Background Palliative sedation is a last-resort intervention designed to alleviate refractory suffering at the end of life. Healthcare professionals frequently encounter ethically complex situations when deciding whether and how to apply palliative sedation. Moral case deliberation supports healthcare professionals in discussing ethical issues in a structured way. Objectives To describe healthcare professionals’ perceptions of ethical issues about the practice of palliative sedation. Design This qualitative study was designed as part of the five-year Palliative Sedation project conducted in eight European countries (Belgium, Germany, Hungary, Italy, the Netherlands, Romania, Spain, and the United Kingdom). Methods Thirty-two moral case deliberation sessions were held in 16 clinical sites with the participation of 231 healthcare professionals. During the sessions, healthcare professionals discussed relevant clinical cases where ethical questions arose regarding the practice of palliative sedation for the management of refractory symptoms. The sessions were audio-recorded and transcribed verbatim. Framework analysis was performed on the data. Results Ethical issues related to palliative sedation were centred on patient autonomy as a fundamental principle. Healthcare professionals identified several ethical concerns about mental capacity, deferring autonomy, and competing ethical principles. Most of the ethical issues arose in the context of decision-making, and participants often experienced moral distress in these challenging situations. Healthcare professionals agreed that shared decision-making represented the optimal approach. Conclusion Healthcare professionals have varying levels of understanding and address ethical issues differently. This study showed that palliative sedation is an ethically dense practice that requires moving beyond individualistic models of autonomy toward a more relational approach. Shared decision-making through timely and open communication enhances patient autonomy in the context of palliative sedation.

ObjectivesThis review explored the perceived barriers and facilitators to accessing statutory and non-statutory health and social care services among disadvantaged populations in England. Community-based services delivered by statutory bodies and the voluntary, community, faith, and social enterprise (VCSFE) sector are critical for addressing social determinants of health, fostering resilience, and promoting equity. However, in disadvantaged areas, complex needs and structural exclusion frequently limit their effectiveness.MethodsCo-produced with academics, VCFSE sector, and public contributors, this review synthesised qualitative research published since 2003, drawing on first-hand accounts of service users to explore how intersecting forms of disadvantage affect service access.ResultsThe review identified four themes influencing access to community-based services among disadvantaged groups: structural and informational barriers, the impact of cultural, social, and economic contexts, institutional trust and continuity, and emotional motivators and barriers.ConclusionImproving access to community-based services requires structural and cultural alignment with users’ lives. Services ought to prioritise flexibility, trust, and navigational support while addressing emotional and institutional barriers.

BackgroundThere has been an increase in the use of online mental health forums to support mental health. These forums are often moderated by trained moderators to ensure a safe, therapeutic environment. While the moderator role is rewarding, it can also be challenging. There is a need to understand the impact of the role on moderators and how they can best be supported to maintain psychological well-being. ObjectiveThis study aimed to understand how, why, and in what contexts moderator well-being is affected by the moderator role and produce actionable recommendations for how moderators can best be supported to maintain workplace psychological well-being. MethodsWe conducted realist synthesis of (1) published and gray literature from 2019 to 2023, (2) stakeholder interviews with forum moderators and hosts, and (3) moderator training manuals developed by organizations that host online mental health forums. Self-determination theory was used as the theoretical basis for this synthesis. ResultsWe developed 24 context-mechanism-outcome configurations from our realist analysis of 9 published papers, 18 interviews, and 5 training manuals. The findings highlight the specific ways in which moderator well-being can be supported through meeting the psychological needs for autonomy, competence, and relatedness. Forums that allow moderators to work in alignment with their personal motivations can increase moderator well-being. Forum organizations should support moderator competence through initial expectation setting, especially around moderator responsibility for user well-being, and ongoing support, such as meaningful supervision and peer support. Co-designed training, reflective practice, and experiential learning are all key to increasing moderator competence and satisfaction in the workplace. Working within a diverse team with access to innovative forum design can increase moderator psychological well-being. Organizational support for moderators’ well-being through monitoring and encouraging self-care is vital to ensure moderators can effectively carry out their role. Making and supporting meaningful relationships in the forum can boost psychological well-being and the therapeutic value of the moderator role. Key challenges for moderators were dealing with conflicts between supporting open discussion and ensuring a safe community environment, sharing lived experiences in positive ways for both moderator and user, and supporting people within the limitations of an anonymous forum. ConclusionsThis realist synthesis is the first to examine the impacts on well-being of being a moderator of an online mental health forum. Recommendations to support moderator psychological well-being are proposed, targeted at specific stakeholder groups to aid implementation. Organizational-level endorsement and facilitation of support are particularly important for the realization of recommendations and interventions to support moderator well-being.

This book assesses territorial governance (that is, all forms of subnational governance) as a constitutional artefact in five Southeast Asian countries - Indonesia, Malaysia, Myanmar, the Philippines, and Thailand. Starting with the linked ideas of localism and subsidiarity, the argument is that these states have used various forms of subsidiarity for dealing with ethnic and religious pluralism and the social diversity for which Southeast Asia is especially noted. Territorial governance mechanisms discussed range from decentralisation to special regional autonomy, federalism, and local government, including village autonomy. A silent revolution has occurred in which our view of these states as highly centralised ‘developmental states’ is in need of serious modification. Southeast Asia, the book argues, presents a high degree of originality in the framing of territorial governance.

There is a growing call for theory-driven evaluation approaches to health research capacity strengthening (HRCS) interventions. Specifically, realist evaluation has gained wide attention given its response to the question: How does an intervention work, why, for whom and under what conditions? In realist evaluation, initial programme theories (IPTs) are first elicited before they are tested and refined. This article describes the IPTs of an HRCS programme aimed at strengthening the research capacity of African universities. Using the 'Developing Excellence in Leadership, Training and Science (DELTAS Africa) programme as a real-world case, the IPTs were drafted through a review of the programme documents and other published literature. Seven programme documents and 32 published papers covering 26 research capacity strengthening initiatives in African universities were reviewed. Different Context, Mechanism and Outcomes (CMO) were extracted and CMO configurations were formulated. Thereafter, the CMO configurations were refined through four interviews with the DELTAS programme designing team. Three transferrable IPTs were elicited. Evidence suggests that, for HRCS interventions to be more effective in strengthening research capacity in African universities, systemic challenges (e.g., lack of funding for health research, ineffective research policy environment and lack of institutional support for research) need to be addressed and the university staff/ researchers empowered, incentivised and motivated. The article underscores the importance of institutional buy-in, effective implementation of research policies (e.g., protected time, research career pathways, gender equality, research ethics and integrity, anti-bullying and anti-harassment, etc.), long-term research funding and equitable research partnerships in fostering a strong research environment and culture. Notably, the article makes a methodological contribution by demonstrating how IPTs can be developed using disparate evidence sources. The IPTs will be tested and refined through a primary realist evaluation, which will further refine the CMOs presented in this article and provide insights into the current HRCS evaluation framework.

BACKGROUND:People with dementia and unpaid carers need to go through a social care or carers needs assessment to access and receive subsidised or fully-funded social care. With no previous evidence, this qualitative study aimed to provide insights into the access to, experiences of receiving and conducting social care or carers needs assessments, and access to social care.METHODS:Unpaid carers of people with dementia and professionals conducting social care or carers needs assessment living or working in England were interviewed remotely about their experiences between April and August 2023. Topic guides were co-produced with two unpaid carers, and both were supported to code anonymised transcripts. Thematic analysis was used to analyse the data.FINDINGS:Twenty-seven unpaid carers (n = 21) and professionals (n = 6) participated. Four themes were generated: (1) Issues with accessing needs assessments, not the process; (2) Knowledge of needs assessments and the health and social care system; (3) Expectations of unpaid carers; and (4) Post-assessment unmet needs. The most prominent barriers unpaid carers and their relatives with dementia encountered were awareness of and access to needs assessment. Unpaid carers were mostly unaware of the existence and entitlement to a needs assessment, and sometimes realised they had participated in one without their knowledge. Professionals described the pressures on their time and the lack of financial resources within services.CONCLUSIONS:To facilitate improved access to dementia care and support for carers, the pathway to accessing needs assessments needs to be clearer, with better integration and communication between health and social care.

Background The disproportionate effect of COVID-19 on long term care facility (LTCF) residents has highlighted the need for clear, consistent guidance on the management of pandemics in such settings. As research exploring the experiences of LTCFs during the pandemic and the implications of mass hospital discharge, restricting staff movement, and limiting visitation from relatives are emerging, an in-depth review of policies, guidance and recommendations issued during this time could facilitate wider understanding in this area.Aims To identify policies, guidance, and recommendations related to LTCF staff and residents, in England issued by the government during the COVID-19 pandemic, developing a timeline of key events and synthesizing the policy aims, recommendations, implementation and intended outcomes.Method A scoping review of publicly available policy documents, guidance, and recommendations related to COVID-19 in LTCFs in England, identified using systematic searches of UK government websites. The main aims, recommendations, implementation and intended outcomes reported in included documents were extracted. Data was analysed using thematic synthesis following a three-stage approach: coding the text, grouping codes into descriptive themes, and development of analytical themes.Results Thirty-three key policy documents were included in the review. Six areas of recommendations were identified: infection prevention and control, hospital discharge, testing and vaccination, staffing, visitation and continuing routine care. Seven areas of implementation were identified: funding, collaborative working, monitoring and data collection, reducing workload, decision making and leadership, training and technology, and communication.Discussion LTCFs remain complex settings, and it is imperative that lessons are learned from the experiences during COVID-19 to ensure that future pandemics are managed appropriately. This review has synthesized the policies issued during this time, however, the extent to which such guidance was communicated to LTCFs, and subsequently implemented, in addition to being effective, requires further research. In particular, understanding the secondary effects of such policies and how they can be introduced within the existing challenges inherent to adult social care, need addressing.

Background and Objectives The inability of individuals in the advanced stage of dementia to communicate about preferences in care at the end-of-life poses a challenge for healthcare professionals and family carers. The proven effective Family Carer Decision Support intervention has been designed to inform family carers about end-of-life care options available to a person living with advanced dementia. The objectives of the mySupport study were to adapt the application of the intervention for use in different countries, assess impact on family satisfaction and decision-making, and identify costs and supportive conditions for the implementation of the intervention.Research Design and Methods A multiple-case study design was chosen where the nursing home was the case. Nursing homes were enrolled from six countries: Canada, Czech Republic, Italy, Netherlands, Republic of Ireland, and United Kingdom.Results Seventeen cases (nursing homes) participated, with a total of 296 interviews completed including family carers, nursing home staff, and health providers. Five themes relevant to the implementation of the intervention were identified: supportive relationships; committed staff; perceived value of the intervention; the influence of external factors on the nursing home; and resource impact of delivery.Discussion and Implications There is a commonality of facilitators and barriers across countries when introducing practice innovation. A key learning point was the importance of implementation being accompanied by committed and supported nursing home leadership. The nursing home context is dynamic and multiple factors influence implementation at different points of time.

BACKGROUND:Person-centred care is becoming increasingly recognised as an important element of palliative care. The current review syntheses evidence in relation to transitions in advanced cancer patients with palliative care needs. The review focuses on specific elements which will inform the Pal-Cycles programme, for patients with advanced cancer transitioning from hospital care to community care. Elements of transitional models for cancer patients may include, identification of palliative care needs, compassionate communication with the patient and family members, collaborative effort to establish a multi-dimensional treatment plan, review and evaluation of the treatment plan and identification of the end of life phase. METHODS:A scoping review of four databases (MEDLINE, EMBASE, CINAHL, PsycINFO) was conducted to identify peer-reviewed studies published from January 2013 to October, 2022. A further hand-search of references to locate additional relevant studies was also undertaken. Inclusion criteria involved cancer patients transitions of care with a minimum of two of components from those listed above. Studies were excluded if they were literature reviews, if transition of care was related to cancer survivors, involved non-cancer patients, had paediatric population, if the transition implied a change of therapy and or a lack of physical transit to a non-hospital place of care. This review was guided by Arksey and O'Malley's framework and narrative synthesis was used. RESULTS:Out of 5695 records found, 14 records were selected. Transition models identified: increases in palliative care consultations, hospice referrals, reduction in readmission rates and the ability to provide end of life care at home. Transition models highlight emotional and spiritual support for patients and families. No uniform model of transition was apparent, this depends on the healthcare system where it is implemented. CONCLUSIONS:The findings highlight the importance of collaboration, coordination and communication as central mechanisms for transitional model for patients with advanced cancer. This may require careful planning and will need to be tailored to the contexts of each healthcare system.

Background : Health research capacity strengthening (HRCS) has been deemed as a complex, multifaceted, and dynamic activity. Despite this, most studies that assess the effectiveness of health research capacity strengthening programmes have not employed complexity-aware approaches and therefore, evidence on how and why such programmes work across different contexts is underdeveloped. This realist study seeks to elicit the initial programme theories (IPTs) that describe how and why the ‘Developing Excellence in Leadership, Training and Science Africa’ (DELTAS Africa) programme – one of the flagship research capacity strengthening programmes in Africa – works to generate research capacity outcomes specifically in the participating African universities. Methods and Analysis : A realist review of the DELTAS Africa programme documents, and relevant published papers that report on similar research capacity interventions will be carried out. This will help to both identify the outcome pathways and underlying assumptions of the DELTAS Africa programme, as well as tacit theories as postulated by other researchers. The review evidence will inform the drafting of the initial programme theories (IPTs). Interviews with the DELTAS Africa programme designing team will be conducted using a realist interviewing technique to unearth ontologically deeper insights on context, mechanism, and outcomes. Using the realist context-mechanism-outcome configurational maps, we will identify how contexts (i.e., within the African universities) shape mechanisms (the processes, reasoning, or behaviours triggered by the HRCS activities) through which the programme brings about an outcome at institutional level. Conclusion: The initial programme theories will describe how and why health research capacity strengthening works, for whom and under what circumstances across the participating African universities. The programme theories will provide policy-relevant insights on the generative causal mechanisms of HRCS; evidence that is critically needed to inform the design, implementation, and evaluation of HRCS initiatives.

BackgroundOnline forums are widely used for mental health peer support. However, evidence of their safety and effectiveness is mixed. Further research focused on articulating the contexts in which positive and negative impacts emerge from forum use is required to inform innovations in implementation. ObjectiveThis study aimed to develop a realist program theory to explain the impacts of online mental health peer support forums on users. MethodsWe conducted a realist synthesis of literature published between 2019 and 2023 and 18 stakeholder interviews with forum staff. ResultsSynthesis of 102 evidence sources and 18 interviews produced an overarching program theory comprising 22 context-mechanism-outcome configurations. Findings indicate that users’ perceptions of psychological safety and the personal relevance of forum content are foundational to ongoing engagement. Safe and active forums that provide convenient access to information and advice can lead to improvements in mental health self-efficacy. Within the context of welcoming and nonjudgmental communities, users may benefit from the opportunity to explore personal difficulties with peers, experience reduced isolation and normalization of mental health experiences, and engage in mutual encouragement. The program theory highlights the vital role of moderators in creating facilitative online spaces, stimulating community engagement, and limiting access to distressing content. A key challenge for organizations that host mental health forums lies in balancing forum openness and anonymity with the need to enforce rules, such as restrictions on what users can discuss, to promote community safety. ConclusionsThis is the first realist synthesis of online mental health peer support forums. The novel program theory highlights how successful implementation depends on establishing protocols for enhancing safety and strategies for maintaining user engagement to promote forum sustainability. Trial RegistrationPROSPERO CRD42022352528; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=352528

This article discusses the constituent elements of law and development, discusses its history, introduces relevant theories, and explores how law and development approaches may contribute to development efforts throughout the world. In the course of addressing these issues, we emphasize those aspects of the subject that bring into focus the traditional concerns of comparative law. We also introduce a General Theory of Law and Development that seeks to capture the different aspects of a subject that has, in general, lacked theoretical articulation. This Theory attempts to define the conceptual parameters of "law" and "development" and sets forth the mechanisms by which law affects development. We also examine the discipline's relationship with comparative law and explore the path forward.

Context A stated preference to die at home is an emerging trend in many national contexts. However, this is a difficult issue, which is reliant on many factors, such as the suitability of the home environment and the caring and emotional burden placed on family carers who are often overwhelmed. Access to health professionals and a wellorganised and collaborative network of services are the key facilitators of providing a dignified death in a home setting. 4 Health professionals need to be empowered to support a person dying at home, and the study by Takemura et al reports an evaluation of a training programme to assess quality of life at work, orientation toward dying and death and selfcompetence in death work.