Palliative Medicine

BackgroundDemand for community-based end-of-life care is rising globally, driven by ageing populations with increasingly complex needs. Community nurses have a central role in providing end-of-life care, yet the proportion of their time spent in supporting people in their final year of life remains unclear. AimsTo investigate how much of community nurses daily work involves caring for people in their last year of life, and the extent to which end-of-life care visits are cancelled, deferred or undertaken to unsatisfactory standards. DesignAnonymous online survey and multimethod analysis. Setting/participantsUnited Kingdom survey of community nurses, circulated via professional networks, social media and snowball sampling, between 28 April and 27 June 2025. ResultsA total of 1,471 nurses responded. Most worked in community and district nursing services (78.6%, 1156/1471) or specialist palliative care services (11.8%, 174/1471). Community and district nurses spent 23.5% (median) of their last shift providing end-of-life care. Over one in ten respondents (11.6% (171/1471) reported deferring at least one end-of-life visit during their last shift. Specialist palliative nurses were twice as likely to defer visits compared to community and district nurses (OR=2.48, 95% CI: 1.63-3.72, p<0.001). Staff shortages, demand exceeding capacity, and other systematic barriers contributed to deferring visits. ConclusionsCommunity nurses play a vital role in end-of-life care, yet some of this important patient care is left undone or deferred. Investment in core and specialist nursing services, with efforts to enable and sustain this workforce, is urgently needed to meet globally growing demand for community-based end-of-life care. What is already known about the topic?O_LIDemand for community end-of-life care is growing in many countries. C_LIO_LICommunity nurses play a key role in end-of-life care, yet the volume and complexity of their daily work supporting people in the last year of life remains poorly understood. C_LI What this paper addsO_LINurses working in community and district nursing services spent a median of 23.5% of their last clinical shift providing end-of-life care. C_LIO_LIHalf (52%) of respondents who provided end-of-life care during their last shift reported delivering one or more aspects of this care below their professional satisfaction, due to workload and capacity issues. C_LIO_LIOver one in ten (11.6%) of nurses reported having deferred or cancelled end-of-life care visits on their last shift, significantly more specialist palliative care nurses (24%) than community and district nurses (10.4%). C_LI Implications for practice, theory or policyO_LIOur findings reveal a notable proportion of deferred and cancelled end-of-life care visits and care not undertaken to nurses professional satisfaction. C_LIO_LISustained, intentional investment in core and specialist nursing services, together with improved system-wide integration, is needed to support this vital workforce. C_LIO_LIFurther research is necessary to understand how community and district nurses and specialist palliative care nurses can most effectively prioritise end-of-life care within finite resources and competing demands. C_LI

Aim(s)To describe adult palliative and end-of-life care provision by community health nursing services using a: O_LINational dataset (2013-2024) to report patterns in service provision over time. C_LIO_LIRegional dataset (2022/23, 2023/24 and 2024/25) to describe palliative and end-of-life care activities. C_LI DesignSecondary analyses of existing national and regional datasets. MethodsWe used national data to describe the populations served; workforce; referrals; unique service users seen annually; contacts; time on caseload; care delivered/care locations; support to other teams/processes; and deferred care. Regional data was used to examine palliative and end-of-life care activities in the context of all nursing care delivered. ResultsNationally, referrals to community health nursing services increased steadily from 4,000 to 6,000 per 100,000 weighted population between 2013 and 2024, while unique service users remained stable (around 2,600-2,800). Median average time on caseload reduced markedly from over 150 days to around 50 days, despite stable contact frequency (median 23 total contacts per service user) and duration (median 26 minutes for face-to-face contacts). Regional data showed that palliative and end-of-life care consistently accounted for 9.6% of all community nursing clinical time (30-32 hours per 1,000 population annually) across three years, even as total care hours declined. A disproportionate amount of palliative and end-of-life care occurred out-of-hours. ConclusionIncreasing referrals and shorter time on caseloads indicate a system under pressure. Time spent on palliative and end-of-life care by community health nursing teams has remained stable over time, despite growing population need. Workforce capacity, skill mix, and out-of-hours provision need to align to support high-quality, person-centred care in the community. Implications for the profession and/or patient careThis evidence informs better planning to ensure sufficient provision and workforce in community health nursing. Patient and public contributionPatients, family carers and public members contributed to interpreting findings and implications for practice. What does this paper contribute to the wider global clinical community?O_LIProvides combined national and regional data to describe the scale and nature of palliative and end-of-life care delivered by community health nursing services over time. C_LIO_LIFindings give a detailed picture of how community health nursing services are under pressure because of increasing referrals and being required to deliver a greater breadth of tasks. C_LIO_LIModels of community health nursing are changing with shorter care episodes and significant palliative and end-of-life care workload (with distinctive challenges out-of-hours). C_LI

BackgroundAcceptance of death is an important aspect of a good death and an indicator of high-quality palliative care. Limited evidence exists on the extent to which patients accept their approaching death and which socio-demographic or end-of-life care characteristics are associated with acceptance, in both cancer and non-cancer patients. MethodsWe conducted a retrospective cross-sectional survey in representative GP networks in the Netherlands and Italy (2013-2015), and Belgium and Spain (2013-2014). GPs registered all deceased adult patients in their practice, reporting health and care characteristics in the last three months of life and the level of acceptance of approaching death on a four-point scale ("1. Yes, completely" to "4. No, not at all"). Non-sudden deaths were included, totaling 2,796 patients (1,474 cancer; 1,322 non-cancer). ResultsAcceptance was recorded for 97% of patients (n=2,713), of which 17% were assessed as unknown. GPs assessed that 30% of patients had complete acceptance, with similar proportions in cancer and non-cancer patients (30% vs 29%). Multivariable logistic regression showed that older age (OR 1.03, 95%CI 1.02-1.04, p<0.01), country (OR 0.27 Belgium, OR 0.11 Italy, OR 0.10 Spain; reference: Netherlands), and palliative care by the GP until death (OR 1.39, 95%CI 1.07-1.79, p<0.01) were independently associated with complete acceptance. ConclusionSocio-demographic, contextual, and end-of-life care factors influence GP-assessed acceptance of approaching death, whereas a cancer diagnosis does not. These findings emphasize the importance of culturally sensitive, age-appropriate, and palliative care-oriented approaches to support patient acceptance at the end of life.

ContextIn the UK, and in other countries, people living with a terminal illness are eligible for financial support to help with the costs of serious illness and to support their dignity and independence. This study investigates the take-up of benefits in the last year of life and identifies sociodemographic, clinical, and geographical factors associated with underclaiming. MethodsRetrospective cohort study using linked mortality, Census and benefits data for all people who died aged 16+ from chronic illnesses in England and Wales between 1 May 2018 and 30 April 2021. Outcome was receipt of non-means tested disability benefits in the last 12 months of life. We describe geographical variation in take up, and association with sociodemographic, clinical and geographical exposures using Poisson models. FindingsOur population included 1,049,493 eligible decedents, with an overall take-up rate of 65.9%. After adjusting for sociodemographic factors, variation in take-up by cause of death was wide: liver disease 44% (95% CI 43-45%), heart failure 52% (51-52%), cancer 62% (61-62%), dementia 75% (74-75%), and neurodegenerative diseases 90% (88-91%). Across Local Authorities, the age-and-sex-standardised take-up varied from 53% to 78%; rates were generally higher in more deprived areas, but not uniformly. ConclusionsIn England and Wales, 1 in 3 people who die from expected causes (120,000 each year) do not receive the benefits for which they are eligible. Our analysis uses novel data linkages and highlights clinical and sociodemographic groups and geographical areas that could be targeted with proactive take-up initiatives.

Background: The quality of palliative care in non-designated cancer hospitals, where approximately 70% of deaths of patients with cancer occur, remains unevaluated. This study aimed to clarify the quality of palliative care in these hospitals by comparing patient characteristics and evaluating the quality of palliative care provided by bereaved families. Methods: A questionnaire survey was conducted among bereaved family members of patients with cancer who died in 2018 at designated and non-designated cancer hospitals (excluding palliative care units). We compared the two groups regarding patient and bereaved family characteristics, quality assessment of palliative care (including Memorial Symptom Assessment Scale [MSAS]), care satisfaction, and the presence of end-of-life discussions. Results: In total, 27,944 bereaved family members agreed to participate. The mean age at death was 73.2 ({+/-}11.9) and 79.7 ({+/-}10.9) years for designated and non-designated cancer hospitals, respectively (p < 0.001, Effect Size [ES] = 0.55). The mean MSAS total score (symptom intensity) was significantly higher for designated cancer hospitals than for non-designated cancer hospitals, even after adjusting for patient characteristics (p < 0.001, ES = 0.39). Conversely, the mean adjusted overall satisfaction was significantly higher in non-designated cancer hospitals (p < 0.001, ES = 0.21) than in designated cancer hospitals. Conclusions: Non-designated cancer hospitals had older and less symptomatic patients than designated cancer hospitals. However, there was no significant clinical difference in the quality of palliative care, as assessed by the bereaved families.

Background Pancreatic Ductal Adenocarcinoma will be the 2nd-most common cause of cancer mortality by 2030. It is associated with rapid deterioration, severe symptoms, and significant quality-of-life concerns. Using input from patients, family caregivers (FCGs), and provider stakeholders, we designed an intervention, PAL-CHW-PDAC, delivered by a community health worker that involves proactive symptom monitoring and management, care navigation, and disease education. Methods We conducted a pilot randomized controlled trial of 60 patients with newly diagnosed PDAC (within 2 weeks of diagnosis) and their caregivers at Loma Linda University Health from 09/2025 to 05/2026. Patients were randomized 1:1 to receive the PAL-CHW-PDAC intervention (6 CHW visits over 3 months) or an attention control. The control comparator involved receiving standard handouts and videos on pancreatic cancer, along with check-in visits with research staff. The primary outcome was symptom burden, defined using the NCCN/FACT Hepatobiliary Symptom Index. Secondary outcomes included quality of life (QoL) measured by the FACT-Hep and psychological distress (measured by the NCCN-Distress Thermometer). Caregiver outcomes included burden, preparedness, quality of life, and psychological distress. Results: 60 out of 74 eligible (81%) were enrolled. The median age was 71, 60% of patients were Hispanic. 68% of patients presented with metastatic PDAC, 23% with borderline resectable disease and 9% with resectable PDAC. There was a trend towards improved symptom burden at 12 weeks (mean increase of 5.3 points vs. decrease of 3.2 points; p=0.093) with the intervention compared to the attention control. The intervention group also had improved psychological distress at 12 weeks (3.31 vs. 5.95, p=0.01), caregiver psychological distress (3.26 vs. 6.86, p<0.001) and caregiver preparedness (2.92 vs. 2.11) at 12 weeks. Telehealth utilization for symptom-focused visits improved with the intervention (82%) compared to the control. (14%, p=0.01) Hospice utilization also improved with the intervention (41% vs 7%, p-0.12). Conclusions: A pilot RCT of the PAL-CHW-PDAC intervention demonstrated preliminary efficacy with a trend towards improved symptom burden, psychological distress, and caregiver psychological distress and preparedness. A larger definitive clinical trial is needed to understand the impact of this promising intervention. ClinicalTrials.gov number, NCT07591571

Introduction: End of life decision making poses unique challenges for individuals with dementia and their family caregivers as cognitive decline shifts decision making responsibility to surrogates. Methods: Using 2010 to 2022 Health and Retirement Study (HRS) exit interview data, we compared advance directive completion, decision making needs near death, involvement of others in decision making, and concordance between expressed preferences and care received among decedents with and without dementia. Analyses incorporated HRS exit interview sampling weights, primary sampling units, and strata to account for the complex multistage probability design of HRS and produce nationally representative estimates of U.S. older adult decedents (50 years or older). Weighted descriptive statistics and design adjusted Wald tests were used to compare groups. Results: Among 5,389 decedents, 1,010 (weighted 17.7%) had dementia prior to death. Decedents with dementia were more likely to have completed advance directives than those without dementia (81.3% vs. 69.1%, p<.001). However, they also had significantly higher decision making needs in the final days of life (54.3% vs. 47.2%, p<.001). Children or grandchildren were more frequently involved in care decisions for decedents with dementia (63.9% vs. 45.6%, p<.001). Despite differences in decision making processes, most decedents in both groups expressed preferences for comfort focused care, and preference care concordance exceeded 90% in both groups. Conclusions: Findings suggested that dementia reshaped the structure and intensity of the shared decision making process by increasing surrogate engagement and decisional demands, underscoring the importance of early advance care planning and structured support for family caregivers to sustain goal concordant care.

Context Despite widespread use of medical cannabinoids for cancer-related symptom management, systematic reviews consistently call for more clinical trial evidence. Objectives This study aimed to determine and explore responses to medical cannabis extracts for cancer-related symptoms using patient-centred methodology. Methods An aggregate N-of-1 study of clinically stable but symptomatic outpatients from 8 Canadian cancer centres, comparing three blinded sublingual extracts (THC; CBD; 1:1) with placebo, self-titrated within a prescribed schedule for four consecutive days each in randomized sequence for up to three cycles (total 16-48 days). The primary outcome was the frequency of at least a 1.4-point (20%) improvement in a 7-point Patient Global Impression of Change (PGIC) for at least one extract over placebo. Results The primary outcome was achieved in 50/89 (56%) participants (p<0.001), with no significant preference of one extract over another on average, but a clear preference between extracts for most individuals. Changes in a modified Edmonton Symptom Assessment score and participant preference (n=91) confirmed these findings. Improved sleep, tiredness and anxiety contributed most to the overall improvement regardless of primary symptom. There were no demographic predictors of response. Mild adverse effects were common with all extracts including placebo but resolved rapidly on dose reduction/cessation. Moderate/severe adverse effects were rare but associated with THC. Conclusions Medical cannabis extracts can be meaningfully beneficial for cancer-related symptoms in approximately 50% of patients, particularly for sleep and related symptoms. A starting dose of 2.5mg of THC/CBD three times a day was well-tolerated. Personalization of treatment is required to optimize response.

Background: Palliative care services improve quality of life and health outcomes for individuals living with chronic and life-limiting illnesses. Although these services have expanded considerably in urban areas, their availability remains limited in many rural communities. This study aimed to identify key components of integrated palliative care services and examine how these elements are implemented within rural healthcare systems in southern Minnesota. Methods: A qualitative case study using deductive content analysis was conducted. Semi-structured interviews were carried out with healthcare professionals involved in palliative and hospice care serving rural communities in southern Minnesota. Results: Participants identified several essential components of integrated palliative care, including multidisciplinary care teams, continuity of care across healthcare settings, interprofessional collaboration, and early identification of patients who may benefit from palliative care. Existing services in southern Minnesota incorporate several integrated elements, such as coordinated care teams, individualized care plans, nurse-led case management, professional training, and the use of virtual visits for geographically distant patients. However, participants also identified important gaps, including limited availability of palliative care services in rural areas, fragmented continuity of care, challenges in early patient identification, funding and insurance barriers, and the absence of a unified palliative care network. Conclusions: While palliative care services in southern Minnesota demonstrate important strengths, further efforts are required to improve service integration, coordination, and access for rural populations. Strengthening integrated PCSs may help reduce disparities in access to care and improve service delivery for rural patients and their families. These findings may inform the development of integrated palliative care models in rural healthcare systems beyond the study setting.

ObjectiveThe study aimed to understand the perspectives of professionals from multi-agencies working with individuals experiencing homelessness with complex health and social circumstances (PHECHS), specifically focusing on how they define and contextualise the concept of "complex needs". Methodsixteen qualitative interviews with multi-agencies working with people experiencing homelessness were analysed using Heideggers interpretive phenomenological analysis (IPA), theories of socioeconomic determinants and international and national policy analysis were utilised to analyse data collected by MM on the multi-agency approach to individuals experiencing homelessness with complex health and social needs (PHECHS). FindingsThe analysis of a multi-agency approach aimed at supporting PHECHS revealed that complex needs arise gradually during childhood and can continue into adulthood. A range of factors contribute to both homelessness and these complex needs. Deconstructing the social and economic factors that underpin this continuum is essential to effectively addressing these challenges. This study conceptualises the complex needs of PHECHS into two key themes: deconstructing the PHECHS and attritional approach to PHECHS. ConclusionHomelessness is a grave human rights violation, depriving people of essentials like housing, food, health, education, and social participation. Governments have a moral and legal duty to end homelessness. Real progress demands comprehensive, sustained, and rights-based strategies that tackle root causes--poverty, trauma, and social exclusion. Homelessness also stems from gaps in vital life skills: job seeking, financial management, accessing services, and self-care. These barriers make it even harder to secure stable housing. Lasting reductions in homelessness result from a strong legislative framework, national guidelines, and sustained financial investment. Strengths and limitations of this study1. Employing qualitative methods and analysing data through the lens of socioeconomic determinants of health inequalities enabled the development of a model that clarifies the structural causes of homelessness and highlights key opportunities for preventive policy interventions. 2. Examining the data through the lens of socioeconomic health determinants reveals how systemic and structural factors, such as housing policy and service access, drive complex needs beyond individual circumstances. 3. The study was conducted in an affluent, demographically homogenous city, resulting in the underrepresentation of individuals from ethnic minority backgrounds, women, and young people. 4. Future research should investigate the experiences of people experiencing homelessness using an asset-based perspective, leveraging frameworks that emphasise resourcefulness to promote their meaningful engagement and inclusion in society.

Aims Moral distress has been studied across many health arenas; however, public health has often been overlooked. Canada is facing a healthcare crisis with a significant number of staff leaving the healthcare field. This study explores the experiences of moral distress in public healthcare practitioners across Canada. Better understanding these experiences can provide insights into how to support staff and prevent attrition in public health. Methods This was a cross-sectional qualitative study. Fifteen in-depth interviews were conducted between May and July 2023, through remote and in person methods. Participants were from nursing, social work, medicine, and dietetics, all working in public health across Canada. Iterative thematic analysis was used. Emergent themes were compared within and across data sets and by participant age and years of experience. Results/Findings Experiences that contributed to moral distress included systemic powerlessness, political and ideological overreach, unethical work environments and undervalued expertise. Years of experience and diversity in gender and ethnicity impacted how practitioners navigated moral distress. Experiences where practitioners felt actions went against their values increased during the pandemic, contributing to moral injury. Conclusions This study situates the unique position of public health within the health system and explores experiences of moral distress both during and outside the COVID-19 pandemic. While the pandemic brought the concept of moral distress to the forefront of many peoples minds, these experiences existed prior. Addressing the underlying causes will contribute to establishing approaches to support public health practitioners suffering from moral distress and injury.

Background Parenting practices shape children's emotional, social, and cognitive developmental wellbeing. Yet, many families face complex challenges that increase the risk of poor outcomes and demand on social care. The Sutton Parenting Offer (SPO) is a universal, peer-led parenting offer that provides early, non-stigmatising support to families with children aged 0-25 years. It combines evidence-based programmes with informal workshops and peer networks delivered through Family Hubs. This present study is an evaluation protocol of the parenting offer. Aim This evaluation aims to explore how, why, and in what contexts SPO supports families in engaging, sustaining positive change, and generating wider system value. Methods A mixed-methods realist evaluation approach will be used to evaluate SPO across four work packages: engagement pathways, early changes and peer-led ecosystems, long-term change, and system value for money. Data sources will include attendance data (anonymised service records), survey data (entry and exit), and qualitative data (dyad interviews, story circles, and stakeholder-value mapping workshops). The COM-B and the Theoretical Domains Framework (TDF) will guide the analysis of behavioural data. Quantitative data will be analysed descriptively and using paired parametric and non-parametric tests, while qualitative data will be analysed thematically following a realist-informed approach to refine context-mechanism-outcome (CMO) configurations. Discussion This protocol presents the first realist informed evaluation of a universal parenting program in a local authority setting. The evaluation will generate evidence on how, when and why a universal, community-based, and peer-led model such as the Sutton Parenting Offer engages families and generates change. The findings will be useful to inform future parenting service design and implementation in local contexts in England.

Background People with severe mental health conditions (SMHC) and caregivers in South Africa experience high rates of poverty. The PRIZE feasibility trial found that recovery groups were broadly acceptable and feasible and potentially effective in reducing relapse. Addressing economic needs was identified as a means to increase impact. This study aimed to understand experiences of financial insecurity and acceptability of poverty alleviation interventions as an adjunct to psychosocial interventions amongst people with SMHC and caregivers. Methods We conducted two focus group discussions and 12 in-depth interviews in isiXhosa with a total of 14 people with SMHC and 13 caregivers who had participated in PRIZE in Eastern Cape Province, South Africa. An inductive thematic analysis was conducted. Results We identified four major themes. Theme 1: Financial insecurity as a defining influence on life. We found that financial security was crucial to recovery, through bringing status and dignity. However, participants experienced substantial financial insecurity, which impacted on social and mental wellbeing. Financial insecurity was entrenched due to fractured and violent communities, cycles of debt and stigma amongst employers. Theme 2: Government disability grants are not a panacea. Difficulties accessing disability grants included problems attending assessments and rejection of applications. Whilst they were generally welcomed, receipt of disability grants sometimes caused problems such as increased stigma and family disagreements about how the money should be spent. Theme 3: Group savings offer conditional hope if carefully managed. Several caregivers had longstanding experiences of stokvels (community-based credit unions). However, some were fearful of group members absconding with funds. Participants emphasised that trust, safety and fairness are essential for successful group savings. Theme 4: Income-generating activities are desired but need capital and come with safety concerns. Many had ideas and motivation for small businesses but stressed the need for financial capital, skills training and financial literacy support. There were serious concerns that owning a business or gaining wealth could make one a target of crime. Conclusion Poverty alleviation interventions could positively impact on the wellbeing of people with SMHC and caregivers in South Africa as an adjunct to psychosocial interventions and psychiatric care. Approaches could include supporting access to social protection or existing savings groups, and nesting new savings groups or income generation initiatives into psychosocial interventions. Any model would need to incorporate robust mechanisms to ensure the safety of participants. All approaches would be enhanced by parallel social and public health interventions to build social capital and reduce violence in neighbourhoods.

ImportanceStigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. ObjectiveTo synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data SourcesA systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article SelectionStudies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and SynthesisTwo independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and MeasuresOutcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. ResultsA total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and RelevanceThis systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. FundingWorld Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation. Key PointsQuestion: What is the global prevalence of stigma, discrimination, and resilience among trans and gender-diverse adults? Findings: A systematic review of 97 articles, and meta-analysis of a subset of 36 articles, found elevated prevalence of stigma in non-institutional settings, discrimination in institutional settings, and resilience. Meaning: These findings illustrate that stigma and discrimination against trans and gender-diverse adults are pervasive globally and should be addressed through targeted interventions and policy reform.

Background Making Every Contact Count (MECC) is a person-centred initiative that enables service providers across settings to support behaviour change through conversations about health and wellbeing. MECC has been widely implemented across the UK and internationally, although training approaches vary considerably and do not consistently translate into MECC delivery. Evidence suggests that Healthy Conversation Skills (HCS) training, which supports service users to identify their own solutions, may be an acceptable and effective means of delivering MECC across settings. This realist evaluation aims to understand which elements of HCS training work, for whom, under what circumstances, in what respects, to what extent, and why, to inform the adaptation of HCS across settings to ensure that all recipients are equipped to deliver MECC. MethodsThis mixed-methods realist evaluation will comprise pre- and post-training surveys (at baseline, immediately post-training, and approximately eight weeks post-training) and realist interviews. Two participant groups were selected for comparison: service providers working or volunteering in the voluntary, community, and social enterprise (VCSE) sector, and undergraduate pharmacy students. Initial programme theories were developed through abductive reasoning, literature scoping, and stakeholder engagement. Survey data will assess outcomes of HCS training, while realist interviews will explore how these outcomes are generated by underlying mechanisms within specific contexts. DiscussionA refined programme theory will be produced, explaining how and why HCS training leads to MECC delivery across different settings. Findings will inform how HCS training can be adapted for distinct audiences, identify the core components of MECC training that must be preserved, and guide future evaluations by examining whether HCS training translates into sustained MECC delivery. The findings of this study will inform resource allocation for preventative health interventions outside of healthcare settings and thus have the potential to shape public health policy, empower non-specialist providers, and strengthen strategies for disease prevention.

BackgroundIndividuals experiencing or at risk of homelessness face substantial barriers to preventive eye care that are poorly addressed by standard service models. Interdisciplinary optometry-social work collaboration offers a rights-based approach to improving engagement and continuity of care. MethodsA convergent mixed-methods study was conducted between February and August 2024 at a multidisciplinary community centre. Clients experiencing or at risk of homelessness received integrated optometry and social work assessment and were prioritised as high, medium, or low based on combined clinical and social risk. Social work follow-up was guided by the Triple Mandate and W-Questions framework. Quantitative data were summarised using mean (SD), median [IQR], or n (%). Qualitative case notes were analysed using content analysis with inductive coding and secondary review for consistency. ResultsA total of 165 clients had priority categories coded (high: 68; medium: 47; low: 154). Demographic data were available for 132 clients (60% male; mean age 49.5 years [SD 16]); 27% had not completed high school, 89% reported weekly income below AUD 1000, and 28% had vision impairment. Two hundred forty-five case-note entries were consolidated into 146 unique records. SMS (46%) and phone calls (38%) were the most documented contact methods, although only 21% of calls were answered; missed calls (13%) and disconnected numbers (7%) were common. Multi-modal contact was more frequently documented for higher-priority clients. Appointment assistance was the most recorded facilitator (71%), while rights-based supports, including interpreter and transport assistance, were infrequently documented ([&le;]5%). Qualitative analysis identified unstable communication, reliance on informal supports, and service fragmentation as key influences on recall outcomes. ConclusionThis study supports an interdisciplinary, rights-based optometry-social work model to address barriers to preventive eye care among people experiencing or at risk of homelessness. Embedding structured handovers and tiered recall processes within community-based services may strengthen continuity and accountability for high-priority clients. Future implementation should evaluate outcomes related to equity of reach, service integration, and sustained engagement in care.

AimsYouth loneliness is associated with poorer mental health, educational disengagement, and adverse long-term health outcomes. While social prescribing shows promise in reducing loneliness in adults, access for young people remains limited as most pathways sit within primary care. Schools offer a near-universal point of contact and may provide a more accessible referral route. The INACT study aimed to pilot a school-based social prescribing pathway and assess its feasibility, acceptability, and preliminary signals of benefit for loneliness and related outcomes. MethodsPupils in Years 4, 5, 7 and 8 (ages 9 to 13; n=672) across 11 schools in London, Manchester, and Leeds were screened for loneliness. Those reporting elevated loneliness (n=140, 20.8%) were randomised to social prescribing or signposting. For follow-up, the social prescribing arm was capped at 41 pupils, and a matched subset of the signposting group (n=45) was followed longitudinally. Outcomes were collected at baseline, three-, and six-months. Feasibility indicators included recruitment, uptake, engagement, and retention. Acceptability and appropriateness were assessed using validated implementation measures and qualitative interviews with pupils and link workers. ResultsOne in five pupils reported elevated loneliness. In the social prescribing group, 83% initiated the pathway, attending a mean of 5.09 sessions, with most delivered in person. Implementation measures indicated high feasibility, acceptability, and appropriateness. Interviews highlighted the importance of relational support and personalised activity matching, although some younger pupils needed support completing questionnaires. Preliminary analyses showed reductions in loneliness at three-months in both groups, with somewhat greater reductions in the social prescribing arm. ConclusionSchool-based social prescribing appears feasible and acceptable, with early indications of benefit. Schools may offer scalable infrastructure for addressing youth loneliness beyond healthcare pathways. A fully powered multi-site trial with economic evaluation is now warranted to determine effectiveness and long-term value. Trial registrationClinicalTrials.gov: NCT06656663

Abstract Background: Resilience is acknowledged to be an important component for successful aging in older adults, but there is scant evidence with which to inform public health interventions for this age group. The aim of this study is to determine whether the public health intervention, mindfulness for later life is both feasible and acceptable to older adults. Methods: Participants were recruited from September 2021 to June 2022 through older adult organisations and charities, such as the University of the Third Age, Age UK, and Age Concern, and by adverts distributed through village newsletters and support organisations. Participants were offered six weekly sessions of mindfulness therapy, the program was based on the mindfulness-based stress reduction program, each session was two hours long with 10-15 participants per program. The following two pre-defined indicators of success needed to be met for the program to be deemed feasible: successful uptake (recruitment of 30 participants over nine months) and initial engagement. Results: Thirty-three potential participants were screened for eligibility over nine months, 31 of whom were recruited to the study (103% of the target sample). Of these, 28 participants (90%) completed four or more online sessions. Thus, predefined indicators of feasibility were met. Conclusions: This study supports the feasibility of delivering the mindfulness for later life program as a public health intervention, including recruitment and treatment completion. A full-scale trial to assess the clinical- and cost-effectiveness of the intervention including its long-term effects is warranted.

This study investigated retirement adjustment in retired police officers in the UK (N = 289), examining how time since leaving the service moderates the relationship between perceived organisational support and retirement adjustment while accounting for resilience. Results indicated a developmental trend: organisational support remains stable initially but becomes increasingly influential in later life. Using Johnson-Neyman analysis, a threshold of 32.07 years was identified, after which the association reaches statistical significance. These findings suggest an organisational legacy effect; for the older generation, the retrospective perception of being valued by the service acts as a durable psychological resource. This study offers a novel conceptualisation of long-term organisational influence by identifying a temporally delayed legacy effect that extends beyond existing models of retirement adjustment. The study advocate for lifelong wellbeing strategies that extend, recognising that the organisational relationship continues to shape adjustment outcomes decades after the conclusion of active duty.

ObjectivesConcerns about COVID-19 were a key driver of infection-prevention behaviour during the pandemic. The aim of this study was to gain an in-depth longitudinal understanding of the type and frequency of concerns experienced throughout the first two years of the COVID-19 pandemic. DesignContent analysis of qualitative descriptions provided in a prospective longitudinal online survey as part of the COVID-19 UK Public Experiences (COPE) Study. MethodAt baseline (March/April 2020), when the UK entered its first national lockdown, 11,113 adults completed the COPE survey. Follow-up surveys were conducted at 3, 12, 18 and 24 months. Participants were recruited via the HealthWise Wales research registry and social media. Baseline surveys collected demographic and health data, and all waves included an open-ended question about COVID-19 concerns. Content analysis was used to identify the type and frequency of concerns at each time point. ResultsA total of 41,564 open-text responses were coded into six categories: personal harm (n=16,353), harm to others (n=11,464), social/economic impact (n=6,433), preventing transmission (n=4,843), government/media (n=1,048), and general concerns (n=1,423). The proportion of respondents reporting any concern declined from 75.3% at baseline to 65.8% at 24 months. Over time, concerns about personal harm increased (baseline 41.8% vs. 24-months 52.7%) whereas concerns about harm to others decreased (baseline 48.5% vs. 24-months 28.6%). Concerns about harm were also expressed in relation to clinical vulnerability, lack of trust in government/media, and perceived lack of adherence by others. These were balanced against concerns about wider social and economic impacts of restrictions. ConclusionsPublic concerns about COVID-19 evolved substantially over the first two years of the pandemic, reflecting changing perceptions of risk and responsibility. Monitoring concerns longitudinally is vital to help guide effective communication and behavioural interventions during future pandemics.