A realist evaluation of a multi-component program with disengaged students

Periods spent in the absence of education, employment, or training (NEET) are associated with adverse psychological wellbeing, social marginalisation, and premature mortality. Implementing effective programs to re-engage young people who are classified, or are at risk of becoming NEET, is of importance to these individuals, family, and society. We conducted a realist evaluation to understand how, and under which circumstances a multi-component program may impact the engagement, behavioural, and psychosocial outcomes of disengaged students at risk of becoming NEET. During the early project phase, a narrative review of the literature and key stakeholder discussions were conducted to develop our initial program theories regarding how the program was expected to achieve its outcomes. Participant observations, video footage, and forty-two interviews were then conducted with teachers and students to form context-mechanism-outcome configurations and to refine these theories. Overall, refined program theories relating to positions of authority, the power of collective experience, exploration of possible life directions, constructivist pedagogies and active learning, and the endorsement of an ethic of caring and strengths-based orientation were developed. Collectively, our findings provide a detailed understanding of the architecture of programs that may benefit disengaged students and help inform the design of future programs aimed at reducing disaffection.

This needs to be a journey that we're actually on together'-the introduction of integrated care systems for children and young people in England: a qualitative study of the views of local system stakeholders during winter 2021/22

BACKGROUND

Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision.

METHODS

A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts.

RESULTS

Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations).

CONCLUSIONS

The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care.

Well-being, burnout and value fulfilment: Let us situate individuals within systems

Bansal explores how systems‐based enquiry might productively shift focus from individual success or failure, to broader support of wellbeing and burnout prevention.

Objective measurement of cough during pulmonary exacerbations in adults with cystic fibrosis

BACKGROUND

Little is known about cough frequency in adults with cystic fibrosis (CF). This study aimed to determine (1) daytime and overnight cough rates in patients with CF at the beginning and end of a course of antibiotics for treatment of an exacerbation; (2) the relationship between cough frequencies and standard clinical measures of disease; and (3) the relationship between objective cough rates and the subjective assessment of cough.

METHODS

Nineteen adult patients admitted with a pulmonary exacerbation performed daytime and overnight sound recordings on admission; 13 had repeat recordings prior to discharge. Coughs were manually quantified in cough seconds (time spent coughing). Patients subjectively scored their cough using a visual analogue scale (VAS) and numerical score. Lung function, C-reactive protein (CRP) levels, and sputum weights were recorded.

RESULTS

Cough rates fell substantially with treatment; median fall in cough rate was 51.3% (IQR 32.3-77.5) (p<0.001) for daytime and 72.2% (28.6-90.1) (p = 0.049) for overnight. Multivariate regression analyses showed that forced expiratory volume in 1 second and CRP levels predicted overnight cough rates on admission. On discharge, sputum volume predicted daytime cough rates. Only the change in overnight VAS correlated with the change in objective cough rates.

CONCLUSIONS

The cough rate significantly decreases with treatment of a pulmonary exacerbation in adults with CF. Lung function, sputum volume, and CRP influences the cough rate, with the effects differing from day to night and between admission and discharge. Subjective reporting of a nocturnal cough may indicate a pulmonary exacerbation of CF in adults.

Degradation of riboflavin by alimentary bacteria of the ruminant and man: production of 7,8-dimethyl-10-carboxymethylisoalloxazine

1. A new product of the bacterial degradation of riboflavin has been isolated from fermentations in vitro of mixtures of either rumen bacteria or caecal bacteria with excess of the vitamin.

2. This product has been identified as 7,8-dimethyl-10-carboxymethylisoalloxazine and has also been shown to occur in the urine of ruminants and man.

3. The bacterial formation of this compound is compared with the bacterial formation of other isoalloxazines previously identified in similar incubation mixtures, and is discussed in relation to the factors influencing the mode of degradation of riboflavin.

Metabolism of riboflavin: reduction of 7,8-dimethyl-10-formylmethylisoalloxazine by an enzyme in liver

1. The riboflavin metabolite, 7,8-dimethyl-10-formylmethylisoalloxazine, has been shown to be reduced to the corresponding alcohol, 7,8-dimethyl-10-(2′-hydroxyethyl)isoalloxazine, by an enzyme present in the soluble fraction of liver and kidney.

2. The enzyme is present in these organs in a number of species but is especially prevalent in the tissues of ruminants. It appears to be different from the normal hepatic alcohol dehydrogenase in that it uses NADPH rather than NADH as cofactor.

Metabolites of riboflavine in milk, urine and tissues of animals in relation to alimentary symbiotic bacteria

1. Riboflavine given orally to sheep, calves, goats and ruminating kids gave rise, in milk and urine, to extra riboflavine accompanied by hydroxyethylflavine, by formylmethylflavine and by other as yet unidentified metabolites, but subcutaneous injection of riboflavine caused prolonged excretion of riboflavine in urine and milk unaccompanied by metabolites.

2. Placement of riboflavine by means of fistulas into the rumen, the abomasum or the caecum and abstraction of samples from the rumen or caecum showed that the rumen was the site of origin of the metabolites, thus accounting for the lapse of time of several hours between the ingestion of riboflavine and the appearance of hydroxyethylflavine in the urine and the absence of metabolites after subcutaneous injection of riboflavine.

3. Kids in which rumination had not yet become established could not produce metabolites from ingested riboflavine although, when fed milk containing the metabolites, they readily excreted them in their urine.

5. Incubation in vitro of kidney or liver tissue from cattle or goats with riboflavine did not give rise to metabolites, but these tissues could both reduce formylmethylflavine to hydroxyethylflavine in vitro.

6. Post-mortem examination of animals to which riboflavine had been fed showed the presence of metabolites only in gut contents, in the urinary bladder and in the bile. When injected, riboflavine reached the bile but no metabolites were produced.

7. Metabolites were found to occur naturally in the urine of ruminants in small amounts. Hydroxyethylflavine was readily demonstrable in the urine of the rabbit, but in the urine of the dog metabolites could not be found.

8. From these and earlier and later experiments the conclusion is drawn that riboflavine metabolites arise in the ruminant from the degradation of riboflavine by rumen bacteria.

Metabolism of riboflavine in germ-free and conventional rabbits

1. Isoalloxazines were characterized and measured in the caecum of two conventional rabbits kept on an adequate diet, two rabbits on the same diet from which vitamin B2 (ribo-flavine) had been omitted and five germ-free rabbits which were also on the adequate diet.

2. Riboflavine (up to 12mg) unaccompanied by any of its degradation products was found in the caecum of germ-free rabbits and 8–9 μg per ml were found in their urine.

3. Hydroxyethylflavine (4–5 mg) accompanied only by traces of riboflavine was found in the caecum of conventional rabbits.

4. There was about 1% ash in the contents of each of five germ-free and two conventional caecums.

5. The five germ-free caecal contents averaged 22.4% of the animal's body-weight. For four conventional animals this figure was only 10.5%.

6. In the caecum of each of two conventional rabbits kept on a diet deficient in riboflavine neither riboflavine nor hydroxyethylflavine was found but there was somewhat less than 1 mg of a yellow-fluorescing material of low RF value in each caecum.

7. The results are discussed in relation to the authors' previous reports on metabolites of riboflavine.

The urinary excretion of metabolites of riboflavine by man

1. A dose of 1 g of riboflavine caused a large excretion of the vitamin in human urine and the rate of excretion showed more than one maximum.

2. Various degradation products of riboflavine appeared in the urine approximately 24 h after the dose was administered and two of these were identified as 7,8-dimethyl-10-(2-hydroxy-ethyl)isoalloxazine, and 7,8-dimethyl-10-formyl-methylisoalloxazine. Reasons are given for believing that the degradation of riboflavine was due to bacterial action in the colon.

The influence of dietary molybdenum on the xanthine oxidase activity of the milk of ruminants

1.The oral administration of sodium molybdate caused a rapid rise of molybdenum in the milk of cows and goats fed on a low-molybdenum diet, but did not affect the xanthine oxidase activities of the milk of either species.

2.In the milks of cows not dosed with sodium molybdate, the regression of the xanthin oxidase activity (y) on the molybdenum content (x) was found to be y = 170.7x+43.86 (r = +0.9386; P < 0.0001), suggesting that all the molybdenum of such milk is bound to enzymically active xanthine oxidase.

3.The molybdenum contents of the milk of goats not does with sodium molybdate varied from animal to anumal and the xanthine oxidase activites were much lower than those of cow' milk. there was no correlation between xanthine oxidase activity and the molybdenum contend of the milks of the goats.

4. These results are discussed in relation to previous work of the authors and others.