Doctors\u27 perspectives on PSA testing illuminate established differences in prostate cancer screening rates between Australia and the UK: A qualitative study

Objectives: To examine how general practitioners (GPs) in the UK and GPs in Australia explain their prostate-specific antigen (PSA) testing practices and to illuminate how these explanations are similar and how they are different. Design: A grounded theory study. Setting: Primary care practices in Australia and the UK. Participants: 69 GPs in Australia (n=40) and the UK (n=29). We included GPs of varying ages, sex, clinical experience and patient populations. All GPs interested in participating in the study were included. Results: GPs’ accounts revealed fundamental differences in whether and how prostate cancer screening occurred in their practice and in the broader context within which they operate. The history of prostate screening policy, organisational structures and funding models appeared to drive more prostate screening in Australia and less in the UK. In Australia, screening processes and decisions were mostly at the discretion of individual clinicians, and varied considerably, whereas the accounts of UK GPs clearly reflected a consistent, organisationally embedded approach based on local evidence-based recommendations to discourage screening. Conclusions: The GP accounts suggested that healthcare systems, including historical and current organisational and funding structures and rules, collectively contribute to how and why clinicians use the PSA test and play a significant role in creating the mindlines that GPs employ in their clinic. Australia’s recently released consensus guidelines may support more streamlined and consistent care. However, if GP mindlines and thus routine practice in Australia are to shift, to ultimately reduce unnecessary or harmful prostate screening, it is likely that other important drivers at all levels of the screening process will need to be addressed

Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions

Objectives: ‘Nanny-state’ accusations can function as powerful rhetorical weapons against interventions intended to promote public health. Public health advocates often lack effective rebuttals to these criticisms. Nanny-state accusations are largely accusations of paternalism. They conjure up emotive concern about undue governmental interference undermining peoples’ autonomy. But autonomy can be understood in various ways. We outline three main conceptions of autonomy, argue that these that can underpin three different conceptions of paternalism, and consider implications for responses to nanny-state accusations and the assessment of public health interventions. Study design and methods: Detailed conceptual analysis. Results: The conceptions of paternalism implicit in nanny-state accusations generally depend on libertarian conceptions of autonomy. These reflect unrealistic views of personal independence and do not discriminate sufficiently between trivial and important freedoms. Decisional conceptions of paternalism, like their underlying decisional conceptions of autonomy, have limited applicability in public health contexts. Relational conceptions of paternalism incorporate relational conceptions of autonomy, so recognise that personal autonomy depends on socially shaped skills, self-identities and self-evaluations as well as externally structured opportunities. They encourage attention to the various ways that social interactions and relationships, including disrespect, stigmatisation and oppression, can undermine potential for autonomy. While nanny-state accusations target any interference with negative freedom, however trivial, relational conceptions direct concerns to those infringements of negative freedom, or absences of positive freedom, serious enough to undermine self-determination, self-governance and/or self-authorisation. Conclusion: Relational conceptions of autonomy and paternalism offer public health policymakers and practitioners a means for rebutting nanny-state accusations, and can support more nuanced and more appropriately demanding appraisals of public health interventions. (249 words) Keywords: Paternalism; autonomy; nanny-state; public health; ethicsThis work is funded by NHMRC grant 1023197. Stacy Carter is funded by an NHMRC Career Development Fellowship 103296

Conceptual learning : the priority for higher education

The common sense notion of learning as the all-pervasive acquisition of new behaviour and knowledge, made vivid by experience, is an incomplete characterisation, because it assumes that the learning of behaviour and the learning of knowledge are indistinguishable, and that acquisition constitutes learning without reference to transfer. A psychological level of analysis is used to argue that conceptual learning should have priority in higher education

Vagueness and variety in person-centred care [version 1; peer review: 2 approved]

Grant information: This work was supported by Wellcome [209811]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Peer reviewe

Exploring concepts of health with male prisoners in three category-C English prisons

Lay understandings of health and illness have a well established track record and a plethora of research now exists which has examined these issues. However, there is a dearth of research which has examined the perspectives of those who are imprisoned. This paper attempts to address this research gap. The paper is timely given that calls have been made to examine lay perspectives in different geographical locations and a need to re-examine health promotion approaches in prison settings. Qualitative data from thirty-six male sentenced prisoners from three prisons in England were collected. The data was analysed in accordance with Attride-Stirling's (2001) thematic network approach. Although the men's perceptions of health were broadly similar to the general population, some interesting findings emerged which were directly related to prison life and its associated structures. These included access to the outdoors and time out of their prison cell, as well as maintaining relationships with family members through visits. The paper proposes that prisoners' lay views should be given higher priority given that prison health has traditionally been associated with medical treatment and the bio-medical paradigm more generally. It also suggests that in order to fulfil the World Health Organization's (WHO) vision of viewing prisons as health promoting settings, lay views should be recognised to shape future health promotion policy and practice

Supporting Patient Autonomy: The Importance of Clinician-patient Relationships

Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients’ independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals’ autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients’ treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients’ autonomy. These understandings support recognition of the value of good patient-professional relationships and can enrich the specification of the principle of respect for autonomy. KEY WORDS: personal autonomy, professional-patient relations, clinical ethics, relationship-centred car

Information flows affecting coverage of medical research in the UK quality press

The project aimed to describe and critically evaluate information flows about medical research affecting UK quality newspapers. It focused particularly on the transfer of information from peer reviewed medical journals. In-depth interviews were conducted with media relations personnel at key organisations involved in medical research or more general health issues, and with specialist medical and health correspondents working for the national broadsheet press. The samples were purposively selected. Content analysis techniques were used to study news articles derived from information published in the British Medical Journal and the Lancet, which were compared with the original journal articles and any news releases associated with them. Many interacting factors shape media coverage of medical research and the personal motivations and preferences of a variety of individuals can play an important role. However, researchers, press officers and journalists are all constrained by their working relationships and contexts, so it is possible to identify certain common patterns of influence on the information flows. Press officers' activities are constrained by the characteristics and context of their organisations, particularly by the formal and cultural position of the press office within the organisation, and by relationships with other organisations in the field of interest which compete with their own for media access. Most importantly, they are constrained by their "go-between" role between their own organisation and media representatives who themselves operate under particular constraints. Press officers who liaise with researchers and journalists must seek acceptable compromises between scientific and news values. Specialist journalists are subject to the constraints of daily news reporting, and their stories must be strong in generally applicable news values if they are to be printed. The medical correspondents interviewed tried to avoid "over-sensationalisation" of stories because they had a sense of responsibility towards both their audience and their sources, but they had to be careful not to "kill" stories in their editors' eyes. Being unable to evaluate research evidence themselves, the journalists relied heavily on the authority of orthodox medical opinion in their story selection and development decisions. Their dependenceo n sourceso f authority encouragedt hem to write within a medical paradigm. Peer reviewed medical journals, articularly prestigious general journals, are regularly used as sources of news stories. Various factors encourage press officers and journalists to focus on a research project when it is about to be published. In particular, the peer review process is used by journalists as a quality safeguard, and journal policies against prior publication of material discourage researchers from discussing their work until it is safely in academically and professionally acceptable print. Several major medical research organisations invest heavily in media relations. Those which journalists regard as credible, and which can package information to suit their needs can successfully improve their media access. Future research should consider the roles of corporate culture and of competition between organisations involved with medical research in shaping information flows and media relations activity

Thinking about Later Life: Insights from the Capability Approach

A major criticism of mainstream gerontological frameworks is the inability of such frameworks to appreciate and incorporate issues of diversity and difference in engaging with experiences of aging. Given the prevailing socially structured nature of inequalities, such differences matter greatly in shaping experiences, as well as social constructions, of aging. I argue that Amartya Sen’s capability approach (2009) potentially offers gerontological scholars a broad conceptual framework that places at its core consideration of human beings (their values) and centrality of human diversity. As well as identifying these key features of the capability approach, I discuss and demonstrate their relevance to thinking about old age and aging. I maintain that in the context of complex and emerging identities in later life that shape and are shaped by shifting people-place and people-people relationships, Sen’s capability approach offers significant possibilities for gerontological research

A 2018 Horizon Scan of Emerging Issues for Global Conservation and Biological Diversity.

This is our ninth annual horizon scan to identify emerging issues that we believe could affect global biological diversity, natural capital and ecosystem services, and conservation efforts. Our diverse and international team, with expertise in horizon scanning, science communication, as well as conservation science, practice, and policy, reviewed 117 potential issues. We identified the 15 that may have the greatest positive or negative effects but are not yet well recognised by the global conservation community. Themes among these topics include new mechanisms driving the emergence and geographic expansion of diseases, innovative biotechnologies, reassessments of global change, and the development of strategic infrastructure to facilitate global economic priorities

Making Ends Meet: A Conceptual and Ethical Analysis of Efficiency

Efficiency is often overlooked as an ethical value and seen as ethically relevant chiefly when it conflicts with other values, such as equality. This article argues that efficiency is a rich and philosophically interesting concept deserving of independent normative examination. Drawing on a detailed healthcare case study, we argue that making assessments of efficiency involves value-laden, delib-erative judgments about how to characterize the functioning of human systems. Personal and emotional resources and ends are crucial to system functioning but are often discounted in favor of a relatively narrow set of financial inputs and institutional or procedural outputs. Judgments about efficiency tend to advantage (or disadvantage) different parties, depending on the resources and ends consid-ered. Different constructions of efficiency can therefore promote or neglect the perspectives and interests of differently placed actors. Models of efficiency do not merely embody contestable ethical standpoints but—put to use—can unwittingly reify and reproduce them