Personal and organisational health literacy in the non-specific symptom pathway for cancer: An ethnographic study.

INTRODUCTION: People being investigated for cancer face a wealth of complex information. Non-specific symptom pathways (NSS) were implemented in the United Kingdom in 2017 to address the needs of patients experiencing symptoms such as weight loss, fatigue or general practitioner 'gut feeling', who did not have streamlined pathways for cancer investigation. This study aimed to explore the health literacy skills needed by patients being investigated for cancer in NSS pathways. METHODS: This study employed ethnographic methods across four hospitals in England, including interviews, patient shadowing and clinical care observations, to examine NSS pathways for cancer diagnosis. We recruited 27 patients who were shadowed and interviewed during their care. We also interviewed 27 professionals. The analysis focused on patient communication and understanding, drawing on the concepts of personal and organisational health literacy. RESULTS: Our analysis derived six themes highlighting the considerable informational demands of the NSS pathway. Patients were required to understand complex blood tests and investigations in primary care and often did not understand why they were referred. The NSS pathway itself was difficult to understand with only a minority of patients appreciating that multiple organs were being investigated for cancer. The process of progressing through the pathway was also difficult to understand, particularly around who was making decisions and what would happen next. The results of investigations were complex, often including incidental findings. Patients whose persistent symptoms were not explained were often unsure of what to do following discharge. CONCLUSION: We have identified several potential missed opportunities for organisations to support patient understanding of NSS pathways which could lead to inappropriate help-seeking post-discharge. Patients' difficulties in comprehending previous investigations and findings could result in delays, overtesting or inadequately targeted investigations, hindering the effective use of their medical history. Third, patients' limited understanding of their investigations and results may impede their ability to engage in patient safety by reporting potential care errors. PATIENT OR PUBLIC CONTRIBUTION: Patient, public, clinical and policy representatives contributed to developing the research objectives through a series of meetings and individual conversations in preparation for the study. We have held several events in which patients and the public have had an opportunity to give feedback about our results, such as local interest groups in North London and academic conferences. A clinical contributor (J.-A. M.) was involved in data analysis and writing the manuscript.

Assessing awareness of blood cancer symptoms and barriers to symptomatic presentation: measure development and results from a population survey in the UK.

BACKGROUND: Low levels of cancer awareness may contribute to delays in seeking medical help and subsequent delays in diagnosis. For blood cancer this may be a particularly prominent problem due to the high prevalence of undifferentiated symptoms such as bodily pain, weakness, nausea and weight loss, resulting in low symptom awareness. The delay is exacerbated by the dismissal of similar symptoms which are often interpreted as mild disease, resulting in multiple consultations prior to diagnosis. This study describes the development of a Cancer Awareness Measure for Blood Cancer (Blood CAM) and presents results from a population-representative survey using the measure. METHODS: A rapid systematic review identified constructs relevant to blood cancer. Items were taken from previous awareness measures and other literature and reviewed by expert groups including health care professionals and patients. Cognitive interviews were conducted with ten members of the public to check comprehension and clarity. A total sample of 434 participants completed the survey at Time 1 and n = 302 at Time 2 (two weeks later). RESULTS: Internal reliability was high across the different constructs included in the questionnaire (> 0.70) and test-retest reliability was moderate to good (0.49-0.79). The most commonly recognised blood cancer symptoms were unexplained weight loss (68.9%) and unexplained bleeding (64.9%) and the least commonly recognised symptoms were night sweats (31.3%) breathlessness and rash/itchy skin (both 44%). In terms of symptom experience, fatigue was the most commonly reported symptom (26.7%) followed by night sweats (25.4%). Exploratory factor analysis of barriers to presenting at primary care revealed three distinct categories of barriers; emotional, external/practical and service/healthcare professional related. Service and emotional barriers were most common. CONCLUSIONS: We developed a valid and reliable tool to assess blood cancer awareness and showed variable awareness of blood cancer symptoms which can help target public health campaigns. We also incorporated additional measures (e.g. confidence to re-consult, ability to understand symptoms) that could be used to tailor public messaging for blood cancer and for other harder to suspect and diagnose cancers.

The relationship between patient enablement and help-seeking in the context of blood cancer symptoms.

OBJECTIVE: Approaches to improve earlier diagnosis of cancer often focus on symptom awareness as a key driver of help-seeking behaviour and other psychological influences are less well understood. This is the first study to explore the role of patient enablement on help-seeking for people experiencing potential blood cancer symptoms. METHODS: A cross-sectional, nationally representative survey was completed by 434 respondents (>18 years). Questions asked about symptom experiences, medical help-seeking and re-consultation. Existing patient enablement items were included in the newly developed Blood Cancer Awareness Measure. We collected data on patient socio-demographic characteristics. RESULTS: Of those responding to the survey 224/434 (51.6%) reported experiencing at least one potential blood cancer symptom. Half of those experiencing symptoms (112/224) had sought medical help. Results from logistic regression analysis showed that higher scores on patient enablement were associated with being less likely to seek help (Odds Ratio [OR] 0.89, Confidence Interval [CI] 0.81-0.98) after controlling for socio-demographics. Separate analyses showed that higher enablement was associated with being more comfortable to re-consult if symptoms didn't go away or got worse (OR 1.31, CI 1.16-1.48); after a test result suggested there was nothing to worry about, but symptoms persisted (OR 1.23, CI 1.12-1.34) or to request further tests, scans or investigations (OR 1.31, CI 1.19-1.44). CONCLUSIONS: Contrary to our hypotheses, patient enablement was associated with lower likelihood of help-seeking for potential blood cancer symptoms. Yet enablement appears to play an important role in likelihood of re-consulting when symptoms persist, get worse or need further investigation.

Evaluating recovery colleges: a co-created scoping review.

BACKGROUND: Recovery Colleges (RCs) are education-based centres providing information, networking, and skills development for managing mental health, well-being, and daily living. A central principle is co-creation involving people with lived experience of mental health/illness and/or addictions (MHA). Identified gaps are RCs evaluations and information about whether such evaluations are co-created. AIMS: We describe a co-created scoping review of how RCs are evaluated in the published and grey literature. Also assessed were: the frameworks, designs, and analyses used; the themes/outcomes reported; the trustworthiness of the evidence; and whether the evaluations are co-created. METHODS: We followed Arksey and O'Malley's methodology with one important modification: "Consultation" was re-conceptualised as "co-creator engagement" and was the first, foundational step rather than the last, optional one. RESULTS: Seventy-nine percent of the 43 included evaluations were peer-reviewed, 21% grey literature. These evaluations represented 33 RCs located in the UK (58%), Australia (15%), Canada (9%), Ireland (9%), the USA (6%), and Italy (3%). CONCLUSION: Our findings depict a developing field that is exploring a mix of evaluative approaches. However, few evaluations appeared to be co-created. Although most studies referenced co-design/co-production, few described how much or how meaningfully people with lived experience were involved in the evaluation.

Healthcare Professional and Patient Perceptions of Changes in Colorectal Cancer Care Delivery During the COVID-19 Pandemic and Impact on Health Inequalities.

BACKGROUND: The COVID-19 pandemic changed the way in which people were diagnosed and treated for cancer. We explored healthcare professional and patient perceptions of the main changes to colorectal cancer delivery during the COVID-19 pandemic and how they impacted on socioeconomic inequalities in care. METHODS: In 2020, using a qualitative approach, we interviewed patients (n = 15) who accessed primary care with colorectal cancer symptoms and were referred for further investigations. In 2021, we interviewed a wide range of healthcare professionals (n = 30) across the cancer care pathway and gathered national and local documents/guidelines regarding changes in colorectal cancer care. RESULTS: Changes with the potential to exacerbate inequalities in care, included: the move to remote consultations; changes in symptomatic triage, new COVID testing procedures/ways to access healthcare, changes in visitor policies and treatment (e.g., shorter course radiotherapy). Changes that improved patient access/convenience or the diagnostic process have the potential to reduce inequalities in care. DISCUSSION: Changes in healthcare delivery during the COVID-19 pandemic have the ongoing potential to exacerbate existing health inequalities due to changes in how patients are triaged, changes to diagnostic and disease management processes, reduced social support available to patients and potential over-reliance on digital first approaches. We provide several recommendations to help mitigate these harms, whilst harnessing the gains.

What are the similarities and differences in lung cancer symptom appraisal and help-seeking according to smoking status? A qualitative study with lung cancer patients.

OBJECTIVE: Lung cancer in never-smokers represents a growing proportion of patients. The relationship between smoking status, symptom appraisal and help-seeking behaviour is complex. Little is known about cancer symptom-related health behaviours according to smoking status. The aim of the study was to explore lung cancer patients' experiences of a lung cancer diagnosis, identifying differences by smoking history. METHOD: This was a qualitative study involving telephone interviews with 40 lung cancer patients (20 never smokers, 11 former smokers and 9 current smokers). We used framework analysis to analyse the data using the Common Sense Model of Illness Self-Regulation as a theoretical framework, developed after initial analysis. RESULTS: All patients were likely to delay seeking help for symptoms in primary care regardless of smoking history, but for different reasons. Smoking history was instrumental to how individuals perceived and responded to early symptoms of lung cancer. Differences in interpretation and coping responses to new symptoms seemed to be caused by the higher presence of comorbidities due to smoking, and perceptions of the current state of health. Individuals with a smoking history reported acting with urgency in seeking help and follow up, whereas patients who experienced low levels of concern were more easily reassured by clinicians, resulting in delays. CONCLUSIONS: Never and former smokers perceive, interpret, and respond to symptoms of lung cancer differently to smokers. However, few people attribute their lung symptoms to cancer initially, even with a smoking history. Interventions that drive increased urgency and vigilance in never smokers may be effective.

Lung cancer symptom appraisal, help-seeking and diagnosis - rapid systematic review of differences between patients with and without a smoking history.

BACKGROUND: Lung cancer is the leading cause of cancer death in the world. A significant minority of lung cancer patients have never smoked (14% in the UK, and ranging from 10% to 25% worldwide). Current evidence suggests that never-smokers encounter delays during the diagnostic pathway, yet it is unclear how their experiences and reasons for delayed diagnoses differ from those of current and former smokers. This rapid review assessed literature about patient experiences in relation to symptom awareness and appraisal, help-seeking, and the lung cancer diagnostic pathway, comparing patients with and without a smoking history. METHODS: MEDLINE, PsychINFO and Google Scholar were searched for studies (2010-2020) that investigated experiences of the pathway to diagnosis for patients with and without a smoking history. Findings are presented using a narrative synthesis. RESULTS: Analysis of seven quantitative and three qualitative studies revealed that some delays during symptom appraisal and diagnosis are unique to never-smokers. Due to the strong link between smoking and lung cancer, and low awareness of non-smoking related lung cancer risk factors and symptoms, never-smokers do not perceive themselves to be at risk. Never-smokers are also likely to evaluate their experiences in comparison with other non-smoking related cancers, where prognosis is likely better, potentially leading to lower satisfaction with healthcare. CONCLUSION: Never-smokers appear to have different experiences in relation to symptom appraisal and diagnosis. However, evidence in relation to help-seeking, and what is driving diagnostic delays for never-smoker patients specifically is lacking.

Acceptability of a standalone written leaflet for the National Health Service for England Targeted Lung Health Check Programme: A concurrent, think-aloud study.

BACKGROUND: Many countries are introducing low-dose computed tomography screening programmes for people at high risk of lung cancer. Effective communication strategies that convey risks and benefits, including unfamiliar concepts and outcome probabilities based on population risk, are critical to achieving informed choice and mitigating inequalities in uptake. METHODS: This study investigated the acceptability of an aspect of NHS England's communication strategy in the form of a leaflet that was used to invite and inform eligible adults about the Targeted Lung Health Check (TLHC) programme. Acceptability was assessed in terms of how individuals engaged with, comprehended and responded to the leaflet. Semi-structured, 'think aloud' interviews were conducted remotely with 40 UK screening-naïve current and former smokers (aged 55-73). The verbatim transcripts were analysed thematically using a coding framework based on the Dual Process Theory of cognition. RESULTS: The leaflet helped participants understand the principles and procedures of screening and fostered cautiously favourable intentions. Three themes captured the main results of the data analysis: (1) Response-participants experienced anxiety about screening results and further investigations, but the involvement of specialist healthcare professionals was reassuring; (2) Engagement-participants were rapidly drawn to information about lung cancer prevalence, and benefits of screening, but deliberated slowly about early diagnosis, risks of screening and less familiar symptoms of lung cancer; (3) Comprehension-participants understood the main principles of the TLHC programme, but some were confused by its rationale and eligibility criteria. Radiation risks, abnormal screening results and numerical probabilities of screening outcomes were hard to understand. CONCLUSION: The TLHC information leaflet appeared to be acceptable to the target population. There is scope to improve aspects of comprehension and engagement in ways that would support informed choice as a distributed process in lung cancer screening. PATIENT OR PUBLIC CONTRIBUTION: The insight and perspectives of patient representatives directly informed and improved the design and conduct of this study.

Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review.

BACKGROUND: The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement. METHODS: We used a scoping review methodology drawing on Arksey and O'Malley's methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 - April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills. RESULTS: We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking. CONCLUSIONS: We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers.

Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals.

BACKGROUND: One reason for the introduction of digital technologies into health care has been to try to improve safety and patient outcomes by providing real-time access to patient data and enhancing communication among health care professionals. However, the adoption of such technologies into clinical pathways has been less examined, and the impacts on users and the broader health system are poorly understood. We sought to address this by studying the impacts of introducing a digitally enabled care pathway for patients with acute kidney injury (AKI) at a tertiary referral hospital in the United Kingdom. A dedicated clinical response team-comprising existing nephrology and patient-at-risk and resuscitation teams-received AKI alerts in real time via Streams, a mobile app. Here, we present a qualitative evaluation of the experiences of users and other health care professionals whose work was affected by the implementation of the care pathway. OBJECTIVE: The aim of this study was to qualitatively evaluate the impact of mobile results viewing and automated alerting as part of a digitally enabled care pathway on the working practices of users and their interprofessional relationships. METHODS: A total of 19 semistructured interviews were conducted with members of the AKI response team and clinicians with whom they interacted across the hospital. Interviews were analyzed using inductive and deductive thematic analysis. RESULTS: The digitally enabled care pathway improved access to patient information and expedited early specialist care. Opportunities were identified for more constructive planning of end-of-life care due to the earlier detection and alerting of deterioration. However, the shift toward early detection also highlighted resource constraints and some clinical uncertainty about the value of intervening at this stage. The real-time availability of information altered communication flows within and between clinical teams and across professional groups. CONCLUSIONS: Digital technologies allow early detection of adverse events and of patients at risk of deterioration, with the potential to improve outcomes. They may also increase the efficiency of health care professionals' working practices. However, when planning and implementing digital information innovations in health care, the following factors should also be considered: the provision of clinical training to effectively manage early detection, resources to cope with additional workload, support to manage perceived information overload, and the optimization of algorithms to minimize unnecessary alerts.

The Influence of Contextual Factors on Running Performance in Female Australian Football Match-Play.

Black, GM, Gabbett, TJ, Naughton, G, Cole, MH, Johnston, RD, and Dawson, B. The influence of contextual factors on running performance in female Australian football match-play. J Strength Cond Res 33(9): 2488-2495, 2019-Given the recent growth of the professional status among multiple female football codes, the aim of this study is to investigate the effects of contextual factors on activity profiles and pacing strategies in female Australian football (AF) players. Thirty-five female AF players participated in this study. Global positioning system analysis was completed over 1 competitive season. Matches were separated into eight 10-minute periods. Greater distances were covered during the first half irrespective of playing position (effect size [ES] = 0.39-0.50, Likelihood ≥90%). Throughout a number of periods half-backs (defensive players) covered greater distances during losses (ES ≥ 0.74, Likelihood ≥92%) and against top 3 opponents (ES ≥ 1.0, Likelihood ≥97%). Midfielders and half-backs covered greater distances (ES ≥ 0.49, Likelihood ≥89%) in the final match period in winning compared with losing matches. A reduction in player work rate is evident during the second half of matches. The influence of contextual factors varied across positional groups. However, it is clear that coaches could use player rotation both early in the match in an attempt to delay the effect of fatigue and more frequently during the second half to increase running intensity.

What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population.

BACKGROUND: Cancer has long inspired fear, but the effect of fear is not well understood; it seems both to facilitate and to deter early diagnosis behaviours. To elucidate fear's behavioural effects, we systematically reviewed and synthesised qualitative literature to explore what people fear about cancer. METHODS: We searched Medline, Embase, PsycInfo, Web of Science, AnthroSource, and Anthrobase for studies on cancer fear in breast, cervical, and colorectal cancer screening and analysed 102 studies from 26 countries using thematic synthesis. RESULTS: Fears of cancer emanated from a core view of cancer as a vicious, unpredictable, and indestructible enemy, evoking fears about its proximity, the (lack of) strategies to keep it at bay, the personal and social implications of succumbing, and fear of dying from cancer. CONCLUSIONS: This view of cancer as 'an enemy' reprises the media's 'war on cancer' theme and may affect the acceptance of cancer early detection and prevention messages, since cancer's characteristics influenced whether 'fight' or 'flight' was considered appropriate.

Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study.

BACKGROUND: Stage at diagnosis of breast cancer varies by socio-economic status (SES), with lower SES associated with poorer survival. We investigated associations between SES (indexed by education), and the likelihood of attributing breast symptoms to breast cancer. METHOD: We conducted an online survey with 961 women (47-92 years) with variable educational levels. Two vignettes depicted familiar and unfamiliar breast changes (axillary lump and nipple rash). Without making breast cancer explicit, women were asked 'What do you think this […..] could be?' After the attribution question, women were asked to indicate their level of agreement with a cancer avoidance statement ('I would not want to know if I have breast cancer'). RESULTS: Women were more likely to mention cancer as a possible cause of an axillary lump (64%) compared with nipple rash (30%). In multivariable analysis, low and mid education were independently associated with being less likely to attribute a nipple rash to cancer (OR 0.51, 0.36-0.73 and OR 0.55, 0.40-0.77, respectively). For axillary lump, low education was associated with lower likelihood of mentioning cancer as a possible cause (OR 0.58, 0.41-0.83). Although cancer avoidance was also associated with lower education, the association between education and lower likelihood of making a cancer attribution was independent. CONCLUSION: Lower education was associated with lower likelihood of making cancer attributions for both symptoms, also after adjustment for cancer avoidance. Lower likelihood of considering cancer may delay symptomatic presentation and contribute to educational differences in stage at diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.

Does the stigma of mental illness contribute to suicidality?

Mental disorders are associated with suicidality and with stigma. Many consequences of stigma, such as social isolation, unemployment, hopelessness or stress, are risk factors for suicidality. Research is needed on the link between stigma and suicidality as well as on anti-stigma interventions and their effects on suicidality.

Improving Olympic health services: what are the common health care planning issues?

INTRODUCTION: Due to their scale, the Olympic and Paralympic Games have the potential to place significant strain on local health services. The Sydney 2000, Athens 2004, Beijing 2008, Vancouver 2010, and London 2012 Olympic host cities shared their experiences by publishing reports describing health care arrangements. HYPOTHESIS: Olympic planning reports were compared to highlight best practices, to understand whether and which lessons are transferable, and to identify recurring health care planning issues for future hosts. METHODS: A structured, critical, qualitative analysis of all available Olympic health care reports was conducted. Recommendations and issues with implications for future Olympic host cities were extracted from each report. RESULTS: The six identified themes were: (1) the importance of early planning and relationship building: clarifying roles early to agree on responsibility and expectations, and engaging external and internal groups in the planning process from the start; (2) the development of appropriate medical provision: most health care needs are addressed inside Olympic venues rather than by hospitals which do not experience significant increases in attendance during the Games; (3) preparing for risks: gastrointestinal and food-borne illnesses are the most common communicable diseases experienced during the Games, but the incidence is still very low; (4) addressing the security risk: security arrangements are one of the most resource-demanding tasks; (5) managing administration and logistical issues: arranging staff permission to work at Games venues ("accreditation") is the most complex administrative task that is likely to encounter delays and errors; and (6) planning and assessing health legacy programs: no previous Games were able to demonstrate that their health legacy initiatives were effective. Although each report identified similar health care planning issues, subsequent Olympic host cities did not appear to have drawn on the transferable experiences of previous host cities. CONCLUSION: Repeated recommendations and lessons from host cities show that similar health care planning issues occur despite different health systems. To improve health care planning and delivery, host cities should pay heed to the specific planning issues that have been highlighted. It is also advisable to establish good communication with organizers from previous Games to learn first-hand about planning from previous hosts.

Match intensity and pacing strategies in rugby league: an examination of whole-game and interchanged players, and winning and losing teams.

There is currently limited information on whether pacing occurs during rugby league match play. In addition, to date no research has investigated whether pacing strategies differ between winning and losing teams. This study investigated the pacing strategies of whole-game and interchanged rugby league players. Furthermore, we investigated the pacing strategies of winning and losing teams. Fifty-two rugby league players, from a sample of 11 teams competing in a semi-elite competition, underwent global positioning system analysis. Performances were divided into match quartiles for whole-game and interchanged players. Total distance, including low- and high-speed distances, and repeated high-intensity effort bouts were recorded. The total distance and low-speed distance covered across all quartiles of the match, but specifically quartiles 1 and 8, were greater for interchanged players than whole-game players. The match outcome differentially affected the pacing strategies of whole-game and interchanged players. Whole-game players from winning teams set a higher pacing strategy than whole-game players from losing teams (effect size [ES] = 1.03 ± 0.77, 96%, very likely), whereas interchanged players from losing teams demonstrated a greater "end-spurt" than interchanged players from winning teams (ES = 0.60 ± 0.52, 96%, very likely). The pacing strategies of interchanged players were higher than whole-game players, irrespective of playing position. The results of this study suggest that pacing strategies differ between interchanged and whole-game rugby league players. Furthermore, our results demonstrate a different pacing strategy between winning and losing teams. These findings suggest that physical preparation for rugby league matches, and recovery from these matches, should be individualized for whole-game and interchanged players. Finally, performing physically intense training on a regular basis is likely to develop the physical and mental qualities required to regularly compete at higher playing intensities.

Understanding the phenomenology of borderline personality disorder from the patient's perspective.

BACKGROUND: Guidelines and clinical practice focuses on behavioural symptoms of borderline personality disorder, yet other experiences are more persistent and detrimental to psychosocial function. It is unclear how this relates to the experience of individuals with the diagnosis. AIMS: To understand more about phenomenology of borderline personality disorder from the patient's perspective. METHODS: We interviewed nine people with a borderline personality disorder from specialist services in South London, UK. The data were analysed using a phenomenological qualitative method. RESULTS: Individuals experienced frightening perceptual changes that were rationalised in meaningful ways. Participants related their intense experiences to their families, finding them both protective and burdensome. CONCLUSIONS: The results illuminate contradictory behaviours, offering content for clinical interventions. Particularly, this study has provided some novel perspectives about suicidality and interactions with family and friends.

Relative sensitivity of depth discrimination for ankle inversion and plantar flexion movements.

25 participants (20 women, 5 men) were tested for sensitivity in discrimination between sets of six movements centered on 8 degrees, 11 degrees, and 14 degrees, and separated by 0.3 degrees. Both inversion and plantar flexion movements were tested. Discrimination of the extent of inversion movement was observed to decline linearly with increasing depth; however, for plantar flexion, the discrimination function for movement extent was found to be non-linear. The relatively better discrimination of plantar flexion movements than inversion movements at around 11 degrees from horizontal is interpreted as an effect arising from differential amounts of practice through use, because this position is associated with the plantar flexion movement made in normal walking. The fact that plantar flexion movements are discriminated better than inversion at one region but not others argues against accounts of superior proprioceptive sensitivity for plantar flexion compared to inversion that are based on general properties of plantar flexion such as the number of muscle fibres on stretch.

Communicating effectively to patients about a cancer referral.

BACKGROUND: The UK's National Institute for Health and Care Excellence (NICE) advises GPs to inform patients referred to the Urgent Suspected Cancer (USC) pathway about their impending service and expectations. However, little is known about patient experiences and information needs post-referral. GPs often grapple with conveying the urgency of referrals while offering reassurance. AIM: This study explores GP communication regarding cancer and USC referrals. METHOD: A secondary analysis of 23 audio-recorded GP-patient consultations, selected from a larger dataset of 200 consultations in Surrey and London (2017-2018), was conducted, focusing on discussions related to cancer. RESULTS: We found that most GPs informed patients that they might have cancer and engaged in reassurance about the patient's low risk of cancer using personalised risk statements. Some GPs, however, avoided all mention of cancer, using symptom-led language instead. GPs tended to focus on communicating practical rather than support-based information when discussing the referral. While most GPs informed patients that they would be seen by a specialist within two weeks, few discussed patients' support needs during the referral or specialist appointment. CONCLUSION: This presentation will offer language recommendations for clear communication about cancer referrals. This plays an important role in promoting shared decision-making and driving patient attendance for investigations. The study highlights the need for further research on communication practices around cancer referral to improve patient understanding and experience. Our recommendations for enhanced communication may improve patient outcomes by optimising routes to diagnosis via primary care.