Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine - A health professional perspective

Abstract Background Non-communicable diseases (NCDs) - including cardiovascular disease (CVD), cancer and diabetes - have become a significant global burden on health. Particularly concerning are CVD rates, causing approximately 18 million deaths worldwide every year. The statistics show that the disease is no longer a predominantly high-income country phenomenon, but affects, increasingly, countries in both developing regions and conflict-affected areas. In the occupied Palestinian territory (oPt), the focus of this article, CVD ranks top of ten NCD killers, accounting for approximately 37.6% of deaths. Key risk factors discerned in primary care settings have been related to both structural determinants (i.e. the Israeli occupation) and individual behavioural factors. Unfortunately, no data are available for secondary care settings in the region and, consequently, little is known about patients and their capacity for risk factor behaviour change to manage their CVD. To begin closing this gap in knowledge, our study provides insight into cardiovascular disease secondary prevention care with the overall aim to enhance the understanding of the complexities of managing NCDs like CVD in conflict-affected settings. Specifically, research was carried out among Palestinian health professionals who specialise in coronary artery disease in the West Bank to elicit their views on (a) how socio-political, health system and individual behavioural factors might hinder patients to change their health behaviour and impact on the provision of healthcare and (b) possible solutions for overcoming identified barriers to behaviour change on societal as well as individual-patient levels within secondary care provision in a context of protracted conflict. Methods This study is based on a qualitative approach in order to provide more in-depth information about health beliefs and behaviours, experiences and views of health professionals with regards to CVD secondary care. In total, 12 semi-structured interviews were conducted among doctors providing treatment to patients with CVD in secondary care settings. Interviews focused on health professionals’ perspectives on risk factors and perceived barriers to behaviour change among known CVD patients receiving secondary care. Interviewees were also asked to propose possible actions that could be taken to overcome the identified barriers at both societal and individual patient levels. All interviews were digitally recorded, transcribed and analysed using thematic analysis. Results Study results confirmed our prior theory of the complex entanglement of socio-political, health system and individual-level factors with regards to CVD experience, health-seeking and treatment. Also confirmed was our assumption that it is crucial to understand experts’ definitions and approaches to treatment in order to grasp their visions for appropriate and improved prevention and treatment options. In particular, study participants highlighted how political determinants, notably the detrimental impact of the Israeli occupation, and social determinants, directly and indirectly influence behavioural determinants due to physical and bureaucratic barriers to accessing health facilities, economic hardship and chronic stress. These stressors, in turn, were perceived as having a negative effect on individual behavioural risk factors including smoking, unhealthy diet and an increasingly sedentary lifestyle. Proposed solutions included more focused interventions from the Ministry of Health as well as surveillance, primary prevention and health promotion, and management to positively effect behaviour change in order to address the growing burden of CVD in the region. Conclusions The study has highlighted medical professionals’ perceptions of how structural and individual behavioural determinants influence their own and individual patient’s abilities to manage cardiovascular risk factors in a setting affected by chronic conflict. Consequently, we propose that medical and social intervention strategies generally used to address CVD risk, be strategically adapted in order to be useful and effective in contexts of armed conflict. Specifically, we call for a solid understanding of the socio-political context and existing health services as well as health providers’ and patients’ health beliefs and related behaviours when developing future health options aimed at addressing CVD in the region. Moreover, for health provision to be effective as well as sustainable, attention needs to be given above all towards a solution for political change

Students as change partners in the School of Literature and Languages at the University of Reading

The pedagogic landscape in Higher Education (HE) has certainly witnessed change in recent years, and involving students as partners in aspects of degree programme development is part of that change (Lowe and Dunne, 2017). Darling-Hammond (2009) described how educational systems internationally are changing priorities to enable students to ‘cope with complexity, use new technologies, and work cooperatively to frame and solve novel problems’ (p. 45). Zhao (2011) asserts that it is vital to engage students as partners in change, giving them an active hand in programme design, to enable students to develop into creative individuals who leave education with much more than just an academic qualification; it is an ‘authentic way to develop professional skills’ (Giles, Martin, Bryce & Hendry, 2004, p. 681) as well as an opportunity to develop a positive and autonomous approach to learning that will be long lasting and productive The case study which follows involved students working cooperatively with each other and with staff in a School of Literature and Languages. Together, we re-designed a new module aimed at developing students’ understanding of the demands of university level study and writing and supporting them in their transition from sixth form to Higher Education

Previous pregnancies among young women having an abortion in England and Wales

Purpose: The purpose of this study is to use national statistics on abortions carried out in England and Wales to more precisely estimate the proportion of young women aged under 20 obtaining an abortion who have had one or more previous pregnancies. Methods: Secondary analysis of abortion data from the Office of National Statistic and the Department of Health by parity for women under 20, ordinarily residing in England and Wales, from 1992 - 2013. Results: Over the last 20 years, the proportion of teenagers in England and Wales having an abortion as a result of a subsequent pregnancy increased by 33% (from 0.172 in 1992 to 0.229 in 2013). The majority of this increase occurred prior to 2004 and the proportion now appears to have stabilised. In 2013, 22.9% of the young women aged under 20 who underwent an abortion had had at least one previous pregnancy (either a birth or an abortion). Only a minority (less than 5% of teenagers who obtained an abortion) had had more than one previous pregnancy. Conclusions: The findings show that nearly one in four teenagers presenting for an abortion have already been in contact with health services for a previous birth or abortion. Greater policy emphasis must be placed on the accurate identification of the proportion of teenage pregnancies that occur as a result of a subsequent pregnancy and developing more effective 'secondary prevention' interventions to help first-time pregnant and parenting teenagers

Vulnerability of horticultural crop production to extreme weather events

The potential impact of future extreme weather events on horticultural crops was evaluated. A review was carried out of the sensitivities of a representative set of crops to environmental challenges. It confirmed that a range of environmental factors are capable of causing a significant impact on production, either as yield or quality loss. The most important of these were un-seasonal temperature, water shortage or excess,and storms. Future scenarios were produced by the LARS-WG1, a stochastic weather generator linked with UKCIP02 projections of future climate. For the analyses, 150 years of synthetic weather data were generated for baseline, 2020HI and 2050HI scenarios at defined locations. The output from the weather generator was used in case studies, either to estimate the frequency of a defined set of circumstances known to have impact on cropping, or as inputs to models of crop scheduling or pest phenology or survival. The analyses indicated that episodes of summer drought severe enough to interrupt the continuity of supply of salads and other vegetables will increase while the frequency of autumns with sufficient rainfall to restrict potato lifting will decrease. They also indicated that the scheduling of winter cauliflowers for continuity of supply will require the deployment of varieties with different temperature sensitivities from those in use currently. In the pest insect studies, the number of batches of Agrotis segetum (cutworm) larvae surviving to third instar increased with time, as did the potential number of generations of Plutella xylostella (diamond-back moth) in the growing season, across a range of locations. The study demonstrated the utility of high resolution scenarios in predicting the likelihood of specific weather patterns and their potential effect on horticultural production. Several limitations of the current scenarios and biological models were also identified

Effects of landscape and region on pests and pathogens in Brassica vegetables and oilseed rape.

Abstract: Pests and pathogens of Brassica vegetables and oilseed rape are mainly managed at a field level. Management of pest insects at a farm level is only suitable for farmers owning compact areas of land, which is not the case in many central European areas. This paper discusses the effects of landscape and region on pests and pathogens in Brassica crops. Topics covered include pest and disease dispersal and persistence, regional races or biotypes, new pests and pathogens, insecticide resistance, conservation biocontrol and monitoring and forecasting

Molecular mechanisms in human hepatocellular carcinoma

MD ThesisHepatocellular carcinoma (HCQ is one of the commonest cancers worldwide. There is, however, a marked geographical variation in incidence and it has been suggested that the pathogenesis may vary in different parts of the world. A retrospective analysis of 110 HCC patients was initially undertaken which confirmed that only 29% of British patients had markers of hepatitis B infection, suggesting a possible role for other environmental agents in the pathogenesis, and that 80% of patients had underlying cirrhosis. The nature of the strong relationship between HCC and cirrhosis has not been established but it has been postulated that increased hepatocyte turnover in the cirrhotic liver may predispose to DNA damage by environmental mutagens. Cell proliferation is required to express the strongly promutagenic DNA base lesion 0'-methylguanine, produced by alkylating agents, as a mutation. &- methylguanine is repaired by the DNA repair enzyme 06-methylguanine-DNA methyltTansferase (06-MT). A microassay was developed which could reliably measure 06-MT levels in liver biopsy samples. Using this approach 06-MT levels were found to be significantly lower in cirrhotic liver when compared to non-cirrhotic and normal liver tissue. No correlation was found between lymphocyte and liver levels from individual patients with liver disease indicating that the deficiency in DNA repair is disease-a nd tissue-specific. Three polyclonal antibodies were subsequently raised to 06-MT peptides and characterised by immunoblotting in an attempt to establish the tissue distribution of the enzyme in liver. Although none of the antisera were able to detect &-MT in tissue sections they were used to analyse structural differences in the enzyme between cirrhotic and non-cirrhotic liver using SDS-PAGE followed by immunoblotting and fluorography. A band of M, 24,000r,e presentingn ative enzyme, was visualised by fluorography in all liver extracts. Densitometry of these bands correlated with the enzyme activity determined by the direct enzyme assay, validating the assay findings. Other small molecular weight bands were seen in all liver extracts and comparison with immunoblots suggested that these bands represent C-terminal truncated enzyme. The spectrum of smaller molecular weight enzyme forms was similar in cirrhotic and non-cirrhotic liver. It was, thus, concluded that although 06-MT levels were lower in'cirrhosis this was not accounted for by structural differences in the enzyme. DNA mutations (G to A) produced by the failure to repair 06-methylguanine are known to activate oncogenes and turnour suppressor genes such as p53. However only 5/55 (9%) of HCC expressed mutant p53. Other factors potentially involved in hepatocarcinogenesis include the growth factor TGF-a and a growth factor receptor encoded by the c-erb B-2 proto-oncogene. Expression of TGF-a and the C-erbB -2 oncoprotein were seen in 8/28 (28%) and 2/26 (8%) of HCC respectively, findings which differ from those observed in HCC from the Far East. Deficient DNA repair by &-MT provides one possible reason why cirrhosis is an important risk factor for the development of HCC. However, failure to repair 06-mothylguanine does not result in mutations within the p53 gene in British HCC. Furthermore, the finding of low expression of mutant p53, TGF-a and the c-erb B-2 oncoprotein in HCC from Britain compared to HCC from the Far East and Africa suggests geographical differences in the molecular mechanisms involved in hepatocarcinogenesis between areas of high and low HCC prevalence.North Of England Cancer Research Campaign

Access to Justice software development, Participatory Action Research Methods and Researching the Lived Experiences of British Military Veterans

Participatory action research (PAR) methods aim to position the people who are most affected by the issue being studied as equal partners in the research process through a cyclical process of data gathering, data analysis, planning and implementing action and evaluation and reflection. In doing so, it ensures that the research better reflects participants’ ideas, priorities, and needs, thereby enhancing its validity and relevance and the support for the findings and proposed changes. Furthermore, it generates immediately applicable results. In this paper, we reflect on our experiences of developing the UK’s first access to justice platform for veterans and their families through an ongoing PAR project that brought together armed forces veterans, representatives from veterans' service providers, and the Veterans Legal Link team members comprising of legal academics, lawyers, sociologists, computer software designers and graphic designers to collect, interpret, and apply community information to address issues related to the delivery of access to justice. We present findings from Stages 1 and 2 of our three-stage iterative research process which includes the following steps: Understanding and cross-checking the lived experience of the veteran community (Stage 1), developing and testing a prototype of the access to justice platform (Stage 2) and creating the final product and giving real users an opportunity to use the platform (Stage 3). Data collection and analysis from Stage 1 of the study informed the themes that underpinned Stage 2. Specifically, data was collected through the following methods: co-facilitated focus group discussions, a web survey that was codesigned with veteran community stakeholders and remote and digitally enabled ethnographic research methods. We include several reflections that may help legal practitioners and researchers interested in applying PAR within the area of access to justice and the field of legal research