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BackgroundMalignant pleural mesothelioma (MPM) is an aggressive cancer linked to asbestos exposure and inhalation. As with other cancers, receiving a diagnosis of MPM is challenging and distressing. Particular challenges are associated with communicating a diagnosis of MPM, including explaining the disease and its prognosis, treatment options and legal and financial implications. Receiving A Diagnosis Of Mesothelioma (RADIO Meso) aimed to understand the experience of communicating a diagnosis of MPM from the perspective of patients, family carers and health professionals.MethodsThis qualitative study comprised 31 individual interviews with patients, family carers and health professionals. This was followed by two group interviews (n=42) and an electronic consultation exercise (n=39).ResultsThis study provides unique insight into the mesothelioma diagnostic experience of patients, family carers and health professionals. Key findings include the importance of regarding diagnosis as a process, and provision of continuity and consistency. The clinical nurse specialist and effective multidisciplinary team working provided vital contributions to successful mesothelioma diagnostic communication. Facilitators to diagnostic communication included honesty and timeliness in communication, partnership working and maintaining a patient-centred approach. Challenges to enhancing mesothelioma diagnosis communication included accessing ongoing training, ensuring a suitable clinical environment and being able to allocate appropriate time.ConclusionThe RADIO Meso study highlights factors that influence the communication of a diagnosis of MPM from the perspectives of individual patients and family carers. These findings provide the basis for a set of recommendations that can be used by health professionals to improve the MPM diagnostic experience.

Background Poor UK lung cancer survival rates may, in part, be due to late diagnosis. Objectives To evaluate the effectiveness of a mixedmethod community-based social marketing intervention on lung cancer diagnoses. Methods A public awareness campaign in conjunction with brief intervention training in general practices was piloted in six localities with a high lung cancer incidence. End points were self-reported awareness of lung cancer symptoms; intention to seek healthcare; chest x-ray referral rates in primary care; secular trends in the incidence of lung cancer and stage at diagnosis, compared before and after the intervention. Results 21% (128/600) (95% CI 18% to 25%) of the targeted population recalled something about the campaign. Compared with a responder in the control area, the odds of a responder in the intervention area saying that they would visit their general practitioner and request a chest x-ray for a cough was 1.97 times (95% CI 1.18 to 3.31, p¼0.01). Primary care chest x-ray referral rates increased by 20% in the targeted practices in the year following the intervention compared with a 2% fall in the control practices. The difference was highly significant, with an incidence rate ratio of 1.22 (95% CI 1.12 to 1.33, p¼0.001). There was a 27% increase in lung cancer diagnoses in the intervention area compared with a fall in the control area. The incidence rate ratio was 1.42 (95% CI 0.83 to 2.44 p¼0.199). Conclusion This is encouraging early evidence that an awareness and early recognition initiative may facilitate lung cancer diagnosis.

Background Chest pain attendances at the emergency department (ED) in the UK are continuing to rise. Chest pain units (CPU) provide nurse-led, protocol-driven care for patients attending the ED with acute chest pain. The ESCAPE trial evaluated the effectiveness, cost-effectiveness and acceptability of CPU care in the NHS. This paper reports the quantitative evaluation of acceptability: patient satisfaction with CPU and routine care. Methods The ESCAPE study was a cluster-randomised controlled trial of 14 hospitals in which seven hospitals were allocated to establish CPU care and seven to continue providing routine care. As part of the study, postal questionnaires were sent to a subgroup of patients attending the ED with chest pain before and after intervention at all 14 hospitals. Results There was a 42.8% response rate (2389/5584) for unsolicited self-administered questionnaires. There was no significant change in any dimension of patient satisfaction, although there was some weak evidence that the introduction of CPU care was associated with reduced satisfaction with explanations about medical procedures and treatments (effect of CPU −0.16 points on a 5-point Likert scale, 95% CI −0.35 to 0.02; p=0.089) and attention given to what the patient had to say (−0.17 points, 95% CI −0.35 to 0.02; p=0.077). CPU care had no effect on overall satisfaction with care (−0.08 points, 95% CI −0.26 to 0.10; p=0.393). Conclusions No evidence was found that improvements in patient satisfaction associated with CPU care in previous single-centre trials were reproduced in this multicentre study. Trial registration number ISRCTN55318418 International Standard Randomised Controlled Trial Number Register.

"Lay epidemiology" is a term used to describe the processes through which health risks are understood and interpreted by laypeople. It is seen as a barrier to public health when the public disbelieves or fails to act on public health messages. Two elements to lay epidemiology are proposed: (a) empirical beliefs about the nature of illness and (b) values about the place of health and risks to health in a good life. Both elements have to be dealt with by effective public health schemes or programmes, which would attempt to change the public's empirical beliefs and values. This is of concern, particularly in a context in which the lay voice is increasingly respected. Empirically, the scientific voice of standard epidemiology should be deferred to by the lay voice, provided a clear distinction exists between the measurement of risk, which is empirical, and its weighting, which is based on values. Turning to engagement with values, health is viewed to be an important value and is discussed and reflected on by most people. Public health professionals are therefore entitled and advised to participate in that process. This view is defended against some potential criticisms.

We appreciate the paper by O'Dowd et al 1 as an interesting contribution to the literature concerning the primary care diagnosis of lung cancer. By concentrating on those patients dying soon after diagnosis, this paper is addressing the issue of access to care of patients with lung cancer who are already gravely ill. The disappointingly low chest X-ray (CXR) referral rates (we calculate obtained in only 40.2% and 50.4% of the patients attending with medium/high frequency and dying before and after 90 days, respectively) may represent irregular recording of CXR requests in The Health Improvement Network (THIN). Electronic research databases store their data in …

Objectives To understand the influences and decisions of vulnerable older people in relation to keeping warm in winter. Design A qualitative study incorporating in-depth, semi-structured individual and group interviews, framework analysis and social marketing segmentation techniques. Setting Rotherham, South Yorkshire, UK. Participants 50 older people (>55) and 25 health and social care staff underwent individual interview. The older people also had household temperature measurements. 24 older people and 19 health and social care staff participated in one of the six group interviews. Results Multiple complex factors emerged to explain whether vulnerable older people were able to keep warm. These influences combined in various ways that meant older people were not able to or preferred not to access help or change home heating behaviour. Factors influencing behaviours and decisions relating to use of heating, spending money, accessing cheaper tariffs, accessing benefits or asking for help fell into three main categories. These were situational and contextual factors, attitudes and values, and barriers. Barriers included poor knowledge and awareness, technology, disjointed systems and the invisibility of fuel and fuel payment. Findings formed the basis of a social marketing segmentation model used to develop six pen portraits that illustrated how factors that conspire against older people being able to keep warm. Conclusions The findings illustrate how and why vulnerable older people may be at risk of a cold home. The pen portraits provide an accessible vehicle and reflective tool to raise the capacity of the NHS in responding to their needs in line with the Cold Weather Plan., Article summary Article focus What factors influence older vulnerable people keeping warm and well in winter? How do these factors interrelate in different people in order to increase the risk an older person is cold at home? How can this be represented by a social marketing segmentation model? Key messages Knowledge and awareness of safe temperatures, the health impact of cold and how to use heating efficiently were low across the study participants. Older people's values and beliefs can interact with the contextual factors and barriers in such a way that they often end up being cold at home. The segmentation model can illustrate the diversity of older people at risk of living in a cold home. It can be used as a reflective tool at a clinical and strategic level to identify and refer vulnerable older people. Strategic responses are required to help bring about the required partnership, systems, boundary spanning approaches and capacity development in staff and communities needed to reduce excess winter deaths. Greater focus is needed to ensure affordable warmth interventions achieve the desired outcome of safe indoor temperatures for older and other vulnerable people. Strengths and limitations of this study The study has provided understanding of the complex environment within which vulnerable older citizens live and the factors that conspire against them being able to keep warm. The study provides some insight into why older people at risk of being cold are not always able to make decisions to keep them warm. It reinforces and expands the findings of others. The study has generated a segmentation model and pen portraits that can be used as a reflective tool at a clinical and strategic level to identify and refer vulnerable older people. The main limitation of the study is that it was conducted on a single site.

Objectives: To identify factors within the South Yorkshire coalfields that influence use of health services by people with angina. Design: Qualitative study using semistructured individual and group interviews. Setting: General practice and community settings in Barnsley and Rotherham health authorities. Participants: 14 patients with stable angina and nine primary care staff had individual interviews plus five community groups and one group of general practitioners. Main outcome measures: Barriers to accessing health services. Results: A complex web of factors was identified that prevented, delayed, or facilitated referral to secondary care. Delay, denial, and self management by patients meant that the full extent of symptoms often remained hidden from general practitioners, resulting in a delayed or missed referral. Barriers identified fell into six categories: structural, personal, social and cultural, past experience and expectations, diagnostic confusion, and knowledge and awareness. Conclusions: Many of the factors influencing referral operate before general practitioners become involved. Community development could be one way of tackling inequalities and promoting sustainable change. Structural changes are needed to improve access and increase the acceptability of general practice services. Primary care staff should be educated to detect underreporting of symptoms and promote appropriate referral. What is already known on this topic An inverse correlation has been shown between deprivation and cardiac revascularisation Fear of hospitals, denial of ill health, and low expectations may prevent people with angina accessing health services What this study adds Fear, denial, and low expectations were important barriers to accessing health services, reinforcing earlier findings Other factors may be specific to the study population—for example, coping, independence, and attributing symptoms to industrially related lung disease Many of the barriers operate before general practitioners are involved, making it difficult to identify solutions