BACKGROUND & AIMS: BACKGROUND:General practitioners' (GPs) negative beliefs about smoking cessation services may act as barriers to them recommending such services to smokers motivated to stop smoking. METHODS:In Study 1, 25 GPs from 16 practices across London were interviewed in this qualitative study. Framework analysis was used to identify key themes in GPs' beliefs about smoking cessation services. In Study 2, a convenience sample of 367 GPs completed an internet-based survey. Path-analysis was used to examine relationships between beliefs identified in Study 1 and intentions to recommend smoking cessation services. RESULTS:In Study 1, GPs felt that smoking cessation assistance was best provided by others. GPs favoured local services (i.e. practice nurses offering stop smoking support) over central services (i.e. offered through the Primary Care Trust), mainly because these were seen as more personalised and accessible for patients. These beliefs appeared to influence GPs' beliefs about the effectiveness of services. In Study 2, GPs' beliefs had a large effect on their intentions to recommend both central services, (f2 = .79) and local services, (f2 = 1.04). GPs' beliefs about effectiveness and cost-effectiveness were key predictors their intentions to recommend central services and local services. Beliefs about the level of personalisation offered and smokers' likelihood of attending services had indirect effects on intentions to recommend services operating via beliefs about effectiveness. CONCLUSION:GPs vary in their perceptions of the effectiveness of smoking cessation services and their intentions to recommend these services vary in line with these beliefs. Interventions aimed at increasing the likelihood with which GPs recommend these services may therefore be more effective if they addressed these beliefs.

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BACKGROUND & AIMS: BACKGROUND:In the UK, 8-15% of women suffer from postnatal depression, with long-term consequences for maternal mood and child development. Previous literature suggests that health visitors struggle with their conflicting roles with respect to mother and infant. Current policy is redirecting the emphasis and organisation of health visitor work, but guidelines state that health visitors and GPs should continue to have a major role in the detection and management of postnatal depression. AIM:To explore the views of GPs and health visitors on the diagnosis and management of postnatal depression. DESIGN OF STUDY:A qualitative study nested within a multicentre randomised controlled trial. SETTING:Nine primary care trusts in Bristol, Manchester, and London. METHOD:In-depth interviews with GPs and health visitors from primary care trusts participating in a randomised controlled trial of antidepressants versus health visitor-delivered non-directive counselling. Interviews were audiotaped and fully transcribed. Thematic analysis with an iterative approach was used to develop conceptual categories from the transcripts. RESULTS:Nineteen GPs and 14 health visitors were interviewed. GPs and health visitors described their work in making and negotiating the diagnosis of postnatal depression, the value of a long-term relationship with the woman, and how labelling affects management of women with postnatal depression. Responders described how they viewed others' roles in the management of postnatal depression, and how national policy and local organisational changes had an impact on patient care, so that no one health professional was assuming overall responsibility for the care of women with postnatal depression. CONCLUSION:Ongoing organisational changes within primary care, such as the implementation of corporate working by health visitors, affect care provided to women after birth, which in turn has an impact on the diagnosis and management of postnatal depression.

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BACKGROUND & AIMS: BACKGROUND:Hypoglycemia is a frequent phenomenon in people being treated for diabetes mellitus, which can acutely disrupt driving performance. For the benefit of personal and public traffic safety, we decided to identify successful diabetes-related (SDR) behaviors to support safe driving for people with diabetes, from the perspective of experiential experts with diabetes mellitus. Experiential experts are people who can manage their own illness and conditions by developing expertise relevant to maintaining health and countering illness, and who are able to use this expertise to the benefit of peers. OBJECTIVE:The aim of our study was to objectify and systematize experiential expertise in terms of SDR behaviors, based on reports by experiential experts, to support safe driving for people with type 1 and type 2 diabetes mellitus. The emphasis was on preventing hypoglycemia as a short-term complication during driving. METHODS:We performed a mixed-methods study involving (i) semi-structured in-depth interviews with 33 experiential experts with diabetes mellitus from the Dutch Diabetes Association (DVN; Diabetesvereniging Nederland), in order to identify SDR behaviors regarding safe driving, and (ii) a validation study by means of a survey among a panel of 98 experiential experts (peers) from the DVN, to determine the extent to which they agreed with the communicability, importance, and feasibility of these behaviors for drivers with diabetes mellitus. RESULTS:We identified a comprehensive set of 11 SDR behaviors, differentiated into seven general and four specific behaviors, to support safe driving. The general behaviors concern the following topics: (i) acquiring knowledge and information; (ii) acquiring and using self-measuring of blood glucose (SMBG) equipment; (iii) knowing one's physical response pattern; (iv) obtaining knowledge about the medication used; (v) preventing long-term eye complications; (vi) influencing factors that can affect blood glucose; and (vii) renewal procedure for driving license. The four specific behaviors refer to the following topics: (i) measures to be taken before driving; (ii) responding effectively to hypoglycemia while driving; (iii) informing and instructing passengers; and (iv) preventing hypoglycemia in drivers with type 2 diabetes mellitus not using SMBG equipment. Key factors for safe driving proved to be the ability of drivers to anticipate and respond effectively to hypoglycemia while driving and to inform and instruct fellow passengers. Participants of the validation survey agreed to a considerable degree with the communicability, importance, and feasibility of these behaviors to support safe driving for people with diabetes mellitus. CONCLUSIONS:This study resulted in the identification and description of SDR behaviors to support safe driving. It proved possible to operationalize experiential expertise in terms of such behaviors. The next step is to have these behaviors validated by professional care providers in the field of diabetes, followed by translation into recommendations in self-management programs.

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BACKGROUND & AIMS: :Given the increasing vehicle numbers and expanding road construction in developing countries, the importance of safe road user behaviour is critical. Road traffic crashes (RTCs) are a significant problem in Pakistan; however, the factors that contribute to RTCs in Pakistan are not well researched. Fatalistic beliefs are a potential barrier to the enhancement of road safety, especially participation in health-promoting and injury prevention behaviours, and also contribute to risk taking. Fatalistic beliefs relating to road safety have been found in some developing countries, although research is scarce and indicates that the nature and extent of fatalism differs in each country. Qualitative research was undertaken with a range of drivers, religious orators, police and policy makers to explore associations between fatalism, risky road use and associated issues. Findings indicate that fatalistic beliefs are pervasive in Pakistan, are strongly linked with religion, present a likely barrier to road safety messages and contribute to risky road use. Fatalism appears to be a default attribution of RTC and the intensity of belief in fate surpasses the kinds of fatalism noted in the limited existing literature. These findings have importance to developing road safety countermeasures in countries where fatalistic beliefs are strong.

背景与目标： : 鉴于发展中国家车辆数量的增加和道路建设的扩大，安全道路使用者行为的重要性至关重要。道路交通事故 (rtc) 是巴基斯坦的一个重要问题; 但是，尚未对导致巴基斯坦区域贸易中心的因素进行很好的研究。宿命论信念是加强道路安全，特别是参与促进健康和预防伤害行为的潜在障碍，也有助于冒险。在一些发展中国家发现了与道路安全有关的宿命论信念，尽管研究很少，并表明每个国家的宿命论性质和程度都不同。对一系列司机、宗教演说家、警察和决策者进行了定性研究，以探索宿命论、危险道路使用和相关问题之间的联系。调查结果表明，宿命论信仰在巴基斯坦普遍存在，与宗教息息相关，可能成为道路安全信息的障碍，并助长了危险的道路使用。宿命论似乎是RTC的默认归因，对命运的信念强度超过了有限的现有文献中提到的宿命论。这些发现对于在宿命论观念强烈的国家制定道路安全对策具有重要意义。

BACKGROUND & AIMS: OBJECTIVES:The National Health Service (NHS) in England recently introduced general practice pharmacists (GPPs) to provide medication-focused support to both patients and the general practice team. This healthcare model may benefit people with asthma, who currently receive suboptimal care and demonstrate low medication adherence. This study aimed to explore the perspectives of adults with asthma on the potential for pharmacist-led adherence support delivered in general practice, with a focus on how these perspectives are formed. DESIGN AND SETTING:The study was conducted in the United Kingdom (UK) utilising a qualitative interview methodology. Participants were invited to partake in a telephone-based semistructured interview, followed by an online questionnaire for demographic details and asthma history. Qualitative data were analysed using thematic analysis. PARTICIPANTS:Participants (n=17) were adults with asthma in the UK with a prescription for an inhaled corticosteroid. Participants did not have previous experience with GPPs and were asked to provide their views on a proposed GPP-led service. RESULTS:Participant perspectives of GPPs were determined by trust in pharmacists, perceived gaps in asthma care and the perceived strain on the NHS. Trust was based on pharmacists' perceived clinical competency, established over time, and gauged through a 'benchmarking' process. GPP's fit in current asthma care was assessed based on potential role overlap with other healthcare professionals, continuity of care and medication-related support needs. Participants navigated the NHS based on a perceived hierarchy of healthcare professionals (general practitioners on top, nurses, then pharmacists), and this influenced their perspectives of GPPs. CONCLUSION:While the GPP scheme shows promise based on the perspectives of people with asthma, the identified barriers to optimal patient engagement and service implementation will need to be addressed for the service to be effective.

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BACKGROUND & AIMS: OBJECTIVES:Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs). DESIGN:Interview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al). SETTING:Eight HASUs in London. PARTICIPANTS:We interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week. RESULTS:Staff were able to deliver 'front door' interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of 'front door' interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays. CONCLUSIONS:Evidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for 'front door' interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.

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BACKGROUND & AIMS: :In this paper we consider a time-delayed mathematical model describing tumor growth with angiogenesis and Gibbs-Thomson relation. In the model there are two unknown functions: One is $\sigma(r,t)$ which is the nutrient concentration at time $t$ and radius $r$, and the other one is $R(t)$ which is the outer tumor radius at time $t$. Since $R(t)$ is unknown and varies with time, this problem has a free boundary. Assume $\alpha(t)$ is the rate at which the tumor attracts blood vessels and the Gibbs-Thomson relation is considered for the concentration of nutrient at outer boundary of the tumor, so that on the outer boundary, the condition $$\dfrac{\partial \sigma}{\partial r}+\alpha(t)\left(\sigma-N(t)\right)=0,~~r=R(t)$$ holds, where $N(t)=\bar{\sigma}\left(1-\dfrac{\gamma}{R(t)}\right)H(R(t))$ is derived from Gibbs-Thomson relation. $H(\cdot)$ is smooth on $(0,\infty)$ satisfying $H(x)=0$ if $x\leq \gamma$, $H(x)=1$ if $x\geq 2\gamma$ and $0\leq H'(x)\leq 2/\gamma$ for all $x\geq 0$. In the case where $\alpha$ is a constant, the existence of steady-state solutions is discussed and the stability of the steady-state solutions is proved. In another case where $\alpha$ depends on time, we show that $R(t)$ will be also bounded if $\alpha(t)$ is bounded and some sufficient conditions for the disappearance of tumors are given.

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BACKGROUND & AIMS: BACKGROUND:Frailty is the leading prognosticator for poor outcomes and palliative care among older adults. Delivery of negative prognostic information entails potentially difficult conversations about decline and death. OBJECTIVE:The study aims were to: 1) examine hospitalized older adults' and family caregivers' receptivity to general (vs. individualized) prognostic information about frailty, injury, and one-year outcomes; and 2) determine information needs based on prognostic information. DESIGN:Provision of general prognostic information followed by semi-structured interview questions. We deductively analyzed qualitative data within the context of problematic integration theory. SETTING:An academic medical center in the Southeast region of the U.S. PARTICIPANTS:Purposive sampling was utilized to obtain a distribution of patients across the frailty continuum (non-frail [N=10], pre-frail [N=9], frail [9=6]). Twenty-five older adults (≥ age 65) hospitalized for a primary injury (e.g. fall) and 15 family caregivers of hospitalized patients were enrolled. METHODS:Hospitalized older patients and family caregivers were shown prognostic information about one-year outcomes of injured older adults in the form of simple pictographs. Semi-structured interview questions were administered immediately afterwards. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Demographic and medical information data were used to contextualize the responses during analysis. RESULTS:Overall, participants (patients [56%], caregivers [73%]) were open to receiving prognostic information. A small number of family caregivers (N=3) expressed reservations about the frankness of the information and suggested delivery through a softer approach or not at all. Qualitative data was coded using categories and constructs of problematic integration theory. Four codes (personalizing the evidence, vivid understanding, downhill spiral, realities of aging) reflected probabilistic and evaluative orientation categories of problematic integration theory. One code (fatalism vs. hope) represented manifestations of ambivalence and ambiguity in the theory; and another code (exceptionalism) represented divergence and impossibility. Two codes (role of thought processes, importance of faith) reflected forms of resolutions as described in problematic integration theory. Information needs based on prognostic information revealed four additional codes: give it to me straight, what can I do? what can I expect? and how can I prevent decline? A consistently reported desire of both patients and caregivers was for honesty and hope from providers. CONCLUSION:This study supports the use of general prognostic information in conversations about aging, injury, frailty and patient outcomes. Incorporating prognostic information into communication aids can facilitate shared decision making before end-of-life is imminent.

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BACKGROUND & AIMS: A qualitative and quantitative analysis of the conformation of Langmuir-Blodgett (LB) dried films of cytochrome C on silicon wafers was performed by Fourier transform ir (FTIR) spectroscopy. A deconvolution procedure was applied to the amide I band analysis, in order to determine the percentage of the different secondary structures. Qualitative analysis was performed by examining difference spectra. Films obtained by spreading protein solutions at pH 7.4 and 1, dried at 25 and 100 degrees C, on silicon wafers were also examined in order to detect spectral components associated with denatured protein domains, and to compare them with cytochrome C LB films. FTIR spectroscopy showed that the following important changes characterise LB film spectra(a) the alpha-helix component is higher (its percentage is 57 and 54%) than the one estimated in dried film obtained by spreading the solutions at pH 7.4 on a silicon substrate (43%), (b) there is an increase in the intensity of bands attributed to protonated carboxy group bands, involved and not involved in the formation of hydrogen bonds, and a decrease in those attributed to deprotonated carboxy groups, (c) the intensity of several bands attributed to aromatic amino acids and aliphatic chains increases, and (d) bands due to O-H stretching vibrations of crystallization water are present. These conformational changes could be induced by protein-protein interaction caused by the close packing of molecules that occurs during LB film formation; it cannot be excluded that they may be accompanied by partial changes in the tertiary structure of the protein. A preferential orientation of protein molecules in LB films is also a possibility.

背景与目标： 通过傅立叶变换红外光谱 (FTIR) 对硅晶片上细胞色素C的Langmuir-Blodgett (LB) 干膜的构象进行了定性和定量分析。将反卷积程序应用于酰胺I带分析，以确定不同二级结构的百分比。通过检查差异光谱进行定性分析。还检查通过在25和100 ℃ 下将pH 7.4和1下的蛋白质溶液在硅晶片上扩散而获得的膜，以便检测与变性蛋白质结构域相关的光谱组分，并将它们与细胞色素C LB膜进行比较。FTIR光谱表明，下列重要变化表征了LB薄膜光谱 (a) α-螺旋组分比在硅衬底上通过在pH 7.4下扩散溶液而获得的干膜中估计的 α-螺旋组分更高 (其百分比为57和54%) (43%)，(b) 归因于质子化羧基带的带强度增加，参与和不参与氢键的形成，归因于去质子化羧基的带强度降低，(c) 归因于芳香族氨基酸和脂肪族链的几个带强度增加，并且 (d) 存在由于结晶水的o-h拉伸振动引起的带。这些构象变化可能是由LB膜形成过程中发生的分子紧密堆积引起的蛋白质-蛋白质相互作用引起的; 不能排除它们可能伴随着蛋白质三级结构的部分变化。LB膜中蛋白质分子的优先取向也是可能的。

BACKGROUND & AIMS: OBJECTIVE:To examine lessons learnt from the implementation of five Vanguard initiatives in the North East of England. DESIGN:Data collection comprised semistructured interviews with key informants at each site. SETTING:The study took place across six local authority areas in the North East of England and within six clinical commissioning groups responsible for the delivery of each Vanguard's aims and objectives. PARTICIPANTS:Sixty-six interviewees with participants from five Vanguard initiatives in the North East of England, including senior clinicians, project leads and directors, commissioners, and healthcare managers. RESULTS:While the context for each Vanguard is separate and distinct, there also exists a set of common issues which have a regional dimension. Participants felt that the national programme helped to raise the profile of local change initiatives and also contributed to the wider understanding of regional service integration issues. At the same time our findings demonstrate that all five sites experienced, and were subject to, unrealistic pressure placed on them to deliver outcomes. Of particular concern among all sites was the sheer scale and pace of change occurring at the same time as the National Health Service was being tasked with making significant, if unrealistic, efficiency savings. CONCLUSIONS:It is too early to conclude with any confidence that a successful outcome for the new care models programme will be forthcoming. While early indications show some encouraging signs of promise, the overall context in which the complex and ambitious changes are being implemented remains both fragile and fluid.

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BACKGROUND & AIMS: BACKGROUND:Although several apps are available to support the treatment of urinary incontinence (UI), little has been reported about the experiences and preferences of their users. OBJECTIVE:The objective of this study was to explore the experiences and preferences of women using a mobile app for the treatment of UI and to identify potential improvements to the app. We developed this app for three types of UI: stress UI, urgency UI, and mixed UI. METHODS:The participants in this qualitative study were women with self-reported stress UI, urgency UI, or mixed UI who used an app-based treatment to manage their condition for at least six weeks. Following the intervention, semistructured interviews were conducted to explore the participants' experiences and preferences regarding the app. All interviews were audio-recorded, transcribed verbatim, and analyzed separately by two researchers. RESULTS:Data saturation was reached after interviewing 9 women (aged 32-68 years) with stress UI (n=1, 11%), urgency UI (n=3, 33%), or mixed UI (n=5, 56%). Accessibility, awareness, usability, and adherence emerged as the main themes. On the one hand, participants appreciated that the app increased their accessibility to care, preserved their privacy, increased their awareness of therapeutic options, was easy to use and useful, and supported treatment adherence. On the other hand, some participants reported that they wanted more contact with a care provider, and others reported that using the app increased their awareness of symptoms. CONCLUSIONS:This qualitative study indicates that women appreciate app-based treatment for UI because it can lower barriers to treatment and increase both awareness and adherence to treatment. However, the app does not offer the ability of face-to-face contact and can lead to a greater focus on symptoms.

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BACKGROUND & AIMS: OBJECTIVE:The purpose of this research was to locate cultural competence within the experiential domain of the non-English-speaking patient. DESIGN:Seven language-specific focus groups were held with 59 hospital patients and carers of patients with limited English to better understand their experience and to identify critical factors leading to their constructions of care. Grounded theory analysis within a constructivist perspective was undertaken. RESULTS:While the majority of patients were positive about their hospital experience, the theme of powerlessness appeared central to many patient experiences. Language facilitation was the most common issue. Inattention to specific cultural mores and racism in some instances contributed to negative experiences. Patients primarily valued positive engagement, information and involvement, compassionate, kind and respectful treatment, and the negotiated involvement of their family. CONCLUSION:Because of the specific nature of each patient-provider interaction within its particular social and political environment, culturally competent behaviour in one context may be culturally incompetent in another. We propose a model of cultural empowerment that reflects the phenomenological basis of cultural competence in that cultural competence must be consistently renegotiated with any particular patient in a particular healthcare context. Similarly, ongoing community consultations are needed for health services and organisations to retain cultural competence.

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BACKGROUND & AIMS: AIMS:The factors contributing to the establishment of high-quality radiotherapy services in low- and middle-income countries (LMICs) are poorly understood. The aim was to identify and describe barriers and facilitators to establishing and sustaining high-quality and accessible radiotherapy services in LMICs based on the experience of successful and unsuccessful attempts. METHODS:An exploratory-descriptive qualitative study using semistructured telephone interviews was undertaken. Purposive and snowball sampling techniques were used to recruit participants. The World Health Organization Innovative Care for Chronic Conditions Framework informed the interview guide. A constant comparative data analysis approach was adopted. FINDINGS:Seventeen participants were interviewed. Ten were working permanently in nine LMICs and seven were permanently employed in four high-income countries. Three themes were developed: committing to a vision of improving cancer care; making it happen and sustaining a safe service; and leveraging off radiotherapy to strengthen integrated cancer care. Identified barriers included lack of political leadership continuity, lack of a coordinated advocacy effort, non-Member State of the IAEA, lack of reliable epidemiological data, lack of a comprehensive budget and lack of local expertise. Facilitators identified included strong political support, vision champion, availability of a regulator, costed cancer control plan, diversified sources of funding, responsible project manager, adoption of evidence-based practice, strategic partnerships, motivation to provide patient-centered care, and availability of supportive technology. CONCLUSIONS:Assessing the level of readiness to establish and sustain a radiotherapy service is highly recommended. Future research is recommended to develop a readiness assessment tool for radiotherapy services implementation at LMICs.

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BACKGROUND & AIMS: BACKGROUND:Few studies have explored patients' experiences of treatment for CFS/ME. This study aims to fill this gap by capturing the perspective of patients who have been treated by NHS specialist CFS/ME services in England. METHODS:Semi-structured interviews were conducted during the period June-September 2014 with 16 adults who were completing treatment at one of three outpatient NHS specialist CFS/ME services. Interviews were analysed thematically using constant comparison techniques, with particular attention paid to contrasting views. RESULTS:Three themes were identified: 'Journey to specialist services'; 'Things that help or hinder treatment'; and 'Support systems'. Within these themes nine sub-themes were identified. A wide range of factors was evident in forming participants' experiences, including personal characteristics such as perseverance and optimism, and service factors such as flexibility and positive, supportive relationships with clinicians. Participants described how specialist services played a unique role, which was related to the contested nature of the condition. Many participants had experienced a lack of validation and medical and social support before attending a specialist service. Patients' experiences of life before referral, and the concerns that they expressed about being discharged, highlighted the hardship and obstacles which people living with CFS/ME continue to experience in our society. CONCLUSIONS:The experiences of CFS/ME patients in our study showed that NHS specialist CFS/ME services played a vital role in patients' journeys towards an improved quality of life. This improvement came about through a process which included validation of patients' experiences, acceptance of change, practical advice and support, and therapeutic outcomes.

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BACKGROUND & AIMS: AIM:This article provides an overview of current sexual behaviour research in later life by describing associated factors, including the physical and psychological benefits. METHODS:Recent systematic reviews were interrogated for findings on sexual behaviour research in adults aged 60+. RESULTS:Regardless of research methods employed, all studies showed that there were a range of physical and psychological benefits to remaining sexually active in later life. While quantitative studies placed an emphasis on measuring penile-vaginal intercourse, they provided no definitive conclusion about the benefits due to 'inconsistent results' across studies. Qualitative studies described the myriad ways in which older adults redefine what constitutes sexual activity despite the onset of dysfunction and disability. CONCLUSION:While the different research methods show that engaging in sexual behaviour has physical and psychological benefits at all adult ages, there is limited conclusive evidence about what the overall benefits might be in later life.

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