An investigation of cancer survival inequalities associated with individual-level socio-economic status, area-level deprivation, and contextual effects, in a cancer patient cohort in England and Wales.

BACKGROUND: People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. However, associations between individual-level socio-economic circumstances and cancer survival are relatively poorly understood. Moreover, few studies have addressed contextual effects, where associations between individual-level socio-economic status and cancer survival vary depending on area-based deprivation. METHODS: Using 9276 individual-level observations from a longitudinal study in England and Wales, we examined the association with cancer survival of area-level deprivation and individual-level occupation, education, and income, for colorectal, prostate and breast cancer patients aged 20-99 at diagnosis. With flexible parametric excess hazard models, we estimated excess mortality across individual-level and area-level socio-economic variables and investigated contextual effects. RESULTS: For colorectal cancers, we found evidence of an association between education and cancer survival in men with Excess Hazard Ratio (EHR) = 0.80, 95% Confidence Interval (CI) = 0.60;1.08 comparing "degree-level qualification and higher" to "no qualification" and EHR = 0.74 [0.56;0.97] comparing "apprenticeships and vocational qualification" to "no qualification", adjusted on occupation and income; and between occupation and cancer survival for women with EHR = 0.77 [0.54;1.10] comparing "managerial/professional occupations" to "manual/technical," and EHR = 0.81 [0.63;1.06] comparing "intermediate" to "manual/technical", adjusted on education and income. For breast cancer in women, we found evidence of an association with income (EHR = 0.52 [0.29;0.95] for the highest income quintile compared to the lowest, adjusted on education and occupation), while for prostate cancer, all three individual-level socio-economic variables were associated to some extent with cancer survival. We found contextual effects of area-level deprivation on survival inequalities between occupation types for breast and prostate cancers, suggesting wider individual-level inequalities in more deprived areas compared to least deprived areas. Individual-level income inequalities for breast cancer were more evident than an area-level differential, suggesting that area-level deprivation might not be the most effective measure of inequality for this cancer. For colorectal cancer in both sexes, we found evidence suggesting area- and individual-level inequalities, but no evidence of contextual effects. CONCLUSIONS: Findings highlight that both individual and contextual effects contribute to inequalities in cancer outcomes. These insights provide potential avenues for more effective policy and practice.

Linkage of national health and social care data: a cross-sectional study of multimorbidity and social care use in people aged over 65 years in Scotland.

BACKGROUND: little is known about the relationship between multimorbidity and social care use (also known as long-term care). The aim of this study was to assess the relationship between receipt of formal social care services and multimorbidity. METHODS: this retrospective data linkage, observational study included all individuals over the age of 65 in the population of Scotland in financial years 2014-15 and 2015-16 (n = 975,265). The main outcome was receipt of social care measured by presence in the Scottish Social Care Survey. Logistic regression models were used to assess the influence of multimorbidity, age, sex and socioeconomic position on the outcome reporting average marginal effects (AME). FINDINGS: 93.3% of those receiving social care had multimorbidity, 16.2% of those with multimorbidity received social care compared with 3.7% of those without. The strongest magnitudes of AME for receiving social care were seen for age and multimorbidity (respectively, 50 and 18% increased probability comparing oldest to youngest and most severe multimorbidity to none). A 5.5% increased probability of receiving social care was observed for the most-deprived compared with the least-deprived. INTERPRETATION: higher levels of social care receipt are observed in those with increasing age, severe multimorbidity and living in more deprived areas. Multimorbidity does not fully moderate the relationship between social care receipt and either age or deprivation.

Health-related behaviours of nurses and other healthcare professionals: A cross-sectional study using the Scottish Health Survey.

AIMS: To estimate the prevalence and co-occurrence of health-related behaviours among nurses in Scotland relative to other healthcare workers and those in non-healthcare occupations. DESIGN: Secondary analysis of nationally representative cross-sectional data, reported following STROBE guidelines. METHODS: Five rounds (2008-2012) of the Scottish Health Survey were aggregated to estimate the prevalence and co-occurrence of health-related behaviours (smoking, alcohol consumption, physical activity, fruit/vegetable intake). The weighted sample (n = 18,820) included 471 nurses (3%), 433 other healthcare professionals (2%), 813 unregistered care workers (4%), and 17,103 in non-healthcare occupations (91%). Logistic regression models compared the prevalence of specific health-related behaviours and principal component analysis assessed co-occurrence of health-related behaviours between occupational groups. RESULTS: Nurses reported significantly better health-related behaviours relative to the general working population for smoking, fruit/vegetable intake, and physical activity. No significant difference was found for alcohol consumption between occupational groups. Nurses reported lower levels of harmful co-occurring behaviours (tobacco smoking and alcohol consumption) and higher levels of preventive behaviours (physical activity and fruit/vegetable intake) compared with the general working population. Other healthcare professionals had the lowest level of harmful health behaviours and the highest level of preventive health behaviours. Health-related behaviours were poorest among unregistered care workers. CONCLUSION: Nurses' health-related behaviours were better than the general population but non-adherence to public health guidelines was concerning. IMPACT: Nurses play an important role in health promotion through patient advice and role-modelling effects. To maximise their impact, healthcare providers should prioritise increasing access to healthy food, alcohol awareness, and smoking cessation programmes.

A retrospective medical records review of risk factors for the development of respiratory tract secretions (death rattle) in the dying patient.

AIM: Identification of risk factors predicting the development of death rattle. BACKGROUND: Respiratory tract secretions, often called death rattle, are among the most common symptoms in dying patients around the world. It is unknown whether death rattle causes distress in patients, but it has been globally reported that distress levels can be high in family members. Although there is a poor evidence base, treatment with antimuscarinic medication is standard practice worldwide and prompt intervention is recognized as crucial for effectiveness. The identification of risk factors for the development of death rattle would allow for targeted interventions. DESIGN: A case-control study was designed to retrospectively review two hundred consecutive medical records of mainly cancer patients who died in a hospice inpatient setting between 2009-2011. Fifteen potential risk factors including the original factors weight, smoking, final opioid dose and final midazolam dose were investigated. METHODS: Binary logistic regression to identify risk factors for death rattle development. RESULTS: Univariate analysis showed death rattle was significantly associated with final Midazolam doses and final opioid doses, length of dying phase and anticholinergic drug load in the pre-terminal phase. In the final logistic regression model only Midazolam was statistically significant and only at final doses of 20 mg/24 hrs or over (OR 3.81 CI 1.41-10.34). CONCLUSIONS: Dying patients with a requirement for a high dose of Midazolam have an increased likelihood of developing death rattle.

Psychological distress, optimism and general health in breast cancer survivors: a data linkage study using the Scottish Health Survey.

PURPOSE: The aim of this study is to examine the association between optimism and psychological distress in women with breast cancer after taking into account their self-rated general health. METHODS: Data were aggregated from the Scottish Health Survey (2008 to 2011) to derive a nationally representative sample of 12,255 women (11,960 cancer-free controls, and 295 breast cancer cases identified from linked cancer registry data). The explanatory variables were optimism and general health, and the outcome variable was symptoms of psychological distress. Logistic regression analyses were conducted, with optimism entered in step 1 and general health entered in step 2. RESULTS: In an unadjusted model, higher levels of optimism were associated with lower odds of psychological distress in both the control group (OR = 0. 57, 95 % CI = 0.51-0.60) and breast cancer group (OR = 0. 64, 95 % CI = 0.47-0.88). However, in a model adjusting for general health, optimism was associated with lower odds of psychological distress only in the control group (OR = 0.50, 95 % CI = 0.44-0.57), but not significantly in the breast cancer group (OR = 1.15, 95 % CI = 0.32-4.11). In the breast cancer group, poor general health was a stronger associate of psychological distress (OR = 4. 98, 95 % CI = 1.32-18.75). Results were consistent after adjusting for age, years since breast cancer diagnosis, survey year, socioeconomic status, education, marital status, body mass index, smoking status, and alcohol consumption. CONCLUSION: This research confirms the value of multicomponent supportive care interventions for women with breast cancer. Specifically, it suggests that following breast cancer diagnosis, health care professionals need to provide advice and signpost to services that assist women to maintain or improve both their psychological and general health.

Nurses' health-related behaviours: protocol for a quantitative systematic review of prevalence of tobacco smoking, physical activity, alcohol consumption and dietary habits.

AIM: To enumerate nurses' health-related behaviour by critically appraising studies on tobacco smoking, physical activity, alcohol consumption and dietary habits. BACKGROUND: Nurses represent the largest occupational group in healthcare systems internationally and have an established and expanding public health role. Nurses own health-related behaviour is known to impact nurses' ability and confidence to engage in health promotion, and how patients receive and respond to advice and guidance nurses' give. However, there has been no comprehensive and comparable assessment of evidence on nurses' health-related behaviours. DESIGN: Quantitative systematic review of prevalence of tobacco smoking, physical activity, alcohol consumption and dietary habits. METHODS: Systematic searches for literature published between January 2000 and February 2015 and indexed in Medical Literature Analysis and Retrieval System, Cumulative Index to Nursing and Allied Health Literature and Psychological Information. Eligibility criteria will be applied to titles and abstracts by two reviewers independently. Full text will be reviewed and the same criteria and process applied. Two reviewers will independently assess study quality guided by the Joanna Briggs Institute handbook for the systematic review of prevalence and incidence data. Discrepancies in eligibility or quality assessment will be resolved through discussion and, where required, a third reviewer. Data synthesis will be conducted and findings reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. DISCUSSION: Enumerating prevalence of nurses' health-related behaviours is crucial to direct future research, inform public health policy, particularly around health promotion and to better support the nursing workforce through the development of behaviour change interventions. PROSPERO registration: CRD42015016751.

"Everybody Knows Everybody Else's Business"-Privacy in Rural Communities.

Patients have a right to privacy in a health care setting. This involves conversational discretion, security of medical records and physical privacy of remaining unnoticed or unidentified when using health care services other than by those who need to know or whom the patient wishes to know. However, the privacy of cancer patients who live in rural areas is more difficult to protect due to the characteristics of rural communities. The purpose of this article is to reflect on concerns relating to the lack of privacy experienced by cancer patients and health care professionals in the rural health care setting. In addition, this article suggests future research directions to provide much needed evidence for educating health care providers and guiding health care policies that can lead to better protection of privacy among cancer patients living in rural communities.

Prevalence of skin problems and leg ulceration in a sample of young injecting drug users.

BACKGROUND: Drug users suffer harm from the injecting process, and clinical services are reporting increasing numbers presenting with skin-related problems such as abscesses and leg ulcers. Skin breakdown can lead to long-term health problems and increased service costs and is often the first indication of serious systemic ill health. The extent of skin problems in injecting drug users has not previously been quantified empirically, and there is a dearth of robust topical literature. Where skin problems have been reported, this is often without clear definition and generic terms such as 'soft tissue infection' are used which lack specificity. The aim of this study was to identify the range and extent of skin problems including leg ulceration in a sample of injecting drug users. Definitions of skin problems were developed and applied to descriptions from drug users to improve rigour. METHODS: Data were collected in needle exchanges and methadone clinics across Glasgow, Scotland, from both current and former drug injectors using face-to-face interviews. RESULTS: Two hundred participants were recruited, of which 74% (n = 148) were males and 26% (n = 52) were females. The age range was 21-44 years (mean 35 years). Just under two thirds (64%, n = 127) were currently injecting or had injected within the last 6 months, and 36% (n = 73) had previously injected and had not injected for more than 6 months.Sixty per cent (n = 120) of the sample had experienced a skin problem, and the majority reported more than one problem. Most common were abscesses, lumps, track marks and leg ulcers. Fifteen per cent (n = 30) of all participants reported having had a leg ulcer. CONCLUSIONS: This is an original empirical study which demonstrated unique findings of a high prevalence of skin disease (60%) and surprisingly high rates of leg ulceration (15%). Skin disease in injecting drug users is clearly widespread. Leg ulceration in particular is a chronic recurring condition that is costly to treat and has long-term implications for drug users and services caring for current or former injectors long after illicit drug use has ceased.

Delivering healthcare information via the internet: cardiac patients' access, usage, perceptions of usefulness, and web site content preferences.

OBJECTIVES: To assess patients' usage of the Internet as a source of personal healthcare information and patients' perceptions of usefulness and content preferences of more locally focused online health-related material. MATERIALS AND METHODS: A paper-based survey was undertaken by a convenience sample of cardiac outpatients. Age, gender, Internet access, Internet usage, perception of usefulness of online information, predicted intention to use a local cardiology Web site if available, and preferred components to be included were recorded. Univariate and bivariate statistics were used. RESULTS: Two hundred thirty-seven patients responded (62.1% males). One hundred seventy-six (74.3%) used the Internet, with 126 (63%) using it daily. For patients who did not have direct access to the Internet, 26 (50%) had a family member to do this on their behalf. Thus, the majority of patients (202 [85%]) had access to the Internet at home or someone who could access it on their behalf. Internet usage declined with age (Kendall's tau_b=0.321, p<0.001). There was no difference in use with gender (p=0.235). There was considerable interest expressed in a locally delivered Web-based information service. CONCLUSIONS: Online healthcare information services have the potential to reach the vast majority of cardiac patients either directly or through family support. The most elderly patients are less likely to use these services. Despite apparent satisfaction with existing online resources, there appears to be an unmet need for more information and considerable support for a locally based cardiac patient Web resource to deliver this. These findings may help guide future patient information Web site redesign.

What might make nurses stay? A protocol for discrete choice experiments to understand NHS nurses' preferences at early-career and late-career stages.

INTRODUCTION: Like many countries, England has a national shortage of registered nurses. Employers strive to retain existing staff, to ease supply pressures. Disproportionate numbers of nurses leave the National Health Services (NHS) both early in their careers, and later, as they near retirement age. Research is needed to understand the job preferences of early-career and late-career nurses working in the NHS, so tailored policies can be developed to better retain these two groups. METHODS AND ANALYSIS: We will collect job preference data for early-career and late-career NHS nurses, respectively using two separate discrete choice experiments (DCEs). Findings from the literature, focus groups, academic experts and stakeholder discussions will be used to identify and select the DCE attributes (ie, job features) and levels. We will generate an orthogonal, fractional factorial design using the experimental software Ngene. The DCEs will be administered through online surveys distributed by the regulator Nursing and Midwifery Council. For each group, we expect to achieve a final sample of 2500 registered NHS nurses working in England. For early-career nurses, eligible participants will be registered nurses who graduated in the preceding 5 years (ie, 2019-2023). Eligible participants for the late-career survey will be registered nurses aged 55 years and above. We will use conditional and mixed logit models to analyse the data. Specifically, study 1 will estimate the job preferences of early-career nurses and the possible trade-offs. Study 2 will estimate the retirement preferences of late-career NHS nurses and the potential trade-offs. ETHICS AND DISSEMINATION: The research protocol was reviewed and approved by the host research organisation Ethics Committees Research Governance (University of Southampton, number 80610) (https://www.southampton.ac.uk/about/governance/regulations-policies/policies/ethics). The results will be disseminated via conference presentations, publications in peer-reviewed journals and annual reports to key stakeholders, the Department of Health and Social Care, and NHS England/Improvement retention leaders. REGISTRATION DETAILS: Registration on OSF http://doi.org/10.17605/OSF.IO/RDN9G.

Local provision of percutaneous coronary intervention increases stenting rates and reduces length of hospital stay in remote regional centre.

INTRODUCTION: An early invasive strategy with follow-on percutaneous coronary intervention (PCI) is recommended in the management of high risk acute coronary syndromes (ACS). This article aimed to assess the impact of a new PCI service in a remote population. METHOD: The study compared patient treatment pre- and post-introduction of the PCI service in a remote regional centre. Patients were identified using ICD discharge code during two 12 week periods ('pre' and 'post' introduction of the new PCI service). Further data was obtained from a catheter laboratory database, electronic patient management systems and clinical notes. Non-parametric statistical tests were used. RESULTS: There were 182 patients in the pre-PCI group and 204 in the post-PCI group. There were no demographic differences between the groups. Patients admitted post service introduction who required active treatment were more likely to have PCI rather than an angiogram only (p = 0.046). Furthermore, patients admitted after the introduction of the PCI service had a shorter period of time from admission to PCI (p = 0.002), were less likely to be transferred to another hospital (p < 0.001), and on average had a shorter hospital stay (p = 0.017). CONCLUSION: A local PCI service in a remote regional centre increased efficiency in the management of patients with ACS with increased rates of PCI, shorter waiting times, reduced requirement for hospital transfer, and shorter length of stay. Nevertheless, many patients still required transfer to other centres. Therefore, maintaining links with other regional centres with clear patient pathways are necessary to provide optimal ACS care to all patients in a rural area.

Competencies and standards in nurse education: The irresolvable tensions.

This paper explores the inherent contradiction between the purpose of nurse education - to produce critical thinking, autonomous and accountable future nurses - and the prescription of standards and competencies to realize this goal. Drawing on examples from the United Kingdom's Nursing and Midwifery Council's (NMC) 'Future Nurse' standards, we argue that standards and competencies offer little more than a veneer of protection to the public and that, fundamentally, educational approaches based on 'dot point' formulations are antithetical to conditions in which genuinely critical-thinking, autonomous and accountable practitioners can develop. The purpose of this paper is to raise debate about the hegemony of competencies and standards. For the sake of academic health and the future of the nursing profession, the ubiquity of competency-based education must be critiqued and challenged.

Exploring the patient experience of remote hypertension management in Scotland during COVID-19: a qualitative study.

OBJECTIVES: The aim of this study was to understand how patients experienced hypertension management, with or without blood pressure (BP) telemonitoring, during the COVID-19 pandemic. DESIGN, METHODS, PARTICIPANTS AND SETTING: This qualitative study conducted between April and November 2022 consisted of 43 semistructured telephone interviews (23 men and 20 women) from 6 primary care practices in one area of Scotland. RESULTS: From the views of 25 participants with experience of using the Connect Me telemonitoring service and 18 participants without such experience, 5 themes were developed. These were: (1) navigating access to services. There were challenges to gaining timely and/or in-person access to services and a reluctance to attend clinical settings because participants were aware of their increased risk of contracting the COVID-19 virus. (2) Adapting National Health Service services. All six practices had adapted care provision in response to potential COVID-19 transmission; however, these adaptations disrupted routine management of in-person primary care hypertension, diabetes and/or asthma checks. (3) Telemonitoring feedback. Telemonitoring reduced the need to attend in-person primary care practices and supported access to remote healthcare monitoring and feedback. (4) Self-management. Many non-telemonitoring participants were motivated to use self-management strategies to track their BP using home monitoring equipment. Also, participants were empowered to self-manage lifestyle and hypertension medication. (5) Experience of having COVID-19. Some participants contracting the COVID-19 virus experienced an immediate increase in their BP while a few experienced ongoing increased BP readings. CONCLUSIONS: The COVID-19 pandemic disrupted routine in-person care for patients with hypertension. Both telemonitoring and some non-telemonitoring patients were motivated to self-manage hypertension, including self-adjusting medication; however, only those with access to telemonitoring had increased access to hypertension monitoring and feedback. BP telemonitoring permitted routine care to continue for participants in this study and may offer a service useful in pandemic proofing hypertension healthcare in the future.

Are deprivation-specific cancer survival patterns similar according to individual-based and area-based measures? A cohort study of patients diagnosed with five malignancies in England and Wales, 2008-2016.

OBJECTIVE: To investigate if measured inequalities in cancer survival differ when using individual-based ('person') compared with area-based ('place') measures of deprivation for three socioeconomic dimensions: income, deprivation and occupation. DESIGN: Cohort study. SETTING: Data from the Office for National Statistics Longitudinal Study of England and Wales, UK, linked to the National Cancer Registration Database. PARTICIPANTS: Patients diagnosed with cancers of the colorectum, breast, prostate, bladder or with non-Hodgkin's lymphoma during the period 2008-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: Differentials in net survival between groups defined by individual wage, occupation and education compared with those obtained from corresponding area-level metrics using the English and Welsh Indices of Multiple Deprivation. RESULTS: Survival was negatively associated with area-based deprivation irrespective of the type analysed, although a trend from least to most deprived was not always observed. Socioeconomic differences were present according to individually-measured socioeconomic groups although there was an absence of a consistent 'gradient' in survival. The magnitude of differentials was similar for area-based and individually-derived measures of deprivation, which was unexpected. CONCLUSION: These unique data suggest that the socioeconomic influence of 'person' is different to that of 'place' with respect to cancer outcomes. This has implications for health policy aimed at reducing inequalities. Further research could consider the separate and additional influence of area-based deprivation over individual-level characteristics (contextual effects) as well as investigate the geographic, socioeconomic and healthcare-related characteristics of areas with poor outcomes in order to inform policy intervention.

Berberine for the treatment of hypertension: A systematic review.

BACKGROUND: Hypertension is the highest risk factor for disease globally. When prescription of drug therapy is recommended, patients might decline treatment due to hypertension asymptomatic nature, sometimes turning to alternative therapies. One popular therapy is berberine, a plant alkaloid that has been used in eastern medicine for millennia to treat several ailments, including cardiovascular diseases and their risk factors. AIMS: Through a transparent and pragmatic approach towards searching, synthesising, assessing, and reporting the available clinical evidence, the present review aimed to investigate berberine effect on blood pressure and cardiovascular disease risk. It also intended to provide guidance for clinician when advising their patients, and to highlight gaps in the research along offering suggestions to fill them. METHODS: The review was conducted following the protocol PRISMA-P, and reported according to the related PRISMA statement. The PICO framework was used to define the scope of the review, and to arrive at a database search strategy. The strategy was run on the databases Medline, CINAHL, AMED, Embase, and Cochrane Library through the platforms EBSCOhost and Ovid. Citations were exported to Mendeley citation manger for screening. Relevant studies were selected based on specified inclusion and exclusion criteria. Data from included studies was extracted in the form of a detailed table of characteristics of studies, and summarised in an evidence table. Quality of studies was assessed using the SIGN methodology checklist for controlled trials. The results from the quality assessment were summarised through an adaptation of the Robvis tool software package output. Effect estimates and their precision were calculated with RevMan 5 computer program from the extracted study outcomes. RESULTS: Five randomised controlled trials and two non-randomised controlled trials were included with 614 participants. All provided data on blood pressure, but none measured cardiovascular events or long-term adverse events. The group of studies was highly heterogeneous in terms of experimental intervention, comparator intervention, length to follow-up, participants' diagnosis, and setting. The heterogeneity prevented a meaningful meta-analysis. Berberine plus amlodipine was not significantly better than amlodipine alone at reducing systolic and diastolic blood pressure. Compared to metformin, berberine provided a statistically significant moderate reduction effect on systolic blood pressure (-11.87 [-16.64, -7.10] mmHg). A proprietary nutraceutical containing berberine as one of its ingredients was in one study significantly effective at reducing blood pressure compared to placebo (-11.80 [-18.73, -4.87] mmHg systolic, and -11.10 [-15.17, -7.43] mmHg diastolic), and also effective in another study compared to dietary advice (-3.40 [-5.48, -1.32] mmHg for systolic 24 h ambulatory blood pressure), although effects could not be reliably attributed to berberine alone. The herbal extract Chunghyul-dan, which contains berberine, showed a significant beneficial moderate effect compared to no treatment on systolic 24 h ambulatory blood pressure (-7.34 [-13.14, -1.54] mmHg) in one study, but in another study employing higher dose and longer treatment duration, no effects were detected. Again, the effects could not be attributed to berberine alone. The quality of the body of evidence was low, especially due to lack of trial design details and presence of outcome reporting bias. CONCLUSIONS: The evidence around berberine effect on blood pressure is limited, of low quality, and ultimately inconclusive. Clinicians should be aware that the evidence from randomised trials is not sufficient to establish berberine effectiveness and safety in the treatment of hypertension, and they should balance these findings with the long history of berberine use in the Eastern world. Researchers should aim at improving quality of studies, by raising the standard of designing and reporting them, e.g., by following the CONSORT guidelines, and strive to measure meaningful clinical endpoints, such as cardiovascular events, mortality, and adverse outcomes.

Impact of area deprivation on the cardiac mortality in the UK between1991 and 2010: evidence from a population-based longitudinal study.

AIMS: Evidence from longitudinal studies on the influence of area deprivation in cardiac mortality is limited. We aimed to examine the impact of area deprivation on cardiac mortality in a large representative Scottish population. We also examined differences between women and men. METHODS AND RESULTS: Retrospective analysis was performed by using linked data from Scottish Longitudinal Study from 1991 to 2010. The main exposure variable was socioeconomic status using the Carstairs deprivation scores, a composite score of area-level factors. Cox proportional-hazards models were constructed to evaluate the hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiac mortality and all-cause mortality associated with area-based deprivation. Subgroup analyses were stratified by sex. In a representative population of 217 965 UK adults, a total of 58 770 deaths occurred over a median of 10 years of follow-up period. The risk of cardiac mortality and all-cause mortality showed a consistent graded increased across the deprived groups. Compared to the least deprived group, the adjusted HR of cardiac mortality in the most deprived group was 1.27 (1.15-1.39, P < 0.000). There was strong evidence that women from more deprived areas had significantly higher cardiac death risk than those from the least deprived areas (HR 1.42, 95% CI 1.22-1.65), while this observation was not strong in men with same background. CONCLUSION: Our study demonstrated area deprivation was the strong predictor of long-term cardiac mortality and all-cause mortality. The inequalities were substantially greater in women from more deprived areas than men from the same background.

Context, complexity and cross-pollination: Nursing leaders' views of the role of the voluntary and community sector in nurse education.

BACKGROUND: Placements in voluntary and community sector (VCS) organisations have long played an important part in student nurses' education in several countries. New standards for nurse education published by the Nursing and Midwifery Council in the United Kingdom include significant changes to practice supervision arrangements that enable students to spend more time in VCS organisations. OBJECTIVES: To assess nursing leaders' views on the role of the VCS in nursing education and benefits of VCS placements for students and organisations. DESIGN: Qualitative interview study. PARTICIPANTS: Twenty-four nursing leaders from academic (n=15), practice (n=4) and regulatory (n=5) sectors. METHODS: Semi-structured interviews were conducted face-to-face (n=21), by telephone (n=2) or Skype (n=1). Interviews were transcribed and analysed, using interview questions as structural themes, followed by inductive thematic analysis. RESULTS: Nursing leaders identified three key roles for the VCS in nursing education: (1) determining knowledge needs; (2) developing curricula; (3) providing placements. Five key benefits of VCS placements for students were shared: (1) understanding the contribution of the VCS to care; (2) seeing the context and complexity of people's lives; (3) challenging attitudes and perceptions; (4) gaining confidence, knowledge and skills; and (5) supporting career decisions. Three benefits for VCS organisations were found: (1) cross-pollinating knowledge, skills and networks; (2) changing organisational cultures; (3) promoting careers in the VCS. CONCLUSIONS: Changes to practice supervision models enabling closer relationships with the VCS were welcomed. Nursing leaders thought that VCS placements had potential to cross-pollinate ideas and harness the role of student nurses as knowledge brokers in increasingly integrated health and social care systems. Nurse educators should embrace opportunities offered through collaboration with the VCS for student learning and deeper partnerships across health and social care settings to enable students to gain deeper insight into the context and complexity of people's lives.

Long-Term Conditions in Older People are Linked with Loneliness, but a Sense of Coherence Buffers the Adverse Effects on Quality of Life: A Cross-Sectional Study.

BACKGROUND: The impact of disability, long-term conditions, rurality, living alone, and being a carer on health has some evidence base, but the extent to which a strong sense of coherence (SoC), a factor hypothesised to promote wellbeing, may moderate these associations is unknown. A model of physical, environmental and social factors on quality of life was tested, with particular emphasis on whether a strong SoC buffered (mitigated) these determinants of quality of life. MATERIAL AND METHODS: A cross-sectional postal survey was undertaken of a random sample of 1471 respondents aged over 65 years, across a population of rural individuals. Physical, environmental, and psychological variables were assessed against quality of life using ANOVA and a generalised linear model including the interaction effects of SoC. RESULTS: ANOVA demonstrated that age, gender, long-term conditions or disability (LTC-D), living alone, >20 hours unpaid care for others per week, SoC, and loneliness, were associated with lower quality of life (p<0.01). There were strong correlations (p>0.01), between age and LTC-D, living alone, and poor SoC. Living alone was correlated with emotional and social loneliness; but those with higher SoC were less likely to experience loneliness. In an adjusted generalised linear model, significant associations with a lower quality of life were observed from: LTC-D, emotional loneliness and social loneliness (B= -0.44, -0.30, and -0.39, respectively, all p<0.001). The only interaction with SoC that was statistically significant (at p<0.05) was LTC-D. A stronger sense of coherence buffered the negative effects of long-term condition/disability on quality of life. DISCUSSION: The physical, environmental and social factors examined, identified LTC-D and loneliness to be the strongest factors associated with poor quality of life. CONCLUSION: SoC somewhat buffered the adverse effect of LTC-D on quality of life, but did not do so for loneliness.

Describing socio-economic variation in life expectancy according to an individual's education, occupation and wage in England and Wales: An analysis of the ONS Longitudinal Study.

People who live in more deprived areas have poorer health outcomes, and this inequality is a major driver of health and social policy. Many interventions targeting these disparities implicitly assume that poorer health is predominantly associated with area-level factors, and that these inequalities are the same for men and women. However, health differentials due to individual socio-economic status (SES) of men and women are less well documented. We used census data linked to the ONS Longitudinal Study to derive individual-level SES in terms of occupation, education and estimated wage, and examined differences in adult mortality and life expectancy. We modelled age-, sex- and SES-specific mortality using Poisson regression, and summarised mortality differences using life expectancy at age 20. We compared the results to those calculated using area-level deprivation metrics. Wide inequalities in life expectancy between SES groups were observed, although differences across SES groups were smaller for women than for men. The widest inequalities were found across men's education (7.2-year (95% CI: 3.0-10.1) difference in life expectancy between groups) and wage (7.0-year (95% CI: 3.5-9.8) difference), and women's education (5.4-year (95% CI: 2.2-8.1) difference). Men with no qualifications had the lowest life expectancy of all groups. In terms of the number of years' difference in life expectancy, the inequalities measured here with individual-level data were of a similar magnitude to inequalities identified previously using area-level deprivation metrics. These data show that health inequalities are as strongly related to individual SES as to area-level deprivation, highlighting the complementary usefulness of these different metrics. Indeed, poor outcomes are likely to be a product of both community and individual influences. Current policy which bases health spending decisions on evidence of inequalities between geographical areas may overlook individual-level SES inequalities for those living in affluent areas, as well as missing important sex differences.

Population health as a 'platform' for nurse education: A qualitative study of nursing leaders.

BACKGROUND: Challenges to the sustainability of global healthcare systems are prompting a shift towards more population-focused models of care. Nurse educators need to develop courses that prepare students for population health practice. However, the educational approaches that can support this shift are poorly understood. Publication of new standards for nurse education by the United Kingdom's (UK) Nursing and Midwifery Council that place greater emphasis on population health presented an opportunity to seek nursing leaders' views on population health in nurse education. OBJECTIVES: To assess the views of nursing leaders within a Scottish context on the connection between nurse education and population health for all students, evaluate what student nurses need to know to support population health practice, and draw insights from the UK for pre-registration programmes internationally. DESIGN: Qualitative interview study. PARTICIPANTS: Twenty-four nursing leaders from academic (n = 15), practice (n = 4) and regulatory (n = 5) sectors. METHODS: Semi-structured interviews were conducted face-to-face (n = 21), by telephone (n = 2) or Skype (n = 1). Interviews were transcribed and analysed, using interview questions as structural themes, followed by thematic and content analyses. RESULTS: Nursing leaders encouraged rebalancing nurse education towards population health, suggesting that population health concepts should sit at the core of spiral curricula to enable students to (re)view learning through a population health lens. Seven outcomes were identified to equip student nurses for practice in any setting. These formed the mnemonic FULCRUM: Find and interpret evidence; Understand the psychology of behavior and change; Link epidemiology to population health; Consider others and themselves in context; Recognise social determinants of health; Understand the impact of policy and politics on health; Motivate to encourage behaviour change. CONCLUSIONS: FULCRUM can guide nurse educators globally to support preparation of graduate nurses for the significant shifts in healthcare delivery and service organisation towards improving population outcomes.