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Background: As digital tools are increasingly used to support COVID‐19 contact tracing, the equity implications must be considered. As part of a study to understand the public's views of digital contact tracing tools developed for the national 'Test and Protect' programme in Scotland, we aimed to explore the views of groups often excluded from such discussions. This paper reports on their views about the potential for contact tracing to exacerbate inequalities. Methods: A qualitative study was carried out; interviews were conducted with key informants from organizations supporting people in marginalized situations, followed by interviews and focus groups with people recruited from these groups. Participants included, or represented, minority ethnic groups, asylum seekers and refugees and those experiencing multiple disadvantage including severe and enduring poverty. Results: A total of 42 people participated: 13 key informants and 29 members of the public. While public participants were supportive of contact tracing, key informants raised concerns. Both sets of participants spoke about how contact tracing, and its associated digital tools, might increase inequalities. Barriers included finances (inability to afford smartphones or the data to ensure access to the internet); language (digital tools were available only in English and required a degree of literacy, even for English speakers); and trust (many marginalized groups distrusted statutory organizations and there were concerns that data may be passed to other organizations). One strength was that NHS Scotland, the data guardian, is seen as a generally trustworthy organization. Poverty was recognized as a barrier to people's ability to self‐isolate. Some participants were concerned about giving contact details of individuals who might struggle to self‐isolate for financial reasons. Conclusions: The impact of contact tracing and associated digital tools on marginalized populations needs careful monitoring. This should include the contact tracing process and the ability of people to self‐isolate. Regular clear messaging from trusted groups and community members could help maintain trust and participation in the programme. Patient and Public Contribution: Our patient and public involvement coapplicant, L. L., was involved in all aspects of the study including coauthorship. Interim results were presented to our local Public and Patient Involvement and Engagement Group, who commented on interpretation and made suggestions about further recruitment. [ABSTRACT FROM AUTHOR]

Legally protected by its own constitution since 1991, the greenbelt (or 'GrünGürtel') forms a ring of greenspace around Frankfurt, Germany and has been considered an effective reaction to municipal development pressures. As a response to Frankfurt's embeddedness within a highly interconnected suburbanized region under extensive growth pressures, the Regionalpark RheinMain was established to upscale the greenbelt to the regional level. In this article, we explore the institutional complexities of upscaling a localized greenbelt to the regional scale in the Frankfurt Rhine-Main region, which is known for its fragmented institutional environment formed by numerous planning authorities and special purpose agencies with overlapping jurisdictions. Engaging with the literature on the governance of greenbelts from an institutional perspective, we analyse how the development of the Regionalpark RheinMain is shaped by horizontal, vertical and territorial coordination problems. We conclude that that the Regionalpark RheinMain is not appropriately institutionalized to serve as an effective regional greenbelt, resulting in localized initiatives and the delegation of greenbelt planning to municipalities. [ABSTRACT FROM AUTHOR]

Summary: Primary care practitioners (PCPs) are well placed to identify individuals with obesity and weight‐related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context‐mechanism‐outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of "candidacy" (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors. [ABSTRACT FROM AUTHOR]

Despite certain similarities in their backgrounds, French philosopher Simone Weil (1909–43) and German-American philosopher Hannah Arendt (1906–75) had dramatically different perspectives on the importance of politics. Yet both thinkers turned to Homer's Iliad as a way of understanding the atrocities of WWII and the rise of authoritarian regimes. While each author comments on the beauty of the poem, they also argue that the Iliad demonstrates the grave injustices that humans are capable of as well as a remedy for the same. This shared love of aesthetic beauty drew them to a common account of justice, one that insists on recognizing the full autonomy of the other while also insisting on a duty to care for those in need. Finally, both authors prescribe aesthetic beauty as necessary for maintaining the health of democratic regimes. [ABSTRACT FROM AUTHOR]

Screening is a well-established tool to advance earlier cancer diagnosis. We used Davison's concept of 'candidacy' to explore how individuals draw on collectively constructed images of 'typical' colorectal cancer (CRC) sufferers, or 'candidates', in order to evaluate their own risk and to ascertain the impact of candidacy on screening participation in CRC. We interviewed 61 individuals who were invited to participate in the Scottish Bowel Screening Programme. Of these, 37 were screeners (17 men and 20 women) and 24 non-screeners (13 men and 11 women). To analyse these data we used a coding frame that drew on: symptoms, risk factors, and retrospective and prospective candidacy. Few participants could identify a definite bowel cancer candidate and notions of candidacy were largely predicated on luck in the sense that anyone could be a candidate for CRC and there was little evidence to support a linear relationship between feelings of risk and screening decisions. Often participants described screening as part of a wider portfolio of being healthy and referred to feeling obliged to look after themselves. Our study suggests that rather than candidates for bowel cancer, screeners viewed themselves as candidates for screening by which screening decisions pointed towards the acceptance and normalisation of the rhetoric of personal responsibility for health. These findings have related theoretical and practical implications; the moral structure that underpins the new public health can be witnessed practically in the narratives by which those who see themselves as candidates for screening embrace wider positive health practices. [ABSTRACT FROM AUTHOR]

Background Recent evidence suggests that the first consultation with a general practitioner (GP) for symptoms of depression may be more than just a vehicle for assessment and management planning (as current guidelines imply). Objectives To identify what patients find helpful, or otherwise, in their first consultation for low mood with a GP. Methods A cross-sectional questionnaire and interview study of patients with low mood who had recently consulted their GP, in the North of England. Patients were asked to complete a questionnaire regarding the consultation, and a Patient Health Questionnaire-9 (PHQ-9), within 2 weeks. They were also invited to take part in a face–face interview with a researcher. Both sources of data were subjected to qualitative thematic analysis. Results Thirty-seven questionnaires were returned; 5 interviews took place. The majority of participants felt better after consulting a GP for the first time for low mood. The factors most commonly cited as helpful were "being listened to" and "understanding or empathy from the GP." Others included "admitting the problem," "being reassured of normality," and "being provided with optimism or hope for change." The most commonly reported difficulty was the patients' struggle to express themselves. Patients often felt that GP follow-up was inadequate. Conclusions These results suggest that the therapeutic benefit of the GP consultation is under-recognized in current guidelines. The results of our study will provide crucial information as to how such consultations can be tailored to improve patient satisfaction. [ABSTRACT FROM AUTHOR]

Context: The Covid-19 pandemic and implementation of measures to limit the spread of the virus significantly affected access to healthcare. Routine care in the UK was transformed; remote consultation was introduced for some services while others were disbanded. Public health messaging encouraged the public to stay at home to protect the NHS. Our study investigating the healthcare experience of people living with multimorbidity (presence of =2 long term conditions) including Rheumatoid Arthritis (RA) and persistent musculoskeletal (MSK) pain, was suspended because of the pandemic. Objective: To investigate the experiences of people living with RA or MSK pain during the pandemic. Study design and analysis: Semi-structured interviews were conducted with 47 people living with RA or persistent MSK pain, with and without multimorbidity. Data were analysed thematically, and findings mapped to the 'candidacy' theoretical framework. Setting and dataset: Participants were recruited from outpatient rheumatology clinics, pain clinics and primary care, in Scotland, UK. Participants were mostly female (31 female, 16 male) and aged between 24 and 92 years. Results: Our analysis identified themes related to: (1) Healthcare system impacts (remote consultations, delays and cancellations, difficulties accessing care, Covid information) and (2) Impacts on individuals (social and emotional wellbeing, pain and mobility, mental health, care seeking behaviour, employment/finance, understandings of Covid). Themes were mapped to the processes of candidacy. It was clear that the move towards remote consultations may have unintended consequences and should not be 'one-size fits all'. Conclusions: Our findings highlight experiences of people with RA/persistent MSK pain and multimorbidity during the Covid-19 pandemic. The health seeking behaviour of some patients has changed, and it is unclear if this will continue in the longer term. These findings support the need for discussion around the longer-term impact of the pandemic on individuals and changes within the healthcare system. [ABSTRACT FROM AUTHOR]

Abstract Though new or altered bodily sensations are a common occurrence they rarely transition to biomedically defined symptoms. When they do, sensations are subject to an appraisal process that can culminate in help-seeking. The transition has particular relevance for cancer diagnoses. Studies of 'symptom appraisal' in cancer patients typically conclude that failure to regard sensations as serious or 'symptom misattribution' results in lengthier help-seeking intervals. Though multiple influences on appraisal processes are acknowledged, including the socio-cultural context, detailed description and analyses of how socio-cultural factors shape appraisal is lacking. In this paper we explore one substantial component of the sociocultural context, namely, publicly recognised shared cancer narratives, and their impact on appraisal. We undertook a secondary analysis of 24 interviews with Scottish colorectal cancer patients originally completed in 2006–2007. Our analysis showed that fear, death and severity dominated cancer narratives and were frequently restated throughout interviews. Yet, early bodily changes were often mild and vague, were commonly experienced in the context of 'feeling well' and failed to match preconceived ideas of what cancer 'feels like'. Moreover, few perceived themselves to be 'at risk' of cancer and diagnoses were characterised as 'shocking' events. Participants engaged in self-monitoring strategies and severe or painful changes prompted help-seeking. Far from misattributing symptoms, responses to bodily changes were sensible and measured; responses are particularly apt in relation to current policy rhetoric, which urges measured use of services. Our findings have resonance across healthcare settings as patients are required to negotiate a narrow and challenging space when making decisions to seek help. There is a pressing need for a more realistic approach to symptom appraisal in order to reduce help-seeking intervals. Future awareness campaigns should emphasise the importance of vague/minor bodily changes although this will necessitate discussions with health professionals on referral thresholds to achieve earlier detection. Highlights • Patients have been shown to misinterpret symptom seriousness and delay help-seeking. • Symptom appraisal is socially contingent but the social context is under-described. • Shared cancer narratives, reproduced in social contexts, shape appraisal processes. • Mild, vague sensations were at odds with ideas about cancer – a most severe illness. [ABSTRACT FROM AUTHOR]

Objectives: Pre-trial focus groups of the Early detection of Cancer of the Lung Scotland (ECLS) trial indicated that those at high risk of lung cancer are more likely to engage with community-based recruitment methods. The current study aimed to understand if general practitioner (GP) and community-based recruitment might attract different groups of people, and to quantitatively explore the demographic and psychosocial differences between people responding to GP or community-based recruitment. Design: Secondary data analysis of ECLS trial baseline data. Methods: Adults (n = 11,164) aged 50 to 75 years completed a baseline questionnaire as part of their participation in the ECLS trial. The questionnaire assessed smoking behaviour, health state, health anxiety and illness perception. Alongside demographic characteristics, how participants were made aware of the study/participant recruitment method (GP recruitment/community recruitment) was also obtained via trial records. Results: The likelihood of being recruited via community-based methods increased as deprivation level decreased. Those recruited via the community had higher levels of perceived personal control of developing lung cancer and were more likely to understand their own risk of developing lung cancer, compared to those who were recruited to the trial via their GP. Health state and health anxiety did not predict recruitment methods in multivariable analysis. Conclusions: Community and opportunistic screening invitations were associated with uptake in people from less-deprived backgrounds, and therefore might not be the optimal method to reach those at high risk of lung cancer and living in more deprived areas. [ABSTRACT FROM AUTHOR]

Background: Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management.Methods: Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach.Results: A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance).Conclusions: Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow. [ABSTRACT FROM AUTHOR]

This paper engages the existing literature on Urban Political Ecology (UPE) from the perspective of regulating urban expansion through greenbelts. The paper makes a contribution to a better understanding of suburbanisation and postsuburbanisation which have so far not been at the centre of the concerns of UPE. In an era of global suburbanisation greenbelts differ from similar boundary setting exercises in the past and are as varied as the suburbanisation processes and their governance themselves. While conscious of those varieties, we focus here on the Greater Golden Horseshoe (GGH) greenbelt in Ontario that was created by provincial legislation in 2005. With the 2005 legislation, the Ontario government declared 720,000 hectares off limits for conventional urban development. The Greenbelt Act created an expansive area under protection from the Niagara Peninsula in the south to the Bruce Peninsula in the north, the Niagara Escarpment in the west to a series of moraines in the east. We will argue that the GGH greenbelt has become a prime negotiation space for the overall re-regulation of urban political ecologies in Southern Ontario. Largely surrounding the booming Toronto region, the GGH greenbelt is expansion space and projection screen of a suburbanizing region in search of redefinition. [ABSTRACT FROM AUTHOR]

How and when we use health services or healthcare provision has dominated exploration of and debates around healthcare access. Levels of utilisation are assumed as a proxy for access. Yet, focusing on utilisation conceals an important aspect of the access conundrum: the relationships that patients and potential patients have with the healthcare system and the professionals within those systems. Candidacy has been proposed as an antidote to traditional utilisation models. The Candidacy construct offers the ability to include patient-professional aspects alongside utilisation and thus promotes a deeper understanding of access. Originally applied to healthcare access for vulnerable populations, additional socio-demographic factors, including age and ethnicity, have also been shown to influence the Candidacy process. Here we propose a further extension of the Candidacy construct and illustrate the importance of illness identities when accessing healthcare. Drawing on a secondary data analysis of three data sets of qualitative interviews from colorectal cancer and heart failure patients we found that though similar access issues are apparent pre-diagnosis, diagnosis marks a critical juncture in the experience of access. Cancer patients describe a person-centred responsive healthcare system where their patienthood requires only modest assertion. Cancer speaks for itself. In marked contrast heart failure patients, describe struggling within a seemingly impermeable system to understand their illness, its implications and their own legitimacy as patients. Our work highlights the pressing need for healthcare professionals, systems and policies to promote a person centred approach, which is responsive and timely, regardless of illness category. To achieve this, attitudes regarding the importance or priority afforded to different categories of illness need to be tackled as they directly influence ideas of Candidacy and consequently access and experiences of care. [ABSTRACT FROM AUTHOR]

Alcohol is a modifiable breast cancer risk, increasing risk in a dose‐dependent manner. Mid‐life women (aged 45–64 years) consume alcohol at higher rates than younger women and this, combined with age, make them a high‐risk group for breast cancer. This critical public health problem has a seemingly obvious solution (reduce drinking); however, women do not necessarily know alcohol causes breast cancer, and if they do, reducing consumption is not always possible, or desirable. To innovate public health responses, we employ an interpretative sociological framework 'candidacy' to understand women's perspectives on breast cancer risk relative to alcohol consumption and their social class. Drawing on 50 interviews with Australian mid‐life women, our findings reveal the socio‐structural determinants of 'candidacy', that mean modifying alcohol consumption for breast cancer prevention is impacted by social class. Utilising Bourdieu's relational capitals, our interpretations show how social class shapes women's ascriptions and enactments of breast cancer candidacy. We offer an important theoretical extension to 'candidacy' by demonstrating more or less fluidity in women's assessment of breast cancer risk according to their agency to adopt breast cancer prevention messages. Understanding the social class possibilities and limitations in women's perceptions of breast cancer risk provides a new opportunity to reduce inequities in breast cancer incidence. [ABSTRACT FROM AUTHOR]

Strong epidemiological evidence concerning the causal role of alcohol consumption in cancer may not fit easily with complex lay understandings of the causes of ill health. [ABSTRACT FROM AUTHOR]

Background: Those with advanced heart failure (HF) experience high levels of morbidity and mortality, similar to common cancers. However, there remains evidence of inequity of access to palliative care services compared to people with cancer. This study examines patient, carer, and professional perspectives on current management of advanced HF and barriers and facilitators to improved care. Methods: Qualitative study involving semi-structured interviews and focus groups with advanced HF patients (n = 30), carers (n = 20), and professionals (n = 65). Data analysed using Normalisation Process Theory (NPT) as the underpinning conceptual framework. Findings: Uncertainty is ubiquitous in accounts from advanced HF patients and their caregivers. This uncertainty relates to understanding of the implications of their diagnosis, appropriate treatments, and when and how to seek effective help. Health professionals agree this is a major problem but feel they lack knowledge, opportunities, or adequate support to improve the situation. Fragmented care with lack of coordination and poor communication makes life difficult. Poor understanding of the condition extends to the wider circle of carers and means that requests for help may not be perceived as legitimate, and those with advanced HF are not prioritised for social and financial supports. Patient and caregiver accounts of emergency care are uniformly poor. Managing polypharmacy and enduring concomitant side effects is a major burden, and the potential for rationalisation exists. This study has potential limitations because it was undertaken within a single geographical location within the United Kingdom. Conclusions: Little progress is being made to improve care experiences for those with advanced HF. Even in the terminal stages, patients and caregivers are heavily and unnecessarily burdened by health care services that are poorly coordinated and offer fragmented care. There is evidence that these poor experiences could be improved to a large extent by simple organisational rather than complex clinical mechanisms. [ABSTRACT FROM AUTHOR]

Simple Summary: People living in rural areas are less likely to survive cancer than those living in urban areas. There is evidence suggesting that poorer survival amongst rural cancer patients may be because these patients take longer to be diagnosed, particularly in the time between their symptoms beginning and them going to hospital to see a specialist. This study explored the experiences of people with symptoms of bowel cancer, in rural Northern England, to examine whether there were any common causes of 'delay' for these patients. Participants reported that their health beliefs and self-reliance, concerns about losing time at work, and having a poor relationship with their GP, could all influence whether they consulted the GP early about their symptoms. Having identified these unique barriers for rural patients, in relation to seeing the GP about bowel symptoms, we can develop ways to support earlier consultations with GPs, to improve the outcomes of rural patients who develop cancer. Rural cancer inequalities are evident internationally, with rural cancer patients 5% less likely to survive than their urban counterparts. There is evidence to suggest that diagnostic delays prior to entry into secondary care may be contributing to these poorer rural cancer outcomes. This study explores the symptom appraisal and help-seeking decision-making of people experiencing symptoms of colorectal cancer in rural areas of England. Patients were randomly invited from 4 rural practices, serving diverse communities. Semi-structured interviews were undertaken with 40 people who had experienced symptoms of colorectal cancer in the preceding 8 weeks. Four key themes were identified as influential in participants' willingness and timeliness of consultation: a desire to rule out cancer (facilitator of help-seeking); stoicism and self-reliance (barrier to help-seeking); time scarcity (barrier to help-seeking); and GP/patient relationship (barrier or facilitator, depending on perceived strength of the relationship). Self-employed, and "native" rural residents most commonly reported experiencing time scarcity and poor GP/patient relationships as a barrier to (re-)consultation. Targeted, active safety-netting approaches, and increased continuity of care, may be particularly beneficial to expedite timely diagnoses and minimise cancer inequalities for rural populations. [ABSTRACT FROM AUTHOR]

The government of Ontario, Canada, has passed legislation to protect large parts of the southern portions of the province from most development. An extensive plan for a Greenbelt that surrounds the Greater Toronto Area and other regional growth centers was introduced. This article looks at the new policy as a spatial strategy that shifts the scales of environmental and growth management policy in Ontario. The legislation also sets the framework for a state spatial project; that is, a set of changes in how the regional state internally operates. The current Greenbelt legislation is a new step in a longer term development by which governments in Ontario have attempted to regulate the relationships between cities and regions, town and hinterland. Overlapping strongly with what is usually called the Toronto bioregion between the Niagara Escarpment, Oak Ridges Moraine, and Lake Ontario, the Greenbelt reorganizes space in southern Ontario in ways that would further ecosystem policies and practices in the area. Theoretically guided by newer debates on rescaling and regionalism, and based on close reading of the planning and policy documents on the Greenbelt as well as a series of expert interviews, we argue that the current Greenbelt legislation is an act of up-scaling traditional urban-regional regulation in southern Ontario, which we shall call extended metropolitanization. Such rescaling recasts traditional political conflicts in new terms. We conclude that extended metropolitanization in southern Ontario has been a process that has brought nature, the state, and governance together into a new regional sustainability fix. [ABSTRACT FROM PUBLISHER]

Abstract: Past research has identified a research gap regarding studies of the reliability and validity of OHS management audit methods. This study describes 17 audit methods used by OHS auditing organizations in the broader public sector in the province of Ontario, emphasizing aspects relevant to audit reliability and validity. Wide variation was found in pertinent characteristics of the audit methods and in their corresponding programs. In addition, some discrepancies were found between actual auditing practices and international standards on management system auditing. Further research is needed to precisely determine the impact of these variations and discrepancies on the measurement properties of audit data and on the performance of audit programs. This study determined that such research is feasible with some, but not all, auditing programs. [Copyright &y& Elsevier]

Background: Depression is frequently cited as the reason for sickness absence, and it is estimated that sickness certificates are issued in one third of consultations for depression. Previous research has considered GP views of sickness certification but not specifically in relation to depression. This study aimed to explore GPs views of sickness certification in relation to depression. Methods: A purposive sample of GP practices across Scotland was selected to reflect variations in levels of incapacity claimants and antidepressant prescribing. Qualitative interviews were carried out between 2008 and 2009. Results: A total of 30 GPs were interviewed. A number of common themes emerged including the perceived importance of GP advocacy on behalf of their patients, the tensions between stakeholders involved in the sickness certification system, the need to respond flexibly to patients who present with depression and the therapeutic nature of time away from work as well as the benefits of work. GPs reported that most patients with depression returned to work after a short period of absence and that it was often difficult to predict which patients would struggle to return to work. Conclusions: GPs reported that dealing with sickness certification and depression presents distinct challenges. Sickness certificates are often viewed as powerful interventions, the effectiveness of time away from work for those with depression should be subject to robust enquiry. [ABSTRACT FROM AUTHOR]

Background: Depression is frequently cited as the reason for sickness absence, and it is estimated that sickness certificates are issued in one third of consultations for depression. Previous research has considered GP views of sickness certification but not specifically in relation to depression. This study aimed to explore GPs views of sickness certification in relation to depression. Methods: A purposive sample of GP practices across Scotland was selected to reflect variations in levels of incapacity claimants and antidepressant prescribing. Qualitative interviews were carried out between 2008 and 2009. Results: A total of 30 GPs were interviewed. A number of common themes emerged including the perceived importance of GP advocacy on behalf of their patients, the tensions between stakeholders involved in the sickness certification system, the need to respond flexibly to patients who present with depression and the therapeutic nature of time away from work as well as the benefits of work. GPs reported that most patients with depression returned to work after a short period of absence and that it was often difficult to predict which patients would struggle to return to work. Conclusions: GPs reported that dealing with sickness certification and depression presents distinct challenges. Sickness certificates are often viewed as powerful interventions, the effectiveness of time away from work for those with depression should be subject to robust enquiry. [ABSTRACT FROM AUTHOR]

The article reports on the study that examines the content validity of occupational health and safety (OHS) management audit methods in Canada. A national and consensus-based OHS management standard developed by the Canadian Standards Association has been the definitional standard utilized by the study. The study revealed that some of the current OHS management audit instruments have been incomplete relative to a recent OHS management standard.

Many migrant groups, particularly those that are politically and economically marginalised, such as asylum seekers and refugees (ASRs), face inequities in access to health care as well as poorer physical and mental health outcomes. The role of post-arrival experiences in contributing to these inequities is increasingly being explored, and it is suggested that being a migrant is itself a determinant of health outcomes. Drawing on the theoretical concept of structural vulnerability, this paper explores ASRs' experiences of health, wellbeing, and health practices in the context of their lived realities in Scotland. 24 semi-structured interviews were conducted with ASRs from Sub-Saharan Africa between January and December 2015. Data were explored using thematic analysis. Experience of the UK asylum system, both alone and in conjunction with other sources of vulnerability including racism, poverty, and language barriers had a negative and ongoing impact on the physical and mental health of ASRs. These impacts continued, even once refugee status was obtained. Efforts to engage ASRs in preventive health programmes and practices must take into account the ways in which the asylum system acts as a determinant of health, affecting both what it means to be healthy and what capacity individuals have to engage with their health. Political choices in how the asylum process is enacted have far-reaching implications for individual and population health. [ABSTRACT FROM AUTHOR]

Background: Increasing age is a risk factor for developing cancer. Yet, older people commonly underestimate this risk, are less likely to be aware of the early symptoms, and are more likely to be diagnosed with advanced stage cancer. Mass media are a key influence on the public's understanding health issues, including cancer risk. This study investigates how news media have represented age and other risk factors in the most common cancers over time.Methods: Eight hundred articles about the four most common cancers (breast, prostate, lung and colorectal) published within eight UK national newspapers in 2003, 2004, 2013 and 2014 were identified using the Nexis database. Relevant manifest content of articles was coded quantitatively and subjected to descriptive statistical analysis in SPSS to identify patterns across the data.Results: Risk was presented in half of the articles but this was rarely discussed in any depth and around a quarter of all articles introduced more than one risk factor, irrespective of cancer site. Age was mentioned as a risk factor in approximately 12% of all articles and this varied by cancer site. Age was most frequently reported in relation to prostate cancer and least often in articles about lung cancer. Articles featuring personal narratives more frequently focused on younger people and this was more pronounced in non-celebrity stories; only 15% of non-celebrity narratives were about people over 60. Other common risks discussed were family history and genetics, smoking, diet, alcohol, and environmental factors. Family history and genetics together featured as the most common risk factors. Risk factor reporting varied by site and family history was most commonly associated with breast cancer, diet with bowel cancer and smoking with lung cancer.Conclusion: Age and older adults were largely obscured in media representation of cancer and cancer experience. Indeed common risk factors in general were rarely discussed in any depth. Our findings will usefully inform the development of future cancer awareness campaigns and media guidelines. It is important that older adults appreciate their heightened risk, particularly in the context of help-seeking decisions. [ABSTRACT FROM AUTHOR]

Background: In the United Kingdom (UK), cancer screening invitations are based on general practice (GP) registrations. We hypothesize that GP electronic medical records (EMR) can be utilised to calculate a lung cancer risk score with good accuracy/clinical utility. Methods: The development cohort was Secure Anonymised Information Linkage-SAIL (2.3 million GP EMR) and the validation cohort was UK Biobank-UKB (N = 211,597 with GP-EMR availability). Fast backward method was applied for variable selection and area under the curve (AUC) evaluated discrimination. Results: Age 55–75 were included (SAIL: N = 574,196; UKB: N = 137,918). Six-year lung cancer incidence was 1.1% (6430) in SAIL and 0.48% (656) in UKB. The final model included 17/56 variables in SAIL for the EMR-derived score: age, sex, socioeconomic status, smoking status, family history, body mass index (BMI), BMI:smoking interaction, alcohol misuse, chronic obstructive pulmonary disease, coronary heart disease, dementia, hypertension, painful condition, stroke, peripheral vascular disease and history of previous cancer and previous pneumonia. The GP-EMR-derived score had AUC of 80.4% in SAIL and 74.4% in UKB and outperformed ever-smoked criteria (currently the first step in UK lung cancer screening pilots). Discussion: A GP-EMR-derived score may have a role in UK lung cancer screening by accurately targeting high-risk individuals without requiring patient contact. [ABSTRACT FROM AUTHOR]

Context: Burden of Treatment Theory (BOTT) proposes poorer outcomes when the work of managing illness (treatment burden) outweighs an individual's capacity. Treatment burden is greater for people experiencing multimorbidity, particularly when living in areas of high socioeconomic deprivation (SED), where factors that reduce capacity (e.g. car access) also cluster. It is likely community factors (e.g. local assets) can enhance, or diminish individual capacity, but how these factors interact is unclear. Objective Explore how individual and community factors influence self-management of multimorbidity in the context of high SED. Study Design: 30 Qualitative semi-structured interviews, analysed thematically. Setting/Population: Individuals with >3 chronic conditions from a community experiencing high SED. Intervention: N/A Outcome Measures: N/A Results: Four key themes: biographical disruption as a catalyst - many successfully implemented lifestyle changes, almost all triggered by a diagnosis, most would not have made changes otherwise; "being known": many described "being known" in the community, creating security. However, there was also stigma of "being known" from their area, experienced in multiple spheres, influencing experience of wider systems. "Fear of failure" where attempts to make changes failed, it often resulted in fatalism, linked to experience of wider stigma. For these participants it was easier to not change, even if less than ideal, than risk failing/being judged, again; Holistic care: people valued care where they were "seen as a person", but experience was often biomedically focused. Interviewees recognised wider structural issues in the health service inhibiting this type of care eg. lack of time. For some reduced agency, particularly unwillingness to challenge staff, were key issues. Conversely, where people felt empowered to make decisions, that adapted to their context/values, this was generally in the context of strong relationships with primary care providers. Conclusion Capacity factors are important but rarely acknowledged, or addressed, by practitioners or health systems. The influence of social stigma on access/treatment decisions needs considered in health system delivery. Future research should explore interventions to empower people, particularly those experiencing stigma in their wider community. The biographical disruption of an illness should also be viewed as an opportunity for health promotion messages. [ABSTRACT FROM AUTHOR]

Context: Most behaviour change interventions targeting individuals rarely take account of context, or community capacity, and are preferentially taken up by more affluent populations. Burden of Treatment Theory proposes that where self-management work outweighs capacity then poorer outcomes result. This is particularly true in the context of multimorbidity in areas of high socioeconomic deprivation (SED). Individual factors that influence capacity to manage multimorbidity (e.g. health literacy) cluster disproportionately in these areas. Objective: To explore how community assets, wider health beliefs and knowledge, and collective community experience influence people's capacity to consider, and engage in, behaviour change Study Design and Analysis: Ethnography with field notes analysed thematically. Setting and population: 70 hours participant observation in four community-based groups (cycle group/male support group/family support group/community garden) based in a Scottish community experiencing high levels of multimorbidity and SED Instrument N/A Outcome Measures N/A Results: Two key themes identified:1. "Influence of Context" - hidden health care barriers (eg. experience of judgement when attending appointments); community experience of every "system" working against them and shared stigma related to their local community produced distrust, and influenced how people approached all systems, including health care. 2. "Safe and authentic communities" were essential when people experienced improved wellbeing/behaviour change in these groups. Authentic community - refers to the importance of groups being "rooted" in the community; and perceived as relatable, local, or meaningful. Safe community - promoted trust, allowed challenge, and reduced stigma. Time and commitment were needed to create these spaces that enabled change. Conclusions Our findings highlight the need to acknowledge the impact of wider social stigma on people's willingness to engage with healthcare. In this work creating authentic and safe community space were pre-requisites for engagement with these groups, a potential explanation for why many current health interventions are not taken up in these communities. Future multimorbidity interventions/services that target such populations/communities should seek to involve patients, find ways to make them authentic; empower, train and utilise peers wherever possible; and understand the importance of safe space as a prerequisite to engagement. [ABSTRACT FROM AUTHOR]

Foster carer commitment to the child has been shown to be of paramount importance in young children's recovery and development following abuse and neglect. In Dozier's definition of commitment in the US, there is a focus on both emotional investment in the child and committing to an enduring relationship with the child. How this relates to the routine practice of short-term, temporary, foster care has not been studied. This is the first qualitative study to explore the drivers of, and barriers to, commitment in short-term foster care within the broader aim of examining whether short-term care is meeting the needs of maltreated young children. Fourteen foster carers took part in research interviews and five focus groups were conducted with infant mental health professionals. Interviews and focus group data were subject to qualitative thematic analysis in order to identify patterns of commonality in relation to our research questions. Three broad themes pertain to commitment and the meeting of young children's needs in short-term foster care: Influence, Timescales and Choice in the fostering role. These themes were found to house both drivers of, and barriers to, commitment in short-term care, which are influenced by systemic normalisations of fostering practices. The emotional investment facet of commitment is more alive in the 'psyche' of short-term foster care than commitment to an enduring relationship. A long-term outlook for the child may be an undefined facet of commitment that is more akin with short-term placements. [ABSTRACT FROM AUTHOR]

The article reports a study which investigated relationship between absence from work and mental ill health by using the General Health Questionnaire 12-item version (GHQ-12). The results revealed that mental ill health is associated with increase in sickness absence from work in all classifications of occupations. Decreased absence was associated with part time working.

Recent developmental studies suggest that the compound leaf is a more or less incompletely developed shoot. Instead of treating compound leaves and shoots as non-homologous, this interpretation draws a continuum between them. The present work considers the plant as a hierarchical series of units on which similar developmental processes are at work, and where each level (shoot, compound leaf, leaflet) is ‘repeated’ by the next higher level. Measurements related to the expression of developmental processes operating on leaves at the shoot level and on leaflets at the compound leaf level were used to determine if similar processes are at work at these different levels during early stages of organogenesis. Plants with compound leaves showing acropetal leaflet inception, representing a total of 16 species from ten eudicot families, were studied. Based on several types of quantitative analyses, there appears to be a continuum between so-called shoots, compound leaves and leaflets in the species studied. This perspective, qualified as dynamic morphology, both parallels and complements the classical interpretation. © 2003 The Linnean Society of London, Botanical Journal of the Linnean Society, 2003, 143, 219−230. [ABSTRACT FROM AUTHOR]

Background: We investigated demographic and clinical predictors of lower participation in bowel screening relative to breast and cervical screening.Methods: Data linkage study of routinely collected clinical data from 430,591 women registered with general practices in the Greater Glasgow & Clyde Health Board. Participation in the screening programmes was measured by attendance at breast or cervical screening or the return of a bowel screening kit.Results: 72.6% of 159,993 women invited attended breast screening, 80.7% of 309,899 women invited attended cervical screening and 61.7% of 180,408 women invited completed bowel screening. Of the 68,324 women invited to participate in all three screening programmes during the study period, 52.1% participated in all three while 7.2% participated in none. Women who participated in breast (OR = 3.34 (3.21, 3.47), p < 0.001) or cervical (OR = 3.48 (3.32, 3.65), p < 0.001) were more likely to participate in bowel screening.Conclusion: Participation in bowel screening was lower than breast or cervical for this population although the same demographic factors were associated with uptake, namely lower social deprivation, increasing age, low levels of comorbidity and prior non-malignant neoplasms. As women who complete breast and cervical are more likely to also complete bowel screening, interventions at these procedures to encourage bowel screening participation should be explored. [ABSTRACT FROM AUTHOR]

Objective: The incidence of lung cancer is four times higher in people with chronic obstructive pulmonary disease (COPD) compared with the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis, but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help seeking for potential lung cancer symptoms.Methods: We conducted qualitative interviews with men (n = 17) and women (n = 23) aged 40 to 83 years with COPD. Topic guides drew on the integrated symptom-response framework and covered symptom experience, interpretation, action, recognition, help seeking, evaluation, and reevaluation. We used the framework method to analyse the data.Results: Participants said that they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently, but increased risk of lung cancer was not discussed.Conclusions: Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms. [ABSTRACT FROM AUTHOR]

Background: Abuse of prescription opioids is a serious problem in North America. Aims: The aim of this study was to conduct a systematic review of peer-reviewed and grey literature to examine existing strategies aimed at improving the appropriate use of prescription opioids and/or reducing the misuse, abuse, and diversion of these drugs. Methods: The following electronic databases were searched to September 2015 without language restrictions: MEDLINE, EMBASE, PsycINFO, and CINAHL; the grey literature was searched to May 2014. Reference lists of retrieved papers were also searched. Studies were eligible if a strategy was implemented and its impact on at least one of the primary outcomes of interest (appropriate prescription opioid use; misuse, abuse, opioid use disorder, diversion; overdose) was measured. Standardized, prepiloted forms were used for relevance screening, quality appraisal, and data extraction. Results: A total of 65 studies that assessed 66 distinct strategies were identified. Due to the heterogeneity of the strategies, a qualitative synthesis was conducted. Many studies combined more than one type of strategy and measured various types of outcomes. The strategies with most promising results involved education, clinical practices, collaborations, prescription monitoring programs, public campaigns, opioid substitution programs, and naloxone distribution. We also found strategies that had some unintended consequences after implementation. Conclusions: Our review identified successful strategies that have been implemented and evaluated in various jurisdictions. There is a need to replicate and disseminate these strategies where the problem of prescription opioid misuse and abuse has taken a toll on society. [ABSTRACT FROM AUTHOR]

Whilst we know that foster care is better than institutional care for abused and neglected children, we know less about the specific qualities of foster care that are important for their development and recovery from maltreatment effects. This is the first study to investigate the effects of foster carer commitment on symptoms of Attachment Disorders (AD) and mental health problems in young children post-maltreatment. 144 children, age 0–5, recently accommodated into foster care as part of an ongoing Randomised Controlled Trial. Children were assessed using the Disturbances of Attachment Interview and the Strengths and Difficulties Questionnaire, then followed up 15 months and 2.5 years thereafter. Commitment of the foster carer was measured by 'This Is My Baby' interview. Multiple regression was used to analyse the data. Higher initial foster carer commitment, measured shortly after entry to care, was associated with a reduction in Reactive Attachment Disorder symptoms 15 months after placement, with a modest (non-significant) association persisting 2.5 years later. Initial commitment was not associated with symptoms of Disinhibited Social Engagement Disorder at any follow-up time point, nor with symptoms of mental health problems at 15 months. However, higher initial commitment was unexpectedly associated with higher mental health symptom scores at 2.5 years post-accommodation. This study highlights the complex and non-linear development of children in committed foster care, underscoring the need to examine multiple time-points and to consider symptoms of Attachment Disorders separately from those of other mental health problems. [ABSTRACT FROM AUTHOR]

Background In this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding - and sometimes preventing - disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment. Discussion As the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization. Summary Burden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts. [ABSTRACT FROM AUTHOR]

Abstract: This exploratory research employs a series of cases studies and a multi-stakeholder perspective to examine safety practices and outcomes in the wider context of business operations. The aims of the research include enhancing the understanding of the practices critical for safe workplaces and of the business value (positive or negative) of safety. Four research questions related to safety practices and outcomes and operational practices and outcomes were addressed. The results provide new and novel insights into safety’s role in the organization and show that when safety is examined in the wider organizational context additional rationale for improving safety becomes visible. [Copyright &y& Elsevier]

Objectives To examine the validity of the Prioritization Scoring Index (PSI) methodology by obtaining the views of our local population and clinicians regarding the criteria and weightings that should be used in deciding how NHS money is spent. Background We have used a PSI in Argyll and Clyde to allocate new money since 1996 and to determine priorities for our 1999/2000–2003/2004 Health Improvement Programme (HIP). Since the criteria and weightings for this methodology were developed subjectively, we sought to validate these by consulting local people and to change our methodology to take account of wider population views. Methods A postal questionnaire was sent to 1969 members of the general public, all 314 general practitioners and all 189 hospital consultants in Argyll and Clyde in March 1999. A reminder was sent after 4 weeks. Questions were asked about general funding and prioritization in the NHS and about specific issues relating to potential criteria for prioritization, including those used in our PSI methodology. Responses were analysed quantitatively in the Statistical Package for the Social Sciences (SPSS) and qualitatively through examination of the responses to open questions. Results The response rate was 51% for the general public and 71% for GPs and consultants. Respondents from the general public were broadly representative of the Argyll and Clyde population. The main findings were that: greater importance should be given to care that improves health, quality of life or prevents ill health rather than to cost, or to government and local health board priorities; half of the general public and most clinicians thought there should be a limit on NHS funding; extra money for the NHS should come from the national lottery (general public) or higher taxes on cigarettes and alcohol (clinicians); doctors should have the greatest influence in deciding how NHS money is spent; a higher priority should not be given to the health-care needs of younger... [ABSTRACT FROM AUTHOR]

Background: In this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding - and sometimes preventing - disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment.Discussion: As the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization.Summary: Burden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective. Methods and Findings: The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce. Conclusions: Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems. [ABSTRACT FROM AUTHOR]

Background: Treatment burden can be defined as the self-care practices that patients with chronic illness must perform to respond to the requirements of their healthcare providers, as well as the impact that these practices have on patient functioning and well being. Increasing levels of treatment burden may lead to suboptimal adherence and negative outcomes. Systematic review of the qualitative literature is a useful method for exploring the patient experience of care, in this case the experience of treatment burden. There is no consensus on methods for qualitative systematic review. This paper describes the methodology used for qualitative systematic reviews of the treatment burdens identified in three different common chronic conditions, using stroke as our exemplar.Methods: Qualitative studies in peer reviewed journals seeking to understand the patient experience of stroke management were sought. Limitations of English language and year of publication 2000 onwards were set. An exhaustive search strategy was employed, consisting of a scoping search, database searches (Scopus, CINAHL, Embase, Medline & PsycINFO) and reference, footnote and citation searching. Papers were screened, data extracted, quality appraised and analysed by two individuals, with a third party for disagreements. Data analysis was carried out using a coding framework underpinned by Normalization Process Theory (NPT).Results: A total of 4364 papers were identified, 54 were included in the review. Of these, 51 (94%) were retrieved from our database search. Methodological issues included: creating an appropriate search strategy; investigating a topic not previously conceptualised; sorting through irrelevant data within papers; the quality appraisal of qualitative research; and the use of NPT as a novel method of data analysis, shown to be a useful method for the purposes of this review.Conclusion: The creation of our search strategy may be of particular interest to other researchers carrying out synthesis of qualitative studies. Importantly, the successful use of NPT to inform a coding frame for data analysis involving qualitative data that describes processes relating to self management highlights the potential of a new method for analyses of qualitative data within systematic reviews. [ABSTRACT FROM AUTHOR]

The article focuses on a study related to a prediction on which type of people with psychosocial distress are prone to the risk of becoming dependent on long term government supported medical benefits. The study found that factors like mild mental disorders and frequent consultations in general practice can help in predicting long term sickness absence up to three years before people become dependent on benefits. It informs that a cut off of 10 or more consultations were used during the study.