapolation made for teenage years. Second, the inclusion of drug abuse by parents impacting on the health of their children would be included, as this issue has consistently emerged as a key problem for children and teenagers throughout the data collection, and can be a major factor in determining whether teenagers participate in drug use and abuse. Finally, although London would still be the locational focus, because a lot of data that is collected for London and the South-East, the locational boundaries would be stretched to incorporate this area within the research. If these changes were put into place, it would be a positive exercise to undertake the research process again to see if it was possible to obtain data and achieve findings that were even more valuable than those already developed.

4.1.4 Applying the Gibb’s Model of Reflection

Figure 2: Biggs’ Reflective Model Applied to This Research

Having applied Gibbs’ model of reflection it is helpful to see that the reflection that is carried out in stages can lead to a targeted plan of action, which can form the framework for new research. Gibbs’ model does not necessarily allow for complexity, however, as it is a linear-cyclical model, and used in this way cannot represent the many complexities and variables that characterise the issue of drug abuse amongst teenagers.

4.2 Conclusions

The research question that this dissertation set out to examine was:

What patterns of drug abuse occur amongst teenagers in London, and what are the causes, health impacts and possible solutions?

Despite the difficulties in obtaining specific data for teenagers aged 13 – 19 in London, there was sufficient information available to be able to provide an answer to this research question. From the prevalence perspective, the data showed that while the prevalence of drug abuse was decreasing overall, there were areas of London that had disproportionately higher levels, especially amongst specific ethnic groups. However, amongst all drug abusers, cannabis was the most used drug. The causes of drug abuse amongst teenagers was found to be a complex mixture of environmental, emotional, mental health and peer pressure related factors, meaning that addressing the problem is always going to be challenging for policy makers and healthcare providers.

In relation to the health impacts, the previous chapter has revealed that there is clear evidence that its use can be clearly associated with health outcomes of mental health including psychosis and the development of schizophrenia for drug abusers of any age. Not only that, but it is also quite apparent that teenagers engaging in drug abuse are much more likely to experience other health related problems because of their attitude to risk, and their participation in high-risk behaviours when they are under the influence of the drug. These other problems include contracting STIs, teenage pregnancy, the taking of other drugs and substances that have more severe health impacts, participating in criminal activities that can lead to violence in an attempt to obtain money to buy drugs and so on.

Looking at the strategy that has most recently been developed to try and address the problem of teenage drug use in London, it is apparent that it has not succeeded in its aims, objectives or targets. This seems to be the result largely of the oppressive nature of all such strategies held by UK Governments over recent years – an attitude that views those with drug abuse and other problems, as ‘problem families’ that need to be ‘solved’, instead of trying to really understand what it is about society in general that leads to such families existing in the first place. A focus on social, economic and environmental issues rather than on the families themselves might result in a better outcome.

4.3 Recommendations

Having carried out a review of the literature surrounding this issue, there are some key recommendations that can immediately be made. The first of these recommendations relates to the data available for this issue – as indicated previously, one of the challenges of completing this dissertation was the paucity of data relating to the specific population being studied. It is, therefore, recommended, that research studies, or government agencies collecting data, should target this age group specifically when data is being collected about drug use or abuse. An alternative to this is for researchers to obtain the raw data from the various data collection agencies and sources, and to extrapolate the data that crosses the boundaries of the targeted populations group, and reprocess that data for the target age group. The second recommendation relates not to the data, but to the issues. It appears that controlling the availability of drugs is difficult, especially as there are so many types, and some, like cannabis, appear to be regularly available. As there seems to be an ongoing reduction in the number of young people using these illegal drugs, it would seem sensible to capitalise on this trend by providing better educational initiatives to inform people of the dangers to their health. It would also be appropriate to try and determine which factors were most likely to cause teenagers to start abusing drugs and to find ways of addressing these factors more effectively than has been the case to date.

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Discuss how MRSA became resistant to antibiotics and became such a prevalent organism associated with British hospitals. Explain how MRSA is treated and touch upon the wider implications for antibiotics and the future of healthcare.

Introduction

It may be argued that micro-organisms are the most successful life form on the planet partly due to their pervasive presence and their utilisation of any available food source, including humans. The ubiquitous presence of micro-organisms and their astronomic numbers give rise to many mutations that account for rapid evolutionary adaptation and in part for emerging antibiotic resistance (Evans and Brachman 1998). Bacteria have evolved numerous structural and metabolic virulence factors that enhance their survival rate in the host. Once such bacteria is Meticillin Resistant Staphylococcus aureus (MRSA).

What is MRSA and why did resistance occur?

The genus Staphylococcus are non-motile, Gram-positive cocci, measuring 0.5-1.5µm in diameter and are commonly found in the nose and on skin. They can occur singly, in pairs, short chains or in grape like clusters. There are several species but Staphylococcus aureus has been a significant pathogen for humans for many years. It is different from other Staphylococci because it produces the enzyme coagulase. Potential virulence factors include surface proteins, which promote colonisation and membrane damaging toxins that can either damage tissue or invoke other disease symptoms. Before the emergence of antibiotics, the mortality rate for Staphylococcus aureus infections was 80% (Fedtke et al 2004). The versatile organism has developed a resistance to Meticillin due to its mobile genetic element the mecA gene, which is found in the Staphylococcal cassette chromosome mec (SCCmec) and this mediates the resistance to ?-lactam antibiotics such as Meticillin (Greenwood 2000).

Of the current antimicrobial resistant organisms, Meticillin-resistant Staphylococcus aureus (MRSA) is probably the most challenging in a hospital setting. MRSA first came to the public’s attention, here in the UK, in the 1980’s when the first epidemic strain, Epidemic Meticillin-resistant Staphylococcus aureus (EMRSA was identified. Subsequently a further sixteen epidemic strains have been recognised. Each strain has its own genetic makeup and display resistance to different antibiotics. EMRSA -15 and EMRSA -16 are the most common strains found in the UK, accounting for 96% of all MRSA bacteraemia. Worryingly, a new strain, EMRSA – 17 was identified in 2000. Not only did it display resistance to the previously recognised antibiotics but also Fusidic acid, Rifampicin, Tetracycline and sometimes Mupirocin.

Evolution and natural selection have produced the mechanism through which micro-organisms can adapt to their ever changing environment, including resistance to natural and man made antibiotics. Bacteria including Staphylococcus aureus are adept at infecting and colonising humans and also aid other microbes to cause infection by producing anti-inflammatory molecules, which allow microbes to evade the body’s immune system (Fedtke et al 2004). They are also able to hide in biofilms and proteins called defensins.Therefore bacteria successful in these evasive strategies are able to pass these strategies down the generations in a process called horizontal gene transfer (Bush 2004). However, this is not a new phenomenon. As far back as 1940, the journal Nature published an article describing the discovery of an enzyme that destroyed Penicillin called Beta-lactamase.

Two mechanisms are used by Staphylococcus aureus to cause infection (Roghmann et al 2005). These are toxin production and tissue invasion. Toxin production is exemplified in gastroenteritis resulting from consuming Staphylococcal enterotoxins in food and tissue invasion is demonstrated in the classical abscess comprised of pus contained in a fibrin wall and surrounded by inflamed tissues.

Why a hospital problem?

Staphylococci are the classic hospital acquired bacteria and Staphylococcus aureus is the commonest cause of surgical site infection. For years, glycopeptides, such as Vancomycin have been the first choice for serious Staphylococcus aureus infections. Now clinicians are facing strains with reduced susceptibility to glycopeptides, with no decline in virulence (Dancer 2003).

Within the hospital environment there are recognised high risk areas/departments where patients are at greater risk of infection. Two such areas are intensive care units and burns units. Examples of factors associated with higher risk MRSA acquisition are previous antibiotic therapy and frequent admissions. The more often a patient is admitted to hospital the greater the chance of exposure to MRSA and being prescribed antibiotics. Patients and their pre-disposing factors,,for example, being immunocompromised,and having wounds make them more susceptible to acquiring MRSA, In addition the healthcare workers and the environment are also potential reservoirs of MRSA. The environment as a reservoir has been more difficult to assess (Dancer 2004), although work done by Rayner 2003 confirmed that MRSA has been isolated on patient equipment.

The term risk factors, which are often used in relation to MRSA, apply to the strength of association between the organism and the odds of going onto develop an infection.

The factors responsible for increasing resistance are complex and varied as are the potential strategies for overcoming the problem. Inappropriate prescribing and overuse of antimicrobials by clinicians may be driven by lack of understanding of the problem and inadequate surveillance for resistance.

Poor prescribing and increasing resistance however not the only issue in the management of Staphylococcus aureus. This is where medical microbiologists are pivotal in the appropriate use of antimicrobials. They can provide clinicians with laboratory reports that contain a restricted number of antimicrobial sensitivities, as well as advising on the correct method and appropriate specimen to obtain. This saves time and resources. Therefore the patient should receive the appropriate antimicrobial treatment at an earlier stage.

However, it needs to be acknowledged that prescribers prefer and adhere more closely to policies that take an educational rather than a restrictive approach. Some view policies as rigorous and fixed and relate better to guidelines, that are seen as more flexible and acknowledge that some patients will fall outside of the recommendations (Binyon 2000). There are also legal aspects to consider, as it is more difficult to justify action taken outside a policy than a guideline.

Ideally a guideline will limit antimicrobial prescribing to situations where there is a clear indication for their use and that they should be administered for the shortest effective duration. The drug of choice should be appropriate, narrowest in spectrum and correct in dose and duration (SIGN 2000). Prophylactic antimicrobials should be only given for the recommended period. Emmerson (2000) argued that perhaps a guideline’s most important function is that of a vehicle for ensuring regular discussion amongst those concerned.

A study by Harrison (1998) found that approximately 20% of all prescribed antimicrobials relate to hospitalised patients. Of this 20%, 20-50% was unnecessary. His study also revealed that 25-50% of all hospital admissions receive an antimicrobial at some point during their stay. The study also made the point that even if numerous bacteria are killed during a single course of antimicrobials, if one mutant microbe remains in that patient; the possibility exists for the rapid establishment of a resistant population.

Current problems within the National Health Service exacerbate the issue. These problems include ‘hot’ bedding, overcrowding of wards, understaffing, inadequate cleaning, poor laundry services, patient relocation and poor isolation facilities. Dancer and Gemmill (2003) argue that erosion of hygiene standards emanated from the ready provision of antimicrobials.

Numerous guidelines have been written in order to attempt to control these problems. However sometimes what is good in theory is not so good in practice and there may be various explanations for this failure. Regardless of how sound the principles are, there may be insufficient resources to implement them. A prime example here is lack of isolation facilities in hospitals (Cooper 1999). There is a wide variance in which resistance is handled in different hospitals. Some hospitals isolate and treat the patient regardless as to whether or not the patient is colonised or infected. Therefore risk assessment in conjunction with the infection control team on a case-to-case basis is vital when resources are scarce.

Presently Vancomycin and Teicoplanin are used to treat MRSA infections. The majority of patients are colonised and are asymptomatic. They carry MRSA on skin or in the naso-pharynx. Patients who are found to be colonised in hospital settings are actively treated or decolonised. This is done by prescribing five days of a body wash used either in the bath or shower. The wash is also used to cleanse the hair. The wash includes chlorhexidine gluconate and is effective but known to dry out the skin with prolonged use. In conjunction with the body wash the patient is also prescribed a nasal cream which is applied 3 times a day for 5 days to both nares. The cream usually used is Bactroban which contains Mupirocin. For MRSA cases displaying intermediate or total resistance to Mupirocin, the cream of choice is Naseptin (BNF 2015).

Discussion

Antibiotic resistance may lead to routine infections being fatal. Antibiotics are losing their effectiveness at a rate that is both alarming and irreversible. The media talks of a post antibiotic era or antibiotic Armageddon.

So what of the future? Researchers are developing a vaccine. In order to achieve herd immunity, 85% of the population would require to be vaccinated and the vaccine would also have to provide protection against all the strains to which someone is likely to be exposed. However, limited vaccination of at risk groups may be possible (Farr 2004). Work is also ongoing in regard to lysostaphin, which is an enzyme that causes the cell wall in Staphylococcus aureus to rupture. It was first described 40 years ago. As it is specific to Staphylococcus aureus, it would not interfere with normal commensal flora. It could be used to reduce nasal carriage and subsequently reduce infection rates. Early clinical trials have been positive.

Assuming all the issues above were overcome, resistance still would not disappear. Thus there remains a need to continue with research into how and why bacterial mutations occur and into the development of new innovative drugs, vaccines and diagnostics. More resources need to be channelled into education of health care professionals, allied with effective infection control measures.

Every healthcare worker has a duty of care to comply with infection control policies. As long as infection control procedures are adhered to, hygiene improves and antibiotics are used prudently, there is the prospect of bringing MRSA under control in the hospital setting. However, we have to be aware that emphasising the importance of MRSA colonisation via policies and guidelines may result in accidental neglect of the factors that cause infection.

As MRSA will continue to spread in the wider community, via both humans and animals, some of the strains spread may be highly toxic and with an ageing population and increasing numbers of immuno-compromised patients, the danger will only increase. As more advances are made in medicine, these vulnerable populations will also increase. Those at most risk are those in long-term care homes, of which there is an ever-increasing number. While cross infection routes are relatively easily defined in a hospital setting, the situation in the community is not and because care homes are major feeders when it comes to hospital admissions, the impact on the crisis stricken NHS will continue.

Therefore MRSA screening was welcomed when introduced in 2013 across the UK following a nationwide study of the efficacy of screening patients on admission to hospital (HPS 2009). The aim of screening patients for MRSA is to identify patients that are colonised or infected with the organism. These patients can then be managed appropriately to reduce the risk of self-infection and of transmitting the organism to other patients.

As for MRSA rates being indicators of quality healthcare, they should be considered as tools that prompt further inquiry, rather than permitting judgements on quality of care.

Conclusion

MRSA has the capability to cause misery, morbidity and even fatalities under certain circumstances. The body is an incredibly complex machine; scientists are making striking advances in elucidating the precise molecular basis for the interaction between adherence surface structures of an organism and corresponding specific surface receptors on a host cell. Much more has still to be learned and microbiology will continue to play a huge part in research in order to understand the mechanisms of pathogenicity and the development of antibiotic resistance. This is essential for future treatment and prevention of infections allowing humans and micro-organisms to continue to co-exist.

Prevention and control of healthcare acquired infection demands the continual development of intervention strategies aimed at curtailing further antimicrobial resistance and reducing the spread of existing infection. Success however will only be achieved with a multi disciplinary approach at individual and organisational level. Infection prevention has to become an integral part of everyday healthcare practice (Fairclough 2006).

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Choose one gender group and critically discuss how their health outcomes can be improved in regards to ageing.

The World Health Organisation’s definition of ‘Health’ emphasizes that the overall health of an individual is determined by not only their physical well-being but also their mental and social well-being. Therefore, NICE has framed its public health outcomes broadly to allow a range of health factors to be addressed. The paper will discuss how the health outcomes of the female gender can be improved in regards to ageing. Hence, due to the limited word count of this discussion, the health initiatives addressed will be physical activity and mental well-being with reference to Menopause, Osteoporosis, Depression and Breast Cancer.

Menopause has not just been chosen because it impacts only women but because in 2007 females expressed the need for more information on menopause and its impacts on their health (BMS, 2015). This has driven the creation of new clinical guidelines to be published in approximately four months time for application in all NHS Healthcare settings (BMS, 2015). The formation of these guidelines in response to the surveyed women may act as a possible improvement in the delivery of the healthcare treatments and advice given by practitioners because a greater focus is hoped to be put on menopause than demonstrated in previous years; this could then improve the quality of health education given to the patient, hence allowing them to understand their condition better. A better personal understanding of a condition can allow a patient to be more active in the decision making processes in partnership with the practitioner (D’Ambrosia, 1999). This could then improve the relationship between the patient and the practitioner; Empowerment via knowledge can also positively impact the confidence of the patient because they may be able to apply principles of self-help in some situations where menopause was affecting them because they would have the knowledge to make changes in their lifestyle choices and routines. For example, exercising regularly is promoted in the menopause period to avoid gaining extra weight or to maintain muscle mass and bone strength (NHS, 2014).

Health Psychologists often unravel menopause as a bio-psychosocial event in which social, cultural and biological factors can impact a woman psychologically. Therefore, weight gain may affect their self-esteem, self-confidence and self-image (Ogden, 2012). Hence, health education is not only a method of improvement for health outcomes related to specific conditions and the associated treatments but it also encourages the individual to self develop.

Interestingly, self-image / self – representation is discussed within all media forms in regards to both men and women, however more so for women. Also, ageing and self-image are often not directly addressed within academic texts that analyse the impacts of ageing, yet the physical symptoms of menopause can psychologically impact a woman as mentioned previously in this discussion. Furthermore, despite surveys and questionnaires forming knowledge in regards to the functional aspects of an elderly woman’s life, we know very little about their own perceptions on being someone who is considered as older by society (Queniart and Charpentier, 2011). The definition of Health by WHO is inclusive of social wellbeing, but we still have very limited specific research on elderly women and self-representations. Therefore, there is a need for both qualitative and quantitative research to be conducted on elderly women to be able to support these women to see ageing as a positive process and not a negative process, as this is still a widely accepted connotation amongst society in general and among women.

Within the NHS outcomes framework, mental illness is addressed to acknowledge the growing recognition of mental disorders both diagnosed and undiagnosed and to improve the quality of care for those suffering from mental health conditions. Mental health conditions are good case studies to analyse to explore the barriers which may prevent individuals from reaching their health outcomes. Generally, statistics show that more women access mental health services in comparison to men, however females from BME communities access mental health services less than females from non BME communities. It is often shown in reports that the relationship between BME individuals and healthcare services differs from the relationship of the native community with the healthcare service (Department of Health, 2011). Furthermore, South East Asian women may be dealt with after a delayed period of time and possibly even with inappropriate mental health services (Department of Health, 2011). This has been shown in some cases even where the female has suffered from severe mental health issues. In this case, the lack of accessibility and engagement will prevent these women achieving better health. Elderly men and women are also victims of mental disorders, with statistics suggesting approximately 15% of adults who are 60 years and older being affected (IHME, 2012). Therefore, barriers to health services will also delay treatments for these individuals. There are a variety of reasons why these barriers exist including; language barriers, cultural reasons, practitioners who do not understand the latter, the location of services and the individual’s own perceptions of the mental health condition. Furthermore, it is extremely difficult for a health service to be specialist and practical for all populations, therefore social inequalities exist as barriers to improving the wider health outcomes for services and governing bodies as well as the personal health outcomes of elderly patients.

Elderly individuals face biological, social and mental changes as part of the ageing process and they have to learn to cope and accept these changes. Many elderly individuals also lack the company of family or friends due to their circumstances. These changes could impact an individual’s everyday activities, which then could negatively impact their mental well-being causing them to suffer from depression because they have become socially excluded. Hence, it is important that elderly individuals know how to access specialist services which may not be necessarily healthcare based but who have personal wellbeing as central to their work.

An example of such services are campaigns which aim to tackle elderly depression by focusing on preventing social isolation amongst this age range though the promotion of social activities within community based environments. It is extremely important to recognise that the older age groups in society desire to have or feel similar positive health and well-being states as the younger age groups. However, the method of achieving these positive health and well-being states will in most cases differ between the age groups and also at what level individuals within these groups will be content with their health outcomes may differ too. For example, the Calderdale Clinical Commissioning Group in West Yorkshire has recently invested approximately one million pounds to improve the health and wellbeing of individuals via inclusion within groups, activities and accessibility to services through ‘The Staying Well Project’ (The Halifax Courier, 2015; James, 2014). Achievement of better physical health is viewed highly in this project so physical activity sessions will be delivered for elderly individuals, however the sessions are most likely not going to be at the pace of what would be delivered for younger individuals, traditional activities may be replaced by walking football, tai chi or salsa (James, 2014; NHS, 2013). Improved fitness is a desired health outcome which can support the improvement or treatment of a variety of conditions both acute and chronic, including the prevention of weight gain due to stress in menopause (The Mayo Clinic, 2013).

Also, recommended guidelines for exercise to prevent the onset of musculoskeletal conditions differ depending on the individual’s age and their present health and well-being. Osteoporosis is more prevalent in elderly women due to hormonal changes in the stages of menopause (NOS, 2010); however this may also be due to a lack of exercise or adopting a sedentary lifestyle in early life (WHO, 2003). Osteoporosis negatively impacts bone density either by reducing bone density or preventing bone from developing hence the individual becomes more at risk of acquiring bone fractures. However, physical activity and healthy eating would still be needed for maintaining overall health and as an attempt to maintain bone density, yet an individual may potentially injure themselves by breaking a bone, which then could directly impact their overall health and wellbeing. Doctors and physiotherapists (and relevant knowledgeable individuals) are advised by NICE to promote sufferers of osteoporosis to exercise safely and gently to avoid injury however most reports highlight patients’ lack knowledge of what is considered safe in accordance to their condition (NICE, 2013; Moore, 2011). Therefore, if more specific knowledge of appropriate exercise was given to the patient in relation to their condition, patients could ensure they are exercising safely; these patients could then become independent exercisers who would be more likely to sustain exercise in their daily habits for a longer period of time are able to feel fuller benefits of exercise.

In addition to this, there is a lack of research into social inequalities due to musculoskeletal conditions associated with ageing. However, a recent paper suggests that some sufferers of musculoskeletal disease are becoming victims of material deprivation because their physical ability is preventing them from using or owning social possessions. For example, the young-old Hertfordshire Cohort Study had 3,225 participants who could not possess a home due to lower grip strength and frailty, of which 23.1% were women (p.54, Sydall, 2011). The health outcomes of these individuals may not be solely related to physical health outcomes in relation to improving their muscular strength but they could also desire better mental and social health outcomes because these women are facing challenging life experiences. These outcomes can be achieved or supported by secure methods such as receiving social care support within their own home, fitting assistive healthcare/Telecare technology, by accessing supported living schemes or by sharing their accommodation. This will allow them to feel at least partially in possession of important materialistic things such as a home. Addressing these wider non physical health implications is important to prevent further health and social care concerns because these elderly women may have lost their residence due to the inability to function within their home due to their condition, and this feeling could lead to a lack of control and autonomy within their life, which could then lead to depression, hence co morbidities. To promote positive thinking and motivation in ageing, alternate therapeutic activities such as life coaching and talking therapies may be more engaging and with little or no side effects in comparison to drug based medication, to tackle what is usually diagnosed as clinical depression or anxiety (NHS, 2014).

Cohort studies suggest that physical activity has a protective role in an individual’s life either to prevent the development of conditions or the deterioration/maintenance of health and wellbeing. A study in the Netherlands has suggested physical activity can protect premenopausal women from breast cancer; this study looked at the recreational activities of women throughout their life (Verloop et al, 2000). This major study suggested that present, past and future studies would struggle in measuring all kinds of physical activity done by women due to the extreme difficulty in classifying all movements and the impact of these movements. This study suggested that the relationship between the initiation of physical activity and the risk of breast cancer needed to be examined further – in order to form more reliable public health recommendations. Also, the public need to understand why physical activity is important for them at a more developed level than it simply being part of a recommended ‘healthy living’ regime or for ‘weight management’ or to ‘prevent arthritis’ or ‘prevent cardiovascular disease’, so that the role of physical activity is of greater importance. This will improve specific health outcomes for individuals suffering from specific disease and a greater need for movements and durations of exercise will be understood by the individual.

To summarise, both physical activity and mental wellbeing health outcomes for women when ageing can be improved via health education because it will motivate individuals to self-help. To improve process this, further research needs to be done on the specific impact of physical activity on conditions and also the psycho-social impact of specific diseases; this will improve public health recommendations. Social inequalities such as accessibility of services and the perceptions of female elderly stereotypes need to be addressed via community engagement work at a local level and via national incentives. Lastly, recognition of the wider implications of poor health outcomes will allow professionals to better support both women and men through the ageing process.

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With reference to the UK, discuss the reasons why tuberculosis (TB) is a contemporary public health issue and give examples of relevant public health and health promotion initiatives.

With the exception of HIV/AIDS, infection with the Mycobacterium tuberculosis complex (MTB) causes more human deaths each year than any other infectious agent (World Health Organization, 2014a). The symptoms of tuberculosis (TB) are often non-specific and depend on the site of infection. Patients may present with fever, anorexia, weight loss, night sweats or lassitude, but a persistent productive cough is the hallmark of pulmonary tuberculosis (Department of Health, 2006). MTB bacilli multiply within infected macrophages for long periods of time and may be transported in the lymphatics or bloodstream to any part of the body (Gill and Beeching, 2004).

Humans are the only reservoir of infection and transmission of tuberculosis occurs when infectious respiratory secretions are aerosolized by coughing, sneezing or talking. These may remain suspended in the air for long periods and are small enough to reach terminal air spaces if inhaled (Gill and Beeching, 2004). Patients with lung disease are the main source of infection and 52% of cases notified in the UK in 2013 had pulmonary disease (Public Health England, 2014c). 5 to 10% of people will develop active tuberculosis after primary infection reducing to 3% within one year of exposure; however over 90% of MTB infection is non-pathogenic within a normal human lifespan (Gill and Beeching, 2004).

The incidence of tuberculosis in the UK in 2013 (12.3/100 000) was higher than most other Western European countries (European Centre for Disease Prevention and Control (ECDC)/WHO Regional Office for Europe, 2013) and nearly five times as high as the United States (Centers for Disease Control and Prevention, 2013), having increased steadily since the late 1980’s (Public Health England, 2014a). Rates of infection have declined by 11.6% in the past two years, where 73% of cases occurred among people born outside the UK. Of these, India, Pakistan and Somalia were the most common countries of origin but only 15% were recent migrants indicating a high rate of reactivation of latent tuberculosis (Public Health England, 2014c). The number of migrants from countries with very high TB incidence (>250 per 100,000) decreased by 68% in the last decade and indicators of recent transmission reflect a decline in primary infections. However, the rate of infection among the UK born adult population has remained stable (Public Health England, 2014c) and strain typing suggests that up to 40% of all UK cases may be newly acquired (Public Health England, 2014a). Consequently, Public Health England has identified TB as a major priority (12).

Globally, tuberculosis affects predominately young adults (World Health Organization, 2014b) and the highest rates of infection in the non-UK born population are among 25 to 29 year olds. Of patients born in Britain, TB is most virulent in those aged over 75 years and both sexes are equally at risk (Public Health England, 2014c). The burden of TB in England is concentrated in the most deprived communities of large urban areas and London accounted for 37.8% of patients in 2013 (Public Health England, 2014c). Nearly half of these cases were unemployed and 10% had a history of alcohol or drug misuse, homelessness or imprisonment. 6% were health-care workers (Public Health England, 2014c). Tuberculosis is particularly virulent among the immunosuppressed and people with HIV are 26 to 31 times more likely to contract the disease. Tobacco use has also been associated with 20% of TB cases worldwide (World Health Organization, 2014b).

TB is transmitted most effectively in environments where MTB microbes accumulate in the atmosphere, for example in overcrowded and poorly ventilated living and working conditions (Gill and Beeching, 2004). Individuals with close and/or prolonged contact with a patient with pulmonary tuberculosis or connections to higher-prevalence areas of the world are particularly at risk (Department of Health, 2006). Transmission is also favoured by dark and humid conditions, such as mines and prisons (Gill and Beeching, 2004) and several authors have implicated vitamin D deficiency in the disease pathogenesis, although findings are varied and inconclusive (Kearns et al., 2014). Active TB may be mild or asymptomatic for many months and sufferers may unknowingly infect up to 15 people over the course of a year (World Health Organization, 2014b). Drug-resistant TB is an increasing problem in the UK and multi-drug resistant TB comprised 1.6% of cases in 2012 (Public Health England, 2013a). Although MDR tuberculosis is unlikely to be more contagious, patients are infectious for longer than those with fully sensitive tuberculosis (Borrell and Gagneux, 2009, Anderson et al., 2014).

The features of effective national TB control programmes have been well documented (National Institute for Health and Care Excellence, 2011, Story et al., 2012, Department of Health – TB Action Plan Team, 2007, Public Health England, 2014a) and include transparent systems of accountability, adequate resources, active local implementation and close outcome monitoring (Abubakar et al., 2011). These activities are managed in the UK by Public Health England together with a wide range of stakeholders such as NHS England, and include screening. Screening strategies differ for the detection of early active and latent asymptomatic TB, the latter of which is recommended by NICE for individuals at high risk of infection (National Institute for Health and Care Excellence, 2011) and referred to as active case finding (ACF) (Golub et al., 2005, Zenner et al., 2013). Identifying tuberculosis early allows for prompt treatment and reduces transmission (Public Health England, 2014b).

In the UK, ACF is targeted at healthcare workers involved in exposure prone procedures, close contacts of known or suspected tuberculosis patients, and people with social risk factors such as homelessness, drug or alcohol misuse, imprisonment or migration from high risk countries (National Institute for Health and Care Excellence, 2012). Several local authorities and primary care trusts have successfully piloted such schemes, although weaknesses in coordination and targeting have been identified (Pareek et al., 2011a). London’s UCLH Find and Treat Service, for example, screens almost 10 000 socially vulnerable people at high risk of tuberculosis annually (University College London Hospitals NHS Foundation Trust, 2014). Various UK charities, such as ‘TB Alert’, raise public awareness of tuberculosis and support Primary Care Trusts. They build capacity of third sector organisations and inform and subsidize patients and communities (TB Alert, 2014).

The UK Border Agency, in collaboration with the International Organization for Migration, conducts pre-entry screening for active infection across 15 countries where tuberculosis is common (over 40/100,000) (Home Office UK Border Agency, 2012, Public Health England, 2013b). Visa applicants from these countries wishing to stay in the UK for more than 6 months are screened for pulmonary TB and granted entry only on receipt of a certificate of clearance (Public Health England, 2014b). Funding from the Health Protection Agency (HPA) also supports screening activity at Heathrow and Gatwick airports (Home Office UK Border Agency, 2012). Screening is routinely offered to asylum seekers and refugees accepted for resettlement into the UK through the Gateway Programme (Home Office UK Border Agency, 2012). There is further evidence that screening migrants for latent TB on entry to the UK is cost effective for the NHS (Pareek et al., 2011b).

Internationally, the World Health Organization operates via the Stop TB Partnership to set targets, procure and grant funds and resources, lobby governments, educate and advocate on behalf of TB communities (World Health Organization, 2006, Stop TB Partnership, 2014). Simultaneously, not-for-profit product development partnerships such as the TB Alliance endeavour to develop new TB drug regimens (Horsburgh et al., 2013, Lienhardt et al., 2012a, Lienhardt et al., 2012b, Clinton Health Access Initiative et al., 2010). School vaccination of the indigenous UK population was halted in 2005 following a decline in the incidence of TB and the Bacillus Calmette-Guerin immunisation (BCG) is now targeted at neonates within high risk groups (Department of Health, 2006). These UK endeavours contribute towards the WHO target to eliminate TB as a public health problem by 2050 (World Health Organization, 2006).

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HOME OFFICE UK BORDER AGENCY 2012. Screening for Tuberculosis and the Immigration Control. UK Border Agency Review of Current Screening Activity 2011 (Central Policy Unit). London: Home Office.

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Introduction

Recently, the concept of patient autonomy has become more prevalent within the healthcare field with the government and the NHS promoting patient choice and providing assurance that individuals will have full control over their care and patient journey. However, a recent publication from Macmillan Cancer Care (MCC) (2013a, pp. 1-27), suggests that there is very little choice available for individuals suffering from terminal cancer with regards to where they spend the end of their lives. Figures provided within the MCC (2013a, p. 8) report suggest that 81% of cancer sufferers would prefer to die at home whilst in reality, 48% of these die in a hospital with only 23% of patients dying within the comfort of their own homes.

For individuals who are approaching the end of their lives, the option of being cared for and dying within their own home with the familiarity and comfort that this brings, is often very important. The National Bereavement Survey (NBS) (Office for National Statistics, 2012, np) showed that that the loved ones of those who had died in hospital often considered the standard of care as being poor when compared to those who died at home, in a care home or within a hospice. Indeed, the NBS (ONS, 2012, np) showed that 53% of loved ones whose friend or family member had died at home and 58% of those who had died in a hospice, rated the standard of care as outstanding or excellent compared to just 34% for those who had died within a hospital.

This essay will consider the barriers that cancer patients are presented with when making their end of life choices and will make recommendations for improvement of service to ensure that these individuals are allowed to make and receive their final choice. However, the essay will begin with a brief overview of the benefits that end of life patient choice can bring to both the individual and to the wider society.

The Benefits of End of Life Patient Choice

According to the National End of Life Intelligence Network (2012, p.7) 89% of patients who die in hospital are brought in as emergency admissions. However, a large number of these individuals have already expressed their desire to die at home, therefore representing a poor patient outcome and negative experiences. In addition, these unnecessary emergency admissions place a costly strain on accident and emergency departments and the patients take up hospital beds that could be used for other cases. When one considers that the number of people in this country is increasing with the elderly becoming the most prevalent age group, it is not unfeasible to believe that the number of individuals dying from terminal cancer over the next few decades is also going to increase. This increase in numbers is likely to cause the current model of care to become unsustainable. However, promoting choice and delivering end of life care choices can actually save money by reducing the number of emergency admissions. According to MCC (2013a, p.9), there is a net saving of just under A?1000 for every individual who dies in the community rather than in a hospital bed.

Barriers to End of Life Care Choices

Evidence suggests that there are multiple barriers that prevent individuals from being cared for and ending their lives in their chosen place. The first barrier is the identification of people approaching the end of their lives. According to MCC (2013a, p.10), 38% of cancer patients approaching their end of life were unaware that they were dying, whilst figures from Marie Curie Cancer Care (2013, p.7) show that only 26% of individuals with a palliative care need are placed on the palliative care register. One of the main reasons for this appears to be a lack of confidence in the health professionals over instigating conversations with individuals over their end of life journey. A study carried out by Revill (2010, p.11) found that 60% of GPs were not confident about discussing death or dying with their patients. This lack of identification and lack of professional confidence therefore prevents many people from being able to make their end of life choice in a timely fashion, therefore increasing the number of emergency admissions that have previously been discussed.

However, another issue that has been raised is that of poor planning and coordination between services. When one considers the needs of a terminally ill cancer patient, it is clear that there is a requirement for multiple health and social care providers to work together to provide a joined up service delivery. Unfortunately, the MCC (2013a, p.11) report suggests that this joined up service is not occurring with 45% of respondents thinking that community services worked well together and only 33% stating that GP and other services outside of the hospital worked well together. The reason for this poor service is considered to be a lack of coordination and communication between the different care entities. Indeed, the MCC (2013a, p.11) report suggests that it is often a requirement of the close family and friends of the dying loved one or the actual patient to coordinate care between health and social care departments. The report suggested that information needed to be repeated to the different professionals suggesting that there is a lack of communication between the different departments and that patient information is not being recorded or shared in an appropriate manner.

Nevertheless, there is evidence to suggest that Advance Care Plans (ACP) are a successful way in which a person’s end of life choices can be successfully achieved. Abel et al (2013, pp.168-173) followed 969 terminally ill patients, 550 of whom had made an ACP. 75% of these individuals successfully achieved their dying wishes with regards to the location that they had chosen. In addition, a study published by the NHS (2012, pp.3-4) suggests that the Electronic Palliative Care Coordination Systems (EPaCCS) where patient information, including their end of life choices, can be stored and shared, is an effective way of achieving pro choice for the patient with up to 80% of individuals living in areas where the EPaCCS system is implemented achieving their preferred choice of location to die. In addition, the NHS (2012, p.12) report shows that the implementation of this system has resulted in savings of A?133,200 where it is implemented. Another positive study has been published by Gao et al (2013, np) who found that the number of individuals being able to die either at home or in a hospice has increased since 2005 when the National End of Life Care Programme was first launched. However, the percentage change was only marginal (0.8%) therefore suggesting that more needs to be done to ensure patient autonomy is at the top of the list for terminally ill patients.

Another barrier that is likely to prevent an individual from dying within their own home is lack of skills and resources within the community workforce. In these cases, the role of the community nurse is vital, however, the number of community nurses is steadily declining (Royal College of Nursing, 2013, np). This reduction of the workforce further dilutes the available skill mix, therefore having a detrimental impact on the quality of care provided to those who choose to die at home. According to the MCC (2013a, p.13) report, only 19% of individuals who chose to die at home received adequate pain relief during their last 3 months of life. Indeed, the lack of 24/7 access to community services forced a large number of these individuals to contact emergency services resulting in admittance to hospital. In 2010, nearly half of the UK’s primary care trusts did not provide 24/7 community nursing services for end of life patients with little progress being made following the subsequent change to Clinical Commissioning Groups (MCC, 2013a, p. 13).

Another report published by MCC (2013b, pp. 1-15) suggests that a lack of access to social care services also restricts the ability of an individual to make end of life care choices. Whilst it is obvious that the right amount of social support is needed in order for a terminally ill individual to be able to remain at home during their last stages of life, this support is often not provided. The MCC (2013b, p. 3) report suggests that this is not always due to the service not being available, but more often being the result of the complex assessment process and the lack of coordination between health and social services. Indeed, 97% of healthcare professionals stated that the complexity of the social care needs assessment is a substantial barrier to gaining the right amount of home care for terminally ill patients. As such, the care for these terminally ill individuals is often left to family members as informal carers. However, only 5% of these individuals actually receive a carers allowance despite them taking on the majority of the personal care responsibilities of these terminally ill patients. Thomas et al (2002, p.531) asserted that the needs of cancer patient carers were greatest as the cancer progressed to end stage; however, a distinct lack of support for these informal carers is prevalent throughout the UK (Soothill et al, 2001, p.468). MCC (2013b, p.6) found that 47% of these informal carers felt that they needed support but were unable to get any. Therefore it is not surprising that this lack of carer support is resulting in many cancer patients being admitted to hospital in the days or hours before death despite it being their wish to die at home.

Recommendations for Improvement

As studies have shown that the local implementation of the EPaCCS has been successful, there should be a renewed commitment by the Department of Health and the NHS to ensure the national implementation of this scheme. Indeed the National End of Life Care Strategy (DOH, 2008, np) made a commitment to pilot and establish end of life care registers that would ensure the coordinated care of terminally ill patients and also ensure that every organisation involved in the care of that individual were aware of their end of life choices. As such, it is asserted that NHS England need to prioritise the roll out of these systems. When this system is implemented on a national basis, EPaCCS will not only coordinate care but will also provide considerable data that can be used to compare outcomes for end of life patients throughout the UK. In addition to this system, it is vital that health care professionals involved with terminally ill cancer patients encourage them to fill out an ACP as a routine part of the care package. A randomised control trial carried out by Detering et al (2010, np) followed 309 terminally ill patients for a period of six month, 154 of whom had completed an advanced care plan. Of the 56 patients who died during the study period, 29 of them had made an ACP with 86% of these achieving their end of life choices compared to just 30% of those who had not made an ACP. This shows that it is vital to document end of life choices to ensure that they are followed by all those involved in the final days of the patient’s care.

Another recommendation is to make end of life care training mandatory for all health professionals who are likely to be involved in palliative care. This includes making a timely identification of individuals who are approaching the end of their lives and providing these professionals, including GPs, with the right training to boost their confidence in instigating end of life discussions with terminally ill patients. This will enable these terminally ill individuals and their families to come to terms with their disease progression and make appropriate plans for their end of life care. It is also recommended that all terminally ill individuals have a named professional who is responsible for the coordination of their care and who will ensure that their end of life choices are met whenever possible. This was a key recommendation of the UK Government’s (2013, pp. 1-62) review of the Liverpool care pathway, which stated that a named consultant or GP should take overall responsibility for a patient’s end of life care, whilst a named registered nurse would have day to day responsibility for the care of that individual and for the communication of information between the patient, family members and other members of the care team.

The UK Government’s (2013, p. 57) review also recommends improving access to community services by increasing funding to ensure that there is a consistent 24/7 access to all social care services throughout the UK. This is considered to be a priority, as without access to 24/7 care, a large number of individuals are not having their pain managed adequately, forcing them to take further action by attending an emergency department. In addition, the government needs to commit to implementing free social care to terminally ill patients and to simplifying the social care assessment to ensure that all those who need social support are able to access this service in a timely fashion. Whilst the UK government has recognised that there is much merit in the proposal of free end of life social care (MCC, 2013a, p. 19), they are yet to offer a firm commitment to this proposal. The continued complexity of the social care assessment and the confusion over who is able to receive social care needs to change if patients’ wishes to die at home are to be honoured. Indeed, Taylor (2012, p.1297) asserts that there is a need to change the way in which all health and social care is provided to elderly patients and suggests a combined health and social care assessment to ensure a proper joined up and coordinated service for these vulnerable patients.

It is also recommended that improved support for carers is instigated to ensure that all those who are caring for a terminally ill patient are recognised as informal carers and are in receipt of a carers allowance. In addition, it is vital that these carers a given the right level of support by health professionals; this support should include having 24/7 access to help and advice, being given regular respite and having adequate information with regards to the progression of their loved ones disease to enable them to encourage the patient to make end of life care plans. Joyce et al (2014, p.1150) found that out of 120 caregivers who were responsible for delivery of medications to their terminally ill relative, only 27 (22.5%) of them received any formal support. This often led to confusion over dose rate and fear that the patient was receiving too much or too little of the medication provided. This issue is compounded by the fact that many of these informal carers are elderly themselves and often have their own health problems (Jack et al, 2015, p.131).

Finally, it is considered that delivering choice for end of life care should be focused on giving that patient a good death, regardless of where they chose to die. As such, it seems logical that there is a need to understand the experiences of terminally ill patients towards the end of their lives in order to deliver adequate care. As such, it is considered vital to explore how the experiences, concerns, fears and feelings of people approaching the end of their lives can be recorded and used to improve future patient outcomes. Whilst it is accepted that the National Bereavement Survey (ONS, 2012, np) provided a large volume of useful information, the current lack of nationally collected information from end of life patients’ needs to be addressed. As such, it is recommended that future study be directed in this way.

Conclusion

In conclusion, it is clear that whilst having a genuine choice over where to spend the last few days and hours of your life is hugely important to terminally ill patients, there are significant barriers to achieving these choices. Current figures suggest that nearly three quarters of cancer patients chose to die at home but less than 29% of them actually do so. The MCC (2013a, p. 3) report estimate that this amounts to 36,000 patients dying in hospital when they had chosen to die at home. A number of barriers exist that are currently preventing the individual from achieving personal choice at the end of their lives; these include poor identification of individuals entering the end of life stage, poor communication from health professionals, poor planning and coordination between health and social services, lack of skills and resources in community nursing and lack of universal access to social care resources. Nevertheless, despite these current barriers, none are insurmountable if current services are simplified and organised in a way that sees the needs of the individuals and their families and carers brought to the forefront. Whilst the government has funded reports and strategies to improve end of life care, it is clear that not enough is being done to change the way in which end of life care is provided. Significant change is required in order to move care and resources out of hospitals and into the community so that people’s preferences can be delivered. However, this can only happen if there is a clear commitment given by all the players involved in end of life care to share the same ambition, that being to deliver a coordinated and integrated care package that meets the needs, wishes and preferences of end of life patients and their carers. A number of recommendations on how this can be achieved have been included in this essay. These recommendations include simplify the social care assessment, providing free social care to end of life patients, improving support for informal carers and ensuring that these carers are recognised, improving the training of health professionals in recognising the transition to end of life stages and encouraging them to instigate discussions over end of life choices, improving access to social services by ensuring a 24/7 service across the UK and implementing the roll out of the EPaCCS across the whole of the UK to ensure that end of life choices are recorded and shared between all the relevant care providers. As it stands at present, whilst end of life patients do have a choice over where they die, these preferences are often not honoured. They do not have full control or autonomy over their end of life care. However, the choice of place to die is not a myth as it is a very achievable option that requires coordination between services and a commitment from the government to improve community health services.

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Introduction

The oral route is still the most desired route for the administration of medicinal products¹ due to the ease and lack of inconvenience associated with this administration route, in comparison to others such as the pulmonary route or the more invasive intravenous route.

The pharmaceutical industry has developed considerably over the past 40 years with respect to the rate at which new chemical entities are being discovered. This increased rate is primarily due to the invention of high throughput screening, but there is no correlation between the rate of synthesis of these novel compounds and the release of new drugs on the market due to the high failure rate during the development process¹.

In order to minimise cost and resources associated with this loss, effective screening methods for both pharmacological action and bioavailability have to be used.

The most important process that influences bioavailability of the drug is absorption and the necessity of creating and using suitable models that can predict the in vivo absorption profile of a drug is absolutely critical in achieving the desired reduction in cost associated with the pharmaceutical development process.

There are two primary phases of absorption for orally administered drugs; the first is dissolution of the drug in the aqueous media present at the site or sites of absorption¹ the second is permeation of the drug particles in solution through predominantly the small intestinal membrane into the hepatic portal vein¹.

The main factors affecting dissolution of a drug in the gastrointestinal (GI) system are the pH of the environment, volume of dissolution media and the presence of food by either encouraging or delaying the passage of the dosage form into the small intestine where many drugs are absorbed.

Permutation of the drug through the small intestinal membrane is influenced by several variables. The presence of influx and efflux pumps on the apical surface is a main consideration². There are three main routes of absorption that drugs can take; transcellular absorption through the cells, paracellular absorption by passing thorough the tight junctions between cells or by using influx transporters present on the apical surface³. Efflux transporters are also present which act to eject the drug molecule out of the cell and limit bioavailability¹.

All of these processes and scenarios need to be considered in developing an in vitro model to accurately predict gastrointestinal drug absorption. The extent to which a particular model represents the results seen in vivo can be conveyed through a mathematical relationship known as the in vitro- in vivo correlation (IVIVC)^2,4. The predictive power of this correlation ultimately depends upon the capacity of the in vitro method used to simulate and reflect what occurred in vivo. The fact that different models are able to do this to different degrees has been appreciated as different levels of IVIVC have been defined; levels A, B, C, multiple C and D with A being the highest level⁵.

There are many factors to consider and appreciate when looking at IVIVC made from drugs absorbed from the gastrointestinal tract, as models are either based on the dissolution of the drug within the GI media at the absorption site or permeability of the drug across the intestinal membrane.

This review primarily considers models used to simulate and predict drug permeability, with a discussion of the ability of each technique to reflect and predict the in vivo environment and response; which would allow a representative IVIVC to be formed.

In silico permeability models

These models are computer programs that aim to predict the absorption and permeability of a drug. One review⁶ gave a very good summary of the programming process and highlighted the specifications against which the physicochemical properties of drugs are judged.

An advantage of using such a model is that a high turnover of compounds can be tested within a short period of time⁶, a property that makes it very practical in industry.

But in terms of developing an IVIVC, this model has limited use⁷. One major argument against the use of this model highlighted by another review ¹ is that absorption predictions are based only on the physicochemical properties of the drug. This assumption is false as there are other factors to consider such as drug – membrane interactions through active transporters and efflux pumps¹

Parallel Artificial membrane permeability assay (PAMPA)

This technique is based on the formation of an artificial membrane by using a hydrophobic filter material as support upon which lecithin and organic solvents are placed upon to produce an artificial lipid¹.

One recent review⁸ greatly criticised the use of this technique in the drug discovery process. It was stated that there was no real benefit in using this technique over the cell culture methods such as caco-2 and MKCD cell lines because it was just as time consuming with less informative data being obtained⁸.

One of the main advantages of using this technique was that it was less labour intensive and quicker to do⁹, but this was a main focus of the argument against use of the technique by this review. Due to the different manipulations such as testing in various pH that need to be carried out, the process was deemed just as labour intensive as the caco-2 or Ussing chamber method.

An attempt to debate against the points raised by this review was done by another⁹ which highlighted the ability to use this technique to obtain various information such as the partition coefficient and apparent permeability (Papp) of a drug.

Nevertheless, both reviews failed to specifically highlight the strengths or weaknesses of the technique in creating IVIVC. It appeared that the capacity of this technique to do so is limited as there is a gross underestimation of active transport of hydrophilic compounds with low molecular weights ¹.

Ussing Chambers

This cell technique involves the isolation of intestinal membrane and cutting the tissue into strips. These strips are clamped onto a suitable clamping device to produce a flat sheet between two chambers, the donor and receiver chamber¹. The measurement is taken as the amount of drug that appears in the receiver chamber¹. To monitor the viability of the intestinal tissue, electrical resistance is measured by placing a current across the membrane¹.

Only few studies have used this technique to reflect its capability but this has only been used to show a level D IVIVC, where drug candidates during the development process are placed in rank order. One such study¹⁰ presented this technique as being equally capable of ranking drug candidates when compared to caco-2 cells and the in situ technique of a perfused jejunum loop.

One article¹¹ opposes the use of this technique and presents the counter argument to the method being used to create such a correlation. The paper identified the ability of this model to be biologically representative but clearly stated that the technique is not robust enough to incorporate as a method which is routinely used in early development, due to the complexity associated with setting up the instrument. This is a good observation and highlights an impracticality of the method.

Caco-2 cell lines and separated clones

The method that has been supported in recent studies is the Caco-2-cell culture model that has been shown to effectively mimic intestinal absorption. These cells are human colon adenocarcinoma cells that undergo proliferation when in culture¹ which are grown on small porous membranes that fit in the wells of welled plates. The sample of the drug being tested is placed on top of the membrane with the amount of drug that passes through being calculated and the Papp is determined.

Arguments in favour of this method state that the ability of this model to reflect in vivo conditions is very good as not only can transcellular and paracellular diffusion occur, both influx and efflux transporters are present, allowing active transport processes to be considered^1,12. Such transport systems are those for sugars, bile acids, the efflux transporter P-glycoprotein¹¹ and the more recently discovered multiple drug resistance protein (MDRP)¹¹.

This view is supported by many whom consider this model to be very representative of the prediction of intestinal absorption. A study by Yee¹³ analysed 36 drugs and observed the correlation between the apparent absorption (Papp) obtained from the cells and the percentage absorbed determined from in vivo testing.

A correlation coefficient of 0.90 between percentage absorbed in vitro and in vivo was obtained, showing that the technique is capable of reliably predicting in vivo results¹³. Another study¹⁴ confirmed the predictive ability of this model using 20 compounds and also established a correlation coefficient of 0.92 between Papp and the percentage of dose absorbed

To further support the use of caco-2 cells, some studies^10,11 have highlighted the ability of this method to be used in early stages of development in order to produce level D IVIVC where drug candidates are placed in rank order.

But despite all these positive aspects some^13,15-16 remain critical of this technique because of an associated low level of reproducibility with gross variability in results from different labs¹⁵. This has been attribute to differing culture conditions within each lab^13,16. For example one study highlighted the importance of culture nutrients and duration of cell feeding as more L-methyldopa was absorbed as the feeding time increased¹³.

Another important limitation of the model that has been recognised is that as the number of cells within a cell line increases, the Trans epithelial electrical resistance (TEER), mannitol flux and cell growth changes¹. The TEER is a validation tool used to quantitatively reflect the integrity of the monolayer as the viability of this cell culture diminishes¹⁷.

The cell line is unable to express mucus¹⁷ which has been shown to act as a barrier to drug permutation in retarding drug contact with the apical membrane of the small intestine and a fixed pH is used in the model¹⁷. This is not reflective of in vivo as the mucus layer has been shown to retard permutation and the pH of the small intestine changes.

A strong counter argument against the use of caco-2 cells is that the predictive power of the method differs depending upon the main absorption route that the drug uses. Two studies^14,15 have indicated variability in the Papp for mannitol, polyethylene glycol (PEG) 4000 and fluorescein that have low paracellular permeability in various batches of caco-2 cells from different origins. Another study¹⁷ clearly showed that caco-2 cells underestimated the absorption of amoxicillin – a passively absorbed drug and was not able to truly model the absorption of drugs that are absorbed using a carrier-mediated process due to the saturation or under-expression of these influx carriers and the over-expression of the efflux transporter P-glycoprotein.

This limitation of the caco-2 cell line is where the calu-2 cell line proves to be superior. This is a sub-clone of the caco-2 cell line that is isolated at a late passage number and has been shown to express different levels of sucrase isomaltase and glucose transporters¹⁷.

Arguments in favour of this model claim that it is more representative of the in vivo situation¹⁷ as it expresses levels of sucrase isomaltase similar to that seen in the human jejunum¹⁷. UDP-transglucoronyltransferase, an enzyme involved in conjugation metabolic reaction is also seen at a level that is more representative of that in vivo and also an IVIVC has been formed using the in-vitro data obtained from this model¹⁷.

Another sub-clone of the caco-2 cell line is the HT29-18-C1. A study¹⁸ used this cell line and the information obtained was used to calculate a permeability coefficient (PC) for a particular compound. A relationship between the percentage absorbed and the PC was formed much in the same manner as that created using Papp and was shown to be a good model to use in the early development process.

Although this method possesses a significant flaw which is that the tight junctions established in this cell line were not as tight as those seen in vivo ¹⁸, therefore allowing passive diffusion to occur to a greater extent than would normally occur. This was shown in the same study¹⁸ where the Pc of mannitol was ten times less than that seen in caco-2 cells, which is not reflective of in vivo conditions.

Madlin Derby Canine Kidney (MDCK) cells

The progressive changes in TEER seen in caco-2 cells have led to the use of Madlin Derby Canine Kidney (MDCK) cells as a model to predict intestinal absorption¹⁴. These are differentiated epithelial cells that form tight junctions when cultured in semi-permeable membranes¹⁴ that also possess transporters, but not as many as seen in the caco-2 cell line¹⁴.

One study¹⁹ highlighted both opposing arguments and those in favour of the technique by comparing the ability of the model with not only in vivo data but also with the caco-2 cell line. The predictive power of the model was similar to that of the caco-2 cells for passively absorbed compounds that showed good permeability¹⁹. For those that were poorly permeable or were actively transported, the model was unable to accurately present the degree of absorption; for the latter this is due to the minimal transporters expressed by the MDCK cells¹⁹, resulting in a poor IVIVC

2/4/A1 cell line

This cell line which originated from fetal rat intestine was reported to mimic the permeability of the small intestine to drugs absorbed via the paracellular route to a greater extent than the caco-2 cell line¹.

One paper²⁰ clearly advocates the use of this cell line because of this point as the tight junctions seen are more representative with the extent of passive absorption being similar to that in vivo. In this study this cell line was transformed in order to improve viability and a sigmoid relationship between fraction of drug absorbed in vivo and permeability coefficient obtained in vitro was obtained.

The predominant argument against the use of this model also presented by the same study²⁰, was that the shape properties of the cell line were not similar to that of the small intestine. The cells are cuboidal as oppose to columnar and there was a lower number of villi present on the apical surface. This limits the model’s capability of reflecting transcellular or carrier mediated absorption, which are major routes for many drugs which negatively impacts the IVIVC created.

Conclusion and the Future

In examining the arguments for and against the different cell culture techniques, the caco-2 cell line appears to be the most reflective of in vivo absorption. This is because the cell line can express transporters, allow all routes of absorption, has an associated low operating cost, high reliability and throughput capacity. All these advantages make it a very practical and useful model to routinely use in industry.

Nevertheless, there is still room for improvement as the in vivo environment is not completely shown with this cell line. One significant aspect omitted is the dissolution of the drug and the impact that this process has on amount of the dose of drug available for permutation.

Therefore the next step in producing a completely reflective model that can be used to form a good IVIVC is the combination of methods to take into account the many aspects influencing bioavailability¹ with an ultimate goal of creating an in vitro gastrointestinal system model.

Incorporation of a modified caco-2 cell line that has been co-cultured with other cells such as MDCK cells with an artificial digestive system model such as the TIM-1 model is an example of such steps that can be investigated into attaining the ultimate goal. Within the TIM-1 model there is still room for improvement but it does provide a foundation to build and develop upon. The incorporation of the newly created PBL dynamic gastric model to replace the gastric compartment of the TIM-1 would be a combination that would shed more insight into actual food effects on drug absorption and permutation. Developments similar to this would eventually lead to the creation of a very reliable and reflective in vitro model.

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Can breastfeeding in the first six months prevent childhood obesity?

Childhood obesity is becoming a worldwide concern given the potential health implications in the future. Obese children are more likely to suffer physical and mental health problems and are likely to develop into obese adults (Labayen, Ruiz et al. 2012), thereby increasing the long term risk of developing chronic conditions such as diabetes, cardiovascular diseases and stroke.

The cause of childhood obesity is multifactorial, including hereditary factors, comorbidities, dietary habits and physical activity. There is much debate as to the impact of breastfeeding during the early stages of life and how it correlates with childhood obesity compared with formula-fed newborns.

Breast milk is nutritionally balanced to provide infants with all dietary requirements during the early stages of life. It also provides antibodies to reduce infection risks in newborns. Breast milk constitutes the appropriate amounts of protein, water, fat and sugar for a newborn and changes composition over time to adapt to a growing child’s needs. Formula tends to be higher in protein and fat than the baby actually requires and this excessive intake has been linked with adiposity (Hernell 2011). Marseglia et al have reviewed the potential impact of key breast milk constituents thought to play a role in reducing obesity risk (Marseglia, Manti et al. 2015).

There have been a number of recent reviews discussing the association between breastfeeding and childhood obesity, all of which have concluded that breastfeeding confers a protective effect against childhood obesity and being overweight (Horta and Victora 2013, Aguilar Cordero, Sanchez Lopez et al. 2014, Lefebvre and John 2014, Yan, Liu et al. 2014). The largest reduction in obesity risk was 81%, reported in a study of females aged 11 years of who had been breastfed for more than three months compared with controls who had never been breastfed (Panagiotakos, Papadimitriou et al. 2008). The males in the same study had a reduced risk of 72% and both results were statistically significant. However, other literature reports either no association between breastfeeding and childhood obesity (Burdette, Whitaker et al. 2006, Huus, Ludvigsson et al. 2008, Jing, Xu et al. 2014), or an increased risk of obesity following breastfeeding of 9% (Kwok, Schooling et al. 2010), 10% (Novaes, Lamounier et al. 2012), 11% (Buyken, Karaolis-Danckert et al. 2008), 14% (Sabanayagam, Shankar et al. 2009), 18% He (2000), 29% (Al-Qaoud and Prakash 2009), 34% (Neutzling, Hallal et al. 2009), 40% (Toschke, Martin et al. 2007) and 83% (Araujo, Victora et al. 2006), although none of which were statistically significant.

Some studies suggest that there is a dose-response relationship, with increased duration of breastfeeding resulting in a decreased prevalence of being obese in childhood (von Kries, Koletzko et al. 2000, Fallahzadeh, Golestan et al. 2009, Griffiths, Smeeth et al. 2009, Yan, Liu et al. 2014). In contrast, other studies have reported no significant association between breastfeeding and its duration and obesity prevention (Burke, Beilin et al. 2005, Al-Qaoud and Prakash 2009, Sabanayagam, Shankar et al. 2009, Vehapoglu, YazA±cA± et al. 2014).

One meta-analysis analysed the association between breastfeeding duration and obesity (Yan, Liu et al. 2014). As eligible studies reported different durations, the review categorised breastfeeding duration into less than three months, 3-4.9 months, 5-6.9 months and seven or more months. Those exclusively breastfed for at least seven months had a 21% decrease in the risk of childhood obesity, whilst those fed for less than three months only showed a 10% decrease. They concluded that the duration of breastfeeding was associated with a decreased likelihood of childhood obesity and reported a stepwise gradient of decreasing risk with increasing duration of breastfeeding.

Single studies report a significant protective effect against childhood obesity when breastfeeding is done for at least one to three months (Goldfield, Paluch et al. 2006), three months (Twells and Newhook 2010), 13-25 weeks (McCrory and Layte 2012), four months (Scholtens, Gehring et al. 2007, Griffiths, Smeeth et al. 2009, Chivers, Hands et al. 2010), nine months (Nelson and Sethi 2005), 12 months (Burke, Beilin et al. 2005) and two or more years (Rathnayake, Satchithananthan et al. 2013). However, the differences in study design make it difficult to directly compare findings as the comparator groups can be formula-fed babies or babies’ breastfed for short durations.

For studies investigating the impact of breastfeeding for at least six months on childhood obesity, the comparator group can be either newborns breastfed for less than six months (i.e. mixed feeding of variable durations) or newborns exclusively formula-fed. Additionally, the age of the children being assessed also differs in studies. When comparing those breastfed for at least six months with those breastfed less than six months, studies report a reduction in obesity risk of 60% when assessing two year olds (Weyermann, Rothenbacher et al. 2006), 54% and 43% in four year olds (Komatsu, Yorifuji et al. 2009, Simon, Souza et al. 2009), and 67% in six year olds (Thorsdottir, Gunnarsdottir et al. 2003). This suggests that the age of assessment affects the degree of risk reduction observed. However, when comparing against formula-fed newborns there are studies reporting reductions of 14%, 28% and 67% for three year olds (Poulton and Williams 2001, Armstrong, Reilly et al. 2002, Taveras, Rifas-Shiman et al. 2006), 6% for four year olds (Moschonis, Grammatikaki et al. 2008), 45% for seven year olds (Yamakawa, Yorifuji et al. 2013), 60% for nine year olds (Toschke, Martin et al. 2007), 64% for 11 year olds (Poulton and Williams 2001), 21% for 21 year olds (Poulton and Williams 2001) and 6% for 45 year olds (Michels, Willett et al. 2007). This data suggests that observing adults to determine the impact of breastfeeding on obesity is not advisable.

Only one study reported an increased risk of obesity for newborns breastfed more than six months compared with formula-fed newborns, reporting a non-significant 40% increased risk of obesity in nine year olds (Toschke, Martin et al. 2007).

Interestingly, very few detailed, for those breastfeeding for at least six months, whether the feeding duration was exclusively breastfeeding or mixed. Only two studies (Simon, Souza et al. 2009, Yamakawa, Yorifuji et al. 2013) reported on exclusive breastfeeding. There is evidence that exclusive breastfeeding also results in a decreased prevalence of being obese in childhood (Fallahzadeh, Golestan et al. 2009, Simon, Souza et al. 2009, Lefebvre and John 2014). Mayer-Davis et al (2006) compared exclusively breastfed newborns with exclusively formula-fed newborns and found that the breastfed children were significantly less likely to be overweight (34%) and that the results were not affected by maternal weight or diabetes status (Mayer-Davis, Rifas-Shiman et al. 2006).

When exploring the differences between studies who defined breastfeeding as “Never – ever” and those reporting “exposure” to breastfeeding (implying mixed feeding practices of different types), a systematic review found a reduced likelihood of obesity in the exclusive feeding group of 20% and in the mixed group of 27% (Yan, Liu et al. 2014). This was supported by another review comparing “ever” breastfed with “exclusively breastfed for a specific number of months”, the latter showing a 27% decreased risk compared with the former at 21% (Horta and Victora 2013). That review postulated that if there is no critical window effect, but rather a cumulative effect of breastfeeding, studies that compared ever vs. never breastfed subjects will tend to underestimate any association.

Any observed association between breastfeeding and later obesity does not prove causality (Butte 2001). There may be any number of potential confounders impacting on the relationship including geography, social deprivation status, parental weight status, smoking, marital status and education, ethnicity, gender, number of hospital admissions during the early stages of life, diet, sleep duration and physical activity. Whilst a number of studies discuss their impact, very few studies actually provide control for these factors in their analysis.

The issue of geography is a potential confounder of any association between breastfeeding and obesity. In high-income countries, the babies usually receive formula, whereas many

non-breastfed infants in low and middle income countries receive whole or diluted animal milk (Horta and Victora 2013). However, Hancox et al have reported that whilst breastfeeding reduced the risk of obesity slightly, there was no evidence that an association between breastfeeding and body mass index (BMI) was different in lower income countries compared with higher income countries (Hancox, Stewart et al. 2014).

The socio-economic status of the mother may also contribute to the child’s weight status in childhood. The World Health Organisation (WHO) review analysed obesity risk in studies also controlling for social deprivation and found a further 3% decrease in the risk of obesity to 37% compared with studies which did not (34%) (Horta and Victora 2013). Armstrong et al reported that the reduced prevalence in obesity for breastfed children also persisted after adjustment for socio-economic status, birth weight and gender (30% reduction) (Armstrong, Reilly et al. 2002).

The impact of gender was prominent as Nelson et al reported that breastfeeding for at least nine months reduced the risk of being overweight more in girls than in boys (Nelson and Sethi 2005). A similar gender inequality was reported by Panagiotakos et al with girls breastfed for more than three months having a larger reduced risk of obesity than the boys (Panagiotakos, Papadimitriou et al. 2008).

Sibling studies have been unable to rule out the impact of confounders on childhood obesity. One study which controlled for this as part of a sibling study reported the adolescent BMIs were 0.39 standard deviations lower in the breastfed sibling than the non-breastfed sibling (Metzger and McDade 2010). However, another study of sibling pairs was unable to prove a protective effect for breastfeeding (Nelson and Sethi 2005).

As well as the lack of control for confounders, other study limitations may affect the results reported. Definitions of obesity vary from a BMI of ?90th to ?97th, making any direct comparison of the outcome problematic. During their meta-analysis Yan et al investigated the association of breastfeeding and obesity, stratifying by the definitions of obesity and found a lower adjusted odds ratio for the BMI ? 97th group (25%) than the BMI ? 95th group (22%) (Yan, Liu et al. 2014).

Most studies varied in the time when obesity was measured. As the definition of childhood can extend from one year olds to adolescents, there is an increasing influence of external and genetic factors on a child’s weight as potential confounders for any weight gain. When Scholtens et al looked at children breastfed for at least four months they reported a significantly lower BMI at age 1 compared to children not breastfed, but at age 7 this difference was no longer significant (Scholtens, Gehring et al. 2007). The WHO review reported a 38% decreased risk of obesity when assessing 10-19 year olds compared with 23% for 1-9 year olds and 11% for adults aged 20 and over, suggesting that endpoint for analysis is critical in determining the impact of breastfeed on obesity at various stages in childhood (Horta and Victora 2013).

Finally, study design and follow up can affect the findings as high dropout rates affect long term follow ups, and the methodology used to analyse the results can produce unreliable results. Beyerlein et al investigated the impact of breastfeeding on children’s BMI in Germany but was unable to make any firm conclusions as the results differed according to whether they used linear or logistic regression (Beyerlein, Toschke et al. 2008).

To summarise, there is a wealth of literature reporting the decreased risk of childhood obesity for newborns who are breastfed, although there was limited literature exploring those breastfed for at least six months. However, most studies cannot completely control for confounding maternal, child, cultural, genetic and environmental factors. The WHO recommend that infants should be exclusively breastfed for the first six months and that it should be supplemented with additional foods for the first two years (World Health Organisation 2015). Following close examination of the literature, we would conclude that breastfeeding for at least six months should reduce the risk of obesity in early childhood, although the protective effect may be lost in latter childhood depending upon the child’s upbringing.

References?

Aguilar Cordero, M. J., A. M. Sanchez Lopez, N. Madrid Banos, N. Mur Villar, M. Exposito Ruiz and E. Hermoso Rodriguez (2014). “[Breastfeeding for the prevention of overweight and obesity in children and teenagers; systematic review].” Nutr Hosp 31(2): 606-620.

Al-Qaoud, N. and P. Prakash (2009). “Breastfeeding and obesity among Kuwaiti preschool children.” Med Princ Pract 18(2): 111-117.

Araujo, C. L., C. G. Victora, P. C. Hallal and D. P. Gigante (2006). “Breastfeeding and overweight in childhood: evidence from the Pelotas 1993 birth cohort study.” Int J Obes (Lond) 30(3): 500-506.

Armstrong, J., J. J. Reilly and C. H. I. Team (2002). “Breastfeeding and lowering the risk of childhood obesity.” Lancet 359(9322): 2003-2004.

Beyerlein, A., A. M. Toschke and R. von Kries (2008). “Breastfeeding and childhood obesity: shift of the entire BMI distribution or only the upper parts?” Obesity (Silver Spring) 16(12): 2730-2733.

Burdette, H. L., R. C. Whitaker, W. C. Hall and S. R. Daniels (2006). “Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age.” Am J Clin Nutr 83(3): 550-558.

Burke, V., L. J. Beilin, K. Simmer, W. H. Oddy, K. V. Blake, D. Doherty, G. E. Kendall, J. P. Newnham, L. I. Landau and F. J. Stanley (2005). “Breastfeeding and overweight: longitudinal analysis in an Australian birth cohort.” J Pediatr 147(1): 56-61.

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

When I was five, my grandmother passed away in hospital just before Christmas. She had been in the hospital for some time and was very elderly. As my sisters and I were at school, we could only visit the hospital at the weekend, whereas my mother and father would visit during the week. At weekends my sisters and I would be given the choice about going to the hospital with our father to visit, or to stay at home. I often chose to stay at home. I understood that my grandmother was old, however I did not understand how ill she was.

When my grandmother passed away, I felt guilty that I had not chosen to visit her. Although I knew that my grandmother had been ill for some time, I had not understood that she was coming to the end of her life, and it had also not been explained to me by the adults. I knew that death was irreversible, however because her death did not impact on my daily routine as my parents sought to maintain normality as far as possible. I found that my life continued as usual, without any major interruptions.

In the week leading up to my grandmother’s funeral I saw my father crying and remember that seeing my father cry made me feel both frightened and upset. I felt upset because I had never seen my father cry before, and I realised that he was suffering greatly. As a result of this, I tried to behave well at all times as I was worried that my actions would cause my father to cry again. I felt frightened because although my grandmother’s death had not had a large impact on myself, I could see that it was having a profound effect on those that I cared about. As I was only a small child, this was the first time that I had seen such a depth of emotion in those close to me, and I was not sure how to react to this.

Research has demonstrated that children, even very young children, are capable of grieving (Melhern et al, 2011). It is important to note that there are differences in the way that adults and children grieve. In particular, children are likely to show their grief in less direct ways than adults, and can move in and out of grief, almost grieving in bursts (Melhern et al, 2011). It is also important to realise that the child’s age, emotional maturity, circumstances of loss, and the level of relationship between the child and the person who has died are all important factors (Dowdney, 2008).

Piaget’s research demonstrated that toddlers and infants understand events in terms of direct experience, and that the dependable presence and emotional expression of loved people are more important than the language used (Piaget, 2013). Studies which have applied Piaget’s work have demonstrated that even children who cannot yet communicate verbally are aware of the distress of adults around them and are aware of the absence of a loved person (Himebauch et al, 2008). It can therefore be thought that not telling young children about the death of a family member will not protect them from the loss as intended, and will only prevent discussion.

This fits with Piaget’s work, who found that young children (between the ages of 3 – 6) do not think in logical sequences, and therefore have illogical explanations for events (Piaget, 2013). This is reflected in the difficulty they may have grasping that death is not reversible (Brown et al, 2008). Families often find it easier to help children after the loss of a grandparent, as they are often in an age group where death is more common (Brown et al, 2008). In my case, I did not have daily interaction with my grandmother due to geographical distance, however we did have regular contact at weekends. This may have meant that there were fewer obvious changes and reminders of the absence.

This is clearly not applicable to all children and cultures, where the grandparents may play a central role in the child’s life and in the family (Salloum, 2008). In these cases, the effect of the loss may be apparent as regression or behavioural problems in the child (Salloum, 2008). Ongoing discussion of the loss can provide the opportunity for children to reinterpret the death over the years as their cognitive comprehension grows (Salloum, 2008). Research has clearly demonstrated that the lack of a well-structured support system during the mourning period can lead to severe disruption of childhood development (Bonanno, 2004).

One study conducted in the United States found that out of 270 children taken to counselling after the death of a loved one and who lacked a well-structured support system, 66% demonstrated aggressive behaviour, 44% lacked social skills, and 18% had delayed cognitive, fine and gross motor development (McClatchy et al, 2009). However, it is not possible to determine from the study whether these children had developmental difficulties before counselling. If this is true, the quoted percentages may not be a true reflection of the impact of a lack of a well-structured support system.

There is also a clear impact on the academic abilities of children who have suffered loss Shear & Shair, 2005). In addition to this, children often have higher levels of absenteeism from school when a close relative is ill, which could have an impact on their academic performance. This impact on academic performance is often seen in children who have witnessed a traumatic death and subsequently develop post-traumatic stress disorder (Shear & Shair, 2005). I believe that my parents made considerable efforts not to disrupt the daily routines of my sisters and I, particularly around school. I think that this ensured that our academic performance did not suffer as much as it may otherwise have.

It is clear that children’s understanding of death develops in parallel with cognitive maturing throughout childhood (Cohen, 2011). The concept of death may develop at different rates in different children, but the developmental sequence seems to be the same (Cohen, 2011). For example, children below the age of five do not understand that death is irreversible, and will demonstrate this by asking when the person is coming back (Salloum, 2008). As a result of this, children at this age will have difficulty understanding abstract explanations of death, and such explanations such as saying the person has gone to sleep may result in fear of sleep (Cohen, 2011). It is therefore clear that although the concept of death is not fully developed in small children, there is little doubt that they still react strongly to loss at this age (Cohen, 2011).

This does not apply to my experience of loss, as I was slightly older; however it is clear that loss at even a very young age can have a lasting impression on children. Between the ages of four and six, it is thought that children begin to develop a biological understanding of life (Crenshaw, 2005). An example of this is knowing that parts of the body work to sustain life. I feel that this is true of my experience – I knew my grandmother was in hospital because she was ill; however I did not understand the seriousness of her illness, or that she had been in hospital for a considerable length.

Children from five to ten years of age develop an understanding of death as an irreversible process (Currier et al, 2008). Concrete thinking is seen in children until the age of 10, and need concrete expressions such as pictures or visiting graves or memorials as support for their grief (Currier et al, 2008). When my grandmother died, I knew that it was an irreversible event. My parents chose not to take me to the funeral, which I feel was a wise decision. I believe that although I knew my grandmother had died and that this was not a reversible event, I would have found it distressing to see my parents and other adults so openly upset. Research has also found that if children do attend funerals, it should be with someone who can provide emotional support (Currier et al, 2008), and I feel that this would have been an unfair demand on my parents at the funeral, particularly as I was so young.

As I grew older I found that accompanying my parents to the graves of my grandparents, particularly my grandmother, helped me to express my feelings and to ask questions. This is supported by literature which states that visiting graves or memorials can offer children or young adolescents a channel for communicating about the deceased person, which can help them to understand the circumstances of the loss and can also act as an opportunity to express their feelings (Paris et al, 2009). I found that as I matured, I could talk about my grandparents away from their graves, as I came to realise that this would not upset my parents. As a result of this, we were able to talk much more freely and openly about their lives.

My grandmother was the only grandparent that I had known, as my other grandparents had died before I was born. As my grandmother had died when I was relatively young, I have no substantial memories of her. Throughout my childhood this did not have a large impact on my beliefs and attitudes, as I believe that I did not possess the emotional maturity to reflect on the changes this had made to my life, and the impact that her death may have had on those around me. As I grew older, I became aware of the effects of loss on those around me, and in turn this altered my beliefs about life. For example, as I matured I became aware that death can happen at any age and so I was more appreciative of the roles that relatives and friends played in my life, and did not take their presence for granted.

This changed when I was at secondary school and I came to appreciate the roles and relationships that grandparents had in the lives of my peers. I felt, and still feel, that I have missed out on these key relationships, particularly as my parents often comment on how similar I am in both personality and appearance to my grandmother on my mother’s side. As I grew older, particularly in adolescence, I came to value relationships with relatives and friends in a different way from childhood, and I think that experiencing loss early in life was a large part of this. I believe that it is important to work hard to overcome obstacles to maintaining relationships, such as geographical distance and cultural differences, particularly as there is now greater mobility for employment.

In conclusion, although the death of my grandmother was perhaps not a shock to the adults in my life, I had not grasped how ill she was, nor had it been explained to me by adults close to me. As a result of this, I felt guilty because I had not chosen to visit her in the hospital when offered the opportunity. However as we had always lived quite far apart, there was no real impact on my daily life, which research has shown to be particularly disruptive for children going through grief (Bonanno, 2004).

There is clear evidence that experiencing death, particularly a traumatic death, can have a profound effect on childhood, and that a well-established support system is key (Brown et al, 2008). I believe that I had a well-established support system, and this allowed me to adapt to life without my grandmother without great levels of difficulty. Whilst I wish I could have had a longer relationship with my grandmother and have known my other grandparents, I believe it is important not to dwell on things that cannot be changed. Instead I invest my energy in building and maintaining relationships with friends and family. I believe that this attitude comes with maturity and experience of loss, and that small children may not have the emotional capacity to understand this.

References

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