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Summary: In the last three decades, global production of oil palm has boomed, which has partly come at the expense of tropical rainforests. Recognizing this, many companies operating in the palm oil industry have committed to eliminate deforestation from their operations, often referred to as zero-deforestation commitments (ZDCs). Here, we estimate that if ZDCs are fully adopted and enforced across all sectors and geographies, the global extent of oil palm plantations may be 11 M ha or 40% smaller in 2030 than in a business-as-usual (BAU) scenario that assumes no compliance with ZDCs. As a result of such land-sparing effects, we estimate that 96 M ha of forests are saved from conversion, of which, 17% would otherwise have been converted (directly or indirectly) due to expanding oil palm plantations. Overall, these figures suggest that ZDCs have the potential to deliver major environmental benefits if they are fully adopted and enforced.

Many companies are making ambitious pledges to achieve positive impacts for climate and nature by financing restoration of carbon- and biodiversity- rich natural habitats. However, companies cannot make evidence-based choices that will deliver successful restoration if the scientific information required to guide investment has not been synthesised in a way that they can use, or there are knowledge gaps. To explore this issue, share information, and identify knowledge gaps and research priorities, we bring together researchers, a conservation NGO and a multinational consumer goods company (Unilever), focusing on Southeast Asian rainforests. These habitats offer significant restoration opportunities for carbon and biodiversity in areas that have been degraded by commercial logging and agriculture. We find that procedures for carbon restoration are much better developed than those for biodiversity, and that new research is urgently needed to deliver evidence-based biodiversity restoration. Companies need to be confident that their actions are fit-for-purpose to meet their environmental pledges. Achieving successful restoration outcomes will require co-designed projects with the potential to deliver positive co-benefits for carbon, biodiversity and local livelihoods.

Previous studies have confirmed the agricultural stage as an important contributor to total tea life cycle greenhouse gas (GHG) emissions. We therefore focus on the growing and processing of black tea and evaluate the GHG reduction potential of possible agricultural management interventions for tea produced from Unilever’s tea estates and factories in Kenya. A baseline GHG footprint was calculated using data collected over four years. Potential interventions to reduce the GHG footprint per kg of black tea focused on key drivers (yield and fertiliser use) of the GHG footprint. These interventions and their effects on production are evidence-based but hypothetical and relate to possible changes in: (1) Harvesting practices; (2) Fertiliser application (timing) and (3) Organic production. Improvements in fertiliser application and harvesting practices could potentially deliver 16% and 9% reduction in GHG emissions, respectively. Under favourable conditions (sourcing fertiliser locally and no yield decline), changing to organic production could theoretically deliver 25% reduction in GHG emissions. However, under less favourable conditions (European sourced fertiliser and 30% yield decline), GHG emissions could increase by 41%. The availability of locally sourced organic fertiliser, sufficient to maintain nitrogen application rates, is seen as the biggest challenge in delivering sustainable organic tea cultivation.

Life cycle assessments are used by corporations to determine the sustainability of raw source materials. Here, Chaplin-Krameret al. develop an improved life cycle assessment approach incorporating spatial variation in land-use change, and apply this framework to a bioplastic case study.

The production of palm oil, soy, beef and timber are key drivers of global forest loss. For this reason, over 470 companies involved in the production, processing or distribution of these commodities have issued commitments to eliminate or reduce deforestation from their supply chains. However, the effectiveness of these commitments is uncertain since there is considerable variation in ambition and scope and there are no globally agreed definitions of what constitutes a forest. Many commitments identify high conservation value forests (HCVFs), high carbon stock forests (HCSFs) and forests on tropical peatland as priority areas for conservation. This allows for mapping of the global extent of forest areas classified as such, to achieve an assessment of the area that may be at reduced risk of development if companies comply with their zero deforestation commitments. Depending on the criteria used, the results indicate that between 34% and 74% of global forests qualify as either HCVF, HCSF or forests on tropical peatland. However, we found that the total extent of these forest areas varies widely depending on the choice of forest map. Within forests which were not designated as HCVF, HCSF or forests on tropical peatland, there is substantial overlap with areas that are highly suitable for agricultural development. Since these areas are unlikely to be protected by zero-deforestation commitments, they may be subject to increased pressure resulting from leakage of areas designated as HCVF, HCSF and tropical peatland forests. Considerable uncertainties around future outcomes remain, since only a proportion of the global market is currently covered by corporate commitments. Further work is needed to map the synergies between corporate commitments and government policies on land use. In addition, standardized criteria for delineating forests covered by the commitments are recommended.

In many regions and at the planetary scale, human pressures on the environment exceed levels that natural systems can sustain. These pressures are caused by networks of human activities, which often extend across countries and continents due to global trade. This has led to an increasing requirement for methods that enable absolute environmental sustainability assessment (AESA) of anthropogenic systems and which have a basis in life cycle assessment (LCA). Such methods enable the comparison of environmental impacts of products, companies, nations, etc, with an assigned share of environmental carrying capacity for various impact categories. This study is the first systematic review of LCA-based AESA methods and their applications. After developing a framework for LCA-based AESA methods, we identified 45 relevant studies through an initial survey, database searches and citation analysis. We characterized these studies according to their intended application, impact categories, basis of carrying capacity estimates, spatial differentiation of environmental model and principles for assigning carrying capacity. We then characterized all method applications and synthesized their results. Based on this assessment, we present recommendations to practitioners on the selection and use of existing LCA-based AESA methods, as well as ways to perform assessments and communicate results to decision-makers. Furthermore, we identify future research priorities intended to extend coverage of all components of the proposed method framework, improve modeling and increase the applicability of methods.

Corporations and other multinational institutions are increasingly looking to evaluate their innovation and procurement decisions over a range of environmental criteria, including impacts on ecosystem services according to the spatial configuration of activities on the landscape. We have developed a spatially explicit approach and modeled a hypothetical corporate supply chain decision representing contrasting patterns of land-use change in four regions of the globe. This illustrates the effect of introducing spatial considerations in the analysis of ecosystem services, specifically sediment retention. We explored a wide variety of contexts (Iowa, USA; Mato Grosso, Brazil; and Jiangxi and Heilongjiang in China) and these show that per-area representation of impacts based on the physical characterization of a region can be misleading. We found two- to five-fold differences in sediment export for the same amount of habitat conversion within regions characterized by similar physical traits. These differences were mainly determined by the distance between land use changes and streams. The influence of landscape configuration is so dramatic that it can override wide variation in erosion potential driven by physical factors like soil type, slope, and climate. To minimize damage to spatially-dependent ecosystem services like water purification, sustainable sourcing strategies should not assume a direct correlation between impact and area but rather allow for possible nonlinearity in impacts, especially in regions with little remaining habitat and highly variable hydrological connectivity.

Abstract Background Coronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential to inform routine cardiac care and to improve quality of care and patient outcomes. This study describes a user-centered development and evaluation of the Alberta Provincial Project for Outcomes Assessment (APPROACH) electronic Patient Reported Outcomes Measurement (e-PROM) system. This e-PROM system is an electronic system for the administration of PROMs to patients with CAD and the delivery of the summarized information to their care providers to facilitate patient-physician communication and shared decision-making. This electronic platform was designed to be accessible via web-based and hand-held devices. Heuristic and user acceptance evaluation were conducted with patients and attending care providers. Results The APPROACH e-PROM system was co-developed with patients and care providers, research investigators, informaticians and information technology experts. Five PROMs were selected for inclusion in the online platform after consultations with patient partners, care providers, and PROMs experts: the Seattle Angina Questionnaire, Patient Health Questionnaire, EuroQOL, and Medical Outcomes Study Social Support Survey, and Self-Care of Coronary Heart Disease Inventory. The heuristic evaluation was completed by four design experts who examined the usability of the prototype interfaces. User acceptance testing was completed with 13 patients and 10 cardiologists who evaluated prototype user interfaces of the e-PROM system. Conclusion Both patients and physicians found the APPROACH e-PROM system to be easy to use, understandable, and acceptable. The APPROACH e-PROM system provides a user-informed electronic platform designed to incorporate PROMs into the delivery of individualized cardiac care for persons with CAD.

Background Older people living in care homes are at high risk of poor health outcomes and mortality if they contract coronavirus disease 2019. Protective measures include social distancing and isolation, although implementation is challenging. Objectives To explore the real-life experiences of social distancing and isolation in care homes for older people, and to develop a toolkit of guidance and resources. Design A mixed-methods, phased design. Setting Six care homes in England caring for older adults. Participants Care home staff (n = 31), residents (n = 17), family members (n = 17), senior health and care leaders (n = 13). Methods A rapid review to assess the social distancing and isolation measures used by care homes to control the transmission of coronavirus disease 2019 and other infectious diseases (phase 1), in-depth case studies of six care homes, involving remote individual interviews with staff, residents and families, collection of policies, protocols and routinely collected care home data, remote focus groups with senior health and care leaders (phase 2) and stakeholder workshops to co-design the toolkit (phase 3). Interview and focus group data and care home documents were analysed using thematic analysis and care home data using descriptive statistics. Results The rapid review of 103 records demonstrated limited empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. The case studies found that social distancing and isolation measures presented moral dilemmas for staff and often were difficult, and sometimes impossible to implement. Social distancing and isolation measures made care homes feel like an institution and denied residents, staff and families of physical touch and other forms of non-verbal communication. This was particularly important for residents with cognitive impairment. Care homes developed new visiting modalities to work around social distancing measures. Residents and families valued the work of care homes to keep residents safe and support remote communication. Social distancing, isolation and related restrictions negatively impacted on residents’ physical, psychological, social and cognitive well-being. There were feelings of powerlessness for families whose loved ones had moved into the care home during the pandemic. It was challenging for care homes to capture frequent updates in policy and guidance. Senior health and care leaders shared that the care home sector felt isolated from the National Health Service, communication from government was described as chaotic, and trauma was inflicted on care home staff, residents, families and friends. These multiple data sources have informed the co-design of a toolkit to care for residents, families, friends and care home staff. Limitations The review included papers published in English language only. The six care homes had a Care Quality Commission rating of either ‘good’ or ‘outstanding’. There was a lack of ethnic diversity in resident and family participants. Conclusions Care homes implemented innovative approaches to social distancing and isolation with varying degrees of success. A legacy of learning can help rebuild trust at multiple levels and address trauma-informed care for residents, families, friends and staff. Future work can include evaluation of the toolkit, research to develop a trauma-informed approach to caring for the care home sector and co-designing and evaluating an intervention to enable residents with different needs to transition to living well in a care home. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132541) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 45. See the NIHR Funding and Awards website for further award information. Plain language summary Older people living in care homes are at risk of poor health and death if they get coronavirus disease 2019 (COVID-19). To protect older people from COVID-19, care homes use different measures, including social distancing and isolation. These measures can be challenging. Our research aimed to explore the challenges and solutions to using social distancing and isolation in care homes. We reviewed existing evidence to examine how care homes have used social distancing and isolation measures to control the spread of COVID-19 and other contagious diseases. We investigated how social distancing and isolation measures have been used in six care homes in England. We spoke with residents, families and staff. We collected care home documents and other data. We held group discussions with senior health and care leaders. The review showed limited research and the limited nature of policy documentation on social distancing and isolation measures. Interviews revealed that social distancing and isolation measures were difficult, and sometimes impossible, for staff to implement. These measures made care homes feel less homely and inhibited touch, for example hugs. Residents and families valued the work of care homes to keep residents safe and the use of technology for keeping connected. Social distancing, isolation and related restrictions negatively affected residents’ physical, psychological, social and cognitive well-being. There were feelings of powerlessness for families whose loved ones had moved into the care home during the pandemic. It was challenging for care homes to capture frequent updates in policy and guidance. Senior health and care leaders shared that the care home sector felt isolated from the National Health Service, communication from government to the care home sector was described as chaotic and trauma was inflicted on care home staff, residents, families and friends. These findings have been used to design guidance to help care homes implement social distancing and isolation measures both now and for any future outbreaks. Scientific summary Background Older people living in care homes (CHs) (i.e. homes that provide residential and/or nursing care) often have complex health and care needs and are at high risk of poor health outcomes and mortality, especially if they contract coronavirus disease 2019 (COVID-19). To protect older people from COVID-19, CHs use interventions such as social distancing and isolation, but these measures have been reported as challenging. Research is needed to explore and understand the challenges experienced by CHs endeavouring to implement these interventions while mitigating any negative consequences. Objectives The overall aim of the study was to explore and understand the real-life experiences of social distancing and isolation measures for older people living in CHs in England from the perspective of multiple stakeholders, and to develop a toolkit of evidence-informed guidance and resources for CHs now and for future outbreaks. The study objectives were as follows: (1) to investigate the mechanisms and measures used by CHs currently and previously to socially distance and isolate older people to prevent and control the spread of COVID-19 and other infectious and contagious diseases (2) to examine the experiences of residents and families/friends of social distancing and isolation measures during the COVID-19 pandemic, including how these measures impacted upon their well-being and how they adapted to change (3) to explore how registered nurses and care staff adapted to and managed the delivery of personal, social and psychological care for residents with different needs while maintaining social distancing and isolation measures (4) to identify how CH managers, owners and external stakeholders developed, managed and adapted policies, procedures and protocols to implement social distancing and isolation measures including workforce organisation, training and support, use of communal spaces, visiting, and working with external health and social care professionals (5) to use the findings to develop a toolkit of evidence-informed guidance and resources, including a mosaic film, detailing which interventions and strategies for social distancing and isolation work well and which do not work in specific situations and contexts to support decision-making about health and care delivery in CHs and to facilitate resilience-building for future planning. Methods A mixed-methods, phased design was undertaken to identify the challenges, consequences and solutions to implementing social distancing and isolation measures in CHs for older adults to prevent and control the spread of COVID-19. The study was conducted in three phases: (1) a rapid evidence review of measures used to prevent or control the transmission of COVID-19 and other infectious diseases in CHs for older people, following the guidance for conducting rapid reviews1 (2) in-depth case studies of six purposively sampled CHs in England involving individual interviews with care staff, managers, residents and family/friends, the collection of social distancing and isolation policies/protocols and routinely collected CH data, and focus groups with purposively sampled CH owners and external stakeholders. Reporting guidance for qualitative research was used2 (3) development of a toolkit of evidence-informed guidance and resources, and a mosaic film for CHs. The findings from earlier phases were used in two co-design workshops with external stakeholders to develop the toolkit. Findings from the 103 papers included in the rapid review were synthesised using tables and a narrative summary organised around the review questions. Interview audio-recordings were transcribed verbatim and data analysed using thematic analysis. Descriptive summary statistics described the quantitative data collected. For the CH documents, information was collated around the key themes of social distancing, isolation, cohorting, zoning and other restrictions. Concurrent data collection and analysis informed decision-making about the need for further data and from which source. Patient and public involvement (PPI) was an integral part of this study, informing its design, method, analysis and dissemination. PPI group members also participated in online workshops to contribute to the co-design of the toolkit. Results The rapid review highlighted the following: There is a lack of empirical evidence around how measures to prevent or control COVID-19 and other infectious diseases are implemented in CHs. Most papers were grey literature or policy documents, which were mainly descriptive, or opinion based. Furthermore, these interventions were generally mentioned as part of a wider discussion of COVID-19 strategies and were not the primary focus of the papers. Key interventions for preventing and controlling the transmission of COVID-19 and other infectious diseases in CHs for older people include social distancing; isolation of residents and staff; restrictions for residents, family members and staff; zoning and cohorting; and surveillance. Evaluative research on the use of these interventions in CHs is needed urgently. The six case study sites were geographically spread and all had a Care Quality Commission rating of good (n = 4) or outstanding (n = 2). All were part of organisations (ranging in size from 7 to 114 CHs per organisation, and between 767 and 5875 beds per organisation). Four of the CHs were part of privately run organisations, and two were part of voluntary/not-for-profit organisations. One CH had a ‘dual’ registration, three had a ‘nursing’ registration and two were registered as ‘without nursing’. Most provided some specialist care such as for dementia, learning disabilities, physical and mental health problems. The number of beds offered ranged between 37 and 73. One CH comprised a household of 12 residents within a village complex. Care homes varied on the number of positive COVID-19 cases, for example one reported only one case between March 2020 and February 2021, while another reported 27 cases within the month November 2020 alone – this home had opened a specially allocated ‘COVID-ward’. In one CH no residents had died within 28 days of a positive COVID-19 test, while 10 residents had died from another home. Policies and protocols about social distancing and isolation measures were collected from each CH and compared. Key findings were as follows: There was significant variation between CHs in the content, length and level of detail presented in policy and guidance documents. Capturing the frequent updates in guidance was challenging with documents sometimes being repetitive and unclear. Many documents had further, embedded documents or links to government guidance that provided a great deal of information, which might be unrealistic for CH staff to read. Shorter documents were less comprehensive and may not provide the necessary detail to guide CH staff. None of the documents included guidance on staff training and development. Research at the case study sites included individual interviews with 31 CH staff. Key findings were as follows: The impact that the COVID-19 pandemic had upon CH staff must not be underestimated. Staff reported trauma and emotional distress. For many staff, the difficulties experienced during the pandemic were compounded by the government’s response to CHs. Some staff felt they had been abandoned by the government, while others criticised the ‘blanket approach’ to government guidance and the rapidly changing rules for CHs. Care home managers valued the support of their senior leadership to help them interpret and implement government guidance. Staff talked of the difficulties of ‘policing’ social distancing measures while simultaneously trying to maintain a sense of ‘normality’ for their residents. Although staff and residents were supposed to maintain a social distance from each other, this was often impossible to uphold when providing personal care. Care homes were perceived as a resident’s home rather than an institution, which made some staff question whether social distancing was appropriate. Many staff felt that social distancing measures denied residents (and themselves) of the important need for touch, as hugs were felt to have a vital role in CH life. Understanding fully the impact on residents living with dementia was recognised as a challenge and not always possible to achieve. The design and layout of CHs meant that there was not always the physical space for social distancing to be implemented. Staff felt that new admissions to CHs had the most difficult experience with isolation regulations. For some managers, isolation measures went against the ethos of the CH environment and ruined the family feel of the CH. The requirement for residents to isolate when returning from hospital could lead to a reluctance in residents to attend hospital appointments and a disinclination of staff to refer residents for hospital care. Several different resident restrictions were implemented in CHs, but restrictions around residents leaving the home, changes to food preparation/delivery and visitor restrictions were perceived to have the greatest negative impact. On occasions, staff became a target of anger and frustration from residents and their families, who could not comprehend that they were being prevented from seeing each other. Good support from CH management was considered by staff to make the process of implementing these measures easier. Individual interviews were conducted with 17 residents and 17 family members. Key findings were as follows: The experiences of residents and families were varied, and their impact was influenced by the existing pattern of relationships residents and families maintained within and beyond the CH. Residents and families valued the work of the CHs in keeping residents safe. They accepted the need for restrictions. Residents and families appreciated the support they received in communicating with one another virtually and the importance of this communication for residents’ health and well-being. Measures relating to isolation were particularly difficult for residents, particularly for those unable to communicate with the outside world through technology. Measures to make isolation less difficult for residents included ensuring that they were entertained purposefully with regular socially distanced visits from staff and various resources to occupy their time. Creative approaches to activities for residents not isolating were also evidenced, for example indoor gardening, yoga and quizzes. Social distancing made aspects of CH life and social visiting difficult and sometimes unsatisfactory; residents and families missed physical touch and other non-verbal forms of communication. This was particularly important for residents with cognitive impairment. Residents and families were involved with staff in complex judgements of risk, choice and control, which were complicated by two factors. First, families (and some residents) were aware that those in CHs were in the twilight of their lives and that time was ebbing away. Second, many families and residents were also learning how to manage their relationships in the new living context of a CH. Two focus groups were conducted with a purposive sample of 13 external senior health and care leaders. Key findings were as follows: Isolation of the sector: the sector felt cut off from the National Health Service (NHS) and pre-pandemic sources of service and support. Government guidance for CHs and communication processes: ‘chaos’ described the approach to cascading information to CHs, especially in the first wave of the pandemic. Visiting: regulations evolved throughout the different waves of the pandemic and led to variations in interpreting and implementing visiting guidance. Trauma: as the pandemic wore on and the different waves and variants emerged, there was a need to take account of the broader health and well-being of residents, families, visitors and the workforce. Trauma impacted at several different levels – for staff, residents and family members. Implications for practice and policy For practice Implications of the study findings for practice are captured in our toolkit for supporting CHs with social distancing and isolation measures. These are framed around six areas: caring for residents when they are social distancing; caring for residents when they are isolating; supporting residents, families and friends to communicate when visiting is not permitted; supporting visits from families and friends when visiting is allowed but with restrictions; caring for care staff; and caring for managers. For policy The study findings can inform discussions involving CH providers, managers and external stakeholders to enhance understanding of social distancing and isolation measures for residents – consequences, challenges, solutions and learning. Our findings also have implications about how guidelines are developed and disseminated. They reinforce the need for CHs and social care to be considered as an integral part of integrated care systems, to ensure that actions taken during national emergencies fully account for the impact on all parts of health and social care. Our findings can inform discussions about developing digital technologies to help residents with different needs stay connected with families and friends, and for CHs to communicate effectively with residents’ families and friends. Our findings can contribute to the content of the digital hub for the social care workforce. Recommendations for further research This study has identified that research is needed in several areas including the following: Evaluations of the toolkit. Evaluation of social distancing and isolation measures used in CHs to prepare for future pandemics. Research to develop and evaluate remote social interaction for residents living with dementia and their families. Research to understand what a trauma-informed approach looks like for the CH sector – to care for residents, families, friends and staff in CHs caring for older people. Research to co-design and evaluate an intervention to enable residents with different needs to transition to living well in a CH. The study of an intervention that cares for families and friends. Conclusions The CH sector was ill-prepared and under-resourced for the COVID-19 pandemic. During the pandemic and for any further surges, it is paramount that CH services are safe, effective, caring, responsive to individual needs and well-led. The loss of older people living in CHs due to COVID-19 has been substantial; it is essential to learn from this devastation, to understand the consequences, challenges, solutions and to evaluate these solutions. Evidence to support learning and recovery of the CH sector from the pandemic and to inform policy-making is paramount. Care homes need evidence-informed guidance that sets out what and how social distancing and isolation measures should be operationalised, while meeting residents’ individual needs. Our toolkit is designed to capture such innovative approaches. Our study makes an important contribution to this learning and recovery, as one of the first to study the challenges and solutions to implementing social distancing and isolation measures for older people living in CHs in England. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132541) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 45. See the NIHR Funding and Awards website for further award information.

Background: HPV (Human Papillomavirus) vaccination is a safe, effective method to prevent HPV-associated disease. Racial-ethnic disparities in HPV vaccination exist, which could lead to widening gaps in cervical cancer mortality. Provider discussion of HPV vaccination has been shown to be a primary factor for increasing vaccination rates. The objective of this study is to assess provider discussion of HPV vaccination pre and post implementation of an intervention, named the HPV Vaccine Toolkit, in an Obstetrics and Gynecology (OB/GYN) clinic in Boyle Heights, Los Angeles. Study design and methods: This quality improvement study occurred over four cycles of development. Its design was guided by the Theory of Planned Behavior. The toolkit components included dot phrases (pre-written phrases to speed documentation), educational posters, electronic health record prompts, HPV vaccine referral guides, and educational sessions. Chart audits and pre- and post-providers surveys were performed between 2019 and 2021 to assess for an increase in provider discussion of the HPV vaccine, as well as to evaluate the various components of the toolkit. Results: Provider discussion increased over the four cycles of this intervention, with HPV vaccination discussion documented in 15 % of patients in 2019, 19 % of patients in 2020 and 47 % of patients in 2021. Gaps identified included limited discussion of vaccination at postpartum visits. Provider uncertainty of where to refer patients for the HPV vaccine decreased following the intervention. Conclusion: Discussion of HPV vaccination is an important preventative strategy that can be overlooked in OB/GYN clinics. Implementation of multicomponent strategies can increase provider discussion of HPV vaccination status, although barriers to discussion remain. Improved counseling on HPV vaccination could have significant impacts on reducing HPV-related disease.

Abstract Background In response to concerns about high hospital mortality rates, patient and carer complaints, a Mid Staffordshire NHS Foundation Trust public inquiry was conducted at the request of the UK government. This inquiry found serious failures in the quality of basic care provided and as a consequence, recommended that patients should have more regular visits, organised at predictable times from nursing staff. Intentional rounding, also known as nursing ward rounds, was widely adopted to meet this need. Objective To test, refine or refute eight programme theories to understand what works, for whom, and in what circumstances. Setting Six wards (older people and acute wards) in three NHS trusts in England. Participants Board level and senior nursing managers (N = 17), nursing ward staff (N = 33), allied health and medical professionals (N = 26), patients (N = 34) and relatives (N = 28) participated in an individual, in-depth interview using the realist method. In addition, ward-based nurses (N = 39) were shadowed whilst they conduced intentional rounds (240 rounds in total) and the direct care of patients (188 h of patient care in total) was observed. Methods The mixed methods design included: Phase (1) Theory development - A realist synthesis was undertaken to identify any programme theories which were tested, refined and/or refuted, using data from phases 2 and 3; Phase (2) A survey of all English NHS acute Trusts; Phase (3) Six case studies of wards involving realist interviews, shadowing and non-participant observations, analysis of ward outcome and cost data; and Phase (4) Synthesis of findings from phases 1, 2 and 3. Results The realist synthesis identified eight programme theories of intentional rounding: ‘Consistency and comprehensiveness’, ‘Accountability’, ‘Visibility of nurses’, ‘Anticipation’, ‘Allocated time to care’, ‘Nurse-patient relationships’, ‘Multi-disciplinary teamwork and communication’ and ‘Patient empowerment’. Key findings showed that of the original eight programme theories of intentional rounding, only two partially explained how the intervention worked (‘Consistency and comprehensiveness’ and ‘Accountability’). Of the remaining six programme theories, the evidence for two was inconclusive (‘Visibility of nurses’ and ‘Anticipation’) and there was no evidence for four (‘Allocated time to care’; ‘Nurse-patient relationships’; ‘Multi-disciplinary teamwork and communication’; and ‘Patient empowerment’). Conclusions This first theory-informed evaluation of intentional rounding, demonstrates that the effectiveness of intentional rounding in the English healthcare context is very weak. Furthermore, the evidence collected in this study has challenged and refuted some of the underlying assumptions about how intentional rounding works. This study has demonstrated the crucial role context plays in determining the effectiveness of an intervention and how caution is needed when implementing interventions developed for the health system of one country into another.

Gypsum is a common mineral at Gale crater on Mars, currently being explored by the Mars Science Laboratory (MSL) rover, Curiosity. In this paper, we summarize the associations of gypsum with other sulfate minerals (bassanite, anhydrite, jarosite, starkeyite, and kieserite) from the lowest levels of the crater’s northern moat zone (Aeolis Palus) up through ~0.8 km of the stratigraphic section in the lower slopes of the sedimentary mound developed around the central peak, Aeolis Mons (informally, Mount Sharp). The analysis is based on results from the CheMin X-ray diffraction instrument on Curiosity, supplemented with information from the rover’s versatile instrument suite. Gypsum does not occur with the same frequency as less hydrous Ca-sulfates, likely, in most cases, because of its dehydration to bassanite and possibly to anhydrite. All three of these Ca-sulfate phases often occur together and, along with other sulfates, in mixed assemblages that are evidence of limited equilibration on a cold, dry planet. In almost all samples, at least one of the Ca-sulfate minerals is present, except for a very limited interval where jarosite is the major sulfate mineral, with the implication of more acidic groundwater at a much later time in Gale crater’s history. Although observations from orbit reveal a sulfate-rich surface, currently active dark basaltic dunes at Gale crater have only small amounts of a single sulfate mineral, anhydrite. Gale crater has provided the most complete mineralogical analysis of a site on Mars so far, but the data in hand show that Gale crater mineralogy is not a blueprint with planet-wide application. The concurrent study of Jezero crater by the Mars 2020 mission and comparisons to what is believed to be the most extensive deposit of gypsum on Mars, in the dune fields at the north polar ice cap, show significant diversity. Unraveling the stories of gypsum and other sulfates on Mars is just beginning.

Introduction One in six people live with disability in Australia with higher levels of disability of people from diverse communities, such as those with culturally and linguistically diverse (CALD) backgrounds. In Australia, CALD refers to people from diverse ethnicity and cultures, nationalities, societal structures and religions that may or may not speak a language other than English. This study employs researchers with lived experience of disability and peer support to study the impact of peer support for people with disability, including people from CALD backgrounds, in two peer-led organisations in New South Wales (NSW) Australia.Methods and analysis This study uses participatory action research and inclusive research design with researchers with lived experience, having lived experience of disability and a peer in the disability community, leading the research.Over three years, three different groups will be recruited through Community Disability Alliance Hunter (CDAH) and Diversity and Disability Alliance (DDAlliance): (1) peers with disability, (2) peer leaders with disability and (3) researchers with lived experience of disability and peer support. Data collection and creation methods include semistructured interviews, surveys and focus groups. Qualitative data will be analysed using thematic analysis through the lens of the researchers with lived experience.Ethics and dissemination Ethical approval was granted by the University of Newcastle Human Research Ethics Committee (Approval No: H-2021-0088). Dissemination includes peer-reviewed publications, presentations at local, national and international conferences and written reports for user-led organisations, disability service providers, disability agencies and people with disability.

Abstract Background Safe and timely anesthesia services are an integral component of modern health care systems. There are, however, increasing concerns about the availability of anesthesia services in Canada. Thus, a comprehensive approach to assess the capacity of the anesthesia workforce to provide service is a critical need. Data regarding the anesthesia services provided by specialists and family physicians are available through the Canadian Institute for Health Information (CIHI) but collating the data across delivery jurisdictions has proven challenging. As a result, information related to the activity of physician anesthesia providers is routinely excluded from annual physician workforce reports. Our goal was to develop a novel approach to identifying and characterizing the anesthesia workforce on a pan-Canadian scale. Methods The study was approved by the University of Ottawa Office of Research Ethics and Integrity. We developed a methodology to identify physicians who provided anesthesia services in Canada between 1996 and 2018 using data elements from the CIHI National Physician Database. We iteratively consulted with expert advisors and compared the results with Scott’s Medical Database, the Canadian Medical Association (CMA) Masterfile, and the College of Family Physicians of Canada membership database. Results The methodology identified providers of anesthesia services using data elements from the CIHI National Physician Database, including categories of the National Grouping System, specialty designations, activity levels and participation thresholds. Physicians who provided anesthesia services only sporadically and medical residents-in-training were excluded. This methodology produced estimates of anesthesia providers that aligned with other sources. The process we followed was sequential, transparent, and intuitive, and was strengthened by collaboration and iterative consultation with experts and stakeholders. Conclusions Using physician activity patterns, this novel methodology allows stakeholders to identify which physician provide anesthesia services in Canada. It is an essential step in developing a pan-Canadian anesthesia workforce strategy that can be used to examine patterns and trends related to the workforce and support evidence-informed workforce decision-making. It also establishes a foundation for assessing the effectiveness of a variety of interventions aimed at optimizing physician anesthesia services in Canada.

For more than a decade, the CheMin X-ray diffraction instrument on the Mars Science Laboratory rover, Curiosity, has been returning definitive and quantitative mineralogical and mineral–chemistry data from ~3.5-billion-year-old (Ga) sediments in Gale crater, Mars. To date, 40 drilled rock samples and three scooped soil samples have been analyzed during the rover’s 30+ km transit. These samples document the mineralogy of over 800 m of flat-lying fluvial, lacustrine, and aeolian sedimentary rocks that comprise the lower strata of the central mound of Gale crater (Aeolis Mons, informally known as Mt. Sharp) and the surrounding plains (Aeolis Palus, informally known as the Bradbury Rise). The principal mineralogy of the sedimentary rocks is of basaltic composition, with evidence of post-depositional diagenetic overprinting. The rocks in many cases preserve much of their primary mineralogy and sedimentary features, suggesting that they were never strongly heated or deformed. Using aeolian soil composition as a proxy for the composition of the deposited and lithified sediment, it appears that, in many cases, the diagenetic changes observed are principally isochemical. Exceptions to this trend include secondary nodules, calcium sulfate veining, and rare Si-rich alteration halos. A surprising and yet poorly understood observation is that nearly all of the ~3.5 Ga sedimentary rocks analyzed to date contain 15–70 wt.% of X-ray amorphous material. Overall, this >800 m section of sedimentary rock explored in lower Mt. Sharp documents a perennial shallow lake environment grading upward into alternating lacustrine/fluvial and aeolian environments, many of which would have been habitable to microbial life.

Objectives: Although routine disinfection of portable medical equipment is required in most hospitals, frontline staff may not be able to disinfect portable medical equipment at a rate that adequately maintains low bioburden on high-use equipment. This study quantified bioburden over an extended time period for two types of portable medical equipment, workstations on wheels and vitals machines, across three hospital wards. Methods: Bioburden was quantified via press plate samples taken from high touch surfaces on 10 workstations on wheels and 5 vitals machines on each of 3 medical surgical units. The samples were taken at three timepoints each day over a 4-week period, with random rotation of timepoints and portable medical equipment, such that frontline staff were not aware at which timepoint their portable medical equipment would be sampled. The mean bioburden from the different locations and portable medical equipment was estimated and compared with Bayesian multilevel negative binomial regression models. Results: Model estimated mean colony counts (95% credible interval) were 14.4 (7.7–26.7) for vitals machines and 29.2 (16.1–51.1) for workstations on wheels. For the workstations on wheel, colony counts were lower on the mouse, 0.22 (0.16–0.29), tray, 0.29 (0.22, 0.38), and keyboard, 0.43 (0.32–0.55), when compared to the arm, as assessed by incident rate ratios. Conclusions: Although routine disinfection is required, bioburden is still present across portable medical equipment on a variety of surfaces. The difference in bioburden levels among surfaces likely reflects differences in touch patterns for the different portable medical equipment and surfaces on the portable medical equipment. Although the association of portable medical equipment bioburden to healthcare-associated infection transmission was not assessed, this study provides evidence for the potential of portable medical equipment as a vector for healthcare-associated infection transmission despite hospital disinfection requirements.