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ImportanceAdults in disadvantaged socioeconomic positions have elevated risks of a severe course of COVID-19, but it is unclear whether this holds true for children.ObjectiveTo investigate whether young people from disadvantaged households have a higher risk of COVID-19 hospitalization and whether differences were associated with comorbidities that predispose children to severe courses.Design, Setting, and ParticipantsThis population-based cohort study included all children and adolescents (aged 0-18 years) who were enrolled in a statutory health insurance carrier in Germany during the observation period of January 1, 2020, to July 13, 2021. Logistic regressions were calculated to compare children from households with and without an indication of poverty. Age, sex, days under observation, nationality, and comorbidities (eg, obesity, diabetes) were controlled for to account for explanatory factors.ExposuresDisadvantage on the household level was assessed by the employment status of the insurance holder (ie, employed, long- or short-term unemployed, low-wage employment, economically inactive). Socioeconomic characteristics of the area of residence were also assessed.Main Outcomes and MeasuresDaily hospital diagnoses of COVID-19 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes U07.1 and U07.2) were recorded. Comorbidities were assessed using inpatient and outpatient diagnoses contained in the insurance records.ResultsA total of 688 075 children and adolescents were included, with a mean (SD) age of 8.3 (5.8) years and 333 489 (48.4%) female participants. COVID-19 hospital diagnosis was a rare event (1637 participants [0.2%]). Children whose parents were long-term unemployed were 1.36 (95% CI, 1.22-1.51) times more likely than those with employed parents to be hospitalized. Elevated odds were also found for children whose parents had low-wage employment (odds ratio, 1.29; 95% CI, 1.05-1.58). Those living in low-income areas had 3.02 (95% CI, 1.73-5.28) times higher odds of hospitalization than those in less deprived areas. Comorbidities were associated with hospitalization, but their adjustment did not change main estimates for deprivation.Conclusions and RelevanceIn this cohort study, children who had parents who were unemployed and those who lived in low-income areas were at higher risk of COVID-19 hospitalization. This finding suggests that attention must be paid to children with SARS-CoV-2 from vulnerable families and closer monitoring should be considered. A number of explanatory factors, including comorbidities, were taken into account, but their analysis yielded no clear picture about underlying processes.

Unemployment is related to poverty and is a risk factor for poor health. The present study investigates if unemployment increases the risk of COVID-19 hospitalization for men and women of working age in Germany.The study uses the health insurance data from AOK Rhineland/Hamburg (from 1 January 2020 until 18 June 2020) of 1,288,745 persons aged between 18 and 65. Four employment situations are distinguished: (1) regular employment, (2) low-wage employment with social support, (3) unemployment with receipt of unemployment benefit 1, and (4) long-term unemployment with receipt of unemployment benefit 2. COVID-19 hospitalizations are measured on the basis of the ICD codes U07.1 and U07.2 reported by the hospitals. Multiple logistic regression models are calculated (adjusted for age and sex).During the observation period, 1521 persons had hospitalization with COVID-19 as primary or secondary diagnosis. Overall, this corresponds to a rate of 118 cases per 100,000 insured persons. Rates varied by employment situation. Compared with regularly employed persons, the odds ratio for a hospitalization was 1.94 (CI 95%: 1.74-2.15) for long-term unemployment, 1.29 (0.86-1.94) for unemployed, and 1.33 (0.98-1.82) for low-wage employment.The results are in line with earlier studies from the USA and Great Britain reporting socioeconomic inequalities in COVID-19 hospitalization risk. This provides the first empirical support that socioeconomic inequalities in the severity of COVID-19 also exists in Germany.HINTERGRUND UND ZIEL: Arbeitslosigkeit steht in Zusammenhang mit Armut und ist ein Risikofaktor für schlechte Gesundheit. Der vorliegende Beitrag untersucht, ob Arbeitslosigkeit das Risiko für einen COVID-19-bedingten Krankenhausaufenthalt für Männer und Frauen im erwerbsfähigen Alter in Deutschland erhöht.Die Auswertungen verwenden Krankenkassendaten der AOK Rheinland/Hamburg (vom 01.01.2020 bis zum 18.06.2020) mit Daten zu 1.288.745 Personen zwischen 18 und 65 Jahren. 4 Erwerbssituationen werden unterschieden: (1) reguläre Erwerbstätigkeit, (2) Niedriglohntätigkeit mit Sozialleistungen, (3) Arbeitslosigkeit mit Bezug von Arbeitslosengeld 1 (Alg I) und (4) Langzeitarbeitslosigkeit mit Bezug von Arbeitslosengeld 2 (Alg II). COVID-19-Krankenhausaufenthalte werden über Meldungen der Krankenhäuser anhand der ICD-Codes U07.1 und U07.2 bestimmt. Berechnet werden multiple logistische Regressionsmodelle (für Alter und Geschlecht adjustiert).1521 Personen hatten im Beobachtungszeitraum einen Krankenhausaufenthalt mit COVID-19 als Haupt- oder als Nebendiagnose. Dies entspricht insgesamt einer Rate von 118 Fällen pro 100.000 Versicherten. Die Raten variieren je nach Erwerbssituation. Im Vergleich zu regulär Erwerbstätigen liegt das Odds Ratio im Falle von Langzeitarbeitslosigkeit (Alg II) bei 1,94 (KI 95 %: 1,74–2,15), für Empfänger von Alg I bei 1,29 (KI 95 %: 0,86–1,94) und für Niedriglohnverdiener bei 1,33 (KI 95 %: 0,98–1,82).Die Ergebnisse stimmen mit früheren Studien aus den USA und Großbritannien zu sozioökonomischen Ungleichheiten bzgl. Risikos von COVID-19-Krankenhausaufenthalten überein. Dies liefert erste Hinweise dafür, dass sozioökonomische Unterschiede in Bezug auf schwere Verläufe von COVID-19 auch in Deutschland auftreten.

Ziel der Studie: Ziel der Studie war es, die subjektive Einschatzung der Betreuungskrafte in niedrigschwelligen Betreuungsangeboten fur Menschen mit Demenz zu ihrem Engagement unter Berucksichtigung des Anstellungsstatus zu untersuchen. Des Weiteren wurde ihre Bewertung dieser Angebotsart allgemein erfasst. Methodik: In einer explorativen Querschnittstudie wurden standardisierte Fragebogen in 2 Regionen Nordrhein-Westfalens eingesetzt und die Ergebnisse deskriptiv ausgewertet. Ergebnisse: Der Anstellungsstatus der Betreuungskrafte war unterschiedlich. So war die Halfte der 92 Befragten rein ehrenamtlich engagiert, wahrend die anderen geringfugig beschaftigt oder vom Trager des Angebotes angestellt waren. Sie suchten uberwiegend eine sinnvolle sowie erfullende Tatigkeit, profitierten personlich stark durch ihre Tatigkeit und zeigten ein hohes Engagement. Bei der Einschatzung zur Gestaltung der Angebote wurden die Aspekte, die das Angebot allgemein betreffen, organisatorischer Natur sind oder sich auf das Verhalten der Betreuungskrafte beziehen, als wichtig bewertet. Der wichtigste Aspekt fur alle Betreuungskrafte war die Beachtung der Bedurfnisse der Menschen mit Demenz. Der Anstellungsstatus spielt bei der Einschatzung dieser Aspekte kaum eine Rolle. Schlussfolgerung: Die Betreuungskrafte zeigen ein hohes Engagement. Hinsichtlich des Anstellungsstatus von Betreuungskraften lassen sich die Anbieter der Angebote in 2 Gruppen unterteilen. Die eine Gruppe bleibt bei dem rein ehrenamtlichen Engagement der Betreuungskrafte, wahrend die andere Gruppe durch den Abschluss von Anstellungsvertragen mit den Betreuungskraften eine kontinuierlichere Betreuung fur die Betroffenen anbieten und sicherstellen kann.

Niedrigschwellige Betreuungsangebote sind eine Möglichkeit, durch eine stundenweise Betreuung von Personen mit Demenz (PmD), pflegende Angehörige zu entlasten. Ziel der Studie ist es, die Aspekte von Niedrigschwelligkeit (Zugang, Flexibilität, Erreichbarkeit, Kostengünstigkeit) sowie die inhaltlichen und organisatorischen Aspekte niedrigschwelliger Angebote aus Sicht der pflegenden Angehörigen zu untersuchen. In einer explorativen Querschnittstudie wurde die Einschätzung von Angehörigen von PmD, welche ein niedrigschwelliges Betreuungsangebot in Anspruch nehmen, zu diesen Angeboten mittels standardisierter Fragebögen in zwei Regionen Nordrhein-Westfalens erhoben und deskriptiv ausgewertet. Die Ergebnisse zeigen, dass für die 53 befragten Angehörigen die inhaltliche Gestaltung der Betreuung v. a. mit Blick auf das Wohlbefinden der PmD von Bedeutung ist, während organisatorische Aspekte sowie die Niedrigschwelligkeit der Angebote als weniger wichtig empfunden werden. Die subjektiv eingeschätzte Belastung der pflegenden Angehörigen spielt dabei keine Rolle. Für die Entscheidung der pflegenden Angehörigen zur Inanspruchnahme scheint von Bedeutung zu sein, dass der Betreuungsschwerpunkt auf den Bedürfnissen der Menschen mit Demenz liegt, und dieser transparent dargestellt wird.

Aims and objectives To evaluate Dementia Care Mapping implementation in nursing homes. Background Dementia Care Mapping, an internationally applied method for supporting and enhancing person-centred care for people with dementia, must be successfully implemented into care practice for its effective use. Various factors influence the implementation of complex interventions such as Dementia Care Mapping; few studies have examined the specific factors influencing Dementia Care Mapping implementation. Design A convergent parallel mixed-methods design embedded in a quasi-experimental trial was used to assess Dementia Care Mapping implementation success and influential factors. Methods From 2011–2013, nine nursing units in nine different nursing homes implemented either Dementia Care Mapping (n = 6) or a periodic quality of life measurement using the dementia-specific instrument QUALIDEM (n = 3). Diverse data (interviews, n = 27; questionnaires, n = 112; resident records, n = 81; and process documents) were collected. Each data set was separately analysed and then merged to comprehensively portray the implementation process. Results Four nursing units implemented the particular intervention without deviating from the preplanned intervention. Translating Dementia Care Mapping results into practice was challenging. Necessary organisational preconditions for Dementia Care Mapping implementation included well-functioning networks, a dementia-friendly culture and flexible organisational structures. Involved individuals’ positive attitudes towards Dementia Care Mapping also facilitated implementation. Precisely planning the intervention and its implementation, recruiting champions who supported Dementia Care Mapping implementation and having well-qualified, experienced project coordinators were essential to the implementation process. Conclusions For successful Dementia Care Mapping implementation, it must be embedded in a systematic implementation strategy considering the specific setting. Organisational preconditions may need to be developed before Dementia Care Mapping implementation. Necessary steps may include team building, developing and realising a person-centred care-based mission statement or educating staff regarding general dementia care. The implementation strategy may include attracting and involving individuals on different hierarchical levels in Dementia Care Mapping implementation and supporting staff to translate Dementia Care Mapping results into practice. Relevance to clinical practice The identified facilitating factors can guide Dementia Care Mapping implementation strategy development.

The majority of people with dementia live at home, and informal carers assume the role of key care providers, often supported by formal services. The purpose of this pilot study was to assess home-based care arrangements, to illustrate utilisation of formal services over time and to identify factors associated with perceived stability of the care situation from the informal carer's perspective. A self-administered questionnaire (D-IVA ‘Instrument for Assessing Home-Based Care Arrangements for People with Dementia’) was developed and distributed in a provincial–rural setting in Germany as a cross-sectional survey. Data analysis used descriptive statistics, unbiased conditional inference trees and thematic analysis for open-ended questions. In total, 84 care arrangements were assessed. The majority of participants were direct relatives of the care-dependent person [mostly adult children (48.8%) or spouses (27.4%)]. Formal services were already sought in the first year after onset of memory problems. The most frequently used formal services were home care nursing services (53.0%), day care (49.4%) and respite care (29.6%), whereas 15.5% did not use any type of formal support. Companion home visit, home care nursing service and day care were used over the longest periods of time. The recruitment strategy used in this study may have recruited persons who were relatively more dependent on their informal carers. In this small sample, carers' perceived stability of the care situation was high, and this was associated with the country of origin and sex of the person with dementia (P = 0.004 and 0.023 respectively). Most care arrangements consisted of a mix of informal and formal services. However, informal carers assumed prime responsibility. The questionnaire D-IVA proved to be suitable. It remains a challenge to further examine factors associated with perceived stability and to explain the phenomenon in its whole complexity. Further research using the D-IVA should consider applying complementing quantitative measures as well as qualitative methods.

Case conferences for people with dementia and challenging behaviors (e.g., apathy) are recommended as useful tools that enable staff in nursing homes to understand the behavior of people with this type of disease. Understanding peoples’ behaviors is the basis for the initiation of targeted interventions to improve the quality of care for people with dementia. Furthermore, case conferences demonstrate positive effects on burnout, dementia-specific burden, and vocational action competence of the staff. The two likely approaches for conducting case conferences include the following: A) using a structured assessment instrument, which guides the staff in understanding the residents’ behaviors and B) using a narrative approach in which the staff must identify the reasons for the residents’ behaviors in an unstructured manner. Case conferences are a complex intervention, and evaluating their multiple effects is challenging. The aim of this study protocol was to describe a likely solution for evaluating this type of complex intervention using a special cluster randomized trial. In this stepped-wedged cluster randomized trial, the two interventions will be sequentially implemented every three months in a group of 12 nursing homes (clusters) with a minimum of 360 residents over 19 months (7 months of intervention for each cluster and follow-up). The primary outcome is the reduction of challenging behavior (measured with the neuropsychiatric inventory-nursing home version [NPI-NH]). Secondary outcomes are residents’ quality of life, prescription of psychotropic medications, staff burnout, dementia-related stress, and vocational action competence. The effectiveness of the study will be accompanied by a process evaluation. The primary data will be analyzed using a Bayesian mixed effect model; the secondary data will be analyzed using descriptive statistics and mixed effects models. The implementation and effect measurement of complex interventions such as case conferences within a cluster randomized trial are challenging (e.g., complex and intensive training, delayed treatment effect). In this study protocol, the methodological advantages and disadvantages of using the stepped wedge design to answer the research questions are discussed. http://www.controlled-trials.com/ISRCTN20203855 ; registered 10 July 2013.

Background:Quality of life (Qol) is an increasingly used outcome measure in dementia research. The QUALIDEM is a dementia-specific and proxy-rated Qol instrument. We aimed to determine the inter-rater and intra-rater reliability in residents with dementia in German nursing homes.Methods:The QUALIDEM consists of nine subscales that were applied to a sample of 108 people with mild to severe dementia and six consecutive subscales that were applied to a sample of 53 people with very severe dementia. The proxy raters were 49 registered nurses and nursing assistants. Inter-rater and intra-rater reliability scores were calculated on the subscale and item level.Results:None of the QUALIDEM subscales showed strong inter-rater reliability based on the single-measure Intra-Class Correlation Coefficient (ICC) for absolute agreement ≥ 0.70. Based on the average-measure ICC for four raters, eight subscales for people with mild to severe dementia (care relationship, positive affect, negative affect, restless tense behavior, social relations, social isolation, feeling at home and having something to do) and five subscales for very severe dementia (care relationship, negative affect, restless tense behavior, social relations and social isolation) yielded a strong inter-rater agreement (ICC: 0.72–0.86). All of the QUALIDEM subscales, regardless of dementia severity, showed strong intra-rater agreement. The ICC values ranged between 0.70 and 0.79 for people with mild to severe dementia and between 0.75 and 0.87 for people with very severe dementia.Conclusions:This study demonstrated insufficient inter-rater reliability and sufficient intra-rater reliability for all subscales of both versions of the German QUALIDEM. The degree of inter-rater reliability can be improved by collaborative Qol rating by more than one nurse. The development of a measurement manual with accurate item definitions and a standardized education program for proxy raters is recommended.

Background Quality of life (Qol) is a widely selected outcome in intervention studies. The QUALIDEM is a dementia-specific Qol-instrument from The Netherlands. The aim of this study is to evaluate the scalability and internal consistency of the German version of the QUALIDEM. Methods This secondary data analysis is based on a total sample of 634 residents with dementia from 43 nursing homes. The QUALIDEM consists of nine subscales that were applied to a subsample of 378 people with mild to severe dementia and six consecutive subscales that were applied to a subsample of 256 people with very severe dementia. Scalability, internal consistency and distribution scores were calculated for each predefined subscale using the Mokken scale analysis. Results In people with mild to severe dementia, seven subscales, care relationship, positive affect, negative affect, restless tense behavior, positive self-image, social relations and feeling at home, were scalable (0.31 ≤ H ≤ 0.65) and internally consistent (Rho ≥ 0.62). The subscales social isolation (H = 0.28) and having something to do (H = 0.18) were not scalable and exhibited insufficient reliability scores (Rho ≤ 0.53). For people with very severe dementia, five subscales, care relationship, positive affect, restless tense behavior, negative affect and social relations, were scalable (0.33 ≤ H ≤ 0.65), but only the first three of these subscales showed acceptable internal consistency (Rho 0.59 – 0.86). The subscale social isolation was not scalable (H = 0.20) and exhibited poor internal consistency (Rho = 0.42). Conclusions The results show an acceptable scalability and internal consistency for seven QUALIDEM subscales for people with mild to severe dementia and three subscales for people with very severe dementia. The subscales having something to do (mild to severe dementia), negative affect (very severe dementia), social relations (very severe dementia) and social isolation (both versions) produced unsatisfactory results and require revision.