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1.  Media actors’ perceptions of their roles in reporting food incidents 
BMC Public Health  2014;14(1):1305.
Background
Previous research has shown that the media can play a role in shaping consumer perceptions during a public health crisis. In order for public health professionals to communicate well-informed health information to the media, it is important that they understand how media view their role in transmitting public health information to consumers and decide what information to present. This paper reports the perceptions of media actors from three countries about their role in reporting information during a food incident. This information is used to present ideas and suggestions for public health professionals working with media during food incidents.
Methods
Thirty three semi-structured interviews with media actors from Australia, New Zealand and the United Kingdom were conducted and analysed thematically. Media actors were recruited via purposive sampling using a sampling strategy, from a variety of formats including newspaper, television, radio and online.
Results
Media actors said that during a food incident, they play two roles. First, they play a role in communicating information to consumers by acting as a conduit for information between the public and the relevant authorities. Second, they play a role as investigators by acting as a public watchdog.
Conclusion
Media actors are an important source of consumer information during food incidents. Public health professionals can work with media by actively approaching them with information about food incidents; promoting to media that as public health professionals, they are best placed to provide the facts about food incidents; and by providing angles for further investigation and directing media to relevant and correct information to inform such investigations. Public health professionals who adapt how they work with media are more likely to influence media to portray messages that fit what they would like the public to know and that are in line with public health recommendations and enable consumers to engage in safe and health promoting behaviours in response to food incidents.
doi:10.1186/1471-2458-14-1305
PMCID: PMC4301931  PMID: 25524217
Food; Food incident; Media; Public health; Public health professional
2.  Newcomers in a hazardous environment: a qualitative inquiry into sex worker vulnerability to HIV in Bali, Indonesia 
BMC Public Health  2014;14(1):832.
Background
Women new to sex work and those with a greater degree of mobility have higher risk of HIV infection. Using social capital as a theoretical framework, we argue that better understanding of the interactions of micro-level structural factors can be valuable in reshaping and restructuring health promotion programmes in Bali to be more responsive to the concerns and needs of newcomer and mobile female sex workers (FSWs).
Methods
We conducted interviews with 11 newcomer FSWs (worked < six months), 9 mobile FSWs (experienced but worked at the current brothel < six months), and 14 senior FSWs (experienced and worked at current brothel > six months). The interviews explored women’s experience of sex work including how and why they came to sex work, relationships with other FSWs and their HIV prevention practices.
Results
A thematic framework analysis revealed newcomer FSWs faced multiple levels of vulnerability that contributed to increased HIV risk. First, a lack of knowledge and self-efficacy about HIV prevention practices was related to their younger age and low exposure to sexual education. Second, on entering sex work, they experienced intensely competitive working environments fuelled by economic competition. This competition reduced opportunities for positive social networks and social learning about HIV prevention. Finally, the lack of social networks and social capital between FSWs undermined peer trust and solidarity, both of which are essential to promote consistent condom use. For example, newcomer FSWs did not trust that if they refused to have sex without a condom, their peers would also refuse; this increased their likelihood of accepting unprotected sex, thereby increasing HIV risk.
Conclusions
Public health and social welfare interventions and programmes need to build social networks, social support and solidarity within FSW communities, and provide health education and HIV prevention resources much earlier in women’s sex work careers.
doi:10.1186/1471-2458-14-832
PMCID: PMC4141952  PMID: 25113395
Sex work; Newcomers; Social network; Social support; HIV prevention knowledge; Trust
3.  The Effects of Housing on Health and Health Risks in an Aging Population: A Qualitative Study in Rural Thailand 
BioMed Research International  2014;2014:289731.
Background. Over the last decade, Thailand has experienced an aging population, especially in rural areas. Research finds a strong, positive relationship between good quality housing and health, and this paper assesses the impact and living experience of housing of older people in rural Thailand. Methods. This was a mixed-method study, using data from observations of the physical adequacy of housing, semistructured interviews with key informants, and archival information from health records for 13 households in rural Thailand. Results. There were four main themes, each of which led to health risks for the older people: “lighting and unsafe wires,” “house design and composition,” “maintenance of the house,” and “health care equipment.” The housing was not appropriately designed to accommodate health care equipment or to fully support individual daily activities of older people. Numerous accidents occurred as a direct result of inadequate housing and the majority of houses had insufficient and unsafe lighting, floor surfaces and furniture that created health risks, and toilets or beds that were at an unsuitable height for older people. Conclusion. This paper provides an improved and an important understanding of the housing situation among older people living in rural areas in Thailand.
doi:10.1155/2014/289731
PMCID: PMC4101953  PMID: 25101268
4.  Interpersonal Trust across Six Asia-Pacific Countries: Testing and Extending the ‘High Trust Society’ and ‘Low Trust Society’ Theory 
PLoS ONE  2014;9(4):e95555.
Background
Trust is regarded as a necessary component for the smooth running of society, although societal and political modernising processes have been linked to an increase in mistrust, potentially signalling social and economic problems. Fukuyama developed the notion of ‘high trust’ and ‘low trust’ societies, as a way of understanding trust within different societies. The purpose of this paper is to empirically test and extend Fukuyama’s theory utilising data on interpersonal trust in Taiwan, Hong Kong, South Korea, Japan, Australia and Thailand. This paper focuses on trust in family, neighbours, strangers, foreigners and people with a different religion.
Methods
Cross-sectional surveys were undertaken in 2009–10, with an overall sample of 6331. Analyses of differences in overall levels of trust between countries were undertaken using Chi square analyses. Multivariate binomial logistic regression analysis was undertaken to identify socio-demographic predictors of trust in each country.
Results
Our data indicate a tripartite trust model: ‘high trust’ in Australia and Hong Kong; ‘medium trust’ in Japan and Taiwan; and ‘low trust’ in South Korea and Thailand. Trust in family and neighbours were very high across all countries, although trust in people with a different religion, trust in strangers and trust in foreigners varied considerably between countries. The regression models found a consistent group of subpopulations with low trust across the countries: people on low incomes, younger people and people with poor self-rated health. The results were conflicting for gender: females had lower trust in Thailand and Hong Kong, although in Australia, males had lower trust in strangers, whereas females had lower trust in foreigners.
Conclusion
This paper identifies high, medium and low trust societies, in addition to high and low trusting population subgroups. Our analyses extend the seminal work of Fukuyama, providing both corroboration and refutation for his theory.
doi:10.1371/journal.pone.0095555
PMCID: PMC3997396  PMID: 24760052
5.  A qualitative study of CVD management and dietary changes: problems of ‘too much’ and ‘contradictory’ information 
BMC Family Practice  2014;15:25.
Background
Nutrition education for cardiovascular disease (CVD) management is not effective for all population groups. There is little understanding of the factors that hinder patients from adhering to dietary recommendations.
Methods
37 interviews were conducted with people living with CVD in Adelaide, Australia. Recruitment occurred via General Practitioner (GP) clinics and hospital cardiac rehabilitation programs. Participants were either receiving preventive treatment or active treatment for established CVD.
Results
The volume and contradictory nature of dietary information were the most prominent barriers to making changes identified in interviews, especially by order participants.
Conclusion
Patients will seek out, or come into contact with information which contradicts advice from their GPs. The volume of information may lead them to resort to old and familiar habits. GPs play a valuable role in highlighting key take-home messages and reliable external sources of information. The findings have implications for GP practice given that lifestyle changes are a cost- and clinically-effective means of managing CVD.
doi:10.1186/1471-2296-15-25
PMCID: PMC3916316  PMID: 24495674
General practice; Cardiovascular disease; Lifestyle; Diet; Australia
6.  ‘Never testing for HIV’ among Men who have Sex with Men in Viet Nam: results from an internet-based cross-sectional survey 
BMC Public Health  2013;13:1236.
Background
Men who have sex with men in Viet Nam have been under-studied as a high-risk group for HIV infection, and this population’s percentage and determinants of HIV testing have not been comprehensively investigated.
Methods
A national Internet-based survey of self-reported sexual and health seeking behaviours was conducted between August and October 2011 with 2077 Vietnamese men who had sex with men in the last twelve months to identify the frequency of ‘never testing for HIV’ among Internet-using MSM living in Viet Nam, as well as the factors associated with this HIV-related high-rish behavior. Logistic regression analyses were conducted to assess the demographic characteristics and behaviours predicting never testing for HIV.
Results
A total of 76.5% of men who have sex with men who were surveyed reported never having been voluntarily tested for HIV. Predictors of never being tested included having a monthly income less than VND 5 Million, being a student, using the Internet less than 15 hour per week, and not participating in a behavioural HIV intervention.
Conclusions
Never testing for HIV is common among Internet-using men who have sex with men in Viet Nam. Given the dangerously high prevalence of this high-risk behaviour, our findings underscore the urgent need for segmented and targeted HIV prevention, care and treatment strategies, focusing on drastically reducing the number of men who have sex with men never testing for HIV in Viet Nam.
doi:10.1186/1471-2458-13-1236
PMCID: PMC3877867  PMID: 24373483
Men who have Sex with Men; High risk HIV behaviours; HIV testing; Viet Nam
7.  Identifying Vulnerable Populations Using a Social Determinants of Health Framework: Analysis of National Survey Data across Six Asia-Pacific Countries 
PLoS ONE  2013;8(12):e83000.
Background
In order to improve the health of the most vulnerable groups in society, the WHO called for research on the multiple and inter-linking factors shaping the social determinants of health (SDH). This paper analyses four key SDH (social cohesion, social inclusion, social empowerment and socioeconomic security) across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.
Methods
Population surveys were undertaken using a validated instrument in 2009-10, with sample sizes around 1000 in each country. The four SDH were analysed using multivariate binomial logistic regression to identify socio-demographic predictors in each country.
Results
Low socio-economic security was associated with low income in all six study countries and with poor subjective health in Japan, South Korea and Thailand and with being married or cohabiting in Australia and Hong Kong. Low social cohesion was associated with low income in all countries and with undertaking household duties in South Korea, Thailand and Taiwan. Low social inclusion was associated with low income in Australia, South Korea and Taiwan and with poor subjective health in Australia, Japan and South Korea. Older people had lower social inclusion in Taiwan (50-59 years) and Hong Kong (retired), younger people in Japan and South Korea (20-29 years in both countries) and younger and middle-aged people in Australia. Low social empowerment was associated with low income in Australia, Thailand and Taiwan, with being aged 60 years or over in Australia, Hong Kong and South Korea, and over 50 years in Thailand.
Conclusions
This paper provides baseline measures for identifying where and how policy should be altered to improve the SDH. Furthermore, these data can be used for future policy evaluation to identify whether changes in policy have indeed improved the SDH, particularly for marginalised and vulnerable populations.
doi:10.1371/journal.pone.0083000
PMCID: PMC3857316  PMID: 24349417
8.  Inequities in access to healthcare: analysis of national survey data across six Asia-Pacific countries 
Background
Evidence suggests that there is a link between inequitable access to healthcare and inequitable distribution of illness. A recent World Health Organization report stated that there is a need for research and policy to address the critical role of health services in reducing inequities and preventing future inequities. The aim of this manuscript is to highlight disparities and differences in terms of the factors that distinguish between poor and good access to healthcare across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.
Methods
A population survey was undertaken in each country. This paper is a secondary analysis of these existing data. Data were collected in each country between 2009 and 2010. Four variables related to difficulties in access to healthcare (distance, appointment, waiting time, and cost) were analysed using binomial logistic regression to identify socio- and demographic predictors of inequity.
Results
Consistent across the findings, poor health and low income were identified as difficulties in access. Country specific indicators were also identified. For Thailand, the poorest level of access appears to be for respondents who work within the household whereas in Taiwan, part-time work is associated with difficulties in access. Within Hong Kong, results suggest that older (above 60) and retired individuals have the poorest access and within Australia, females and married individuals are the worst off.
Conclusion
Recognition of these inequities, from a policy perspective, is essential for health sector policy decision-making. Despite the differences in political and economic climate in the countries under analysis, our findings highlight patterns of inequity which require policy responses. Our data should be used as a means of deciding the most appropriate policy response for each country which includes, rather than excludes, socially marginalised population groups. These findings should be of interest to those involved in health policy, but also in policy more generally because as we have identified, access to health care is influenced by determinants outside of the health system.
doi:10.1186/1472-6963-13-238
PMCID: PMC3734194  PMID: 23816181
Equity; Access; Healthcare; Asia; Pacific; Social determinants; Policy
9.  Evaluating the use of citizens’ juries in food policy: a case study of food regulation 
BMC Public Health  2013;13:596.
Background
Deliberative engagement techniques and citizens’ juries are touted as means of incorporating the public into policy decision-making, managing community expectations and increasing commitment to public health policy. This paper reports a study to examine the feasibility of citizens’ juries as a means of collecting data to inform public health policy related to food regulation through evaluation of the conduct of a citizens’ jury.
Methods
A citizens’ jury was conducted with a representative sample of 17 South Australians to explore their willingness to consider the proposition that food and drink advertising and/or sponsorship should be banned at children’s sporting events.
Results
The results showed that, in relation to the central proposition and evaluation data from the jury, opinion on the proposition remained comparatively stable. Most jurors indicated that they thought that food and drink sponsorship and/or advertising at children’s sporting events would have little or no effect on altering children’s diet and eating habits, with the proportion increasing during the jury process. Jurors were given evaluation sheets about the content of the jury and the process of the citizens’ jury to complete at the end of the session. The evaluation of the citizens’ jury process revealed positive perceptions. The majority of jurors agreed that their knowledge of the issues of food and drink sponsorship in children’s sport had increased as a result of participation in the citizens’ jury. The majority also viewed the decision-making process as fair and felt that their views were listened to. One important response in the evaluation was that all jurors indicated that, if given the opportunity, they would participate in another citizens’ jury.
Conclusions
The findings suggest that the citizens’ jury increased participant knowledge of the issue and facilitated reflective discussion of the proposition. Citizens’ juries are an effective means of gaining insight into public views of policy and the circumstances under which the public will consider food regulation; however a number of issues need to be considered to ensure the successful conduct of a citizens’ jury.
doi:10.1186/1471-2458-13-596
PMCID: PMC3733832  PMID: 23782688
Citizens’ juries; Deliberative democracy; Food regulation; Food sponsorship; Children sporting events
10.  The impact of education programs on smoking prevention: a randomized controlled trial among 11 to 14 year olds in Aceh, Indonesia 
BMC Public Health  2013;13:367.
Background
School-based smoking prevention programs have been shown to increase knowledge of the negative effects of smoking and prevent tobacco smoking. The majority of evidence on effectiveness comes from Western countries. This study investigated the impact of school-based smoking prevention programs on adolescents’ smoking knowledge, attitude, intentions and behaviors (KAIB) in Aceh, Indonesia.
Methods
We conducted a 2 × 2 factorial randomized controlled trial among 7th and 8th grade students aged 11 to 14 years. Eight schools were randomly assigned to a control group or one of three school-based programs: health-based, Islamic-based, or a combined program. Students in the intervention groups received eight classroom sessions on smoking prevention education over two months. The KAIB impact of the program was measured by questionnaires administered one week before and one week after the intervention.
Results
A total of 477 students participated (58% female, 51% eighth graders). Following the intervention, there was a significant main effect of the Health based intervention for health knowledge scores (β = 3.9 ± 0.6, p < 0.001). There were significant main effects of the Islamic-based intervention in both health knowledge (β = 3.8 ± 0.6, p < 0.001) and Islamic knowledge (β = 3.5 ± 0.5, p < 0.001); an improvement in smoking attitude (β = −7.1 ± 1.5, p < 0.001). The effects of Health and Islam were less than additive for the health and Islamic factors for health knowledge (β = −3.5 ± 0.9, p < 0.01 for interaction) and Islamic knowledge (β = −2.0 ± 0.8, p = 0.02 for interaction). There were no significant effects on the odds of intention to smoke or smoking behaviors.
Conclusions
Both Health and Islamic school-based smoking prevention programs provided positive effects on health and Islamic related knowledge respectively among adolescents in Indonesia. Tailoring program interventions with participants’ religion background information may provide additional benefits to health only focused interventions.
Trial registration
Australia and New Zealand Clinical Trials Register, ACTRN12612001070820
doi:10.1186/1471-2458-13-367
PMCID: PMC3640933  PMID: 23596980
Smoking prevention; Indonesia; Schools; Health knowledge; Attitude; Behavior; Intention
11.  Trust makers, breakers and brokers: building trust in the Australian food system 
BMC Public Health  2013;13:229.
Background
The importance of consumer trust in the food supply has previously been identified, and dimensions of consumer trust in food—who they trust and the type of trust that they exhibit—has been explored. However, there is a lack of research about the mechanisms through which consumer trust in the food supply is developed, maintained, broken and repaired. This study seeks to address this gap by exploring if, and how, consumer trust in the food supply is considered by the media, food industry and governments when responding to food scares. The aim of the research is to develop models of trust building that can be implemented following food scares.
Methods
Semi-structured interviews will be undertaken with media, public relations officials and policy makers in Australia, New Zealand and the United Kingdom. Participants will be recruited through purposive sampling and will be asked to discuss a hypothetical case study outlining a food incident, and any experiences of specific food scares. Models of trust development, maintenance and repair will be developed from interview data. Comment on these models will be sought from experts in food-related organizations through a Delphi study, where participants will be asked to consider the usefulness of the models. Participants’ comments will be used to revise the models until consensus is reached on the suitability and usability of the models.
Discussion
This study will contribute to the literature about systems-based trust, and explore trust as a social and regulatory process. The protocol and results will be of interest and use to the food industry, food regulators, consumer advocate groups, media seeking to report food-related issues and policy makers concerned with public health and consumer health and well-being. This research represents an important contribution to the translation of the theoretical conceptualizations of trust into practical use in the context of food.
doi:10.1186/1471-2458-13-229
PMCID: PMC3729665  PMID: 23496819
Food; Trust; Food scare; Food safety; Australia; United Kingdom
12.  Food Stress in Adelaide: The Relationship between Low Income and the Affordability of Healthy Food 
Healthy food is becoming increasingly expensive, and families on low incomes face a difficult financial struggle to afford healthy food. When food costs are considered, families on low incomes often face circumstances of poverty. Housing, utilities, health care, and transport are somewhat fixed in cost; however food is more flexible in cost and therefore is often compromised with less healthy, cheaper food, presenting an opportunity for families on low incomes to cut costs. Using a “Healthy Food Basket” methodology, this study costed a week's supply of healthy food for a range of family types. It found that low-income families would have to spend approximately 30% of household income on eating healthily, whereas high-income households needed to spend about 10%. The differential is explained by the cost of the food basket relative to household income (i.e., affordability). It is argued that families that spend more than 30% of household income on food could be experiencing “food stress.” Moreover the high cost of healthy foods leaves low-income households vulnerable to diet-related health problems because they often have to rely on cheaper foods which are high in fat, sugar, and salt.
doi:10.1155/2013/968078
PMCID: PMC3569900  PMID: 23431321
13.  HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention 
Systematic Reviews  2012;1:56.
Background
Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.
Methods
We undertook a realist review to answer the research question: ‘How are HIV prevention interventions in high-income countries adapted to suit immigrants’ needs?’ A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.
Results
Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of ‘consonance’ mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms – ‘understanding’, ‘specificity’ and ‘embeddedness’ – which indicated that using the language of immigrants, usually the ‘mother tongue’, targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of ‘authenticity’ and ‘framing’ mechanisms and only partial evidence to support role of ‘endorsement’ mechanisms.
Conclusions
This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.
doi:10.1186/2046-4053-1-56
PMCID: PMC3534573  PMID: 23168134
HIV prevention; Immigrants; Realist review; Culturally appropriate; Behavioural interventions
14.  Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patients with coronary disease in South Australia 
BMJ Open  2012;2(5):e001389.
Objectives
There is concern across a range of healthcare settings worldwide that trust in physicians is declining. Decreased trust may lead to lesser tolerance of prognosis uncertainty and an increased demand for tests, referrals and second opinions. Literature suggests that there has been a recent cultural shift towards decreased trust in, and increased questioning of, medical advice. We investigated the impact of varying prognosis and socioeconomic status (SES) on trust in physicians, and patient questioning of medical advice.
Design
Semistructured, audio-recorded transcribed interviews were conducted. The interview schedule was developed with reference to the Health Belief Model. Interviews were conducted between October 2008 and September 2009.
Setting
Participants were recruited via general practitioner clinics and hospital cardiac rehabilitation programmes.
Participants
Participants consisted of patients either receiving preventive treatment or active treatment for established cardiovascular disease.
Outcome measures
A coding structure was developed based on the aim of the research, to investigate the impact of varying prognosis and SES on trust in physicians.
Results
Older participants are more likely than their younger counterparts to be unquestioning of medical advice. Higher SES participants are more likely to question medical advice than lower SES participants. Also, unlike primary prevention participants, established pathology increased participants’ trust, or decreased questioning behaviour. Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to doubt medical advice.
Conclusions
Blind trust in physicians remains strong in older participants, participants who perceive their prognosis to be uncertain and a proportion of lower SES participants. This is important for practitioners in terms of patient agency and points to the importance of moral and ethical practice. However, physicians also need to be aware that there are a growing proportion of patients for whom trust needs to be developed, and cannot be assumed.
doi:10.1136/bmjopen-2012-001389
PMCID: PMC3488703  PMID: 23035015
Preventive Medicine; Medical Education & Training
15.  Elevated HIV prevalence and risk behaviours among men who have sex with men (MSM) in Vietnam: a systematic review 
BMJ Open  2012;2(5):e001511.
Objectives
To review and analyse original studies on HIV prevalence and risk behaviours among men who have sex with men (MSM) in Vietnam.
Design
Systematic literature review. Comprehensive identification of material was conducted by systematic electronic searches of selected databases. Inclusion criteria included studies conducted from 2002 onwards, following a systematic review concluding in 2001 conducted by Colby, Nghia Huu and Doussantousse. Data analysis was undertaken through the application of both the Cochrane Collaboration and ePPI Centre approaches to the synthesis of qualitative and quantitative studies.
Setting
Vietnam.
Results
Sixteen studies, undertaken during 2005–2011, were identified that met the inclusion criteria. The analysis showed that HIV prevalence among MSM in Vietnam has increased significantly (eg, from 9.4% in 2006 to 20% in 2010 in Hanoi) and that protective behaviours, such as condom use and HIV testing and counselling, continue at inadequately low levels.
Conclusions
Increasing HIV prevalence and the lack of effective protective behaviours such as consistent condom use during anal sex among MSM in Vietnam indicate a potential for a more severe HIV epidemic in the future unless targeted and segmented comprehensive HIV prevention strategies for MSM in Vietnam are designed and programmes implemented.
doi:10.1136/bmjopen-2012-001511
PMCID: PMC3467604  PMID: 23015604
HIV; AIDS; Homosexuality; Gay men; Sexual behaviour
16.  Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study 
BMJ Open  2012;2(3):e000939.
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
doi:10.1136/bmjopen-2012-000939
PMCID: PMC3358628  PMID: 22586286
17.  Complex problems require complex solutions: the utility of social quality theory for addressing the Social Determinants of Health 
BMC Public Health  2011;11:630.
Background
In order to improve the health of the most vulnerable groups in society, the WHO Commission on Social Determinants of Health (CSDH) called for multi-sectoral action, which requires research and policy on the multiple and inter-linking factors shaping health outcomes. Most conceptual tools available to researchers tend to focus on singular and specific social determinants of health (SDH) (e.g. social capital, empowerment, social inclusion). However, a new and innovative conceptual framework, known as social quality theory, facilitates a more complex and complete understanding of the SDH, with its focus on four domains: social cohesion, social inclusion, social empowerment and socioeconomic security, all within the same conceptual framework. This paper provides both an overview of social quality theory in addition to findings from a national survey of social quality in Australia, as a means of demonstrating the operationalisation of the theory.
Methods
Data were collected using a national random postal survey of 1044 respondents in September, 2009. Multivariate logistic regression analysis was conducted.
Results
Statistical analysis revealed that people on lower incomes (less than $45000) experience worse social quality across all of the four domains: lower socio-economic security, lower levels of membership of organisations (lower social cohesion), higher levels of discrimination and less political action (lower social inclusion) and lower social empowerment. The findings were mixed in terms of age, with people over 65 years experiencing lower socio-economic security, but having higher levels of social cohesion, experiencing lower levels of discrimination (higher social inclusion) and engaging in more political action (higher social empowerment). In terms of gender, women had higher social cohesion than men, although also experienced more discrimination (lower social inclusion).
Conclusions
Applying social quality theory allows researchers and policy makers to measure and respond to the multiple sources of oppression and advantage experienced by certain population groups, and to monitor the effectiveness of interventions over time.
doi:10.1186/1471-2458-11-630
PMCID: PMC3167771  PMID: 21819576
18.  The Karyotype of the Yellow Dung Fly, Scathophaga stercoraria, a Model Organism in Studies of Sexual Selection 
Knowledge of karyotypical characteristics of a species is essential for understanding how sexually selected and sexually antagonistic traits evolve. The yellow dung fly Scathophaga stercoraria L. (Diptera: Scathophagidae) is an established model system for studies of sexual selection and sexual conflict, but karyotypical data are lacking to date. Here, the karyotype of S. stercoraria was characterized using conventional Giemsa-staining and C-banding techniques. The diploid chromosome set consists of 6 pairs of bi-armed meta- or submetacentric chromosomes. The sex chromosomes are the largest chromosomes and constitute 30% of the total length of the diploid set in females and about 25% in males. Males are the heterogametic sex, and the length of the Y chromosome is about three-quarters of that of the X chromosome. C-banding revealed that both sex chromosomes are largely heterochromatic. In contrast, in the five autosome pairs, heterochromatin is limited to narrow bands in the centromeric regions. This karyotypic information will help provide a more profound understanding of the inheritance of phenotypic variation in reproductive traits and the chromosomal locations of underlying genes.
doi:10.1673/031.010.11801
PMCID: PMC3016996  PMID: 20874599
antagonistic; dimorphism; Diptera; heterochromatin; Scatophaga; sex chromosome; sexual conflict
19.  Health and happiness in a materially deprived, ethnically mixed locality 
PMCID: PMC2465540  PMID: 16361461
happiness; health; social exclusion; social model of health; trust
20.  Learning to prescribe – pharmacists' experiences of supplementary prescribing training in England 
Background
The introduction of non-medical prescribing for professions such as pharmacy and nursing in recent years offers additional responsibilities and opportunities but attendant training issues. In the UK and in contrast to some international models, becoming a non-medical prescriber involves the completion of an accredited training course offered by many higher education institutions, where the skills and knowledge necessary for prescribing are learnt. Aims: to explore pharmacists' perceptions and experiences of learning to prescribe on supplementary prescribing (SP) courses, particularly in relation to inter-professional learning, course content and subsequent use of prescribing in practice.
Methods
A postal questionnaire survey was sent to all 808 SP registered pharmacists in England in April 2007, exploring demographic, training, prescribing, safety culture and general perceptions of SP.
Results
After one follow-up, 411 (51%) of pharmacists responded. 82% agreed SP training was useful, 58% agreed courses provided appropriate knowledge and 62% agreed that the necessary prescribing skills were gained. Clinical examination, consultation skills training and practical experience with doctors were valued highly; pharmacology training and some aspects of course delivery were criticised. Mixed views on inter-professional learning were reported – insights into other professions being valued but knowledge and skills differences considered problematic. 67% believed SP and recent independent prescribing (IP) should be taught together, with more diagnostic training wanted; few pharmacists trained in IP, but many were training or intending to train. There was no association between pharmacists' attitudes towards prescribing training and when they undertook training between 2004 and 2007 but earlier cohorts were more likely to be using supplementary prescribing in practice.
Conclusion
Pharmacists appeared to value their SP training and suggested improvements that could inform future courses. The benefits of inter-professional learning, however, may conflict with providing profession-specific training. SP training may be perceived to be an instrumental 'stepping stone' in pharmacists' professional project of gaining full IP status.
doi:10.1186/1472-6920-8-57
PMCID: PMC2615422  PMID: 19061487
21.  How equitable are GP practice prescribing rates for statins?: an ecological study in four primary care trusts in North West England 
Background
There is a growing body of literature highlighting inequities in GP practice prescribing rates for a number of drug therapies. The small amount of research on statin prescribing has either focussed on variations rather than equity per se, been based on populations other than GP practices or has used cost-based prescribing rates.
Aim
To explore the equity of GP practice prescribing rates for statins, using the theoretical framework of equity of treatment (also known as horizontal equity or comparative need).
Methods
The study involved a cross-sectional secondary analysis in four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices. Prescribing rates and health care needs indicators (HCNIs) were developed for all GP practices.
Results
Scatter-plots revealed large differences between individual GP practices, both within and between PCTs, in terms of the relationship between statin prescribing and healthcare need. In addition, there were large differences between GP practices in terms of the relationship between actual and expected prescribing rates for statins. Multiple regression analyses explained almost 30% of the variation in prescribing rates in the combined dataset, 25% in PCT1, 31% in PCT3, 51% in PC4 and 58% in PCT2. There were positive associations with variables relating to CHD hospital diagnoses and procedures and negative associations with variables relating to ethnicity, material deprivation, the proportion of patients aged over 75 years and single-handed GP practices.
Conclusion
Overall, this study found inequitable relationships between actual and expected prescribing rates, and possible inequities in statin prescribing rates on the basis of ethnicity, deprivation, single-handed practices and the proportion of patients aged over 75 years.
doi:10.1186/1475-9276-6-2
PMCID: PMC1847516  PMID: 17386118
22.  Post-copulatory sexual selection and female fitness in Scathophaga stercoraria. 
Whether sexual selection increases or decreases female fitness is determined by the occurrence and relative importance of sexual-conflict processes and the ability of females to choose high-quality males. Experimentally enforced polyandry and monogamy have previously been shown to cause rapid evolution in the yellow dung fly Scathophaga stercoraria. Flies from polyandrous lines invested more in reproductive tissue, and this investment influenced paternity in sperm competition, but came at a cost to immune function. While some fitness consequences of enforced polyandry or monogamy have been examined when flies mate multiply, the consequences for female fitness when singly copulated remain unexplored. Under a good-genes scenario females from polyandrous lines should be of higher general quality and should outperform females from monogamous lines even with a single copulation. Under sexual conflict, costly adaptations will afford no advantages when females are allowed to mate only once. We investigate the lifetime reproductive success and longevity of females evolving under enforced monogamy or polyandry when mating once with males from these selection regimes. Females from polyandrous lines were found to have lower fitness than their monogamous counterparts when mating once. They died earlier and produced significantly fewer eggs and offspring. These results suggest that sexual conflict probably drove evolution under enforced polyandry as female fitness did not increase overall as expected with purely good-genes effects.
PMCID: PMC1691601  PMID: 15101693
23.  Differential associations between actual and expected GP practice prescribing rates for statins, ACE inhibitors, and beta-blockers: a cross-sectional study in England 
Aim
To explore the relationship between actual and expected general medical practitioner (GP) practice prescribing rates for statins, angiotensin converting enzyme (ACE) inhibitors, and beta-blockers.
Background
There is a growing body of literature highlighting inequities in GP practice prescribing rates for many drug therapies. The equity of prescribing is of central importance in the area of therapeutics since it explores the interface between those patients who should and those who actually do receive a drug therapy.
Setting
Four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices.
Methods
Actual and expected prescribing rates for statins, beta-blockers, and ACE inhibitors were specifically developed for each GP practice.
Results
There were no statistically significant correlations between actual and expected prescribing rates in PCT2 and PCT3, although in PCT1 there were statistically significant correlations for statins (0.286, p < 0.05) and ACE inhibitors (0.381, p < 0.01). In PCT4, correlations were moderate to high for beta-blockers (0.693, p < 0.01), and moderate for statins (0.541, p < 0.05) and ACE inhibitors (0.585, p < 0.01). Scatterplots highlighted large variations between individual GP practices (both within and between PCTs) in terms of the relationship between actual and expected prescribing rates.
Conclusion
This paper highlights variability between PCTs and GP practices in terms of the relationship between actual and expected prescribing rates. The findings from this paper may further advance the suggestion of inequities in prescribing rates for coronary heart disease (CHD) drugs, and studies such as this may be repeated in different therapeutic areas, healthcare settings, and countries.
PMCID: PMC1661602  PMID: 18360545
prescribing rates; equity; coronary heart disease; statins; beta-blockers; ACE inhibitor
24.  Exploring the equity of GP practice prescribing rates for selected coronary heart disease drugs: a multiple regression analysis with proxies of healthcare need 
Background
There is a small, but growing body of literature highlighting inequities in GP practice prescribing rates for many drug therapies. The aim of this paper is to further explore the equity of prescribing for five major CHD drug groups and to explain the amount of variation in GP practice prescribing rates that can be explained by a range of healthcare needs indicators (HCNIs).
Methods
The study involved a cross-sectional secondary analysis in four primary care trusts (PCTs 1–4) in the North West of England, including 132 GP practices. Prescribing rates (average daily quantities per registered patient aged over 35 years) and HCNIs were developed for all GP practices. Analysis was undertaken using multiple linear regression.
Results
Between 22–25% of the variation in prescribing rates for statins, beta-blockers and bendrofluazide was explained in the multiple regression models. Slightly more variation was explained for ACE inhibitors (31.6%) and considerably more for aspirin (51.2%). Prescribing rates were positively associated with CHD hospital diagnoses and procedures for all drug groups other than ACE inhibitors. The proportion of patients aged 55–74 years was positively related to all prescribing rates other than aspirin, where they were positively related to the proportion of patients aged >75 years. However, prescribing rates for statins and ACE inhibitors were negatively associated with the proportion of patients aged >75 years in addition to the proportion of patients from minority ethnic groups. Prescribing rates for aspirin, bendrofluazide and all CHD drugs combined were negatively associated with deprivation.
Conclusion
Although around 25–50% of the variation in prescribing rates was explained by HCNIs, this varied markedly between PCTs and drug groups. Prescribing rates were generally characterised by both positive and negative associations with HCNIs, suggesting possible inequities in prescribing rates on the basis of ethnicity, deprivation and the proportion of patients aged over 75 years (for statins and ACE inhibitors, but not for aspirin).
doi:10.1186/1475-9276-4-3
PMCID: PMC548940  PMID: 15701165
25.  Anthelmintic Baiting of Foxes against Urban Contamination with Echinococcus multilocularis 
Emerging Infectious Diseases  2003;9(10):1266-1272.
In recent years, increases in the urban fox population have been observed in many countries of the Northern Hemisphere. As a result, Echinococcus multilocularis has entered the urban environment. Because of a possible increased risk for alveolar echinococcosis, intervention strategies need to be evaluated. In Zürich, Switzerland, 50 praziquantel-containing baits per km2 were distributed monthly in six 1-km2 bait areas and one 6-km2 bait area from April 2000 through October 2001. The proportion of E. multilocularis coproantigen–positive fox fecal samples collected remained unchanged in six control areas but decreased significantly in the 1-km2 bait areas (from 38.6% to 5.5%) and in the 6-km2 bait area (from 66.7% to 1.8%). E. multilocularis prevalence in the intermediate host Arvicola terrestris also decreased significantly in baited areas. This controlled baiting study shows that a pronounced reduction of E. multilocularis egg contamination is feasible in urban areas where the organism is highly endemic.
doi:10.3201/eid0910.030138
PMCID: PMC3033062  PMID: 14609462

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