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For at least the past 5 decades, population genetics, as a field, has worked to describe the precise balance of forces that shape patterns of variation in genomes. The problem is challenging because modeling the interactions between evolutionary processes is difficult, and different processes can impact genetic variation in similar ways. In this paper, we describe how diversity and divergence between closely related species change with time, using correlations between landscapes of genetic variation as a tool to understand the interplay between evolutionary processes. We find strong correlations between landscapes of diversity and divergence in a well-sampled set of great ape genomes, and explore how various processes such as incomplete lineage sorting, mutation rate variation, GC-biased gene conversion and selection contribute to these correlations. Through highly realistic, chromosome-scale, forward-in-time simulations, we show that the landscapes of diversity and divergence in the great apes are too well correlated to be explained via strictly neutral processes alone. Our best fitting simulation includes both deleterious and beneficial mutations in functional portions of the genome, in which 9 % of fixations within those regions is driven by positive selection. This study provides a framework for modeling genetic variation in closely related species, an approach which can shed light on the complex balance of forces that have shaped genetic variation. [ABSTRACT FROM AUTHOR]

Public health agencies are increasingly concerned with ensuring that they are maximizing limited resources by delivering effective programs to enhance population-level health outcomes. Preventing mis-implementation (ending effective activities prematurely or continuing ineffective ones) is necessary to sustain public health efforts and resources needed to improve health and well-being. The purpose of this paper is to identify the important qualities of leadership in preventing mis-implementation of public health programs. In 2019, 45 state health department chronic disease employees were interviewed via phone and audio-recorded, and the conversations were transcribed verbatim. Thematic analysis focused on items related to mis-implementation and the manners in which leadership were involved in continuing ineffective programs. Final themes were based on a Public Health Leadership Competency Framework. The following themes emerged from their interviews regarding the important leadership competencies to prevent mis-implementation: '(1) leadership and communication; (2) collaborative leadership (3) leadership to adapt programs; (4) leadership and organizational learning and development; and (5) political leadership'. This first of its kind study showed the close interrelationship between mis-implementation and leadership. Increased attention to public health leader competencies might help to reduce mis-implementation in public health practice and lead to more effective and efficient use of limited resources. [ABSTRACT FROM AUTHOR]

Background Clinical commissioning groups (CCGs) were in early development when fieldwork took place. Public Health (PH) was moving into the local authority, and new ways of working were being established. Methods Three qualitative case studies in the North of England were undertaken using three different data collection methods: observations, interviews and the collection of documents that were related to the project. Comprehensive field notes were taken during observations, analysed alongside interview transcriptions and collected documentation using the software programme Atlas.ti. Results The relationship between the CCG and their local PH team was in development at the time of data collection. Three different PH roles could be discerned from the data: 'co-owner', 'service provider' and 'critical friend'. These roles impacted on the utilization of PH by CCGs and the wider relationship between the CCG and PH. Conclusions These models are 'ideal types', and in reality the CCG-PH relationship in most areas will contain elements of all three models. However, to think of them as set out in this paper is instructive for both CCGs and PH. It is important that CCGs and their PH colleagues to think clearly about what they are trying to achieve and how that can most effectively work together. [ABSTRACT FROM AUTHOR]

Background This paper aims to examine determinants of multiple sexual partnerships (MSPs) among South African men and women using a nationally representative sample. Methods Quantitative and qualitative data from a 2008 population-based cross-sectional survey were used. The analysis focused on the 6990 (33.6% of total sample) who were 15 years and older and reported sexual activity in the prior 12 months. The qualitative component consisted of 15 focus group interviews investigating values underlying MSP behaviors. Results Predictors of MSP common across gender were race, having a history of STI, being in a short relationships (<1 year) and suspecting the current partner of infidelity. MSP among men enjoyed greater community acceptance and was mainly done for social status. Furthermore, men reporting MSP were mostly younger (15–24 years old) and use condom at last sex. Among women, determinants of MSP included economic vulnerability, younger age at sexual debut and living in formal urban rather than formal rural areas. Conclusions The data presented in this paper reinforces the importance of MSP as a risk factor for HIV and outline factors that should strongly be considered in strengthening condom use promotion and of partner reduction programs messaging in South Africa. [ABSTRACT FROM PUBLISHER]

As evidence generators, we need to respond to the changes in the health delivery landscape if we are to continue to support public health decision-makers to make informed and judicious evidence-based choices. This study employs documentary analysis to (i) explore the extent of research evidence use in public health decision-making; (ii) to analyse occurrences of research evidence use in decision-making and (iii) to ascertain whether patterns of evidence use overlap with other area characteristics. Health and Wellbeing Strategies constitute the main source of documentary evidence. Initial results highlight that local areas are undertaking their own programmes of research that are used to inform specific questions, although the methodological robustness of these studies is unknown. There are also commonalities with previous findings, particularly with regard to the underutilization of qualitative research evidence and evidence on the effectiveness of interventions. Using Qualitative Comparative Analysis, this paper also highlights that underutilization of more academic research evidence appears disproportionally weighted towards areas with some of the most complex needs but that are not receiving the highest level of spending to meet these challenges. These areas in particular may be those where knowledge brokerage activities may have the greatest impacts. [ABSTRACT FROM AUTHOR]

This paper examines lay interpretations of lay health worker roles within three UK community-based health promotion projects. It argues that understanding lay health worker roles requires critical analysis of the complex interrelationships between professionals, lay workers and the communities receiving a programme. Findings are presented that are drawn from a qualitative study of lay engagement in public health programme delivery where a key objective was to examine the perspectives of community members with the experience of receiving services delivered by lay health workers. Interviews and focus groups were conducted with 46 programme recipients from three case study projects; a breastfeeding peer support service, a walking for health scheme and a neighbourhood health project. The results show how participants interpreted the function and responsibilities of lay health workers and how those roles provided personalized support and facilitated engagement in group activities. Further insights into community participation processes are provided revealing the potential for active engagement in both formal and informal roles. The paper concludes that social relationships are core to understanding lay health worker programmes and therefore analysis needs to take account of the capacity for community members to move within a spectrum of participation defined by increasing responsibility for others. [ABSTRACT FROM PUBLISHER]

This paper investigates the reasoning processes of social workers in child protection social work as they make decisions. Within this interpretive process, they assign meaning to clients' behaviours in a context containing a multitude of competing discourses relating to the nature and cause of clients' problems. The study used a qualitative approach, specifically a critical incident framework. It asked workers to describe cases they felt ‘pleased with’ and explain the reasoning processes they used in those cases. It also asked clients their views of decisions made about them. This article draws on social constructionist theorising to describe and analyse the discourses used to frame the aims of practice and the causes of clients' problems. It found that workers valued family maintenance and sought to bolster this while managing potential risk. In the cases selected by workers, they constructed the causes of clients' problems in non-blaming but individualised ways, viewed clients as being capable of change and honest in their dealings with workers. It is proposed that these ways of viewing contributed to maintaining relationships with clients despite the challenges of balancing risk, care, control and power. [ABSTRACT FROM PUBLISHER]

Adolescents from urban communities are at risk for unhealthy snacking behaviors. Youth advocacy interventions are shown to improve certain adolescent health behaviors, such as substance use. However, it remains unclear if youth advocacy is a feasible method to promote healthy snacking. As such, the aim of this study was to examine the feasibility of a youth advocacy program promoting healthy snacking among adolescents in New York City by conducting a mixed-methods process evaluation. Adolescents (12–18 years) at a Boys and Girls Club in New York City were recruited to participate in a 12-session adaptation of the Youth Engagement and Action for Health! program to advocate for the promotion of healthy snacks in corner stores. A mixed-methods process evaluation was conducted to assess recruitment, reach (attendance), dose delivered (amount of intervention delivered), fidelity (degree to which intervention was implemented according to curriculum) and dose received (participant engagement/satisfaction). Satisfaction was also evaluated through focus groups. Descriptive statistics were calculated for quantitative data, and focus groups were analyzed using thematic analysis. Participant retention (94.74%), attendance (93.52%), dose delivered (98.94%), fidelity (98.5%), engagement (4.97/5) and program satisfaction (4/5) were high. Focus groups (n  = 6; 28 participants) revealed that participants learned about nutrition, enjoyed being advocates and improved snacking behaviors. [ABSTRACT FROM AUTHOR]

Recess is a critical source of physical, social and emotional health and well-being for children, but generally not prioritized during online learning. A 13-week structured recreation intervention was delivered virtually during recess to students in the fifth and sixth grades (age 10–12 years; N  = 71) at one elementary school (Phoenix, AZ, USA). We used embedded mixed method with a prospective pre-/post-design to measure change in student-reported emotion and qualities of engagement in an online setting. Students completed an online pre-/post-survey to measure emotion and motivational responses (enjoyment, competence and relatedness). We used narrative notes to qualitatively assess student engagement during programming. Differences in student-reported emotion were analyzed using paired t -tests. The effect of motivational responses on emotion was analyzed using multiple regression analyses. In vivo coding and concept coding were used to analyze qualitative data. We found no statistically significant differences in student-reported emotion; however, student relationships with peers predicted increased positive and decreased negative emotions after the intervention. Seven categories promoted student engagement: challenging, enjoyable, experiential, practical, purposeful, relatable and relevant. School-based health practitioners can offer structured activities virtually during recess, when in-person learning is interrupted and in all-online settings, to promote emotional well-being. [ABSTRACT FROM AUTHOR]

Background NHS Health Checks began in England in 2009 and were subsequently introduced into English prisons. Uptake has been patchy and there is limited understanding about factors that may limit or enhance uptake in prison settings. Uptake of this programme is a key policy in reducing the risk of cardiovascular disease and death in these settings. Method Semi-structured focus groups were conducted with groups of prisoners (attendees and non-attendees to the health check), prison healthcare staff, custodial staff and ex-prisoners (n  = 50). Participants were asked about their awareness and experiences of the NHS Health Check Programme in prison. Results All groups highlighted barriers for not attending a health check appointment, such as poor accessibility to the healthcare department, stigma and fear. The majority of participants expressed a lack of awareness and discussed common misconceptions regarding the health check programme. Methods of increasing the uptake of health checks through group-based approaches and accessibility to healthcare were suggested. Conclusions This study reports on prisoner, staff and ex-prisoner perspectives on the implementation of NHS Health Checks within a restrictive prison environment. These findings have potentially substantial implications for successful delivery of care within offender healthcare services. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic has had a huge effect on adolescents' health and learning. Health promotion strategies should be valued, and life skill education is a potential approach in this direction. This study aimed to investigate the implementation of an evidence-based life skill education programme during the COVID-19 pandemic in the Lombardy Region (Italy) by collecting opinions about the programme's usefulness and feasibility and identifying the strategies for implementing it through distance teaching. The study involved 63 middle school expert teachers, principals or coordinators in life skill education. An online questionnaire with closed- and open-ended questions was used. A qualitative content analysis was carried out using N-Vivo Answers software. The participants recognized the high value of life skill education at the time of COVID-19, but they showed reticence regarding its feasibility. Positive effects of the programme on both health and learning outcomes were reported. The obstacles were related to interpersonal aspects, student involvement, methods, organization and planning. Many strategies were suggested related to the teaching method, the curriculum organization and the adaptation needs. These strategies can be used to implement active and cooperative learning at a distance to reinforce students' life skills to cope with the crisis and promote their health. [ABSTRACT FROM AUTHOR]

Background Gypsies, Roma and Travellers are at risk of low uptake of routine immunizations. Interventions to improve uptake in these communities are seldom evaluated. As part of a qualitative study exploring barriers and facilitators to immunization uptake in Travellers, we report service provider (SP) perspectives. Methods We interviewed immunization SPs working with six Traveller communities across four UK cities. Participants included frontline staff and those with strategic or commissioning roles. Semi-structured interviews explored perceived attitudes of Travellers to vaccinations, local service delivery, and opportunities and challenges to improving uptake. Audio-recordings were transcribed, analyzed thematically and mapped to a socio-ecological model of health. Results 39 SPs participated. Four overarching themes were identified: building trusting relationships between SPs and Travellers; facilitating attendance at appointments; improving record keeping and monitoring and responding to local and national policy change. Travellers were perceived as largely supportive of immunizations, though system and organizational processes were recognized barriers to accessing services. Conclusions Findings were broadly consistent across Traveller groups and settings. The barriers identified could often be addressed within existing infrastructure, though require system or policy change. Development of a culturally competent system appears important to enable equity in access to immunizations for Travellers. [ABSTRACT FROM AUTHOR]

Background This study explored barriers and facilitators to integrating health evidence into spatial planning at local authority levels and examined the awareness and use of the Public Health England 'Spatial Planning for Health' resource. Methods A sequential exploratory mixed-methods design utilized in-depth semi-structured interviews followed by an online survey of public health, planning and other built environment professionals in England. Results Views from 19 individuals and 162 survey responses revealed high awareness and use of the Spatial Planning for Health resource, although public health professionals reported greater awareness and use than other professionals. Key barriers to evidence implementation included differences in interpretation and the use of 'evidence' between public health and planning professionals, lack of practical evidence to apply locally and lack of resource and staff capacity in local authorities. Key facilitators included integrating health into the design of local plans, articulating wider benefits to multiple stakeholders and simplifying presenting evidence (regarding language and accessibility). Conclusion The Spatial Planning for Health resource is a useful resource at local authority level. Further work is needed to maximize its use by built environment professionals. Public health teams need support, capacity and skills to ensure that local health and well-being priorities are integrated into local planning documents and decisions. [ABSTRACT FROM AUTHOR]

The number of people with disabilities who study at university is rising. Previous studies have revealed that it is not enough simply to provide these students with access to university, it is also important to guarantee their retention and success. This article explores participants' actions and their appraisals of their teaching practice in relation to disability in campus-based education. The study was conducted with 19 Spanish faculty members from the Health Sciences who were nominated by their students with disabilities for having contributed to their inclusion. We carried out a qualitative study based on individual, in-depth, semi-structured interviews. We analysed the data progressively, using a system of categories and codes. The results section outlines the actions taken by faculty members upon learning that they were going to be teaching a student with disabilities, analysing what specific measures they took in accordance with the type of disability in question, and what they found most rewarding and most difficult or unpleasant about their experience with these students in the classroom. The study concludes that the voices of these faculty members may encourage other colleagues to rethink their actions in the classroom and engage in more inclusive practices. [ABSTRACT FROM AUTHOR]

Background The situation of frontline health workers in the rural areas of Bauchi and Cross River States has been classified as critical regarding the shortages due to attrition. This affects health service delivery and outcomes. Methods We targeted 402 participants, and 389 frontline health workers (nurses, midwives, nurse/midwives, community health officers and community health extension workers) responded. They were drawn from 42 public primary healthcare centers: 23 from Cross River and 19 from Bauchi States. Five focused-group discussions were conducted with 42 facilities in-charges to identify what they perceived as the main causes of attrition in the rural areas. Results Our findings indicate that the reasons that had potential to cause attrition of the frontline health workers were either voluntary or involuntary. Out of the 81 nurses in the study, 66 (81 percent) would voluntarily exit the workforce while 15 (19 percent) would leave involuntarily. From a total number of 81 nurses, midwives and nurse/midwives from the two states, 75% would exit due to resignations in search of better prospects in the urban areas. Ninety-nine percent of the community health worker's attrition had very low intentions of exit, and it would mainly be due to retirements and deaths. Conclusion Implementation of tailor-made strategies that reflect their needs is imperative in the two states to reduce attrition among frontline health workers and improve health service outcomes. [ABSTRACT FROM AUTHOR]

Background Urban design can influence population levels of physical activity and subsequent health impacts. This qualitative study investigates local level decision-making for 'active living' infrastructure (ALI)—walking and cycling infrastructure and open spaces in new communities. Methods Thirty-five semi-structured interviews with stakeholders, and limited ethnographic observations, were conducted with local government and private sector stakeholders including urban and transport planners, public health practitioners, elected councillors and developers. Interview transcripts were coded and analysed thematically. Results Public health practitioners in local government could act as knowledge brokers and leaders to motivate non-health stakeholders such as urban and transport planners to consider health when designing and building new communities. They needed to engage at the earliest stages and be adequately resourced to build relationships across sectors, supporting non-health outcomes such as tackling congestion, which often had greater political traction. 'Evidence' for decision-making identified problems (going beyond health), informed solutions, and also justified decisions post hoc, although case study examples were not always convincing if not considered contextually relevant. Conclusion We have developed a conceptual model with three factors needed to bridge the gap between evidence and ALI being built: influential public health practitioners; supportive policies in non-health sectors; and adequate resources. [ABSTRACT FROM AUTHOR]

Background The rising prevalence of mental health problems is a growing public health issue. Poor mental health is not equally distributed across social groups and is associated with poverty and insecure housing. An evaluation of a social housing intervention provided an opportunity to explore the connections between housing and wider determinants of health and wellbeing. Methods We undertook 44 interviews with social housing tenants over a two-year period to explore their views on housing, health and wellbeing. Results Poor mental health was common. The results suggest that perceptions of housing quality, service responsiveness, community safety, benefit changes and low income all have a detrimental effect on tenants' mental health. Conclusions Social housing providers who wish to have a positive impact on the mental health of their tenants need to consider how to best support or mitigate the impact of these stresses. Addressing traditional housing officer functions such as reporting or monitoring home repairs alongside holistic support remains an important area where social housing departments can have substantial health impact. Tackling the complex nature of mental health requires a joined up approach between housing and a number of services. [ABSTRACT FROM AUTHOR]

While there is some guidance to support the adaptation of evidence-based public health interventions, little is known about adaptation in practice and how to best support public health practitioners in its operationalization. This qualitative study was undertaken with researchers, methodologists, policy makers and practitioners representing public health expert organizations and universities internationally to explore their views on available adaptation frameworks, elicit potential improvements to such guidance, and identify opportunities to improve implementation of public health initiatives. Participants attended a face to face workshop in Newcastle, Australia in October 2018 where World Café and focus group discussions using Appreciative Inquiry were undertaken. A number of limitations with current guidance were reported, including a lack of detail on 'how' to adapt, limited information on adaptation of implementation strategies and a number of structural issues related to the wording and ordering of elements within frameworks. A number of opportunities to advance the field was identified. Finally, a list of overarching principles that could be applied together with existing frameworks was generated and suggested to provide a practical way of supporting adaptation decisions in practice. [ABSTRACT FROM AUTHOR]

Background Area-based initiatives that include a focus on community empowerment are increasingly being seen as potentially an important way of improving health and reducing inequalities. However, there is little empirical evidence on the pathways between communities having more control and health outcomes. Purpose To identify pathways to health improvement in a community-led area-based community empowerment initiative. Methods Longitudinal data on mental health, community control, area belonging, satisfaction, social cohesion and safety were collected over two time points, 6 months apart from 48 participants engaged in the Big Local programme, England. Qualitative comparative analysis (QCA) was used to explore pathways to health improvement. Results There was no clear single pathway that led to mental health improvement but positive changes in 'neighbourhood belonging' featured in 4/5 health improvement configurations. Further, where respondents experienced no improvement in key social participation/control factors, they experienced no health improvement. Conclusion This study demonstrates a potential pathway between an improvement in 'neighbourhood belonging' and improved mental health outcomes in a community empowerment initiative. Increasing neighbourhood belonging could be a key target for mental health improvement interventions. [ABSTRACT FROM AUTHOR]

Background While qualitative studies suggested that continuity of care by primary care physicians (PCPs) facilitated consultations for psychological problems, there was limited quantitative evidence. This survey compared management of psychological distress between patients with and without a regular PCP. Methods A questionnaire survey was conducted with 1626 adult primary care attenders from 13 private and 6 public clinics in Hong Kong. Management of psychological distress between respondents with a regular PCP and those without were compared. Effects of demographic factors were adjusted for by multivariable logistic regression. Results Among the 1626 respondents, 650 (40.0%) reported that they had ever experienced psychological distress. Of the 650 respondents experienced distress, 307 (47.2%) had a regular PCP. A significantly higher proportion of patients with a regular PCP than those without reported: (i) their PCPs sometimes/often asked about psychological problems [37.7 versus 20.1%, adjusted OR = 2.241]; (ii) they sometimes/often mentioned their psychological problems to PCPs [45.2 versus 24.9%, adjusted OR = 2.503]; and (iii) their distress had been treated by PCPs [22.1 versus 13.4%, adjusted OR = 1.702]. Conclusion Patients with a regular PCP have around double odds of receiving mental health care. Continuity of care by PCPs should be emphasized in mental health care delivery. [ABSTRACT FROM AUTHOR]

Background There is evidence that key health behaviours of people who migrate deteriorate over time, which has a consequent impact upon the health of dependent children. As health in the early years sets the course for lifelong health, it is important to explore parents' views on maintaining children's health following migration. Methods Five focus groups were held with parents of preschool children who had migrated to the UK within the last 10 years (n = 28). Parents originated from Romania, Poland, Somalia and Pakistan, with one group of Roma Gypsy parents. Data collection took place in January to March 2015. Results All groups, apart from the Roma, perceived barriers to maintaining optimal health and well-being for their preschool children following migration to the UK. Eastern European parents experienced difficulties in ensuring family financial security, while parents from more established communities focused on barriers to children's exercise, play and nutrition. Conclusions This study highlights aspects of public health where migrants and their children can experience adverse effects in the UK. These findings have implications for policymakers, commissioners and providers of health services who aim to promote good health among preschool children. [ABSTRACT FROM AUTHOR]

Background: patient empowerment, through which patients become self-determining agents with some control over their health and healthcare, is a common theme across health policies globally. Most care for older people is in the acute setting, but there is little evidence to inform the delivery of empowering hospital care. Objective: we aimed to explore challenges to and facilitators of empowerment among older people with advanced disease in hospital, and the impact of palliative care. Methods: we conducted an ethnography in six hospitals in England, Ireland and the USA. The ethnography involved: interviews with patients aged ≥65, informal caregivers, specialist palliative care (SPC) staff and other clinicians who cared for older adults with advanced disease, and fieldwork. Data were analysed using directed thematic analysis. Results: analysis of 91 interviews and 340 h of observational data revealed substantial challenges to empowerment: poor communication and information provision, combined with routinised and fragmented inpatient care, restricted patients' self-efficacy, self-management, choice and decision-making. Information and knowledge were often necessary for empowerment, but not sufficient: empowerment depended on patient-centredness being enacted at an organisational and staff level. SPC facilitated empowerment by prioritising patient-centred care, tailored communication and information provision, and the support of other clinicians. Conclusions: empowering older people in the acute setting requires changes throughout the health system. Facilitators of empowerment include excellent staff-patient communication, patient-centred, relational care, an organisational focus on patient experience rather than throughput, and appropriate access to SPC. Findings have relevance for many high- and middle-income countries with a growing population of older patients with advanced disease. [ABSTRACT FROM AUTHOR]

Background: understanding how best to provide palliative care for frail older people with non-malignant conditions is an international priority. We aimed to develop a community-based episodic model of short-term integrated palliative and supportive care (SIPS) based on the views of service users and other key stakeholders in the United Kingdom. Method: transparent expert consultations with health professionals, voluntary sector and carer representatives including a consensus survey; and focus groups with older people and carers were used to generate recommendations for the SIPS model. Discussions focused on three key components of the model: potential benefit of SIPS, timing of delivery and processes of integrated working between specialist palliative care and generalist practitioners. Content and descriptive analysis was employed and findings were integrated across the data sources. Findings: we conducted two expert consultations (n = 63), a consensus survey (n = 42) and three focus groups (n = 17). Potential benefits of SIPS included holistic assessment, opportunity for end of life discussion, symptom management and carer reassurance. Older people and carers advocated early access to SIPS, while other stakeholders proposed delivery based on complex symptom burden. A priority for integrated working was the assignment of a key worker to co-ordinate care, but the assignment criteria remain uncertain. Interpretation: key stakeholders agree that a model of SIPS for frail older people with non-malignant conditions has potential benefits within community settings, but differ in opinion on the optimal timing and indications for this service. Our findings highlight the importance of consulting all key stakeholders in model development prior to feasibility evaluation. [ABSTRACT FROM AUTHOR]

As part of water, sanitation and hygiene interventions in low-income settings, it is frequently assumed that pupils can disseminate information and catalyze change at home, yet this assumption has not been rigorously assessed. We employed qualitative research methods in two phases to assess the potential for children to be change agents in five schools in rural Zambia. Phase 1 included role-play and focus group discussions among pupils on their percieved ability to serve as change agents. Children were then given 'homework' that included information on health messages and on how to build a handwashing station, and were encouraged to engage their family. In Phase 2, we conducted separate focus group discussions with pupils and mothers on their experiences with the 'homework'. We found that, in general, pupils were enthusiastic about engaging with parents--typically male heads of household--and were successful at constructing handwashing stations. Mothers reported high levels of trust in children to relay health information learned at school. Pupils were able to enact small changes to behavior, but not larger infrastructure changes, such as construction of latrines. Pupils are capable of communicating knowledge and behaviors to family members; however, discrete activities and guidance is required. [ABSTRACT FROM AUTHOR]

Purpose: Use of electronic cigarettes ('ecigarettes' is rapidly rising, and is especially prevalent among young adults. A better understanding of e-cigarette perceptions and motivations for use is needed to inform health communication and educational efforts. This study aims to explore these aspects of use with a focus on comparing young adults to older adults. Methods: In this qualitative study, the investigator conducted semi-structured interviews among a purposive sample of e-cigarette users. Thematic content analysis was used to analyze qualitative data and document themes. Results: e-cigarettes were most commonly used for smoking cessation among both age groups. Young adults described other motivations for use including doing smoke tricks, being able to consume a wide variety of flavors, and helping them study. Some interviewees (11%) believed e-cigarettes were a healthy alternative to conventional cigarettes, while many other users (30%) expressed concerns about the unknown risks of e-cigarettes. Conclusion: Findings were generally consistent across both age groups in their perceptions of harm from e-cigarettes and in subjective effects such as perceived addictiveness. However, individuals under 30 described unique motivations for e-cigarette use. Health messaging targeted to young adults should emphasize the potential health risks of e-cigarette use and recognize their distinct motivational aspects. [ABSTRACT FROM AUTHOR]

Children with mild bilateral and unilateral hearing loss are now commonly identified early through newborn hearing screening initiatives. There remains considerable uncertainty about how to support parents and about which services to provide for children with mild bilateral and unilateral hearing loss. The goal of this study was to learn about parents' experiences and understand, from their perspectives, the impact of hearing loss in the mild range on the child's functioning. Parents of 20 children in Ontario, Canada, participated in the study. The median age of identification of hearing loss was 4.6 months (interquartile range: 3.6,10.8). Parents appreciated learning early about hearing loss, but their experiences with the early process were mixed. Parents felt that professionals minimized the importance of milder hearing loss. There was substantial uncertainty about the need for hearing aids and the findings suggest that parents need specific guidance. Parents expressed concerns about the potential impact of hearing loss on their child's development, particularly at later ages. [ABSTRACT FROM AUTHOR]

Aims: Provision of effective treatment for dependent drinkers has been identified as a priority in England yet evidence suggests that access is problematic and there are low levels of retention. This qualitative study explores how the alcohol treatment system is experienced by service users, identifying barriers and facilitators that influence treatment outcomes. Methods: A total of 20 semi-structured face-to-face interviews were conducted with patients from community alcohol treatment services in three London boroughs in 2012. Interviews were undertaken one year after initially entering treatment. A thematic analysis was conducted, with the results further abstracted to relate them to specific aspects of the treatment journey. Results: Patients journeys were characterized by a perceived lack of control leading to help-seeking, with treatment outcomes influenced by an individuals’ self-efficacy and the capabilities and skills of staff in actively engaging and supporting patients on the journey. A focus of services on the detoxification process and fragmented care pathways impacted negatively on engagement. Conclusions: Current alcohol care pathways require significant levels of motivation and self-efficacy to navigate that few patients possess. Pathways need to better reflect the capacity and capabilities of patients to be successful in supporting recovery. [ABSTRACT FROM AUTHOR]

Background: The positive effects of lifestyle intervention programmes might be enhanced when targeted to the health-related behaviour of the users. This study explores the beliefs and attitudes regarding a healthy lifestyle, the influences on lifestyle behavioural change and the needs to support a healthy lifestyle in the local community, during an integrated community-based prevention project in newly developed urban area in the Netherlands. Methods: Three focus groups were conducted with urban residents aged 45-70 (n = 28). Thematic qualitative analysis was applied to verbatim transcripts to identify emerging themes. Results: The following themes were identified: beliefs to healthy behaviour, responsibility for health, perceived behavioural control, external influences on behavioural change and needs in the local community. Within these themes, personal responsibility for health and the influence of the social and physical environment emerged to be important for health and lifestyle. The participants expressed the need for clearly organized health and lifestyle facilities, a personalized approach and an easily accessible health risk assessment to support lifestyle behavioural change in the community. Conclusion: In our study, urban residents experienced a strong influence of the social and physical environment to their lifestyle behaviour. This finding supports an integrated approach for preventive health services in this population. [ABSTRACT FROM AUTHOR]

Objective The prescription opioid epidemic is currently responsible for the greatest number of unintentional deaths in the United States. One potential strategy for decreasing this epidemic is implementation of state-based Prescription Drug Monitoring Programs (PDMPs), which are designed for providers to identify patients who 'doctor shop' for prescriptions. Emergency medicine physicians are some of the most frequent PDMP users and opioid prescribers, but little is known about how they actually use PDMPs, for which patients, and for what reasons. Methods We conducted and transcribed semistructured qualitative interviews with 61 physicians at a national academic conference in October 2012. Deidentified transcripts were entered into QSR NVivo 10.0, coded, and analyzed for themes using modified grounded theory. Results There is variation in pattern and frequency of PDMP access by emergency physicians. Providers rely on both structural characteristics of the PDMP, such as usability, and also their own clinical gestalt impression when deciding to use PDMPs for a given patient encounter. Providers use the information in PDMPs to alter clinical decisions and guide opioid prescribing patterns. Physicians describe alternative uses for the databases, such as improving their ability to facilitate discussions on addiction and provide patient education. Conclusion PDMPs are used for multiple purposes, including identifying opioid misuse and enhancing provider-patient communication. Given variation in practice, standards may help direct indication and manner of physician use. Steps to minimize administrative barriers to PDMP access are warranted. Finally, alternative PDMP uses should be further studied to determine their appropriateness and potentially expand their role in clinical practice. [ABSTRACT FROM AUTHOR]

Medication mismanagement is a growing public health concern, especially among elders. Annually, it is a major contributor to emergency hospitalization and nursing home placement. Elders and their caregivers, as healthcare consumers and stakeholders in this issue, are uniquely qualified to inform strategies to improve medication adherence. We conducted a qualitative study to ascertain caregiver and elder perceptions of barriers to medication management and to identify community-derived solutions to improve medication management. Nine focus groups (N=65, mean age = 71) were conducted with caregivers or elders from five communities. Participants were recruited by key informants utilizing snowball sampling methodology. The following themes were identified in the participant-recommended proposed solutions improving medication adherence: (i) use of personal systems to overcome barriers to medication adherence, (ii) various solutions to address cost concerns, (iii) the need for regular review of medications by doctors or pharmacists to eliminate unnecessary medications, (iv) desire for community-driven support systems, and (v) using medical advocates. Elders and caregivers recognized medication non-adherence as a community-wide issue and were eager to offer solutions they thought would work in their communities. These solutions can lend credibility to strategies currently being developed/utilized and offer innovative recommendations for future interventions. [ABSTRACT FROM AUTHOR]

Studies on health promoting schools (HPS) in low-and middle-income countries (LMICs) are scarce. To contribute to the development of HPS in these countries, we conducted formative research to understand the school environment in Lao PDR, Mongolia, Nepal, and Sri Lanka. Forty-three teachers, 10 government workers and 5 parents participated in three one-on-one interviews and 14 natural group interviews. Six themes emerged that centered on insufficient resources as reasons for suboptimal health conditions. At the individual level, participants mentioned the deficiency of personal resources to cope with cold weather and poor diet. At the school level, the lack of physical resources such as water purifiers and latrines was discussed. Interviewees also pointed out the schools' overdependence on external resources and therefore the lack of sustainability. Last, the shortage of health services at the school and community level was commonly mentioned. Based on these results, we believe that the basic concept of HPSs should also be applied when working with schools in LMICs. In conclusion, there was a lack of perception of the importance of policy and capacity development programs, which are important in developing HPSs. Therefore, future school health programs should stress improving these elements. [ABSTRACT FROM AUTHOR]

Background. Sympatheticandfrankcommunication aboutthe terminal nature of advanced cancer is important to improve patients' prognostic understanding and, thereby, to allow for adjustment of treatment intensity to realistic goals; however, decisions against aggressive treatments are often made only when death is imminent. This qualitative study explores the factors that hinder such communication and reconstructs how physicians and nurses in oncology perceive their roles in preparing patients for end-of-life (EOL) decisions. Methods. Qualitative in-depth interviews were conducted with physicians (n 5 12) and nurses (n 5 6) working at the Department ofHematology/Oncology at the university hospital in Munich, Germany. The data were analyzed using grounded theory methodology and discussed from a medical ethics perspective. Results. Oncologists reported patients with unrealistic expectations to be a challenge for EOL communication that is especially prominent in comprehensive cancer centers. Oncologistsrespondedto this challenge quite differentlybyeither proactively trying to facilitate advanced care planning or passively leaving the initiative to address preferences for care at the EOL to the patient. A major impediment to the proactive approach was uncertainty about the right timing for EOL discussions and about the balancing the medical evidence against the physician's own subjective emotional involvement and the patient's wishes. Conclusion. These findings provide explanations of why EOL communication is often started rather late with cancer patients. For ethical reasons, a proactive stance should be promoted, andoncologists should takeonthe taskof preparing patients for their last phase of life. To do this, more concrete guidance on when to initiate EOL communication is necessary to improve the quality of decision making for advanced cancer patients. [ABSTRACT FROM AUTHOR]

Background. The world’s global cancer burden disproportionally affects lower income countries, where 80% of patients present with late-stage disease and have limited access to palliative care and effective pain-relieving medications, such as morphine. Consequently, millions die each year with unrelieved pain. Objective. The objective of this study was to examine barriers to opioid availability and cancer pain management in India, with an emphasis on the experiences of nurses, who are often the front-line providers of palliative care. Methods. Fifty-nine participants were recruited using a purposive, snowball sampling strategy. Ethnographic data collection included in-depth, semistructured interviews (n = 54), 400+ hours of participant observation, and review of documents over 9 months at a government cancer hospital in South India. Systematic qualitative analysis led to identification of key barriers that are exemplified by representative quotes. Results. Morphine is more available at this study site than in most of India, but access is limited to patients seen by the palliative care service, and significant gaps in supply still occur. Systems to measure and improve pain outcomes are largely absent. Key barriers related to pain management include the role of nursing, opioid misperceptions, bureaucratic hurdles, and sociocultural/infrastructure challenges. Implications. Interventions must streamline process details of morphine procurement, work within the existing sociocultural infrastructure to ensure opioids reach patients most in need, target unexpected audiences for symptom management education, and account for role expectations of health care providers. Conclusion. Macro- and micro-level policy and practice changes are needed to improve opioid availability and cancer pain management in India. [ABSTRACT FROM AUTHOR]

This study evaluates the perceptions of teachers in charge of coordinating health education in schools: the School Health Coordinators (SHCs). It addresses the success and barriers of the development and implementation regarding the first year of healthy eating programmes in their schools. This research is based on 16 face-to-face semi-structured interviews with SHCs from Portuguese public schools offering from fifth to ninth grades. A thematic analysis was performed and themes were identified, taking into consideration similarities and differences among the participants’ opinions. The results showed that the schools in this study often involved a set of separate healthy diet promotion activities with a low level of joint effort from all members of the school. Nevertheless, in Portugal, health education is based on the broad concept that school health promotion is compulsory for all schools. Two main barriers were identified in order to explain this divergence: structural and political idiosyncrasies among schools and the food environment inside and outside the schools. The results are discussed considering the wide range of factors influencing young people’s eating behaviours and recommendations are made for the different agents interacting with them in order to promote appropriate eating habits. [ABSTRACT FROM PUBLISHER]

Human immunodeficiency virus (HIV) interventions can significantly reduce risky sexual behaviors among vulnerable populations. However, not everyone exposed to an intervention will reduce their sexual risk behavior. This qualitative study sought to identify factors associated with young African American females’ lack of increase in condom use post-participation in an HIV prevention intervention. Semi-structured interviews were conducted with 50 young African American women (18–23 years; approximately half were mothers) after participating in a demonstrated effective HIV prevention intervention; 24 did not increase condom use post-intervention. Interviews were thematically coded for barriers to condom-use post-intervention. Although nearly all young women reported partner-associated challenges to using condoms, there were relational differences observed among those who changed their condom use versus those who did not. Many ‘non-changers’ were engaged in non-stable ‘on and off’ relationships, with high rates of infidelity, often with the father of their child, in which they were fearful of requesting condom use. ‘Non-changers’ also reported more substance use, feeling incapable of change and not thinking about condom use. Thus, future HIV prevention efforts may benefit from incorporating strategies on how young mothers can maintain a non-sexual relationship with their child’s father, as well as elaborating on the intersection of substance use and risky sexual decision-making. [ABSTRACT FROM PUBLISHER]

Background Food outlets may make an important contribution to an obesogenic environment. This study investigated barriers and facilitators to public health work with food outlets in disadvantaged areas. Methods In-depth qualitative interviews with 36 directors, managers and public health service delivery staff in a coterminous primary care trust and local authority in northwest England. Data were analysed using the constant comparative method. Results Three interventions were available to engage with businesses; awards for premises that welcomed breastfeeding mothers or offered healthy menu options and local authority planning powers. Sensitivity to the potential conflict between activities that generate profit and those that promote health, led to compromises, such as awards for cafés that offer only one healthy option on an otherwise unhealthy menu. An absence of existing relationships with businesses and limited time were powerful disincentives to action, leading to greater engagement with public rather than private sector organizations. Hiring staff with commercial experience and incentives for businesses were identified as useful strategies, but seldom used. Conclusions Encouraging food outlets to contribute to tackling the obesogenic environment is a major challenge for local public health teams that requires supportive national policies. Commitment to engage with the local public health service should be part of any national voluntary agreements with industry. [ABSTRACT FROM AUTHOR]

Background. Physical therapists often prescribe exercises for fall prevention.Understanding the factors influencing the clinical decision-making processes used by expert physical therapists working in specialist fall and balance clinics may assist other therapists in prescribing exercises for fall prevention with greater efficacy. Objectives. The objective of this study was to describe the factors influencing the clinical decision-making processes used by expert physical therapists to prescribe exercises for fall prevention. Design. This investigation was a qualitative study from a phenomenological perspective. Methods. Semistructured telephone interviews were conducted with 24 expertphysical therapists recruited primarily from the Victorian Falls Clinic Coalition.Interviews focused on 3 exercise prescription contexts: face-to-face individual therapy, group exercise programs, and home exercise programs. Interviews elicited information about therapist practices and the therapist, patient, and environmental factors influencing the clinical decision-making processes for the selection of exercise setting, type, dosage (intensity, quantity, rest periods, duration, and frequency), and progression. Strategies for promoting adherence and safety were also discussed. Data were analyzed with a framework approach by 3 investigators. Results. Participants described highly individualized exercise prescription approaches tailored to address key findings from physical assessments. Dissonance between prescribing a program that was theoretically correct on the basis of physiological considerations and prescribing one that a client would adhere to was evident. Safety considerations also were highly influential on the exercise type and setting prescribed. Terminology for describing the intensity of balance exercises was vague relative to terminology for describing the intensity of strength exercises. Conclusions. Physical therapists with expertise in fall prevention adopted an individualized approach to exercise prescription that was based on physical assessment findings rather than "off-the-shelf" exercise programs commonly used in fall prevention research. Training programs for people who prescribe exercises for older adults at risk of falling should encompass these findings. [ABSTRACT FROM AUTHOR]

Background. The popularity of elliptical training has grown in rehabilitation, fitness, and home settings as a means for improving fitness and walking, yet many people with physical disabilities and chronic conditions experience difficulties when trying to use elliptical trainers. Objective. The purpose of this study was to compare, for people with disabilities and chronic conditions, perceptions of safety, comfort, workout, and usability of 4 elliptical trainers before and after the development of a set of low-cost adaptations. Design. This study was a quasi-experimental repeated-measures investigation. Methods. Twenty adults with diverse medical conditions and functional abilities evaluated 4 elliptical trainers for safety, comfort, workout, and usability. Barriers to the use of the elliptical trainers and solutions to improve the use of the trainers were identified. Prototype modifications were designed, and participants reassessed the same features after the modifications were made. Results. An integrated system (steps, bench, side rails, center rail or handle, deeper foot wells, and 1-handed heart rate monitor) was developed. Although at least 25% of participants required physical assistance to get on or off the elliptical trainers before modification, only one required this after modification. Before modification, only 1 participant was able to mount each device independently; after modification, 6 to 8 participants were able to do so. Up to 25% of participants continued to require assistance to initiate or sustain pedal movement. Compared with participants' ratings of the elliptical trainers before modification, those after modification were higher for safety (55% increase in visual analog scale ratings), comfort (43% higher), ability to achieve a good workout (23% greater), and usability (24% increase). Limitations. To date, only 4 elliptical trainers have been studied with a small sample of convenience. Conclusions. Elliptical trainers posed access challenges to people with disabilities, chronic conditions, or both. Implementation of low-cost modifications successfully reduced barriers and the need for assistance, enabling greater access for people who could benefit from using the devices for functional training and fitness. [ABSTRACT FROM AUTHOR]

Background: During the past decades, many governments have introduced patient cost-sharing in their public health-care system. This trend in health-care reforms affected the European Union (EU) member states as well. This article presents a review of patient cost-sharing for health-care services in the 27 EU countries, and discusses directions for their improvement. Methods: Data are collected based on a review of international data bases, national laws and regulations, as well as scientific and policy reports. The analysis presents a combination of qualitative and quantitative research techniques. Results: Patient cost-sharing arrangements in the EU have been changing considerably over the past two decades (mostly being extended) and are quite diverse at present. There is a relation between patient cost-sharing arrangements and some characteristics of the health-care system in a country. In a few EU countries, a mix of formal and informal charges exists, which creates a double financial burden for health-care consumers. Conclusions: The adequacy of patient cost-sharing arrangements in EU countries needs to be reconsidered. Most importantly, it is essential to deal with informal patient payments (where applicable) and to assure adequate exemption mechanisms to diminish the adverse equity effects of patient cost-sharing. A close communication with the public is needed to clarify the objectives and content of a patient payment policy in a country. [ABSTRACT FROM AUTHOR]