Working across boundaries to improve health outcomes: a case study of a housing support and outreach service for homeless people living with HIV

This paper reports the findings of an evaluation of the ‘Housing Support, Outreach and Referral’ service developed to support people living with HIV who were homeless or at risk of homelessness. The service was set up as part of the Supporting People Health Pilot programme established to demonstrate the policy links between housing support services and health and social care services by encouraging the development of integrated services. The paper considers the role of housing support in improving people's health, and considers the challenges of working across housing, health and social care boundaries. The evaluation of the health pilot employed two main sources of data collection: quarterly project evaluation reports, which collected process data as well as reporting progress against aims and objectives, and semi-structured interviews with professionals from all key stakeholder groups and agencies, and with people who used services. Over the course of 15 months, 56 referrals were received of which 27 were accepted. Fifteen people received tenancy support of whom 12 were helped to access temporary accommodation. At the end of the 15 months, all of the tenancies had been maintained. In addition, 18 people registered with a general practitioner and 13 registered with an HIV clinic. Interviews with professionals emphasised the importance of the local joint working context, the involvement of the voluntary sector and the role of the support workers as factors that accounted for these outcomes. Those using services placed most emphasis on the flexibility of the support worker role. Importantly, interviews with professionals and those using services suggest that the role of support worker incorporates two dimensions – those of networker/navigator as well as advocate – and that both dimensions are important in determining the effectiveness of the service.

Enhancing family physician capacity to deliver quality palliative home care:An end-of-life, shared-care model

PROBLEM BEING ADDRESSED: Family physicians face innumerable challenges to delivering quality palliative home care to meet the complex needs of end-of-life patients and their families. OBJECTIVE OF PROGRAM: To implement a model of shared care to enhance family physicians' ability to deliver quality palliative home care, particularly in a community-based setting. PROGRAM DESCRIPTION: Family physicians in 3 group practices (N = 21) in Ontario's Niagara West region collaborated with an interprofessional palliative care team (including a palliative care advanced practice nurse, a palliative medicine physician, a bereavement counselor, a psychosocial-spiritual advisor, and a case manager) in a shared-care partnership to provide comprehensive palliative home care. Key features of the program included systematic and timely identification of end-of-life patients, needs assessments, symptom and psychosocial support interventions, regular communication between team members, and coordinated care guided by outcome-based assessment in the home. In addition, educational initiatives were provided to enhance family physicians' knowledge and skills. CONCLUSION: Because of the program, participants reported improved communication, effective interprofessional collaboration, and the capacity to deliver palliative home care, 24 hours a day, 7 days a week, to end-of-life patients in the community.

Teaching and cognitive outcomes in A-levels and Advanced GNVQ's: Case studies from Science and Business Studies Classrooms

The purpose of the paper is to demonstrate how a research diary methodology, designed to analyse A-level and GNVQ classrooms, can be a powerful tool for examining pedagogy and quality of learning at the level of case study. Two subject areas, science and business studies, are presented as cases. Twelve teachers and thirty-four students were studied over a four-week period in May 1997 and contrasts were drawn between lessons from three A-level physics teachers/three Advanced GNVQ science teachers and two A-level business/economics teachers/four Advanced GNVQ business teachers. Lessons were analysed within a cognitive framework which distinguishes between conceptual and procedural learning and emphasizes the importance of metacognition and epistemological beliefs. Two dimensions of lessons were identified: pedagogical activities (e.g. teacher-led explanation, teacher-led guidance on a task, question/answer sessions, group discussions, working with IT) and cognitive outcomes (e.g. structuring and memorizing facts, understanding concepts and arguments, critical thinking, problem-solving, learning core skills, identifying values). Immediately after each lesson, teachers and students (three per class) completed structured research diaries with respect to the above dimensions. Data from the diaries reveal general and unique features of the lessons. Time-ofyear effects were evident (examinations pending in May), particularly in A-level classrooms. Students in business studies classes reported a wider range of learning activities and greater variety in cognitive outcomes than did students in science classes. Science students self-rating of their ability to manage and direct their own learning was generally low. The phenomenological aspects of the classrooms were consistently linked to teachers' lesson plans and what their teaching objectives were for those particular students at that particular time of the year.

The Outcomes of Cross-Cultural Adjustment: A Case of British Expatriates Working on International Architectural, Engineering and Construction Assignments

The main aim of this study is to investigate the consequences of cross-cultural adjustment in an under researched sample of British expatriates working on International Architectural, Engineering and Construction (AEC) assignments. Adjustment is the primary outcome of an expatriate assignment. According to Bhaskar-Srinivas et al., (2005), Harrison et al., (2004) it is viewed to affect other work related outcomes which could eventually predict expatriate success. To address the scarcity of literature on expatriate management in the AEC sector, an exploratory design was adopted. Phase one is characterised by extensive review of extant literature, whereas phase two was qualitative exploration from British expatriates’ perspective; here seven unstructured interviews were carried out. Further, cognitive mapping analysis through Banaxia decision explorer software was conducted to develop a theoretical framework and propose various hypotheses. The findings imply that British AEC firms could sustain their already established competitive advantage in the global marketplace by acknowledging the complexity of international assignments, prioritising expatriate management and offering a well-rounded support to facilitate expatriate adjustment and ultimately achieve critical outcomes like performance, assignment completion and job satisfaction.

The outcomes of cross-cultural adjustment: A case of British expatriates working on international architectural, engineering and construction assignments

The main aim of this study is to investigate the consequences of cross-cultural adjustment in an under researched sample of British expatriates working on International Architectural, Engineering and Construction (AEC) assignments. Adjustment is the primary outcome of an expatriate assignment. According to Bhaskar-Srinivas et al., (2005), Harrison et al., (2004) it is viewed to affect other work related outcomes which could eventually predict expatriate success. To address the scarcity of literature on expatriate management in the AEC sector, an exploratory design was adopted. Phase one is characterised by extensive review of extant literature, whereas phase two was qualitative exploration from British expatriatesÕ perspective; here seven unstructured interviews were carried out. Further, cognitive mapping analysis through Banaxia decision explorer software was conducted to develop a theoretical framework and propose various hypotheses. The findings imply that British AEC firms could sustain their already established competitive advantage in the global marketplace by acknowledging the complexity of international assignments, prioritising expatriate management and offering a well-rounded support to facilitate expatriate adjustment and ultimately achieve critical outcomes like performance, assignment completion and job satisfaction.

Using postal questionnaires to evaluate physical activity and diet behaviour change: case study exploring implications of valid responder characteristics in interpreting intervention outcomes.

Background: Patient reported outcome measures (PROMs) are used to evaluate lifestyle interventions but littleis known about differences between patients returning valid and invalid responses, or of potential for bias inevaluations. We aimed to examine the characteristics of patients who returned valid responses to lifestylequestionnaires compared to those whose responses were invalid for evaluating lifestyle change. 
Methods: We conducted a secondary data analysis from the SPHERE Study, a trial of an intervention to improveoutcomes for patients with coronary heart disease in primary care. Postal questionnaires were used to assessphysical activity (Godin) and diet (DINE) among study participants at baseline and 18 month follow-up. Three binaryresponse variables were generated for analysis: (1) valid Godin score; (2) valid DINE Fibre score; and (3) validDINE Total Fat score. Multivariate analysis comprised generalised estimating equation regression to examine theassociation of patients’ characteristics with their return of valid responses at both timepoints. 
Results: Overall, 92.1% of participants (832/903) returned questionnaires at both baseline and 18 months. Relativelyfewer valid Godin scores were returned by those who left school aged <15 years (36.5%) than aged 18 and over(50.5%), manual workers (39.5%) than non-manual (49.5%) and those with an elevated cholesterol (>5 mmol)(34.7%) than those with a lower cholesterol (44.4%) but multivariate analysis identified that only school leaving age(p = 0.047) was of statistical significance.Relatively fewer valid DINE scores were returned by manual than non-manual workers (fibre: 80.8% v 86.8%;fat: 71.2% v 80.0%), smokers (fibre: 72.6% v 84.7%; fat: 67.5% v 76.9%), patients with diabetes (fibre: 75.9% v 82.9%;fat: 66.9% v 75.8%) and those with cholesterol >5 mmol (fat: 68.2% v 76.2%) but multivariate analysis showedstatistical significance only for smoking (fibre: p = 0.013; fat: p = 0.045), diabetes (fibre: p = 0.039; fat: p = 0.047), andcholesterol (fat: p = 0.039). 
Conclusions: Our findings illustrate the importance of detailed reporting of research methods, with clearinformation about response rates, respondents and valid outcome data. Outcome measures which are relevant to astudy population should be chosen carefully. The impact of methods of outcome measurement and valid responserates in evaluating healthcare requires further study.

Design of a Virtual Reality Framework for Maintainability and assemblability test of complex systems

This paper presents a unique environment whose features are able to satisfy requirements for both virtual maintenance and virtual manufacturing through the conception of original virtual reality (VR) architecture. Virtual Reality for the Maintainability and Assemblability Tests (VR_MATE) encompasses VR hardware and software and a simulation manager which allows customisation of the architecture itself as well as interfacing with a wide range of devices employed in the simulations. Two case studies are presented to illustrate VR_MATE's unique ability to allow for both maintainability tests and assembly analysis of an aircraft carriage and a railway coach cooling system respectively. The key impact of this research is the demonstration of the potentialities of using VR techniques in industry and its multiple applications despite the subjective character within the simulation. VR_MATE has been presented as a framework to support the strategic and operative objectives of companies to reduce product development time and costs whilst maintaining product quality for applications which would be too expensive to simulate and evaluate in the real world.

Judging where a ball will go: the case of curved free kicks in football

This study examined whether adding spin to a ball in the free kick situation in football affects a professional footballer's perception of the ball's future arrival position. Using a virtual reality set-up, participants observed the flight paths of aerodynamically realistic free kicks with (+/- 600 rpm) and without sidespin. With the viewpoint being fixed in the centre of the goal, participants had to judge whether the ball would have ended up in the goal or not. Results show that trajectories influenced by the Magnus force caused by sidespin gave rise to a significant shift in the percentage of goal responses. The resulting acceleration that causes the ball to continually change its heading direction as the trajectory unfolds does not seem to be taken into account by the participants when making goal judgments. We conclude that the visual system is not attuned to such accelerated motion, which may explain why goalkeepers appear to misjudge the future arrival point of such curved free kicks.

Addressing Bed Costs for the Elderly: A New Methodology for Modelling Patient Outcomes and Length of Stay

The proportion of elderly in the population has dramatically increased and will continue to do so for at least the next 50 years. Medical resources throughout the world are feeling the added strain of the increasing proportion of elderly in the population. The effective care of elderly patients in hospitals may be enhanced by accurately modelling the length of stay of the patients in hospital and the associated costs involved. This paper examines previously developed models for patient length of stay in hospital and describes the recently developed conditional phase-type distribution (C-Ph) to model patient duration of stay in relation to explanatory patient variables. The Clinics data set was used to demonstrate the C-Ph methodology. The resulting model highlighted a strong relationship between Barthel grade, patient outcome and length of stay showing various groups of patient behaviour. The patients who stay in hospital for a very long time are usually those that consume the largest amount of hospital resources. These have been identified as the patients whose resulting outcome is transfer. Overall, the majority of transfer patients spend a considerably longer period of time in hospital compared to patients who die or are discharged home. The C-Ph model has the potential for considering costs where different costs are attached to the various phases or subgroups of patients and the anticipated cost of care estimated in advance. It is hoped that such a method will lead to the successful identification of the most cost effective case-mix management of the hospital ward.

From Quality Management to Socially Responsible Organisations: the Case for CSR

Purpose – The purpose of this paper is to focus on the growing interest of the role of business in society, commonly referred to as CSR. Historically CSR can be traced back to the 1950s, although in very recent times there has been a virtual explosion of interest in its use and applicability in organisations. However, there are many unresolved issues, most notably in terms of how CSR should or can be implemented and embedded in an organisation. This paper therefore seeks to explore the relationship and potential synergies between quality management and CSR. Design/methodology/approach – The qualitative exploratory study in this paper represents the first stage of an ongoing research programme, and is based on an in-depth analysis of quality award submission documentation from six case organisations that have recently been recognised as winners in relation to their quest for business improvement. Findings – The paper finds that substantial evidence from each of the case organisations demonstrates the breadth and depth of activities in which they are engaging under the broad headings of workplace, environment, social impact, and economic impact. However, whilst there is no doubting the sincerity of the actions, the approaches and activities, a strategic focus on CSR is still very much in its infancy. Research limitations/implications – In this paper there is a paucity of empirical research examining how existing management tools, techniques and methodologies can be used to further the CSR debate. This paper represents an important first step in redressing this imbalance. Practical implications – The paper suggests that the quality management and business excellence frameworks can offer a strong foundation from which to develop CSR strategies, behaviours and activities in an organisation. Originality/value – This paper represents an important first step in understanding how and where CSR “fits” into an organisation and potentially how existing quality methodologies, tools and frameworks can be used to aid the implementation of CSR.

Widening our knowledge concerning young looked after children: the case for research using sociological models of childhood

The Assessment and Action framework for looked after children, designed to improve outcomes for all children in public care and those at home on care orders, is now well established in the UK. This paper offers a critical evaluation of the framework by examining the model of childhood upon which it is premised and by exploring its relationship to children's rights as conceptualized in the United Nations Convention on the Rights of the Child (1989). It will be argued that the particular child development model which underpins the framework addresses the rights of looked after children to protection and provision but does not allow for their participation rights to be sufficiently addressed. A critical review of the research concerning the education and health of looked after children is used to illustrate these points. It will be argued that what are missing are the detailed accounts of looked after children themselves. It is concluded that there is a need for the development of additional research approaches premised upon sociological models of childhood. These would allow for a greater engagement with the participation rights of this group of children and complement the pre-existing research agenda

Tooth loss and implant outcomes in patients refractory to treatment in a periodontal practice

Aim: The aim of this study was to investigate the factors associated with continued significant tooth loss due to periodontal reasons during maintenance following periodontal therapy in a specialist periodontal practice in Norway.
Material and Methods: A case-control design was used. Refractory cases were patients who lost multiple teeth during a maintenance period of 13.4 (range 8-19) years following definitive periodontal treatment in a specialist practice. Controls were age- and gender-matched maintenance patients from the same practice. Characteristics and treatment outcomes were assessed, and all teeth classified as being lost due to periodontal disease during follow-up were identified. The use of implants in refractory cases and any complications relating to such a treatment were recorded.
Results: Only 27 (2.2%) patients who received periodontal treatment between 1986 and 1998 in a specialist practice met the criteria for inclusion in the refractory to treatment group. Each refractory subject lost 10.4 (range 4-16) teeth, which represented 50% of the teeth present at baseline. The rate of tooth loss in the refractory group was 0.78 teeth per year, which was 35 times greater than that in the control group. Multivariate analysis indicated that being in the refractory group was predicted by heavy smoking (p=0.026), being stressed (p=0.016) or having a family history of periodontitis (p=0.002). Implants were placed in 14 of the refractory patients and nine (64%) of these lost at least one implant. In total, 17 (25%) of the implants placed in the refractory group were lost during the study period.
Conclusions: A small number of periodontal maintenance patients are refractive to treatment and go on to experience significant tooth loss. These subjects also have a high level of implant complications and failure. Heavy smoking, stress and a family history of periodontal disease were identified as factors associated with a refractory outcome.