Physical activity and retirement: original analysis of responses to the English Adult Active Lives Survey.

OBJECTIVES: Opportunities for older adults to do physical activity may depend on other commitments. We wanted to see if reported physical activity was higher or lower among older adults depending on work status: full-time, part-time work or retired. METHODS: This is a secondary analysis of The Active Lives Survey 2016/17 in England. The dataset was used to see how active people were depending on employment or retirement status. Types of physical activity (PA) considered were: leisure, gardening, active travel and combined total, adjusted for age, sex, BMI, disability, rurality and deprivation in models using hurdle regression. Analysis was divided into mostly working age (under 65) or mostly retired (age 65 +) to have sensitivity to the likely transition point. RESULTS: Total PA was significantly greater for retired persons compared to both full- and part-time workers age 55-64, while being retired or working part-time at age 65-74 meant more PA. People did more leisure or gardening with less work, but active travel decreased with fewer work hours, at all ages. Retirement meant more leisure and gardening PA but less active travel. CONCLUSIONS: Demand for opportunities to engage in leisure and gardening PA appears to be high among retired people. Greater promotion of active travel in this cohort may be possible.

The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient's priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman's concept of 'frames' to present an examination of how doctors' and patients' sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients' understanding of the goal-setting consultation, GPs actively aligning with patients' framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided "telling cases" of goal-setting interactions, where doctors and patients need to negotiate each other's perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations.

Health Literacy in the Everyday Lives of Older Adults in Greece, Hungary, and the Netherlands.

Health literacy (HL) encompasses someone's knowledge and abilities to access and use health information in order to make appropriate health decisions in life. HL is particularly valuable in later life when health challenges grow. An individual's HL is typically considered a fixed and skills-based characteristic, without taking into account how these are situated in the context of everyday life. Also, lay perspectives on health literacy are relatively scarce. Therefore, the aim of this article is to explore the context-specific perspectives of older adults and health professionals on HL in later life in Greece, Hungary, and the Netherlands. We adopted a qualitative methodology and conducted 12 focus groups: seven with 50 older adults and five with 30 health professionals to gain insight into individual perspectives on HL as situated in the health care and everyday life contexts. An informed grounded theory approach was used in analyzing the data. The results are structured in three themes: (1) interactions with health professionals, (2) perceived quality of the health care system, and (3) managing health in the context of everyday life. An overarching finding is that, for older adults, HL reflects the demands placed on them when managing their health. In the experience of older adults, these demands are placed upon them by healthcare professionals, the healthcare system, as well as their everyday lives. Our findings underscore the importance of Critical Health Literacy (CHL) as that concept foregrounds that HL is context specific. Also, CHL has been argued to be a community characteristic, which is why we call for community-based approaches to improve HL.

Continuous glucose monitoring in older people with diabetes and memory problems: a mixed-methods feasibility study in the UK.

OBJECTIVES: Older people with diabetes are at increased risk of harm from hypoglycaemia, particularly where there are coexisting memory problems. Continuous glucose monitoring (CGM) offers important benefits in terms of detecting hypoglycaemia, but the feasibility of use and extent of data capture has not been tested in this patient group. Our objective was to investigate the feasibility of trialling a CGM intervention in the community setting in older people with diabetes and memory problems. DESIGN: Mixed-methods feasibility study. SETTING: Community dwellings in the UK. PARTICIPANTS: Patients aged ≥65 with diabetes and abbreviated mental test score ≤8 or known dementia. INTERVENTION: FreeStyle Libre CGM. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility criteria were numbers of eligible patients, recruitment, attrition, extent of capture of glucose readings and adverse events. Qualitative interview. RESULTS: We identified 49 eligible participants; 17 consented, but 5 withdrew before recording of data because they or their carers felt unable to manage study procedures. 12 participants (mean age 85 years) completed the study without adverse events. Data capture across 14 days ranged between 3% and 92% (mean 55%); 6 participants had <60% capture. Hypoglycaemic events were recorded in six out of nine insulin users. Qualitative interviews found: the device does not interfere with daily activities, usability and comfort was positive, and it was helpful for carers in monitoring participants' glucose concentrations. CONCLUSIONS: The device was acceptable to participants, and carers reported greater ease in monitoring the participant's glucose concentrations. However, completeness of data capture varied considerably with this device due to the need for users to conduct ≥3 scans per day. Real-time devices with automated data transfer may be more suitable in older people with memory problems.

Setting goals with patients living with multimorbidity: qualitative analysis of general practice consultations.

BACKGROUND: Establishing patient goals is widely recommended as a way to deliver care that matters to the individual patient with multimorbidity, who may not be well served by single-disease guidelines. Though multimorbidity is now normal in general practice, little is known about how doctors and patients should set goals together. AIM: To determine the key components of the goal-setting process in general practice. DESIGN AND SETTING: In-depth qualitative analysis of goal-setting consultations in three UK general practices, as part of a larger feasibility trial. Focus groups with participating GPs and patients. The study took place between November 2016 and July 2018. METHOD: Activity analysis was applied to 10 hours of video-recorded doctor-patient interactions to explore key themes relating to how goal setting was attempted and achieved. Core challenges were identified and focus groups were analysed using thematic analysis. RESULTS: A total of 22 patients and five GPs participated. Four main themes emerged around the goal-setting process: patient preparedness and engagement; eliciting and legitimising goals; collaborative action planning; and GP engagement. GPs were unanimously positive about their experience of goal setting and viewed it as a collaborative process. Patients liked having time to talk about what was most important to them. Challenges included eliciting goals from unprepared patients, and GPs taking control of the goal rather than working through it with the patient. CONCLUSION: Goal setting required time and energy from both parties. GPs had an important role in listening and bearing witness to their patients' goals. Goal setting worked best when both GP and patient were prepared in advance.

Can goal-setting for patients with multimorbidity improve outcomes in primary care? Cluster randomised feasibility trial.

INTRODUCTION: Goal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice. OBJECTIVE: To assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial. DESIGN AND SETTING: Cluster-randomised controlled feasibility trial of goal-setting compared with control in six general practices. PARTICIPANTS: Adults with two or more long term health conditions and at risk of unplanned hospital admission. INTERVENTIONS: General practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation 6 months later. The control group received usual care planning. OUTCOME MEASURES: Health-related quality of life (EQ-5D-5L), capability (ICEpop CAPability measure for Older people), Patient Assessment of Chronic Illness Care and healthcare use. All consultations were video-recorded or audio-recorded, and focus groups were held with participating GPs and patients. RESULTS: Fifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years, 54% were female and the median number of prescribed medications was 13, compared with 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 min in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting and felt it delivered more patient-centred care, and they highlighted the importance of training. CONCLUSIONS: This goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN13248305; Post-results.

Age, sex and other correlates with active travel walking and cycling in England: Analysis of responses to the Active Lives Survey 2016/17.

Active travel (walking or cycling for transport) can generate personal and environmental benefits. We determined the frequency of participation in walking or cycling active travel by age and sex, as well as used multivariate analysis to find correlations with many other factors using a large cross-sectional 2016/17 survey of people living in England. Walking and cycling active travel were explored separately. Most respondents reported no active travel, but at least 25% of people under age 45 met activity recommendations only from active travel. Otherwise, (unlike other types of physical activity) active travel declined consistently with increased age. Men reported much more cycling active travel than women, who were more likely to do any active travel walking and therefore more likely to meet activity guidelines from just active travel walking. Lower levels of disability, fewer children in household, and working full time increased active travel. Season was sometimes relevant. BMI, personal-effectiveness, deprivation and rurality had mixed relationships with types of active travel. Understanding differences in correlates for cycling vs. walking active travel could help tailor local promotion programmes for each. The analysis suggests that motivators and barriers for active travel greatly by age.

The politics of ageing: health consumers, markets and hegemonic challenge.

In recent years ageing has travelled from the placid backwaters of politics into the mainstream of economic, social and cultural debate. What are the forces that have politicised ageing, creating a sustained opposition to the supply side hegemony of pharmaceuticals, medicine and state which has historically constructed, propagated and legitimised the understanding of ageing as decline in social worth? In addressing this question, the paper develops Gramsci's theory of hegemony to include the potentially disruptive demand side power of consumers and markets. It shows how in the case of ageing individuals acting in concert through the mechanisms of the market, and not institutionalised modes of opposition, may become the agents of hegemonic challenge through a combination of lifecourse choice and electoral leverage. In response, the hegemony is adapting through the promotion of professionally defined interpretations of 'active ageing' designed to retain hegemonic control. With the forces of hegemony and counter-hegemony nicely balanced and fresh issues such as intergenerational justice constantly emerging, the political tensions of ageing are set to continue.

Patient and public involvement in health literacy interventions: a mapping review.

PLAIN ENGLISH SUMMARY: If people can read, understand and act on health information to better their health and reduce illness, they are thought to have "adequate" health literacy. Poor health literacy can mean people are less able to access health care and manage their health. Health literacy tends to worsen as adults get older, and is especially poor in adults age 65 and over. Ideally, health literacy interventions target people before age 65, to establish good skills and habits before people have many health problems associated with ageing. It is also good if researchers consult ordinary people, including patients and the public (PPI) when planning a programme to try to improve health literacy. This may help ensure individual needs are catered for.We therefore looked for studies that described any role of patient or public representatives in the research planning stages. We explored how the representatives contributed to each project. We found only 20 studies that included people other than the research team. Lack of reporting and consultation with patient and public representatives may contribute to less success when public health programmes are undertaken. BACKGROUND: Health literacy is the ability to understand, access and use health care and is a critical mediating factor that affects the health of older adults. Patient and public involvement in health and social care research, policy and design of care delivery is one mechanism that can promote production of better health literacy. This mapping review looks for and describes practices, concepts and methods that have been reported involving patients and public in the development and design of health literacy interventions for older people. METHODS: Studies for the present review were selected from an inventory of health behaviour studies published between 2003 and 2013. The inventory was created by systematic searches on bibliographic databases (Medline, CINAHL, Scopus, Google) for health literacy interventions involving older people (50+ years) and resulted in screening of 5561 articles, of which 1097 met study inclusion criteria. For the research described in this article 96 of the 1097 studies specifically focused on health literacy and were independently screened by two reviewers to assess involvement of stakeholders other than investigators and participants. RESULTS: Twenty studies included patient and/or public involvement in at least one research domain: design, management or evaluation. Involvement included volunteers, older people, patients, and/or community representatives. CONCLUSIONS: Patient and public involvement were rarely reported in studies on health literacy interventions for older people. Future intervention development needs high quality PPI, which is well reported to develop the evidence base and inform practice.

A systematic review of the physical activity assessment tools used in primary care.

Background: Primary care is an ideal setting for physical activity interventions to prevent and manage common long-term conditions. To identify those who can benefit from such interventions and to deliver tailored support, primary care professionals (e.g. GPs, practice nurses, physiotherapists, health care assistants) need reliable and valid tools to assess physical activity. However, there is uncertainty about the best-performing tool. Objective: To identify the tools used in the literature to assess the physical activity in primary care and describe their psychometric properties. Method: A systematic review of published and unpublished literature was undertaken up to 1 December 2016). Papers detailing physical activity measures, tools or approaches used in primary care consultations were included. A synthesis of the frequency and context of their use, and their psychometric properties, was undertaken. Studies were appraised using the Downs and Black critical appraisal tool and the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) initiative checklist. Results: Fourteen papers reported 10 physical activity assessment tools. The General Practice Physical Activity Questionnaire (GPPAQ) was most frequently reported. None of the assessment tools identified showed high reliability and validity. Intra-rater reliability ranged from kappa: 0.53 [Brief Physical Activity Assessment Tool (BPAAT)] to 0.67 (GPPAQ). Criterion validity ranged from Pearson's rho: 0.26 (GPPAQ) to 0.52 (Physical Activity Vital Sign). Concurrent validity ranged from kappa: 0.24 (GPPAQ) to 0.64 (BPAAT). Conclusion: The evidence base about physical activity assessment in primary care is insufficient to inform current practice.

Controlling new knowledge: Genomic science, governance and the politics of bioinformatics.

The rise of bioinformatics is a direct response to the political difficulties faced by genomics in its quest to be a new biomedical innovation, and the value of bioinformatics lies in its role as the bridge between the promise of genomics and its realization in the form of health benefits. Western scientific elites are able to use their close relationship with the state to control and facilitate the emergence of new domains compatible with the existing distribution of epistemic power - all within the embrace of public trust. The incorporation of bioinformatics as the saviour of genomics had to be integrated with the operation of two key aspects of governance in this field: the definition and ownership of the new knowledge. This was achieved mainly by the development of common standards and by the promotion of the values of communality, open access and the public ownership of data to legitimize and maintain the governance power of publicly funded genomic science. Opposition from industry advocating the private ownership of knowledge has been largely neutered through the institutions supporting the science-state concordat. However, in order for translation into health benefits to occur and public trust to be assured, genomic and clinical data have to be integrated and knowledge ownership agreed upon across the separate and distinct governance territories of scientist, clinical medicine and society. Tensions abound as science seeks ways of maintaining its control of knowledge production through the negotiation of new forms of governance with the institutions and values of clinicians and patients.

Developing a new empathy-specific admissions test for applicants to medical schools: A discourse-pragmatic approach.

The ability to empathise with patients is an important professional skill for doctors. Medical students practise this skill as part of their medical education, and are tested on their use of empathy within their final examination. Evidence shows that appropriate training makes a difference but that natural aptitude also plays a role. Most medical schools, therefore, probe applicants' basic understanding of empathy at admissions interviews. The purpose of the project presented in this paper was to apply existing understanding of how empathy may be communicated in a clinical context (building on a literature review by Pounds [2011]) to develop a new empathy-specific medical admissions interview station, probing applicants' empathic communicative performance (not just theoretical knowledge) and fitting the widely used Multiple Mini Interview (MMI) format. The paper outlines how this tool was developed, trialled and implemented by: (1) conceptualising empathic communication in discourse-pragmatic terms - that is, as a set of specific but context-dependant empathic speech acts; and (2) formulating and trialling a written and two oral versions of a situational test, capable of probing the applicants' ability to communicate empathically in everyday conversation and suitable for use at Norwich Medical School and other similar educational institutions.

Bioinformatics and the Politics of Innovation in the Life Sciences: Science and the State in the United Kingdom, China, and India.

The governments of China, India, and the United Kingdom are unanimous in their belief that bioinformatics should supply the link between basic life sciences research and its translation into health benefits for the population and the economy. Yet at the same time, as ambitious states vying for position in the future global bioeconomy they differ considerably in the strategies adopted in pursuit of this goal. At the heart of these differences lies the interaction between epistemic change within the scientific community itself and the apparatus of the state. Drawing on desk-based research and thirty-two interviews with scientists and policy makers in the three countries, this article analyzes the politics that shape this interaction. From this analysis emerges an understanding of the variable capacities of different kinds of states and political systems to work with science in harnessing the potential of new epistemic territories in global life sciences innovation.

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial.

BACKGROUND: Medication organisation devices (MODs) provide compartments for a patient's medication to be organised into the days of the week and the recommended times the medication should be taken. AIM: To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs. DESIGN: The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated. SETTING: Potential participants were identified by medical practices. PARTICIPANTS: Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable. INTERVENTIONS: One of three MODs widely used in routine clinical practice supplied either weekly or monthly. OBJECTIVES: To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation. METHODS: The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery. RESULTS: Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50-60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly. CONCLUSIONS: MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients. FUTURE WORK: A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required. STUDY REGISTRATION: Current Controlled Trials ISRCTN 30626972 and UKCRN 12739. FUNDING: This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

Methodological review: quality of randomized controlled trials in health literacy.

BACKGROUND: The growing move towards patient-centred care has led to substantial research into improving the health literacy skills of patients and members of the public. Hence, there is a pressing need to assess the methodology used in contemporary randomized controlled trials (RCTs) of interventions directed at health literacy, in particular the quality (risk of bias), and the types of outcomes reported. METHODS: We conducted a systematic database search for RCTs involving interventions directed at health literacy in adults, published from 2009 to 2014. The Cochrane Risk of Bias tool was used to assess quality of RCT implementation. We also checked the sample size calculation for primary outcomes. Reported evidence of efficacy (statistical significance) was extracted for intervention outcomes in any of three domains of effect: knowledge, behaviour, health status. Demographics of intervention participants were also extracted, including socioeconomic status. RESULTS: We found areas of methodological strength (good randomization and allocation concealment), but areas of weakness regarding blinding of participants, people delivering the intervention and outcomes assessors. Substantial attrition (losses by monitoring time point) was seen in a third of RCTs, potentially leading to insufficient power to obtain precise estimates of intervention effect on primary outcomes. Most RCTs showed that the health literacy interventions had some beneficial effect on knowledge outcomes, but this was typically for less than 3 months after intervention end. There were far fewer reports of significant improvements in substantive patient-oriented outcomes, such as beneficial effects on behavioural change or health (clinical) status. Most RCTs featured participants from vulnerable populations. CONCLUSIONS: Our evaluation shows that health literacy trial design, conduct and reporting could be considerably improved, particularly by reducing attrition and obtaining longer follow-up. More meaningful RCTs would also result if health literacy trials were designed with public and patient involvement to focus on clinically important patient-oriented outcomes, rather than just knowledge, behaviour or skills in isolation.

Healthy ageing in Europe: prioritizing interventions to improve health literacy.

BACKGROUND: Health literacy (HL) is low for 40-50 % of the population in developed nations, and is strongly linked to many undesirable health outcomes. Older adults are particularly at risk. The intervention research on health literacy in ageing populations project systematically created a large inventory of HL interventions targeting adults age 50+ , to support practical production of policy and practice guidelines for promoting health literacy in European populations. METHODS: We comprehensively surveyed international scientific literature, grey literature and other sources (published 2003+) for implemented HL interventions that involved older adults. Studies were screened for eligibility criteria and further selected for aspects important in European public health policy, including priority diseases, risk factors and vulnerable target groups. Interventions were prioritised using a multiple criteria tool to select final interventions that also featured strong evidence of efficacy and a broad range of strategies. RESULTS: From nearly 7000 written summaries, 1097 met inclusion criteria, of which 233 were chosen for scoring and ranking. Of these, seven had the highest multi-criteria scores. Eight more articles were selected based on rounded criteria including a high multi-criteria score as well as elements of innovation. Final selections were 18 articles describing 15 programmes, which feature strong evidence of efficacy among important diseases or risk factors and vulnerable groups, or that had success with elements of innovation were identified. Most programmes tried to increase skills in communication, self-management and understanding healthcare or lifestyle choices. CONCLUSIONS: These programmes have multiple positive attributes which could be used as guidance for developing innovative intervention programmes to trial on European older adults. They provide evidence of efficacy in addressing high priority diseases and risk factors.

The association of health literacy with adherence in older adults, and its role in interventions: a systematic meta-review.

BACKGROUND: Low health literacy is a common problem among older adults. It is often suggested to be associated with poor adherence. This suggested association implies a need for effective adherence interventions in low health literate people. However, previous reviews show mixed results on the association between low health literacy and poor adherence. A systematic meta-review of systematic reviews was conducted to study the association between health literacy and adherence in adults above the age of 50. Evidence for the effectiveness of adherence interventions among adults in this age group with low health literacy was also explored. METHODS: Eight electronic databases (MEDLINE, ERIC, EMBASE, PsycINFO, CINAHL, DARE, the Cochrane Library, and Web of Knowledge) were searched using a variety of keywords regarding health literacy and adherence. Additionally, references of identified articles were checked. Systematic reviews were included if they assessed the association between health literacy and adherence or evaluated the effectiveness of interventions to improve adherence in older adults with low health literacy. The AMSTAR tool was used to assess the quality of the included reviews. The selection procedure, data-extraction, and quality assessment were performed by two independent reviewers. Seventeen reviews were selected for inclusion. RESULTS: Reviews varied widely in quality. Both reviews of high and low quality found only weak or mixed associations between health literacy and adherence among older adults. Reviews report on seven studies that assess the effectiveness of adherence interventions among low health literate older adults. The results suggest that some adherence interventions are effective for this group. The interventions described in the reviews focused mainly on education and on lowering the health literacy demands of adherence instructions. No conclusions could be drawn about which type of intervention could be most beneficial for this population. CONCLUSIONS: Evidence on the association between health literacy and adherence in older adults is relatively weak. Adherence interventions are potentially effective for the vulnerable population of older adults with low levels of health literacy, but the evidence on this topic is limited. Further research is needed on the association between health literacy and general health behavior, and on the effectiveness of interventions.

Challenging social cognition models of adherence: cycles of discourse, historical bodies, and interactional order.

Attempts to model individual beliefs as a means of predicting how people follow clinical advice have dominated adherence research, but with limited success. In this article, we challenge assumptions underlying this individualistic philosophy and propose an alternative formulation of context and its relationship with individual actions related to illness. Borrowing from Scollon and Scollon's three elements of social action­historical body, interaction order, and discourses in place­we construct an alternative set of research methods and demonstrate their application with an example of a person talking about asthma management. We argue that talk- or illness-related behavior, both viewed as forms of social action, manifest themselves as an intersection of cycles of discourse, shifting as individuals move through these cycles across time and space. We conclude by discussing how these dynamics of social action can be studied and how clinicians might use this understanding when negotiating treatment with patients.

The preparedness of newly qualified doctors - Views of Foundation doctors and supervisors.

BACKGROUND: There is evidence that newly qualified doctors do not feel prepared to start work. AIM: This study examined the views of first year Foundation doctors (F1) and supervisors regarding how prepared they felt newly qualified doctors were for the early weeks of work. METHODS: Fifty-two F1s took part in a focus group or individual interview during their first year of Foundation training. Twenty-two supervisors took part in an individual interview. RESULTS: The F1s struggled with new responsibilities, decision-making, time management, prioritizing tasks and the large administrative component to their role. They felt unprepared for making diagnoses, prescribing and acting in an emergency. Supervisors felt F1s were generally well prepared to start work, with skills improving through experience. However, F1s needed more practical experience with real patients and more opportunities to take responsibility, make decisions and perform some clinical skills. Supervisors did not feel that F1s accessed senior support appropriately. F1s indicated they preferred to go to peers for assistance in the first instance, and felt unsupported by seniors, particularly at weekends and on night shifts. CONCLUSIONS: Specific areas of unpreparedness were identified by both F1s and supervisors; leading to recommendations to enhance effective transition from medical student to F1.