Search

Non-communicable diseases (NCDs), associated with health-related suffering, can benefit from palliative care in resource-limited settings, where over four-fifths of these deaths occur.To measure the prevalence of depressive symptoms, palliative care-related concerns, physical and other psychological symptoms among adult patients with NCDs in Malawi and Namibia.This multi-center, cross-sectional study consecutively recruited outpatients from four tertiary referral hospitals. Stepwise regression analysis was used to assess factors associated with physical and psychological symptom burden.Among 457 participants, primary diagnosis was cancer (n=147, 32%); cardiovascular disease (CVD) (n=130, 28%), chronic respiratory disease (CRESD) (n=73, 16%) or diabetes (n=107, 23%). Over half were female (58.9%; n=269), mean age was 48 (SD=15.7). Clinically significant psychological distress was identified among cancer (57.2%), diabetes (57.0%), CRESD (45.2%) and CVD patients (43.1%), with criterion for major depression symptoms met for cancer (42.9%), diabetes (39.2%), CVD (30.0%) and CRESD (28.8%). Most severe palliative care concerns were: first sharing feelings (i.e., not at all/not very often), reported by CVD (28%), CRESD (23%), cancer (22%) and diabetes (21%) patients; second help and advice (i.e., none/very little), among cancer (28%), CVD (26%), diabetes (22%), and CRESD (16%) patients. High prevalence of moderate-to-severe pain was reported (cancer 54%, CVD 41%, CRESD 38%, diabetes 38%). Functional status, age, and presence of comorbidities were associated with physical and psychological symptom distress.Given the high burden of physical and psychosocial symptoms and symptom distress, the findings highlight the need for integrated person-centered palliative care for NCDs to optimize care outcomes.

Background The responsible use of existing antimicrobials is essential in reducing the threat posed by antimicrobial resistance (AMR). With the introduction of restrictions during the COVID-19 pandemic, a substantial reduction in face-to-face appointments in general practice was observed. To understand if this shift in healthcare provision has impacted on prescribing practices, we investigated antibiotic prescribing for upper respiratory tract infections (URTI) consultations Methods We conducted an interrupted time-series analysis using patient-level primary care data to assess the impact of the COVID-19 pandemic on consultations and antibiotic prescribing for URTI in England. Results We estimated an increase of 105.7 antibiotic items per 1000 URTI consultations (95% CI: 65.6–145.8; P Conclusions Overuse of antibiotics is known to be a driver of resistance and it is essential that efforts to reduce inappropriate prescribing continue subsequent to the COVID-19 pandemic. Further work should examine drivers of increased antibiotic prescribing for URTI to inform the development of targeted antibiotic stewardship interventions.

BACKGROUND Self-directed supports (SDS) are a model of disability service delivery that focuses on supporting increased decision-making authority and budget autonomy for people with disabilities and their families. This study identifies supervisory and administrative staff's perspectives within a self-directed, individualised budgeting programme for people with intellectual and developmental disabilities. METHOD Data were collected through 28 face-to-face interviews with supervisory and fiscal administrative staff in Minnesota, USA. RESULTS A qualitative analysis of these interviews resulted in four major themes: (1) the benefits of SDS, (2) the relationship between SDS and person-centred strategies, (3) the perception that a natural tension arises when balancing person-centred approaches with the need for consistent and fair state policy-including rules and regulations within state systems and (4) the unique challenges related to SDS benefits and challenges occurring across Minnesota. CONCLUSIONS The results indicate the importance of providing effective communication and training to all stakeholders.

A system dynamics model of energy transition, TEMPEST, represents political and societal factors along with energy, emissions and mitigation measures, within a system of feedbacks. TEMPEST simulates energy transition from 1980 to 2080, calibrated to UK historical data. An exogenous uncertainty analysis showed most cases would achieve net zero before 2080, but only 20% would stay within the required carbon budget. Low probability, high impact cases have twice the future cumulative emissions than the best cases. High political capital for energy transition early on would likely reduce total mitigation required, but risks public pushback. Endogenous uncertainty about pushback and new measure difficulty could increase total emissions by a quarter. Dealing with unwanted feedbacks between society and government that reduce political capital will require responsive policy making. The socio-political feasibility of achieving the UK's net zero target is likely less than the techno-economic feasibility estimated through standard energy systems models.

Throughout the COVID-19 pandemic, policy makers have tried to balance the effectiveness of lockdowns (i.e., stay-at-home orders) with their potential mental health costs. Yet, several years into the pandemic, policy makers lack solid evidence about the toll of lockdowns on daily emotional functioning. Using data from two intensive longitudinal studies conducted in Australia in 2021, we compared the intensity, persistence, and regulation of emotions on days in and out of lockdown. Participants (N = 441, observations = 14,511) completed a 7-day study either entirely in lockdown, entirely out of lockdown, or both in and out of lockdown. We assessed emotions in general (Dataset 1) and in the context of social interactions (Dataset 2). Lockdowns took an emotional toll, but this toll was relatively mild: In lockdown, people experienced slightly more negative and less positive emotion; returned to a mildly negative emotional state more quickly; and used low-effort emotion regulation strategies (i.e., distraction). There are three interpretations for our findings, which are not mutually exclusive. First, people may be relatively resilient to the emotional challenges posed by repeated lockdowns. Second, lockdowns may not compound the emotional challenges of the pandemic. Third, because we found effects even in a mostly childless and well-educated sample, lockdowns may take a greater emotional toll in samples with less pandemic privilege. Indeed, the high level of pandemic privilege of our sample limits the generalizability of our findings (e.g., to people with caregiving roles).

Social work and social policy are intertwined in the Republic of Namibia and heavily influenced by its complex colonial sociopolitical history, struggle for human rights, and progress toward social development. These factors inform how the social and human needs of Namibians are being met. A human rights lens was adopted in 1990 by a democratic government that guided the delivery of social services to a diverse ethnic population. Namibia has successfully integrated social work into its society, supported by (a) a social justice mandate, (b) a capacity-building framework, and (c) Vision 2030. Social and human service needs are provided naturally by indigenous families and communities, and formal services are provided by governmental and nongovernmental agencies. This article consists of an overview of the socio-historical and political contexts of social work and social policies in this emerging democracy, along with special attention to four challenging and interrelated areas of social work practice including poverty, language and national identity, intergenerational caregiving and the Coronavirus pandemic.

Test and Rapid Response Treatment (TRRT) linkage programs have demonstrated improved HIV suppression rates. This paper describes the design and implementation of the Miami TRRT initiative and its clinical impact. Assisted by a dedicated care navigator, patients receiving a reactive HIV rapid test at the Florida Department of Health STD Clinic were offered same-day HIV care at the University of Miami/Jackson Memorial Medical Center Adult HIV Outpatient Clinic. Patient retention and labs were tracked for 12 months. Of the 2337 individuals tested, 46 had a reactive HIV test; 41 (89%) consented to participate. For the 36 patients in continued care for a year, 33 (91.7%) achieved virological suppression (< 200 copies/mL) within 70 days of their reactive HIV rapid test; at 12 months, 35 (97.2%) remained suppressed, and mean CD4 T cell counts increased from 452 ± 266 to 597 ± 322 cells/mm(3). The Miami TRRT initiative demonstrated that immediate linkage to care is feasible and improves retention and suppression in a public/academic medical center in the U.S. South.

Gender-based violence (GBV) has been associated with many negative mental health outcomes, including depression. This study sought to explore the relationship between protective factors (so...

This session will discuss risks and opportunities for firms, organisations, communities and other actors in the transition to net-zero.

In this chapter, the authors describe the essential need of mental health and psychosocial support for people accommodated in mandatory quarantine and isolation facilities during the outbreak of COVID-19 pandemic in Namibia through a multi-sectoral response. Namibia recorded its first two index cases on 13 March 2020 when a married couple arrived in the Windhoek district in Namibia from Madrid, Spain on 11 March 2020. Namibia has since March 2020 provided supervised quarantine services to 12,128 persons in facilities around the country. The Ministry of Health and Social Services provides mental health and psychosocial support services, which were critical in the short and long-term response to COVID-19 pandemic. Public health measures were developed in line with WHO guidelines to contain the virus. These measures include the need of setting up quarantine and isolation facilities. Recommendations for future research in strengthening mental health and psychosocial support services and coping strategies are provided in the chapter.

Orientation: Day labouring is becoming more frequent in developing countries. Long spells of unemployment and the uncertainty of informal wage employment impact negatively on the subjective well-being (SWB) of day labourers. Research purpose: The aim of the article was to investigate the level and possible determinants of the SWB of day labourers in Pretoria and Windhoek. Motivation for the study: Up to now, only one study has been carried out in South Africa on the SWB of day labourers and none in Namibia. This study aimed to start filling this gap in the literature. The choice of the two cities was based on their status as the capital cities of two countries that are both experiencing increasing numbers of day labourers. Research design, approach and method: A mixed-method research design and purposeful sampling were used to obtain representative samples. Data were sourced from comparable surveys amongst day labourers in the two cities between 2015 and 2017. Questionnaires with quantitative and qualitative sections were completed during structured interviews with 290 and 80 day labourers in Pretoria and Windhoek respectively. The ordinary least squares model and ordered-probit analysis were employed to analyse the data. Main findings: In Pretoria, the number of dependents, the living conditions and whether they had a full-time job before were all significant in explaining the SWB of the day labourers. In Windhoek, education levels, total days without food, staying with their families and being a foreigner were also significant. Practical/managerial implications: The needs of the informally employed must be addressed in the integrated development plans of municipalities and integrated with day labour worker centres. Contribution/value-add: This is the first study to analyse SWB amongst day labourers in Namibia and lays the foundation for future expanded studies.

The current study investigated the support that a facility dog can provide to survivors of sexual crimes when undergoing video-recorded police interviews. In total, 13 survivors of sexual offences, who were undergoing a video-recorded interview, were provided with a facility dog for the interview process. For each case, data were collected via interviews, observations and surveys. Using a multiple case study approach, qualitative data were analysed to identify patterns, with observational and survey data used to provide further support to these outcomes. A total of four main themes emerged from the data: (1) a change in focus for the survivor, (2) a difference in the survivors’ engagement, (3) the dog as a comforter to keep the survivor calm and (4) a positive environment. Overall, the findings suggest that the facility dog provided a much needed and beneficial service to survivors, helping them feel calmer and more comfortable. The dog also provided survivors with a more positive environment, allowing them to focus on the interview and communicate more openly about their experiences. The current study, therefore, presents very positive findings relating to improving survivors’ perspectives of justice within the framework of kaleidoscopic justice, bridging their perceived justice gap.

Namibia has one of the highest human immunodeficiency virus (HIV) prevalence rates and one of the highest rates of orphanhood in the world, and older caregivers provide much of the care to Namibians living with HIV and acquired immune deficiency syndrome (AIDS) (UNAIDS, 2014). In this study, the authors explore how financial status, social support, and health were related to the resilience of caregivers caring for people affected by HIV and AIDS in rural northern Namibia, Africa.Data were collected through a structured interview from (N = 147) caregivers from the Zambezi region.Findings from this study show that employment and physical health were significantly associated with increased resilience in older caregivers.Our findings point to the need for employment assistance and health services to improve the resilience of caregivers caring for people living with HIV and AIDS. We conclude that there is a need for more vigorous concerted efforts from public and private sector practitioners and policy makers to create more sustained formal employment opportunities and intervention programs aimed at improving the overall health of older HIV caregivers, especially those residing in rural HIV endemic communities in developing countries.

Despite evidence suggesting that parent involvement was beneficial for infant and parent outcomes, the Family Integrated Care (FICare) programme was one of the first pragmatic approaches to enable parents to become primary caregivers in the neonatal intensive care unit (NICU). We aimed to analyse the effect of FICare on infant and parent outcomes, safety, and resource use.In this multicentre, cluster-randomised controlled trial, we stratified 26 tertiary NICUs from Canada, Australia, and New Zealand by country and size, and assigned them, using a computer-generated random allocation sequence, to provide FICare or standard NICU care. Eligible infants were born at 33 weeks' gestation or earlier, and had no or low-level respiratory support; parents gave written informed consent for enrolment. To be eligible, parents in the FICare group had to commit to be present for at least 6 h a day, attend educational sessions, and actively care for their infant. The primary outcome, analysed at the individual level, was infant weight gain at day 21 after enrolment. Secondary outcomes were weight gain velocity, high frequency breastfeeding (≥6 times a day) at hospital discharge, parental stress and anxiety at enrolment and day 21, NICU mortality and major neonatal morbidities, safety, and resource use (including duration of oxygen therapy and hospital stay). This trial is registered with ClinicalTrials.gov, number NCT01852695.From Oct 1, 2012, 26 sites were randomly assigned to provide FICare (n=14) or standard care (n=12). One site assigned to FICare discontinued because of poor site enrolment. Parents and infants were enrolled between April 1, 2013, and Aug 31, 2015, with 895 infants being eligible in the FICare group and 891 in the standard care group. At day 21, weight gain was greater in the FICare group than in the standard care group (mean change in Z scores -0·071 [SD 0·42] vs -0·155 [0·42]; p0·0002). Average daily weight gain was significantly higher in infants receiving FICare than those receiving standard care (mean daily weight gain 26·7 g [SD 9·4] vs 24·8 g [9·5]; p0·0001). The high-frequency exclusive breastmilk feeding rate at discharge was higher for infants in the FICare group (279 [70%] of 396) than those in the standard care group (394 [63%] of 624; p=0·016). At day 21, parents in the FICare group had lower mean stress scores than did parents in the standard care group (2·3 [SD 0·8] vs 2·5 [0·8]; p0·00043), and lower mean anxiety scores (70·8 [20·1] vs 74·2 [19·9]; p=0·0045). There were no significant differences between groups in the rates of the secondary outcomes of mortality, major morbidity, duration of oxygen therapy, and duration of hospital stay. Although the safety assessment was not completed, there were no adverse events.FICare improved infant weight gain, decreased parent stress and anxiety, and increased high-frequency exclusive breastmilk feeding at discharge, which together suggest that FICare is an important advancement in neonatal care. Further research is required to examine if these results translate into better long-term outcomes for families.Canadian Institutes of Health Research Partnerships for Health System Improvement, and Ontario Ministry of Health and Long-Term Care.

Childhood sexual abuse (CSA) is highly prevalent and associated with a wide variety of negative mental and physical health outcomes. School-based CSA education and prevention programs have shown promise, but it is unclear to what extent community-level characteristics are related to their effectiveness. The present cluster randomized controlled trial evaluated community-level moderators of the Safe@Last program compared to a waitlist control condition. Knowledge gains from pre- to post-intervention were assessed in 5 domains: safe versus unsafe people; safe choices; problem-solving; clear disclosure; and assertiveness. Participants were 1,177 students (46% White, 26% African American, 15% Hispanic, 4% Asian American, 6% Other) in grades 1 through 6 from 14 public schools in Tennessee. Multilevel models accounting for the nesting of children within schools revealed large effect sizes for the intervention versus control across all knowledge domains (d’s ranged from 1.56 to 2.13). The effectiveness of the program was moderated by mean per capita income and rates of substantiated cases of child abuse and neglect in the community. Intervention effects were stronger for youth living in lower as compared to higher income counties, and for youth attending schools in counties with lower as compared to higher abuse/neglect rates. Child characteristics (sex, race) did not moderate intervention effects. This research identified two community-level factors that predicted the effectiveness of a CSA education and prevention program designed to improve children’s knowledge of personal safety skills. School-based CSA prevention programs may require modification for communities with higher rates of child abuse and neglect.

Summary Background In response to increasing numbers of carbapenemase-producing Enterobacterales (CPE) in England, Public Health England (PHE) launched an electronic reporting system (ERS) for the enhanced surveillance of carbapenemase-producing Gram-negative bacteria. Our study aimed to describe system engagement and the epidemiology of CPE in England. Methods Engagement with the ERS was assessed by calculating the proportion of referrals submitted this system. ERS data were extracted and cases defined as patients with CPE isolated from a screening or clinical specimen in England between 1st May 2015 to 31st March 2019. Descriptive summary statistics for each variable were prepared. Results The ERS processed 12,656 suspected CPE reports. Uptake of the ERS by local microbiology laboratories varied, with approximately 70% of referrals made via the ERS by April 2016; this steadily decreased after March 2018. Six-thousand eight-hundred and fifty-seven cases were included in the analysis. Most cases were from colonised patients (80.6%) rather than infected, and the majority were inpatients in acute hospital settings (87.3%). Carbapenemases were most frequently detected in Klebsiella pneumoniae (39.1%) and Escherichia coli (30.3%). The most frequently identified carbapenemase families were OXA-48-like (45.1%) and KPC (26.4%). Enhanced data variables were poorly completed. Conclusions The ERS has provided some insight into the epidemiology of CPE in England. An increasing number of routine diagnostic laboratories have introduced methods to routinely identify acquired carbapenemases and PHE has modified its approach to ensure robust surveillance, which is an essential aspect of an effective response to prevent and control the spread of CPE.

Summary There is large heterogeneity in approaches to tackling nosocomial outbreaks caused by carbapenemase-producing Enterobacterales (CPE), however there is limited guidance on how to approach their management. Rapid and robust infection prevention and control interventions can be effective in preventing and reducing the impact of outbreaks in healthcare environments. We present a stepwise approach to aspects of CPE outbreak management, including the development of an action plan, engagement and communication with key stakeholders, developing a dynamic risk assessment, and staff education. These can provide a blueprint for organisations to create templates and checklists to inform their own outbreak response.

Prediabetes has a high prevalence, with early detection essential to facilitate optimal management to prevent the development of conditions such as type 2 diabetes and cardiovascular disease. Prediabetes can include impaired fasting glucose, impaired glucose tolerance and elevated HbA1c. This position statement outlines the approaches to screening and management of prediabetes in primary care. There is good evidence to implement intensive, structured lifestyle interventions for individuals with impaired glucose tolerance. The evidence for those with impaired fasting glucose or elevated HbA1c is less clear, but individuals should still be provided with generalised healthy lifestyle strategies. A multidisciplinary approach is recommended to implement healthy lifestyle changes through education, nutrition and physical activity. Individuals should aim to lose weight (5-10% of body mass) using realistic and sustainable dietary approaches supported by an accredited practising dietitian, where possible. Physical activity and exercise should be used to facilitate weight maintenance and reduce blood glucose. Moderate-vigorous intensity aerobic exercise and resistance training should be prescribed by an accredited exercise physiologist, where possible. When indicated, pharmacotherapy, metabolic surgery and psychosocial care should be considered, in order to enhance the outcomes associated with lifestyle change. Individuals with prediabetes should generally be evaluated annually for their diabetes status.

Positive Behavior Support (PBS) was introduced to community-based providers in Kansas in 2012 in response to a federally funded initiative to reduce the placement of youth in psychiatric facilities. As core project activities concluded in 2016, researchers investigated the impact of this comprehensive PBS initiative on youth, families, mental health centers, and other stakeholders. This paper describes how qualitative interviews and focus groups were used to investigate the perceptions of families, advocates, and implementers involved in wraparound (WA), regional interagency collaboration, and the addition of PBS services. Themes reflected the changes occurring over time in statewide WA implementation and how state funding for the PBS effort was used as part of regional interagency collaboration to continue supporting principles outlined in systems of care.

Summary Background An electronic reporting system (ERS) for the enhanced surveillance of carbapenemase-producing Gram-negative bacteria (CPGNB) was launched by Public Health England in May 2015. Aim This evaluation aimed to assess uptake, timeliness and completeness of data provided and explore potential barriers and facilitators to adopting the system. Methods The evaluation comprised a retrospective analysis of surveillance data and semi-structured interviews with ERS users. Findings The proportion of organisms referred for investigation of carbapenem resistance via ERS increased over the first 12 months post-implementation from 35% to 73%; uptake varied widely across regions of England. Completeness of enhanced data fields was poor in 78% of submitted isolates. The median number of days to report confirmatory test results via ERS was 1 day for the regional service and nine days for the national reference laboratory, which additionally conducts phenotypic testing to confirm carbapenemase negativity. Hindrances to ERS utility included: a lack of designated, ongoing resource for system maintenance, technical support and development; uncertainty about how and when to use ERS and workload. Incomplete data prevented gaining a better understanding of important risk factors and transmission routes of CPGNB in England. Conclusion The ERS is the only surveillance system in England with the potential to gather intelligence on important risk factors for CPGNB to inform public health measures to control their spread. Although the ERS captures more information on CPGNB than other surveillance systems, timeliness and completeness of the enhanced data require substantial improvements in order to deliver the desired health benefits.

Objectives: To evaluate the association between use of different antibiotics and trimethoprim resistance at the population level.Methods: Monthly primary care prescribing data were obtained from NHS Digital. Positive Enterobacteriaceae records from urine samples from patients between April 2014 and January 2016 in England were extracted from PHE's Second Generation Surveillance System (SGSS). Elastic net regularization and generalized boosted regression models were used to evaluate associations between antibiotic prescribing and trimethoprim resistance, both measured at Clinical Commission Group level.Results: In total, 2 487 635 (99%) of 2 513 285 urine Enterobacteriaceae samples from 1 667 839 patients were tested for trimethoprim resistance. Using both elastic net regularization and generalized boosted regression models, geographical variation in trimethoprim resistance among Enterobacteriaceae urinary samples could be partly explained by geographical variation in use of trimethoprim (relative risk = 1.14, 95% CI = 1.02-1.75; relative influence = 4.1) and penicillins with extended spectrum (mainly amoxicillin/ampicillin in England) (relative risk = 1.19, 95% CI = 1.11-1.30; relative influence = 7.4). Nitrofurantoin use was associated with lower trimethoprim resistance levels (relative risk = 0.83, 95% CI = 0.57-0.96; relative influence = 9.2).Conclusions: Use of amoxicillin/ampicillin explained more of the variance in trimethoprim resistance than trimethoprim use, suggesting that co-selection by these antibiotics is an important driver of trimethoprim resistance levels at the population level. Nitrofurantoin use was consistently associated with lower trimethoprim resistance levels, indicating that trimethoprim resistance levels could be lowered if trimethoprim use is replaced by nitrofurantoin.

SUMMARYTimely recruitment of population controls in infectious disease outbreak investigations is challenging. We evaluated the timeliness and cost of using a market research panel as a sampling frame for recruiting controls in a case-control study during an outbreak ofSalmonellaMikawasima in the UK in 2013. We deployed a web-survey by email to targeted members of a market research panel (panel controls) in parallel to the outbreak control team interviewing randomly selected public health staff by telephone and completing paper-based questionnaires (staff controls). Recruitment and completion of exposure history web-surveys for panel controls (n= 123) took 14 h compared to 15 days for staff controls (n= 82). The average staff-time cost per questionnaire for staff controls was £13·13 compared to an invoiced cost of £3·60 per panel control. Differences in the distribution of some exposures existed between these control groups but case-control studies using each group found that illness was associated with consumption of chicken outside of the home and chicken from local butchers. Recruiting market research panel controls offers time and resource savings. More rapid investigations would enable more prompt implementation of control measures. We recommend that this method of recruiting controls is considered in future investigations and assessed further to better understand strengths and limitations.

This article examines the dynamic relationship between the consumption of goods and services, technological efficiency, and associated resource use, as described by the theory of Jevons’ Paradox (JP). A theory is presented about what causes JP, in which resource efficiency savings are eventually overtaken by increases in consumption to produce a net increase in resource use and therefore environmental impacts. An application of the theory was carried out using system dynamics, modeling carbon dioxide equivalent (CO2-eq) emissions from private road transport in the UK between 1970 and 2010. The model results indicate the approximate impact of JP within the historical period: a rise in travel consumption of approximately one half and a rise in CO2-eq emissions of approximately one third. The model was used to estimate whether the European Union (EU) goal of a 40% drop in CO2-eq emissions by 2030 is achievable in the road transport sector, by adding interventions, and the results indicate that higher increases in fleet efficiency than are currently forecast, costlier travel, and a reduction in travel consumption would all be required. The theory and model presented in this article highlight the need to implement a system of interventions that can influence the strength and direction of each of the feedback loops within the system being intervened with, if CO2-eq emissions are to be more reliably reduced than they are at present. Further, because the system is constantly evolving, intervening with it requires a responsive, holistic approach, while maintaining focus on a long-term goal.

Cities around the world have set climate change mitigation targets, yet actions to implement these targets have so far proved inadequate. Better methodology is needed to support this impetus for action. Problem structuring methods (PSMs) enable improvements to be made in wicked problem situations; they appear to have potential to improve climate change mitigation actions but they are difficult to carry out in highly pluralist problem contexts. A case study (STEEP) that applied a PSM to support low-carbon urban energy master planning in three cities is presented. The STEEP methodology was effective in reducing the wickedness of the problem but issues of a lack of clarity on problem ownership and lack of interessement were seen. A reflective boundary critique study found that there was a mismatch between power and interest amongst key stakeholders towards the low-carbon vision. Three key issues identified in the case study were discussed through the lens of critical systems thinking: (i) the need for new competencies, (ii) dealing with wickedness, and (iii) behavioural complexity and discordant reference systems. The paper suggests how these issues might be improved through the application of non-PSM theories which can support the use of PSMs in improving city-level climate change mitigation.

Objectives: We examined the four-year trend in antimicrobial susceptibilities and prescribing across levels-of-care at two London teaching hospitals and their multisite renal unit, and for the surrounding community. Methods: Laboratory and pharmacy information management systems were interrogated, with antimicrobial use and susceptibilities analysed between hospitals, within hospitals, and over time. Results: 108,717 isolates from 71,687 patients were identified, with significant differences (at p