Journal articles on the topic 'Provision of health and support services not elsewhere classified'

The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades—but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an ‘organisational change’ approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.

Substitution among the providers of old-age care has usually meant a process whereby the state ‘takes over’ what families used to do, but during the 1980s and 1990s, both home help and institutional care were cut back substantially in Sweden as elsewhere. Comparable, nationally representative surveys in Sweden of the provision of care for older people living in the community enable analysis of the effects of these cutbacks on the sources and patterns of care. It emerges that increased inputs from families match the decline of public services, that is, a ‘reverse’ substitution has recently been taking place. Local studies, of older people who have been followed over time as the provision of home help has changed, support these conclusions. Of the increased informal care, most has been provided by daughters, but sons have also contributed. A problematic aspect of these shifting patterns of care is that an increasing number of family carers with increasingly heavy care commitments are now without formal or informal support, whereas in the recent past many could expect their responsibilities to be shared with the state. The evidence from this study also calls into question common metaphors and assumptions about the assumed interdependence between informal care and public services for older people, and challenges the so-called substitution thesis.

Purpose – The purpose of this paper is to describe specific features of a Victorian (Australia) state-wide hub and spoke model of speech pathology provision established for adults with complex communication needs (CCN). Two case studies highlighting successful examples of services developed to enhance community inclusion will be described and the challenges discussed. Design/methodology/approach – The route to community inclusion is described through a case study illustration of one communication accessible community site and one disability service study. The disability service research involved focus groups, survey and interview data and demonstrated the efficacy and sustainability of a support worker training model. Findings – Sustainable change in the community and in disability services can occur through partnerships, training, and long-term commitment. Support workers who can facilitate interactions for people who have cognitive and communicative disabilities are an essential component of building the capacity of communities to include people with CCN. Collaboration between community members, specialised supports and people with disabilities enhances active community participation. Originality/value – This innovative, state-wide model has the capacity to be replicated elsewhere. On-going speech pathology services are integral to support adults with CCN providing both short-term individualised services, sustainable staff training and community engagement.

Purpose This study aims to develop a framework for the management of medical records in support of health-care service delivery in the hospitals in the Limpopo province of South Africa. Design/methodology/approach The study was predominantly quantitative and has used the questionnaires, system analysis, document analysis and observation to collect data in 40 hospitals of Limpopo province. The sample of 49 per cent (306) records management officials were drawn out of 622 (100 per cent) total population. The response rate was 71 per cent (217) out of the entire sample. Findings The study discovered that a framework for management of medical records in the public hospitals is not in place because of several reasons and further demonstrates that public health-care institutions need an integrative framework for the proper management of medical records of all forms and in all media. Originality/value The study develops and suggests a framework to embed medical records management into the health-care service delivery workflow for effective records management and ease of access. It is hoped that such a framework will help hospitals in South Africa and elsewhere to improve their medical records management to support health-care service provision.

This paper describes the setting up of a pilot community neurocase management service for homeless adults with a brain injury. Whilst homelessness is a major problem in the UK and elsewhere, to date few brain injury or homelessness services have considered the complex medical, psychological and social factors affecting this population specifically. Investment of resources in service provision should be based upon evidence of the presenting needs and best practice in meeting these. This paper addresses the first of these two requirements, focusing on the initial cohort referred into our service. More detail about the interventions received and outcomes achieved, along with a discussion of the challenges encountered in providing the service will be provided in a follow-up paper. The need for psychologically-informed services to promote social inclusion is supported by our data which revealed concerning levels of community estrangement. Our data also confirm that homelessness often occurs in the context of multiple comorbidities which traverse conventional boundaries across medical, social care and criminal justice systems, meaning that collaborative working is essential. The argument for neuropsychological input in designing and delivering support alongside other services is clear.

There have been increasing calls for more gender-specific service provision to support young men’s (20-29 years) mental health and well-being. In Ireland, young men are the demographic group that are most likely to die by suicide but among the least likely to seek help. This study sought to investigate service providers’ perspectives on the factors that support or inhibit young men from engaging in services targeted at supporting their mental/emotional well-being. Qualitative methodologies (focus groups, n = 9; interviews, n = 7) were used for this study. Disconnection from family and community was identified as a key indicator of “at-risk” groups of young men who, more typically, had experienced significant disruption in their lives. The discord between demands and expectations facing young men on one hand, and insufficient life-management and coping skills on the other, left many young men vulnerable and bereft. The desire to save face and preserve one’s masculine identity was linked to young men’s reluctance to seek help when feeling down. There was a strong consensus that there could be no shortcuts to [re]connecting with young men. While sport, technology, and social media were cited as appropriate media in which to engage young men, the essence of sustained connection revolved around creating safety, trust, rapport, and meaningful relationships. The findings from this study have informed the development of a Train the Trainer program (“Connecting with Young Men”), which is currently being delivered to service providers in Ireland and which may have implications for service provision elsewhere.

Background/aims Chronic heart failure is a common condition with a poor prognosis, and its prevalence is increasing in the UK and elsewhere. Patients with heart failure require complex multidisciplinary care, with appropriate medicines optimisation, nursing support and management of comorbidities, ideally delivered via a multidisciplinary team integrated between the community and the hospital. This study aimed to investigate how heart failure care services are structured and delivered. Methods A survey of 100 health professionals in 79 heart failure centres was conducted by post or telephone using the same structured question format. Results There was widespread variability in the provision of key elements of heart failure nursing (specialist heart failure nurses, nurse prescriber, nurse consultant). A total of 15% of trusts had no local consultant with special interest in heart failure; 73% had no pharmacist; and 83% had no mental health specialist working in the heart failure healthcare team. Dedicated administrative support was absent in 24% of trusts. One-fifth (20%) did not offer exercise rehabilitation. A total of 68% reported insufficient resources available locally for individualised exercise rehabilitation, in accordance with guidelines from the National Institute for Health and Care Excellence. Conclusions The structure and provision of heart failure care is variable across the UK, and not always consistent with current guidelines. Reducing this variability across the UK is an urgent priority and will require increased resources, especially for specialist nurses embedded within the routine care of patients with chronic heart failure.

ObjectiveTo identify factors associated with accessing and utilisation of healthcare and provision of health services in slums.DesignA scoping review incorporating a conceptual framework for configuring reported factors.Data sourcesMEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from their inception to December 2021 using slum-related terms.Eligibility criteriaEmpirical studies of all designs reporting relevant factors in slums in low and middle-income countries.Data extraction and synthesisStudies were categorised and data were charted according to a preliminary conceptual framework refined by emerging findings. Results were tabulated and narratively summarised.ResultsOf the 15 469 records retrieved from all years, 4368 records dated between 2016 and 2021 were screened by two independent reviewers and 111 studies were included. The majority (63 studies, 57%) were conducted in Asia, predominantly in India. In total, 104 studies examined healthcare access and utilisation from slum residents’ perspective while only 10 studies explored provision of health services from providers/planners’ perspective (three studies included both). A multitude of factors are associated with accessing, using and providing healthcare in slums, including recent migration to slums; knowledge, perception and past experience of illness, healthcare needs and health services; financial constraint and competing priorities between health and making a living; lacking social support; unfavourable physical environment and locality; sociocultural expectations and stigma; lack of official recognition; and existing problems in the health system.ConclusionThe scoping review identified a significant body of recent literature reporting factors associated with accessing, utilisation and provision of healthcare services in slums. We classified the diverse factors under seven broad categories. The findings can inform a holistic approach to improving health services in slums by tackling barriers at different levels, taking into account local context and geospatial features of individual slums.Systematic review registration numberhttps://osf.io/694t2.

AbstractObjectives: Continuing deinstitutionalisation has led to growing concern about the availability and accessibility of services for people with learning disabilities transferring to community living. This study was undertaken in order to assess the configuration of services in terms of availability and uptake for people with learning disabilities who have left long-stay hospital care and to identify gaps or barriers to service provision within the unique integrated health and social services structure in Northern Ireland.Method: The ‘keyworkers’ of 195 people – most of whom were aged 40-59 years with a diagnosis of moderate intellectual impairment – were interviewed by a researcher one year after discharge using the Service Interview.Results: While a wide range of generic and specialist services was available, ‘packages’ of care consisted largely of public sector services (eg. GPs, chiropodists and social workers) and relied, to some extent, on the type of community accommodation. Although services appeared well co-ordinated in terms of care reviews and keyworker arrangements, 40% of people required more one-to-one support particularly in areas related to integration. However, services were perceived by care staff to be satisfactoryConclusions: The development of community care has been slower in Northern Ireland than elsewhere and a large proportion of resources remain tied up in hospital care. However, existing community-based services appear to be addressing individual needs. Some former patients, though, may have been subject to transinstitutionalisation in the sense that their choice of accommodation was restricted mainly to large private sector homes and work and daytime opportunities were insufficient to facilitate integration. Service planners and providers need to give further consideration to the likely effects of different forms of rehabilitation, reprovision and resettlement and to be aware that the pattern of service provision is likely to be different for the more dependent cohorts of people who leave hospital in the future.

The cascade model is a commonly applied framework to evaluate ecosystem services provision, highlighting their benefits to society and assigning non-monetary and monetary values to these services. Adapting this model, we present a methodology to establish the most suitable indicators for monitoring Payment for Ecosystem Services (PES) programs related to water resources in Brazil. Through a participatory process, a set of ecosystem functions indicators were assigned for each ecosystem service (ES) considered in the study. The indicators were then classified following these criteria: clarity, viability, sensitivity, and relevance. The indicators were organized by their final score according to each evaluated criterion. The results demonstrated that “clarity” and “relevance” criteria were those most important for the experts to choose an indicator. In general, we could also observe a preference for analytical and well-established indicators in the literature for all ES evaluated. The indicators list presented can support the PES program monitoring in Brazil. Additionally, the methodology developed can be easily applied in other areas and provide the definition of the most suitable indicators to monitor water-based PES in different Brazilian contexts. Keywords:cascade model, ecosystem functions, ecosystem service indicators, tropical areas.

ABSTRACT INTRODUCTION Recognition of the need to reduce harm and optimise patient outcomes from the use of medicines is contributing to an evolution of pharmacy practice in primary health care internationally. This evolution is changing community pharmacy and leading to new models of care that enable pharmacist contribution beyond traditional realms. There is little information about the extent of these changes in New Zealand. AIM The aim of this study was to investigate emerging roles of pharmacists in primary health care. METHODS A 10-question electronic survey was used to collect quantitative data about location, employment and roles of pharmacists practising in primary health care. RESULTS There were 467 survey responses. Although most pharmacists are employed by (78%, n = 357/458) and located in (84%, n = 393/467) community pharmacies, small numbers are dispersed widely across the primary health care sector. Of the 7% (n = 31/467) working in general practices, most are employed by Primary Health Organisations or District Health Boards. Limited cognitive pharmacy service provision is evident in the sector overall, but is much greater for pharmacists spending time located within general practices. DISCUSSION The large proportion of pharmacists practising in community pharmacies emphasises the importance of the Community Pharmacy Services Agreement in facilitating increased cognitive pharmacy service provision to optimise patient outcomes. The small numbers of pharmacists located elsewhere in the primary health care sector suggest there is scope to improve collaboration and integration in these areas. Flexible funding models that promote innovation and support sustainable practice change are key.

Purpose – The purpose of this paper is to describe the benefits of a social prescribing service for older people with sensory impairments experiencing social isolation. The paper draws on the findings from a 12-week programme run by Sense, a voluntary sector organisation, and illustrates how integrated services, combining arts-based participation and voluntary sector support, can create positive health and wellbeing outcomes for older people. Design/methodology/approach – The research took a mixed-methodological approach, conducting and analysing data from interviews and dynamic observation proformas with facilitators and quantitative psychological wellbeing scores with participants throughout the course of the programme. Observations and case study data were also collected to complement and contextualise the data sets. Findings – The research found that participatory arts programmes can help combat social isolation amongst older people with sensory impairments and can offer an important alliance for social care providers who are required to reach more people under increasing pecuniary pressures. The research also highlights other benefits for health and wellbeing in the group including increased self-confidence, new friendships, increased mental wellbeing and reduced social isolation. Research limitations/implications – The research was based on a sample size of 12 people with sensory impairments and therefore may lack generalisability. However, similar outcomes for people engaging in participatory arts through social prescription are documented elsewhere in the literature. Practical implications – The paper includes implications for existing health and social care services and argues that delivering more integrated services that combine health and social care pathways with arts provision have the potential to create social and medical health benefits without being care/support resource heavy. Originality/value – This paper fulfils a need to understand and develop services that are beneficial to older people who become sensory impaired in later life. This cohort is growing and, at present, there are very few services for this community at high risk of social isolation.

ObjectivesTo evaluate the effectiveness of a complex intervention to improve referral and treatment of pregnant smokers in routine practice, and to assess the incremental costs to the National Health Service (NHS) per additional woman quitting smoking.DesignInterrupted time series analysis of routine data before and after introducing the intervention, within-study economic evaluation.SettingEight acute NHS hospital trusts and 12 local authority areas in North East England.Participants37 726 records of singleton delivery including 10 594 to mothers classified as smoking during pregnancy.InterventionsA package of measures implemented in trusts and smoking cessation services, aimed at increasing the proportion of pregnant smokers quitting during pregnancy, comprising skills training for healthcare and smoking cessation staff; universal carbon monoxide monitoring with routine opt-out referral for smoking cessation support; provision of carbon monoxide monitors and supporting materials; and an explicit referral pathway and follow-up protocol.Main outcome measuresReferrals to smoking cessation services; probability of quitting smoking during pregnancy; additional costs to health services; incremental cost per additional woman quitting.ResultsAfter introduction of the intervention, the referral rate increased more than twofold (incidence rate ratio=2.47, 95% CI 2.16 to 2.81) and the probability of quitting by delivery increased (adjusted OR=1.81, 95% CI 1.54 to 2.12). The additional cost per delivery was £31 and the incremental cost per additional quit was £952; 31 pregnant women needed to be treated for each additional quitter.ConclusionsThe implementation of a system-wide complex healthcare intervention was associated with significant increase in rates of quitting by delivery.

The organization of multifunctional agriculture for the provision of social/health/educational services is spreading throughout Europe and elsewhere. This concept is not new, and the organization of practices differs according to each country’s welfare model. The aim of this paper is to reflect on the existing practices and trends and to provide a suitable comprehensive framework. Starting from long-term research action on this topic started in 1999 and from participation in European research projects and networks, this paper reflects on the features of existing practices and distinguishes emerging social farming models. Specific attention is given to the potential of social farming for both global change and the re-organization of local societies and welfare organizations. The diverse social farming models and their interactions with emerging constraints and needs during times of challenge and crisis, such as those we are currently experiencing, are considered in order to understand their basic principles (from direct support to co-production models), as well as how they correlate with the ongoing process of welfare reorganization and evolutionary societal demands.

Purpose. This report evaluates a beginning Nurse Practitioner (NP) role in Acute Pain Management. Healthcare setting. The role was implemented within an anaesthesiology-based pain service. The NP author developed this pain service in 2002 and was endorsed as an NP 6 years later. The NP reviews all clients undergoing major surgery or trauma and provides pain management to women for caesarean section. Prior to this role, there were significant delays for some patients requiring prompt analgesia. This was because of the decreased availability of anaesthetists to fully participate in the pain service due to the demand for complex anaesthesiology practice. Method of data collection. Data were conveniently collected by the NP on prescription and service provision over 200 working days. Main findings. Therapeutic activity reflected contemporary pain management practice and espouse the NP as a safe and effective clinician. The role has improved patient access to pain management through the prompt use of non-pharmacological interventions, drugs used to treat analgesic side effects, opioids and non-opioid analgesics. Principal conclusions. These initial positive outcomes are consistent with NP role development described elsewhere in Australia and overseas across a variety of healthcare settings. To sustain this role, robust continuing education and clinical support is required. What is known about the topic? There is little published information on the development of the Nurse Practitioner (NP) role in acute pain services in Australia or overseas. The acute pain role is a new development in Australia and so previous descriptions of NP practice have focussed on other specialty areas such as Emergency or Mental Health. What does this paper add? This report demonstrates positive and safe client outcomes as a result of a NP role in acute pain management. More importantly, it may contribute to accumulating evidence that NPs are safe prescribers of opioids and other analgesics in acute settings. What are the implications for practitioners? Novice NPs and Candidates practising in this specialty need to use this information as support for their own role development and implementation in other acute pain services in Australia.

Secondary or high school (HS) educational professionals expressed concerns about dealing with environmental and occupational health and safety protocols due to COVID-19. Concerns related to fall 2020 school re-opening and getting back into in-person teaching—whether full-time, part-time or some other approved hybrid model—plus ongoing uncertainty with how the state and federal government will be handling matters about mandates for virtual learning, rapid testing, vaccine distribution, etc. These concerns were related to both their experience as educational professionals and genuine interest in personal and student well-being. This study was a cross-sectional online survey in early fall from mid-September–early October 2020. Of a possible maximum participation of 740 New Jersey (NJ) supervisory-level HS teachers and administrators (e.g., department chairs, district and school principals), 100 confirmed unique respondents (13.5%) consented and completed the survey. Of 100 experienced (mean 18 years teaching) participants, 70% responded to the gender identity question (overall, 61% female, 39% male; by NJ region, gender ratios were similar). There were statistically significant differences (using Fischer’s exact test) between NJ regions regarding provision of online counseling and support services for teachers (p < 0.001); for resources and equipment for teachers to mediate online learning (p = 0.02); for assistive video technology tools (p = 0.03) and accessibility to structured online learning and professional development (p = 0.002); concerning learning aids to engage students in online instruction, online counseling, and support services for students and their families (p = 0.006); appropriate protocol is clean and disinfect areas used by a person with COVID-19 (p = 0.002); and, immediately separate staff and students who screen positive for COVID-19 (p = 0.03). There were few statistical differences by gender. This study reported what participants wanted regarding the development of future policies then implemented as reopening practices. Data can inform recommendations in NJ and elsewhere at federal, state, and local levels. Data provide new insights and valuable information to inform the consideration of acceptability of various policy measures among HS education professionals.

Background Since the COVID-19 outbreak, South Korea has been engaged in various efforts to overcome the pandemic. One of them is to provide app-based COVID-19–related services to the public. As the pandemic continues, a need for various apps has emerged, including COVID-19 apps that can support activities aimed at overcoming the COVID-19 pandemic. Objective We aimed to determine which apps were considered the most necessary according to users and evaluate the current status of the development of COVID-19–related apps in South Korea. We also aimed to determine users’ acceptance and concerns related to using apps to support activities to combat COVID-19. Methods We collected data from 1148 users from a web-based survey conducted between November 11 and December 6, 2020. Basic statistical analysis, multiple response analysis, and the Wilcoxon rank sum test were performed using R software. We then manually classified the current status of the development of COVID-19–related apps. Results In total, 68.4% (785/1148) of the respondents showed high willingness to protect themselves from COVID-19 by using related apps. Users considered the epidemiological investigation app to be the most necessary app (709/1148, 61.8%) overall, followed by the self-management app for self-isolation (613/1148, 53.4%), self-route management app (605/1148, 52.7%), COVID-19 symptom management app (483/1148, 42.1%), COVID-19–related information provision app (339/1148, 29.5%), and mental health management app (270/1148, 23.5%). Despite the high intention to use these apps, users were also concerned about privacy issues and media exposure. Those who had an underlying disease and had experience using COVID-19–related apps showed significantly higher intentions to use those apps (P=.05 and P=.01, respectively). Conclusions Targeting users is very important in order to design and develop the most necessary apps. Furthermore, to gain the public’s trust and make the apps available to as many people as possible, it is vital to develop diverse apps in which privacy protection is maximized.

During tertiary education, students embark on a journey of role exploration and decision-making about their future, to define who they want to be in their adult lives. Psychological services for students may be needed to help students gain better awareness of their mental health. The purpose of this systematic literature review is to analyze psychological interventions for university students in Europe. The review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were identified using the Scopus, Web of Science, PubMed, ProQuest Psychology Journals, PsycINFO, and PsycARTICLES databases. The results were classified into seven categories: counseling and group counseling (eight papers); psychodynamic interventions (six papers); cognitive–behavioral interventions (fifteen papers); other psychological interventions (eighteen papers); mindfulness (nine papers); online interventions (seventeen papers); and app and mobile interventions (ten papers). Student psychological services are becoming one of the most important sources of support for students, and the number of approaches offered is expanding. Our results suggest the need to further investigate and promote the provision of psychological care for university students, explore long-term treatment options, and invest in professionally trained staff.

SummaryIndonesia's infant mortality rates are among the highest in South-East Asia, and there are substantial variations between its sub-national regions. This qualitative study aims to explore early mortality-related health service provision and gender inequity issues based on mothers' pregnancy, delivery and early-age survival experience in Ende district, Nusa Tenggara Timur province. Thirty-two mothers aged 18–45 years with at least one birth in the previous five years were interviewed in depth in May 2013. The results show most mothers have little knowledge about the danger signs for a child's illness. Mothers with early-age deaths generally did not know the cause of death. Very few mothers had received adequate information on maternal and child health during their antenatal and postnatal visits to the health facility. Some mothers expressed a preference for using a traditional birth attendant, because of their ready availability and the more extensive range of support services they provide, compared with local midwives. Unprofessional attitudes displayed by midwives were reported by several mothers. As elsewhere in Indonesia, the power of health decision-making lies with the husband. Policies aimed at elevating mothers' roles in health care decision-making are discussed as measures that would help to improve early-age survival outcomes. Widening the public health insurance distribution, especially among poorer mothers, and equalizing the geographical distribution of midwives and health facilities are recommended to tackle geographical inequities and to increase early-age survival in Ende district.

This article reports findings from a study to support the inclusion of a Whole Family Approach (WFA) within policy and provision for children and families conducted in one large northern local authority in England. In recent years mainly from research and good practice elsewhere WFA had been seen to offer opportunities to focus on shared needs, developing strengths and assessing risk factors. The principal aim was to design an evaluation framework to enable partners to assess and measure progress in the delivery of a WF strategy. Methods included individual interviews with professionals and managers (N=22) on knowledge and experience of WFA, for example their understanding of multi-agency work, along with their evidence of adopting a WFA approach. Findings demonstrate the process of how an evaluation framework was constructed based on adapting preexisting outcome-focused 'models' used to evaluate functions of partnership-working along with indigenous sources. The first type of 'model' entailed a number of dimensions including Vision and Strategy, Partnership Dynamics, Impact and Performance Measurement. The second had two key features: it drew upon the idea of realist evaluation, a paradigm used by practitioner researchers where the focus is upon identifying mechanisms that explain how an action affects outcomes in particular contexts; and the 'model' had been applied extensively to an analysis of family intervention projects. What has emerged is an evaluation framework characterised by a number of key 'signifiers' each of which is populated by a series of questions. The framework embraces introducing changes to the culture of planning and delivering services, placing building family strengths at centre-stage.

Support is growing for the incorporation of fetching time and/or distance considerations in the definition of access to improved water supply used for global monitoring. Current efforts typically rely on self-reported distance and/or travel time data that have been shown to be unreliable. To date, however, there has been no head-to-head comparison of such indicators with other possible distance/time metrics. This study provides such a comparison. We examine the association between both straight-line distance and self-reported one-way travel time with measured route distances to water sources for 1,103 households in Nampula province, Mozambique. We find straight-line, or Euclidean, distance to be a good proxy for route distance (R2 = 0.98), while self-reported travel time is a poor proxy (R2 = 0.12). We also apply a variety of time- and distance-based indicators proposed in the literature to our sample data, finding that the share of households classified as having versus lacking access would differ by more than 70 percentage points depending on the particular indicator employed. This work highlights the importance of the ongoing debate regarding valid, reliable, and feasible strategies for monitoring progress in the provision of improved water supply services.

Background Digital health care is increasingly used to improve health service accessibility and reduce costs. Remote health care requires a significant self-management role for service users, and this generates information provision and support needs that should be reflected in service planning. SMS text messaging offers a convenient and low-cost method of communication and is increasingly used across digital health care services to provide remote support. Objective The aim of this study was to quantify the number of messages generated through user interaction with a two-way SMS text messaging support service within an online sexual health service and to thematically explore the content of the messages and type of support required to facilitate self-management. Methods The content of all SMS text messages received by an online sexual health service was analyzed from April 4, 2018, to July 5, 2018. Messages were classified as being either administrative or clinical in nature and service or user initiated. For those messages that were both clinical and user initiated, a qualitative thematic analysis was completed to fully describe the content of the interactions. Results A total of 267 actionable messages were generated per 1000 orders requested through the service. Of the 8562 messages, 5447 (63.62%) messages were administrative and 3115 (36.38%) were clinical. Overall, 4306 of the 8562 messages (50.29%) responded to service-generated queries reflecting the public health and clinical responsibilities of an online provider, and 4256 (49.71%) were user-generated queries, demonstrating a willingness by users to proactively engage with a two-way SMS text messaging support service. Of the 3115 clinical messages, 968 (31.08%) clinical messages were user initiated and shared personal and complex clinical information, including requests for help with the self-testing process and personalized clinical advice relating to symptoms and treatment. Conclusions This study demonstrates the willingness of users of an online sexual health service to engage with two-way SMS text messaging and provides insight into the quantity and nature of the support required to facilitate service delivery and self-care. Further work is required to understand the range of clinical problems that can be managed within this medium.

Abstract Introduction Provision of pharmacy services to patients requires the pharmacist to well communicate with the patients. Research has shown that healthcare providers, including community pharmacists, face many challenges while providing services to deaf and hard-of-hearing patients (DHOH). Aim To investigate community pharmacists’ experiences and beliefs about providing pharmacy services to DHOH in Riyadh, Saudi Arabia. Methods This was a sequential explanatory mixed-method study involving a survey and semi-structured interviews. At first, a web-based, self-administered survey was disseminated to community pharmacists in Riyadh, Saudi Arabia during the period October to November 2020. The survey was disseminated through the official twitter account of Saudi Pharmaceutical Society. Two reminders were sent. It was made clear that the survey targeted community pharmacists working in Riyadh city. To calculate an appropriate sample size, according to Hair et al, the general rule to have a minimum sample size would be five observations per variable (5:1), and an acceptable sample size would be ten observations per variable (10:1). In this survey, there are 16 items, and hence the acceptable sample size was 160 participants. The semi-structured telephone-based interviews were conducted with a purposive sample of survey respondents to gather in-depth information on experiences, beliefs, and barriers about providing pharmacy services to DHOH. The interviews were conducted until saturation occurred. Survey data was analysed using Statistical Package for Social Sciences (SPSS version 24), and the semi-structured interviews were analysed by Framework analysis. Results A total of 175 community pharmacists completed the survey. The majority were: male (84.6%), aged between 25 to 35 years (74.9%). Of the respondents, 32.2% and 29.1% had experience in community pharmacy of 1-5 and 6-10 years, respectively. The number of DHOH patients the pharmacists met during the past 6 months were as follows: 68 (38.9%) pharmacists met 1-2 patients, 71 (40.6%) %) pharmacists met 3-4 patients, and 19 (11%) %) pharmacists met ≥ 5 patients. The provided services included: prescription medications (by 82.9%), counselling on prescription medications (by 56.6%), OTC medication dispensing (by 4.3%), and counselling on OTC medications (by 52.6%). Forty participants (22.8%) reported their awareness of the basics of Saudi sign language (SSL). Of the participants, 101 (57.7%) believed that they have handled communication barriers appropriately, while 61(35%) acknowledged unmanageable communication barriers. Among the main barriers identified were the lack of knowledge of the basics of SSL. (70.9%) and the inability to recognize disability (52.6%). The semi-structured interviews further explored pharmacists’ experiences and views on providing such a service. Of the main themes emerged were: (1) Experience; interviewees preferred written communication with DHOH patients regardless of their literacy level, while spontaneous hand gesturing was the least preferred method of communication, and they also acknowledged that their roles in providing services, to the DHOH, need to be improved (2) Beliefs; interviewees believed that awareness of the basics of SSL is important to ensure safe medication use. The barriers emerged from the interview were classified as pharmacist-related, system-related, and patient-related. Conclusion To our knowledge, this is the first study of its kind to be conducted in Saudi Arabia. The study highlighted that when providing pharmacy services to DHOH patients, community pharmacists encountered multiple barriers. These barriers need to be addressed for better support and provision of pharmacy services to DHOH. Further studies with large sample size, are warranted to better understand the situation. References (1) Hair J, Black W, Babin B, Anderson R. Multivariate data analysis. 7th ed. Harlow: Pearson Education Limited; 2014 (2) Scheier DB. Barriers to health care for people with hearing loss: a review of the literature. J N Y State Nurses Assoc. 2009 Mar 22;40(1):4-11. (3) Ferguson MC, Shan L. Survey evaluation of pharmacy practice involving deaf patients. Journal of pharmacy practice. 2016 Oct;29(5):461-6.

AbstractAimsDespite the magnitude and protracted nature of the Rohingya refugee situation, there is limited information on the culture, mental health and psychosocial wellbeing of this group. This paper, drawing on a report commissioned by the United Nations High Commissioner for Refugees (UNHCR), aims to provide a comprehensive synthesis of the literature on mental health and psychosocial wellbeing of Rohingya refugees, including an examination of associated cultural factors. The ultimate objective is to assist humanitarian actors and agencies in providing culturally relevant Mental Health and Psychosocial Support (MHPSS) for Rohingya refugees displaced to Bangladesh and other neighbouring countries.MethodsWe conducted a systematic search across multiple sources of information with reference to the contextual, social, economic, cultural, mental health and health-related factors amongst Rohingya refugees living in the Asia-Pacific and other regions. The search covered online databases of diverse disciplines (e.g. medicine, psychology, anthropology), grey literature, as well as unpublished reports from non-profit organisations and United Nations agencies published until 2018.ResultsThe legacy of prolonged exposure to conflict and persecution compounded by protracted conditions of deprivations and displacement is likely to increase the refugees' vulnerability to wide array of mental health problems including posttraumatic stress disorder, anxiety, depression and suicidal ideation. High rates of sexual and gender-based violence, lack of privacy and safe spaces and limited access to integrated psychosocial and mental health support remain issues of concern within the emergency operation in Bangladesh. Another challenge is the limited understanding amongst the MHPSS personnel in Bangladesh and elsewhere of the language, culture and help-seeking behaviour of Rohingya refugees. While the Rohingya language has a considerable vocabulary for emotional and behavioural problems, there is limited correspondence between these Rohingya terms and western concepts of mental disorders. This hampers the provision of culturally sensitive and contextually relevant MHPSS services to these refugees.ConclusionsThe knowledge about the culture, context, migration history, idioms of distress, help-seeking behaviour and traditional healing methods, obtained from diverse sources can be applied in the design and delivery of culturally appropriate interventions. Attention to past exposure to traumatic events and losses need to be paired with attention for ongoing stressors and issues related to worries about the future. It is important to design MHPSS interventions in ways that mobilise the individual and collective strengths of Rohingya refugees and build on their resilience.

Abstract In the 21st century, urban agriculture renews and diversifies approaches to the practice within the context of urban regeneration, climate change risks, sustainable development and resource consumption balance problems. Influenced by the long historical evolution and intensification of various risks, food production in urban areas involves the widest multifunctionality to date. Therefore, the aim of this research is to identify the main functions of urban agriculture and to evaluate their significance in Latvia. The following tasks were set to achieve the aim: 1) to identify and classify functions of urban agriculture, 2) to analyse the performance and significance of functions in Latvia. Several methods were employed to perform tasks and achieve the aim: the monographic and descriptive methods for making a theoretical discussion; the analysis, synthesis and deduction methods for obtaining information, systematisation and classification of functions; a structured expert interview for rating and ranking functions and identifying interactions between them. The research identified 14 functions of urban agriculture, which were classified into 5 groups: political, economic, social, environmental and technological. The most significant functions of urban agriculture in Latvia are social (promotion of social cohesion and public health, education and maintaining traditions and values) and technological innovations. There are interactions between all functions, and support for urban sustainability, education, provision of ecosystem services and technological innovations have the strongest impact on other functions. Interactions of functions proved the multifunctionality of urban agriculture, which could be an important support tool to contributing to sustainable urban development.

Background: Nurses in public health centers, or known as public health nurses (PHNs), have duties in implementing promotive, preventive, curative, and rehabilitative efforts. In Indonesia, there is no basic reference to the competencies that should be performed by PHNs. The provision of health services in the community should cover two areas, namely inside and outside the building (Minister of Health’s Regulation No. 279 Year 2006); it causes nurses in the community to further hone their skills while in the field.Purpose: This study aimed to identify the competencies of the Indonesian PHNs from experts using the C/PHN competencies of the Quad Council Coalition through a Delphi method.Methods: This study was quantitative research with a Delphi method. We employed a purposive sampling technique to recruit the experts of public health nurses. The experts did a Delphi method to identify, analyze, and modify the C/PHN Competencies of the Quad Council Coalition into the Indonesian version of C/PHN Competencies with local cultures.Results: Results showed that from eight domains of the Quad Council Coalition C/PHN competencies, there were changes for priority of the PHN competencies in Indonesia. All priorities were classified into eight groups, namely: (1) Leadership Skills and Thinking Systems; (2) Community Dimensions of Practice; (3) Assessment Analytic; (4) Policy Development and Program Planning; (5) Communication Skills; (6) Financial Planning and Management and Planning; (7) Public Health Sciences Skills; and (8) Cultural Competency.Conclusion: The Quad Council Coalition of C/PHN competencies are appropriate with the Indonesian PHN competencies, although the priority is changed related of local wisdom as stated in the Minister of Health’s Regulation No. 279 Year 2006. Therefore, the Indonesian P/HN competencies should be developed to support the Indonesian health people through family approach.

Abstract COVID-19 infections are particularly lethal in older adults; thus, social activities of older adults and their families in the community have been restricted. The threat of infection, restrictions on social activities, and limitations on the provision of care services for older adults could increase family caregivers’ burden and impact their mental health. This cross-sectional study examined the association between family caregiving and change in depression during the COVID-19 pandemic. In October 2020, we conducted a mailed questionnaire survey on a random sample of functionally independent community-dwelling older adults in a semi-urban area of Japan. Based on the depression status between March and October 2020, participants were classified into four groups: “consistently non-depressed,” “depression onset,” “recovering from depression,” and “remained depressed.” Participants were assessed for providing care for their family members or not. Caregiver participants were also assessed on their caregiving role (primary or secondary), the severity of their care-recipient’s needs, and an increased caregiver burden. Data from 957 older adults were analyzed. The participants’ mean age (SD) was 80.8 (4.8) years, and 53.5% were female. Multivariable multinomial logistic regression analysis revealed that family caregiving was associated with depression onset (OR=3.17 [95%CI=1.57-6.40], p=0.001) and remaining depressed (2.53 [1.36-4.71], p=0.004). Particularly, primary caregivers, those providing care for family members with severer care need-levels, and those with an increased caregiver burden had a higher risk of depression onset and remaining depressed. Family caregivers could have severe mental health conditions during the pandemic. Developing a support system is essential to protect their mental health.

Background and designThis research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.Research objectives(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.SettingCommunity-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).ParticipantsThe combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.InterventionsThe interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.Outcome measures(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.Results(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.ConclusionsThis study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.FundingThe NIHR Health Services and Delivery Research programme.

Background Some children born to adolescent mothers may have developmental challenges, while others do not. Research focusing on which children of adolescent mothers are at the highest risk for cognitive delay is still required. Both maternal HIV status and maternal mental health may affect child development. An examination of maternal mental health, especially in the presence of maternal HIV infection may be timely. This study explores the relationship between the mental health of adolescent mothers (comparing those living with and not living with HIV) and the cognitive development performance scores of their children. Additional possible risk and protective factors for poor child development are explored to identify those children born to adolescent mothers who may be at the greatest risk of poor cognitive development. Methods Cross-sectional data utilised within the analyses was drawn from a large cohort of adolescent mothers and their children residing in South Africa. Detailed study questionnaires were completed by adolescent mothers relating to their self and their child and, standardised cognitive assessments were completed by trained researchers for all children using in the Mullen Scales of Early Learning. Chi-square, t-tests (Kruskal Wallis tests, where appropriate), and ANOVA were used to explore sample characteristics and child cognitive development scores by maternal mental health status (operationalised as likely common mental disorder) and combined maternal mental health and HIV status. Multivariable linear regression models were used to explore the relationship between possible risk factors (including poor maternal mental health and HIV) and, child cognitive development scores. Results The study included 954 adolescent mothers; 24.1% (230/954) were living with HIV, 12.6% (120/954) were classified as experiencing likely common mental disorder. After adjusting for covariates, maternal HIV was found to be associated with reduced child gross motor scores (B = -2.90 [95%CI: -5.35, -0.44], p = 0.02), however, no other associations were identified between maternal likely common mental disorder, or maternal HIV status (including interaction terms), and child cognitive development scores. Sensitivity analyses exploring individual maternal mental health scales identified higher posttraumatic stress symptomology scores as being associated with lower child cognitive development scores. Sensitivity analyses exploring potential risk and protective factors for child cognitive development also identified increased maternal educational attainment as being protective of child development scores, and increased child age as a risk factor for lower development scores. Conclusions This study addresses a critical evidence gap relating to the understanding of possible risk factors for the cognitive development of children born to adolescent mothers affected by HIV. This group of mothers experience a complex combination of risk factors, including HIV, likely common mental disorder, and structural challenges such as educational interruption. Targeting interventions to support the cognitive development of children of adolescent mothers most at risk may be of benefit. Clearly a basket of interventions needs to be considered, such as the integration of mental health provision within existing services, identifying multiple syndemics of risk, and addressing educational and structural challenges, all of which may boost positive outcomes for both the mother and the child.

Abstract In a recent ruling (Parry Sound (District) Social Services Administration Board v. O.P.S.E.U., Local 324, 2003 SCC 42), the Supreme Court of Canada states that an arbitrator has jurisdiction to hear a dispute that involves rights guaranteed by codes, charters and employment legislation even if the arbitrator has been barred from such recourse under a collective agreement. In the case at issue, an employee with probationary status benefited from maternity leave and was discharged upon her return. Despite the clarity of the wording under the collective agreement stating that a probationary employee may not resort to arbitration, a grievance was filed and was worded as follows: [Translation] “. . . was discharged without reason and this decision is arbitrary, discriminatory, unjust and vitiated by bad faith.” Owing to the rights vesting in the employee under the Employment Standards Act (Ontario), the Board of Arbitration ruled on its own jurisdiction to hear such a grievance. This decision was quashed in judicial review (Superior Court) and but was then upheld in Court of Appeal and once again by the Supreme Court of Canada (majority 7/9). The Supreme Court of Canada began by making several observations concerning the criteria of judgment applicable to judicial review, namely that which is considered patently unreasonable. An attempt was made to distinguish between an unreasonable decision and one that would be patently unreasonable. It seems to us that such a distinction remains ambiguous and further confuses the exercising of a fair judicial review; unreasonableness should not be graded by degrees. In a second approach, the ruling establishes the relationship between State standards (Codes, Charters and employment legislation) and contractual standards. Working from the basis that State standards would be incorporated into the collective agreement, the Court establishes that the limit imposed upon the collective agreement regarding access to arbitration had the practical effect of denying the right to maternity leave, elsewhere guaranteed by law. For this reason, the arbitrator had to intervene and exercise control in order to ensure respect for established standards of public order. To achieve these ends, the Supreme Court of Canada seemed to experience considerable difficulty in qualifying the collective agreement and classified it in the category of private contracts. Such a categorization, confined to the traditional “public/private” dichotomy, dismisses the true legal and desired effect seeking to make the collective agreement a regulatory labour provision complementary to statutes governing public order and intimately related to the latter. In support of his line of reasoning, Judge Iacobucci, on behalf of the majority (7/9), repeatedly referred to the ruling: McLeod v. Egan, [1975] 1 S.C.R. 517. The referrals denied under this ruling are hardly convincing and uselessly weigh down the reasoning. Moreover, Judge Major (dissenting) also referred to it and considered that Judge Iacobucci was reading into the McLeod v. Egan ruling a purport that it just does not have. In all, we believe that the codes, charters and employment legislation serve as the basis upon which the collective agreement is built and, consequently, the parties’ contractual freedom both derives from this basis and is limited thereto. This interrelation would be analogous to that of the Constitution and employment statutes, without it being possible to affirm that the Constitution would be found to be a part of each of these statutes. This ruling is especially interesting because it recognizes the employee’s right to resort to arbitration in order to ensure respect for guarantees stipulated in employment legislation, despite wording to the contrary in the collective agreement. Parties to collective agreements and arbitrators must therefore respectively correct their approach and grant access to arbitration for all employees from the very moment that their fundamental rights are jeopardized in any way.

In this issue of Journal of Disaster Research, we introduce nine papers on societal responses to recent catastrophic disasters with special focus on long-term recovery processes in Japan and the United States. As disaster impacts increase, we also find that recovery times take longer and the processes for recovery become more complicated. On January 17th of 1995, a magnitude 7.2 earthquake hit the Hanshin and Awaji regions of Japan, resulting in the largest disaster in Japan in 50 years. In this disaster which we call the Kobe earthquake hereafter, over 6,000 people were killed and the damage and losses totaled more than 100 billion US dollars. The long-term recovery from the Kobe earthquake disaster took more than ten years to complete. One of the most important responsibilities of disaster researchers has been to scientifically monitor and record the long-term recovery process following this unprecedented disaster and discern the lessons that can be applied to future disasters. The first seven papers in this issue present some of the key lessons our research team learned from the studying the long-term recovery following the Kobe earthquake disaster. We have two additional papers that deal with two recent disasters in the United States – the terrorist attacks on World Trade Center in New York on September 11 of 2001 and the devastation of New Orleans by the 2005 Hurricane Katrina and subsequent levee failures. These disasters have raised a number of new research questions about long-term recovery that US researchers are studying because of the unprecedented size and nature of these disasters’ impacts. Mr. Mammen’s paper reviews the long-term recovery processes observed at and around the World Trade Center site over the last six years. Ms. Johnson’s paper provides a detailed account of the protracted reconstruction planning efforts in the city of New Orleans to illustrate a set of sufficient and necessary conditions for successful recovery. All nine papers in this issue share a theoretical framework for long-term recovery processes which we developed based first upon the lessons learned from the Kobe earthquake and later expanded through observations made following other recent disasters in the world. The following sections provide a brief description of each paper as an introduction to this special issue. 1. The Need for Multiple Recovery Goals After the 1995 Kobe earthquake, the long-term recovery process began with the formulation of disaster recovery plans by the City of Kobe – the most severely impacted municipality – and an overarching plan by Hyogo Prefecture which coordinated 20 impacted municipalities; this planning effort took six months. Before the Kobe earthquake, as indicated in Mr. Maki’s paper in this issue, Japanese theories about, and approaches to, recovery focused mainly on physical recovery, particularly: the redevelopment plans for destroyed areas; the location and standards for housing and building reconstruction; and, the repair and rehabilitation of utility systems. But the lingering problems of some of the recent catastrophes in Japan and elsewhere indicate that there are multiple dimensions of recovery that must be considered. We propose that two other key dimensions are economic recovery and life recovery. The goal of economic recovery is the revitalization of the local disaster impacted economy, including both major industries and small businesses. The goal of life recovery is the restoration of the livelihoods of disaster victims. The recovery plans formulated following the 1995 Kobe earthquake, including the City of Kobe’s and Hyogo Prefecture’s plans, all stressed these two dimensions in addition to physical recovery. The basic structure of both the City of Kobe’s and Hyogo Prefecture’s recovery plans are summarized in Fig. 1. Each plan has three elements that work simultaneously. The first and most basic element of recovery is the restoration of damaged infrastructure. This helps both physical recovery and economic recovery. Once homes and work places are recovered, Life recovery of the impacted people can be achieved as the final goal of recovery. Figure 2 provides a “recovery report card” of the progress made by 2006 – 11 years into Kobe’s recovery. Infrastructure was restored in two years, which was probably the fastest infrastructure restoration ever, after such a major disaster; it astonished the world. Within five years, more than 140,000 housing units were constructed using a variety of financial means and ownership patterns, and exceeding the number of demolished housing units. Governments at all levels – municipal, prefectural, and national – provided affordable public rental apartments. Private developers, both local and national, also built condominiums and apartments. Disaster victims themselves also invested a lot to reconstruct their homes. Eleven major redevelopment projects were undertaken and all were completed in 10 years. In sum, the physical recovery following the 1995 Kobe earthquake was extensive and has been viewed as a major success. In contrast, economic recovery and life recovery are still underway more than 13 years later. Before the Kobe earthquake, Japan’s policy approaches to recovery assumed that economic recovery and life recovery would be achieved by infusing ample amounts of public funding for physical recovery into the disaster area. Even though the City of Kobe’s and Hyogo Prefecture’s recovery plans set economic recovery and life recovery as key goals, there was not clear policy guidance to accomplish them. Without a clear articulation of the desired end-state, economic recovery programs for both large and small businesses were ill-timed and ill-matched to the needs of these businesses trying to recover amidst a prolonged slump in the overall Japanese economy that began in 1997. “Life recovery” programs implemented as part of Kobe’s recovery were essentially social welfare programs for low-income and/or senior citizens. 2. Requirements for Successful Physical Recovery Why was the physical recovery following the 1995 Kobe earthquake so successful in terms of infrastructure restoration, the replacement of damaged housing units, and completion of urban redevelopment projects? There are at least three key success factors that can be applied to other disaster recovery efforts: 1) citizen participation in recovery planning efforts, 2) strong local leadership, and 3) the establishment of numerical targets for recovery. Citizen participation As pointed out in the three papers on recovery planning processes by Mr. Maki, Mr. Mammen, and Ms. Johnson, citizen participation is one of the indispensable factors for successful recovery plans. Thousands of citizens participated in planning workshops organized by America Speaks as part of both the World Trade Center and City of New Orleans recovery planning efforts. Although no such workshops were held as part of the City of Kobe’s recovery planning process, citizen participation had been part of the City of Kobe’s general plan update that had occurred shortly before the earthquake. The City of Kobe’s recovery plan is, in large part, an adaptation of the 1995-2005 general plan. On January 13 of 1995, the City of Kobe formally approved its new, 1995-2005 general plan which had been developed over the course of three years with full of citizen participation. City officials, responsible for drafting the City of Kobe’s recovery plan, have later admitted that they were able to prepare the city’s recovery plan in six months because they had the preceding three years of planning for the new general plan with citizen participation. Based on this lesson, Odiya City compiled its recovery plan based on the recommendations obtained from a series of five stakeholder workshops after the 2004 Niigata Chuetsu earthquake. <strong>Fig. 1. </strong> Basic structure of recovery plans from the 1995 Kobe earthquake. <strong>Fig. 2. </strong> “Disaster recovery report card” of the progress made by 2006. Strong leadership In the aftermath of the Kobe earthquake, local leadership had a defining role in the recovery process. Kobe’s former Mayor, Mr. Yukitoshi Sasayama, was hired to work in Kobe City government as an urban planner, rebuilding Kobe following World War II. He knew the city intimately. When he saw damage in one area on his way to the City Hall right after the earthquake, he knew what levels of damage to expect in other parts of the city. It was he who called for the two-month moratorium on rebuilding in Kobe city on the day of the earthquake. The moratorium provided time for the city to formulate a vision and policies to guide the various levels of government, private investors, and residents in rebuilding. It was a quite unpopular policy when Mayor Sasayama announced it. Citizens expected the city to be focusing on shelters and mass care, not a ban on reconstruction. Based on his experience in rebuilding Kobe following WWII, he was determined not to allow haphazard reconstruction in the city. It took several years before Kobe citizens appreciated the moratorium. Numerical targets Former Governor Mr. Toshitami Kaihara provided some key numerical targets for recovery which were announced in the prefecture and municipal recovery plans. They were: 1) Hyogo Prefecture would rebuild all the damaged housing units in three years, 2) all the temporary housing would be removed within five years, and 3) physical recovery would be completed in ten years. All of these numerical targets were achieved. Having numerical targets was critical to directing and motivating all the stakeholders including the national government’s investment, and it proved to be the foundation for Japan’s fundamental approach to recovery following the 1995 earthquake. 3. Economic Recovery as the Prime Goal of Disaster Recovery In Japan, it is the responsibility of the national government to supply the financial support to restore damaged infrastructure and public facilities in the impacted area as soon as possible. The long-term recovery following the Kobe earthquake is the first time, in Japan’s modern history, that a major rebuilding effort occurred during a time when there was not also strong national economic growth. In contrast, between 1945 and 1990, Japan enjoyed a high level of national economic growth which helped facilitate the recoveries following WWII and other large fires. In the first year after the Kobe earthquake, Japan’s national government invested more than US$ 80 billion in recovery. These funds went mainly towards the repair and reconstruction of infrastructure and public facilities. Now, looking back, we can also see that these investments also nearly crushed the local economy. Too much money flowed into the local economy over too short a period of time and it also did not have the “trickle-down” effect that might have been intended. To accomplish numerical targets for physical recovery, the national government awarded contracts to large companies from Osaka and Tokyo. But, these large out-of-town contractors also tended to have their own labor and supply chains already intact, and did not use local resources and labor, as might have been expected. Essentially, ten years of housing supply was completed in less than three years, which led to a significant local economic slump. Large amounts of public investment for recovery are not necessarily a panacea for local businesses, and local economic recovery, as shown in the following two examples from the Kobe earthquake. A significant national investment was made to rebuild the Port of Kobe to a higher seismic standard, but both its foreign export and import trade never recovered to pre-disaster levels. While the Kobe Port was out of business, both the Yokohama Port and the Osaka Port increased their business, even though many economists initially predicted that the Kaohsiung Port in Chinese Taipei or the Pusan Port in Korea would capture this business. Business stayed at all of these ports even after the reopening of the Kobe Port. Similarly, the Hanshin Railway was severely damaged and it took half a year to resume its operation, but it never regained its pre-disaster readership. In this case, two other local railway services, the JR and Hankyu lines, maintained their increased readership even after the Hanshin railway resumed operation. As illustrated by these examples, pre-disaster customers who relied on previous economic output could not necessarily afford to wait for local industries to recover and may have had to take their business elsewhere. Our research suggests that the significant recovery investment made by Japan’s national government may have been a disincentive for new economic development in the impacted area. Government may have been the only significant financial risk-taker in the impacted area during the national economic slow-down. But, its focus was on restoring what had been lost rather than promoting new or emerging economic development. Thus, there may have been a missed opportunity to provide incentives or put pressure on major businesses and industries to develop new businesses and attract new customers in return for the public investment. The significant recovery investment by Japan’s national government may have also created an over-reliance of individuals on public spending and government support. As indicated in Ms. Karatani’s paper, individual savings of Kobe’s residents has continued to rise since the earthquake and the number of individuals on social welfare has also decreased below pre-disaster levels. Based on our research on economic recovery from the Kobe earthquake, at least two lessons emerge: 1) Successful economic recovery requires coordination among all three recovery goals – Economic, Physical and Life Recovery, and 2) “Recovery indices” are needed to better chart recovery progress in real-time and help ensure that the recovery investments are being used effectively. Economic recovery as the prime goal of recovery Physical recovery, especially the restoration of infrastructure and public facilities, may be the most direct and socially accepted provision of outside financial assistance into an impacted area. However, lessons learned from the Kobe earthquake suggest that the sheer amount of such assistance may not be effective as it should be. Thus, as shown in Fig. 3, economic recovery should be the top priority goal for recovery among the three goals and serve as a guiding force for physical recovery and life recovery. Physical recovery can be a powerful facilitator of post-disaster economic development by upgrading social infrastructure and public facilities in compliance with economic recovery plans. In this way, it is possible to turn a disaster into an opportunity for future sustainable development. Life recovery may also be achieved with a healthy economic recovery that increases tax revenue in the impacted area. In order to achieve this coordination among all three recovery goals, municipalities in the impacted areas should have access to flexible forms of post-disaster financing. The community development block grant program that has been used after several large disasters in the United States, provide impacted municipalities with a more flexible form of funding and the ability to better determine what to do and when. The participation of key stakeholders is also an indispensable element of success that enables block grant programs to transform local needs into concrete businesses. In sum, an effective economic recovery combines good coordination of national support to restore infrastructure and public facilities and local initiatives that promote community recovery. Developing Recovery Indices Long-term recovery takes time. As Mr. Tatsuki’s paper explains, periodical social survey data indicates that it took ten years before the initial impacts of the Kobe earthquake were no longer affecting the well-being of disaster victims and the recovery was completed. In order to manage this long-term recovery process effectively, it is important to have some indices to visualize the recovery processes. In this issue, three papers by Mr. Takashima, Ms. Karatani, and Mr. Kimura define three different kinds of recovery indices that can be used to continually monitor the progress of the recovery. Mr. Takashima focuses on electric power consumption in the impacted area as an index for impact and recovery. Chronological change in electric power consumption can be obtained from the monthly reports of power company branches. Daily estimates can also be made by tracking changes in city lights using a satellite called DMSP. Changes in city lights can be a very useful recovery measure especially at the early stages since it can be updated daily for anywhere in the world. Ms. Karatani focuses on the chronological patterns of monthly macro-statistics that prefecture and city governments collect as part of their routine monitoring of services and operations. For researchers, it is extremely costly and virtually impossible to launch post-disaster projects that collect recovery data continuously for ten years. It is more practical for researchers to utilize data that is already being collected by local governments or other agencies and use this data to create disaster impact and recovery indices. Ms. Karatani found three basic patterns of disaster impact and recovery in the local government data that she studied: 1) Some activities increased soon after the disaster event and then slumped, such as housing construction; 2) Some activities reduced sharply for a period of time after the disaster and then rebounded to previous levels, such as grocery consumption; and 3) Some activities reduced sharply for a while and never returned to previous levels, such as the Kobe Port and Hanshin Railway. Mr. Kimura focuses on the psychology of disaster victims. He developed a “recovery and reconstruction calendar” that clarifies the process that disaster victims undergo in rebuilding their shattered lives. His work is based on the results of random surveys. Despite differences in disaster size and locality, survey data from the 1995 Kobe earthquake and the 2004 Niigata-ken Chuetsu earthquake indicate that the recovery and reconstruction calendar is highly reliable and stable in clarifying the recovery and reconstruction process. <strong>Fig. 3.</strong> Integrated plan of disaster recovery. 4. Life Recovery as the Ultimate Goal of Disaster Recovery Life recovery starts with the identification of the disaster victims. In Japan, local governments in the impacted area issue a “damage certificate” to disaster victims by household, recording the extent of each victim’s housing damage. After the Kobe earthquake, a total of 500,000 certificates were issued. These certificates, in turn, were used by both public and private organizations to determine victim’s eligibility for individual assistance programs. However, about 30% of those victims who received certificates after the Kobe earthquake were dissatisfied with the results of assessment. This caused long and severe disputes for more than three years. Based on the lessons learned from the Kobe earthquake, Mr. Horie’s paper presents (1) a standardized procedure for building damage assessment and (2) an inspector training system. This system has been adopted as the official building damage assessment system for issuing damage certificates to victims of the 2004 Niigata-ken Chuetsu earthquake, the 2007 Noto-Peninsula earthquake, and the 2007 Niigata-ken Chuetsu Oki earthquake. Personal and family recovery, which we term life recovery, was one of the explicit goals of the recovery plan from the Kobe earthquake, but it was unclear in both recovery theory and practice as to how this would be measured and accomplished. Now, after studying the recovery in Kobe and other regions, Ms. Tamura’s paper proposes that there are seven elements that define the meaning of life recovery for disaster victims. She recently tested this model in a workshop with Kobe disaster victims. The seven elements and victims’ rankings are shown in Fig. 4. Regaining housing and restoring social networks were, by far, the top recovery indicators for victims. Restoration of neighborhood character ranked third. Demographic shifts and redevelopment plans implemented following the Kobe earthquake forced significant neighborhood changes upon many victims. Next in line were: having a sense of being better prepared and reducing their vulnerability to future disasters; regaining their physical and mental health; and restoration of their income, job, and the economy. The provision of government assistance also provided victims with a sense of life recovery. Mr. Tatsuki’s paper summarizes the results of four random-sample surveys of residents within the most severely impacted areas of Hyogo Prefecture. These surveys were conducted biannually since 1999,. Based on the results of survey data from 1999, 2001, 2003, and 2005, it is our conclusion that life recovery took ten years for victims in the area impacted significantly by the Kobe earthquake. Fig. 5 shows that by comparing the two structural equation models of disaster recovery (from 2003 and 2005), damage caused by the Kobe earthquake was no longer a determinant of life recovery in the 2005 model. It was still one of the major determinants in the 2003 model as it was in 1999 and 2001. This is the first time in the history of disaster research that the entire recovery process has been scientifically described. It can be utilized as a resource and provide benchmarks for monitoring the recovery from future disasters. <strong>Fig. 4.</strong> Ethnographical meaning of “life recovery” obtained from the 5th year review of the Kobe earthquake by the City of Kobe. <strong>Fig. 5.</strong> Life recovery models of 2003 and 2005. 6. The Need for an Integrated Recovery Plan The recovery lessons from Kobe and other regions suggest that we need more integrated recovery plans that use physical recovery as a tool for economic recovery, which in turn helps disaster victims. Furthermore, we believe that economic recovery should be the top priority for recovery, and physical recovery should be regarded as a tool for stimulating economic recovery and upgrading social infrastructure (as shown in Fig. 6). With this approach, disaster recovery can help build the foundation for a long-lasting and sustainable community. Figure 6 proposes a more detailed model for a more holistic recovery process. The ultimate goal of any recovery process should be achieving life recovery for all disaster victims. We believe that to get there, both direct and indirect approaches must be taken. Direct approaches include: the provision of funds and goods for victims, for physical and mental health care, and for housing reconstruction. Indirect approaches for life recovery are those which facilitate economic recovery, which also has both direct and indirect approaches. Direct approaches to economic recovery include: subsidies, loans, and tax exemptions. Indirect approaches to economic recovery include, most significantly, the direct projects to restore infrastructure and public buildings. More subtle approaches include: setting new regulations or deregulations, providing technical support, and creating new businesses. A holistic recovery process needs to strategically combine all of these approaches, and there must be collaborative implementation by all the key stakeholders, including local governments, non-profit and non-governmental organizations (NPOs and NGOs), community-based organizations (CBOs), and the private sector. Therefore, community and stakeholder participation in the planning process is essential to achieve buy-in for the vision and desired outcomes of the recovery plan. Securing the required financial resources is also critical to successful implementation. In thinking of stakeholders, it is important to differentiate between supporting entities and operating agencies. Supporting entities are those organizations that supply the necessary funding for recovery. Both Japan’s national government and the federal government in the U.S. are the prime supporting entities in the recovery from the 1995 Kobe earthquake and the 2001 World Trade Center recovery. In Taiwan, the Buddhist organization and the national government of Taiwan were major supporting entities in the recovery from the 1999 Chi-Chi earthquake. Operating agencies are those organizations that implement various recovery measures. In Japan, local governments in the impacted area are operating agencies, while the national government is a supporting entity. In the United States, community development block grants provide an opportunity for many operating agencies to implement various recovery measures. As Mr. Mammen’ paper describes, many NPOs, NGOs, and/or CBOs in addition to local governments have had major roles in implementing various kinds programs funded by block grants as part of the World Trade Center recovery. No one, single organization can provide effective help for all kinds of disaster victims individually or collectively. The needs of disaster victims may be conflicting with each other because of their diversity. Their divergent needs can be successfully met by the diversity of operating agencies that have responsibility for implementing recovery measures. In a similar context, block grants made to individual households, such as microfinance, has been a vital recovery mechanism for victims in Thailand who suffered from the 2004 Sumatra earthquake and tsunami disaster. Both disaster victims and government officers at all levels strongly supported the microfinance so that disaster victims themselves would become operating agencies for recovery. Empowering individuals in sustainable life recovery is indeed the ultimate goal of recovery. <strong>Fig. 6.</strong> A holistic recovery policy model.

Abstract Background Poor oral health due to dental caries is one of the most prevalent non-communicable diseases worldwide. It has a significant impact on individuals across the lifespan and is a leading cause of preventable hospitalizations. The impacts of COVID-19 on oral health at the practice level are well documented, but gaps in understanding the impact on individual oral health remain. This review addresses this gap. Methods Using a JBI scoping review process we mapped and summarized the evidence to identify the impact of COVID-19 on individual oral health. Key search terms were developed, and searches were undertaken by an experienced research librarian. Results The 85 included studies were conducted in 23 countries from 5 regions across the world classified using the United Nations Geoscheme system. The majority (82/85) were quantitative, 2 were reviews and there was one qualitative interview study. Cross-sectional surveys were the most common data collection approach followed by an analysis of clinical data, analysis of internet trends and other online methods. Five key areas were identified including changes to the provision of emergency dental services, provision of routine oral health services, oral hygiene maintenance at home, changes in dietary preferences, alternative models of dental provision and help-seeking and attitudes towards dental care in the future. Conclusions This scoping review has demonstrated that the pandemic has impacted on oral health at the individual level. It is important that we are aware of these impacts and ensure that support systems are in place to overcome future periods where access to dental care might be compromised. The provision of preventive care remains a vital first step in ensuring good overall oral health as is paramount during periods where access to dental treatment might be limited.

Abstract Background Advances in the field of Information and Communication Technology (ICT) are revolutionizing healthcare, while massive migration flows and cross-border populations’ transit impose the planning, implementation, and evaluation of new integrated healthcare services and programmes. Nevertheless, no conclusive evidence exists on the vast potential offered by ICT to promote healthcare in migrant populations. Methods We carried out a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to retrieve, pool and critically appraise all the available evidence on the effectiveness of ICT-based interventions to support the healthcare provision to migrant and in-transit populations in Europe. We searched the electronic databases Medline and Embase, relevant grey literature and consulted with experts in the field. We restricted the area of interest to EU/EEA countries and included studies providing original quantitative data. Results Out of 127 retrieved records, 53 (42%) met the inclusion criteria. Included studies were classified in the following four interventions: implementation of healthcare services (47%), patients’ education (26%), healthcare services’ monitoring (17%), and interventions on providers (10%). The most relevant data refer to telemedicine, prevention interventions, and healthcare data sharing and the most represented specific health-topic is that of mental health (26%). We present available data qualitatively and quantitatively pooled by country, type of ICT, target population and health topic. Conclusions Selected ICT-based interventions have been implemented in Europe to promote healthcare in migrant populations; however, in most cases, no monitoring and evaluation exist on their impact, effectiveness, and cost-effectiveness. Strengthened efforts are needed to identify, plan, implement and evaluate effective interventions and share best practices to protect in-transit populations’ health. Key messages Information and Communication Technology (ICT) offer great potential to promote health-care in migrant populations. Effective ICT interventions and best practices should be shared across Europe.

The imperfection of the normative legal acts regulating legal relations between participants and subjects of obligatory medical insurance (OMI) inevitably leads to the impossibility or difficulties for the parties to fulfill their obligations in provision of medical care to insured persons within the framework of OMI programs. Medical organizations included in the unified register of medical organizations operating in the field of OMI are limited in providing medical care to citizens under the state guarantees program in the case of excess of the volume of medical services provided from the planned services provided for by the OMI agreement. The “forced” provision of “supervolume” medical care is primarily aimed at meeting the actual need of patients for this service. This fact neglect by medical organizations is unacceptable and contradicts the basic principles of protecting the health of citizens, namely, the priority of its provision in the field of health protection, since malignant neoplasms are classified as socially significant. The inadmissibility of refusal to provide medical care and the revision of legal instruments for its provision in order to avoid a negative impact on patients suffering from oncopathology and on the performer represented by a medical organization is the topic of this discussion. Contractor’s submission of payment for medical care in excess of the distributed volume and (or) financial security established by the medical organization in accordance with the legislation on obligatory medical insurance should not be a reason for refusing to provide medical services at the time of the consumer's request and in the future. At the same time, acts of medical and economic control were drawn up based on the results of examinations conducted by insurance medical organizations for monitoring the volume of medical care for identified cases of medical care in excess of the distributed volume established by the decision of the commission for the development of the territorial program. Non-payment by insurance medical organizations of bills for the rendered medical services, motivated by the excess of volumes and financial support established by the territorial OMI program, serves as the basis for the medical organization to file a lawsuit.

Abstract Background In addition to healthcare entitlements, ‘migrant-friendly health services’ in Thailand include interpretation and cultural mediation services which aim to reduce language and cultural barriers between health personnel and migrants. Although the Thai Government started implementing these services in 2003, challenges in providing them still remain. This study aims to analyse the health system functions which support the interpretation and cultural mediation services of migrant health worker (MHW) and migrant health volunteer (MHV) programmes in Thailand. Methods In-depth interviews were conducted in two migrant-populated provinces using purposive and snowball sampling. A total of fifty key informants were recruited, including MHWs, MHVs, health professionals, non-governmental organisation (NGO) staff and policy stakeholders. Data were triangulated using information from policy documents. The deductive thematic analysis was classified into three main themes of evolving structure of MHW and MHV programmes, roles and responsibilities of MHWs and MHVs, and supporting systems. Results The introduction of the MHW and MHV programmes was one of the most prominent steps taken to improve the migrant-friendliness of Thai health services. MHWs mainly served as interpreters in public facilities, while MHVs served as cultural mediators in migrant communities. Operational challenges in providing services included insufficient budgets for employment and training, diverse training curricula, and lack of legal provisions to sustain the MHW and MHV programmes. Conclusion Interpretation and cultural mediation services are hugely beneficial in addressing the health needs of migrants. To ensure the sustainability of current service provision, clear policy regulation and standardised training courses should be in place, alongside adequate and sustainable financial support from central government, NGOs, employers and migrant workers themselves. Moreover, regular monitoring and evaluation of the quality of services are recommended. Finally, a lead agency should be mandated to collaborate with stakeholders in planning the overall structure and resource allocation for the programmes.

Background: Daily emergency health services are a human right of everyone and an obligation that everyone should have. The government and the entire community are responsible for maintaining and improving the quality of health services. In everyday circumstances, the handling of emergency patients will involve pre-hospital services, services in hospitals and services between hospitals, so an integrated daily emergency management system is needed. Based on the results of the study at the Imam As-Syafi'I Genteng Islamic Boarding School, from interviews with disaster management volunteers, data was obtained that the volunteers at the Imam As-Syafi'I Genteng Islamic Boarding School were classified as volunteers who lacked knowledge deficits related to first aid in accidents because they had never received first aid education and training for emergency patients. Based on data obtained from one of the administrators and participants at the Imam As-Syafi'I Genteng Islamic Boarding School, they have never been given counseling related to material on basic life support (BHD), shelter and how to transport emergency patients as a provision for first aid in an accident. The purpose: of this community service is for students to know and understand about basic life support. Method: this community service uses BHD material counseling and then practice using mannequins. Result: This program activity has increased the knowledge of female students about basic life support. Conclusion: Community service carried out through the presentation of material and direct practice to mannequins not only provides new insights to students but can also provide their own experiences for students in carrying out basic life support.

Abstract Background Sweden has provided around 300 youth clinics (YCs) to address the health needs of young people since the 1970s. During the last few years, and as part of an effort to strengthen mental healthcare for young people, YCs’ role in the provision of mental healthcare has been widely debated. With such debates as background, the aim of this study is to analyse Swedish YCs’ responses to the mental (ill) healthcare needs of young people, from the perspective of national level stakeholders. Methods We used thematic analysis of interviews with eight national level stakeholders in the field of youth mental health in Sweden. Building upon the concept of biomedicalization we examined the discourses on mental (ill) health, healthcare and youth that such responses reproduce. Results YCs engage in the three simultaneous, but at times contradictory, responses of protecting, managing and bending boundaries. Remaining true to their mission as a health-promotion service compels them to protect their boundaries and limit the type of mental health issues they address. However, the perceived malfunctioning of specialized services has led them to bend these boundaries to allow in more young people with severe mental health problems. Caught between protecting and bending boundaries, the response of managing boundaries to decide who should be allowed in and who should be sent elsewhere has emerged as a middle-way response. However, it is not free from conflicts. Conclusion Building upon the concept of biomedicalization, this study poses two questions. The first relates to whether it is possible to support young people and their health without reinforcing discourses that represent young people as collectively at risk, and if so how this can be done. The second relates to the provision of mental healthcare for young people, and the need to identify conditions for integrating diagnosis and treatment within YCs, without hindering their holistic and youth-centred approach.

Abstract Background There has been a recent focus on resettlement of migrants and refugee in rural settings in Australia and elsewhere. Rural resettlement is seen as an opportunity to revitalise rural communities, to fill the needs of employers in these areas, and to provide a welcoming community within which new arrivals can integrate and settle. However, challenges to rural resettlement have been identified including difficulties securing employment, discrimination and social isolation. These challenges can affect resettlement outcomes including health and wellbeing, though relatively little research has examined these links. In this paper we explored experiences of people from refugee background settling in a rural Australian town, examining interconnections between social determinants of health (SDH) and integration. Methods Face-to-face interviews were conducted with 44 participants from Southeast Asia and Africa in a rural setting in South Australia, covering experiences of resettlement and impacts on health and wellbeing. Participants were recruited through existing connections within the community and snowball sampling. Audio recorded data were transcribed verbatim and analysed using framework thematic analysis. Results The study findings revealed a mixture of settlement experiences for participants across a range of elements of SDH and integration. A sense of safety and some elements of social connectedness and support were key enablers for integration and health and wellbeing, with main challenges including limitations in employment opportunities, mismatched education provision, experiences of discrimination and constrained access to services. Conclusions Challenges experienced by refugees resettled in rural areas can affect integration, health and wellbeing and subsequent onward migration intentions. Attention to broader socioeconomic, cultural and environmental conditions, alongside tailored settlement support policies and practices for individual rural resettlement sites, is required to support integration and health and wellbeing.

Abstract Background Mother and baby units (MBUs) are an inpatient mental health service where women experiencing acute severe postpartum psychiatric difficulties can be admitted with their babies. They are currently viewed as best practice in the UK and elsewhere. However, as service provision is fragmented, some women residing in areas without MBUs are admitted to acute general psychiatric wards without their infants. This study aimed to compare qualitatively experiences of these two service types from the perspectives of women and clinicians. Methods Semi-structured interviews were conducted with fifteen women who received treatment for perinatal mental health problems on a general psychiatric ward and/or MBU in England. Two focus groups were also conducted, one with MBU staff (n = 11) and one with acute ward staff (n = 6). Data were analysed thematically. Results Women generally preferred being co-admitted with their baby to an MBU over lone admission to a general psychiatric ward. Women and clinicians felt that MBUs provided more perinatally-focused, family-centred care, and were better-equipped to meet women’s needs. General wards were reported by women and staff to lack the necessary facilities and expertise to support perinatal women adequately, while separation of mothers and babies was often experienced by women as traumatic and detrimental to recovery. However, some areas for improvement were also identified across both service types, particularly relating to difficulties transitioning home post-discharge, inadequate support for family members, staffing issues and access problems (with MBUs). Conclusions Findings suggest that specialist perinatal inpatient care is considered preferable to generic care in the perinatal period from both service user and staff perspectives. Increased collaboration between perinatal and non-perinatal services could help improve perinatal expertise on general psychiatric wards, while further expansion of perinatal services (e.g. to cater for women currently considered too high risk for MBUs and for those discharged from inpatient settings) could tackle other shortfalls in care.

Abstract Background Primary health care (PHC) in Ethiopia serves as the main entry point for preventive, promotive and curative health services. The district health office is responsible for the planning, implementation and evaluation of all district health activities. In addition, district health offices manage service delivery facilities working on provision of PHC – primary hospitals, health centers and health posts. As the leader of the health care system tier, district health management must ensure direction, alignment and commitment within teams and organizations and make sure that achievements are consistent with the vision, values and strategy of the organization. USAID Transform: Primary Health Care provides diverse support to improve district health manager competencies including in-service trainings followed by planning and implementation of performance improvement projects and on-the-job mentoring and support. Methods This study was conducted to compare district level capacity and performances between leadership, management and governance (LMG) and non-LMG districts. Project outcome monitoring data that shows the performance of districts was collected from 284 districts from January to December 2019. The study was carried out using a comparative-cross sectional study design, which assessed and compared district health office level indicators. Districts were classified into two categories: LMG and non-LMG districts. The study compared data from 94 LMG and 190 non-LMG districts. Propensity score matching was used to control the effect of differences between LMG and non-LMG districts. Results Results of the independent samples t-test revealed that LMG districts scored better average performances of 61.8 ± 121.45 standard deviation (SD) compared to non-LMG districts 56.89 ± 110.39 SD, with t (282243) = − 3.407317 and p < 0.001, two-tailed. The difference of 4.9 percentage unit in the average performance indicated a statistically significant difference between the LMG and non-LMG districts. Conclusion District level leadership development program contributes to improving district capacity, structure and management practices, and quality of care.

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiomyopathy has been highlighted as one of the key drivers of heart failure, particularly dilated cardiomyopathy (DCM) (5,1). Finding the correct diagnosis for patients is not only important to their health, but to that of their family members (2). European guidelines recommend genetic counselling and testing for all patients with a cardiomyopathy diagnosis (3). Genetic counselling involves communicating complex information and providing support to patients and families with inherited conditions. It is recommended that patients undergo genetic counselling alongside genetic testing (6). Purpose historically, the heart failure team had no formal pathway in place for genetic testing. We set to establish a remote provision for genetic counselling and testing. We hoped to increase access to genetic services, without additional trips to the hospital in this already burdened patient group. Methods A genetic counsellor (GC) attended the weekly team meeting to raise awareness of the genetic service and help identify eligible patients. Eligibility was determined using criteria from the national genomic test directory (4). Eligible patients had appointments via video or phone call. Outpatients who consented to genetic testing had blood samples arranged locally or at an upcoming hospital appointment. Inpatients had blood samples taken during their hospital stay. Forty-one eligible patients were identified, the majority had DCM (n=40) and one had arrhythmogenic right ventricular cardiomyopathy (ARVC). Genetic testing was performed using a diagnostic DCM or ARVC panel. Results were classified as positive, i.e. pathogenic or likely pathogenic variant identified; negative, i.e. no pathogenic variant identified; or inconclusive, i.e. variant of unknown significance identified. Results were fed back to patients by virtual genetic counselling appointment. GCs facilitated screening of family members as appropriate. Results In the period, July 2020 to January 2022, 41 patients attended virtual genetic counselling appointments and consented to genetic testing. Of these, 19 received a positive genetic result, 4 an inconclusive result, and 18 a negative result. The majority of positive results were identified in the TTN gene (n=9) (see Figure 1). To date, six family members have been identified as gene positive and requiring ongoing screening, whilst six have now been discharged on the basis of a gene negative result. These are preliminary figures and expected to grow as more family members are able to access genetic counselling Conclusion Heart failure patients represent an underserved population who may benefit from genetic testing alongside genetic counselling. Remote genetic counselling is an effective service delivery model. A significant proportion of patients (46.3%) received a positive genetic result. This has potential benefits, not only to the patient but to family members.

Abstract Background The demand for General Practice services in the UK, and elsewhere, is rising quickly. In part, the increasing demand is from an aging population that requires management of multiple long-term conditions. The General Practice Nurse is increasingly taking on the role. It is acknowledged that if general practice is to be able to recruit sufficient General Practice Nurses (GPNs) to meet this increasing demand in the future, new graduate nurses must be encouraged to consider general practice as a viable career option. This research is part of a review of the Advanced Training Practice Scheme (ATPS) which supported clinical placements in participating general practices. Methods The aim of the study was to examine nursing students’ perceptions of GP placements, and their effect upon career intentions following graduation from Sheffield Hallam University (SHU), in the UK. Interviews and an online survey were used collect data. Only the survey is reported here. The bespoke survey examined students’ views of: opportunities for learning new clinical skills and consolidating existing clinical skills; the learning environment in general practice and their views on a career in general practice. Results One thousand one hundred twenty undergraduate adult-field nursing students were contacted, with a response rate of 41% (N = 462). Ninety respondents had a placement and, 92% (N = 84) viewed practice nursing positively, and 77% (N = 70) felt that the placement had transformed their views on general practice. The opportunity to participate in the management of the various aspects of chronic disease was identified by 84% (N = 76) of the students as a key new skill they had acquired. They also reported that they valued a team ethos, control over aspects of work, and the variety of health problems they encountered. Conclusion The findings from this study demonstrate a positive experience arising from the provision of General Practice placements for nursing students. The use of ‘targeted’ placement schemes with appropriate support such as this may be seen as a viable way of exposing nursing students to General Practice nursing, and of encouraging new graduate nurses to consider General Practice nursing as a viable career option.

The present case concerns the legality of assisted suicide and active euthanasia in South Africa. This particular issue has been a major point of contention, having been debated in South Africa and elsewhere for many years and is generally accepted to be unlawful. In November 1998, the South African Law Commission submitted a report to the then Minister of Health on this issue, entitled “Euthanasia and the Artificial Preservation of Life”. At the time of its submission, the country was facing a number of imposing crises, including the HIV/AIDS epidemic. As a consequence of this, this report did not receive the necessary attention of either the Minister of Health or the legislature at the time. Sixteen years have since passed and in the interim South Africa became a democracy (in 1994). A Constitution was promulgated that inter alia guarantees fundamental human rights to all persons. However, the status quo on euthanasia and assisted suicide has remained unchanged in South Africa.The advances made in medical science have resulted in patients living longer. For some, the advances in medical technology are welcomed in that they can prolong a meaningful life. For others, however, the prolonging of a poor quality of life is viewed as a burden rather than a benefit.On an international level the importance placed on the autonomy of the mentally-sound patient’s right to refuse any medical treatment that will unnecessarily prolong the agony of such patient, and also, for such a patient to receive assistance in ending his or her life at a point where his or her suffering has become so unbearable, has received more attention (at present there are 11 countries or States which recognise the right to assisted suicide and active euthanasia). In South Africa, doctors are placed in a situation where they might wish to act in the best interest of the patient under their care, but at the same time there is no clarity as to their legal position and there is uncertainty as to the scope and content of the legal obligation to provide medical care. The basis for this uncertainty will be referred to within this case note. The potential of being exposed to civil claims and criminal prosecution should they decide to withhold life support to the patient or to provide drugs which may shorten the suffering of the patient, notwithstanding the fact that they are acting in accordance with the wishes of the patient, is real. Cases are dealt with on an ad hoc basis and with no national policy.With the dawning of the constitutional era, a consideration and decision on the right of an individual to assisted suicide in light of the principles of the Bill of Rights contained in the Constitution of South Africa is long overdue. For this reason, the present case is of great significance. The matter concerned an urgent application requiring an immediate decision regarding the Applicant’s request that a medical practitioner, registered in terms of the Health Professions Act 56 of 1974, terminate or enable the Applicant to terminate his life by the administration or provision of a lethal agent which would enable him to end his life. The application was opposed by the Minister of Justice and Correctional Services, the Minister of Health, the Health Professional Council of South Africa and the National Director of Public Prosecutions.

Photo by Ferenc Horvath on Unsplash ABSTRACT Malta is a small, predominantly Catholic island-nation in the Mediterranean ocean where there is a complete ban on abortion – there are no exemptions for rape, incest, fetal anomalies, or to save a pregnant woman’s life. Both medical and surgical abortions are illegal. Those who choose to end pregnancies have often sought abortion care outside of Malta, traveling abroad at great personal cost. Medical care in Malta is otherwise free at the point of care. Options for pregnancy termination within Malta are essentially non-existent as there is great public support for the Maltese abortion ban. As the government of Malta imposed travel restrictions in the interest of containing the spread of SARS-CoV2, women faced further limitations in their ability to access safe, effective abortion care in other countries. Many women have ordered medications online and have self-managed their abortion care. Women who have had abortions or people who facilitate abortions in Malta face criminal charges. Women who seek medical management of complications of self-managed abortions do so with the possibility of facing legal charges. Denying women access to safe and private abortion care can cause significant physical, psychological, and social effects and unfairly harms those experiencing an unwanted pregnancy. Given the global COVID pandemic and in the event of future pandemics wherein lockdowns may be indicated to maintain public health and safety, the Maltese government has a responsibility to ensure access to safe abortion care whether abroad or self-managed and such care should be decriminalized. INTRODUCTION The official and predominant religion of Malta is Roman Catholicism. This is recognized in Article 2 of the Constitution of Malta; the Constitution gives the church the duty and right to “teach which principles are right and which are wrong,” and religious education is compulsory.[1] The Constitution does afford Maltese citizens freedom of religious choice though most citizens in Malta are Catholic. The Maltese Criminal Code is clear regarding abortion: 241. (1) Whosoever, by any food, drink, medicine, or by violence, or by any other means whatsoever, shall cause the miscarriage of any woman with child, whether the woman be consenting or not, shall, on conviction, be liable to imprisonment for a term from eighteen months to three years. (2) The same punishment shall be awarded against any woman who shall procure her own miscarriage, or who shall have consented to the use of the means by which the miscarriage is procured. 242. If the means used shall cause the death of the woman, or shall cause a serious injury to her person, whether the miscarriage has taken place or not, the offender shall, on conviction, be liable to the punishment applicable to willful homicide or willful bodily harm, diminished by one to three degrees. 243. Any physician, surgeon, obstetrician, or apothecary, who shall have knowingly prescribed or administered the means whereby the miscarriage is procured, shall, on conviction, be liable to imprisonment for a term from eighteen months to four years, and to perpetual interdiction from the exercise of his profession.[2] The language used in the Constitution reflects the persistence of Catholic values through time and excludes all methods of and exemptions for pregnancy terminations. The prohibitions above apply to cases of rape, incest, and where the pregnant woman's life is in jeopardy – the only other country in the European Union with equally restrictive laws is the Vatican. However, a key difference between Malta and the Vatican is that someone living in the Vatican wanting an abortion would have easy access to medical services in Rome. Malta is isolated in comparison. The coronavirus placed additional stress on those seeking abortion care when infection control measures were implemented.[3] As Malta is an island, travel outside of the country requires travel by boat or plane, both prohibited as part of government-imposed infection control measures. Those who did return to Malta following international travel were required to quarantine for two weeks and risked fines of up to €10,000.[4] While someone in the first trimester of an unwanted pregnancy may have previously been able to plan a quick trip abroad without raising suspicion that they were traveling for abortion care, with travel restrictions in place, such trips were not easily executed. When pregnant women cannot access abortions, whether medical or surgical, they must self-manage their abortion care. l. The Harms of a Lack of Access to Care As the pandemic is a time of significant mental, spiritual, and existential distress, the added stress of an unwanted pregnancy can cause great harm to an individual. Some may argue that the societal benefits of restricting travel, thus limiting disease spread to individuals and their communities, can outweigh the rights of the individual. But even during a public health emergency, such as a pandemic, it is important that medical care continue where possible to ensure robust baseline health of the community. Abortion care is essential medical care,[5] and in the case of a global infectious pandemic, it would ideally be available locally so as not to harm the community through needless travel abroad. Given the significant implications and downstream effects caused by the continuation of an unwanted pregnancy, those seeking abortion care are likely to pursue the options available to them even if there is the potential risk to the individual or their community. Underlying the increased challenges regarding access to abortion care is the existing legislation that does not have provisions for emergency care. The potential harms to pregnant women in criminalizing access to abortion care, especially given the ongoing COVID-19 pandemic, are significant. The current legislation does not provide exemptions for abortions that would save the woman’s life. Rather, the woman and her health care team are at risk of criminal consequences if they implement this lifesaving care. If a woman remains in Malta and is unable to self-manage abortion care, or if self-managed care is not medically appropriate or safe, she faces the possibility of dying because of pregnancy continuation. Alternately, the woman can leave the country to pursue the appropriate care, though there is the potential for social and financial repercussions, and pandemic travel restrictions severely limit this option.[6] ll. Injustice Malta’s criminalization of all abortions is a significant violation of the bioethical principle of justice. The Maltese Criminal Code legislates no other medical procedures.[7] The burden that results from these restrictions weighs most heavily on Maltese women. Pregnant women seeking an abortion must either determine a strategy to get such care (potentially violating the criminal code) or continue a dangerous or unwanted pregnancy. Although those who seek to support and help women may also face criminal consequences, the criminal code essentially targets women with unwanted or unsafe pregnancies. Furthermore, as their request for abortion puts doctors or other facilitators at risk, the potential criminal liability of healthcare professionals is a deterrent to their seeking abortion care. Thus, the criminal code undervalues women and creates a crime that categorically applies to women only. Restrictive reproductive care policies in Malta also create significant socio-economic injustice, which was amplified by stay-at-home orders and travel bans. Those who can afford to leave the island to seek medical care abroad are also those who are most likely to have the financial flexibility for a post-travel two-week quarantine. The financial stress associated with seeking medical care abroad or self-managed abortion care disproportionately affects women of low socioeconomic standing. There are non-profit organizations outside of Malta that may be able to facilitate access to medically supervised abortion care outside of the country. However, COVID-19 travel restrictions likely limited their ability to help women. lll. Autonomy and Healthcare Decisions Ultimately, allowing pregnant women access to the reproductive care they require is important for the preservation of individual autonomy. Ideally, women would have the assistance of healthcare providers to inform reproductive decisions with accurate, evidence-based information that is free from bias. Certainly, where a provider is at risk of criminal charges, a patient is denied the information necessary to make an autonomous choice regarding the appropriateness of such care. The provision of comprehensive and exhaustive information is also essential to the preservation of trust between the medical care team and the patient. Abortion care is acceptable in many jurisdictions, and information around this care should be included as part of comprehensive family planning discussions whether the provider is willing to facilitate the care or not. lV. Denying the Consequences of a Local Ban on Abortion There is a perception among those supporting the complete abortion ban that those wanting abortion care, even in pregnancies resulting from rape, can easily travel to other countries to do so. As discussed above, this perception does not consider financial inequities and the burdens on those with limited financial resources.[8] People holding this “not in my backyard” stance on abortion may be using the perceived easy international access to abortions as an excuse to avoid considering the consequences of a total ban (for example, the death of pregnant women from pregnancy complications, a woman forced to continue a pregnancy despite severe fetal abnormality that is not compatible with survival upon delivery). Because international travel for abortion can no longer be presumed, ban supporters can no longer use it as a shield to avoid grappling with difficult problems. Issues like the ethics of permitting a woman to die or forcing a birth resulting from rape or incest would be addressed head-on if the legislators did not dismiss the issues using the assumption women can travel for care. Exploration of an ethical justification for a complete ban is sidelined by the perception of the ability to access care elsewhere. CONCLUSION It is an oversimplification to consider the legality of abortion the sole barrier to accessing this care, especially in a country driven by culture and religion. Yet abortion and reproductive care are essential to the wellbeing of pregnant individuals and should be part of every health system. The COVID-19 pandemic remains a significant public health concern and has highlighted some of the consequences of not having any abortion care available within Malta. Illegal self-managed abortions remain one of the few options for many pregnant women in the country. It can be challenging to navigate abortion care, particularly in a country where the prohibition of such care is widely accepted, and it is important to allow for provisions that support safe reproductive care. Research and examination of the pandemic’s effect on access to abortion care would provide much-needed data. Protections and immunity in place for those who sought or delivered such care during the pandemic would be a just response to the restrictive policies. The pandemic has successfully highlighted significant inequities in care, and access to safe and effective abortions for those who wish to have them should be facilitated – whether it be in Malta or abroad. - [1] “Constitution of Malta,” 1964., 7. [2] Malta Criminal Code, CAP. 9, Book First, Part II, Title VIII, Sub-title VII, Articles 241-243, available at Refworld, accessed April 24, 2021, https://www.refworld.org/docid/5d36fc847.html. [3] Different countries in Europe responded to the COVID-19 pandemic in different ways. Hungary, for example, stopped all non-life-threatening surgeries in state hospitals, while in the Netherlands, those who had or lived with someone with COVID-19 symptoms were restricted from accessing abortion care. Caroline Moreau et al., “Abortion Regulation in Europe in the Era of COVID-19: A Spectrum of Policy Responses,” BMJ Sexual & Reproductive Health, October 22, 2020, https://doi.org/10.1136/bmjsrh-2020-200724. [4] “COVID-19: Confirmed Patients Who Ignore Isolation Orders to Be Fined €10,000,” Times of Malta, accessed April 24, 2021, https://timesofmalta.com/articles/view/covid-19-fines-may-be-increased-up-to-10000.780452. [5] Elizabeth Janiak and Alisa B. Goldberg, ‘Eliminating the Phrase “Elective Abortion”: Why Language Matters’, Contraception, 93.2 (2016), 89–92, https://doi.org/10.1016/j.contraception.2015.10.008. [6] Of course, It is also important to consider the well-being of women who have unwanted pregnancies and are choosing abortion care. The abortion argument is often framed solely in the context of pregnancies where a woman’s health and/or life are in jeopardy or in cases of incest and rape – this neglects the needs of the women who have unwanted pregnancies outside of those circumstances. The continuation of such pregnancies can have significant social and financial consequences for an individual – ensuring that appropriate and safe care can be pursued is essential to the minimization of harm to that individual. Legislation that denies any individual the opportunity to seek such care, and that goes so far as to criminalize it, can cause significant emotional and physical harms to pregnant individuals. This can happen regardless of the motivation for pursuing abortion care and the argument is most appropriately framed in general terms to preserve the right to seek abortion care for all pregnant women. [7] Malta Criminal Code, CAP. 9, amendments up until 2018, available at Refworld, accessed April 24, 2021, https://www.refworld.org/docid/5d36fc847.html. [8] “Abortion Debate: Between Progress, Catholic Morality and Patriarchy,” MaltaToday.com.mt, accessed April 8, 2021, http://www.maltatoday.com.mt/news/national/100419/abortion_debate_between_progress_catholic_morality_and_patriarchy.

Introduction As social-distancing mandates in response to COVID-19 restricted in-person data collection methods such as participant observation and interviews, researchers turned to socially distant methods such as interviewing via video-conferencing technology (Lobe et al.). These were not new tools nor methods, but the pandemic muted any bias towards face-to-face data collection methods. Exemplified in crowd-sourced documents such as Doing Fieldwork in a Pandemic, researchers were encouraged to pivot to digital methods as a means of fulfilling research objectives, “specifically, ideas for avoiding in-person interactions by using mediated forms that will achieve similar ends” (Lupton). The benefits of digital methods for expanding participant cohorts and scope of research have been touted long before 2020 and COVID-19, and, as noted by Murthy, are “compelling” (“Emergent” 172). Research conducted by digital methods can expect to reap benefits such as “global datasets/respondents” and “new modalities for involving respondents” (Murthy, “Emergent” 172). The pivot to digital methods is not in and of itself an issue. What concerns us is that in the dialogues about shifting to digital methods during COVID-19, there does not yet appear to have been a critical consideration of how participant samples and collected data will be impacted upon or skewed towards recording the experiences of advantaged cohorts. Existing literature focusses on the time-saving benefits for the researcher, reduction of travel costs (Fujii), the minimal costs for users of specific platforms – e.g. Skype –, and presumes ubiquity of device access for participants (Cater). We found no discussion on data costs of accessing such services being potential barriers to participation in research, although Deakin and Wakefield did share our concern that: Online interviews may ... mean that some participants are excluded due to the need to have technological competence required to participate, obtain software and to maintain Internet connection for the duration of the discussion. In this sense, access to certain groups may be a problem and may lead to issues of representativeness. (605) We write this as a provocation to our colleagues conducting research at this time to consider the cultural and material capital of their participants and how that capital enables them to participate in digitally-mediated data gathering practices, or not, and to what extent. Despite highlighting the potential benefits of digital methods within a methodological tool kit, Murthy previously cautioned against the implications posed by digital exclusion, noting that “the drawback of these research options is that membership of these communities is inherently restricted to the digital ‘haves’ ... rather than the ‘have nots’” (“Digital” 845). In this article, we argue that while tools such as Zoom have indeed enabled fieldwork to continue despite COVID disruptions, this shift to online platforms has important and under-acknowledged implications for who is and is not able to participate in research. In making this argument, we draw on examples from the Connected Students project, a study of digital inclusion that commenced just as COVID-19 restrictions came into effect in the Australian state of Victoria at the start of 2020. We draw on the experiences of these households to illustrate the barriers that such cohorts face when participating in online research. We begin by providing details about the Connected Students project and then contextualising it through a discussion of research on digital inclusion. We then outline three areas in which households would have experienced (or still do experience) difficulties participating in online research: data, devices, and skills. We use these findings to highlight the barriers that disadvantaged groups may face when engaging in data collection activities over Zoom and question how this is impacting on who is and is not being included in research during COVID-19. The Connected Students Program The Connected Students program was conducted in Shepparton, a regional city located 180km north of Melbourne. The town itself has a population of around 30,000, while the Greater Shepparton region comprises around 64,000 residents. Shepparton was chosen as the program’s site because it is characterised by a unique combination of low-income and low levels of digital inclusion. First, Shepparton ranks in the lowest interval for the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) and the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), as reported in 2016 (Australian Bureau of Statistics, “Census”; Australian Bureau of Statistics, “Index”). Although Shepparton has a strong agricultural and horticultural industry with a number of food-based manufacturing companies in the area, including fruit canneries, dairies, and food processing plants, the town has high levels of long-term and intergenerational unemployment and jobless families. Second, Shepparton is in a regional area that ranks in the lowest interval for the Australian Digital Inclusion Index (Thomas et al.), which measures digital inclusion across dimensions of access, ability, and affordability. Funded by Telstra, Australia’s largest telecommunications provider, and delivered in partnership with Greater Shepparton Secondary College (GSSC), the Connected Students program provided low-income households with a laptop and an unlimited broadband Internet connection for up to two years. Households were recruited to the project via GSSC. To be eligible, households needed to hold a health care card and have at least one child attending the school in year 10, 11, or 12. Both the student and a caregiver were required to participate in the project to be eligible. Additional household members were invited to take part in the research, but were not required to. (See Kennedy & Holcombe-James; and Kennedy et al., "Connected Students", for further details regarding household demographics.) The Australian Digital Inclusion Index identifies that affordability is a significant barrier to digital inclusion in Australia (Thomas et al.). The project’s objective was to measure how removing affordability barriers to accessing connectivity for households impacts on digital inclusion. By providing participating households with a free unlimited broadband internet connection for the duration of the research, the project removed the costs associated with digital access. Access alone is not enough to resolve the digital exclusion confronted by these low-income households. Digital exclusion in these instances is not derived simply from the cost of Internet access, but from the cost of digital devices. As a result, these households typically lacked sufficient digital devices. Each household was therefore provided both a high speed Internet connection, and a brand new laptop with built-in camera, microphone, and speakers (a standard tool kit for video conferencing). Data collection for the Connected Students project was intended to be conducted face-to-face. We had planned in-person observations including semi-structured interviews with household members conducted at three intervals throughout the project’s duration (beginning, middle, and end), and technology tours of each home to spatially and socially map device locations and uses (Kennedy et al., Digital Domesticity). As we readied to make our first research trip to commence the study, COVID-19 was wreaking havoc. It quickly became apparent we would not be travelling to work, much less travelling around the state. We thus pivoted to digital methods, with all our data collection shifting online to interviews conducted via digital platforms such as Zoom and Microsoft Teams. While the pivot to digital methods saved travel hours, allowing us to scale up the number of households we planned to interview, it also demonstrated unexpected aspects of our participants’ lived experiences of digital exclusion. In this article, we draw on our first round of interviews which were conducted with 35 households over Zoom or Microsoft Teams during lockdown. The practice of conducting these interviews reveals insights into the barriers that households faced to digital research participation. In describing these experiences, we use pseudonyms for individual participants and refer to households using the pseudonym for the student participant from that household. Why Does Digital Inclusion Matter? Digital inclusion is broadly defined as universal access to the technologies necessary to participate in social and civic life (Helsper; Livingstone and Helsper). Although recent years have seen an increase in the number of connected households and devices (Thomas et al., “2020”), digital inclusion remains uneven. As elsewhere, digital disadvantage in the Australian context falls along geographic and socioeconomic lines (Alam and Imran; Atkinson et al.; Blanchard et al.; Rennie et al.). Digitally excluded population groups typically experience some combination of education, employment, income, social, and mental health hardship; their predicament is compounded by a myriad of important services moving online, from utility payments, to social services, to job seeking platforms (Australian Council of Social Service; Chen; Commonwealth Ombudsman). In addition to challenges in using essential services, digitally excluded Australians also miss out on the social and cultural benefits of Internet use (Ragnedda and Ruiu). Digital inclusion – and the affordability of digital access – should thus be a key concern for researchers looking to apply online methods. Households in the lowest income quintile spend 6.2% of their disposable income on telecommunications services, almost three times more than wealthier households (Ogle). Those in the lowest income quintile pay a “poverty premium” for their data, almost five times more per unit of data than those in the highest income quintile (Ogle and Musolino). As evidenced by the Australian Digital Inclusion Index, this is driven in part by a higher reliance on mobile-only access (Thomas et al., “2020”). Low-income households are more likely to access critical education, business, and government services through mobile data rather than fixed broadband data (Thomas et al., “2020”). For low-income households, digital participation is the top expense after housing, food, and transport, and is higher than domestic energy costs (Ogle). In the pursuit of responsible and ethical research, we caution against assuming research participants are able to bear the brunt of access costs in terms of having a suitable device, expending their own data resources, and having adequate skills to be able to complete the activity without undue stress. We draw examples from the Connected Students project to support this argument below. Findings: Barriers to Research Participation for Digitally Excluded Households If the Connected Students program had not provided participating households with a technology kit, their preexisting conditions of digital exclusion would have limited their research participation in three key ways. First, households with limited Internet access (particularly those reliant on mobile-only connectivity, and who have a few gigabytes of data per month) would have struggled to provide the data needed for video conferencing. Second, households would have struggled to participate due to a lack of adequate devices. Third, and critically, although the Connected Students technology kit provided households with the data and devices required to participate in the digital ethnography, this did not necessarily resolve the skills gaps that our households confronted. Data Prior to receiving the Connected Students technology kit, many households in our sample had limited modes of connectivity and access to data. For households with comparatively less or lower quality access to data, digital participation – whether for the research discussed here, or in contemporary life – came with very real costs. This was especially the case for households that did not have a home Internet connection and instead relied solely on mobile data. For these households, who carefully managed their data to avoid running out, participating in research through extended video conferences would have been impossible unless adequate financial reimbursement was offered. Households with very limited Internet access used a range of practices to manage and extend their data access by shifting internet costs away from the household budget. This often involved making use of free public Wi-Fi or library internet services. Ellie’s household, for instance, spent their weekends at the public library so that she and her sister could complete their homework. While laborious, these strategies worked well for the families in everyday life. However, they would have been highly unsuitable for participating in research, particularly during the pandemic. On the most obvious level, the expectations of library use – if not silent, then certainly quiet – would have prohibited a successful interview. Further, during COVID-19 lockdowns, public libraries (and other places that provide public Internet) became inaccessible for significant periods of time. Lastly, for some research designs, the location of participants is important even when participation is occurring online. In the case of our own project, the house itself as the site of the interview was critical as our research sought to understand how the layout and materiality of the home impacts on experiences of digital inclusion. We asked participants to guide us around their home, showing where technologies and social activities are colocated. In using the data provided by the Connected Students technology kit, households with limited Internet were able to conduct interviews within their households. For these families, participating in online research would have been near impossible without the Connected Students Internet. Devices Even with adequate Internet connections, many households would have struggled to participate due to a lack of suitable devices. Laptops, which generally provide the best video conferencing experience, were seen as prohibitively expensive for many families. As a result, many families did not have a laptop or were making do with a laptop that was excessively slow, unreliable, and/or had very limited functions. Desktop computers were rare and generally outdated to the extent that they were not able to support video conferencing. One parent, Melissa, described their barely-functioning desktop as “like part of the furniture more than a computer”. Had the Connected Students program not provided a new laptop with video and audio capabilities, participation in video interviews would have been difficult. This is highlighted by the challenges students in these households faced in completing online schooling prior to receiving the Connected Students kit. A participating student, Mallory, for example, explained she had previously not had a laptop, reliant only on her phone and an old iPad: Interviewer: Were you able to do all your homework on those, or was it sometimes tricky?Mallory: Sometimes it was tricky, especially if they wanted to do a call or something ... . Then it got a bit hard because then I would use up all my data, and then didn’t have much left.Interviewer: Yeah. Right.Julia (Parent): ... But as far as schoolwork, it’s hard to do everything on an iPad. A laptop or a computer is obviously easier to manoeuvre around for different things. This example raises several common issues that would likely present barriers to research participation. First, Mallory’s household did not have a laptop before being provided with one through the Connected Students program. Second, while her household did prioritise purchasing tablets and smartphones, which could be used for video conferencing, these were more difficult to navigate for certain tasks and used up mobile data which, as noted above, was often a limited resource. Lastly, it is worth noting that in households which did already own a functioning laptop, it was often shared between several household members. As one parent, Vanessa, noted, “yeah, until we got the [Connected Students] devices, we had one laptop between the four of us that are here. And Noel had the majority use of that because that was his school work took priority”. This lack of individuated access to a device would make participation in some research designs difficult, particularly those that rely on regular access to a suitable device. Skills Despite the Connected Students program’s provision of data and device access, this did not ensure successful research participation. Many households struggled to engage with video research interviews due to insufficient digital skills. While a household with Internet connectivity might be considered on the “right” side of the digital divide, connectivity alone does not ensure participation. People also need to have the knowledge and skills required to use online resources. Brianna’s household, for example, had downloaded Microsoft Teams to their desktop computer in readiness for the interview, but had neglected to consider whether that device had video or audio capabilities. To work around this restriction, the household decided to complete the interview via the Connected Students laptop, but this too proved difficult. Neither Brianna nor her parents were confident in transferring the link to the interview between devices, whether by email or otherwise, requiring the researchers to talk them through the steps required to log on, find, and send the link via email. While Brianna’s household faced digital skills challenges that affected both parent and student participants, in others such as Ariel’s, these challenges were focussed at the parental level. In these instances, the student participant provided a vital resource, helping adults navigate platforms and participate in the research. As Celeste, Ariel’s parent, explained, it's just new things that I get a bit – like, even on here, because your email had come through to me and I said to Ariel "We're going to use your computer with Teams. How do we do this?" So, yeah, worked it out. I just had to look up my email address, but I [initially thought] oh, my god; what am I supposed to do here? Although helpful in our own research given its focus on school-aged young people, this dynamic of parents being helped by their dependents illustrates that the adults in our sample were often unfamiliar with the digital skills required for video conferencing. Research focussing only on adults, or on households in which students have not developed these skills through extended periods of online education such as occurred during the COVID-19 lockdowns, may find participants lacking the digital skills to participate in video interviews. Participation was also impacted upon by participants' lack of more subtle digital skills around the norms and conventions of video conferencing. Several households, for example, conducted their interviews in less ideal situations, such as from both moving and parked cars. A portion of the household interview with Piper’s household was completed as they drove the 30 minutes from their home into Shepperton. Due to living out of town, this household often experienced poor reception. The interview was thus regularly disrupted as they dropped in and out of range, with the interview transcript peppered with interjections such as “we’re going through a bit of an Internet light spot ... we’re back ... sorry ...” (Karina, parent). Finally, Piper switched the device on which they were taking the interview to gain a better connection: “my iPad that we were meeting on has worse Internet than my phone Internet, so we kind of changed it around” (Karina). Choosing to participate in the research from locations other than the home provides evidence of the limited time available to these families, and the onerousness of research participation. These choices also indicate unfamiliarity with video conferencing norms. As digitally excluded households, these participants were likely not the target of popular discussions throughout the pandemic about optimising video conferences through careful consideration of lighting, background, make-up and positioning (e.g. Lasky; Niven-Phillips). This was often identified by how participants positioned themselves in front of the camera, often choosing not to sit squarely within the camera lens. Sometimes this was because several household members were participating and struggled to all sit within view of the single device, but awkward camera positioning also occurred with only one or two people present. A number of interviews were initially conducted with shoulders, or foreheads, or ceilings rather than “whole” participants until we asked them to reposition the device so that the camera was pointing towards their faces. In noting this unfamiliarity we do not seek to criticise or apportion responsibility for accruing such skills to participating households, but rather to highlight the impact this had on the type of conversation between researcher and participant. Such practices offer valuable insight into how digital exclusion impacts on individual’s everyday lives as well as on their research participation. Conclusion Throughout the pandemic, digital methods such as video conferencing have been invaluable for researchers. However, while these methods have enabled fieldwork to continue despite COVID-19 disruptions, the shift to online platforms has important and under-acknowledged implications for who is and is not able to participate in research. In this article, we have drawn on our research with low-income households to demonstrate the barriers that such cohorts experience when participating in online research. Without the technology kits provided as part of our research design, these households would have struggled to participate due to a lack of adequate data and devices. Further, even with the kits provided, households faced additional barriers due to a lack of digital literacy. These experiences raise a number of questions that we encourage researchers to consider when designing methods that avoid in person interactions, and when reviewing studies that use similar approaches: who doesn’t have the technological access needed to participate in digital and online research? What are the implications of this for who and what is most visible in research conducted during the pandemic? Beyond questions of access, to what extent will disadvantaged populations not volunteer to participate in online research because of discomfort or unfamiliarity with digital tools and norms? When low-income participants are included, how can researchers ensure that participation does not unduly burden them by using up precious data resources? And, how can researchers facilitate positive and meaningful participation among those who might be less comfortable interacting through mediums like video conferencing? In raising these questions we acknowledge that not all research will or should be focussed on engaging with disadvantaged cohorts. Rather, our point is that through asking questions such as this, we will be better able to reflect on how data and participant samples are being impacted upon by shifts to digital methods during COVID-19 and beyond. As researchers, we may not always be able to adapt Zoom-based methods to be fully inclusive, but we can acknowledge this as a limitation and keep it in mind when reporting our findings, and later when engaging with the research that was largely conducted online during the pandemic. 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Prelude: 2020 in Words Each year the Australian National Dictionary Centre, based at the Australian National University (ANU), selects “a word or expression that has gained prominence in the Australian social landscape”. In 2020, “iso” took out first place, with “bubble” following close behind. On the Centre’s website, Senior Researcher Mark Gywnn explains that “iso” was selected not only for its flexibility, merrily combining with other words to create new compound words (for instance “being in iso”, doing “iso baking” and putting on “iso weight”), but also because it “stood out as a characteristically Aussie abbreviation” (Australian National Dictionary Centre). Alongside the flexibility of the word “iso” and its affinity with the Australian English tradition of producing and embracing diminutives, iso’s appeal might well be that it does not carry the associations that the word “bubble” has acquired in the time of COVID. While COVID-19 has put many of us in various forms of “iso”, the media imagery—and indeed experiences—of many older people living in residential aged care during COVID has shifted some of the associations of the word “bubble”, heightening its associations with fragility and adding vulnerability and helplessness into the mix. 2020 was not the first time “bubble” has appeared in the Australian word of the year list. In 2018 “Canberra bubble” took out the first spot. What interests us about bubble’s runner-up position behind “iso” in 2020’s word of the year is what this might also reveal about the way ideas of independence vs dependence, and youthfulness vs aged underlie and inflect new usages of these words. In the era of COVID-19, the buoyancy of “iso” is tied to its association with a particular kind of Aussie-youth-speak, while the sense of heaviness and negative resonances that now accompany the word bubble are tied to its associations with the experiences of those in aged care. In 2020 “bubble”—a word that has primarily been associated with children and the child-like (bubble baths, bubble tea)—took on new associations and overtones. As the pandemic unfolded, “bubble” also became intertwined with media depictions of and popular discourses around those in later life, many of whom experienced “iso” much more brutally than the easy-Aussie-speak of “iso” would convey. There is much less play—and a lot less mingling—in the Australian National Dictionary Centre description of new uses of the word “bubble”: “a district, region, or a group of people viewed as a closed system, isolating from other districts, regions, or groups as a public health measure to limit the spread of Covid-19”. There have been various kinds of “closed system[s]”, isolated groups and regions constructed in the management of the pandemic, but there is one group—and one kind of location—that has been “bubbled” in quite specific ways. While the sectioning off and isolating of older age people in the name of protecting their health has often been ineffectively—and in some places, disastrously—managed in terms of disease prevention, it has been very effective in reducing the rights and voices of those it acts in the name of. Speaking from Ireland but commenting on the situation in the UK and parts of Europe, Anne Fuchs and colleagues write that “the discursive homogenization and ‘frailing’ of the over 65s meant that people in this category were an object of public discourse rather than participants in the debate” (2). In many instances the “bubbling” of older people, particularly those in aged care residences, has served to both isolate and render largely voiceless the residents of these care homes. Although the global impact of COVID-19 on the aged has been significant, including across many affluent societies, it has been particularly disastrous in Australia. At the time of writing (1 January 2021), of the 909 COVID-related deaths in Australia to date, 693 have been of people aged 80 or over: in other words, more than 75% of COVID-related deaths in Australia have been of people over 80. According to the federal government’s records of COVID-19 deaths by age group and sex, 685 of these deaths have been of aged care residents. It is not surprising therefore that many speak of the heavy impact of COVID-19 on older people as a form of genocide. Public discourse and government policies and priorities around COVID-19 have thrown into relief and exacerbated some of the deeply troubling ways that older people, particularly those living in aged care residences, are not recognised or treated as “equal partners in our future” (Royal Commission into Aged Care 1). Both the management of and public discourse around COVID-19 have highlighted and escalated the forms of ageism, especially ageism around later life, that have become embedded in Australian culture. In late 2019 the Royal Commission into Aged Care Quality and Safety released its Interim Report, titled simply Neglect. In the Foreword, the commissioners write: the Australian community generally accepts that older people have earned the chance to enjoy their later years, after many decades of contribution and hard work. Yet the language of public discourse is not respectful towards older people. Rather, it is about burden, encumbrance, obligation and whether taxpayers can afford to pay for the dependence of older people. (Royal Commission into Aged Care 1) Written and released before the COVID-19 pandemic, the Interim Report highlighted the “fundamental fact that our aged care system essentially depersonalises older people” (Royal Commission into Aged Care 6) and identified many ways “the aged care system fails to meet the needs of our older, often very vulnerable, citizens” (Royal Commission into Aged Care 1). In 2020 we saw some of the effects of these failures in the often disastrous mismanagement of disease transmission prevention in many aged care residences in Australia. Equally troubling, the resulting deaths have at times been accompanied by a general acceptance of the loss of so many in later life to COVID-19. The fact that these deaths are often regarded as somehow more inevitable, or as less significant than the deaths of others, is an indication of how deeply “Australia has drifted into an ageist mindset that undervalues older people and limits their possibilities” (Royal Commission into Aged Care 1). It assumes that one’s later-life years are of less significance and value (to oneself, to the community) than one’s younger years. At various times in the pandemic, sizable parts of the global population have been variously asked, advised, or required by their governments to remain within their household or residential “bubble”. These COVID-related “bubbles” are more buoyant for some. Jackie Gulland has written a feminist analysis of the ways that the UK COVID-19 lockdown rules are premised on “neo-liberal assumptions about the family as autonomous and sufficient for the provision of reproductive labour” (330). In many places the requirement to stay within one’s “household bubble” both assumes that the home is safe for all, and that most care and dependency requirements are provided and received within a household. As Gulland’s essay demonstrates, the idea of the household bubble constructs an image or idea of who and what constitutes a household, and which relationships “count”. Drawing on critiques of neo-liberal and able-ist ideas about autonomy by feminist and disability scholars, Gulland “shows how the failure of policymakers to take account of interdependency has made lockdown more difficult for carers and those in receipt of care” (330). In this essay we look at some of the ways that the required and/or imagined COVID-19 bubbles for people in later life are thought of differently to the COVID-19 bubbles that younger, and mixed age, households are imagined as forming. This is particularly the case, we argue, for those in aged care residences. Younger and mixed age COVID bubbles often include extended or linked households (as we will discuss below in relation to the idea of the compassionate bubble) and function as a bubble that can link and enclose. In contrast, COVID bubbles in and for aged care and those in later life, work to isolate and separate. They function as bubbles that close off and shut out, as if placing the older person and older people behind glass (in some cases, quite literally). Likewise, while the COVID-19 bubbles for the “general” population (a category from which those in later life are often excluded) are regarded as temporary structures that will in time be dissolved to re-allow social movement and intermingling, the later life and aged care COVID-19 bubble is imagined very differently. This is because it is overlaid upon a pre-existing conception of later life—and in particular the fourth age—as itself a kind of bubbled existence, a fragile state held somewhat separate and apart from the general population and moving inexorably toward death—a bubble that pops. Bubbling the Fourth Age The idea that later life can be divided into different stages and ages has a long history, although the shape, meaning and valuing of different ages in later life is historically specific. Back in the late 1980s the Cambridge historian Peter Laslett proposed that rather than falling into three main stages—childhood, adulthood and old age—there are in fact four stages and that “later life can be divided into a ‘third age’ and a ‘fourth age’” (Gilleard and Higgs, “The Fourth Age” 368). Laslett’s distinction between a third age (active and characterised by personal fulfillment) and a fourth age (for Laslett an age of infirmity) has become increasingly significant in both age studies and in the provision and imagining of aged care. While the third age is increasingly depicted as something that, when managed “successfully”, can expand and fill with rich experiences and rewards (assuming one has the economic and social privilege and mobility to embrace these rich offerings—see Katz and McHugh cited in Zeilig, “Critical Use of Narrative”), the fourth age, on the other hand, is associated with frailty, increased dependence, vulnerability, precarity (see Lloyd; Gilleard and Higgs; and Morganroth Gullette on the fourth age). Of course, experiences of vulnerability, dependency and precarity run throughout the life course and cannot be reduced to chronological age. However, the distinction between a third and fourth age tends to assume that once one “leaves” the third age, it is a one-way path to “the three ‘Ds’: decrepitude, dependence, and death” (Laslett). The fourth age becomes associated with those aspects of ageing that are culturally rejected and pushed aside—in particular physical dependence which, as in much able-ist thinking, is rendered abject. As Morganroth Gullette has argued, a “savage contradiction” underlies and fuels this distinction, as “fantasies of the longevity bonanza proliferate alongside growing terrors of living too long” and becoming a “‘burden’” (21). In other words, those aspects of ageing—indeed those aspects of being human—that are seen as undesirable and/or abject are associated with the fourth age and imagined as somehow exclusive to it: they are placed elsewhere, contained in a fourth age “bubble”. The understanding of the fourth age as a kind of bubble is evident in and enabled by various kinds of cultural representations and institutional discourses around later life, including the kind of language used (particularly language connoting precarity and fragility and liminality) and recurrent media imagery in which people in their “fourth age” are depicted as mentally and physically out of reach (for instance isolated behind glass). Legislation around the movements of residents, visitors, and staff in aged care residence does not simply create “protective” bubbles around aged care residences but also constructs and imagines these residences and their inhabitants as “bubbled”, removed, and voiceless. Vulnerability, ephemerality, precarity and decline have become increasingly significant in representations of and discourses around ageing. Much of the media coverage of those in later life, particularly those living in aged care residences, has further fuelled what Sally Chivers has called the “nursing home specter” and delivered, in heightened and often spectacularised form, the “life-course narrative that dominant culture provides—an unliveable mind and unrecognizable body, mountainous expense” (Morganroth Gullette, 24). The discourse on ageing is characterised by the use of metaphor and metonymy, of which “the bubble” or “bubbling” is only one notable example. The culture of fear that surrounds the fourth age stems from the presumption that ageing inevitably leads to decay and decline in quality of life, and that the experience of ageing is characterised by various forms of physical and cognitive deterioration, such as dementia. Cultural gerontologist Hannah Zeilig has drawn attention to the pervasive use of metaphors—in both medical journals and mass media reports—to describe the experience of living with dementia. These metaphors attempt to capture and simplify the complexities of being, speaking, and knowing experienced by people with dementia. They are frequently used to communicate these experiences to people who do not live with dementia. The cultural metaphors of dementia are potent examples of ageism. They are not neutral in their connotations or implicit value judgements. These metaphors reveal wider social anxieties around ageing, despite the fact that people in their 40s and 50s can have dementia (Dementia Australia). As Zeilig has pointed out, many of these metaphors have presented a negative framing of dementia, describing the rising numbers of dementia diagnoses in apocalyptic, biblical terms such as “plague”, “crisis”, and “epidemic” (“Cultural Metaphor” 260). While this hyperbole may be grounded in statistics and the realities of an ageing population, it has nevertheless been alarming. This rhetoric has often been a necessary tactic for dementia organisations as part of their efforts to secure media coverage, raise public awareness of dementia, and lobby for increased government and private investment in funding research and support services. Despite these noble intentions, this rhetoric can risk excluding or marginalising the voices of people living with dementia. Some of the metaphors that have been used to describe dementia are particularly dehumanising and stigmatising, such as the perception of Alzheimer’s disease as a form of “living death”. This conception of Alzheimer’s, which Susan M. Behuniak has observed in both scholarly and popular discourse, elicits strong negative emotional responses of revulsion and fear. It constructs people with Alzheimer’s as abject zombie-like figures living a half-life or twilight existence. These trends in dementia discourse that Zeilig and Behuniak identified in the first half of the 2010s are also apparent in media imagery and discourse about older people in the COVID-19 pandemic. Much like the cultural narratives of dementia, these representations often reinforce the fourth age’s association with forms of vulnerability, decline and decay that are rendered abject. In contrast to this negative framing of both dementia and the fourth age, the trope of “living in a bubble” can also present a more ambivalent conception of both living with dementia and, by extension, the sociocultural experience of living in the fourth age during the time of COVID-19. “Bubbling” can serve a protective function for the person living with dementia by reducing sensory overload and cognitive confusion that may lead to anxiety and emotional distress. In dementia care, bubble wands and bubble wrap are two of the most commonly used tools in sensory therapy for reducing anxiety and agitation, and providing comfort (DailyCaring). These examples remind us of the materiality of the bubble, which functions as both cultural trope and material condition that affects people’s lives (to borrow from Helen Deutsch and Felicity Nussbaum, cited in Vivian Sobchack’s essay on metaphor and materiality). Within the diversity and range of caring practices encompassed by the trope of “bubbling”, there is clear potential for the bubble to be enabling, rather than disabling, if it is used to enhance quality of life and wellbeing for older people, rather than to separate, marginalise and isolate. Despite the multivalent possibilities of the bubble for enhancing quality of life for people with dementia, the bubble’s association with precarity has been heightened by its deployment to protect older people during the COVID-19 pandemic. This is a source of ambivalence around the COVID-19 bubble, a public health response that is acknowledged as having both protective and harmful effects. It involves “bubbling” older people, especially those living in residential care, by physically isolating them and limiting their contact with family and friends to conversations mediated by digital technology or a windowpane. By restricting physical and direct contact with the outside world in order to reduce and contain transmission of the virus, the COVID-19 bubble is intended to protect the physical health of older adults. But as Karra Harrington and Martin J. Sliwinski caution, this can also risk the cognitive health and mental wellbeing of older people by creating social isolation. These concerns about the negative health impacts of the COVID-19 bubble compound the existing popular understanding of late life as isolated and isolating, perpetuating the ageist assumptions that characterise the social imaginary around the fourth age. Creating Compassionate Bubbles The distress of separation caused by COVID-19 lockdowns and restrictions is felt by all generations, not just older people. Recognising the costs to our emotional and mental wellbeing of living in isolation to protect our bodies and our communities from viral invasion, Australian epidemiologist Mary-Louise McLaws has called for “a compassionate germ bubble”, modelled on New Zealand’s concept of an extended bubble that allows close contacts beyond one household. This alternative approach to “bubbling” is designed to strike a better balance between physical and mental health. Writing during Melbourne’s strict and prolonged lockdown following a second wave of cases in the winter of 2020, McLaws argued that “a compassionate germ bubble may foster resilience by reducing a sense of isolation for people living alone and friends, extended family and partners distressed by the separation”. There have been a number of creative and compassionate responses to the necessity of the COVID-19 bubble for protecting those most vulnerable to the virus. Aged care residences have developed innovative ways to safely maintain in-person visits and provide opportunities for face-to-face contact between residents and their families and friends. One example reported in the Australian media (Steger) is “The Window of Love” in Perth, which demonstrates the positive potential of the bubble—represented here as a pane of glass bordered by a painted frame—for facilitating social connection and supporting wellbeing despite restrictions on physical contact. The media reporting of these innovations tends to spectacularise the residents of these homes, reinforcing their fragility and vulnerability as they are framed behind plastic or glass. In December 2020, international media outlets The Guardian, RTE News, and Star Media posted a Reuters video story on their respective YouTube channels about a “hug bubble” created in an aged care home in Jeumont, France. This inflatable plastic tunnel allows physical touch between those living in the home and those outside it through hermetically sealed sleeves. Separating the resident from their visitors is a clear plastic sheet, which is disinfected by staff in between each visit. Recognising the importance of physical contact for wellbeing, nursing staff reported that the hug bubble has brought comfort to the residents, whose previous contact with family and friends since the outbreak of COVID-19 in March 2020 had been limited to video calls or talking through a window. Viewer comments reveal divergent responses to this media story across all three YouTube channels. Some viewers applaud the innovation while others disparage the hug bubble as “cruel” and “disgraceful”. Other comments register viewers’ ambivalence, recognising the good intentions behind the idea while despairing at the need for it. Several comments offer a snapshot of the cynical, often incoherent views about the pandemic commonly found on social media platforms like Facebook and Twitter, while also demonstrating the persistence of ageist attitudes that regard the elderly as a burden. These negative responses are striking in contrast with the positive framing of the original media report, which is presented as a “feel good” human interest story through brief interviews with family members and nursing home staff, reflecting on the residents’ experiences using the hug bubble. This positive framing is reinforced by the gentle music track accompanying the video posted on the RTE News channel. Beyond the institutional context of aged care residences, many families and communities have also engineered solutions to reduce the stress of separation. Craving physical contact after months of isolation, they have embraced the materiality and tactility inherent in the bubble trope. People have improvised using household objects, such as plastic sleeves attached to transparent shower curtains, to build “cuddle curtains”, and “hug machines” to enable safe—and playful—physical contact. These innovations and adaptations tap into the bubble’s playful qualities, while also “going viral” as families document their creativity, delight and joy through their own video stories shared on YouTube. As we move into the second year of the COVID-19 pandemic, with case numbers and the death toll continuing to climb globally, the concept of the COVID-19 bubble and its role in protecting the community will continue to be debated, refined and reconfigured in both public health responses and media discourse. Despite Australia’s relatively good fortune in terms of total number of COVID-related deaths compared to other Western nations such as the US and the UK, the disproportionately high number of deaths among Australians in aged care is a sobering reminder of the systemic failures in Australia’s aged care residences. As we move in and out of periods of social isolation, restrictions and lockdowns, it will become increasingly important to address the mental health impacts of “living in a bubble” and to consider creative, compassionate alternatives that challenge ageism and maintain quality of life for fourth age Australians. *** As COVID-19 and its management continue to reshape our world(s) and our relations to each other, its impacts continue to be unevenly felt, particularly for those in later life. For this reason, it becomes increasingly important to be alert to the ways in which “bubbling” the fourth age in response to COVID-19 risks reinforcing a homogenising view of older people as vulnerable and isolated, defenceless against viral invasion and voiceless in expressing agency and maintaining social connection. This essay responds to Hannah Zeilig’s earlier call to “radically rethink the ways in which age and ageing have been culturally configured” (“Critical Use of Narrative” 16). One of the purposes of this essay has been to critically assess some of the ways that the relatively new discourse of a fourth age—as somehow both qualitatively and quantifiably different to and separate from the third age—entails a homogenising view of older people. This view has enabled forms of ageism that have often been particularly brutal in their impact during the pandemic. In this essay we have argued that popular conceptions of and public health discourse and policy around the fourth age have often enabled—or, at the very least, supported—forms of ageism. This ageism has been further heightened through both the discourse and the imagery of the COVID-19 bubble. The fourth age, we argued, has often been understood as bubble-like: as a “stage” of life when one is somehow separated from the larger community and culture. The fourth age is configured as physically fragile and precarious, transient and temporary, ephemeral, and enclosed in—and as—its own world. Created in the name of protecting “our most vulnerable”, the bubble in the time of COVID-19 has heightened these pre-existing social anxieties around the fourth age. The challenge, as we move into the second year of the pandemic in Australia, is to find new ways of protecting the health and wellbeing of people in later life, while creating opportunities for connection, agency and play that are supported, rather than hindered, by the COVID-19 bubble. References Australian National Dictionary Centre. “2020 Word of the Year.” Canberra: School of Literature, Languages and Linguistics, ANU College of Arts and Social Sciences, Australian National University. 17 Nov. 2020. 12 Jan. 2021 <https://slll.cass.anu.edu.au/centres/andc/news/2020-word-year>. Behuniak, Susan M. “The Living Dead? The Construction of People with Alzheimer’s Disease as Zombies.” Ageing & Society 21 (2011): 70–92. Chivers, Sally. “‘Blind People Don’t Run’: Escaping the ‘Nursing Home Specter’ in Children of Nature and Cloudburst.” Journal of Aging Studies 34 (2015): 134–41. “COVID-19 Deaths by Age Group and Sex.” Australian Government Department of Health: Coronovirus (COVID-19) Current Situation and Case Numbers. 1 Jan. 2021 <https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers#cases-and-deaths-by-age-and-sex>. DailyCaring. “6 Alzheimer’s Sensory Activities Reduce Anxiety without Medication.” 12 Jan. 2021 <https://dailycaring.com/6-alzheimers-sensory-activities-reduce-anxiety-without-medication/>. Dementia Australia. “What Is Dementia?” 12 Jan. 2021 <https://www.dementia.org.au/about-dementia/what-is-dementia>. Fuchs, Anne, Desmond O'Neill, Mary Cosgrove, and Julia Langbein. “Report on COVID-19 – Reframing Ageing Webinar 12 June 2020.” Preprint. Aug. 2020. DOI: 10.13140/RG.2.2.34508.44161. 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This article investigates the prosthesis of identity through the process of branding. It examines cross-cultural manifestations of this phenomena from sixth millennium BCE Syria to twelfth century Japan and Britain. From the Neolithic Era, humanity has sort to extend their identities using pictorial signs that were characteristically simple. Designed to be distinctive and instantly recognisable, the totemic symbols served to signal the origin of the bearer. Subsequently, the development of branding coincided with periods of increased in mobility both in respect to geography and social strata. This includes fifth millennium Mesopotamia, nineteenth century Britain, and America during the 1920s.There are fewer articles of greater influence on contemporary culture than A Theory of Human Motivation written by Abraham Maslow in 1943. Nearly seventy-five years later, his theories about the societal need for “belongingness” and “esteem” remain a mainstay of advertising campaigns (Maslow). Although the principles are used to sell a broad range of products from shampoo to breakfast cereal they are epitomised by apparel. This is with refence to garments and accessories bearing corporation logos. Whereas other purchased items, imbued with abstract products, are intended for personal consumption the public display of these symbols may be interpreted as a form of signalling. The intention of the wearers is to literally seek the fulfilment of the aforementioned social needs. This article investigates the use of brands as prosthesis.Coats and Crests: Identity Garnered on Garments in the Middle Ages and the Muromachi PeriodA logo, at its most basic, is a pictorial sign. In his essay, The Visual Language, Ernest Gombrich described the principle as reducing images to “distinctive features” (Gombrich 46). They represent a “simplification of code,” the meaning of which we are conditioned to recognise (Gombrich 46). Logos may also be interpreted as a manifestation of totemism. According to anthropologist Claude Levi-Strauss, the principle exists in all civilisations and reflects an effort to evoke the power of nature (71-127). Totemism is also a method of population distribution (Levi-Strauss 166).This principle, in a form garnered on garments, is manifested in Mon Kiri. The practice of cutting out family crests evolved into a form of corporate branding in Japan during the Meiji Period (1868-1912) (Christensen 14). During the Muromachi period (1336-1573) the crests provided an integral means of identification on the battlefield (Christensen 13). The adorning of crests on armour was also exercised in Europe during the twelfth century, when the faces of knights were similarly obscured by helmets (Family Crests of Japan 8). Both Mon Kiri and “Coat[s] of Arms” utilised totemic symbols (Family Crests of Japan 8; Elven 14; Christensen 13). The mon for the imperial family (figs. 1 & 2) during the Muromachi Period featured chrysanthemum and paulownia flowers (Goin’ Japaneque). “Coat[s] of Arms” in Britain featured a menagerie of animals including lions (fig. 3), horses and eagles (Elven).The prothesis of identity through garnering symbols on the battlefield provided “safety” through demonstrating “belongingness”. This constituted a conflation of two separate “needs” in the “hierarchy of prepotency” propositioned by Maslow. Fig. 1. The mon symbolising the Imperial Family during the Muromachi Period featured chrysanthemum and paulownia. "Kamon (Japanese Family Crests): Ancient Key to Samurai Culture." Goin' Japaneque! 15 Nov. 2015. 27 July 2019 <http://goinjapanesque.com/05983/>.Fig. 2. An example of the crest being utilised on a garment can be found in this portrait of samurai Oda Nobunaga. "Japan's 12 Most Famous Samurai." All About Japan. 27 Aug. 2018. 27 July 2019 <https://allabout-japan.com/en/article/5818/>.Fig. 3. A detail from the “Index of Subjects of Crests.” Elven, John Peter. The Book of Family Crests: Comprising Nearly Every Family Bearing, Properly Blazoned and Explained, Accompanied by Upwards of Four Thousand Engravings. Henry Washbourne, 1847.The Pursuit of Prestige: Prosthetic Pedigree from the Late Georgian to the Victorian Eras In 1817, the seal engraver to Prince Regent, Alexander Deuchar, described the function of family crests in British Crests: Containing The Crest and Mottos of The Families of Great Britain and Ireland; Together with Those of The Principal Cities and Heraldic Terms as follows: The first approach to civilization is the distinction of ranks. So necessary is this to the welfare and existence of society, that, without it, anarchy and confusion must prevail… In an early stage, heraldic emblems were characteristic of the bearer… Certain ordinances were made, regulating the mode of bearing arms, and who were entitled to bear them. (i-v)The partitioning of social classes in Britain had deteriorated by the time this compendium was published, with displays of “conspicuous consumption” displacing “heraldic emblems” as a primary method of status signalling (Deuchar 2; Han et al. 18). A consumerism born of newfound affluence, and the desire to signify this wealth through luxury goods, was as integral to the Industrial Revolution as technological development. In Rebels against the Future, published in 1996, Kirkpatrick Sale described the phenomenon:A substantial part of the new population, though still a distinct minority, was made modestly affluent, in some places quite wealthy, by privatization of of the countryside and the industrialization of the cities, and by the sorts of commercial and other services that this called forth. The new money stimulated the consumer demand… that allowed a market economy of a scope not known before. (40)This also reflected improvements in the provision of “health, food [and] education” (Maslow; Snow 25-28). With their “physiological needs” accommodated, this ”substantial part” of the population were able to prioritised their “esteem needs” including the pursuit for prestige (Sale 40; Maslow).In Britain during the Middle Ages laws “specified in minute detail” what each class was permitted to wear (Han et al. 15). A groom, for example, was not able to wear clothing that exceeded two marks in value (Han et al. 15). In a distinct departure during the Industrial Era, it was common for the “middling and lower classes” to “ape” the “fashionable vices of their superiors” (Sale 41). Although mon-like labels that were “simplified so as to be conspicuous and instantly recognisable” emerged in Europe during the nineteenth century their application on garments remained discrete up until the early twentieth century (Christensen 13-14; Moore and Reid 24). During the 1920s, the French companies Hermes and Coco Chanel were amongst the clothing manufacturers to pioneer this principle (Chaney; Icon).During the 1860s, Lincolnshire-born Charles Frederick Worth affixed gold stamped labels to the insides of his garments (Polan et al. 9; Press). Operating from Paris, the innovation was consistent with the introduction of trademark laws in France in 1857 (Lopes et al.). He would become known as the “Father of Haute Couture”, creating dresses for royalty and celebrities including Empress Eugene from Constantinople, French actress Sarah Bernhardt and Australian Opera Singer Nellie Melba (Lopes et al.; Krick). The clothing labels proved and ineffective deterrent to counterfeit, and by the 1890s the House of Worth implemented other measures to authenticate their products (Press). The legitimisation of the origin of a product is, arguably, the primary function of branding. This principle is also applicable to subjects. The prothesis of brands, as totemic symbols, assisted consumers to relocate themselves within a new system of population distribution (Levi-Strauss 166). It was one born of commerce as opposed to heraldry.Selling of Self: Conferring Identity from the Neolithic to Modern ErasIn his 1817 compendium on family crests, Deuchar elaborated on heraldry by writing:Ignoble birth was considered as a stain almost indelible… Illustrious parentage, on the other hand, constituted the very basis of honour: it communicated peculiar rights and privileges, to which the meaner born man might not aspire. (v-vi)The Twinings Logo (fig. 4) has remained unchanged since the design was commissioned by the grandson of the company founder Richard Twining in 1787 (Twining). In addition to reflecting the heritage of the family-owned company, the brand indicated the origin of the tea. This became pertinent during the nineteenth century. Plantations began to operate from Assam to Ceylon (Jones 267-269). Amidst the rampant diversification of tea sources in the Victorian era, concerns about the “unhygienic practices” of Chinese producers were proliferated (Wengrow 11). Subsequently, the brand also offered consumers assurance in quality. Fig. 4. The Twinings Logo reproduced from "History of Twinings." Twinings. 24 July 2019 <https://www.twinings.co.uk/about-twinings/history-of-twinings>.The term ‘brand’, adapted from the Norse “brandr”, was introduced into the English language during the sixteenth century (Starcevic 179). At its most literal, it translates as to “burn down” (Starcevic 179). Using hot elements to singe markings onto animals been recorded as early as 2700 BCE in Egypt (Starcevic 182). However, archaeologists concur that the modern principle of branding predates this practice. The implementation of carved seals or stamps to make indelible impressions of handcrafted objects dates back to Prehistoric Mesopotamia (Starcevic 183; Wengrow 13). Similar traditions developed during the Bronze Age in both China and the Indus Valley (Starcevic 185). In all three civilisations branding facilitated both commerce and aspects of Totemism. In the sixth millennium BCE in “Prehistoric” Mesopotamia, referred to as the Halaf period, stone seals were carved to emulate organic form such as animal teeth (Wengrow 13-14). They were used to safeguard objects by “confer[ring] part of the bearer’s personality” (Wengrow 14). They were concurrently applied to secure the contents of vessels containing “exotic goods” used in transactions (Wengrow 15). Worn as amulets (figs. 5 & 6) the seals, and the symbols they produced, were a physical extension of their owners (Wengrow 14).Fig. 5. Recreation of stamp seal amulets from Neolithic Mesopotamia during the sixth millennium BCE. Wengrow, David. "Prehistories of Commodity Branding." Current Anthropology 49.1 (2008): 14.Fig. 6. “Lot 25Y: Rare Syrian Steatite Amulet – Fertility God 5000 BCE.” The Salesroom. 27 July 2019 <https://www.the-saleroom.com/en-gb/auction-catalogues/artemis-gallery-ancient-art/catalogue-id-srartem10006/lot-a850d229-a303-4bae-b68c-a6130005c48a>. Fig. 7. Recreation of stamp seal designs from Mesopotamia from the late fifth to fourth millennium BCE. Wengrow, David. "Prehistories of Commodity Branding." Current Anthropology 49. 1 (2008): 16.In the following millennia, the seals would increase exponentially in application and aesthetic complexity (fig. 7) to support the development of household cum cottage industries (Wengrow 15). In addition to handcrafts, sealed vessels would transport consumables such as wine, aromatic oils and animal fats (Wengrow 18). The illustrations on the seals included depictions of rituals undertaken by human figures and/or allegories using animals. It can be ascertained that the transition in the Victorian Era from heraldry to commerce, from family to corporation, had precedence. By extension, consumers were able to participate in this process of value attribution using brands as signifiers. The principle remained prevalent during the modern and post-modern eras and can be respectively interpreted using structuralist and post-structuralist theory.Totemism to Simulacrum: The Evolution of Advertising from the Modern to Post-Modern Eras In 2011, Lisa Chaney wrote of the inception of the Coco Chanel logo (fig. 8) in her biography Chanel: An Intimate Life: A crucial element in the signature design of the Chanel No.5 bottle is the small black ‘C’ within a black circle set as the seal at the neck. On the top of the lid are two more ‘C’s, intertwined back to back… from at least 1924, the No5 bottles sported the unmistakable logo… these two ‘C’s referred to Gabrielle, – in other words Coco Chanel herself, and would become the logo for the House of Chanel. Chaney continued by describing Chanel’s fascination of totemic symbols as expressed through her use of tarot cards. She also “surrounded herself with objects ripe with meaning” such as representations of wheat and lions in reference prosperity and to her zodiac symbol ‘Leo’ respectively. Fig. 8. No5 Chanel Perfume, released in 1924, featured a seal-like logo attached to the bottle neck. “No5.” Chanel. 25 July 2019 <https://www.chanel.com/us/fragrance/p/120450/n5-parfum-grand-extrait/>.Fig. 9. This illustration of the bottle by Georges Goursat was published in a women’s magazine circa 1920s. “1921 Chanel No5.” Inside Chanel. 26 July 2019 <http://inside.chanel.com/en/timeline/1921_no5>; “La 4éme Fête de l’Histoire Samedi 16 et dimache 17 juin.” Ville de Perigueux. Musée d’art et d’archéologie du Périgord. 28 Mar. 2018. 26 July 2019 <https://www.perigueux-maap.fr/category/archives/page/5/>. This product was considered the “financial basis” of the Chanel “empire” which emerged during the second and third decades of the twentieth century (Tikkanen). Chanel is credited for revolutionising Haute Couture by introducing chic modern designs that emphasised “simplicity and comfort.” This was as opposed to the corseted highly embellished fashion that characterised the Victorian Era (Tikkanen). The lavish designs released by the House of Worth were, in and of themselves, “conspicuous” displays of “consumption” (Veblen 17). In contrast, the prestige and status associated with the “poor girl” look introduced by Chanel was invested in the story of the designer (Tikkanen). A primary example is her marinière or sailor’s blouse with a Breton stripe that epitomised her ascension from café singer to couturier (Tikkanen; Burstein 8). This signifier might have gone unobserved by less discerning consumers of fashion if it were not for branding. Not unlike the Prehistoric Mesopotamians, this iteration of branding is a process which “confer[s]” the “personality” of the designer into the garment (Wengrow 13 -14). The wearer of the garment is, in turn, is imbued by extension. Advertisers in the post-structuralist era embraced Levi-Strauss’s structuralist anthropological theories (Williamson 50). This is with particular reference to “bricolage” or the “preconditioning” of totemic symbols (Williamson 173; Pool 50). Subsequently, advertising creatives cum “bricoleur” employed his principles to imbue the brands with symbolic power. This symbolic capital was, arguably, transferable to the product and, ultimately, to its consumer (Williamson 173).Post-structuralist and semiotician Jean Baudrillard “exhaustively” critiqued brands and the advertising, or simulacrum, that embellished them between the late 1960s and early 1980s (Wengrow 10-11). In Simulacra and Simulation he wrote,it is the reflection of a profound reality; it masks and denatures a profound reality; it masks the absence of a profound reality; it has no relation to any reality whatsoever: it is its own pure simulacrum. (6)The symbolic power of the Chanel brand resonates in the ‘profound reality’ of her story. It is efficiently ‘denatured’ through becoming simplified, conspicuous and instantly recognisable. It is, as a logo, physically juxtaposed as simulacra onto apparel. This simulacrum, in turn, effects the ‘profound reality’ of the consumer. In 1899, economist Thorstein Veblen wrote in The Theory of the Leisure Class:Conspicuous consumption of valuable goods it the means of reputability to the gentleman of leisure… costly entertainments, such as potlatch or the ball, are peculiarly adapted to serve this end… he consumes vicariously for his host at the same time that he is witness to the consumption… he is also made to witness his host’s facility in etiquette. (47)Therefore, according to Veblen, it was the witnessing of “wasteful” consumption that “confers status” as opposed the primary conspicuous act (Han et al. 18). Despite television being in its experimental infancy advertising was at “the height of its powers” during the 1920s (Clark et al. 18; Hill 30). Post-World War I consumers, in America, experienced an unaccustomed level of prosperity and were unsuspecting of the motives of the newly formed advertising agencies (Clark et al. 18). Subsequently, the ‘witnessing’ of consumption could be constructed across a plethora of media from the newly emerged commercial radio to billboards (Hill viii–25). The resulting ‘status’ was ‘conferred’ onto brand logos. Women’s magazines, with a legacy dating back to 1828, were a primary locus (Hill 10).Belonging in a Post-Structuralist WorldIt is significant to note that, in a post-structuralist world, consumers do not exclusively seek upward mobility in their selection of brands. The establishment of counter-culture icon Levi-Strauss and Co. was concurrent to the emergence of both The House of Worth and Coco Chanel. The Bavarian-born Levi Strauss commenced selling apparel in San Francisco in 1853 (Levi’s). Two decades later, in partnership with Nevada born tailor Jacob Davis, he patented the “riveted-for-strength” workwear using blue denim (Levi’s). Although the ontology of ‘jeans’ is contested, references to “Jene Fustyan” date back the sixteenth century (Snyder 139). It involved the combining cotton, wool and linen to create “vestments” for Geonese sailors (Snyder 138). The Two Horse Logo (fig. 10), depicting them unable to pull apart a pair of jeans to symbolise strength, has been in continuous use by Levi Strauss & Co. company since its design in 1886 (Levi’s). Fig. 10. The Two Horse Logo by Levi Strauss & Co. has been in continuous use since 1886. Staff Unzipped. "Two Horses. One Message." Heritage. Levi Strauss & Co. 1 July 2011. 25 July 2019 <https://www.levistrauss.com/2011/07/01/two-horses-many-versions-one-message/>.The “rugged wear” would become the favoured apparel amongst miners at American Gold Rush (Muthu 6). Subsequently, between the 1930s – 1960s Hollywood films cultivated jeans as a symbol of “defiance” from Stage Coach staring John Wayne in 1939 to Rebel without A Cause staring James Dean in 1955 (Muthu 6; Edgar). Consequently, during the 1960s college students protesting in America (fig. 11) against the draft chose the attire to symbolise their solidarity with the working class (Hedarty). Notwithstanding a 1990s fashion revision of denim into a diversity of garments ranging from jackets to skirts, jeans have remained a wardrobe mainstay for the past half century (Hedarty; Muthu 10). Fig. 11. Although the brand label is not visible, jeans as initially introduced to the American Goldfields in the nineteenth century by Levi Strauss & Co. were cultivated as a symbol of defiance from the 1930s – 1960s. It documents an anti-war protest that occurred at the Pentagon in 1967. Cox, Savannah. "The Anti-Vietnam War Movement." ATI. 14 Dec. 2016. 16 July 2019 <https://allthatsinteresting.com/vietnam-war-protests#7>.In 2003, the journal Science published an article “Does Rejection Hurt? An Fmri Study of Social Exclusion” (Eisenberger et al.). The cross-institutional study demonstrated that the neurological reaction to rejection is indistinguishable to physical pain. Whereas during the 1940s Maslow classified the desire for “belonging” as secondary to “physiological needs,” early twenty-first century psychologists would suggest “[social] acceptance is a mechanism for survival” (Weir 50). In Simulacra and Simulation, Jean Baudrillard wrote: Today abstraction is no longer that of the map, the double, the mirror or the concept. Simulation is no longer that of a territory, a referential being or a substance. It is the generation by models of a real without origin or reality: a hyperreal… (1)In the intervening thirty-eight years since this document was published the artifice of our interactions has increased exponentially. In order to locate ‘belongness’ in this hyperreality, the identities of the seekers require a level of encoding. Brands, as signifiers, provide a vehicle.Whereas in Prehistoric Mesopotamia carved seals, worn as amulets, were used to extend the identity of a person, in post-digital China WeChat QR codes (fig. 12), stored in mobile phones, are used to facilitate transactions from exchanging contact details to commerce. Like other totems, they provide access to information such as locations, preferences, beliefs, marital status and financial circumstances. These individualised brands are the most recent incarnation of a technology that has developed over the past eight thousand years. The intermediary iteration, emblems affixed to garments, has remained prevalent since the twelfth century. Their continued salience is due to their visibility and, subsequent, accessibility as signifiers. Fig. 12. It may be posited that Wechat QR codes are a form individualised branding. Like other totems, they store information pertaining to the owner’s location, beliefs, preferences, marital status and financial circumstances. “Join Wechat groups using QR code on 2019.” Techwebsites. 26 July 2019 <https://techwebsites.net/join-wechat-group-qr-code/>.Fig. 13. Brands function effectively as signifiers is due to the international distribution of multinational corporations. This is the shopfront of Chanel in Dubai, which offers customers apparel bearing consistent insignia as the Parisian outlet at on Rue Cambon. Customers of Chanel can signify to each other with the confidence that their products will be recognised. “Chanel.” The Dubai Mall. 26 July 2019 <https://thedubaimall.com/en/shop/chanel>.Navigating a post-structuralist world of increasing mobility necessitates a rudimental understanding of these symbols. Whereas in the nineteenth century status was conveyed through consumption and witnessing consumption, from the twentieth century onwards the garnering of brands made this transaction immediate (Veblen 47; Han et al. 18). The bricolage of the brands is constructed by bricoleurs working in any number of contemporary creative fields such as advertising, filmmaking or song writing. They provide a system by which individuals can convey and recognise identities at prima facie. They enable the prosthesis of identity.ReferencesBaudrillard, Jean. Simulacra and Simulation. Trans. Sheila Faria Glaser. United States: University of Michigan Press, 1994.Burstein, Jessica. Cold Modernism: Literature, Fashion, Art. United States: Pennsylvania State University Press, 2012.Chaney, Lisa. Chanel: An Intimate Life. United Kingdom: Penguin Books Limited, 2011.Christensen, J.A. Cut-Art: An Introduction to Chung-Hua and Kiri-E. New York: Watson-Guptill Publications, 1989. Clark, Eddie M., Timothy C. 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