Culturally sensitive neonatal palliative care: a critical review.

Although there are known disparities in neonatal and perinatal deaths across cultural groups, less is known about how cultural diversity impacts neonatal palliative care. This article critically reviews available literature and sets out key questions that need to be addressed to enhance neonatal palliative care provision for culturally diverse families. We begin by critically reviewing the challenges to recording, categorizing and understanding data which need to be addressed to enable a true reflection of the health disparities in neonatal mortality. We then consider whose voices frame the current neonatal palliative care agenda, and, importantly, whose perspectives are missing; what this means in terms of limiting current understanding and how the inclusion of diverse perspectives can potentially help address current inequities in service provision. Utilizing these insights, we make recommendations towards setting a research agenda, including key areas for future enquiry and methodological and practice-based considerations.

Moving psychiatric deinstitutionalization forward: A scoping review of barriers and facilitators.

Psychiatric deinstitutionalization (PDI) processes aim to transform long-term psychiatric care by closing or reducing psychiatric hospitals, reallocating beds, and establishing comprehensive community-based services for individuals with severe and persistent mental health difficulties. This scoping review explores the extensive literature on PDI, spanning decades, regions, socio-political contexts, and disciplines, to identify barriers and facilitators of PDI implementation, providing researchers and policymakers with a categorization of these factors. To identify barriers and facilitators, three electronic databases (Medline, CINAHL, and Sociological Abstracts) were searched, yielding 2,250 references. After screening and reviewing, 52 studies were included in the final analysis. Thematic synthesis was utilized to categorize the identified factors, responding to the review question. The analysis revealed that barriers to PDI include inadequate planning, funding, and leadership, limited knowledge, competing interests, insufficient community-based alternatives, and resistance from the workforce, community, and family/caregivers. In contrast, facilitators encompass careful planning, financing and coordination, available research and evidence, strong and sustained advocacy, comprehensive community services, and a well-trained workforce engaged in the process. Exogenous factors, such as conflict and humanitarian disasters, can also play a role in PDI processes. Implementing PDI requires a multifaceted strategy, strong leadership, diverse stakeholder participation, and long-term political and financial support. Understanding local needs and forces is crucial, and studying PDI necessitates methodological flexibility and sensitivity to contextual variation. At the same time, based on the development of the review itself, we identify four limitations in the literature, concerning "time," "location," "focus," and "voice." We call for a renewed research and advocacy agenda around this neglected aspect of contemporary global mental health policy is needed.

Erratum: Moving psychiatric deinstitutionalization forward: A scoping review of barriers and facilitators - CORRIGENDUM.

[This corrects the article DOI: 10.1017/gmh.2023.18.].

How does housing affect end-of-life care and bereavement in low-income communities? A qualitative study of the experiences of bereaved individuals and service providers in the United Kingdom.

Background: Access to affordable, appropriate housing is one of the key social determinants of health, affecting well-being across the lifecourse. However, beyond a recognition that housing quality is linked to place of death, little is known about the ways in which housing status impacts social, emotional, and practical aspects of dying and bereavement. Method: The Checking Out project is a qualitative study aiming to explore the ways in which socio-economic status impacts people's experiences of, and attitudes towards, death, dying, and bereavement in the United Kingdom. Qualitative interviews were carried out with 14 bereaved individuals with experience of poverty at end of life or in bereavement, and 15 professionals supporting individuals in low-income communities. Interviews were conducted via phone/video call, and data include experiences of end of life and bereavement both before and during the pandemic. Transcripts were examined using thematic analysis. Results: Housing emerged as an important factor affecting people's experiences, with 7 of the 14 bereaved individuals and all except 1 of the professionals discussing housing-related issues. Participants described ways in which unsuitable housing and housing insecurity impacted practical aspects of dying but also emotional and social well-being at end of life. Housing-related issues affected both patients and their families, though families found it difficult to air these concerns when their relative was dying. Conclusion: The paper demonstrates how trusted professionals are able to advocate or address the issues faced by bereaved individuals and suggests implications for policy and practice. A greater awareness of the potential impact of housing status across public services, including healthcare practitioners, welfare support, and housing providers, could better support patients and practitioners to address these issues proactively. Housing providers and policy-makers should be included as key partners in collaborative public health approaches to palliative care.

An engaged approach to exploring issues around poverty and mental health: A reflective evaluation of the research process from researchers and community partners involved in the DeStress study.

BACKGROUND: Involving patients, service users, carers and members of the public in research has been part of health policy and practice in the UK for the last 15 years. However, low-income communities tend to remain marginalized from the co-design and delivery of mental health research, perpetuating the potential for health inequalities. Greater understanding is therefore needed on how to meaningfully engage low-income communities in mental health research. OBJECTIVES: To explore and articulate whether and how an engaged research approach facilitated knowledge coproduction relating to poverty and mental distress. SETTING: A reflective evaluation of community and researcher engagement in the DeStress study that took place in two low-income areas of South-west England. DESIGN: Reflective evaluation by the authors through on-going feedback, a focus group and first-person writing and discussion on experiences of working with the DeStress project, and how knowledge coproduction was influenced by an engaged research approach. RESULTS: An engaged research approach influenced the process and delivery of the DeStress project, creating a space where community partners felt empowered to coproduce knowledge relating to poverty-related mental distress, treatment and the training of health professionals that would otherwise have been missed. We examine motivations for involvement, factors sustaining engagement, how coproduction influenced research analysis, findings and dissemination of outputs, and what involvement meant for different stakeholders. CONCLUSION: Engaged research supported the coproduction of knowledge in mental health research with low-income communities which led to multiple impacts.

Asking about self-harm and suicide in primary care: Moral and practical dimensions.

OBJECTIVE: Self-harm and suicide are important topics to discuss with people experiencing mental health conditions. This study explores how such discussions unfold in practice, and how their moral and practical repercussions manifest for patients and doctors. METHODS: Conversation analysis (CA) was used to examine 20 recorded examples of doctors' questions about self-harm and suicide and their ensuing discussions with patients. RESULTS: A tendency to frame questions about self-harm towards a 'no' response, to amalgamate questions around self-harm and suicide, and to limit dialogue around the protective factors offered by family and friends restricted discussion of patients' experiences and concerns. Closed questions about thoughts and actions in the context of risk assessment resulted in missed opportunities to validate distressing thoughts. Patients responding affirmatively often did so in a way that distanced themselves from the negative stigma associated with suicide. CONCLUSION: The wording of questions, along with negative stigma, can make it difficult for patients to talk about self-harm. PRACTICE IMPLICATIONS: Discussions could be improved by asking about self-harm and suicide separately, encouraging discussion when responses are ambiguous and validating distressing thoughts. Negative stigma could be countered by exploring patients' positive reasons for wanting to stay alive.

Use of the Patient Health Questionnaire (PHQ-9) in Practice: Interactions between patients and physicians.

We analyze the use of nine-item Patient Health Questionnaire (PHQ-9), an instrument that is widely used in diagnosing and determining the severity of depression. Using conversation analysis, we show how the doctor deploys the PHQ-9 in response to the patient's doubts about whether she is depressed. Rather than relaying the PHQ-9 verbatim, the doctor deviates from the wording so that the response options are selectively offered to upgrade the severity of the patient's symptoms. This works in favor of a positive diagnosis and is used to justify a treatment recommendation that the patient previously resisted. This contrasted with the rest of the data set, where diagnosis was either not delivered (as patients are presenting with ongoing problems) or delivered without using the PHQ-9. When clinician-administered, the PHQ-9 can be influenced by how response items are presented. This can lead to either downgrading or upgrading the severity of depression.

The violence of narrative: embodying responsibility for poverty-related stress.

Narratives of self-responsibility are pervasive in neoliberally oriented contexts, and have been found to engender feelings of shame and failure amongst those affected by poverty. Here, we use findings from research in two low-income communities in south-west England to examine how these narratives become embodied within people's daily lives when they intersect with systems of welfare support and the current political drive to upscale treatment for common mental health conditions. Drawing on Bourdieu's notion of symbolic violence, we examine how narratives of self-responsibility and associated welfare reform strategies impact on the mental health of people living in economic hardship. The data show how such narratives inflict, sustain and exacerbate mental distress and suffering, and how they become naturalised and normalised by individuals themselves. We demonstrate how this situation pushes people to seek support from General Practitioners, and how clinical interactions can normalise, and in turn, medicalise, poverty-related distress. Whilst some people actively resist dominant narratives around self-responsibility, we argue that this is insufficient under broader sociocultural and political circumstances, to free themselves from the harms perpetuated by symbolic violence.

Understanding and building resilience to early life trauma in Belarus and Ukraine

In 2018 and early 2019, the WHO Regional Office for Europe’s cultural contexts of health and well-being project worked alongside the University of Exeter’s WHO Collaborating Centre on Culture and Health, the Minsk Regional Centre for Psychiatry and Addiction, and the Institute of Mental Health of the Ukrainian Catholic University to engage researchers, practitioners, health-care workers and other relevant stakeholders in a series of workshops on the cultural contexts of early life trauma in Belarus and Ukraine. The initiative built on previous collaborative work to support the development of culturally informed mental health care in central and eastern Europe. This report reflects the content of the workshops through a collection of participant essays highlighting key cultural contexts and opportunities for fostering more protective and health-enhancing environments for young people in Belarus and Ukraine. It highlights the important role of subjective forms of evidence within culturally nuanced approaches to health and wellbeing enhancement, and aims to open up further interest in and opportunities for collaboration to address this under-researched area of mental health in the WHO European Region.

Exploring how patients respond to GP recommendations for mental health treatment: an analysis of communication in primary care consultations.

BACKGROUND: Patient take-up and adherence to antidepressants and talking therapy is low. However, little is known about how GPs recommend these treatments and whether patients accept them. AIM: To examine how GPs recommend antidepressants and talking therapy, and how patients respond. DESIGN & SETTING: A total of 52 recorded primary care consultations for depression, anxiety, and stress were analysed. METHOD: Using a standardised coding scheme, five ways doctors recommend treatment were coded, conveying varying authority and endorsement. The treatment recommendation types were as follows: more directive pronouncements (I'll start you on X); proposals (How about we start X?); less directive suggestions (Would you like to try X?); offers (Do you want me to give you X?); and assertions (There are medications that might help). It was also coded whether patients accepted, passively resisted (for example, withholding response), or actively resisted (for example, I've tried that before). RESULTS: A total of 33 recommendations occurred in 23 consultations. In two-thirds of cases, GPs treated the patient as primary decision-maker by using suggestions, offers, or assertions. In one-third of cases, they used more directive pronouncements or proposals. GPs endorsed treatment moderately (67%), weakly (18%), or strongly (15%). Only one-quarter of recommendations were accepted immediately. Patients cited fears about medication side effects and/or dependency, group therapy, and doubts about treatment efficacy. Despite three-quarters of patients resisting, 76% got prescriptions or self-referral information for talking therapy. CONCLUSION: Initially, GPs treat patients as the decision-maker. However, although patients resist, most end up with treatment. This may impact negatively on treatment uptake and success. Social prescribing may fill a treatment gap for some patients.

Antibiotic resistance: using a cultural contexts of health approach to address a global health challenge

This policy brief has been developed in response to the contemporary challenge of antibiotic resistance (ABR). ABR poses a formidable threat to global health and sustainable development. It is now increasingly recognized that the systematic neglect of cultural factors is one of the biggest obstacles to achieving better health outcomes and better standards of living worldwide. Using a cultural contexts of health approach, the policy brief explores the centrality of culture to the challenge of ABR. The brief examines how the prescription and use of antibacterial medicines, the transmission of resistance, and the regulation and funding of research are influenced by cultural, social and commercial, as well as biological and technological factors. The brief moves beyond the ready equation of culture with individual behaviours and demonstrates how culture serve as an enabler of health and provide new possibilities for change.

Устойчивость к антибиотикам: у чет культ урных контекстов здоровья при решении глобальной проблемы здравоохранения

Подготовка настоящего аналитического обзора представляет собой одну из мер реагирования на существующую в современном мире проблему устойчивости к антибиотикам, которая является серьезной угрозой для глобального здравоохранения и устойчивого развития. Сегодня всё чаще приходится признавать, что пренебрежение культурными факторами, носящее систематический характер, стало одним из крупнейших препятствий на пути к улучшению здоровья и повышению качества жизни людей во всем мире. В настоящем обзоре, подготовленном с учетом культурных контекстов здоровья, рассматривается центральная роль культуры в борьбе с устойчивостью к антибиотикам и описывается, каким образом назначение и применение противомикробных препаратов, передача резистентности и регулирование и финансирование научных исследований связаны с воздействием культурных, социальных и коммерческих, а также биологических и технологических факторов. Авторы выходят за рамки упрощенного представления о культуре как о совокупности поведения индивидов и демонстрируют, что культура может выступать фактором, способствующим укреплению здоровья населения и создающим возможности для перемен.

Healthy publics: enabling cultures and environments for health.

Despite extraordinary advances in biomedicine and associated gains in human health and well-being, a growing number of health and well-being related challenges have remained or emerged in recent years. These challenges are often 'more than biomedical' in complexion, being social, cultural and environmental in terms of their key drivers and determinants, and underline the necessity of a concerted policy focus on generating healthy societies. Despite the apparent agreement on this diagnosis, the means to produce change are seldom clear, even when the turn to health and well-being requires sizable shifts in our understandings of public health and research practices. This paper sets out a platform from which research approaches, methods and translational pathways for enabling health and well-being can be built. The term 'healthy publics' allows us to shift the focus of public health away from 'the public' or individuals as targets for intervention, and away from the view that culture acts as a barrier to efficient biomedical intervention, towards a greater recognition of the public struggles that are involved in raising health issues, questioning what counts as healthy and unhealthy and assembling the evidence and experience to change practices and outcomes. Creating the conditions for health and well-being, we argue, requires an engaged research process in which public experiments in building and repairing social and material relations are staged and sustained even if, and especially when, the fates of those publics remain fragile and buffeted by competing and often more powerful public formations.

Культура имеет значение: учет культурных контекстов здоровья при выработке политики

Данный аналитический обзор подготовлен в связи с растущей осведомленностью лиц, формирующих политику, и специалистов общественного здравоохранения о важной связи, которая существует между культурой и здоровьем. Отражение осведомленности в вопросах культуры в выработке политики имеет огромное значение для формирования адаптивных, справедливых и устойчивых систем медико-санитарной помощи, а также для общего прогресса во многих вопросах здоровья и благополучия населения. В обзоре рассматриваются три ключевые сферы общественного здравоохранения – питание, миграция и окружающая среда – и демонстрируется, насколько важную роль осведомленность в вопросах культуры играет в понимании концепций здоровья и благополучия и в выработке более эффективных и справедливых стратегий здравоохранения. В нем утверждается, что научные исследования в сфере гуманитарных и социальных дисциплин, имеющих отношение к здоровью, способны внести немалый вклад в выработку политики в области общественного здравоохранения.

Culture matters: using a cultural contexts of health approach to enhance policy making

This policy brief has been developed in response to the increasing awareness among policy-makers and the public health community of the important relationship between culture and health. Incorporating cultural awareness into policy-making is critical to the development of adaptive, equitable and sustainable health care systems, and to making general improvements in many areas of population health and well-being. By exploring the three key public health areas of nutrition, migration and environment, the policy brief demonstrates how cultural awareness is central to understanding health and well-being and to developing more effective and equitable health policies. Consequently, it argues that public health policy-making has much to gain from applying research from the health-related humanities and social sciences.

Young people's use of medicines: Pharmaceuticalised governance and illness management within household and school settings.

Recent decades have witnessed a significant rise in the use and 'misuse' of pharmaceutical medicines. Without significant behavioural change, the adverse health and environmental impacts resulting from medicine misuse will be most felt by today's young people. Yet despite real concerns surrounding pharmaceutical sustainability, insights into the ways that understandings of, and expectations to take medicines are communicated to, and taken up by young people remain limited. This paper draws on research focused around everyday home and school settings, to examine how understandings and norms relating to medicine use become embedded within the lives of young people. Between May 2014-January 2015, fifty students (aged 11-14) from one secondary school in England participated in focus groups and forty-three in interviews. Two focus groups were held with parents (n = 10). Findings demonstrate that attitudes towards medicine use were bound up with notions of parental responsibility, risk, peer governance and social acceptability, labour-related expectations, and processes of regulation within the school. Indeed, it was clear that medication use was often a compromised solution in response to wider structural pressures and demands and that such thinking was embedded at an early stage in the life course. The study found that few opportunities arose for open and informed discussion relating to responsible medicine use. Such circumstances demonstrate that any attempts to change medicine-related attitudes and behaviours should be considered within the wider social and structural contexts that govern their use.

Blood Glucose Levels of Subelite Athletes During 6 Days of Free Living.

BACKGROUND: Continuous glucose monitoring (CGM) devices, with their 1-5 min measurement interval, allow blood glucose (BG) concentration dynamics to be captured more frequently and less invasively than traditional BG measures. One cohort CGM could provide insight is athletes. This study investigates what impact their heightened energy expenditure and dietary intake may have on their ability to achieve optimal BG. METHODS: Ten subelite athletes (resting HR<60 bpm, training>6 hrs per week) were recruited. Two Ipro2 CGM devices (Medtronic Minimed, Northridge, CA) were inserted into the abdomen and remained in place for ~6 days. Time in band was calculated as the percentage of CGM BG measurements with in the 4.0-6.0 mmol/L. Fasting glucose was calculated using CGM calibration BG measurements and postprandial glucose response was also calculated using the CGM values. RESULTS: 4/10 athletes studied spent more than 70% of the total monitoring time above 6.0 mmol/L even with the 2-hour period after meals is excluded. Fasting BG was also in the ADA defined prediabetes range for 3/10 athletes. Only 1 participant spent substantial time below 4.0 mmol/L which was largely due to significantly lower energy intake compared to recommendations. CONCLUSIONS: Contrary to expectations high BG appears to be more of a concern for athletes then low BG even in those with the highest energy expenditure and consuming below the recommended carbohydrate intake. This study warrants further investigation on the recommended diets and the BG of athletes to better determine the causes and impact of this hyperglycemia on overall athlete health.

Safety, efficacy and clinical generalization of the STAR protocol: a retrospective analysis.

BACKGROUND: The changes in metabolic pathways and metabolites due to critical illness result in a highly complex and dynamic metabolic state, making safe, effective management of hyperglycemia and hypoglycemia difficult. In addition, clinical practices can vary significantly, thus making GC protocols difficult to generalize across units.The aim of this study was to provide a retrospective analysis of the safety, performance and workload of the stochastic targeted (STAR) glycemic control (GC) protocol to demonstrate that patient-specific, safe, effective GC is possible with the STAR protocol and that it is also generalizable across/over different units and clinical practices. METHODS: Retrospective analysis of STAR GC in the Christchurch Hospital Intensive Care Unit (ICU), New Zealand (267 patients), and the Gyula Hospital, Hungary (47 patients), is analyzed (2011-2015). STAR Christchurch (BG target 4.4-8.0 mmol/L) is also compared to the Specialized Relative Insulin and Nutrition Tables (SPRINT) protocol (BG target 4.4-6.1 mmol/L) implemented in the Christchurch Hospital ICU, New Zealand (292 patients, 2005-2007). Cohort mortality, effectiveness and safety of glycemic control and nutrition delivered are compared using nonparametric statistics. RESULTS: Both STAR implementations and SPRINT resulted in over 86 % of time per episode in the blood glucose (BG) band of 4.4-8.0 mmol/L. Patients treated using STAR in Christchurch ICU spent 36.7 % less time on protocol and were fed significantly more than those treated with SPRINT (73 vs. 86 % of caloric target). The results from STAR in both Christchurch and Gyula were very similar, with the BG distributions being almost identical. STAR provided safe GC with very few patients experiencing severe hypoglycemia (BG < 2.2 mmol/L, <5 patients, 1.5 %). CONCLUSIONS: STAR outperformed its predecessor, SPRINT, by providing higher nutrition and equally safe, effective control for all the days of patient stay, while lowering the number of measurements and interventions required. The STAR protocol has the ability to deliver high performance and high safety across patient types, time, clinical practice culture (Christchurch and Gyula) and clinical resources.