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Rich literature abounds concerning the clinical effectiveness of programs aiming to produce weight gain/obesity prevention outcomes. However, there is very little evidence on how these outcomes are produced, and what interplay of factors made those programs effective (or not) in the environment that produced those effects. This study aims to describe the application of realistic evaluation in the field of obesity prevention, as an approach to unravel those components that influence the capacity of a program to produce its effects and to examine its significance in an effort to understand those components. The concepts of critical realism have informed the development of an interview topic guide, while three European programs were selected as case studies after a rigorous selection process. In total, 26 in-depth semi-structured interviews were taken, paired with personal observation and secondary data research. Several grounded context-mechanisms-outcomes (CMO) configurations were described within the respective context of each location, with the mechanisms introduced from each project resulting in distinctive outcomes. This study highlights the potential of realistic evaluation as a comprehensive framework to explain in which contextual circumstances of each program’s effects are produced, how certain underlying mechanisms produce those effects, and how to explicitly connect the context and the acting mechanisms into distinct outcome patterns, which will ultimately form unique configuration sets for each of the analyzed projects.
Catholic Ownership, Physician Leadership and Operational Strategies: Evidence from German Hospitals
(2022)
Previous research has revealed that Catholic hospitals are more likely follow a strategy of horizontal diversification and maximization of the number of patients treated, whereas Protestant hospitals follow a strategy of horizontal specialization and focus on vertical differentiation. However, there is no empirical evidence pertaining to this mechanism. We conduct an empirical study in a German setting and argue that physician leadership mediates the relationship between ownership and operational strategies. The study includes the construction of a model combining data from a survey and publicly available information derived from the annual quality reports of German hospitals. Our results show that Catholic hospitals opt for leadership structures that ensure operational strategies in line with their general values, i.e., operational strategies of maximizing volume throughout the overall hospital. They prefer part-time positions for chief medical officers, as chief medical officers are identified to foster strategies of maximizing the overall number of patients treated. Hospital owners should be aware that the implementation of part-time and full-time leadership roles can help to support their strategies. Thus, our results provide insights into the relationship between leadership structures at the top of an organization, on the one hand, and strategic choices, on the other.
Since child maltreatment has highly negative effects on child adjustment, early identification of at-risk families is important. This study focuses on longitudinal risk factors for child maltreatment and associations between abuse risk and occurrence. It also examines whether abuse risk and involvement in early childhood intervention are associated. The sample comprises 197 German caregivers with children under 3 years of age. Data was collected in two waves. The Brief Child Abuse Potential Inventory assessed abuse risk. Socio-demographic, parent, child and family-related risk factors were measured using screening tools. The analysis revealed that parental characteristics (psychopathology, own maltreatment experiences etc.) were associated with concurrent abuse risk. Longitudinal changes in abuse risk were linked to caregiver education and child-related factors. Cumulative risk did not explain more variance than specific risk factors. Significant associations with caregiverreported abuse were found, and data suggest that some burdened families cannot be reached by early childhood intervention.
Growing up in high-risk environments is detrimental to children’s development of attachment security. Parenting behavior is hypothesized to be the mechanism through which risks exert their influence. However, risk influences can vary between individuals by gender. Aim of this study was to explore specific pathways of family risk on early attachment security and additionally examine the transmission via parenting behavior. The sample consisted of 197 children and their primary caregivers. Children’s age ranged between 10 and 21 months (M = 15.25, SD = 3.59). Data assessment included 21 distal and proximal family risk factors, children’s attachment security, and parental responsivity and supportive presence. Whereas distal risk factors had an adverse effect only on girls’ attachment security, proximal risks negatively affected only boys’ attachment security. Additionally, patterns of risk factors occurring in our sample were analyzed using an exploratory principal component analysis. Regardless of the child’s gender, a low socio-economic status was negatively related to attachment security of all children. Migration and crowding and a high emotional load of the primary caregiver both negatively predicted girls’ but not boys’ attachment security. However, the attachment security of boys was affected by a negative family climate. Most of the adverse risk effects on attachment security were mediated by parental responsivity and supportive presence so that the transmission of risk occurs through parenting behavior. Results revealed a different susceptibility of family risks for girls and boys. The consideration of a gender-sensitive approach in developmental psychopathology and interventions of developmental child welfare services is recommended.
Background
In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention.
Methods
This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs’ home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed.
Discussion
This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers.
Family risks are known to be detrimental to children’s attachment development. This study investigated whether parental sensitivity plays different roles in early attachment development in the context of risk: Sensitivity was hypothesized to mediate risk effects on attachment, as well as a moderator that shapes the relation between risk and attachment. Multiple family risks, parental sensitivity (defined as responsivity and supportive presence), and children’s attachment security of 197 infants and toddlers (Mage = 15.25 months) and their caregivers were assessed in a prospective study with a cohort-sequential-design in Germany. Caregivers’ sensitivity served as a mediator of risk effects on attachment as well as a moderator that buffers adverse consequences of risk. Early sensitivity might be relevant in setting the stage for attachment development supporting resilience.
Background: To improve interprofessional collaboration between registered nurses (RNs) and general practitioners (GPs) for nursing home residents (NHRs), the interprof ACT intervention package was developed. This complex intervention includes six components (e.g., shared goal setting, standardized procedures for GPs’ nursing home visits) that can be locally adapted. The cluster‑randomized interprof ACT trial evaluates the effects of this intervention on the cumulative incidence of hospital admissions (primary outcome) and secondary outcomes (e.g., length of hospital stays, utilization of emergency care services, and quality of life) within 12 months. It also includes a process evaluation which is subject of this protocol. The objectives of this evaluation are to assess the implementation of the interprof ACT intervention package and downstream effects on nurse–physician collaboration as well as preconditions and prospects for successive implementation into routine care.
Methods: This study uses a mixed methods triangulation design involving all 34 participating nursing homes (clusters). The quantitative part comprises paper‑based surveys among RNs, GPs, NHRs, and nursing home directors at baseline and 12 months. In the intervention group (17 clusters), data on the implementation of preplanned implementation strategies (training and supervision of nominated IPAVs, interprofessional kick‑off meetings) and local implementation activities will be recorded. Major outcome domains are the dose, reach and fidelity of the implementation of the intervention package, changes in interprofessional collaboration, and contextual factors. The qualitative part will be conducted in a subsample of 8 nursing homes (4 per study group) and includes repeated non‑participating observations and semistructured interviews on the interaction between involved health professionals and their work processes. Quantitative and qualitative data will be descriptively analyzed and then triangulated by means of joint displays and mixed methods informed regression models.
Discussion: By integrating a variety of qualitative and quantitative data sources, this process evaluation will allow comprehensive assessment of the implementation of the interprof ACT intervention package, the changes induced in interprofessional collaboration, and the influence of contextual factors. These data will reveal expected and unexpected changes in the procedures of interprofessional care delivery and thus facilitate accurate conclusions for the further design of routine care services for NHRs.
Background:
This study examined the extent to which regulatory problems in infants at 4 and 6 months influence childhood development at 12 months. The second aim of the study was to examine the influence maternal distress has on 4-month-old children’s subsequent development as well as gender differences with regard to regulatory problems and development.
Methods:
153 mother-child dyads enrolled in the family support research project “Nobody slips through the net” constituted the comparison group. These families faced psychosocial risks (e.g. poverty, excessive demands on the mother, and mental health disorders of the mother, measured with the risk screening instrument Heidelberger Belastungsskala - HBS) and maternal stress, determined with the Parental Stress Index (PSI-SF). The children’s developmental levels and possible early regulatory problems were evaluated by means of the Ages and Stages Questionnaires (ASQ) and a German questionnaire assessing problems of excessive crying along with sleeping and feeding difficulties (SFS).
Results:
A statistically significant but only low, inverse association between excessive crying, whining and sleep problems at 4 and 6 months and the social development of one-year-olds (accounting for 5% and 8% of the variance respectively) was found. Feeding problems had no effect on development. Although regulatory problems in infants were accompanied by increased maternal stress level, these did not serve as a predictor of the child’s social development at 12 months. One-year-old girls reached a higher level of development in social and fine motor skills. No gender differences were found with regard to regulatory problems, nor any moderating effect of gender on the relation between regulatory problems and level of development.
Conclusions:
Our results reinforce existing knowledge pertaining to the transactional association between regulatory problems in infants, maternal distress and dysfunctionality of mother-child interactions. They also provide evidence of a slight but distinct negative influence of crying and sleeping problems on children’s subsequent social development. Easily accessible support services provided by family health visitors (particularly to the so-called “at-risk families”) are strongly recommended to help prevent the broadening of children’s early regulatory problems into other areas of behavior.
Background: Interprofessionalism, considered as collaboration between medical professionals, has gained prominence over recent decades and evidence for its impact has grown. The steadily increasing number of residents in nursing homes will challenge medical care and the interaction across professions, especially nurses and general practitioners (GPS). The nursing home visit, a key element of medical care, has been underrepresented in research. This study explores GP perspectives on interprofessional collaboration with a focus on their visits to nursing homes in order to understand their experiences and expectations. This research represents an aspect of the interprof study, which explores medical care needs as well as the perceived collaboration and communication by nursing home residents, their families, GPS and nurses. This paper focusses on GPS' views, investigating in particular their visits to nursing homes in order to understand their experiences. Methods: Open guideline-interviews covering interprofessional collaboration and the visit process were conducted with 30 GPS in three study centers and analyzed with grounded theory methodology. GPS were recruited via postal request and existing networks of the research partners. Results: Four different types of nursing home visits were found: visits on demand, periodical visits, nursing home rounds and ad-hoc-decision based visits. We identified the core category "productive performance" of home visits in nursing homes which stands for the balance of GPŚ individual efforts and rewards. GPS used different strategies to perform a productive home visit: preparing strategies, on-site strategies and investing strategies. Conclusion: We compiled a theory of GPS home visits in nursing homes in Germany. The findings will be useful for research, and scientific and management purposes to generate a deeper understanding of GP perspectives and thereby improve interprofessional collaboration to ensure a high quality of care.
Background: Given both the increase of nursing home residents forecast and challenges of current interprofessional interactions, we developed and tested measures to improve collaboration and communication between nurses and general practitioners (GPs) in this setting. Our multicentre study has been funded by the German Federal Ministry of Education and Research (FK 01GY1124).
Methods: The measures were developed iteratively in a continuous process, which is the focus of this article. In part 1 “exploration of the situation”, interviews were conducted with GPs, nurses, nursing home residents and their relatives focusing on interprofessional interactions and medical care. They were analysed qualitatively. Based on these results, in part 2 “development of measures to improve collaboration”, ideas for improvement were developed in nine focus groups with GPs and nurses. These ideas were revisited in a final expert workshop. We analysed the focus groups and expert workshop using mind mapping methods, and finally drew up the compilation of measures. In an exploratory pilot study "study part 3" four nursing homes chose the measures they wanted to adopt. These were tested for three months. Feasibility and acceptance of the measures were evaluated via guideline interviews with the stakeholders which were analysed by content analyses.
Results: Six measures were generated: meetings to establish common goals, main contact person, standardised pro re nata medication, introduction of name badges, improved availability of nurse/GP and standardised scheduling/ procedure for nursing home visits. In the pilot study, the measures were implemented in four nursing homes. GPs and nurses reviewed five measures as feasible and acceptable, only the designation of a “main contact person” was not considered as an improvement.
Conclusions: Six measures to improve collaboration and communication could be compiled in a multistep qualitative process respecting the perspectives of involved stakeholders. Five of the six measures were positively assessed in an exploratory pilot study. They could easily be transferred into the daily routine of other nursing homes, as no special models have to exist in advance. Impact of the measures on patient oriented outcomes should be examined in further research.
Trial registration: Not applicable.