Creating change in government to address the social determinants of health: how can efforts be improved?

Background: The evidence base for the impact of social determinants of health has been strengthened considerably in the last decade. Increasingly, the public health field is using this as a foundation for arguments and actions to change government policies. The Health in All Policies (HiAP) approach, alongside recommendations from the 2010 Marmot Review into health inequalities in the UK (which we refer to as the ‘Fairness Agenda’), go beyond advocating for the redesign of individual policies, to shaping the government structures and processes that facilitate the implementation of these policies. In doing so, public health is drawing on recent trends in public policy towards ‘joined up government’, where greater integration is sought between government departments, agencies and actors outside of government. Methods: In this paper we provide a meta-synthesis of the empirical public policy research into joined up government, drawing out characteristics associated with successful joined up initiatives. We use this thematic synthesis as a basis for comparing and contrasting emerging public health interventions concerned with joined-up action across government. Results: We find that HiAP and the Fairness Agenda exhibit some of the characteristics associated with successful joined up initiatives, however they also utilise ‘change instruments’ that have been found to be ineffective. Moreover, we find that – like many joined up initiatives – there is room for improvement in the alignment between the goals of the interventions and their design. Conclusion: Drawing on public policy studies, we recommend a number of strategies to increase the efficacy of current interventions. More broadly, we argue that up-stream interventions need to be ‘fit-for-purpose’, and cannot be easily replicated from one context to the next

Occupational therapy-led pulmonary rehabilitation: A practice analysis

Statement of context: Pulmonary rehabilitation is accepted as an essential strategy for the management of respiratory disease. However, there is wide variation in models of service delivery, and evidence to understand which elements are most effective is less clear. This analysis outlines key elements of an occupational therapy-led pulmonary rehabilitation programme. Critical reflection on practice: It is proposed that the core focus on occupation and the unique skills and reasoning of occupational therapists contribute to positive outcomes for service users. Implications for practice: Occupational therapists are ideally placed to lead and develop pulmonary rehabilitation programmes. As there is genuine uncertainty about which elements are most effective, this analysis should encourage further evaluation and research

A systematic review and meta-analysis of the association between emotional stress reactivity and psychosis

AimEmotional stress reactivity may be a mediating factor in the association between trauma and psychosis. This review aimed to (i) identify, summarise and critically evaluate the link between emotional stress reactivity and psychotic experiences (ii) examine evidence for a 'dose–response' relationship between stress reactivity and psychosis in the wider psychosis phenotype (i.e., sub-clinical symptoms).MethodsElectronic database searches (PsychINFO, MEDLINE, EMBASE) were conducted for studies which investigated the link between stress reactivity and psychosis, psychotic symptoms, or a vulnerability to developing psychosis (wider phenotype). Cross-sectional, experimental and experience sampling method study designs were eligible for inclusion.ResultsFourty five eligible articles were identified (N participants = 8830). Narrative synthesis showed that increased emotional stress reactivity was associated with psychosis and subclinical psychotic experiences across all study designs, however, findings were inconsistent across studies. The preliminary meta-analysis (k = 4, n = 383) showed increases in emotional stress reactivity was associated with higher negative affect in response to event-related stress, in those with psychosis compared to controls (mean difference in beta coefficients = 0.05, 95% CI 0.02–0.08, p = .004). However, this difference was small with a considerable degree of heterogeneity (p = .001, I2 = 81%) so results should be interpreted with caution.ConclusionsOverall, the evidence suggests that there is a link between emotional stress reactivity and psychosis in those with psychosis, those at high risk of developing psychosis and in relation to subclinical psychotic-like experiences in the general population

“Have they got rehab potential?” – An ethnographic study exploring meaning and evaluations of rehabilitation potential for an older person following an acute admission

Rehabilitation potential is the potential of an individual to benefit from interventions which aim to optimise and restore function after a period of ill-health or new onset of disability. Health professionals are frequently required to evaluate this potential to determine who may be most likely to benefit from the provision of ongoing rehabilitation services. This doctoral study explored decision-making related to the assessment of rehabilitation potential of older people in hospital and the recommendation of rehabilitation pathways. To explore this in real-time, and in the shared patient and professional context in which decision-making occurred, principles of ethnographic and case-study research were utilised. The case study site was one acute medical ward within a local acute hospital in the North East of England. Three phases of fieldwork were undertaken, including a 2-week orientation and mapping phase, an 8 week period centred on the practice of occupational therapists and physiotherapists in relation to five patient cases, and finally a phase which involved five in-depth interviews with individual health professionals. Data was generated through observation, interviews and the review of clinical records. The whole data-set was analysed using thematic analysis. Key findings highlight that rehabilitation in this context was understood as a process to facilitate physical improvements and associated with an organisational aim for optimum safety rather than optimum function. And, although idealised as a phase of care, rehabilitation was often linked to a specific place, with the evaluation of rehabilitation potential subsequently linked with a hospital transfer. Furthermore, rehabilitation potential was ambiguous and poorly explained to patients and families. Health professionals recognised that their evaluation of rehabilitation potential was linked to high-stakes decisions about access to, or withholding services, and therefore the ethical dimensions of this decision had far-reaching influence. The involvement of the older person in judgements about rehabilitation potential and pathways was minimal, and there were many critical challenges to older people receiving fair and just access to services. The research findings conclude that there are significant tensions between the context of acute hospital care and the philosophy and ideals of rehabilitation. Furthermore, findings can assist professionals to recognise and reconcile tensions in practice and to move towards reframing rehabilitation to place the individual needs of older people at the centre of service delivery

Social prescribing nomenclature, occupational therapy and the theory of Institutional Work: Creating, maintaining and disrupting medical dominance

Social prescribing is a process of helping people to access non-medical activities and services which address health and wellbeing needs. The process is frequently (although not exclusively) initiated by primary health care professionals and often involves prescribing activities or initiatives provided by community and voluntary organizations. To occupational therapy, the links between activity, social-connectedness and health are clearly not new, although there are emerging international examples of social prescribing initiatives, and examples of newly developed roles, processes and funding opportunities, all of which are creating momentum behind the agenda. In this commentary, we draw upon the theory of Institutional Work to examine how the language of “prescription,” and the purposive action of policy-makers and practitioners, is shaping thinking and action in relation to activity and health. Arguably, this language has helped to translate the recommendation of activity to meet a range of health needs in to an accessible and implementable concept. However, it has also potentially contributed to positioning the concept within a medical model of health, upholding medical dominance, and leaving occupational therapy on the margins of the debate

Exploring how occupational therapists and physiotherapists evaluate rehabilitation potential of older people in acute care

Introduction Evaluations of rehabilitation potential are an everyday occurrence, yet the concept is poorly understood and there is a lack of understanding about the reasoning process. This study aimed to explore how occupational therapists and physiotherapists evaluated the rehabilitation potential of older people following an acute hospital admission. Method Focused ethnography was utilised, primarily using observation, interviewing and review of records within one acute medical ward in a general hospital in the United Kingdom. Five patient participants gave consent for their episode of care to be studied, for interactions with professionals to be observed and for their clinical records to be reviewed. Three occupational therapists and two physiotherapists then participated in individual interviews. Findings Thematic analysis of data led to the identification of a four-stage reasoning process. The four stages are as follows: gathering baseline information; provision of curative and supportive interventions; provision and monitoring of rehabilitative interventions; the evaluation of rehabilitation potential and decision about the subsequent pathway. Conclusions The reasoning process illustrates the professional reasoning of occupational therapists and physiotherapists when evaluating rehabilitation potential for older adults in acute care. However, it also highlights vulnerabilities to professional reasoning which may contribute to subjectivity, inconsistency or risk to patients

Service User Perspectives on Engagement in an Occupational Therapy-Led Pulmonary Rehabilitation Programme: A Qualitative Interview Study

Introduction: Pulmonary rehabilitation (PR) is an intervention for people with chronic respiratory conditions. There are questions about which components are important to its success, including the nature of occupational therapy involvement. The aim of this research was to explore the experiences of people who had attended an occupational therapy-led PR programme in the United Kingdom to determine the most important components.Method: Semi-structured telephone interviews were conducted with service users who had experience of a community based PR programme. Interviews were transcribed verbatim. Data were analysed using the framework analysis method with three researchers contributing to the analysis. Findings: Nine people took part in the interviews, with a mean age of 72 years. Four themes were identified which were organised around the concepts of Doing, Being, Becoming Belonging. These were ‘Doing exercise and physical activity’, ‘being breathless’, ‘belonging as an individual within the group’ and ‘becoming a person who lives with COPD’. Conclusion: Doing physical activity, whilst coping with being breathless and belonging as an individual within a group can positively influence experiences and perceived outcomes during and after PR. These dimensions have the potential to shape occupation-focussed PR programmes and the occupational therapy contribution in this area of practice

Optimizing dry-matter partitioning for increased spike growth, grain number and harvest index in spring wheat

Improving biomass is an important goal for future genetic gains in yield potential in wheat, but it will also be crucial to identify physiological traits to maximize harvest index (HI, proportion of aboveground biomass in grain). Increased grain partitioning will require increased dry-matter (DM) partitioning to the spikes at anthesis as well as enhanced fruiting efficiency (FE, grains per g spike dry matter at anthesis or chaff dry matter at harvest), whilst optimizing the partitioning amongst the non-grain components to maintain post-anthesis photosynthetic capacity and soluble carbohydrate translocation. The objectives of this study were to: i) quantify genetic variation in DM partitioning among plant organs at anthesis (GS65) + 7days and associations with spike growth and FE and ii) identify optimized partitioning traits associated with enhanced HI and grain yield, in CIMMYT elite spring wheat backgrounds. Two field experiments were conducted in 2011-12 and 2012-13 testing 26 CIMMYT spring wheat cultivars in NW Mexico in irrigated conditions in which DM partitioning was assessed in plant organs at anthesis + 7 days, and within-spike (glume, palea, lemma, rachis and awn) partitioning was assessed at harvest. Grain yield, yield components, HI and FE were assessed at harvest. Our results identified new traits for HI (decreased DM partitioning to stem internodes 2 (top down, peduncle-1) and 3, and decreased rachis DM partitioning and rachis specific weight (rachis DM per rachis unit length) and increased lemma DM partitioning), potentially allowing breeders to maximize the exploitation of enhanced carbon assimilation for grain biomass. Further work will focus on understanding the role of soluble carbohydrate re-translocation in these relationships and establishing high-throughput and cost-effective phenotyping methods for these traits for deployment in breeding

Backpack

The Personal Data Store (PDS), herein referred to as the Backpack, was proposed as an opportunity to improve the experience of accessing services and enabling integrated and person-centred care. The project explored the potential solution developed by the project partners: Mydex CIC, a community interest company who specialise in personal data management, together with NHS Grampian and Moray Social Health and Care Partnership. The overall aims of the research project were to explore how people living with Multiple Sclerosis (MS) would like to manage their personal information in order to improve the experience of accessing services, and understand the potential of the Backpack to support health and care professionals to deliver more integrated and person-centred care. To meet these aims, design researchers at The Glasgow School of Art led a participatory design process with people living with MS and health and social care professionals. People living with MS were identified as highly knowledgeable co-design participants, due to the complex and progressive nature of the condition, requiring wide-ranging interactions with statutory services. Participants living with MS were involved in a Mini-Lab to explore current experiences of accessing services and managing information and an Experience Lab, which used design-led activities to map key moments of data sharing and developed paper-based prototypes of the Backpack. A second Experience Lab involved health and social care professionals in testing prototypes of the Backpack, identifying user requirements from the perspective of service providers, and understanding how access to person-owned data stores would change current working practices. Analysis of the conversations, maps and prototypes led to: i) a wealth of insight about the current experience and challenges of service users and providers; ii) the identification of a set of overall principles to shape the development of the person-owned data store; iii) synthesis of the main ideas for functionality as four overarching but complementary concepts that describe how the Backpack could manifest; and iv) a number of scenarios of use to describe how the principles and concepts could support person-centred and convenient access to services