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Background Female genital mutilation is an important UK health-care challenge. There are no health benefits of female genital mutilation, and it is associated with lifelong physical, psychological and sexual impacts. The annual cost to the NHS to care for survivors is £100M. Deinfibulation may improve the health and well-being of some women, but there is no consensus on the optimal timing of surgery for type 3 survivors. UK care provision is reportedly suboptimal. Objectives We aimed to explore the views of survivors, men and health-care professionals on the timing of deinfibulation surgery and NHS service provision. Methods This was a qualitative study informed by the Sound of Silence framework. This framework is useful for researching sensitive issues and the health-care needs of marginalised populations. A total of 101 interviews with 44 survivors, 13 men and 44 health-care professionals were conducted, supplemented by two workshops with affected communities (participants, n = 10) and one workshop with stakeholders (participants, n = 30). Data were analysed using a hybrid framework method. Results There was no clear consensus between groups on the optimal timing of deinfibulation. However, within groups, survivors expressed a preference for deinfibulation pre pregnancy; health-care professionals preferred antenatal deinfibulation, with the caveat that it should be the survivor’s choice. There was no consensus among men. There was agreement that deinfibulation should take place in a hospital setting and be undertaken by a suitable health-care professional. Decision-making around deinfibulation was complex. Deficiencies in professionals’ awareness, knowledge and understanding resulted in impacts on the provision of appropriate care. Although there were examples of good practice and positive care interactions, in general, service provision was opaque and remains suboptimal, with deficiencies most notable in mental health. Deinfibulation reportedly helps to mitigate some of the impacts of female genital mutilation. Interactions between survivors and health-care professionals were disproportionately framed around the law. The way in which services are planned and provided often silences the perspectives and preferences of survivors and their families. Limitations Only a minority of the interviews were conducted in a language other than English, and the recruitment of survivors was predominantly through maternity settings, which meant that some voices may not have been heard. The sample of men was relatively small, limiting interpretation. Conclusions In general, service provision remains suboptimal and can silence the perspectives and preferences of survivors. Deinfibulation services need to be widely advertised and information should highlight that the procedure will be carried out in hospital by suitable health-care professionals and that a range of time points will be offered to facilitate choice. Future services should be developed with survivors to ensure that they are clinically and culturally appropriate. Guidelines should be updated to better reflect the needs of survivors and to ensure consistency in service provision. Future work Research is needed to (1) map female genital mutilation service provision; (2) develop and test effective education to address deficits in awareness and knowledge for affected communities and health-care professionals; and (3) develop, monitor and evaluate clinically and culturally competent female genital mutilation services. Trial registration Current Controlled Trials ISRCTN14710507. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 27, No. 3. See the NIHR Journals Library website for further project information.

Reconstructing environments around archaeological sites is complicated by past land management practices and regional-scale climate proxies that can be contradictory and are often located at a distance from the sites themselves. Here we explore environmental information from fossil snail shells which, even when few in number on an archaeological site, may prove invaluable in constructing site-specific data. The palaeoecology of fossil snails and the stable isotopic composition of their shell carbonate can provide context-specific information on vegetation, water availability, and relative humidity during the occupation of a site. We studied terrestrial and aquatic snails from two later Neolithic archaeological sites in the Jordanian badia, Wadi al-Qattafi and Wisad Pools. At specific archaeological site-scale our study highlights the importance of aquatic snails in the reconstruction of semi-arid environments. At Wisad pools rare aquatic snails in contexts dating between ~8.0 and ~7.6 ka demonstrate episodes of wetness; moreover, their shell isotopic compositions indicate that local watercourses were well established, corroborating previous findings that during this period the immediate environs of Wisad Pools were host to C3 plant species more typical of the Mediterranean zone. Moreover, the δ18O signal in these snail shells allow tentative reconstruction of rainwater isotopic compositions and identify the effects of evaporation. Such fine-grained environmental information is much less evident from the terrestrial snail-shell data alone, showing that an ensemble of snail-shell data can be highly sensitive to environmental differentials across an archaeological site. Finally, at a regional palaeoclimate-scale our Wisad Pools snail-shell stable isotope data are consistent with a sustained, Rapid Climate Change (RCC)-driven wetness between 8.6 and 7.6 ka concurrent with cold and wet conditions in the wider Levant.

India boasts a rich sporting heritage dating back thousands of years. Despite its rich sporing culture, India only began developing its own sporting ecosystem in 1954 with the creation of the All-India Council of Sports (AICS) in 1954, shortly after gaining independence from the United Kingdom in 1947. However, in the seven decades that have passed, the systematisation and development of sport of India has been relatively slow and internationally India have had limited success on the elite stage. The aim of this profile is to provide a detailed insight into the vast sporting ecosystem in India by exploring the policies, enablers, and barriers in relation to sport participation, elite sport, and the use of sport across the nation to tackle non-sporting objectives. Following an introduction highlighting the key demographics and sporting culture in India, the profile moves onto outline the state led provision of sport in India, including how sport is organised and funded. Next, the significance of the commercial sport sector in India is highlighted, followed by a section detailing the growth of the not-for-profit sector. Finally, the profile highlights the current public policy priorities and challenges, which include elite sport success, tackling inactivity and poor governance in sport before offering some concluding observations.

The COVID-19 pandemic led to increases in family violence in Australia and elsewhere. In response, organisations in the domestic and family violence (DFV) sector, had to adapt to the emerging public health measures and worked collaboratively to protect the most vulnerable in the community. These services, including courts, rapidly transformed their methods of service delivery that are likely to continue for some time. But what have been the implications/impacts of these rapid changes on the DFV service sector in Australia? How have these impacts informed the future needs of the DFV sector? And what is needed to strengthen this community sector of the future? This article reports on the findings of a national research project examining the impacts of COVID-19 on the DFV service sector and the adaptations and innovations that emerged in response. The study highlights that the surge in demand for services put pressure on an already overwhelmed workforce/service sector and provided an opportunity for front line workers to contribute to building a robust sector to respond to future crisis events. These findings have significant implications for future DFV sector service delivery, and for the social work profession as a whole.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe prothrombotic complication of adenoviral vaccines, including the ChAdOx1 nCoV-19 (Vaxzevria) vaccine. The putative mechanism involves formation of pathological anti–platelet factor 4 (PF4) antibodies that activate platelets via the low-affinity immunoglobulin G receptor FcγRIIa to drive thrombosis and thrombocytopenia. Functional assays are important for VITT diagnosis, as not all detectable anti-PF4 antibodies are pathogenic, and immunoassays have varying sensitivity. Combination of ligand binding of G protein–coupled receptors (protease-activated receptor-1) and immunoreceptor tyrosine–based activation motif–linked receptors (FcγRIIa) synergistically induce procoagulant platelet formation, which supports thrombin generation. Here, we describe a flow cytometry–based procoagulant platelet assay using cell death marker GSAO and P-selectin to diagnose VITT by exposing donor whole blood to patient plasma in the presence of a protease-activated receptor-1 agonist. Consecutive patients triaged for confirmatory functional VITT testing after screening using PF4/heparin ELISA were evaluated. In a development cohort of 47 patients with suspected VITT, plasma from ELISA-positive patients (n = 23), but not healthy donors (n = 32) or individuals exposed to the ChAdOx1 nCov-19 vaccine without VITT (n = 24), significantly increased the procoagulant platelet response. In a validation cohort of 99 VITT patients identified according to clinicopathologic adjudication, procoagulant flow cytometry identified 93% of VITT cases, including ELISA-negative and serotonin release assay–negative patients. The in vitro effect of intravenous immunoglobulin (IVIg) and fondaparinux trended with the clinical response seen in patients. Induction of FcγRIIa-dependent procoagulant response by patient plasma, suppressible by heparin and IVIg, is highly indicative of VITT, resulting in a sensitive and specific assay that has been adopted as part of a national diagnostic algorithm to identify vaccinated patients with platelet-activating antibodies.

Aims Behaviour modification and mood management are essential to recovery after a cardiac event. Recent times have seen a major shift to remote delivery of cardiac services. This study assessed behavioural and psychological outcomes of the Back on Track online self-management programme, comparing the programme undertaken alone (self-directed) vs. with telephone support (supported). Relevance for people with depression was also assessed. Methods and results Participants with cardiac conditions (n = 122) were randomly assigned to self-directed or supported groups and given access to the online programme for 2 months. The programme addressed depression, anxiety, physical activity, and healthy eating. Supported group participants also received two telephone sessions facilitated by a trained counsellor to further enhance their self-management skills and engagement with the online modules. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Active Australia Survey and Diet Quality Tool were administered at baseline, 2, and 6 months. χ2 tests were used to compare self-directed and supported groups. Cochrane’s Q tests assessed changes over time in depression, anxiety, and physical activity (PA) and healthy diet guideline achievement. Participants in both groups showed reduced depression rates (self-directed, P < 0.05) and increased PA after programme completion (both groups, P < 0.05). Amongst those classified as depressed at baseline, significantly fewer were classified as depressed over time (P < 0.001) and significantly more were achieving the PA guidelines (P < 0.01) compared to those who were not depressed at baseline. Conclusions The Back on Track telehealth programme was effective in assisting with behavioural and emotional recovery after a cardiac event. The programme may be particularly beneficial for those who are depressed early in their recovery period. Trial Registration Australian New Zealand Clinical Trials Registry: ACTRN12620000102976.

While there is growing evidence about the financial burden of completing long, compulsory (mostly unpaid) placements for social work students, this Australian study contemporizes existing research by exploring this issue in the current context (2020–2022), during which time we have experienced the COVID-19 pandemic, the related economic problems, and modified ASWEAS standards. The data is drawn from 372 undergraduate and Masters (qualifying) students across four universities in different states and explores their experiences of financial stress associated with current placement arrangements; their sources of income and employment arrangements; and how they navigated balancing paid work around placement, or how they supported themselves if they did not work alongside placement. The study evidences no improvement in the situation facing social work students in Australia despite modest ASWEAS modifications that offered limited flexibility around placement requirements during 2020 and 2021 due to the COVID-19 pandemic. The findings contribute to an expanding body of research that indicates the current model of field education is unsustainable for both social work students and the profession and confirms that urgent changes are required for the social work profession to consider our student population in its social justice mandate. Refereed/Peer-reviewed

Outdoor and nature experiences including play have been shown to be beneficial for children's physical, cognitive, social and emotional development. Parents/carers play an important role in encouraging or impeding their child's access to the outdoor environment and participation in outdoor play. The COVID-19 pandemic and associated restrictions on free movement and social interactions placed an unprecedented pressure on families to manage the drastic change in their daily routines. This paper reports findings from two combined data sets generated in 2020 during the COVID-19 pandemic and provides a deeper understanding of the interconnected nature of how contextual factors influence parenting processes and outcomes relating to young children's outdoor and nature experiences and subsequent child health. Findings have the potential to inform the messaging of existing outdoor play policies and the content of new interventions aiming to promote the exposure of children to the natural outdoor environment.

BackgroundDuring COVID-19 restrictions in England in spring 2020, early years settings for young children were closed to all but a small percentage of families, social contact was limited and play areas in parks were closed. Concerns were raised about the impact of these restrictions on young children’s emotional wellbeing. The aim of this study was to explore parents’ perceptions of young children’s emotional wellbeing during these COVID-19 restrictions.MethodsWe interviewed 20 parents of children 3-4 years due to begin school in England in September 2020. Interviews were conducted via telephone (n=18) and video call (n=2), audio-recorded and transcribed verbatim. Interviews focused on childcare arrangements, children’s behaviour and transition to school. A sample of transcripts were coded line-by-line to create a coding framework, which was subsequently applied to the remaining transcripts. Coded data were then analysed using a nurture lens to develop themes and further understanding.ResultsParticipants were predominantly mothers (n=16), White British (n=10), and educated to degree level (n=13), with half the sample living in the highest deprivation quintile in England (n=10). Five were single parents. Three themes developed from nurturing principles were identified: creating age-appropriate explanations; understanding children’s behaviour; concerns about school transition. Parents reported that their children’s emotional wellbeing was impacted and described attempts to support their young children whilst looking ahead to their transition to primary school.ConclusionsThis study is one of the first to examine in-depth perceptions of COVID-19 restrictions on young children’s emotional wellbeing. The longer-term impacts are not yet understood. Although young children may be unable to understand in detail what the virus is, they undoubtedly experience the disruption it brings to their lives. The wellbeing of families and children needs to be nurtured as they recover from the effects of the pandemic to allow them to thrive.

Objective: To explore the views of female genital mutilation (FGM) survivors, men, and healthcare professionals (HCPs) on the timing of deinfibulation surgery and NHS service provision. Design: Qualitative study informed by the sound of silence framework. Setting: Survivors and men were recruited from three FGM prevalent areas of England. HCPs and stakeholders were from across the UK. Sample: 44 survivors, 13 men and 44 HCPs. 10 participants at two community workshops and 30 stakeholders at a national workshop. Methods: Hybrid framework analysis of 101 interviews and three workshops. Results: There was no consensus across groups on the optimal timing of deinfibulation for survivors who wished to be deinfibulated. Within group, survivors expressed a preference for deinfibulation pre-pregnancy and HCPs antenatal deinfibulation. There was no consensus for men. Participants reported that deinfibulation should take place in a hospital setting and be undertaken by a suitable HCP. Decision making around deinfibulation was complex but for those who underwent surgery it helped to mitigate FGM impacts. Whilst there were examples of good practice, in general, FGM service provision was sub-optimal. Conclusion: Deinfibulation services need to be widely advertised. Information should highlight that the procedure can be carried out at different time points, according to preference, and in a hospital by suitable HCPs. Future services should ideally be developed with survivors, to ensure that they are clinically and culturally appropriate. Guidelines would benefit from being updated to reflect the needs of survivors and to ensure consistency in provision. Study registration number ISRCTN 14710507

Background The UK has low levels of breastfeeding initiation and continuation, with evident socioeconomic disparities. To be inclusive, peer-support interventions should be woman-centred rather than breastfeeding-centred. Assets-based approaches to public health focus on the positive capabilities of individuals and communities, rather than their deficits and problems. The Assets-based feeding help Before and After birth (ABA) intervention offers an assets-based approach based on behaviour change theory. Objective To investigate the feasibility of delivering the ABA infant feeding intervention in a randomised controlled trial. Design This was an individually randomised controlled feasibility trial; women were randomised in a 1 : 1 ratio to either the intervention group or the comparator (usual care) group. Setting Two separate English sites were selected because they had an existing breastfeeding peer support service, relatively high levels of socioeconomic disadvantage and low rates of breastfeeding. Participants Women aged ≥ 16 years who were pregnant with their first child, irrespective of feeding intention (n = 103), were recruited by researchers in antenatal clinics. Interventions Proactive, woman-centred support, using an assets-based approach and including behaviour change techniques, was provided by an infant-feeding helper (a breastfeeding peer supporter trained in the ABA intervention) and delivered through face-to-face contact, telephone conversations and text messages. The intervention commenced at around 30 weeks’ gestation and could continue until 5 months postnatally. Main outcome measures The main outcome measures were feasibility of intervention delivery with the requisite intensity and duration; acceptability to women, infant-feeding helpers and maternity services; and feasibility of a future randomised controlled trial. Outcomes included recruitment rates and follow-up rates at 3 days, 8 weeks and 6 months postnatally, and outcomes for a future full trial were collected via participant questionnaires. A mixed-methods process evaluation included qualitative interviews with women, infant-feeding helpers and maternity services; infant-feeding helper logs; and audio-recordings of antenatal contacts to check intervention fidelity. Results Of the 135 eligible women approached, 103 (76.3%) agreed to participate. The study was successful in recruiting teenagers (8.7%) and women living in areas of socioeconomic disadvantage (37.3% resided in the most deprived 40% of small areas in England). Postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3 days, 8 weeks and 6 months, respectively. Feeding status at 8 weeks was obtained for 95.1% of participants. Recruitment took place from February 2017 until August 2017. It was possible to recruit and train existing peer supporters to the infant-feeding helper role. The intervention was delivered to most women with relatively high fidelity. Among the 50 women in the intervention group, 39 received antenatal visits and 40 received postnatal support. Qualitative data showed that the intervention was acceptable. There was no evidence of intervention-related harms. Limitations Birth notification delays resulted in delays in the collection of postnatal feeding status data and in the offer of postnatal support. In addition, the intervention needs to better consider all infant-feeding types and did not adequately accommodate women who delivered prematurely. Conclusion It is feasible to deliver the intervention and trial. Future work The intervention should be tested in a fully powered randomised controlled trial. Trial registration Current Controlled Trials ISRCTN14760978. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

Background and context. Breastfeeding peer support is valued and well-liked by women, but trials have not demonstrated efficacy in the UK. The ABA feasibility trial offered proactive peer support underpinned by behaviour change theory and an assets-based approach to women having their first baby, regardless of feeding intention. This paper explores viewsof women and infant feeding helpers (IFHs) of the ABA intervention. Setting and participants. Trained infant feeding helpers (IFHs) offered 50 women an antenatal meeting to discuss infant feeding and identify community assets in two English sites - one with a paid peer support service and the other volunteer-led. Daily contact was offered postnatally for the first 2 weeks after birth, followed by less frequent contact until 5 months.Methods. Interviews with 21 women and focus groups/interviews with 13 IFHs were analysed using thematic and framework methods.Results. Women talked positively about the antenatal meeting, mapping their network of support, receiving proactive contact from their IFH, keeping in touch using text messaging and access to local groups. The face-to-face antenatal visit facilitated the regular text-based communication both in pregnancy and in the early weeks after birth. Volunteer IFHs were more supportive of and enthusiastic about the intervention whereas most paid IFHs disliked some features of the intervention.Conclusions. Putting the ABA intervention into practice was challenging for some peer supporters. Despite this, breastfeeding rates may be improved by using a community assetsbased approach and focusing on infant feeding as an acceptable alternative to focusing on breastfeeding alone.

ObjectivesUK general practice has radically altered in response to COVID-19. The general practice nursing team has been central to these changes. To help learn from COVID-19 and maintain a sustainable nursing workforce, general practice should reflect on their support needs and perceptions of organisational strategies. This study aimed to explore primary care nurses’ and healthcare assistants’ experiences and perceptions of general practice, and the changes made to it, during the pandemic.DesignExploratory qualitative study using semistructured interviews. Interview data were analysed using Braun and Clarke’s ‘codebook’ thematic analysis.SettingGeneral practices in the Midlands, South East and South West England. Interviews were conducted in February and March 2021, as England began to unlock from its third national lockdown.ParticipantsPractice nurses (n=12), healthcare assistants (n=7), advanced nurse practitioners (n=4) and nursing associates (n=1) recruited using convenience and snowball sampling.ResultsThree themes were identified. Difficult changes describes dramatic changes made to general practice at the onset of the pandemic, creating confusion and anxiety. Dealing with change characterises how negative emotions were intensified by fear of infection, problematic government guidance, personal protective equipment (PPE) shortages and friction with doctors; but could be mitigated through effective practice communication, peer support and individual coping strategies. An opportunity for improvement highlights certain changes (eg, the increased use of telehealth) that participants believed could be adopted long term to improve efficiency.ConclusionGeneral practice should learn from the COVID-19 pandemic to nurture the clinical role and resilience of nurses and healthcare assistants in the postpandemic ‘new normal’. Robust PPE provision could enable them to undertake their patient-facing duties safely and confidently. Judicious implementation of telehealth could help preserve the practical and caring nature of nursing. Improving channels of communication and interprofessional collaboration could help realise their potential within the primary care team.

Climate change poses a threat to heritage globally. Decolonial approaches to climate change–heritage research and practice can begin to address systemic inequities, recognize the breadth of heritage and strengthen adaptation action globally.

BACKGROUND After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management. OBJECTIVE The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone. METHODS People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only. RESULTS Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study. CONCLUSIONS The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs. CLINICALTRIAL Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true INTERNATIONAL REGISTERED REPORT DERR1-10.2196/34534

BackgroundIn spring 2020, the COVID-19 lockdown placed unprecedented restrictions on the behaviour and movements of the UK population. Citizens were ordered to ‘stay at home’, only allowed to leave their houses to buy essential supplies, attend medical appointments or exercise once a day. This qualitative study explored how ‘lockdown’ and its subsequent easing changed young children’s everyday activities, eating and sleep habits to gain insight into the impact for health and wellbeing.MethodsIn summer 2020 we interviewed 20 parents of children due to start school in September 2020 (aged 3-5 years) by phone or video call to explore their experiences of lockdown and its easing. We recruited participants through nurseries and local Facebook community groups in the South West and West Midlands of England. Half the sample were from Black, Asian or Minority Ethnic backgrounds and half lived in the most deprived quintile. We analysed interviews using thematic analysis.ResultsChildren’s activity, screen time, eating, and sleep routines had some level of disruption. Parents reported children ate more snacks during lockdown, but also spent more time preparing meals and eating as a family. Most parents reported a reduction in their children’s physical activity and an increase in screen time, which some linked to difficulties in getting their child to sleep. Parents sometimes expressed guilt about changes in activity, screen time and snacking over lockdown. Most felt these changes would be temporary with no lasting impact, though others worried about re-establishing healthy routines.ConclusionsThe spring COVID-19 lockdown negatively impacted on pre-school children’s eating, activity and sleep routines. While some positive changes were reported, there were wide-spread reports of lack of routines, habits and boundaries which, at least in the short-term, were likely to have been detrimental for child health and development. Guidance and support for families during times of COVID-19 restrictions could be valuable to help them maintain healthy activity, eating, screen-time and sleeping routines to protect child health and ensure unhealthy habits are not adopted.

Important heritage sites along the African coast are at risk from the threats associated with rising sea levels. Here, we quantify the exposure of natural and cultural heritage sites in Africa to coastal flooding and erosion in the 21st century. We develop a comprehensive database of 284 coastal African Heritage Sites (AHS), composed of 213 natural and 71 cultural heritage sites, which is then combined with coastal flooding and erosion projections to assess exposure to coastal extreme events for a moderate (RCP4.5) and high (RCP8.5) greenhouse gas emissions scenario. We find that 56 AHS are presently at risk from a 100-year extreme sea-level event, with a total exposed heritage area of 2,222 km2. Most of the currently exposed AHS are located in Northern and Western Africa. By mid-century, the number of exposed AHS is projected to increase more than 3 times to reach 191 and 198 under moderate and high emissions respectively. In the second half of the century, the number of exposed sites stabilizes, but the median exposed area increases to 6.6 to 8.5 times the present-day value, under moderate and high emissions, respectively. Mitigation from high to moderate emissions will reduce the end-century median exposed area and number of very highly exposed sites by 20% and 25% respectively.

Background and objectives Fluid overload and intradialytic hypotension are associated with cardiovascular events and mortality in patients on hemodialysis. We investigated associations between hemodialysis facility practices related to fluid volume and intradialytic hypotension and patient outcomes. Design, setting, participants, & measurements Data were analyzed from 10,250 patients in 273 facilities across 12 countries, from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009–2012). Cox regression models (shared frailty) were used to estimate associations between facility practices reported by medical directors in response to the DOPPS Medical Directors Survey and all-cause and cardiovascular mortality and hospitalization, and cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual kidney function, dialysis adequacy, and vascular access type. Results Of ten facility practices tested (chosen a priori ), having a protocol that specifies how often to assess dry weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78; 99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR, 0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97) and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate temperature to limit or prevent intradialytic hypotension was associated with lower cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online volume indicator to assess dry weight was associated with higher all-cause hospitalization (HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04 to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). Conclusions Hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension are associated with patient outcomes.

Background Childhood obesity is an urgent worldwide concern associated with increased morbidity in adulthood. Healthcare professionals (HCPs) are well placed to influence childhood obesity trends and implement interventions. English-language studies regarding HCPs’ perceptions of childhood obesity are limited to high-income countries. Peru is an upper-middle-income country with regional disparities in childhood obesity prevalence. This qualitative study aims to explore HCPs’ perceptions of childhood obesity in Iquitos, Peru, where prevalence is relatively low. Methods Twenty-one HCPs with child healthcare experience were purposively recruited from two primary healthcare centres. Semi-structured, individual interviews were conducted with a translator and audio recorded. Transcribed data were analysed using thematic analysis. Results Eight themes were identified and divided into four categories: (1) HCPs’ perceptions and attitudes towards childhood obesity (level of concern regarding childhood obesity, perceived consequences of childhood obesity); (2) Factors which HCPs perceive to be important in the development of childhood obesity (parental factors, contextual factors); (3) HCPs’ perceptions of their role in childhood obesity prevention and management (educating parents about childhood obesity, regular monitoring of child growth); and (4) Barriers and facilitators in childhood obesity prevention and management (in healthcare, in schools). Conclusions HCPs had a low level of concern regarding childhood obesity in Iquitos and prioritised undernutrition. Parental factors were perceived to be the most influential in the development of childhood obesity. HCPs perceived themselves to have minimal influence due to prevailing positive views of excess weight and difficulties engaging parents. Educating parents about childhood obesity was felt to be essential to prevention and management although regular monitoring of child growth and home healthcare visits were viewed as useful additional measures. This study can help to inform the development of targeted public health strategies which are sensitive to local contexts and could prevent the upward childhood obesity trends evident elsewhere in Peru.

This article critically examines the portrayal of sport for development (SfD) international volunteering by UK Higher Education Institutions (HEIs). Volunteer tourism or ‘voluntourism’ is a popular experience in which individuals combine international travel with voluntary work in a destination typically in the Global South in a bid to offer support to those in need. A body of literature offers an optimistic view of volunteer tourism, suggesting that it can facilitate the development of cross-cultural understanding among volunteers and host communities. However, there is also critical literature which argues that if volunteer tourism programmes are not carefully developed and managed, they can lead to cross-cultural misunderstanding and reinforce negative cultural stereotypes; this latter critique provides both the justification and context for this article. Several studies have acknowledged the centrality of Global Northern volunteers to the delivery of sport-based programmes in the Global South under the banner of SfD [Darnell (2007). Playing with race: Right to play and the production of whiteness in ‘development through sport’. Sport in Society, 10(4), 560–579; Darnell (2011). Identity and learning in international volunteerism: ‘Sport for development and peace’ internships. Development in Practice, 21(7), 974–986; Lucas & Jeanes (2019). Ethnographic reflections of the role of global north volunteers in sport-for-development. International Review for the Sociology of Sport, 55(7), 953–974]. However, given the pivotal role that UK HEIs play in marketing and facilitating such opportunities for students, there is a lack of research that critically examines how such volunteer opportunities are portrayed by HEIs. The article draws from a sample of thirteen UK HEIs to examine how they discursively frame SfD international volunteer opportunities. The findings illustrate how student volunteers benefit and even socially transform because of volunteering in poor Global South communities. The article concludes by outlining a series of recommendations for UK HEIs to consider regarding their portrayal of international SfD volunteering.

ObjectiveWe aimed to examine the association between food and physical activity environments in primary schools and child anthropometric, healthy eating and physical activity measures.DesignObservational longitudinal study using data from a childhood obesity prevention trial.SettingState primary schools in the West Midlands region, UK.Participants1392 pupils who participated in the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) childhood obesity prevention trial (2011–2015).Primary and secondary outcome measuresSchool environment (exposure) was categorised according to questionnaire responses indicating their support for healthy eating and/or physical activity. Child outcome measures, undertaken at three time points (ages 5–6, 7–8 and 8–9 years), included body mass index z-scores, dietary intake (using a 24-hour food ticklist) and physical activity (using an Actiheart monitor over 5 days). Associations between school food and physical activity environment categories and outcomes were explored through multilevel models.ResultsData were available for 1304 children (94% of the study sample). At age 8–9 years, children in 10 schools with healthy eating and physical activity-supportive environments had a higher physical activity energy expenditure than those in 22 schools with less supportive healthy eating/physical activity environments (mean difference=5.3 kJ/kg body weight/24 hours; p=0.05). Children in schools with supportive physical activity environments (n=8) had a lower body mass index z-score than those in schools with less supportive healthy eating/physical activity environments (n=22; mean difference=−0.17, p=0.02). School food and physical activity promoting environments were not significantly associated with dietary outcomes.ConclusionsSchool environments that support healthy food and physical activity behaviours may positively influence physical activity and childhood obesity.Trial registration numberISRCTN97000586.

In the context of the COVID-19 pandemic, Australian universities have had to radically rethink and reconfigure many aspects of social work education. This has been particularly pronounced for field...

Background A lack of perceived social support influences women’s infant feeding behaviours. The Infant Feeding Genogram is a visual co-constructed diagram which details people/services that can provide support to women and can facilitate a connection between mothers and their existing assets landscape. The aim of this study is to explore women’s and infant feeding helpers’ experiences and use of an infant feeding genogram delivered to the intervention group of the “Assets-based infant feeding help Before and After birth (ABA)” randomised feasibility trial. Methods 103 primiparous mothers aged 16+ years were recruited to the trial (trial registration number) in two sites (Site A and Site B) with low breastfeeding prevalence in the UK. Infant feeding helpers (IFHs) co-constructed a genogram at the first antenatal meeting for the intervention group (n = 50), and then provided proactive, woman-centered support from ~ 32 weeks gestation to up to 5 months postnatal. Infant feeding helpers' and women’s experiences of the infant feeding genogram were collected via interviews or focus groups. Completed genograms were shared with researchers. Content analysis of the genograms and qualitative data from the interviews and focus groups were analysed thematically. Results Data comprised 32 completed genograms, and qualitative insights from all 13 infant feeding helpers (two focus groups; 4 interviews) and interviews with a purposive sample of 21 of 50 intervention group women between 4 and 21 weeks after birth. Content analysis of the genograms highlighted variations, with more personal, individualised genograms completed at Site B compared to Site A. The perceived impact of the genogram was related to the IFHs’ application of the tool. The genogram was either used as intended to raise women’s awareness of available assets and motivate help-seeking behaviour, or as a data collection tool with limited perceived utility. Negative and positive unintended consequences of genogram use were highlighted. Conclusions The genogram has the potential to offer a woman, family and community-centred approach that focusses on building assets for infant feeding. However, variations in genogram application indicate that revised training is required to clarify the purpose and ensure it is used as intended. Trial registration ISRCTN ISRCTN14760978; Registered 30 January 2017.

BACKGROUND: Globally, over 33 million people have atrial fibrillation (AF). In eligible patients, oral anticoagulation (OAC) is recommended for stroke risk reduction. Despite recent increases in OAC prescribing, global under-prescription to high-risk AF patients and inappropriate prescription to low-risk patients is leading to unnecessary risk of stroke and haemorrhage. This meta-synthesis explored clinicians' beliefs and experiences regarding OAC prescription to AF patients, highlighting barriers to stroke prevention and informing future clinician-focused interventions.METHODS AND RESULTS: A qualitative meta-synthesis exploring clinicians' views and experiences of prescribing OACs for stroke prevention in AF patients. Databases including MEDLINE, EMBASE, PsychINFO and CINAHL were searched to June 2018, with a further Medline search to February 2020. Thematic synthesis was performed with data coding, descriptive theme categorisation and generation of analytical themes. From 3499 records, 101 full text papers were screened, with 13 eligible studies identified. Four analytical themes were found to affect clinicians' prescribing: (i) 'Clinicians' intellectual and emotional responses to the evidence'; (ii) 'Prescribing in primary and secondary care'; (iii) 'Clinicians' views of how patients' characteristics and opinions influence prescribing'; and (iv) 'Clinicians' views on their interactions with patients'.CONCLUSIONS: This review highlights focal points for future clinician-focused interventions to improve guideline-adherent OAC prescription in AF patients. Interventions should aim to improve clinicians' knowledge around NOAC prescription and stroke and haemorrhage risk assessment tools as well as their emotional responses to difficult prescribing scenarios. Multidisciplinary interventions promoting cohesive care and input from different clinicians to overcome time-related barriers may increase guideline-adherent OAC prescription for AF patients.

This article proposes that the Pre-Pottery Neolithic A (PPNA) hunter-forager-cultivator introductions to Cyprus from the northern Levant had a much more enduring impact on the Cypriot Aceramic Neol...