Migration and the informal support networks of older people in Scotland- Iain Atherton - University of St Andrews

This thesis investigates the effects of national patterns of migration on informal support for older adults in contemporary Scotland. It argues that geography matters, and develops a multi-scale conceptual framework to analyse the relationships among population mobility, contrasting local contexts in which older people live, and care and support from the intergenerational family and the community. 130 older persons from three locales with different migration patterns are recruited to the study and a mixed-method approach is adopted, using data from the census, a questionnaire survey and a set of in-depth interviews with both older people and formal service providers.

The findings demonstrate significant differences between the three study locales in terms of the geography of the intergenerational family and the extent and nature of informal support received. Daughters provide more support than sons, suggesting the continuation of traditional gender norms. Local community is important, especially in the rural locale, but friends and neighbours are not providing a substitute for adult children living at a distance. It appears that non-kin respond to need where physical health is compromised but not where the older person suffers from depression. This raises serious questions about the future of family support in an increasingly mobile society with declining fertility and growing numbers of adult daughters in full-time employment. The relationships demonstrated confirm and extend many previous findings, but the discussion concludes that there are some grounds for optimism. The intergenerational family remains important to its members who can and do overcome geographical separation at times of crisis. Further, slowly changing gender norms, combined with contemporary demographic trends, may effect changes in the pattern of intergenerational support, which will, to some extent, offset the worsening older-age dependency ratios predicted for Scotland and other European countries over the next few decades.

 

Connection to Nature at the Building Edge: Towards a Therapeutic Architecture for Dementia Care Environments - Garuth Eliot Chalfont – University of Sheffield

Residential dementia care environments were investigated to discover a potential therapeutic role for architecture by facilitating a connection to nature for residents. A study of ‘place as process’ included over two years of observational data highlighting multiple factors of the built and social environment that challenged or enabled sensory stimulation and nature-related activities. ‘Nature’ was defined and SLANT was developed to quantitatively assess fourteen facilities for their potential to provide a ‘connection’ to nature.

The Edge Space Study facilitated sensory stimulation and social interaction and assisted the ability of people with dementia to express themselves creatively, including using nature symbolically, for ethical reasoning, introspection and personification. Because edge spaces supported social interaction while affording natural stimuli, these informal dialogues enabled manifestations of selfhood which contributed to well-being. People with dementia used nature as a tool to communicate.

A discourse analysis method based on relationships was developed and demonstrated which contributes to research on selfhood in dementia. The Prosentia Hypothesis was proposed to test the key mechanisms of beneficial human-environment interactions involving people and nature within the context of relationship. Contributions also include the ‘triangle conversation’ interview method and the concept of ‘time frame identity.’

The edge space typology showed therapeutic potential by affording a person the tools and opportunity to explore emotional and spiritual issues. Such benefits are possible if care practice is routinely involved. Design guidance is proposed for edge spaces and for connection to nature in residential care homes, illustrated with examples from existing facilities. This thesis argues for an integration of architecture, landscape and care practice, a re-conceptualisation of the building edge as permeable and inclusive, advancing a new paradigm of integration and creativity over exclusion, separation and learned disability.

 

Gender, the Life Course and Pension Provision in the UK – Liam Foster - University of Sheffield

This thesis explores the notion that retirement is a gendered concept with particular reference to differences in pension acquisition between men and women. It employs a life course approach embedded within a political economy perspective. Central to this approach is the notion that events and experiences earlier in the life course influence later outcomes. An individual’s social, economic and political situation is both the outcome of previous actions and the result of a contingent historical process. By using a large secondary data set, the General Household Survey (GHS), this thesis analyses the links between education, employment and pension acquisition for both men and women. In order to establish further causation logistic regression is used which treats ‘variables’ as if they possessed causal powers and isolates the significance of various factors on pension accumulation. By also conducting a case study of the Teachers Pension Scheme (TPS) largely dependent on the use of interviews this thesis is able to provide a more detailed explanation of some of the trends apparent within the survey data as to the causes of women’s inferior pensions situation within a particular profession. This process of triangulation in association with the literature work enabled an assessment of the current debates about the future of the British pensions system and the potential affect of policy changes. This is not confined to the suggestions of the government but the ideas put forward by a number of alternative commentaries. In doing so it provides a comprehensive account of the strengths and weaknesses of approaches towards the future of pensions and the potential implications for women.

 

“Medication Review": A study of the pharmacist-older patient encounter, using discourse analysis – C. Salter - University of East Anglia

This is a study of the emerging ecology of a new healthcare communication environment: Pharmacy led Medication Review.

The National Service Framework for Older People called for appropriate medicines management systems to ‘ensure that the medication needs of older people would be regularly reviewed and discussed with the individual or their corer’ (DOH, 2001: 3).

Medication Review has been described as a corner stone of medicines management and defined by the Medicines Partnership as a structured and critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste (Shaw et al., 2002).

The main context for this study was the micro-level interaction between pharmacist and older patient. However, the research was informed by the broader context concerning the social construction of older people as long-term users of medicines and the social position of the pharmacy profession.

The study involved the researcher in non-participant observation, tape recording and transcribing of twenty-nine medication review encounters between review pharmacists and older patients. In addition, ethnographic style interviews were conducted with review pharmacists and older patients. The investigation focused on the construction of the encounter and the way in which the encounter supported older people as users of long-term medication.

Using Levinson’s concept of activity type, medication review was defined as an emergent activitytype. Two separable yet overlapping discoursetypes were identified: ‘screening and assessment’ and ‘advice giving and counselling’. The analysis demonstrated the institutional, professional and lifeworld properties of the discourse and highlighted a degree of discord. Issues of delicacy, morality and competence arose throughout the interactions threatening the interactional order. Older patients resisted the advisory role of the review pharmacists.

The interaction during the medication review encounter had the potential to undermine and threaten the older participants’ assumed competence, their integrity and ultimately their self-governance.

The implications for older people, pharmacy practice and training, and future medication review service development are discussed.

 

The Protective Effect of Healthy Ageing on the Risk of Fall-Related Hip Fracture Injury in Older People - Nancye May Peel - University of Queensland

Introduction
Promoting and maintaining good health in ageing, as well as prevention of fall-related injury are two of the National Priority Areas for health research. These priority areas have been endorsed because of the impact on public health of two concurrent trends - population ageing and the increasing incidence of fall-related injuries. Hip fractures are the most serious fall-related injury because they contribute substantially to increased disability and mortality in older age. The incidence of hip fractures worldwide is increasing with ageing of the population and they present a serious challenge to health care systems in future years.

As a response to demographic trends and social forces, Healthy Ageing policies have been advanced to promote quality of life and reduce disability in older age. One of the strategies for promoting healthy ageing is to reduce the incidence of falls and fall-related injuries. Currently, the majority of falls prevention initiatives are based on screening patients at high risk of falling and implementing targeted multi-factorial interventions aimed at both intrinsic and extrinsic proximal risk factors. Opposed to this ‘high risk strategy’ is the ‘mass strategy’, which aims to change the distribution of a risk variable in the whole population, thereby producing greater population health gains. However, whole of population approaches to falls injury prevention are rare, due, in part, to lack of evidence of population-wide risk factors which can be addressed by community-based strategies.

This thesis was based on the premise that healthy ageing strategies present an opportunity to address fall-related injury prevention using population-based interventions. The purpose of the research was, therefore, to test the hypothesis that healthy ageing factors are protective of fall-related hip fracture injury in older people.

Aims

The aims of the study were:

• To define healthy ageing and to document the empirical evidence of determinants that are associated with healthy ageing outcome.
• To demonstrate that healthy ageing determinants are protective of the special case adverse health outcome of fall-related hip fracture injury and to quantify that protection.

Methods

A literature review was undertaken of the definition, domains and measurement of healthy ageing, together with a systematic review of the behavioural and psychosocial determinants. This information formed the basis for the questionnaire development in the quantitative study.

A primary analytic case control study was conducted with 387 participants, with a case control ratio of 1:2. Incident cases of fall-related hip fracture in community-dwelling people aged 65 and older were recruited from six hospital sites in Brisbane, Australia in 2003-04. Community-based controls, matched by age, sex and postcode were recruited via electoral roll sampling. A questionnaire designed to assess behavioural and psychosocial factors, identified as determinants of healthy ageing, was administered at face-to-face interviews. Data were coded and entered into a computerised database. Conditional logistic regression models, adjusted for health status confounders, examined differences between cases and controls on distribution of healthy ageing factors.

Results

After adjustment for health status, behavioural factors which had a significant independent protective effect on the risk of hip fracture included never smoking [AOR: 0.33 (0.12 to 0.88)], moderate alcohol consumption in mid and older age [AOR: 0.49 (0.25 to 0.95)], not losing weight between mid and older age [AOR: 0.36 (0.20 to 0.65)], playing sport in older age [AOR: 0.49 (0.29 to 0.83)], and practising a greater number of preventive medical care [AOR: 0.54 (0.32 to 0.94)] and self-health behaviours [AOR: 0.56 (0.33 to 0.94)].

Psychosocial factors which had a significant independent protective effect on the risk of hip fracture included currently being married [AOR: 0.44 (0.22 to 0.88)], living in current residence for five years or more [AOR: 0.43 (0.22 to 0.84)], having private health insurance [AOR: 0.49 (0.27 to 0.90)], using proactive coping strategies in response to stress [AOR: 0.52 (0.29 to 0.92)], having a higher level of life satisfaction [AOR: 0.47 (0.27 to 0.81)] and engagement in social activities in older age [AOR: 0.30 (0.17 to 0.54)].

The public health measure of effect (PAF) suggests that between eight and 44 percent of hip fractures could be prevented in this population by the universal adoption of any one of these protective behaviours.

Conclusions

This study provides evidence that healthy ageing factors are protective of the special case adverse outcome of fall-related hip fracture injury in older people. With universal exposures, clear associations, modifiable behavioural and psychosocial factors and readily implemented strategies, there is a strong argument for addressing falls among older people using population-based healthy ageing interventions.

 

The Structural Determinants of Quality in Residential Aged Care – Bev Richardson – University of Queensland

Within the residential aged care field, all providers have implemented a quality system consistent with the regulatory requirements of The Aged Care Act (1997), and have completed two cycles of Accreditation. The variation in assessed resident outcome ratings suggested it may be of value to explore possible causative factors of influence, in an attempt to identify the determinants of quality. Avedis Donabedian (1980:82-83), an acknowledged leader in quality in health care, proposed in his quality framework that organisational structure influences process, and process is directly related to outcomes. Further, he theorized that structural characteristics may have a direct influence on outcomes. This study chose to test Donabedian’s theory by investigating the impact of organisational structural components on resident outcome ratings, and to explore relationships between those structural elements to determine their relative levels of influence in order to identify whether there was predictive validity for an optimal structural model of care.

The defined scope for the research was a population study of the residential aged care field in Queensland. The study design employed a time-series data collection approach involving secondary data analysis of accreditation reports for the first and second accreditation cycles. Structural elements for investigation were aligned to Donabedian’s structural framework, and included levels of centralization or decentralization within the governance structure; provider size in terms of the number of facilities under its control; facility size in terms of numbers of beds; ownership by sector; geographic region of operation; mix of resident dependency ratios; and accessibility by special needs groups.

Statistical analysis found that for both the first and second accreditation cycles, provider size had the greatest predictive power of the structural variables in determining ratings compliance, with the large provider category having the greatest effect. Large providers managing 15-25 facilities, including those from public, private and nonprofit sectors, were found to adhere to a theoretically-based structural efficiency model, and also to achieve the highest levels of total compliance with the Accreditation Standards. Plaudits on the particular success of large providers in demonstrating both efficiency and effectiveness need to be tempered by concerns about the balance between efficiency and equity. The research findings demonstrated that when structural design was directed by technical and allocative efficiency decisions, barriers to access were created for residents who were regionally or culturally disadvantaged, as operations in remote areas, and in planning and delivering culturally appropriate services, incur greater costs.

Donabedian (2003:64) submits that the degree to which standards are specified can be perceived as a continuum, and that not all standards measurements are explicitly stated. It is implicitly understood that the regulations do not require demonstrated effectiveness of outcomes compliance for select segments of the resident population, but rather for the total resident population. Therefore the low incidence of response by large providers to residents living in remote areas, and those with culturally-specific needs, led to exploration of an alternative optimal structure.

In addition to the predicted success of large providers in achieving high effectiveness ratings, the logistic regression equations also predicted small providers managing 2-4 facilities had a statistically significant influence in determining total ratings compliance. Only a small differentiation in the Mean compliance ratings was found between these two most effective provider-size categories. However, the resident benefits offered by small providers included their success in addressing equity of access barriers for residents experiencing regional or cultural disadvantage. Examination of their structural characteristics suggested that in contrast with the efficiency model adopted by large providers, small providers tended to adhere to a structural equity model.

The research findings confirmed that structural design choices do have the capacity to directly influence effectiveness in terms of outcomes, thus validating Donabedian’s theory of outcome-structure dependence. Moreover, an organisation’s structural characteristics also influence the scale and scope of its operations, which have a subsequent impact on efficiency and equity. While both large and small provider sizes were found to be highly effective in compliance with the regulated outcome standards, large scale operations with limited scope were more likely to be efficient, while small scale operations with a broad scope were more likely to be equitable. Although the latter model most strongly aligns with regulatory and policy instruments, which are inclusive of principles of equity and access, it is the former model that appears to have garnered greatest political favour.

Analysis of the implications of the research findings confirmed the existence of a policy tension between efficiency drivers and equity principles, and concluded that the regulatory and policy frameworks are currently exerting contradictory pressures on the institutional operating environment of the residential aged care field. The research found that in the pursuit of increased industry efficiency, equity of access is sacrificed. The structural design choices of the most effective service providers focus on either breadth of scale or of scope. Policy makers are therefore faced with the choice of which model should be promoted – one that is efficiency-driven, or one that is equity-driven.