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Socioeconomic crisis and humanitarian disasters can cause increased stress for women who experience inter-partner violence (IPV). This study analyzed the impact of the COVID-19 lockdown on this important issue, their related health and social services and working conditions from the perspectives of professionals in different sectors. Forty-three semi-structured interviews were carried out with 47 professionals (44 women and 3 men) from 40 different entities (September 2020-April 2021). This content analysis suggests that the pandemic and its associated prevention measures have had a negative impact on women exposed to IPV and their children, which affected their social wellbeing. Professionals described burnout, difficult and slow administrative processes, and problems with coordination and access to information. These negative impacts were mitigated, in part, by the work of professionals, but this suggests that a series of key strategies are needed to improve the response capacity of the service sector to IPV in situations of crisis. These improvements are related to the availability of human and material resources; an efficient coordination network between the professionals from different sectors; existence of informal support networks in the community; protocols/procedures and prior training for better implementation; and greater flexibility and accessibility of basic services that benefit women who experience IPV. This study was financed through the project “Gender violence and social and health responses during the COVID-19 crisis” by the Fondo Supera Covid-19 CRUE-Santander for the period 2020-2021 (Ref. FSCovid19-03). It was also co-supported by the CIBER of Epidemiology and Public Health of Spain for its aid to the Gender-based Violence and Youth Research Program. Sí

Background: In 2014, the World Health Assembly (WHA) approved the Resolution “Strengthening of palliative care as a component of comprehensive care throughout the life course” (WHA67.19), urging national governments to carry out actions to develop palliative care.\ud \ud Objective: To establish the origins and assess the influence and early impact of this Resolution.\ud \ud Methods: Semistructured interviews conducted with key informants (n = 20). A thematic content analysis was conducted and triangulated on the transcriptions.\ud \ud Results: The collaborative work done by Non-State Actors, palliative care associations, individuals, Member States, and the World Health Organization (WHO) itself was crucial to the drafting and the approval of WHA67.19. Several post-Resolution actions undertaken by the WHO were highlighted (e.g., appointment of a dedicated officer and the creation of advisory working groups) and its role was identified as a key element in the implementation. Inadequate funding, lack of resources, and cultural factors were the most relevant barriers to implementation. The wide network of NGOs and palliative care associations was identified as the main facilitator. The key identified impact of the Resolution was its value as an advocacy tool and its contribution to raising awareness about palliative care around the world.\ud \ud Conclusions: Despite the lack of indicators to monitor the implementation of Resolution WHA67.19, key experts evaluate its effects in the short term as positive. Policy potential and its use in championing palliative care are its main early successes. The role of Non-State Actors, the WHO, and Member States working together is crucial to achieving its goals.

Context Mobile health (mHealth) provides an opportunity to use internet coverage in low- and middle-income countries to improve palliative care access and quality. Objectives This study aimed to design a mobile phone application (app) to enable or improve communication between family caregivers, community caregivers, and palliative care teams; to evaluate its acceptability, processes, and mechanisms of action; and to propose refinements. Methods A codesign process entailed collaboration between a Project Advisory Group and collaborators in India, Uganda, and Zimbabwe. We then trained community and family caregivers to use an app to communicate patient-reported outcomes to their palliative care providers each week on a data dashboard. App activity was monitored, and qualitative in-depth interviews explored experience with the app and its mechanisms and impact. Results N = 149 caregivers participated and uploaded n = 837 assessments of patient-reported outcomes. These data were displayed to the palliative care team on an outcomes dashboard on n = 355 occasions. Qualitative data identified: 1) high acceptability and data usage; 2) improved understanding by team members of patient symptoms and concerns; 3) a need for better feedback to caregivers, for better prioritisation of patients according to need, for enhanced training and support to use the app, and for user-led recommendations for ongoing improvement. Conclusion An outcomes-focused app and data dashboard are acceptable to caregivers and health-care professionals. They are beneficial in identifying, monitoring, and communicating patient outcomes and in allocating staff resource to those most in need.

Background Lack of social awareness is a major barrier to the development of palliative care. Mass media influences public opinion, and frequently deal with palliative care contributing to its image and public understanding. Aim To analyse how palliative care is portrayed in Spanish newspapers, as well as the contribution made by the press to its social representation. Design Based on criteria of scope and editorial plurality, four print newspapers were selected. Using the newspaper archive MyNews (www.mynews.es), articles published between 2009 and 2014 containing the words “palliative care” or “palliative medicine” were identified. Sociological discourse analysis was performed on the identified texts on two levels: a) contextual analysis, focusing on the message as a statement; b) interpretative analysis, considering the discourse as a social product. Results We examined 262 articles. Politician and healthcare professionals were the main representatives transmitting messages on palliative care. The discourses identified were characterised by: strong ideological and moral content focusing on social debate, strong ties linking palliative care and death and, to a lesser degree, as a healthcare service. The messages transmitted by representatives with direct experience in palliative care (professionals, patients and families) contributed the most to building a positive image of this healthcare practice. Overall, media reflect different interests in framing public understanding about palliative care. Conclusion The knowledge generated about how palliative care is reflected in the printed media may help to understand better one of the main barriers to its development not only in Spain, but also in other contexts.

Background: With the goal of achieving greater unity and coherence, the Council of Europe developed a national palliative care (PC) policy framework—Recommendation (2003) 24. Although directed at member states, the policy spread to the wider World Health Organisation (WHO) European Region. This article aims to present the current situation relating to national PC health policies in European countries. Methods: A cross-sectional survey was conducted in 53 European countries of the WHO European Region. Relevant data reported (i) the existence of official documents concerning the provision of PC; (ii) the role of health departments and policymakers in the evaluation of PC provision and (iii) the availability of financial resources for PC provision. Results: In total, 46/53 (87%) EU and non-EU countries responded. PC legislation is established in 20 (71%) EU and nine (50%) non-EU countries. A total of 12 (43%) EU countries possess a PC plan or strategy in comparison with six (33%) non-EU countries. Individuals from Departments of Health and designated policymakers have established collaborative PC efforts. Quality systems have been initiated in 15 (54%) EU and four (22%) non-EU countries. Significant differences were not found in the reporting of payments for PC services between European regions. Conclusion: An improvement in national PC policy in both EU and non-EU countries was observed. Future priorities include potential initiatives to improve relationships with policymakers, establish quality control programmes and ensure financial support for PC.

Background: The evolution of the provision of palliative care specialised services is important for planning and evaluation. Aim: To examine the development between 2005 and 2012 of three specialised palliative care services across the World Health Organization European Region – home care teams, hospital support teams and inpatient palliative care services. Design and setting: Data were extracted and analysed from two editions of the European Association for Palliative Care Atlas of Palliative Care in Europe. Significant development of each type of services was demonstrated by adjusted residual analysis, ratio of services per population and 2012 coverage (relationship between provision of available services and demand services estimated to meet the palliative care needs of a population). For the measurement of palliative care coverage, we used European Association for Palliative Care White Paper recommendations: one home care team per 100,000 inhabitants, one hospital support team per 200,000 inhabitants and one inpatient palliative care service per 200,000 inhabitants. To estimate evolution at the supranational level, mean comparison between years and European sub-regions is presented. Results: Of 53 countries, 46 (87%) provided data. Europe has developed significant home care team, inpatient palliative care service and hospital support team in 2005–2012. The improvement was statistically significant for Western European countries, but not for Central and Eastern countries. Significant development in at least a type of services was in 21 of 46 (46%) countries. The estimations of 2012 coverage for inpatient palliative care service, home care team and hospital support team are 62%, 52% and 31% for Western European and 20%, 14% and 3% for Central and Eastern, respectively. Conclusion: Although there has been a positive development in overall palliative care coverage in Europe between 2005 and 2012, the services available in most countries are still insufficient to meet the palliative care needs of the population. Support for this work was received from the Institute for Culture and Society (ICS) of the University of Navarra, particularly since 2012 as part of the ATLANTES Project (unrestricted research grant ad hoc). Additional support has been received from the Fondazione Maruzza Lefebvre D’Ovidio Onlus, in Rome (unrestricted research grant ad hoc), and the University of Glasgow Knowledge Exchange Fund (unrestricted grant ad hoc).

Resumen: El resumen de evidencia para políticas es un documento de referencia en la toma de decisiones políticas. De forma breve y directa, se define un problema, se realiza una síntesis de la evidencia disponible en torno al mismo, se identifican posibles líneas de actuación y se proponen recomendaciones. El objetivo de esta nota es describir su metodología, partiendo del modelo propuesto por Eugene Bardach y nuestra propia experiencia. Se describe la metodología en seis pasos: 1) identificación de la audiencia a la que se dirige el documento; 2) delimitación del problema; 3) recopilación de información y evidencias; 4) consideración de alternativas; 5) proyección de resultados y diseño de recomendaciones o mensajes clave; y 6) descripción de la historia. Se presenta también el resumen de evidencia para políticas como parte de una estrategia de comunicación más amplia que puede generar puntos de encuentro entre equipos de investigación y grupos de interés. Abstract: A policy brief is a document that summarizes research to inform policy. In a brief and succinct way, it defines a policy problem, presents a synthesis of relevant evidence, identifies possible courses of action and makes recommendations or key points. The objective of this note is to describe the methodology used to produce a policy brief for communicating public health research. This note is based on the model presented by Eugene Bardach in addition to the authors’ own experiences. We describe six steps: 1) identifying the audience; 2) defining the problem; 3) gathering information and evidence; 4) consideration of policy alternatives; 5) projecting results and designing recommendations; and 6) telling the story. We make a case for the use of policy briefs as a part of an overall communications strategy for research that aims to bring together research teams and stakeholders. Palabras clave: Métodos, Resumen de evidencia para políticas, Salud pública, Defensa de la salud, Políticas, Keywords: Methods, Policy brief, Public health, Health advocacy, Policies

Item does not contain fulltext BACKGROUND: Palliative care (PC) development is diverse and lacks an effective integration into European healthcare systems. This article investigates levels of integrated PC in European countries. METHODS: A qualitative survey was undertaken for the 2013 EAPC Atlas of PC in Europe with boards of national associations, eliciting opinions on opportunities for, and barriers to, PC development. ANALYSIS: Barriers and opportunities directly related to PC integration were identified and analyzed thematically according (1) to the dimensions of the World Health Organization (WHO) public health model and (2) by the degree of service provision in each country. A frequency analysis of dimensions and level of provision was also conducted. RESULTS: In total, 48/53 (91%) European countries responded to the survey. A total of 43 barriers and 65 opportunities were identified as being related to PC integration. Main barriers were (1) lack of basic PC training, with a particular emphasis on the absence of teaching at the undergraduate level; (2) lack of official certification for professionals; (3) lack of coordination and continuity of care for users and providers; (4) lack of PC integration for noncancer patients; (5) absence of PC from countries' regulatory frameworks; and (6) unequal laws or regulations pertaining to PC within countries. Innovations in education and new regulatory frameworks were identified as main opportunities in some European countries, in addition to opportunities around the implementation of PC in home care, nursing home settings, and the earlier integration of PC into patients' continuum of care. With increasing provision of services, more challenges for the integration are detected (p < 0.005). CONCLUSION: A set of barriers and opportunities to PC integration has been identified across Europe, by national associations, offering a barometer against which to check the challenge of integration across countries.

INTRODUCTION: The goal of palliative care (PC) is to improve the quality of life of terminal stage patients and their families. The subject frequently appears in the mass-media and this helps create a socially accepted identity. The aim of this study is to describe and analyse PC related news items appeared in the Spanish written media. METHODOLOGY: A descriptive cross-sectional study was designed. Considering diffusion, scope and the range in editorial policy criteria, four printed newspapers (PN) were selected, together with four exclusively digital media sources (DM). Through Mynews, a newspaper content depository, and the search tool for each DM website, articles published between 2009 and 2014 which included the terms "palliative care" and "palliative medicine" were sought. A questionnaire was created to characterise each article identified and a descriptive analysis was undertaken. RESULTS: A total of 627 articles were identified, of which 359 (57%) were published in PN (42% in the printed editions -PE- 16% in their online editions -OE-) and 268 (43%) in DM. In general, they appeared mainly in sections concerning Health (23%), Culture and Society (18%) and General/Home News (15%). In PE, just 2% were found in the Health section and nearly 70% in Culture and Society and General/Home News. Most of the articles were informative in nature and contained socio-political messages (90%). Statements by PC professionals were found in 35% of the articles and by politicians in 32%. The most frequent content was related to facing end of life (74%) and patient quality of life (70%). CONCLUSIONS: The Spanish written media reflects the socio-political interest aroused by PC. Nevertheless, messages circulating about PC do not describe professional practice, or the contribution of the same for patients. Content more in line with the clinical practice might help contribute to the development of this new area of medicine.

To develop a disease activity index for patients with uveitis (UVEDAI) encompassing the relevant domains of disease activity considered important among experts in this field. The steps for designing UVEDAI were: (a) Defining the construct and establishing the domains through a formal judgment of experts, (b) A two-round Delphi study with a panel of 15 experts to determine the relevant items, (c) Selection of items: A logistic regression model was developed that set ocular inflammatory activity as the dependent variable. The construct "uveitis inflammatory activity" was defined as any intraocular inflammation that included external structures (cornea) in addition to uvea. Seven domains and 15 items were identified: best-corrected visual acuity, inflammation of the anterior chamber (anterior chamber cells, hypopyon, the presence of fibrin, active posterior keratic precipitates and iris nodules), intraocular pressure, inflammation of the vitreous cavity (vitreous haze, snowballs and snowbanks), central macular edema, inflammation of the posterior pole (the presence and number of choroidal/retinal lesions, vascular inflammation and papillitis), and global assessment from both (patient and physician). From all the variables studied in the multivariate model, anterior chamber cell grade, vitreous haze, central macular edema, inflammatory vessel sheathing, papillitis, choroidal/retinal lesions and patient evaluation were included in UVEDAI. UVEDAI is an index designed to assess the global ocular inflammatory activity in patients with uveitis. It might prove worthwhile to motorize the activity of this extraarticular manifestation of some rheumatic diseases. The Spanish Society of Rheumatology is the sponsor and funder of this study and has participated in the study design; in the analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The corresponding author had full access to all study data and had final responsibility for the decision to submit the manuscript for publication. Sí

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated., Background: Family members are involved in the care of palliative patients at home and therefore, should be viewed as important sources of information to help clinicians better understand the quality palliative care service patients receive. The objective of the study was to analyse what is valued most by family carers undergoing bereavement of a palliative care home service in order to identify factors of quality of care. Methods: Qualitative exploratory study based on documentary analysis. Content analysis of 77 gratitude documents received over 8 years by a palliative home service in Odivelas, near Lisbon (Portugal) was undertaken, through an inductive approach and using investigator triangulation. Frequency of distinct categories was quantitatively defined. Results: Three different content categories emerged from the analysis: a) Recognition of the care received and the value of particular aspects of care within recognised difficult situations included aspects such as kindness, listening, attention to the family, empathy, closeness, affection and the therapeutic relationships established (63/77 documents); b) Family recognition of the achievements of the palliative care team (29/77) indicated as relief from suffering for the patient and family, opportunity of dying at home, help in facing difficult situations, improvement in quality of life and wellbeing, and feeling of serenity during bereavement; c) Messages of support (45/77) related to the need of resources provided. The relational component emerges as an underlying key aspect of family carers' experience with palliative care home service. Conclusion: Family carers show spontaneous gratitude for the professionalism and humanity found in palliative care. The relational component of care emerges as key to achieve a high quality care experience of palliative care homes service, and could be one indicator of quality of palliative care.

Background Integrated palliative care (IPC) involves bringing together administrative, organisational, clinical and service aspects in order to achieve continuity of care between all actors involved in the care network of patients receiving palliative care (PC) services. The purpose of this study is to identify literature on IPC in the Spanish context, either in cancer or other advanced chronic diseases. Methods Systematic review of the literature about IPC published in Spain between 1995 and 2013. Sources searched included PubMed, Cochrane Library, Cinahl, the national palliative care Journal (Medicina Paliativa), and Google. Evidence on IPC in care models, pathways, guidelines and other relevant documents were searched. Additionally, data were included from expert sources. Elements of IPC were considered based on the definition of IPC and the Emmanuel´s IPC tool. The main inclusion criterion was a comprehensive description of PC integration. Results Out of a total of 2,416 titles screened, 49 were included. We found two models describing IPC interventions achieving continuity and appropriateness of care as a result, 12 guidelines or pathways (most of them with a general approach including cancer and non-cancer and showing a theoretical IPC inclusion as measured by Emmanuel’s tool) and 35 other significant documents as for their context relevance (17 health strategy documents, 14 analytical studies and 4 descriptive documents). These last documents comprised respectively: regional and national plans with an IPC inclusion evidence, studies focused on IPC into primary care and resource utilisation; and descriptions of fruitful collaboration programmes between PC teams and oncology departments. Conclusions The results show that explications of IPC in the Spanish literature exist, but that there is insufficient evidence of its impact in clinical practice. This review may be of interest for Spanish-speaking countries and for others seeking to know the status of IPC in the literature in their home nations. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0120-9) contains supplementary material, which is available to authorized users.

The purpose of this study was to evaluate exposure conditions and acute health effects in subjects participating in the Prestige oil spill cleanup activities and the association between these and the nature of the work and use of protection devices in the regions of Asturias and Cantabria (Spain). The sample comprised 400 subjects in each region, selected from a random sampling of all persons involved in cleanup activities, stratified by type of worker and number of working days. Data were obtained via a structured questionnaire and included information on specific tasks, number of working days, use of protective materials, and acute health effects. These effects were classified into two broad groups: injuries and toxic effects. Data analysis was performed using complex survey methods. Significant differences between groups were evaluated using Pearson's chi(2) test. Unconditional logistic regression was used to compute odds ratios and 95% confidence intervals. Bird cleaners accounted for the highest prevalence of injuries (19% presented with lesions). Working more than 20 days in highly polluted areas was associated with increased risk of injury in all workers. Occurrence of toxic effects was higher among seamen, possibly due to higher exposure to fuel oil and its components. Toxic effects were more frequent among those working longer than 20 days in highly polluted areas, performing three or more different cleaning activities, having skin contact with fuel oil on head/neck or upper limbs, and eating while in contact with fuel or perceiving disturbing odors. No severe disorders were identified among individuals who performed these tasks. However, potential health impact should be considered when organizing cleanup activities in similar environmental disasters.

The objective of this study was to identify occupations and industries with increased incidence of thyroid cancer in Swedish workers.Standardized incidence ratios were computed for each job and industry for the period 1971-1989 through record-linkage with the Swedish National Cancer and Death Registers. Age-, period-, geographically adjusted relative risks were calculated using Poisson models.Increased risks were found for teachers, construction carpenters, policemen, and prison/reformatory officials in men, and medical technicians, shop managers, tailors, and shoecutters among women. Industries with risk excess are manufacture of agricultural machinery, manufacture of computing/accessories, and public administration/police among men; and manufacture of prefabricated wooden buildings, electric installation work, and wholesale of live animals/fertilizers/oilseed/grain among women.Our results corroborate some previously reported increased risks. Further research is needed to assess the influence of specific chemical agents related with some of the highlighted work environments.

Objective The purpose of this study was to understand how the nurse-patient relationship is interpreted by nurses and patients with advanced and terminal cancer (ATC) and which aspects of this relationship are perceived to be the most valuable for patients. Methods A literature search was conducted using the Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, and PsycINFO databases and was supported by reviewing reference lists. Nine articles were selected, and the quality of them was assessed using the Critical Appraisal Skills Program. A synthesis was performed following the seven-stage meta-ethnography described by Noblit and Hare. Results Four primary themes were derived from the synthesis: (a) being with and being for the person with ATC, (b) time is required for establishing the relationship, (c) the influence of the primary actors in the relationship: the nurse and the person with ATC, and (d) the effects of the relationship on both the nurse and the person with ATC. Finally, an explanatory model of the relationship between the nurse and the patient with ATC was developed, which shows that the relationship is an interpersonal process with several key elements including familiarity with one another, reciprocity, respect, and confidence. The nurses and patients with ATC perceive that their relationship is important and beneficial. The patients demand a helping and caring relationship focused on them as persons, not only as patients. Conclusions Patients with ATC and nurses consider their relationship to be important and beneficial. An approach to caring focused on patients as persons should be fostered among health care professionals and students.

Palliative care (PC) education has become a priority in many European countries where PC is quickly developing. There remains, however, a lack of information on acceptability and medical students' experiences in PC education. This kind of information is important because it could encourage universities to adapt their curricula appropriately to the demographic and societal necessity.To explore medical students' reactions to an optional PC course using their reflective written comments.316 medical students at the University of Navarra, over a period of 4 years, wrote evaluative comments regarding their experience and what they perceived as the course's contribution to their education. With these comments, a qualitative thematic analysis was carried out.With a response ratio of 90%, five main themes were identified: (1) The course helped medical students to become and act as doctors, (2) The benefits of having a holistic view of the patient and taking the family into account, (3) PC opens up a new a field of knowledge, (4) The course makes students think and reflect on their personal development and encourages them to deepen humanistic aspects of their practice, (5) The practical aspect is essential in PC learning. In addition, significantly, students used vigorous and positive expressions when writing about their experiences.The subject of PC turns out to be very important to students, who almost unanimously evaluated their experience positively and highlighted the benefits of attending a PC course. Students especially reported being surprised by the humane and holistic features of the course, and they found that what they learned in the course is applicable to all patients and prepares them to work better as doctors. Participants recommend the course for all undergraduate students as a core component of the curricula.

Background Burnout is the result of prolonged workplace exposure to chronic stress factors and may present itself in one of the following subtypes: “frenetic”, “under-challenged” and “worn-out”. The aims of the present study were to identify the causes of workplace discomfort that affect employees in large organizations and to determine the predictive power of these causes with regard to the burnout subtypes. Method We employed a qualitative and quantitative analysis (QQA), using a cross-sectional design with an online survey administered to a randomly selected sample of University workers (n = 409). To determine the causes of discomfort, we raised the following open question: “What aspects of your work generate discomfort for you?”. The responses were subjected to content analysis and categorized by three independent referees. The concordance between the responses was estimated with the kappa coefficient (k). Subtype classification was assessed according to the “Burnout Clinical Subtype Questionnaire” (BCSQ-36). The degree of association between the motives for the complaint and the burnout profiles was evaluated using adjusted odds ratio (OR), which was based on multivariate logistic regression models. Results The causes of discomfort included: physical environment (setting aspects, material conditions, journey/access), organization (schedules, structure, functions, interpersonal relations) and individual conditions (workload, powerlessness, rewards, negligence). The concordance index between the referees was k = 0.80. Employees who were upset with the hierarchical structure were more likely to be classified as frenetic (OR = 4.32; 95% CI = 1.43-13.06; p = 0.010); those who complained of routine duties were more likely to be classified as under-challenged (OR = 5.33; 95% CI = 1.84-15.40; p = 0.002); those whose discomfort was caused by structure control systems were more likely to be classified as worn-out (OR = 6.13; 95% CI = 1.57-23.91; p = 0.009). Conclusions The causes of discomfort among the different burnout subtypes are primarily attributable to the organization itself, in response to the structure and functions. The associations observed between the different subtypes and motives for complaint are consistent with the clinical profile-based syndrome definition, which suggests that interventions should be case-specific.

Background In the year 2020, depression will cause the second highest amount of disability worldwide. One quarter of the population will suffer from depression symptoms at some point in their lives. Mental health services in Western countries are overburdened. Therefore, cost-effective interventions that do not involve mental health services, such as online psychotherapy programs, have been proposed. These programs demonstrate satisfactory outcomes, but the completion rate for patients is low. Health professionals’ attitudes towards this type of psychotherapy are more negative than the attitudes of depressed patients themselves. The aim of this study is to describe the profile of depressed patients who would benefit most from online psychotherapy and to identify expectations, experiences, and attitudes about online psychotherapy among both patients and health professionals that can facilitate or hinder its effects. Methods A parallel qualitative design will be used in a randomised controlled trial on the efficiency of online psychotherapeutic treatment for depression. Through interviews and focus groups, the experiences of treated patients, their reasons for abandoning the program, the expectations of untreated patients, and the attitudes of health professionals will be examined. Questions will be asked about training in new technologies, opinions of online psychotherapy, adjustment to therapy within the daily routine, the virtual and anonymous relationship with the therapist, the process of online communication, information necessary to make progress in therapy, process of working with the program, motivations and attitudes about treatment, expected consequences, normalisation of this type of therapy in primary care, changes in the physician-patient relationship, and resources and risks. A thematic content analysis from the grounded theory for interviews and an analysis of the discursive positions of participants based on the sociological model for focus groups will be performed. Discussion Knowledge of the expectations, experiences, and attitudes of both patients and medical personnel regarding online interventions for depression can facilitate the implementation of this new psychotherapeutic tool. This qualitative investigation will provide thorough knowledge of the perceptions, beliefs, and values of patients and clinicians, which will be very useful for understanding how to implement this intervention method for depression.

Background Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods. Methods We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee. Results Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations. Conclusions Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally.

Background The impact of obesity on health-related quality of life (HRQL) has been little explored in rural areas. The goal of this study is to ascertain the association between obesity and HRQL among Spanish women living in a rural area, and the influence of their educational level. Methods Cross-sectional study with personal interview of 1298 women (aged 18 to 60) randomly selected from the electoral rolls of 14 towns in Galicia, a region in the north-west of Spain. HRQL was assessed using the SF-36 questionnaire. The association between body mass index (BMI) and suboptimal scores in the different HRQL dimensions was summarised using odds ratios (ORs), obtained from multivariate logistic regression models. Separate analyses were conducted for women who had finished their education younger than 16 years old and women with secondary education to assess differences in the relationship between BMI and HRQL according to educational level. Results Among women with primary or lower education, obesity was associated with a higher prevalence of suboptimal values in the following dimensions: Physical functioning (OR: 1.97; 95%CI: 1.22–3.18); Role-physical (OR: 1.81; 95%CI: 1.04–3.14); General health (OR: 1.76; 95%CI: 1.10–2.81); and Role-emotional (OR: 2.52; 95%CI: 1.27–5.03). In women with higher education, physical functioning was the only dimension associated with obesity (OR: 2.02: 95%CI 0.83–4.97). Conclusion The impact of obesity on women's HRQL is greater among those with a lower educational level. This group registered higher prevalence of obesity and poorer self-perceived health.

Background In 2002 the oil-tanker Prestige sank off the Galician coast. This study analyzes the effect of this accident on health-related quality of life (HRQoL) and mental health in the affected population. Methods Using random sampling stratified by age and sex, 2700 residents were selected from 7 coastal and 7 inland Galician towns. Two exposure criteria were considered: a) residential exposure, i.e., coast versus interior; and b) individual exposure-unaffected, slightly affected, or seriously affected-according to degree of personal affectation. SF-36, GHQ-28, HADS and GADS questionnaires were used to assess HRQoL and mental health. Association of exposure with suboptimal scores was summarized using adjusted odds ratios (OR) obtained from logistic regression. Results For residential exposure, the SF-36 showed coastal residents as having a lower likelihood of registering suboptimal HRQoL values in physical functioning (OR:0.69; 95%CI:0.54–0.89) and bodily pain (OR:0.74; 95%CI:0.62–0.91), and a higher frequency of suboptimal scores in mental health (OR:1.28; 95%CI:1.02–1.58). None of the dimensions of the other questionnaires displayed statistically significant differences. For individual exposure, no substantial differences were observed, though the SF-36 physical functioning dimension rose (showed better scores) with level of exposure (91.51 unaffected, 93.86 slightly affected, 95.28 seriously affected, p < 0.001). Conclusion Almost one and a half years after the accident, worse HRQoL and mental health levels were not in evidence among subjects exposed to the oil-spill. Nevertheless, some of the scales suggest the possibility of slight impact on the mental health of residents in the affected areas.

BACKGROUND: Spain has one of the lowest rates of breast cancer in Europe, though estimated incidence has risen substantially in recent decades. Some years ago, the Spanish Cancer Mortality Atlas showed Spain as having a heterogeneous distribution of breast cancer mortality at a provincial level. This paper describes the municipal distribution of breast cancer mortality in Spain and its relationship with socio-economic indicators. METHODS: Breast cancer mortality was modelled using the Besag-York-Molliè autoregressive spatial model, including socio-economic level, rurality and percentage of population over 64 years of age as surrogates of reproductive and lifestyle risk factors. Municipal relative risks (RRs) were independently estimated for women aged under 50 years and for those aged 50 years and over. Maps were plotted depicting smoothed RR estimates and the distribution of the posterior probability of RR>1. RESULTS: In women aged 50 years and over, mortality increased with socio-economic level, and was lower in rural areas and municipalities with higher proportion of old persons. Among women aged under 50 years, rurality was the only statistically significant explanatory variable. For women older than 49 years, the highest relative risks were mainly registered for municipalities located in the Canary Islands, Balearic Islands, the Mediterranean coast of Catalonia and Valencia, plus others around the Ebro River. In premenopausal women, the pattern was similar but tended to be more homogeneous. In mainland Spain, a group of municipalities with high RRs were located in Andalusia, near the left bank of the Guadalquivir River. CONCLUSION: As previously observed in other contexts, mortality rates are positively related with socio-economic status and negatively associated with rurality and the presence of a higher proportion of people over age 64 years. Taken together, these variables represent the influence of lifestyle factors which have determined the increase in breast cancer frequency over recent decades. The results for the younger group of women suggest an attenuation of the socio-economic gradient in breast cancer mortality in Spain. The geographical variation essentially suggests the influence of other environmental variables, yet the descriptive nature of this study does not allow for the main determinants to be established. This study was funded by Grant No. EPY-1176/02 from the Carlos III Institute of Health (Instituto de Salud Carlos III – ISCIII) and the Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP). Sí

The Patient Dignity Inventory (PDI) is an instrument to measure sources of distress related to dignity at the end of life.To obtain a Spanish version of the PDI and measure psychometric aspects in patients with advanced cancer.A back-translation method was used to obtain the Spanish version. Inpatients and outpatients with advanced cancer were included. Patients completed the Spanish versions of the PDI (PDI-s), Edmonton Symptom Assessment System (ESAS), Hospital Anxiety and Depression Scale (HADS), and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) instruments. The psychometric properties evaluated were internal consistency; concurrent validity between PDI-s/ESAS, PDI-s/HADS, and PDI-s/FACIT-Sp-12; discriminant validity, test-retest reliability, and factor analysis. The usefulness of the instrument also was tested.A Spanish version of the PDI was obtained. One hundred twenty-four patients completed the study. Cronbach's alpha coefficient for the PDI-s was 0.89. The PDI-s significantly correlated with the ESAS (rs = 0.669; P0.001), HADS (rs = 0.788; P0.001), and FACIT-Sp-12 (rs = -0.442; P = 0.008). The instrument distinguished outpatients from inpatients and between patients with differing Karnofsky Performance Status scores (rs = -0.328; P0.001). The test-retest method indicated excellent reproducibility (intraclass correlation coefficient = 0.931). Factor analysis showed three factors accounting for 79.4% of the variance. Factors were labeled psychological and existential distress, physical symptoms and dependency, and social support. Patients had no difficulties in understanding or completing the questionnaire (mean time to complete: 7.2 minutes).The Spanish version of the PDI showed adequate psychometric properties when tested with advanced cancer patients. This research provides a three-factor alternative in Spanish to the PDI.

Background Three different burnout types have been described: The "frenetic" type describes involved and ambitious subjects who sacrifice their health and personal lives for their jobs; the "underchallenged" type describes indifferent and bored workers who fail to find personal development in their jobs and the "worn-out" in type describes neglectful subjects who feel they have little control over results and whose efforts go unacknowledged. The study aimed to describe the possible associations between burnout types and general sociodemographic and occupational characteristics. Methods A cross-sectional study was carried out on a multi-occupational sample of randomly selected university employees (n = 409). The presence of burnout types was assessed by means of the "Burnout Clinical Subtype Questionnaire (BCSQ-36)", and the degree of association between variables was assessed using an adjusted odds ratio (OR) obtained from multivariate logistic regression models. Results Individuals working more than 40 hours per week presented with the greatest risk for "frenetic" burnout compared to those working fewer than 35 hours (adjusted OR = 5.69; 95% CI = 2.52-12.82; p < 0.001). Administration and service personnel presented the greatest risk of "underchallenged" burnout compared to teaching and research staff (adjusted OR = 2.85; 95% CI = 1.16-7.01; p = 0.023). Employees with more than sixteen years of service in the organisation presented the greatest risk of "worn-out" burnout compared to those with less than four years of service (adjusted OR = 4.56; 95% CI = 1.47-14.16; p = 0.009). Conclusions This study is the first to our knowledge that suggests the existence of associations between the different burnout subtypes (classified according to the degree of dedication to work) and the different sociodemographic and occupational characteristics that are congruent with the definition of each of the subtypes. These results are consistent with the clinical profile definitions of burnout syndrome. In addition, they assist the recognition of distinct profiles and reinforce the idea of differential characterisation of the syndrome for more effective treatment.

Background: Dignity therapy is psychotherapy to relieve psychological and existential distress in patients at the end of life. Little is known about its effect. Aim: To analyse the outcomes of dignity therapy in patients with advanced life-threatening diseases. Design: Systematic review was conducted. Three authors extracted data of the articles and evaluated quality using Critical Appraisal Skills Programme. Data were synthesized, considering study objectives. Data sources: PubMed, CINAHL, Cochrane Library and PsycINFO. The years searched were 2002 (year of dignity therapy development) to January 2016. ‘Dignity therapy’ was used as search term. Studies with patients with advanced life-threatening diseases were included. Results: Of 121 studies, 28 were included. Quality of studies is high. Results were grouped into effectiveness, satisfaction, suitability and feasibility, and adaptability to different diseases and cultures. Two of five randomized control trials applied dignity therapy to patients with high levels of baseline psychological distress. One showed statistically significant decrease on patients’ anxiety and depression scores over time. The other showed statistical decrease on anxiety scores pre–post dignity therapy, not on depression. Nonrandomized studies suggested statistically significant improvements in existential and psychosocial measurements. Patients, relatives and professionals perceived it improved end-of-life experience. Conclusion: Evidence suggests that dignity therapy is beneficial. One randomized controlled trial with patients with high levels of psychological distress shows DT efficacy in anxiety and depression scores. Other design studies report beneficial outcomes in terms of end-of-life experience. Further research should understand how dignity therapy functions to establish a means for measuring its impact and assessing whether high level of distress patients can benefit most from this therapy.

Background This paper examines the association between use of protective devices, frequency of acute health problems and health-protection information received by participants engaged in the Prestige oil spill clean-up in Asturias and Cantabria, Spain. Methods We studied 133 seamen, 135 bird cleaners, 266 volunteers and 265 paid workers selected by random sampling, stratified by type of worker and number of working days. Information was collected by telephone interview conducted in June 2003. The association of interest was summarized, using odds ratios (OR) obtained from logistic regression. Results Health-protection briefing was associated with use of protective devices and clothing. Uninformed subjects registered a significant excess risk of itchy eyes (OR:2.89; 95%CI:1.21–6.90), nausea/vomiting/dizziness (OR:2.25; 95%CI:1.17–4.32) and throat and respiratory problems (OR:2.30; 95%CI:1.15–4.61). There was a noteworthy significant excess risk of headaches (OR:3.86: 95%CI:1.74–8.54) and respiratory problems (OR:2.43; 95%CI:1.02–5.79) among uninformed paid workers. Seamen, the group most exposed to the fuel-oil, were the worst informed and registered the highest frequency of toxicological problems. Conclusion Proper health-protection briefing was associated with greater use of protective devices and lower frequency of health problems. Among seamen, however, the results indicate poorer dissemination of information and the need of specific guidelines for removing fuel-oil at sea.

Context:\ud \ud The lack of palliative medicine (PM) education has been identified as a barrier to the development of the discipline. A number of international institutions have called for its implementation within undergraduate medical curricula.\ud \ud Objectives:\ud \ud The objectives are to describe the situation of undergraduate PM education in Europe and to propose a scoring system to evaluate its status.\ud \ud Methods:\ud \ud This descriptive study was conducted with data provided by key experts from countries of the World Health Organization European Region (n = 53). A numerical scoring system was developed through consensus techniques.\ud \ud Results:\ud \ud Forty-three countries (81%) provided the requested information. In 13 countries (30%), a PM course is taught in all medical schools, being compulsory in six of them (14%). In 15 countries (35%), PM is taught in at least one university. In 14 countries (33%), PM is not taught within medical curricula. A full professor of PM was identified in 40% of countries. Three indicators were developed to construct a scale (rank 0–100) of educational development: 1) proportion of medical schools that teach PM (weight = 32%); 2) proportion of medical schools that offer PM as a compulsory subject (weight = 40%); 3) total number of PM professors (weight = 28%). The highest level of PM educational development was found in Israel, Norway, the U.K., Belgium, France, Austria, Germany, and Ireland.\ud \ud Conclusion:\ud \ud PM is taught in a substantial number of undergraduate medical programs at European universities, and a qualified teaching structure is emerging; however, there is a wide variation in the level of PM educational development between individual countries.