Symbicort online usa

To the http://tvandfilmtoys.com/how-to-get-symbicort/ Editor symbicort online usa. During the current symbicort, severe acute respiratory syndrome anti-inflammatories 2 (anti-inflammatories), the causative agent of anti-inflammatories disease 2019 (anti inflammatory drugs), has diversified considerably. As of September 2021, the World Health Organization had defined four variants of concern (alpha [B.1.1.7], beta [B.1.351], gamma [P.1], and delta [B.1.617.2 symbicort online usa and AY]), as well as five variants of interest (eta [B.1.525], iota [B.1.526], kappa [B.1.617.1], lambda [C.37], and mu [B.1.621]).1 Figure 1. Figure 1. anti-inflammatories in symbicort online usa Colombia and Characterization of the Mu Variant.

Panel A shows new cases of anti-inflammatories disease 2019 (anti inflammatory drugs) from January through August 2021 in Colombia. The mu variant was first isolated on January 11, 2021, in Colombia (Global Influenza Surveillance and Response System accession number, EPI_ISL_1220045). The black line symbicort online usa reflects the number of new weekly cases, and the colored bars indicate the percentage of each variant of severe acute respiratory syndrome anti-inflammatories 2 (anti-inflammatories) among the cases. The raw data are summarized in Table S2 in the Supplementary Appendix. Panels B and C show the results of symbicort neutralization symbicort online usa assays.

Neutralization assays were performed with the use of pseudosymbicortes harboring the anti-inflammatories spike proteins of the alpha, beta, gamma, delta, epsilon, lambda, or mu variants or the B.1 lineage symbicort, which harbors the D614G mutation (parental symbicort). Serum samples were obtained from 13 persons who had recovered from anti inflammatory drugs (Panel B) and from 14 persons who had received the BNT162b2 treatment (Panel C). The assay symbicort online usa of each serum sample was performed in triplicate to determine the 50% neutralization titer. Each data point represents an individual sample (circles) and indicates the 50% neutralization titer obtained with each sample against the indicated pseudosymbicort. The heights of the bars and the numbers over the bars symbicort online usa indicate the geometric mean titers, and the 𝙸 bars indicate 95% confidence intervals.

The numbers in parentheses indicate the average difference in neutralization resistance of the indicated variants as compared with that of the parental symbicort. The horizontal dashed lines indicate the limit of symbicort online usa detection. The raw data and information regarding the convalescent donors (sex, age, severity of disease, and dates of testing and sampling) and vaccinated donors (sex, age, and dates of second vaccination and sampling) of serum samples are summarized in Tables S6 and S7 in the Supplementary Appendix.Mu represents the most recently recognized variant of interest.1 As of August 30, 2021, the mu variant had been detected in 39 countries (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The epicenter of mu transmission is Colombia, where the variant was first isolated on January 11, 2021 (Figure 1A and Table S2). There was a huge surge in anti inflammatory drugs symbicort online usa cases in Colombia from March through July 2021.

Although the gamma variant was dominant during the initial phase of the surge, the mu variant outnumbered all other variants in May, and it has driven the epidemic in Colombia since that time (Figure 1A). Newly emerging anti-inflammatories variants need to be carefully monitored for potentially increased transmission rate, pathogenicity, and symbicort online usa resistance to immune responses. The resistance of variants of concern and variants of interest to serum obtained from persons who have recovered from anti inflammatory drugs and persons who have been vaccinated can be attributed to a variety of mutations in the viral spike protein.2 The majority of mu variants harbor the T95I and YY144-145TSN mutations in the N-terminal domain. The R346K, E484K, and N501Y mutations in the receptor-binding domain. And the D614G, P681H, and D950N symbicort online usa mutations in other regions of the spike protein (Tables S3 and S4).

Some of these mutations are commonly identified in variants of concern (Table S5). Of these mutations, E484K (shared by the beta and gamma variants) has shown the symbicort online usa greatest reduction in sensitivity to antibodies induced by natural anti-inflammatories and vaccination.3,4 To assess the sensitivity of the mu variant to antibodies induced by anti-inflammatories and by vaccination, we generated pseudosymbicortes harboring the spike protein of the mu variant or the spike protein of other variants of concern or variants of interest. symbicort neutralization assays, performed with the use of serum samples obtained from 13 persons who had recovered from anti inflammatory drugs who were infected early in the symbicort (April through September 2020), showed that the mu variant was 10.6 times as resistant to neutralization as the B.1 lineage symbicort (parental symbicort), which bears the D614G mutation (Figure 1B). Assays performed with symbicort online usa serum samples obtained from 14 persons who had received the BNT162b2 treatment showed that the mu variant was 9.1 as resistant as the parental symbicort (Figure 1C). Although the beta variant (a variant of concern) was thought to be the most resistant variant to date,3,4 the mu variant was 2.0 as resistant to neutralization by convalescent serum (Figure 1B) and 1.5 times as resistant to neutralization by treatment serum as the beta variant (Figure 1C).

Thus, the mu variant shows a pronounced resistance to antibodies elicited by natural anti-inflammatories and by the BNT162b2 mRNA treatment. Because breakthrough s are a major threat of newly emerging anti-inflammatories variants,5 symbicort online usa we suggest that further characterization and monitoring of this variant of interest is warranted. Keiya Uriu, M.S.Izumi Kimura, M.S.University of Tokyo, Tokyo, JapanKotaro Shirakawa, M.D., Ph.D.Akifumi Takaori-Kondo, M.D., Ph.D.Kyoto University, Kyoto, JapanTaka-aki Nakada, M.D., Ph.D.Atsushi Kaneda, M.D., Ph.D.Chiba University, Chiba, JapanSo Nakagawa, Ph.D.Tokai University, Kanagawa, JapanKei Sato, Ph.D.University of Tokyo, Tokyo, Japan [email protected]for the Genotype to Phenotype Japan (G2P-Japan) Consortium Supported in part by grants from the Japan Agency for Medical Research and Development (AMED) Research Program on Emerging and Re-emerging Infectious Diseases (20fk0108146 [to Dr. Sato], 20fk0108413 [to Drs symbicort online usa. Kaneda, Nakagawa, and Sato], and 20fk0108451 [to the Genotype to Phenotype Japan Consortium and Drs.

Takaori-Kondo, Kaneda, Nakagawa, and Sato]). The AMED symbicort online usa Research Program on HIV/AIDS (21fk0410039 [to Drs. Shirakawa and Sato]). Japan Science and Technology (JST) Strategic International Collaborative Research symbicort online usa Program (SICORP) e-ASIA (JPMJSC20U1 [to Dr. Sato]).

JST SICORP (JPMJSC21U5 [to Dr. Sato]). JST CREST (JPMJCR20H6 [to Dr. Nakagawa] and JPMJCR20H4 [to Drs. Kaneda and Sato]).

Japan Society for the Promotion of Science (JSPS) Grants-in-Aid for Scientific Research B (18H02662 and 21H02737 [to Dr. Sato]). JSPS Fund for the Promotion of Joint International Research (Fostering Joint International Research) (18KK0447 [to Dr. Sato]). JSPS Core-to-Core Program, Advanced Research Networks (JPJSCCA20190008 [to Dr.

Sato]). JSPS Research Fellow (DC1 19J20488 [to Mr. Kimura]). And the Tokyo Biochemical Research Foundation (to Dr. Sato).

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on November 3, 2021, at NEJM.org. Mr. Uriu and Mr. Kimura contributed equally to this letter.

5 References1. World Health Organization. Tracking anti-inflammatories variants. 2021 (https://www.who.int/en/activities/tracking-anti-inflammatories-variants/).Google Scholar2. Harvey WT, Carabelli AM, Jackson B, et al.

anti-inflammatories variants, spike mutations and immune escape. Nat Rev Microbiol 2021;19:409-424.3. Collier DA, De Marco A, Ferreira IATM, et al. Sensitivity of anti-inflammatories B.1.1.7 to mRNA treatment-elicited antibodies. Nature 2021;593:136-141.4.

Wang P, Nair MS, Liu L, et al. Antibody resistance of anti-inflammatories variants B.1.351 and B.1.1.7. Nature 2021;593:130-135.5. Hacisuleyman E, Hale C, Saito Y, et al. treatment breakthrough s with anti-inflammatories variants.

N Engl J Med 2021;384:2212-2218.Participants Figure 1. Figure 1. Enrollment and Randomization. The diagram represents all enrolled participants through November 14, 2020. The safety subset (those with a median of 2 months of follow-up, in accordance with application requirements for Emergency Use Authorization) is based on an October 9, 2020, data cut-off date.

The further procedures that one participant in the placebo group declined after dose 2 (lower right corner of the diagram) were those involving collection of blood and nasal swab samples.Table 1. Table 1. Demographic Characteristics of the Participants in the Main Safety Population. Between July 27, 2020, and November 14, 2020, a total of 44,820 persons were screened, and 43,548 persons 16 years of age or older underwent randomization at 152 sites worldwide (United States, 130 sites. Argentina, 1.

Brazil, 2. South Africa, 4. Germany, 6. And Turkey, 9) in the phase 2/3 portion of the trial. A total of 43,448 participants received injections.

21,720 received BNT162b2 and 21,728 received placebo (Figure 1). At the data cut-off date of October 9, a total of 37,706 participants had a median of at least 2 months of safety data available after the second dose and contributed to the main safety data set. Among these 37,706 participants, 49% were female, 83% were White, 9% were Black or African American, 28% were Hispanic or Latinx, 35% were obese (body mass index [the weight in kilograms divided by the square of the height in meters] of at least 30.0), and 21% had at least one coexisting condition. The median age was 52 years, and 42% of participants were older than 55 years of age (Table 1 and Table S2). Safety Local Reactogenicity Figure 2.

Figure 2. Local and Systemic Reactions Reported within 7 Days after Injection of BNT162b2 or Placebo, According to Age Group. Data on local and systemic reactions and use of medication were collected with electronic diaries from participants in the reactogenicity subset (8,183 participants) for 7 days after each vaccination. Solicited injection-site (local) reactions are shown in Panel A. Pain at the injection site was assessed according to the following scale.

Mild, does not interfere with activity. Moderate, interferes with activity. Severe, prevents daily activity. And grade 4, emergency department visit or hospitalization. Redness and swelling were measured according to the following scale.

Mild, 2.0 to 5.0 cm in diameter. Moderate, >5.0 to 10.0 cm in diameter. Severe, >10.0 cm in diameter. And grade 4, necrosis or exfoliative dermatitis (for redness) and necrosis (for swelling). Systemic events and medication use are shown in Panel B.

Fever categories are designated in the key. Medication use was not graded. Additional scales were as follows. Fatigue, headache, chills, new or worsened muscle pain, new or worsened joint pain (mild. Does not interfere with activity.

Moderate. Some interference with activity. Or severe. Prevents daily activity), vomiting (mild. 1 to 2 times in 24 hours.

Moderate. >2 times in 24 hours. Or severe. Requires intravenous hydration), and diarrhea (mild. 2 to 3 loose stools in 24 hours.

Moderate. 4 to 5 loose stools in 24 hours. Or severe. 6 or more loose stools in 24 hours). Grade 4 for all events indicated an emergency department visit or hospitalization.

Н™¸ bars represent 95% confidence intervals, and numbers above the 𝙸 bars are the percentage of participants who reported the specified reaction.The reactogenicity subset included 8183 participants. Overall, BNT162b2 recipients reported more local reactions than placebo recipients. Among BNT162b2 recipients, mild-to-moderate pain at the injection site within 7 days after an injection was the most commonly reported local reaction, with less than 1% of participants across all age groups reporting severe pain (Figure 2). Pain was reported less frequently among participants older than 55 years of age (71% reported pain after the first dose. 66% after the second dose) than among younger participants (83% after the first dose.

78% after the second dose). A noticeably lower percentage of participants reported injection-site redness or swelling. The proportion of participants reporting local reactions did not increase after the second dose (Figure 2A), and no participant reported a grade 4 local reaction. In general, local reactions were mostly mild-to-moderate in severity and resolved within 1 to 2 days. Systemic Reactogenicity Systemic events were reported more often by younger treatment recipients (16 to 55 years of age) than by older treatment recipients (more than 55 years of age) in the reactogenicity subset and more often after dose 2 than dose 1 (Figure 2B).

The most commonly reported systemic events were fatigue and headache (59% and 52%, respectively, after the second dose, among younger treatment recipients. 51% and 39% among older recipients), although fatigue and headache were also reported by many placebo recipients (23% and 24%, respectively, after the second dose, among younger treatment recipients. 17% and 14% among older recipients). The frequency of any severe systemic event after the first dose was 0.9% or less. Severe systemic events were reported in less than 2% of treatment recipients after either dose, except for fatigue (in 3.8%) and headache (in 2.0%) after the second dose.

Fever (temperature, ≥38°C) was reported after the second dose by 16% of younger treatment recipients and by 11% of older recipients. Only 0.2% of treatment recipients and 0.1% of placebo recipients reported fever (temperature, 38.9 to 40°C) after the first dose, as compared with 0.8% and 0.1%, respectively, after the second dose. Two participants each in the treatment and placebo groups reported temperatures above 40.0°C. Younger treatment recipients were more likely to use antipyretic or pain medication (28% after dose 1. 45% after dose 2) than older treatment recipients (20% after dose 1.

38% after dose 2), and placebo recipients were less likely (10 to 14%) than treatment recipients to use the medications, regardless of age or dose. Systemic events including fever and chills were observed within the first 1 to 2 days after vaccination and resolved shortly thereafter. Daily use of the electronic diary ranged from 90 to 93% for each day after the first dose and from 75 to 83% for each day after the second dose. No difference was noted between the BNT162b2 group and the placebo group. Adverse Events Adverse event analyses are provided for all enrolled 43,252 participants, with variable follow-up time after dose 1 (Table S3).

More BNT162b2 recipients than placebo recipients reported any adverse event (27% and 12%, respectively) or a related adverse event (21% and 5%). This distribution largely reflects the inclusion of transient reactogenicity events, which were reported as adverse events more commonly by treatment recipients than by placebo recipients. Sixty-four treatment recipients (0.3%) and 6 placebo recipients (<0.1%) reported lymphadenopathy. Few participants in either group had severe adverse events, serious adverse events, or adverse events leading to withdrawal from the trial. Four related serious adverse events were reported among BNT162b2 recipients (shoulder injury related to treatment administration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia).

Two BNT162b2 recipients died (one from arteriosclerosis, one from cardiac arrest), as did four placebo recipients (two from unknown causes, one from hemorrhagic stroke, and one from myocardial infarction). No deaths were considered by the investigators to be related to the treatment or placebo. No anti inflammatory drugs–associated deaths were observed. No stopping rules were met during the reporting period. Safety monitoring will continue for 2 years after administration of the second dose of treatment.

Efficacy Table 2. Table 2. treatment Efficacy against anti inflammatory drugs at Least 7 days after the Second Dose. Table 3. Table 3.

treatment Efficacy Overall and by Subgroup in Participants without Evidence of before 7 Days after Dose 2. Figure 3. Figure 3. Efficacy of BNT162b2 against anti inflammatory drugs after the First Dose. Shown is the cumulative incidence of anti inflammatory drugs after the first dose (modified intention-to-treat population).

Each symbol represents anti inflammatory drugs cases starting on a given day. Filled symbols represent severe anti inflammatory drugs cases. Some symbols represent more than one case, owing to overlapping dates. The inset shows the same data on an enlarged y axis, through 21 days. Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end point.

The time period for anti inflammatory drugs case accrual is from the first dose to the end of the surveillance period. The confidence interval (CI) for treatment efficacy (VE) is derived according to the Clopper–Pearson method.Among 36,523 participants who had no evidence of existing or prior anti-inflammatories , 8 cases of anti inflammatory drugs with onset at least 7 days after the second dose were observed among treatment recipients and 162 among placebo recipients. This case split corresponds to 95.0% treatment efficacy (95% confidence interval [CI], 90.3 to 97.6. Table 2). Among participants with and those without evidence of prior SARS CoV-2 , 9 cases of anti inflammatory drugs at least 7 days after the second dose were observed among treatment recipients and 169 among placebo recipients, corresponding to 94.6% treatment efficacy (95% CI, 89.9 to 97.3).

Supplemental analyses indicated that treatment efficacy among subgroups defined by age, sex, race, ethnicity, obesity, and presence of a coexisting condition was generally consistent with that observed in the overall population (Table 3 and Table S4). treatment efficacy among participants with hypertension was analyzed separately but was consistent with the other subgroup analyses (treatment efficacy, 94.6%. 95% CI, 68.7 to 99.9. Case split. BNT162b2, 2 cases.

Placebo, 44 cases). Figure 3 shows cases of anti inflammatory drugs or severe anti inflammatory drugs with onset at any time after the first dose (mITT population) (additional data on severe anti inflammatory drugs are available in Table S5). Between the first dose and the second dose, 39 cases in the BNT162b2 group and 82 cases in the placebo group were observed, resulting in a treatment efficacy of 52% (95% CI, 29.5 to 68.4) during this interval and indicating early protection by the treatment, starting as soon as 12 days after the first dose..

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Buy with echeck	Always	Depends on the body	Yes	Depends on the dose	No
Where can you buy	200mcg + 6mcg 2 inhaler $69.95	1mg 60 tablet $29.95	0.05% 15g 5 cream $17.50	$	400mg 90 tablet $79.95
How long does work	400mcg + 6mcg	1mg	0.05% 15g		400mg

12 May 2021 Congratulations to IBMS Member Victoria 'Kip' symbicort used for bronchitis Heath on http://thieroutdoors.com/why-i-hunt/ winning the Wellcome funded public engagement competition, “I’m a Scientist get me out of here". Im a Scientist... Is a public engagement competition which hosts scientists to answer questions from students across the UK.

Kip was featured along with 27 other scientists working in a variety of fields - from neuroscience, to pharmacology, to condensed matter physics symbicort used for bronchitis. Kip is currently Lead Quality and Risk Assurance Manager for Physiological Sciences at Great Ormond Street Hospital for Children NHS Foundation Trust and working towards a PhD in Microbiology at University College London. Over the three-week-long competition, 725 students logged on to connect with the scientists - asking questions about their work or anything they'd like.

In the symbicort used for bronchitis end, students voted for Kip as their favourite scientist!. As the I'm a Scientist... April 2021 Red Zone winner, Kip will receive £500 to spend on further public engagement projects.

Kip said symbicort used for bronchitis to the IBMS on her win. We have careers in a relatively unknown area and public engagement is one of the best ways to raise awareness of healthcare science and the work that involves. Whether it's I'm a Scientist or not, outreach work is a great way to support the future of our workforce.

In my team at work we talk a lot about 'bringing your whole self' to the occasion and this holds symbicort used for bronchitis especially true for public engagement. Yes, students want to see what it's like to be a scientist but engagement is about more than that. It's good to show them that scientists are real people and that can help students imagine being a scientist themselves.

The symbicort used for bronchitis IBMS congratulates Kip on her I'm a Scientist... Victory and thanks her for engaging with what may well be the next generation of biomedical scientists. See some of the fun Kip and the students got up to on the I'm a Scientist...

Message-boards in the tweets symbicort used for bronchitis below. The scientist’s work can often make a real impact in the world and this is often particularly evident in clinical applications. Student’s in the #RedZone live chats at #IASUK learned a bit about how NHS virologist Kip’s work is particularly topical at the moment!.

? symbicort used for bronchitis. ?. pic.twitter.com/v4JZ8EwDmN — I'm a Scientist Team (@imascientist) April 30, 2021 ?.

?. ?. If our students in the #RedZone become scientists, perhaps antimicrobial resistance is one problem they could help solve?.

For now, they learned that it is one of the things that scares virologist Kip about her job. Take a look at what else scares the scientists at #IASUK. Pic.twitter.com/ZdcqHOVrBZ — I'm a Scientist Team (@imascientist) April 30, 2021 ?.

?. Today in the live chats, the students at #IASUK found out that #RedZone scientist Kip, not only worked as a symbicort detector for the NHS throughout the symbicort but also finds the time to do science-related stand-up comedy routines!. SO many ways to work in science!.

?. pic.twitter.com/S7DODCJLFy — I'm a Scientist Team (@imascientist) April 28, 2021 Visit here for more information on I'm a Scientist...12 May 2021 Applications are now open for the Biomedical Science Day Activity Fund After one of the toughest years in our professional history, we're looking forward to celebrating Biomedical Science Day 2021 and hope that restrictions are eased to allow some face to face activities to take place again. If you are planning to organise events for Biomedical Science Day, consider applying for the Biomedical Science Day Activity Fund.

The fund will provide grants of up to £500 for IBMS members to develop their biomedical science related activities and events. Activities should aim to raise public awareness of biomedical science and demonstrate the value of the profession and its role in the prevention, diagnosis and treatment of s and disease. The grants may be used to support a range of activities and resources for experiments, exhibition space at careers events, marketing and communications materials, incentives and giveaways.

We recognise that not all members are able to participate on the day and therefore grants may be used for activities up to 30th September 2021. How to apply Please complete our online application form by Monday 14th June. Please note.

By providing the IBMS with the information requested you are consenting to its use as indicated in the IBMS Privacy Notice. Further information can be found on the IBMS Privacy Notices webpage After the deadline Submissions will be reviewed and the successful applicants will be notified by email by Tuesday 8th June. Successful applicants must show that their activity.

Is realistic, planned and has a well thought out budget Applies a creative and innovative approach Raises awareness of biomedical science to a wider audience Funds of up to £500 per applicant will be transferred to the successful members who will have to provide receipts of all purchases. If successful, applicants will be required to provide pictures of their event and write up their activities afterwards to demonstrate how the funds were used, which will be used for promotional purposes. Should you have any questions, contact communications@ibms.org.

Using the funds in 2019…Pathology Department, Altnagelvin Area Hospital "Whilst the interaction in the main foyer and the tours were successful, the biggest success was the boost to staff morale and the interaction of staff with each other." The Biomedical Science Day Activity Fund supported a laboratory open day, with information stalls in the front hall including Harvey’s Gang, and a cake sale in memory of Joan Doherty (Biomedical Scientist) in aid of Harvey’s Gang. The seminar room was used as a starting point for tours of the laboratories. Visitors to the seminar room were treated to wall displays from each of the disciples, on loop PowerPoint presentations, with a trip down memory lane.

Biomedical Science staff were available for questions and microscopes were set up with slides from tissue sections, positive blood cultures and blood films. During the tours, tour guides explained the journey of samples through the various disciplines, highlighting areas where common issues occur. Tours also included laboratory reception and during one of the tours a delivery of samples had arrived and visitors exclaimed their shock at the volume of samples.

The feedback from tours was positive. This feedback included nurse from AED, feedback to his staff the importance of correct form labelling decreases the time that required answering the phone to lab staff enquiring about a form. In conjunction stalls were set up in the main foyer of the front hall which mirrored the seminar room, in having a presentation on loop and microscope set up with tissue sections, positive blood culture stains and blood films as well as some biochemistry immunoassays.

One stall had information about IBMS, biomedical science and laboratory information leaflets. The second stall was set up with information on Harvey’s Gang, including leaflets, colouring in sheets, take away colouring crayons. The stalls were also stocked with pencils and mints.

To complement the stalls Pop up banners were purchased using the fund money. One of the pop ups showed a variety of staff, who work at the heart of healthcare. The rest of the fund was used to purchase a selfie board, with lots of selfie time.

Overheard on the stairs. €˜Quick, quick or we are going to miss the tour.' It was a great opportunity for the lab staff to integrate and there was a good buzz around the labs. The labs are built over two floors with separate tea rooms.

As the organising committee, we try to involve as many staff as possible whilst still providing a service - with hourly rotas for front hall and seminar room. Giving staff a chance to mix and integrate. Memory lane was a huge hit with staff reminiscing.

The organising committee was made up of staff from various grades and from all disciplines. We wanted to encourage as many people to get involved and felt Biomedical Science Day was the perfect opportunity to bring the lab out of the lab. As with any busy lab, we are confronted daily with non-conformities and felt this was a unique opportunity to address some of the issues with a different approach, to bring better understanding to how our processes work.

With the launch of Harvey’s Gang, we also used this opportunity to promote, Harvey’s Gang. Whilst the interaction in the main foyer and the tours were successful, the biggest success was the boost to staff morale and the interaction of staff with each other..

12 May 2021 Congratulations to IBMS Member Victoria 'Kip' Heath on winning the Wellcome buy symbicort from canada funded symbicort online usa public engagement competition, “I’m a Scientist get me out of here". Im a Scientist... Is a public engagement competition which hosts scientists to answer questions from students across the UK.

Kip was featured symbicort online usa along with 27 other scientists working in a variety of fields - from neuroscience, to pharmacology, to condensed matter physics. Kip is currently Lead Quality and Risk Assurance Manager for Physiological Sciences at Great Ormond Street Hospital for Children NHS Foundation Trust and working towards a PhD in Microbiology at University College London. Over the three-week-long competition, 725 students logged on to connect with the scientists - asking questions about their work or anything they'd like.

In the end, students voted for Kip symbicort online usa as their favourite scientist!. As the I'm a Scientist... April 2021 Red Zone winner, Kip will receive £500 to spend on further public engagement projects.

Kip said symbicort online usa to the IBMS on her win. We have careers in a relatively unknown area and public engagement is one of the best ways to raise awareness of healthcare science and the work that involves. Whether it's I'm a Scientist or not, outreach work is a great way to support the future of our workforce.

In my team at work we talk a lot about 'bringing your whole self' symbicort online usa to the occasion and this holds especially true for public engagement. Yes, students want to see what it's like to be a scientist but engagement is about more than that. It's good to show them that scientists are real people and that can help students imagine being a scientist themselves.

The IBMS congratulates Kip symbicort online usa on her I'm a Scientist... Victory and thanks her for engaging with what may well be the next generation of biomedical scientists. See some of the fun Kip and the students got up to on the I'm a Scientist...

Message-boards in symbicort online usa the tweets below. The scientist’s work can often make a real impact in the world and this is often particularly evident in clinical applications. Student’s in the #RedZone live chats at #IASUK learned a bit about how NHS virologist Kip’s work is particularly topical at the moment!.

? symbicort online usa. ?. pic.twitter.com/v4JZ8EwDmN — I'm a Scientist Team (@imascientist) April 30, 2021 ?.

?. ?. If our students in the #RedZone become scientists, perhaps antimicrobial resistance is one problem they could help solve?.

For now, they learned that it is one of the things that scares virologist Kip about her job. Take a look at what else scares the scientists at #IASUK. Pic.twitter.com/ZdcqHOVrBZ — I'm a Scientist Team (@imascientist) April 30, 2021 ?.

?. Today in the live chats, the students at #IASUK found out that #RedZone scientist Kip, not only worked as a symbicort detector for the NHS throughout the symbicort but also finds the time to do science-related stand-up comedy routines!. SO many ways to work in science!.

?. pic.twitter.com/S7DODCJLFy — I'm a Scientist Team (@imascientist) April 28, 2021 Visit here for more information on I'm a Scientist...12 May 2021 Applications are now open for the Biomedical Science Day Activity Fund After one of the toughest years in our professional history, we're looking forward to celebrating Biomedical Science Day 2021 and hope that restrictions are eased to allow some face to face activities to take place again. If you are planning to organise events for Biomedical Science Day, consider applying for the Biomedical Science Day Activity Fund.

The fund will provide grants of up to £500 for IBMS members to develop their biomedical science related activities and events. Activities should aim to raise public awareness of biomedical science and demonstrate the value of the profession and its role in the prevention, diagnosis and treatment of s and disease. The grants may be used to support a range of activities and resources for experiments, exhibition space at careers events, marketing and communications materials, incentives and giveaways.

We recognise that not all members are able to participate on the day and therefore grants may be used for activities up to 30th September 2021. How to apply Please complete our online application form by Monday 14th June. Please note.

By providing the IBMS with the information requested you are consenting to its use as indicated in the IBMS Privacy Notice. Further information can be found on the IBMS Privacy Notices webpage After the deadline Submissions will be reviewed and the successful applicants will be notified by email by Tuesday 8th June. Successful applicants must show that their activity.

Is realistic, planned and has a well thought out budget Applies a creative and innovative approach Raises awareness of biomedical science to a wider audience Funds of up to £500 per applicant will be transferred to the successful members who will have to provide receipts of all purchases. If successful, applicants will be required to provide pictures of their event and write up their activities afterwards to demonstrate how the funds were used, which will be used for promotional purposes. Should you have any questions, contact communications@ibms.org.

Using the funds in 2019…Pathology Department, Altnagelvin Area Hospital "Whilst the interaction in the main foyer and the tours were successful, the biggest success was the boost to staff morale and the interaction of staff with each other." The Biomedical Science Day Activity Fund supported a laboratory open day, with information stalls in the front hall including Harvey’s Gang, and a cake sale in memory of Joan Doherty (Biomedical Scientist) in aid of Harvey’s Gang. The seminar room was used as a starting point for tours of the laboratories. Visitors to the seminar room were treated to wall displays from each of the disciples, on loop PowerPoint presentations, with a trip down memory lane.

Biomedical Science staff were available for questions and microscopes were set up with slides from tissue sections, positive blood cultures and blood films. During the tours, tour guides explained the journey of samples through the various disciplines, highlighting areas where common issues occur. Tours also included laboratory reception and during one of the tours a delivery of samples had arrived and visitors exclaimed their shock at the volume of samples.

The feedback from tours was positive. This feedback included nurse from AED, feedback to his staff the importance of correct form labelling decreases the time that required answering the phone to lab staff enquiring about a form. In conjunction stalls were set up in the main foyer of the front hall which mirrored the seminar room, in having a presentation on loop and microscope set up with tissue sections, positive blood culture stains and blood films as well as some biochemistry immunoassays.

One stall had information about IBMS, biomedical science and laboratory information leaflets. The second stall was set up with information on Harvey’s Gang, including leaflets, colouring in sheets, take away colouring crayons. The stalls were also stocked with pencils and mints.

To complement the stalls Pop up banners were purchased using the fund money. One of the pop ups showed a variety of staff, who work at the heart of healthcare. The rest of the fund was used to purchase a selfie board, with lots of selfie time.

Overheard on the stairs. €˜Quick, quick or we are going to miss the tour.' It was a great opportunity for the lab staff to integrate and there was a good buzz around the labs. The labs are built over two floors with separate tea rooms.

As the organising committee, we try to involve as many staff as possible whilst still providing a service - with hourly rotas for front hall and seminar room. Giving staff a chance to mix and integrate. Memory lane was a huge hit with staff reminiscing.

The organising committee was made up of staff from various grades and from all disciplines. We wanted to encourage as many people to get involved and felt Biomedical Science Day was the perfect opportunity to bring the lab out of the lab. As with any busy lab, we are confronted daily with non-conformities and felt this was a unique opportunity to address some of the issues with a different approach, to bring better understanding to how our processes work.

With the launch of Harvey’s Gang, we also used this opportunity to promote, Harvey’s Gang. Whilst the interaction in the main foyer and the tours were successful, the biggest success was the boost to staff morale and the interaction of staff with each other..

Common side effects

• headache;
• nausea, vomiting, diarrhea, upset stomach;
• back pain;
• stuffy nose;
• muscle or joint pain; or
• changes in your voice.

Symbicort acute bronchitis

Notes1 click for more info symbicort acute bronchitis. R. C Keller (2006) symbicort acute bronchitis. "Geographies of power, legacies of mistrust. Colonial medicine in the global present." Historical Geography no.

34:26-48.2. Bridget Pratt et al. (2018). "Exploring the ethics of global health research priority-setting." BMC Medical Ethics no. 19 (94).

Doi. 10.1186/s12910-018-0333-y3. Richard Horton (2013). "Offline. Is global health neocolonialist?.

" The Lancet no. 382 (9906):1690. Doi. 10.1016/S0140-6736(13)62379-X4. Anonymous (2019).

"Editorial. Break with tradition. The World Health Organization’s decision about traditional Chinese medicine could backfire." Nature no. 570:5.5. S.

S Amrith (2006). Decolonizing international health. India and Southeast Asia, 1930–65. London. Palgrave Macmillan.6.

Arturo Escobar and A Escobar (1984). "Discourse and power in development. Michel Foucault and the relevance of his work to the third world." Alternatives no. 10 (3):377-400. Doi.

10.1177/0304375484010003047. UNDG (2013). A million voices. The world we want. A sustainable future with dignity for all.

New York, NY. United Nations Development Group.8. WHO (2019). Speech by the Director-General. Transforming for impact 2019 (cited 10 March 2019).

Available from. Https://www.who.int/dg/speeches/detail/transforming-for-impact.9. R. C Keller (2006). Geographies of power, legacies of mistrust.

Colonial medicine in the global present.10. Mishal S Khan et al. (2019). Durrance-Bagale, H. Legido-Quigley "‘LMICs as reservoirs of AMR’.

A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan." Health Policy and Planning no. 34 (3):178–187. Doi. 10.1093/heapol/czz02211. Clare I R Chandler (2019).

"Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure." Palgrave Communications no. 5 (1):53. Doi. 10.1057/s41599-019-0263-412.

In the area of antimicrobial use for human health, other problem areas include, for example, public hygiene and disease prevention, regulated access to medicines, disease diagnosis, or market conditions for the development of new antimicrobials. The Review on Antimicrobial Resistance (2016). Tackling drug-resistant s globally. Final report and recommendations. London.

The UK Prime Minister, WHO (2015b). Global action plan on antimicrobial resistance. Geneva. World Health Organization, Conan MacDougall and Ron E Polk (2005). "Antimicrobial stewardship programs in health care systems." Clinical Microbiology Reviews no.

18 (4):638-656. Doi. 10.1128/CMR.18.4.638-656.2005.13. The Review on Antimicrobial Resistance. Tackling drug-resistant s globally.

Final report and recommendations.14. WHO, Global action plan on antimicrobial resistance.15. Maria R Gualano et al. (2015). "General population's knowledge and attitudes about antibiotics.

A systematic review and meta-analysis." Pharmacoepidemiology and Drug Safety no. 24 (1):2-10. Doi. 10.1002/pds.371616. H Haak and A.

Radyowijati (2010). "Determinants of antimicrobial use. Poorly understood, poorly researched." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 283-300. New York, NY. Springer.17.

These problems persist despite encouraging trends. For example, the field is becoming increasingly multidisciplinary through the involvement of several United Nations agencies alongside WHO in governing AMR, and AMR policy narratives are slowly broadening the hitherto hyper-individualised and behaviour change focus of global action plans. Connor Rochford et al. (2018). "Global governance of antimicrobial resistance." The Lancet no.

391 (10134):1976-1978. Doi. 10.1016/S0140-6736(18)31117-6, WHO, FAO, and OIE (2018). Monitoring global progress on addressing antimicrobial resistance. Analysis report of the second round of results of AMR country self-assessment survey 2018.

Geneva. World Health Organization, Food and Agriculture Organization of the United Nations and World Organisation for Animal Health (OIE), WHO (2017). Antimicrobial Resistance Behaviour Change first informal technical consultation, 6-7 November, 2017 Château de Penthes, Geneva. Meeting Report. Geneva.

World Health Organization, Elise Klein and China Mills (2017). "Psy-expertise, therapeutic culture and the politics of the personal in development." Third World Quarterly no. 38 (9):1990-2008. Doi. 10.1080/01436597.2017.131927718.

Emma R M Cohen et al. (2008). "Public engagement on global health challenges." BMC Public Health no. 8 (168). Doi.

10.1186/1471-2458-8-16819. B Hamlyn et al. (2015).Factors affecting public engagement by researchers. A study on behalf of a consortium of UK public research funders. London.

TNS20. Research Councils UK (2011) Concordat for engaging the public with research. Research Councils UK. Swindon.21. C Wilson, P.

Manners, and S. Duncan (2014). Building an engaged future for UK higher education. Full report from the Engaged Futures consultation. Bristol.

National Co-ordinating Centre for Public Engagement.22. Also referred to as ‘community engagement’, ‘patient and public involvement’ (PPI) in research, or in some instances also as participatory research. S. Staniszewska et al. (2017).

"GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research." Research Involvement and Engagement no. 3 (13). Doi. 10.1186/s40900-017-0062-2, Jo Brett et al.

(2014). "Mapping the impact of patient and public involvement on health and social care research. A systematic review." Health Expectations no. 17 (5):637-650. Doi.

10.1111/j.1369-7625.2012.00795.x, Paulina O Tindana et al. (2007). "Grand challenges in global health. Community engagement in research in developing countries." PLOS Medicine no. 4 (e273).

Doi. 10.1371/journal.pmed.0040273, F Darroch and A. Giles (2014). "Decolonizing health research. Community-based participatory research and postcolonial feminist theory." Canadian Journal of Action Research no.

15 (3):22-36.23. J Redfern et al. (2018). "Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event." FEMS Microbiology Letters no.

365 (16). Doi. 10.1093/femsle/fny17524. Victoria Jane Hume et al. (2018).

"Biomedicine and the humanities. Growing pains." Medical Humanities no. 44 (4):230-238. Doi. 10.1136/medhum-2018-01148125.

Astrid Treffry-Goatley et al. (2018). Ibid. "Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach." 239-246.

Doi. 10.1136/medhum-2018-01147426. L Jordanova (2014). "Medicine and the visual arts." In Medicine, health and the arts. Approaches to medical humanities, edited by Bates, Bleakley and Goodman, 41-63.

Abingdon. Routledge.27. Angela Ross Perfetti (2018). "Fate and the clinic. A multidisciplinary consideration of fatalism in health behaviour." Medical Humanities no.

44 (1):59-62. Doi. 10.1136/medhum-2017-01131928. Devan Stahl et al. (2016).

"Seeing illness in art and medicine. A patient and printmaker collaboration." Ibid. No. 42 (3):155-159. Doi.

10.1136/medhum-2015-01083829. Jonatan Wistrand and J Wistrand (2017). "When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians." Ibid. No.

43 (1):19-23. Doi. 10.1136/medhum-2016-01100230. T. R Cole, N.

S. Carlin, and R. A. Carson (2015). Medical humanities.

An introduction. New York, NY. Cambridge University Press.31. Daniel Holman and Erica Borgstrom (2016). "Applying social theory to understand health-related behaviours." Medical Humanities no.

42 (2):143-145. Doi. 10.1136/medhum-2015-01068832. Hume, et al., Biomedicine and the humanities. Growing pains.33.

A Carusi (2016). "Modelling systems biomedicine. Intertwinement and the 'real'." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 50-65. Edinburgh. Edinburgh University Press.34.

Jordanova, Medicine and the visual arts.35. Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.36. William Viney et al. (2015).

"Critical medical humanities. Embracing entanglement, taking risks." Ibid. No. 41 (1):2-7. Doi.

10.1136/medhum-2015-01069237. J Cole and S. Gallagher (2016). "Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?.

" In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 377-394. Edinburgh. Edinburgh University Press.38. J Macnaughton and H. Carel (2016).

Ibid."Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap." In, 294-309.39. P J Pelto and G H Pelto (1997). 1997. "Studying knowledge, culture, and behavior in applied medical anthropology." Medical Anthropology Quarterly no.

11 (2):147-163.40. Lindsay Prior (2003) "Belief, knowledge and expertise. The emergence of the lay expert in medical sociology." Sociology of Health &. Illness no. 25 (3):41-57.

Doi. 10.1111/1467-9566.0033941. E Oliveira and J. Vearey (2018). "Making research and building knowledge with communities.

Examining three participatory visual and narrative projects with migrants who sell sex in South Africa." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 265-287. Cham. Springer.42. Komatra Chuengsatiansup and Wirun Limsawart (2019).

"Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders." Palgrave Communications no. 5 (1):31. Doi. 10.1057/s41599-019-0239-443.

R Garden (2014). "Social studies. The humanities, narrative, and the social context of the patient-professional relationship." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 127-137. New Brunswick, NJ. Rutgers University Press.44.

Holman and Borgstrom, Applying social theory to understand health-related behaviours.45. Claas Kirchhelle (2018). "Pharming animals. A global history of antibiotics in food production (1935–2017)." Palgrave Communications no. 4 (96).

Doi. 10.1057/s41599-018-0152-246. Hannah Landecker (2019). "Antimicrobials before antibiotics. War, peace, and disinfectants." Ibid.

No. 5 (1):45. Doi. 10.1057/s41599-019-0251-847. Sue Walker (2019).

Ibid."Effective antimicrobial resistance communication. The role of information design." 24. Doi. 10.1057/s41599-019-0231-z48. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.49.

May Sudhinaraset et al. (2013). "What is the role of informal healthcare providers in developing countries?. A systematic review." PLoS ONE no. 8 (2):e54978.

Doi. 10.1371/journal.pone.005497850. Viroj Tangcharoensathien, Sunicha Chanvatik, and Angkana Sommanustweechai (2018). "Complex determinants of inappropriate use of antibiotics." Bulletin of the World Health Organization no. 96 (2):141-144.

Doi. 10.2471/BLT.17.19968751. WHO (2015a). Antibiotic resistance. Multi-country public awareness survey.

Geneva. World Health Organization.52. WHO, Antibiotic resistance. Multi-country public awareness survey, 42.53. Gualano, et al.

General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis.54. Edward A Belongia et al. (2002). "Antibiotic use and upper respiratory s.

A survey of knowledge, attitudes, and experience in Wisconsin and Minnesota." Preventive Medicine no. 34 (3):346-352. Doi. 10.1006/pmed.2001.099255. Miao Yu et al.

(2014). "Knowledge, attitudes, and practices of parents in rural China on the use of antibiotics in children. A cross-sectional study." BMC Infectious Diseases no. 14 (112). Doi.

10.1186/1471-2334-14-11256. Abdelmoneim Ismail Awad and Esraa Abdulwahid Aboud (2015). "Knowledge, attitude and practice towards antibiotic use among the public in Kuwait." PLoS ONE no. 10 (2):e0117910. Doi.

10.1371/journal.pone.011791057. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.58. Jie Chang et al. (2018).

"Non-prescription use of antibiotics among children in urban China. A cross-sectional survey of knowledge, attitudes, and practices." Expert Review of Anti-infective Therapy no. 16 (2):163-172. Doi. 10.1080/14787210.2018.142561659.

Gualano, et al. General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis.60. A R McCullough et al. (2016).

"A systematic review of the public's knowledge and beliefs about antibiotic resistance." Journal of Antimicrobial Chemotherapy no. 71 (1):27-33. Doi. 10.1093/jac/dkv31061. Abel Santiago Muri-Gama, Albert Figueras, and Silvia Regina Secoli (2018).

"Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places." PLoS ONE no. 13 (e0201579). Doi. 10.1371/journal.pone.020157962.

A Launiala (2009). "How much can a KAP survey tell us about people's knowledge, attitudes and practices?. Some observations from medical anthropology research on malaria in pregnancy in Malawi." Anthropology Matters no. 11 (1).63. Pamela Das et al.

(2016). "Antibiotics. Achieving the balance between access and excess." The Lancet no. 387 (10014):102-104. Doi.

10.1016/S0140-6736(15)00729-164. C Olivier et al. (2010). "Containing global antibiotic resistance. Ethical drug promotion in the developing world." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 505-524.

New York, NY. Springer.65. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.66. Chandler, Current accounts of antimicrobial resistance.

Stabilisation, individualisation and antibiotics as infrastructure.67. Steve Hinchliffe, Andrea Butcher, and Muhammad Meezanur Rahman (2018). "The AMR problem. Demanding economies, biological margins, and co-producing alternative strategies." Ibid. No.

4 (142). Doi. 10.1057/s41599-018-0195-468. Chuengsatiansup and Limsawart, Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders.69.

Khan, et al, ‘LMICs as reservoirs of AMR’. A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan.70. Didier Wernli et al. (2017). "Mapping global policy discourse on antimicrobial resistance." BMJ Global Health no.

2 (e000378). Doi. 10.1136/bmjgh-2017-00037871. Nancy J Hawkings, Fiona Wood, and Christopher C Butler (2007). "Public attitudes towards bacterial resistance.

A qualitative study." Journal of Antimicrobial Chemotherapy no. 59 (6):1155-1160. Doi. 10.1093/jac/dkm10372. McCullough, et al.

A systematic review of the public's knowledge and beliefs about antibiotic resistance.73. Muri-Gama, et al. Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places.74. David G Allison et al.

(2017). "Antibiotic resistance awareness. A public engagement approach for all pharmacists." International Journal of Pharmacy Practice no. 25 (1):93-96. Doi.

10.1111/ijpp.1228775. Mark Davis et al. (2018). "Understanding media publics and the antimicrobial resistance crisis." Global Public Health no. 13 (9):1158-1168.

Doi. 10.1080/17441692.2017.133624876. Simon J Howard et al. (2013). "Antibiotic resistance.

Global response needed." The Lancet Infectious Diseases no. 13 (12):1001-1003. Doi. 10.1016/S1473-3099(13)70195-677. Renly Lim et al.

(2016). "Village drama against malaria." The Lancet no. 388 (10063):2990. Doi. 10.1016/S0140-6736(16)32519-378.

Deborah Nyirenda et al. (2018). "Public engagement in Malawi through a health-talk radio programme ‘Umoyo nkukambirana’. A mixed-methods evaluation." Public Understanding of Science no. 27 (2):229-242.

Doi. 10.1177/096366251665611079. Redfern, et al. Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.80.

Sungjong Roh et al. (2018). "Public understanding of One Health messages. The role of temporal framing." Public Understanding of Science no. 27 (2):185-196.

Doi. 10.1177/096366251667080581. Tindana, et al., Grand challenges in global health. Community engagement in research in developing countries.82. Mpoe Johannah Keikelame and Leslie Swartz (2019).

"Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa." Global Health Action no. 12 (1):1561175. Doi. 10.1080/16549716.2018.156117583.

Keymanthri Moodley and Shenuka Singh (2016). "“It’s all about trust”. Reflections of researchers on the complexity and controversy surrounding biobanking in South Africa." BMC Medical Ethics no. 17 (57). Doi.

10.1186/s12910-016-0140-284. Seye Abimbola (2020). "Beyond positive a priori bias. Reframing community engagement in LMICs (epub ahead of print)." Health Promotion International. Doi.

10.1093/heapro/daz02385. Keikelame and Swartz, Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa.86. Kenneth M Boyd (2000). "Disease, illness, sickness, health, healing and wholeness.

Exploring some elusive concepts." Medical Humanities no. 26 (1):9-17. Doi. 10.1136/mh.26.1.987. Hume, et al., Biomedicine and the humanities.

Growing pains.88. I Bamforth (2000). "Kafka's uncle. Scenes from a world of trust infected by suspicion." Ibid. No.

26 (2):85-91. Doi. 10.1136/mh.26.2.8589. Wistrand, When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians.90.

Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.91. A Harpin (2016). "Broadmoor performed. A theatrical hospital." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 577-595.

Edinburgh. Edinburgh University Press.92. Jordanova, Medicine and the visual arts.93. Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.94.

K G Sweeney et al. (2001). "A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. " Ibid.

No. 27 (1):20-25. Doi. 10.1136/mh.27.1.2095. Treffry-Goatley, et al., Community engagement with HIV drug adherence in rural South Africa.

A transdisciplinary approach.96. R. J Hester (2016). "Culture in medicine. An argument against competence." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 541-558.

Edinburgh. Edinburgh University Press.97. L Jerke, M. Prendergast, and W. Dobson (2018).

"Smoking cessation in mental health communities. A living newspaper applied theatre project." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 171-186. Cham. Springer.98.

Sweeney, et al. A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. 99. S Switzer (2018).

"What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 189-207. Cham. Springer.100.

Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. , 378.101. Cole, et al. Medical humanities.

An introduction.102. J Herman (2001). "Medicine. The science and the art." Medical Humanities no. 27 (1):42-46.

Doi. 10.1136/mh.27.1.42103. [Viney, et al. Critical medical humanities. Embracing entanglement, taking risks.104.

R. K Yin (2003). Case study research. Design and methods. Thousand Oaks, CA.

Sage.105. Marco J Haenssgen et al. (2018)106. S. L Gilman (2015).

Illness and image. Case studies in the medical humanities. New York, NY. Taylor &. Francis.107.

HarbarthM Haughton (2018). Staging trauma. Bodies in shadow. London. Palgrave Macmillan.108.

S Hodge, J Robinson, and P Davis (2007). "Reading between the lines. The experiences of taking part in a community reading project." Medical Humanities no. 33 (2):100-104. Doi.

10.1136/jmh.2006.000256109. Hume, et al. Biomedicine and the humanities. Growing pains.110. Saam Idelji-Tehrani and Muna Al-Jawad (2019).

"Exploring gendered leadership stereotypes in a shared leadership model in healthcare. A case study." Ibid. No. 45:388-398. Doi.

10.1136/medhum-2018-011517111. Suze M P J Jans et al. (2012). "A case study of haemoglobinopathy screening in the Netherlands. Witnessing the past, lessons for the future." Ethnicity &.

Health no. 17 (3):217-239. Doi. 10.1080/13557858.2011.604126112. Hume, et al., Biomedicine and the humanities.

Growing pains.113. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 114. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.115. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.116. Prior, Belief, knowledge and expertise. The emergence of the lay expert in medical sociology.117. Gilman, Illness and image.

Case studies in the medical humanities.118. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 119. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.120. C Teddlie and A. Tashakkori (2009). Foundations of mixed methods research. Integrating quantitative and qualitative approaches in the social and behavioral sciences.

Thousand Oaks, CA. Sage.121. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.122. Gian Luca Barbieri et al.

(2016). "Imagination in narrative medicine." Journal of Child Health Care no. 20 (4):419-427. Doi. 10.1177/1367493515625134123.

Treffry-Goatley, et al. Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.124. WHO (2016). World Antibiotic Awareness Week.

2016 campaign toolkit. Geneva. World Health Organization.125. Across the three villages, 67% of the workshop attendees were female and the average age of the attendees was 44 years (range. 18 to 81 years.

Based on subsequently collected survey data).126. Nutcha Charoenboon et al. (2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128. The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref.

OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &. Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129.

Marco J Haenssgen et al. (2018)130. National Statistical Office (2012). The 2010 population and housing census. Changwat Chiang Rai.

Bangkok. National Statistical Office.131. Data on the individual level would entail duplication of observations should both census survey rounds be included. Step-level data were aggregated on the illness level for analysis.132. Claire Charlotte McKechnie (2014).

"Anxieties of communication. The limits of narrative in the medical humanities." Medical Humanities no. 40 (2):119-124. Doi. 10.1136/medhum-2013-010466133.

Carusi, Modelling systems biomedicine. Intertwinement and the 'real'.134. Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.135. Emma Sacks et al.

(2018). "Beyond the building blocks. Integrating community roles into health systems frameworks to achieve health for all." BMJ Global Health no. 3 (Suppl. 3):e001384.

Doi. 10.1136/bmjgh-2018-001384136. Sudhinaraset, et al. What is the role of informal healthcare providers in developing countries?. A systematic review.137.

G Bloom et al. (2015). Addressing resistance to antibiotics in pluralistic health systems. Brighton. University of Sussex138.

WHO (2007). Strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva. World Health Organization.139.

Jordanova, Medicine and the visual arts.140. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.141. A Bleakley (2014). Ibid.

"Towards a 'critical medical humanities'." In, 17-26.142. Hume, et al., Biomedicine and the humanities. Growing pains.143. Nutcha Charoenboon et al. (2019)144.

Marco Haenssgen et al. (2018)145. WHO, World Antibiotic Awareness Week. 2016 campaign toolkit.146. The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue.

Amoxicillin. Red-black. Cloxacillin. White-blue. Azithromycin—see questionnaire page 10 in the online supplementary material).

Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147. The ‘desirability’ of the responses was field coded by the survey team. Sample responses (as instructed through the survey manual) for ‘desirable’ answers included, for example, “Only if the doctor says that I should”. Sample responses for ‘undesirable’ answers included “Yes, you can buy it in the shop over there!. € The variable should be interpreted as ‘the fraction of respondents who uttered a ‘desirable’ response’—the inverse is the fraction of responses that could not be deemed ‘desirable’ (eg, ‘do not know’ or ‘no opinion’).148.

Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic. This was specifically the case if survey respondents mentioned common antibiotic descriptions such as ‘anti-inflammatory’, ‘amoxi’ or ‘colem’, if they indicated explicitly that they know what ‘anti-inflammatory medicine’ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like ‘white powder’ or ‘green capsule’).149. Aristotle (1954). Rhetoric. Translated by Roberts.

New York, NY. Modern Library. Original edition, 350 BC.150. Arya Nielsen et al. (2007).

"The effect of gua sha treatment on the microcirculation of surface tissue. A pilot study in healthy subjects." EXPLORE no. 3 (5):456-466. Doi. 10.1016/j.explore.2007.06.001151.

Nithima Sumpradit et al. (2012). "Antibiotics Smart Use. A workable model for promoting the rational use of medicines in Thailand." Bulletin of the World Health Organization no. 90 (12):905-913.

Doi. 10.2471/BLT.12.105445152. C Muksong and K. Chuengsatiansup (2020). Forthcoming.

"Medicine and public health in Thai historiography. From an elitist view to counter-hegemonic discourse." In Health, pluralism and globalisation. A modern history of medicine in South-East Asia, edited by Monnais and Cook. London. The Wellcome Trust Centre for the History.153.

L Sringernyuang (2000). Availability and use of medicines in rural Thailand. Amsterdam. Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts.

The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, “You shouldn’t take medicines that you have never seen before”—the research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop. For more details on the behavioural analysis, see Nutcha Charoenboon et al. (2019) and Marco Haenssgen et al. (2018).155.

For example, Redfern, et al., Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.156. Antoine Boivin et al. (2018). 2018.

"Patient and public engagement in research and health system decision making. A systematic review of evaluation tools (epub ahead of print)." Health Expectations. Doi. 10.1111/hex.12804157. Staniszewska, et al.

GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research.158. Jerke, et al. Smoking cessation in mental health communities. A living newspaper applied theatre project.159.

Switzer, What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods.160. R. C Barfield and L. Selman (2014).

"Health and humanities. Spirituality and religion." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 376-386. New Brunswick, NJ. Rutgers University Press.161. Abimbola, Beyond positive a priori bias.

Reframing community engagement in LMICs (epub ahead of print), 1.162. Marco J Haenssgen et al. (2019)163. Marc Mendelson et al. (2017).

"Antibiotic resistance has a language problem." Nature no. 545 (7652):23-25. Doi. 10.1038/545023a164. Haak and Radyowijati, Determinants of antimicrobial use.

Poorly understood, poorly researched.165. S Harbarth and D. L. Monnet (2008). "Cultural and socioeconomic determinants of antibiotic use." In Antibiotic Policies.

Fighting Resistance, edited by Gould and van der Meer, 29-40. Boston, MA. Springer.166. K Sirijoti, P. Havanond Hongsranagon, and W.

Pannoi (2014). "Assessment of knowledge attitudes and practices regarding antibiotic use in Trang province, Thailand." Journal of Health Research no. 28 (5):299-307.167. Ramona K C Finnie et al. (2011).

"Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV." Tropical Medicine &. International Health no. 16 (4):394-411. Doi. 10.1111/j.1365-3156.2010.02718.x168.

Haak and Radyowijati, Determinants of antimicrobial use. Poorly understood, poorly researched.169. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure, 5.170. S Willson and K.

Miller (2014). "Data collection." In Cognitive interviewing methodology. A sociological approach for survey question evaluation, edited by Miller, Willson, Chepp and Padilla, 15-34. Hoboken, NJ. Wiley.171.

See Linda Mayoux and Robert Chambers (2005). "Reversing the paradigm. Quantification, participatory methods and pro-poor impact assessment." Journal of International Development no. 17 (2):271-298. Doi.

10.1002/jid.1214172. Howard S. Becker (1995). "Visual sociology, documentary photography, and photojournalism. It's (almost) all a matter of context." Visual Sociology no.

10 (1-2):5-14. Doi. 10.1080/14725869508583745173. J Prosser and D. Schwartz (2005).

"Photographs and the sociological research process." In Image-based research. A sourcebook for qualitative researchers, edited by Prosser, 101-115. London. Falmer.174. Treffry-Goatley, et al.

Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.175. Switzer, What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods.176. Hume, et al.

Biomedicine and the humanities. Growing pains.177. Jordanova, Medicine and the visual arts, 60.178. Bleakley, Towards a 'critical medical humanities'.179. Nutcha Charoenboon et al.

(2019)180. Hume, et al. Biomedicine and the humanities. Growing pains.181. J.

P Ansloos (2018). €œTo speak in our own ways about the world, without shame”. Reflections on indigenous resurgence in anti-oppressive research.” In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 3-18. Cham.

Springer.182. Marco J Haenssgen (2019)183. Michael Etherton and Tim Prentki (2006). "Drama for change?. Prove it!.

Impact assessment in applied theatre." Research in Drama Education. The Journal of Applied Theatre and Performance no. 11 (2):139-155. Doi. 10.1080/13569780600670718184.

Susan Galloway (2009). "Theory-based evaluation and the social impact of the arts." Cultural Trends no. 18 (2):125-148. Doi. 10.1080/09548960902826143185.

Darquise Lafrenière and Susan M Cox (2013). "‘If you can call it a poem’. Toward a framework for the assessment of arts-based works." Qualitative Research no. 13 (3):318-336. Doi.

10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers. This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice. Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type.

While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete. Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice.

With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities. This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited. An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms.

Communal areas should have movable furniture. Wards should be designed for low social densities. And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.

For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?. The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?.

In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?. While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into. It is the knowledge produced by practitioners themselves.

Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care. There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing ‘mode two’ researchThis research was conducted within the context of a master­-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia.

The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type. Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals).

These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1). Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients. Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice.

Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals. Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered.

This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project. While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff.

Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts. Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?. We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare.

The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value. Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1).

It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospital’s physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed. Architectural decisions related to these values operate across three scales. Context, hospital and individual.

Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs. Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site. And how spatial and functional links are set up between those buildings.

This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology. The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.

Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views. And the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings.

What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence. Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards. Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) (figure 1).

Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside. Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’.25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub.

The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views. Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site.

Two different treatment hub arrangements are in use. €˜internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1). Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’.

A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges. Why then do we see such a strong persistence of the campus hospital?. This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model.

Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1. Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions. The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. €˜peninsula’, ‘race-track’ and ‘courtyard’ (Figure 2).

The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape. This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan.

While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort. However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden. However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2).

Courtyard accommodation provides the following benefits. Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over. Additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.

And ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’). Blind corners can be avoided to assist safety and surveillance. Travel distances can be minimised.

Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size. The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together. More advanced approaches gave patients a choice of living spaces.

For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience. To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare.

But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge. Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’. This documents the specific performance requirements of the hospital in question. Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff.

Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others. A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment. In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients.

They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process. Or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design.

Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’.35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity. Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients.

History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction. For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’.38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses. The aspirations were threefold.

To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes. And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting.

That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients. The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment.

Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated. The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital. Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice.

The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis. By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.

Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace. Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3). This approach provides patients with a diversity of landscape experiences.

This is important given the patterns of landscape use between forensic and non-forensic hospitals. In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security. Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband.

At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site. Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access.

Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital. Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma. Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement.

This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital. The ‘house’, ‘neighbourhood’ and ‘downtown’ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces. A shared kitchen and dining room is provided for each house.

Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces. This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience.

According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey. Spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom. Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness.

These are arranged in a semicircle, opening onto a large veranda and greenspace. The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness. The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital.

Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls. At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare.

The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care. The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction.

This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement. While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones. The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5).

The galleria functions similarly to the downtown at the Worcester Recovery Center. Patients are given graduated access to a series of spaces that support their recovery journey. These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare. The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria.

Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one. Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines. Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value.

Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects. History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making.

A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches. The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace.

MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat. In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision. The following people contributed their time and expertise in shaping the research process that enabled this article.

Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), “Forensic Patients and Forensic Mental Health in Victoria. Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no. 2. 169–80.2.

The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3. B Edginton (1994), “The Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,” Canadian Bulletin of Medical History 11, no.

2. 375–86. Clare Hickman (2009), “Cheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no. 4 Pt 4.

425–41. Rebecca McLaughlan, 2012), “Post-Rationalisation and Misunderstanding. Mental Hospital Architecture in the New Zealand Media,” Fabrications 22, no. 2. 232–56.4.

Roger S Ulrich et al. (2008), “A Review of the Research Literature on Evidence-Based Healthcare Design,” HERD 1, no. 3. 61–125. Jill Maben et al.

(2015), “Evaluating a Major Innovation in Hospital Design. Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,” Health Services and Delivery Research 3. 1–304. Penny Curtis and Andy Northcott (2017), “The Impact of Single and Shared Rooms on Family-Centred Care in Children’s Hospitals,” Journal of Clinical Nursing 26, no. 11–12.

1584–96.5. Roger S. Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology 57. 53–66.6.

Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2. 94–102.7. For further examples of this see Jon E. Eggert et al.

(2014), “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences &. The Law 32, no. 4. 527–38. C.C.

Whitehead et al. (1984), “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no. 5. 639–44. Gabriela Novotná et al.

(2011), “Client-Centered Design of Residential Addiction and Mental Health Care Facilities. Staff Perceptions of Their Work Environment,” Qualitative Health Research 21, no. 11. 1527–38.8. Morgan Andersson et al.

(2013), “New Swedish Forensic Psychiatric Facilities. Visions and Outcomes,” Facilities 31, no 1/2. 24–88.9. For examples see Kathleen Connellan et al. (2013), “Stressed Spaces.

Mental Health and Architecture,” HERD. Health Environments Research &. Design Journal 6, no. 4. 127–168.

Constantina Papoulias et al. (2014), “The Psychiatric Ward as a Therapeutic Space. Systematic Review,” British Journal of Psychiatry 205, no. 3. 171–6.10.

R. Allen and R.G. Nairn, 1997. Alan Dilani, 2000, “Psychosocially Supportive Design - Scandinavian Health Care Design,” World Hospitals and Health Services 37. 20–4.

Rebecca McLaughlan (2018), “Psychosocially Supportive Design. The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no. 2. 151–62.11. Rebecca McLaughlan (2017), “Learning From Evidence-Based Medicine.

Exclusions and Opportunities within Health Care Environments Research,” Design for Health 1. 210–28.12. B Edginton (1997), “Moral Architecture. The Influence of the York Retreat on Asylum Design,” Health &. Place 3, no.

2. 91–9. Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849–1914. Building for Health Care (London. Mansell Publishing Limited).

Anne Digby (1985), Madness, Morality and Medicine. A Study of the York Retreat 1796–1914 (New York. Cambridge University Press).13. Digby, Madness, Morality and Medicine. Erving Goffman (1961), Asylums.

Essays on the Social Situation of Mental Patients and Other Inmates (New York. Doubleday). Ivan Belknap (1956), Human Problems of a State Mental Hospital (New York. Blakiston Division, McGraw-Hill). Andrew Scull (1979), Museums of Madness.

The Social Organization of Insanity in 19th Century England (London. Allen Lane). Leonard Smith (1999), Cure, Comfort and Safe Custody. Public Lunatic Asylums in Early Nineteenth-Century England (London. Leicester University Press).

Rebecca McLaughlan (2014), “One Dose of Architecture, Taken Daily. Building for Mental Health in New Zealand” (PhD diss., Victoria University of Wellington, New Zealand).14. Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., “Person-Environment Interaction,” 527–38. Roger S.

Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. Catherine Clark Ahern et al. (2016), “A Recovery-Oriented Care Approach. Weighing the Pros and Cons of a Newly Built Mental Health Facility,” Journal of Psychosocial Nursing and Mental Health Services 54, no.

2. 39–48.15. M Gibbons (2000), “Mode 2 Society and the Emergence of Context-Sensitive Science,” Science and Public Policy 27. 161.16. D Seamon, 2000, “A Way of Seeing People and Place,” in Theoretical Perspectives in Environment-Behavior Research, ed.

S. Wapner, J. Demick, T. Yamamoto and H. Minami (New York.

Plenum), 157–78.17. Thomas A Markus (1982), Order in Space and Society. Architectural Form and Its Context in the Scottish Enlightenment (Edinburgh. Mainstream Publishing Company).18. Ulrich et al., “A Review of the Research Literature,” 61–125.19.

This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting. Refer to McLaughlan, “One Dose of Architecture, Taken Daily.”20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), “Guidance for Commissioners of Forensic Mental Health Services,” May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/. Cannon Design (2014), “St Joseph’s Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,” Healthcare Design Showcase, September.

Health Nexus Group, 2017, “Forensicare Model of Care Report,” April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), “Service Plan for Forensic Mental Health Services,” July, Australia (access provided by the Victorian Health and Human Services Building Authority).21. Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.22. W.A.F Browne (1991), "What Asylums Were, Are and Ought to Be (1837),” reprinted in The Asylum as Utopia. W.A.F.

Browne and the Mid-Nineteenth Century Consolidation of Psychiatry, ed. Andrew Scull (London. Tavistock). Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38.

Eggert et al., “Person-Environment Interaction.”23. Anon (1895), “Review. The Colonization of the Insane in Connection with the Open-Door System. Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor. By Dr.

Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin. Springer, 1983),” The Journal of Mental Science 41. 697–703.24. Theodore Gray (1958), The Very Error of the Moon (Ilfracombe &. Devon.

Arthur H. Stockwell Ltd), 64.25. John Galt (1854), “The Farm of St. Anne,” American Journal of Insanity II (1854). 352.26.

Galt, “The Farm of St. Anne,” 352.27. Martin James (1948), “Diagnostic Measures,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London. Buttefwork &.

Co. Ltd), 146. World Health Organization (1953), The Community Mental Hospital. Third Report of the Expert Committee on Mental Health (Geneva. WHO).28.

Carla Yanni (2007), The Architecture of Madness. Insane Asylums in the United States. Minneapolis (London. University of Minnesota Press).29. Key British examples included the 1923 rebuild of London’s Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.30.

Taylor, Hospital and Asylum Architecture in England.31. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. O. Jenkins, S. Dye and C.

Foy (2015) (Oliver Jenkins et al., 2015), “A Study of Agitation, Conflict and Containment in Association With Change in Ward Physical Environment,” Journal of Psychiatric Intensive Care 11, no. 01. 27–35. M. Daffern, M.M.

Mayer, and T. Martin (2004), “Environmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,” International Journal of Forensic Mental Health 3 no. 1. 105–114. Kathryn L.

Brooks et al. (1994), “Patient Overcrowding in Psychiatric Hospital Units. Effects on Seclusion and Restraint,” Administration and Policy in Mental Health 22, no. 2. 133–44.

T. T Palmstierna, B Huitfeldt, and B Wistedt (1991), “The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,” Psychiatric Services 42, no. 12. 1237–40.32. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 57.

Charles Mercier (1894), Lunatic Asylums. Their Organisation and Management (London. Charles Griffin and Company), 135.33. Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38.

Joel A Dvoskin et al. (2002), “Architectural Design of a Secure Forensic State Psychiatric Hospital,” Behavioral Scients &. The Law, 20, no. 3. 481-493.

J. Enser and D. Maclnnes (1999), “The Relationship between Building Design and Escapes from Secure Units,” Journal of the Royal Society for the Promotion of Health 119, no. 3. 170–4.

Jon E. Eggert et al. (2014), “Person-Environment Interaction,” 527–38.34. Tom Brooks-Pilling cited in Mike Lear (2015), “Designer. New Fulton State Hospital Will Be Better, Safer,” Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/35.

Leslie Topp (2007), “The Modern Mental Hospital in Late Nineteenth-Century Germany and Austria. Psychiatric Space and Images of Freedom and Control,” in Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, ed. Leslie Topp, James Moran and Jonathan Andrews (London and New York. Routledge), 244.36.

McLaughlan, “One Dose of Architecture, Taken Daily,” 35. Digby, Madness, Morality and Medicine.37. Anon (1908), “Proposed New Hospital for Mental Diseases,” The Lancet 171, no. 4410. 728–9.38.

Anon, “Proposed New Hospital for Mental Diseases.”39. McLaughlan, “One Dose of Architecture, Taken Daily.”40. Samuel Tuke (1964), “Description of the Retreat (1813),” reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London. Dawsons of Paul Mall). Scull, Museums of Madness.

Digby, Madness, Morality and Medicine. Smith, Cure, Comfort and Safe Custody.41. World Health Organization (1953), The Community Mental Hospital. Also refer to T.F Main (1946), “The Hospital as a Therapeutic Institution”, Bulletin of the Menninger Clinic 10, no. 3.

66–71. David Clark (1965), “The Therapeutic Community Concept, Practice and Future,” The Journal of Mental Science 111. 947–54.42. Jolanda Maas et al. (2009), “Social Contacts as a Possible Mechanism behind the Relation between Green Space and Health,” Health &.

Place 15, no. 2. 586–95. Gayle Souter-Brown (2015), Landscape and Urban Design for Health and Well-Being. Using Healing, Sensory and Therapeutic Gardens (Oxon &.

New York. Routledge). Ulrich et al., “A Review of the Research Literature,” 61–125.43. Leon Festinger et al. (1950), Social Pressures in Informal Groups.

A Study of Human Factors in Housing, vol. 11 (New York. Harper Bros). David Halpern (1995), Mental Health and the Built Environment. More than Bricks and Mortar?.

(London. Taylor and Francis). A. Baum and G.E. Davis (1980), “Reducing the Stress of High-Density Living.

An Architectural Intervention,” Journal of Personality and Social Psychology 38, no. 3. 471–81. I. Altman and M.M.

Chemers (1984), Culture and Environment (Monterey, CA. Brooks &. Cole Publishing). Gary W Evans (2003), “The Built Environment and Mental Health,” Journal of Urban Health. Bulletin of the New York Academy of Medicine 80 no.

4. 536–55. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66.44. Stence Guldager cited in Troldtekt, “Innovative Architecture is Good for Mental Health,” https://www.troldtekt.com/News/Themes/Healing_architecture/Innovative_architecture_is_good_for_mental_health (accessed June 30, 2019). Clare Hickman and “Cheerful Prospects (2009).45.

Frank Pitts cited in Patricia Wen (2012), “For Mentally Ill, A Design Departure,” B News, August 16, https://www.boston.com/news/local-news/2012/08/16/for-mentally-ill-a-design-departure46. Ellenzweig with Architecture Plus, “Massachusetts Department of Mental Health, Worcester Recovery Center and Hospital – Worcester, MA,” Healthcare Design (2013), July 30, https://www.healthcaredesignmagazine.com/architecture/massachusetts-department-mental-health-worcester-recovery-center-and-hospital-worcester-ma/47. Sane Australia (2003), “A Life Without Stigma,” July 25, http://apo.org.au/resource/life-without-stigma. Otto F Wahl (2012), “Stigma as a Barrier to Recovery from Mental Illness,” Trends in Cognitive Sciences 16, no. 1.

9–10. New Zealand Ministry of Health and Health Promotion Agency (2014), “Like Minds, Like Mine National Plan 2014–2019. Programme to Increase Social Inclusion and Reduce Stigma and Discrimination for People with Experience of Mental Illness,” May 20, https://www.likeminds.org.nz/assets/National-Plans/like-minds-like-mine-national-plan-2014-2019-may14.pdf. G Moon (2000), “Risk and Protection. The Discourse of Confinement in Contemporary Mental Health Policy," Health &.

Nairn (1997), “Media Depictions of Mental Illness. An Analysis of the Use of Dangerousness,” Australian &. New Zealand Journal of Psychiatry 31, no. 3. 375–81.

Greg Philo et al. (1994), “The Impact of the Mass Media on Public Images of Mental Illness. Media Content and Audience Belief,” Health Education Journal 53, no. 3. 271–81.48.

G Moon (2000), “Risk and Protection,” 239–50. T.F Main (1948), “Rehabilitation and the Individual,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London. Buttefwork &. Co.

Ltd). D.A Fuller, E. Sinclair, and J. Snook (2016), “Released, Relapsed, Rehospitalized. Length of Stay and Readmission Rates in State Hospitals.

A Comparative State Survey,” 2016, https://www.treatmentadvocacycenter.org/storage/documents/released-relapsed-rehospitalized.pdf. Leila Salem et al. (2015), “Supportive Housing and Forensic Patient Outcomes,” Law and Human Behavior 39, no. 3. 311.49.

National Institute for Health and Clinical Excellence, Manchester (2016), “Transition between Inpatient Mental Health Settings and Community or Care Home Settings. Guideline,” August, https://www.nice.org.uk/guidance/ng53/evidence/full-guideline-pdf-260695191750. Catherine Clark Ahern et al. (2016), “A Recovery-Oriented Care Approach,” 47..

Notes1. R. C Keller (2006). "Geographies of power, legacies of mistrust.

Colonial medicine in the global present." Historical Geography no. 34:26-48.2. Bridget Pratt et al. (2018).

"Exploring the ethics of global health research priority-setting." BMC Medical Ethics no. 19 (94). Doi. 10.1186/s12910-018-0333-y3.

Richard Horton (2013). "Offline. Is global health neocolonialist?. " The Lancet no.

382 (9906):1690. Doi. 10.1016/S0140-6736(13)62379-X4. Anonymous (2019).

"Editorial. Break with tradition. The World Health Organization’s decision about traditional Chinese medicine could backfire." Nature no. 570:5.5.

S. S Amrith (2006). Decolonizing international health. India and Southeast Asia, 1930–65.

London. Palgrave Macmillan.6. Arturo Escobar and A Escobar (1984). "Discourse and power in development.

Michel Foucault and the relevance of his work to the third world." Alternatives no. 10 (3):377-400. Doi. 10.1177/0304375484010003047.

UNDG (2013). A million voices. The world we want. A sustainable future with dignity for all.

New York, NY. United Nations Development Group.8. WHO (2019). Speech by the Director-General.

Transforming for impact 2019 (cited 10 March 2019). Available from. Https://www.who.int/dg/speeches/detail/transforming-for-impact.9. R.

C Keller (2006). Geographies of power, legacies of mistrust. Colonial medicine in the global present.10. Mishal S Khan et al.

(2019). Durrance-Bagale, H. Legido-Quigley "‘LMICs as reservoirs of AMR’. A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan." Health Policy and Planning no.

34 (3):178–187. Doi. 10.1093/heapol/czz02211. Clare I R Chandler (2019).

"Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure." Palgrave Communications no. 5 (1):53. Doi.

10.1057/s41599-019-0263-412. In the area of antimicrobial use for human health, other problem areas include, for example, public hygiene and disease prevention, regulated access to medicines, disease diagnosis, or market conditions for the development of new antimicrobials. The Review on Antimicrobial Resistance (2016). Tackling drug-resistant s globally.

Final report and recommendations. London. The UK Prime Minister, WHO (2015b). Global action plan on antimicrobial resistance.

Geneva. World Health Organization, Conan MacDougall and Ron E Polk (2005). "Antimicrobial stewardship programs in health care systems." Clinical Microbiology Reviews no. 18 (4):638-656.

Doi. 10.1128/CMR.18.4.638-656.2005.13. The Review on Antimicrobial Resistance. Tackling drug-resistant s globally.

Final report and recommendations.14. WHO, Global action plan on antimicrobial resistance.15. Maria R Gualano et al. (2015).

"General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis." Pharmacoepidemiology and Drug Safety no. 24 (1):2-10. Doi.

10.1002/pds.371616. H Haak and A. Radyowijati (2010). "Determinants of antimicrobial use.

Poorly understood, poorly researched." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 283-300. New York, NY. Springer.17. These problems persist despite encouraging trends.

For example, the field is becoming increasingly multidisciplinary through the involvement of several United Nations agencies alongside WHO in governing AMR, and AMR policy narratives are slowly broadening the hitherto hyper-individualised and behaviour change focus of global action plans. Connor Rochford et al. (2018). "Global governance of antimicrobial resistance." The Lancet no.

391 (10134):1976-1978. Doi. 10.1016/S0140-6736(18)31117-6, WHO, FAO, and OIE (2018). Monitoring global progress on addressing antimicrobial resistance.

Analysis report of the second round of results of AMR country self-assessment survey 2018. Geneva. World Health Organization, Food and Agriculture Organization of the United Nations and World Organisation for Animal Health (OIE), WHO (2017). Antimicrobial Resistance Behaviour Change first informal technical consultation, 6-7 November, 2017 Château de Penthes, Geneva.

Meeting Report. Geneva. World Health Organization, Elise Klein and China Mills (2017). "Psy-expertise, therapeutic culture and the politics of the personal in development." Third World Quarterly no.

38 (9):1990-2008. Doi. 10.1080/01436597.2017.131927718. Emma R M Cohen et al.

(2008). "Public engagement on global health challenges." BMC Public Health no. 8 (168). Doi.

10.1186/1471-2458-8-16819. B Hamlyn et al. (2015).Factors affecting public engagement by researchers. A study on behalf of a consortium of UK public research funders.

London. TNS20. Research Councils UK (2011) Concordat for engaging the public with research. Research Councils UK.

Swindon.21. C Wilson, P. Manners, and S. Duncan (2014).

Building an engaged future for UK higher education. Full report from the Engaged Futures consultation. Bristol. National Co-ordinating Centre for Public Engagement.22.

Also referred to as ‘community engagement’, ‘patient and public involvement’ (PPI) in research, or in some instances also as participatory research. S. Staniszewska et al. (2017).

"GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research." Research Involvement and Engagement no. 3 (13). Doi.

10.1186/s40900-017-0062-2, Jo Brett et al. (2014). "Mapping the impact of patient and public involvement on health and social care research. A systematic review." Health Expectations no.

17 (5):637-650. Doi. 10.1111/j.1369-7625.2012.00795.x, Paulina O Tindana et al. (2007).

"Grand challenges in global health. Community engagement in research in developing countries." PLOS Medicine no. 4 (e273). Doi.

10.1371/journal.pmed.0040273, F Darroch and A. Giles (2014). "Decolonizing health research. Community-based participatory research and postcolonial feminist theory." Canadian Journal of Action Research no.

15 (3):22-36.23. J Redfern et al. (2018). "Spreading the message of antimicrobial resistance.

A detailed account of a successful public engagement event." FEMS Microbiology Letters no. 365 (16). Doi. 10.1093/femsle/fny17524.

Victoria Jane Hume et al. (2018). "Biomedicine and the humanities. Growing pains." Medical Humanities no.

44 (4):230-238. Doi. 10.1136/medhum-2018-01148125. Astrid Treffry-Goatley et al.

(2018). Ibid. "Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach." 239-246.

Doi. 10.1136/medhum-2018-01147426. L Jordanova (2014). "Medicine and the visual arts." In Medicine, health and the arts.

Approaches to medical humanities, edited by Bates, Bleakley and Goodman, 41-63. Abingdon. Routledge.27. Angela Ross Perfetti (2018).

"Fate and the clinic. A multidisciplinary consideration of fatalism in health behaviour." Medical Humanities no. 44 (1):59-62. Doi.

10.1136/medhum-2017-01131928. Devan Stahl et al. (2016). "Seeing illness in art and medicine.

A patient and printmaker collaboration." Ibid. No. 42 (3):155-159. Doi.

10.1136/medhum-2015-01083829. Jonatan Wistrand and J Wistrand (2017). "When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians." Ibid.

No. 43 (1):19-23. Doi. 10.1136/medhum-2016-01100230.

A. Carson (2015). Medical humanities. An introduction.

New York, NY. Cambridge University Press.31. Daniel Holman and Erica Borgstrom (2016). "Applying social theory to understand health-related behaviours." Medical Humanities no.

42 (2):143-145. Doi. 10.1136/medhum-2015-01068832. Hume, et al., Biomedicine and the humanities.

Growing pains.33. A Carusi (2016). "Modelling systems biomedicine. Intertwinement and the 'real'." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 50-65.

Edinburgh. Edinburgh University Press.34. Jordanova, Medicine and the visual arts.35. Stahl and Stahl, Seeing illness in art and medicine.

A patient and printmaker collaboration.36. William Viney et al. (2015). "Critical medical humanities.

Embracing entanglement, taking risks." Ibid. No. 41 (1):2-7. Doi.

10.1136/medhum-2015-01069237. J Cole and S. Gallagher (2016). "Narrative and clinical neuroscience.

Can phenomenologically informed approaches and empirical work cross-fertilise?. " In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 377-394. Edinburgh. Edinburgh University Press.38.

J Macnaughton and H. Carel (2016). Ibid."Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap." In, 294-309.39.

P J Pelto and G H Pelto (1997). 1997. "Studying knowledge, culture, and behavior in applied medical anthropology." Medical Anthropology Quarterly no. 11 (2):147-163.40.

Lindsay Prior (2003) "Belief, knowledge and expertise. The emergence of the lay expert in medical sociology." Sociology of Health &. Illness no. 25 (3):41-57.

Doi. 10.1111/1467-9566.0033941. E Oliveira and J. Vearey (2018).

"Making research and building knowledge with communities. Examining three participatory visual and narrative projects with migrants who sell sex in South Africa." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 265-287. Cham.

Springer.42. Komatra Chuengsatiansup and Wirun Limsawart (2019). "Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders." Palgrave Communications no.

5 (1):31. Doi. 10.1057/s41599-019-0239-443. R Garden (2014).

"Social studies. The humanities, narrative, and the social context of the patient-professional relationship." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 127-137. New Brunswick, NJ. Rutgers University Press.44.

Holman and Borgstrom, Applying social theory to understand health-related behaviours.45. Claas Kirchhelle (2018). "Pharming animals. A global history of antibiotics in food production (1935–2017)." Palgrave Communications no.

4 (96). Doi. 10.1057/s41599-018-0152-246. Hannah Landecker (2019).

"Antimicrobials before antibiotics. War, peace, and disinfectants." Ibid. No. 5 (1):45.

Doi. 10.1057/s41599-019-0251-847. Sue Walker (2019). Ibid."Effective antimicrobial resistance communication.

The role of information design." 24. Doi. 10.1057/s41599-019-0231-z48. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.49.

May Sudhinaraset et al. (2013). "What is the role of informal healthcare providers in developing countries?. A systematic review." PLoS ONE no.

8 (2):e54978. Doi. 10.1371/journal.pone.005497850. Viroj Tangcharoensathien, Sunicha Chanvatik, and Angkana Sommanustweechai (2018).

"Complex determinants of inappropriate use of antibiotics." Bulletin of the World Health Organization no. 96 (2):141-144. Doi. 10.2471/BLT.17.19968751.

WHO (2015a). Antibiotic resistance. Multi-country public awareness survey. Geneva.

World Health Organization.52. WHO, Antibiotic resistance. Multi-country public awareness survey, 42.53. Gualano, et al.

General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis.54. Edward A Belongia et al. (2002).

"Antibiotic use and upper respiratory s. A survey of knowledge, attitudes, and experience in Wisconsin and Minnesota." Preventive Medicine no. 34 (3):346-352. Doi.

10.1006/pmed.2001.099255. Miao Yu et al. (2014). "Knowledge, attitudes, and practices of parents in rural China on the use of antibiotics in children.

A cross-sectional study." BMC Infectious Diseases no. 14 (112). Doi. 10.1186/1471-2334-14-11256.

Abdelmoneim Ismail Awad and Esraa Abdulwahid Aboud (2015). "Knowledge, attitude and practice towards antibiotic use among the public in Kuwait." PLoS ONE no. 10 (2):e0117910. Doi.

10.1371/journal.pone.011791057. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.58. Jie Chang et al.

(2018). "Non-prescription use of antibiotics among children in urban China. A cross-sectional survey of knowledge, attitudes, and practices." Expert Review of Anti-infective Therapy no. 16 (2):163-172.

Doi. 10.1080/14787210.2018.142561659. Gualano, et al. General population's knowledge and attitudes about antibiotics.

A systematic review and meta-analysis.60. A R McCullough et al. (2016). "A systematic review of the public's knowledge and beliefs about antibiotic resistance." Journal of Antimicrobial Chemotherapy no.

71 (1):27-33. Doi. 10.1093/jac/dkv31061. Abel Santiago Muri-Gama, Albert Figueras, and Silvia Regina Secoli (2018).

"Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places." PLoS ONE no. 13 (e0201579). Doi.

10.1371/journal.pone.020157962. A Launiala (2009). "How much can a KAP survey tell us about people's knowledge, attitudes and practices?. Some observations from medical anthropology research on malaria in pregnancy in Malawi." Anthropology Matters no.

11 (1).63. Pamela Das et al. (2016). "Antibiotics.

Achieving the balance between access and excess." The Lancet no. 387 (10014):102-104. Doi. 10.1016/S0140-6736(15)00729-164.

C Olivier et al. (2010). "Containing global antibiotic resistance. Ethical drug promotion in the developing world." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 505-524.

New York, NY. Springer.65. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.66.

Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.67. Steve Hinchliffe, Andrea Butcher, and Muhammad Meezanur Rahman (2018). "The AMR problem.

Demanding economies, biological margins, and co-producing alternative strategies." Ibid. No. 4 (142). Doi.

10.1057/s41599-018-0195-468. Chuengsatiansup and Limsawart, Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders.69. Khan, et al, ‘LMICs as reservoirs of AMR’.

A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan.70. Didier Wernli et al. (2017). "Mapping global policy discourse on antimicrobial resistance." BMJ Global Health no.

2 (e000378). Doi. 10.1136/bmjgh-2017-00037871. Nancy J Hawkings, Fiona Wood, and Christopher C Butler (2007).

"Public attitudes towards bacterial resistance. A qualitative study." Journal of Antimicrobial Chemotherapy no. 59 (6):1155-1160. Doi.

10.1093/jac/dkm10372. McCullough, et al. A systematic review of the public's knowledge and beliefs about antibiotic resistance.73. Muri-Gama, et al.

Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places.74. David G Allison et al. (2017).

"Antibiotic resistance awareness. A public engagement approach for all pharmacists." International Journal of Pharmacy Practice no. 25 (1):93-96. Doi.

10.1111/ijpp.1228775. Mark Davis et al. (2018). "Understanding media publics and the antimicrobial resistance crisis." Global Public Health no.

13 (9):1158-1168. Doi. 10.1080/17441692.2017.133624876. Simon J Howard et al.

(2013). "Antibiotic resistance. Global response needed." The Lancet Infectious Diseases no. 13 (12):1001-1003.

Doi. 10.1016/S1473-3099(13)70195-677. Renly Lim et al. (2016).

"Village drama against malaria." The Lancet no. 388 (10063):2990. Doi. 10.1016/S0140-6736(16)32519-378.

Deborah Nyirenda et al. (2018). "Public engagement in Malawi through a health-talk radio programme ‘Umoyo nkukambirana’. A mixed-methods evaluation." Public Understanding of Science no.

27 (2):229-242. Doi. 10.1177/096366251665611079. Redfern, et al.

Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.80. Sungjong Roh et al. (2018).

"Public understanding of One Health messages. The role of temporal framing." Public Understanding of Science no. 27 (2):185-196. Doi.

10.1177/096366251667080581. Tindana, et al., Grand challenges in global health. Community engagement in research in developing countries.82. Mpoe Johannah Keikelame and Leslie Swartz (2019).

"Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa." Global Health Action no. 12 (1):1561175. Doi.

10.1080/16549716.2018.156117583. Keymanthri Moodley and Shenuka Singh (2016). "“It’s all about trust”. Reflections of researchers on the complexity and controversy surrounding biobanking in South Africa." BMC Medical Ethics no.

17 (57). Doi. 10.1186/s12910-016-0140-284. Seye Abimbola (2020).

"Beyond positive a priori bias. Reframing community engagement in LMICs (epub ahead of print)." Health Promotion International. Doi. 10.1093/heapro/daz02385.

Keikelame and Swartz, Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa.86. Kenneth M Boyd (2000). "Disease, illness, sickness, health, healing and wholeness.

Exploring some elusive concepts." Medical Humanities no. 26 (1):9-17. Doi. 10.1136/mh.26.1.987.

Hume, et al., Biomedicine and the humanities. Growing pains.88. I Bamforth (2000). "Kafka's uncle.

Scenes from a world of trust infected by suspicion." Ibid. No. 26 (2):85-91. Doi.

10.1136/mh.26.2.8589. Wistrand, When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians.90. Garden, Social studies.

The humanities, narrative, and the social context of the patient-professional relationship.91. A Harpin (2016). "Broadmoor performed. A theatrical hospital." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 577-595.

Edinburgh. Edinburgh University Press.92. Jordanova, Medicine and the visual arts.93. Stahl and Stahl, Seeing illness in art and medicine.

A patient and printmaker collaboration.94. K G Sweeney et al. (2001). "A comparison of professionals' and patients' understanding of asthma.

Evidence of emerging dualities?. " Ibid. No. 27 (1):20-25.

Doi. 10.1136/mh.27.1.2095. Treffry-Goatley, et al., Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.96.

R. J Hester (2016). "Culture in medicine. An argument against competence." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 541-558.

Edinburgh. Edinburgh University Press.97. L Jerke, M. Prendergast, and W.

Dobson (2018). "Smoking cessation in mental health communities. A living newspaper applied theatre project." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 171-186.

Cham. Springer.98. Sweeney, et al. A comparison of professionals' and patients' understanding of asthma.

Evidence of emerging dualities?. 99. S Switzer (2018). "What’s in an image?.

Towards a critical and interdisciplinary reading of participatory visual methods." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 189-207. Cham. Springer.100.

Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. , 378.101. Cole, et al.

Medical humanities. An introduction.102. J Herman (2001). "Medicine.

The science and the art." Medical Humanities no. 27 (1):42-46. Doi. 10.1136/mh.27.1.42103.

[Viney, et al. Critical medical humanities. Embracing entanglement, taking risks.104. R.

K Yin (2003). Case study research. Design and methods. Thousand Oaks, CA.

Sage.105. Marco J Haenssgen et al. (2018)106. S.

L Gilman (2015). Illness and image. Case studies in the medical humanities. New York, NY.

Taylor &. Francis.107. HarbarthM Haughton (2018). Staging trauma.

Bodies in shadow. London. Palgrave Macmillan.108. S Hodge, J Robinson, and P Davis (2007).

"Reading between the lines. The experiences of taking part in a community reading project." Medical Humanities no. 33 (2):100-104. Doi.

10.1136/jmh.2006.000256109. Hume, et al. Biomedicine and the humanities. Growing pains.110.

Saam Idelji-Tehrani and Muna Al-Jawad (2019). "Exploring gendered leadership stereotypes in a shared leadership model in healthcare. A case study." Ibid. No.

45:388-398. Doi. 10.1136/medhum-2018-011517111. Suze M P J Jans et al.

(2012). "A case study of haemoglobinopathy screening in the Netherlands. Witnessing the past, lessons for the future." Ethnicity &. Health no.

17 (3):217-239. Doi. 10.1080/13557858.2011.604126112. Hume, et al., Biomedicine and the humanities.

Growing pains.113. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 114.

Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.115. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.116. Prior, Belief, knowledge and expertise.

The emergence of the lay expert in medical sociology.117. Gilman, Illness and image. Case studies in the medical humanities.118. Cole and Gallagher, Narrative and clinical neuroscience.

Can phenomenologically informed approaches and empirical work cross-fertilise?. 119. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.120.

C Teddlie and A. Tashakkori (2009). Foundations of mixed methods research. Integrating quantitative and qualitative approaches in the social and behavioral sciences.

Thousand Oaks, CA. Sage.121. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.122.

Gian Luca Barbieri et al. (2016). "Imagination in narrative medicine." Journal of Child Health Care no. 20 (4):419-427.

Doi. 10.1177/1367493515625134123. Treffry-Goatley, et al. Community engagement with HIV drug adherence in rural South Africa.

A transdisciplinary approach.124. WHO (2016). World Antibiotic Awareness Week. 2016 campaign toolkit.

Geneva. World Health Organization.125. Across the three villages, 67% of the workshop attendees were female and the average age of the attendees was 44 years (range. 18 to 81 years.

Based on subsequently collected survey data).126. Nutcha Charoenboon et al. (2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128.

The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref. OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &.

Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129. Marco J Haenssgen et al. (2018)130.

National Statistical Office (2012). The 2010 population and housing census. Changwat Chiang Rai. Bangkok.

National Statistical Office.131. Data on the individual level would entail duplication of observations should both census survey rounds be included. Step-level data were aggregated on the illness level for analysis.132. Claire Charlotte McKechnie (2014).

"Anxieties of communication. The limits of narrative in the medical humanities." Medical Humanities no. 40 (2):119-124. Doi.

10.1136/medhum-2013-010466133. Carusi, Modelling systems biomedicine. Intertwinement and the 'real'.134. Garden, Social studies.

The humanities, narrative, and the social context of the patient-professional relationship.135. Emma Sacks et al. (2018). "Beyond the building blocks.

Integrating community roles into health systems frameworks to achieve health for all." BMJ Global Health no. 3 (Suppl. 3):e001384. Doi.

10.1136/bmjgh-2018-001384136. Sudhinaraset, et al. What is the role of informal healthcare providers in developing countries?. A systematic review.137.

G Bloom et al. (2015). Addressing resistance to antibiotics in pluralistic health systems. Brighton.

University of Sussex138. WHO (2007). Strengthening health systems to improve health outcomes. WHO’s framework for action.

Geneva. World Health Organization.139. Jordanova, Medicine and the visual arts.140. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.141. A Bleakley (2014). Ibid. "Towards a 'critical medical humanities'." In, 17-26.142.

Hume, et al., Biomedicine and the humanities. Growing pains.143. Nutcha Charoenboon et al. (2019)144.

Marco Haenssgen et al. (2018)145. WHO, World Antibiotic Awareness Week. 2016 campaign toolkit.146.

The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue. Amoxicillin. Red-black. Cloxacillin.

White-blue. Azithromycin—see questionnaire page 10 in the online supplementary material). Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147. The ‘desirability’ of the responses was field coded by the survey team.

Sample responses (as instructed through the survey manual) for ‘desirable’ answers included, for example, “Only if the doctor says that I should”. Sample responses for ‘undesirable’ answers included “Yes, you can buy it in the shop over there!. € The variable should be interpreted as ‘the fraction of respondents who uttered a ‘desirable’ response’—the inverse is the fraction of responses that could not be deemed ‘desirable’ (eg, ‘do not know’ or ‘no opinion’).148. Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic.

This was specifically the case if survey respondents mentioned common antibiotic descriptions such as ‘anti-inflammatory’, ‘amoxi’ or ‘colem’, if they indicated explicitly that they know what ‘anti-inflammatory medicine’ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like ‘white powder’ or ‘green capsule’).149. Aristotle (1954). Rhetoric. Translated by Roberts.

New York, NY. Modern Library. Original edition, 350 BC.150. Arya Nielsen et al.

(2007). "The effect of gua sha treatment on the microcirculation of surface tissue. A pilot study in healthy subjects." EXPLORE no. 3 (5):456-466.

Doi. 10.1016/j.explore.2007.06.001151. Nithima Sumpradit et al. (2012).

"Antibiotics Smart Use. A workable model for promoting the rational use of medicines in Thailand." Bulletin of the World Health Organization no. 90 (12):905-913. Doi.

10.2471/BLT.12.105445152. C Muksong and K. Chuengsatiansup (2020). Forthcoming.

"Medicine and public health in Thai historiography. From an elitist view to counter-hegemonic discourse." In Health, pluralism and globalisation. A modern history of medicine in South-East Asia, edited by Monnais and Cook. London.

The Wellcome Trust Centre for the History.153. L Sringernyuang (2000). Availability and use of medicines in rural Thailand. Amsterdam.

Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts. The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, “You shouldn’t take medicines that you have never seen before”—the research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop.

For more details on the behavioural analysis, see Nutcha Charoenboon et al. (2019) and Marco Haenssgen et al. (2018).155. For example, Redfern, et al., Spreading the message of antimicrobial resistance.

A detailed account of a successful public engagement event.156. Antoine Boivin et al. (2018). 2018.

"Patient and public engagement in research and health system decision making. A systematic review of evaluation tools (epub ahead of print)." Health Expectations. Doi. 10.1111/hex.12804157.

Staniszewska, et al. GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research.158. Jerke, et al.

Smoking cessation in mental health communities. A living newspaper applied theatre project.159. Switzer, What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods.160.

R. C Barfield and L. Selman (2014). "Health and humanities.

Spirituality and religion." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 376-386. New Brunswick, NJ. Rutgers University Press.161. Abimbola, Beyond positive a priori bias.

Reframing community engagement in LMICs (epub ahead of print), 1.162. Marco J Haenssgen et al. (2019)163. Marc Mendelson et al.

(2017). "Antibiotic resistance has a language problem." Nature no. 545 (7652):23-25. Doi.

10.1038/545023a164. Haak and Radyowijati, Determinants of antimicrobial use. Poorly understood, poorly researched.165. S Harbarth and D.

L. Monnet (2008). "Cultural and socioeconomic determinants of antibiotic use." In Antibiotic Policies. Fighting Resistance, edited by Gould and van der Meer, 29-40.

Boston, MA. Springer.166. K Sirijoti, P. Havanond Hongsranagon, and W.

Pannoi (2014). "Assessment of knowledge attitudes and practices regarding antibiotic use in Trang province, Thailand." Journal of Health Research no. 28 (5):299-307.167. Ramona K C Finnie et al.

(2011). "Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV." Tropical Medicine &. International Health no. 16 (4):394-411.

Doi. 10.1111/j.1365-3156.2010.02718.x168. Haak and Radyowijati, Determinants of antimicrobial use. Poorly understood, poorly researched.169.

Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure, 5.170. S Willson and K. Miller (2014).

"Data collection." In Cognitive interviewing methodology. A sociological approach for survey question evaluation, edited by Miller, Willson, Chepp and Padilla, 15-34. Hoboken, NJ. Wiley.171.

See Linda Mayoux and Robert Chambers (2005). "Reversing the paradigm. Quantification, participatory methods and pro-poor impact assessment." Journal of International Development no. 17 (2):271-298.

Doi. 10.1002/jid.1214172. Howard S. Becker (1995).

"Visual sociology, documentary photography, and photojournalism. It's (almost) all a matter of context." Visual Sociology no. 10 (1-2):5-14. Doi.

10.1080/14725869508583745173. J Prosser and D. Schwartz (2005). "Photographs and the sociological research process." In Image-based research.

A sourcebook for qualitative researchers, edited by Prosser, 101-115. London. Falmer.174. Treffry-Goatley, et al.

Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.175. Switzer, What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods.176.

Hume, et al. Biomedicine and the humanities. Growing pains.177. Jordanova, Medicine and the visual arts, 60.178.

Bleakley, Towards a 'critical medical humanities'.179. Nutcha Charoenboon et al. (2019)180. Hume, et al.

Biomedicine and the humanities. Growing pains.181. J. P Ansloos (2018).

€œTo speak in our own ways about the world, without shame”. Reflections on indigenous resurgence in anti-oppressive research.” In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 3-18. Cham.

Springer.182. Marco J Haenssgen (2019)183. Michael Etherton and Tim Prentki (2006). "Drama for change?.

Prove it!. Impact assessment in applied theatre." Research in Drama Education. The Journal of Applied Theatre and Performance no. 11 (2):139-155.

Doi. 10.1080/13569780600670718184. Susan Galloway (2009). "Theory-based evaluation and the social impact of the arts." Cultural Trends no.

18 (2):125-148. Doi. 10.1080/09548960902826143185. Darquise Lafrenière and Susan M Cox (2013).

"‘If you can call it a poem’. Toward a framework for the assessment of arts-based works." Qualitative Research no. 13 (3):318-336. Doi.

10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers. This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice.

Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type. While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete.

Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice. With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities. This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare.

We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited. An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms. Communal areas should have movable furniture.

Wards should be designed for low social densities. And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.

For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?. The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design.

This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?. In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?. While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796.

With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into. It is the knowledge produced by practitioners themselves. Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care.

There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing ‘mode two’ researchThis research was conducted within the context of a master­-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia. The industry-led nature of this project demanded a less conventional and more inclusive methodological approach.

Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type. Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals).

These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1). Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients.

Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice. Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals. Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations.

It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered. This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA.

Both practices had recently completed a significant forensic psychiatric hospital project. While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff. Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts.

Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?. We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare.

The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value. Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients.

While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1). It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospital’s physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed.

Architectural decisions related to these values operate across three scales. Context, hospital and individual. Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs. Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts.

Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site. And how spatial and functional links are set up between those buildings. This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs.

But it can also impact patient and community psychology. The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.

Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views. And the question of staff spaces relative to safety, ease of communication and collaboration.

Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings. What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence. Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility.

The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards. Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) (figure 1). Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside.

Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’.25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub.

The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views. Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site.

Two different treatment hub arrangements are in use. €˜internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1).

Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’. A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges. Why then do we see such a strong persistence of the campus hospital?.

This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model. Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1.

Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions. The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. €˜peninsula’, ‘race-track’ and ‘courtyard’ (Figure 2). The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape.

This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations.

(1) Peninsula. Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped).

Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan. While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort. However, cultural trends again emerge.

Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden. However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2). Courtyard accommodation provides the following benefits.

Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over. Additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.

And ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’). Blind corners can be avoided to assist safety and surveillance.

Travel distances can be minimised. Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size. The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds.

Typically, each ward was provided with one large living space that all 24 or 32 patients used together. More advanced approaches gave patients a choice of living spaces. For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience.

To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare. But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge.

Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’. This documents the specific performance requirements of the hospital in question. Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff.

Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others. A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment.

In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients. They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process. Or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially.

There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design. Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’.35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible.

The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity. Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients. History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction.

For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’.38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses. The aspirations were threefold.

To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes. And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated.

The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting. That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients.

The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment. Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated. The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients.

Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital. Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice. The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence.

At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis. By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.

Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace. Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3).

This approach provides patients with a diversity of landscape experiences. This is important given the patterns of landscape use between forensic and non-forensic hospitals. In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients.

Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security. Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband. At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site.

Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access. Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital.

Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma. Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement.

This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital. The ‘house’, ‘neighbourhood’ and ‘downtown’ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces.

A shared kitchen and dining room is provided for each house. Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces. This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub).

The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience. According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey. Spaces become larger as they move further from the ward.

This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom. Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness. These are arranged in a semicircle, opening onto a large veranda and greenspace.

The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness. The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital.

Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls. At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training.

More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare. The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care.

The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction. This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement. While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary.

At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones. The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5). The galleria functions similarly to the downtown at the Worcester Recovery Center.

Patients are given graduated access to a series of spaces that support their recovery journey. These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare. The galleria zone is on the second floor (shown in black).

The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one. Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology.

In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines. Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value. Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects.

History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making. A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field.

There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches. The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace.

MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat. In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision.

The following people contributed their time and expertise in shaping the research process that enabled this article. Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), “Forensic Patients and Forensic Mental Health in Victoria. Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no.

2. 169–80.2. The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments.

In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3. B Edginton (1994), “The Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,” Canadian Bulletin of Medical History 11, no. 2.

375–86. Clare Hickman (2009), “Cheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no. 4 Pt 4.

425–41. Rebecca McLaughlan, 2012), “Post-Rationalisation and Misunderstanding. Mental Hospital Architecture in the New Zealand Media,” Fabrications 22, no. 2.

232–56.4. Roger S Ulrich et al. (2008), “A Review of the Research Literature on Evidence-Based Healthcare Design,” HERD 1, no. 3.

61–125. Jill Maben et al. (2015), “Evaluating a Major Innovation in Hospital Design. Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,” Health Services and Delivery Research 3.

1–304. Penny Curtis and Andy Northcott (2017), “The Impact of Single and Shared Rooms on Family-Centred Care in Children’s Hospitals,” Journal of Clinical Nursing 26, no. 11–12. 1584–96.5.

Roger S. Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology 57. 53–66.6.

Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2. 94–102.7. For further examples of this see Jon E.

Eggert et al. (2014), “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences &. The Law 32, no. 4.

527–38. C.C. Whitehead et al. (1984), “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no.

5. 639–44. Gabriela Novotná et al. (2011), “Client-Centered Design of Residential Addiction and Mental Health Care Facilities.

Staff Perceptions of Their Work Environment,” Qualitative Health Research 21, no. 11. 1527–38.8. Morgan Andersson et al.

(2013), “New Swedish Forensic Psychiatric Facilities. Visions and Outcomes,” Facilities 31, no 1/2. 24–88.9. For examples see Kathleen Connellan et al.

(2013), “Stressed Spaces. Mental Health and Architecture,” HERD. Health Environments Research &. Design Journal 6, no.

4. 127–168. Constantina Papoulias et al. (2014), “The Psychiatric Ward as a Therapeutic Space.

Systematic Review,” British Journal of Psychiatry 205, no. 3. 171–6.10. R.

Allen and R.G. Nairn, 1997. Alan Dilani, 2000, “Psychosocially Supportive Design - Scandinavian Health Care Design,” World Hospitals and Health Services 37. 20–4.

Rebecca McLaughlan (2018), “Psychosocially Supportive Design. The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no. 2. 151–62.11.

Rebecca McLaughlan (2017), “Learning From Evidence-Based Medicine. Exclusions and Opportunities within Health Care Environments Research,” Design for Health 1. 210–28.12. B Edginton (1997), “Moral Architecture.

The Influence of the York Retreat on Asylum Design,” Health &. Place 3, no. 2. 91–9.

Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849–1914. Building for Health Care (London. Mansell Publishing Limited). Anne Digby (1985), Madness, Morality and Medicine.

A Study of the York Retreat 1796–1914 (New York. Cambridge University Press).13. Digby, Madness, Morality and Medicine. Erving Goffman (1961), Asylums.

Essays on the Social Situation of Mental Patients and Other Inmates (New York. Doubleday). Ivan Belknap (1956), Human Problems of a State Mental Hospital (New York. Blakiston Division, McGraw-Hill).

Andrew Scull (1979), Museums of Madness. The Social Organization of Insanity in 19th Century England (London. Allen Lane). Leonard Smith (1999), Cure, Comfort and Safe Custody.

Public Lunatic Asylums in Early Nineteenth-Century England (London. Leicester University Press). Rebecca McLaughlan (2014), “One Dose of Architecture, Taken Daily. Building for Mental Health in New Zealand” (PhD diss., Victoria University of Wellington, New Zealand).14.

Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., “Person-Environment Interaction,” 527–38. Roger S. Ulrich et al.

(2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. Catherine Clark Ahern et al. (2016), “A Recovery-Oriented Care Approach. Weighing the Pros and Cons of a Newly Built Mental Health Facility,” Journal of Psychosocial Nursing and Mental Health Services 54, no.

2. 39–48.15. M Gibbons (2000), “Mode 2 Society and the Emergence of Context-Sensitive Science,” Science and Public Policy 27. 161.16.

D Seamon, 2000, “A Way of Seeing People and Place,” in Theoretical Perspectives in Environment-Behavior Research, ed. S. Wapner, J. Demick, T.

Yamamoto and H. Minami (New York. Plenum), 157–78.17. Thomas A Markus (1982), Order in Space and Society.

Architectural Form and Its Context in the Scottish Enlightenment (Edinburgh. Mainstream Publishing Company).18. Ulrich et al., “A Review of the Research Literature,” 61–125.19. This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting.

Refer to McLaughlan, “One Dose of Architecture, Taken Daily.”20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), “Guidance for Commissioners of Forensic Mental Health Services,” May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/. Cannon Design (2014), “St Joseph’s Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,” Healthcare Design Showcase, September.

Health Nexus Group, 2017, “Forensicare Model of Care Report,” April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), “Service Plan for Forensic Mental Health Services,” July, Australia (access provided by the Victorian Health and Human Services Building Authority).21. Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.22. W.A.F Browne (1991), "What Asylums Were, Are and Ought to Be (1837),” reprinted in The Asylum as Utopia.

W.A.F. Browne and the Mid-Nineteenth Century Consolidation of Psychiatry, ed. Andrew Scull (London. Tavistock).

Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38. Eggert et al., “Person-Environment Interaction.”23. Anon (1895), “Review.

The Colonization of the Insane in Connection with the Open-Door System. Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor. By Dr. Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin.

Springer, 1983),” The Journal of Mental Science 41. 697–703.24. Theodore Gray (1958), The Very Error of the Moon (Ilfracombe &. Devon.

Arthur H. Stockwell Ltd), 64.25. John Galt (1854), “The Farm of St. Anne,” American Journal of Insanity II (1854).

352.26. Galt, “The Farm of St. Anne,” 352.27. Martin James (1948), “Diagnostic Measures,” in Modern Trends in Psychological Medicine, ed.

Noel Haris (London. Buttefwork &. Co. Ltd), 146.

World Health Organization (1953), The Community Mental Hospital. Third Report of the Expert Committee on Mental Health (Geneva. WHO).28. Carla Yanni (2007), The Architecture of Madness.

Insane Asylums in the United States. Minneapolis (London. University of Minnesota Press).29. Key British examples included the 1923 rebuild of London’s Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.30.

Taylor, Hospital and Asylum Architecture in England.31. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. O. Jenkins, S.

Dye and C. Foy (2015) (Oliver Jenkins et al., 2015), “A Study of Agitation, Conflict and Containment in Association With Change in Ward Physical Environment,” Journal of Psychiatric Intensive Care 11, no. 01. 27–35.

M. Daffern, M.M. Mayer, and T. Martin (2004), “Environmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,” International Journal of Forensic Mental Health 3 no.

(1994), “Patient Overcrowding in Psychiatric Hospital Units. Effects on Seclusion and Restraint,” Administration and Policy in Mental Health 22, no. 2. 133–44.

T. T Palmstierna, B Huitfeldt, and B Wistedt (1991), “The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,” Psychiatric Services 42, no. 12. 1237–40.32.

Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 57. Charles Mercier (1894), Lunatic Asylums. Their Organisation and Management (London. Charles Griffin and Company), 135.33.

Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38. Joel A Dvoskin et al. (2002), “Architectural Design of a Secure Forensic State Psychiatric Hospital,” Behavioral Scients &.

Enser and D. Maclnnes (1999), “The Relationship between Building Design and Escapes from Secure Units,” Journal of the Royal Society for the Promotion of Health 119, no. 3. 170–4.

Jon E. Eggert et al. (2014), “Person-Environment Interaction,” 527–38.34. Tom Brooks-Pilling cited in Mike Lear (2015), “Designer.

New Fulton State Hospital Will Be Better, Safer,” Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/35. Leslie Topp (2007), “The Modern Mental Hospital in Late Nineteenth-Century Germany and Austria. Psychiatric Space and Images of Freedom and Control,” in Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, ed.

Leslie Topp, James Moran and Jonathan Andrews (London and New York. Routledge), 244.36. McLaughlan, “One Dose of Architecture, Taken Daily,” 35. Digby, Madness, Morality and Medicine.37.

Anon (1908), “Proposed New Hospital for Mental Diseases,” The Lancet 171, no. 4410. 728–9.38. Anon, “Proposed New Hospital for Mental Diseases.”39.

McLaughlan, “One Dose of Architecture, Taken Daily.”40. Samuel Tuke (1964), “Description of the Retreat (1813),” reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London. Dawsons of Paul Mall). Scull, Museums of Madness.

Digby, Madness, Morality and Medicine. Smith, Cure, Comfort and Safe Custody.41. World Health Organization (1953), The Community Mental Hospital. Also refer to T.F Main (1946), “The Hospital as a Therapeutic Institution”, Bulletin of the Menninger Clinic 10, no.

3. 66–71. David Clark (1965), “The Therapeutic Community Concept, Practice and Future,” The Journal of Mental Science 111. 947–54.42.

Jolanda Maas et al. (2009), “Social Contacts as a Possible Mechanism behind the Relation between Green Space and Health,” Health &. Place 15, no. 2.

586–95. Gayle Souter-Brown (2015), Landscape and Urban Design for Health and Well-Being. Using Healing, Sensory and Therapeutic Gardens (Oxon &. New York.

Routledge). Ulrich et al., “A Review of the Research Literature,” 61–125.43. Leon Festinger et al. (1950), Social Pressures in Informal Groups.

A Study of Human Factors in Housing, vol. 11 (New York. Harper Bros). David Halpern (1995), Mental Health and the Built Environment.

More than Bricks and Mortar?. (London. Taylor and Francis). A.

Baum and G.E. Davis (1980), “Reducing the Stress of High-Density Living. An Architectural Intervention,” Journal of Personality and Social Psychology 38, no. 3.

471–81. I. Altman and M.M. Chemers (1984), Culture and Environment (Monterey, CA.

Brooks &. Cole Publishing). Gary W Evans (2003), “The Built Environment and Mental Health,” Journal of Urban Health. Bulletin of the New York Academy of Medicine 80 no.

4. 536–55. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66.44. Stence Guldager cited in Troldtekt, “Innovative Architecture is Good for Mental Health,” https://www.troldtekt.com/News/Themes/Healing_architecture/Innovative_architecture_is_good_for_mental_health (accessed June 30, 2019).

Clare Hickman and “Cheerful Prospects (2009).45. Frank Pitts cited in Patricia Wen (2012), “For Mentally Ill, A Design Departure,” B News, August 16, https://www.boston.com/news/local-news/2012/08/16/for-mentally-ill-a-design-departure46. Ellenzweig with Architecture Plus, “Massachusetts Department of Mental Health, Worcester Recovery Center and Hospital – Worcester, MA,” Healthcare Design (2013), July 30, https://www.healthcaredesignmagazine.com/architecture/massachusetts-department-mental-health-worcester-recovery-center-and-hospital-worcester-ma/47. Sane Australia (2003), “A Life Without Stigma,” July 25, http://apo.org.au/resource/life-without-stigma.

Otto F Wahl (2012), “Stigma as a Barrier to Recovery from Mental Illness,” Trends in Cognitive Sciences 16, no. 1. 9–10. New Zealand Ministry of Health and Health Promotion Agency (2014), “Like Minds, Like Mine National Plan 2014–2019.

Programme to Increase Social Inclusion and Reduce Stigma and Discrimination for People with Experience of Mental Illness,” May 20, https://www.likeminds.org.nz/assets/National-Plans/like-minds-like-mine-national-plan-2014-2019-may14.pdf. G Moon (2000), “Risk and Protection. The Discourse of Confinement in Contemporary Mental Health Policy," Health &. Place 6, no.

Nairn (1997), “Media Depictions of Mental Illness. An Analysis of the Use of Dangerousness,” Australian &. New Zealand Journal of Psychiatry 31, no. 3.

375–81. Greg Philo et al. (1994), “The Impact of the Mass Media on Public Images of Mental Illness. Media Content and Audience Belief,” Health Education Journal 53, no.

3. 271–81.48. G Moon (2000), “Risk and Protection,” 239–50. T.F Main (1948), “Rehabilitation and the Individual,” in Modern Trends in Psychological Medicine, ed.

Noel Haris (London. Buttefwork &. Co. Ltd).

D.A Fuller, E. Sinclair, and J. Snook (2016), “Released, Relapsed, Rehospitalized. Length of Stay and Readmission Rates in State Hospitals.

A Comparative State Survey,” 2016, https://www.treatmentadvocacycenter.org/storage/documents/released-relapsed-rehospitalized.pdf. Leila Salem et al. (2015), “Supportive Housing and Forensic Patient Outcomes,” Law and Human Behavior 39, no. 3.

311.49. National Institute for Health and Clinical Excellence, Manchester (2016), “Transition between Inpatient Mental Health Settings and Community or Care Home Settings. Guideline,” August, https://www.nice.org.uk/guidance/ng53/evidence/full-guideline-pdf-260695191750. Catherine Clark Ahern et al.

(2016), “A Recovery-Oriented Care Approach,” 47..

Symbicort fda label

There are not enough health symbicort fda label workers in California to meet the needs of the state’s increasingly diverse, growing, and aging population, and the situation is getting worse. In 2019, 39 percent of Californians identified as Latinx, but only 14 percent of medical school students and 6 percent of active patient care physicians in California were Latinx.Researchers from Mathematica, with support from the California Health Care Foundation, recently reviewed evidence from key health workforce policy interventions to determine their impact on access to health care, the diversity of the health workforce, and providers’ ability to deliver services in a language other than English (“language concordance”). The evidence review symbicort fda label included academic literature and interviews of key experts in the field. It focused on health professions that require an advanced degree, because it has been particularly challenging to improve access, diversity, and language concordance through these jobs.“There have been many public and private efforts in California to increase the number and diversity of health professionals, but they have not been sufficient to alleviate the crisis,” said Diane Rittenhouse, a senior fellow at Mathematica.

€œIn a year with a state budget surplus, this report reviews evidence and presents options for public investment to improve health care access and health workforce diversity.” Mathematica’s researchers concluded that a blended approach is necessary to achieve better health care access and improve the diversity of the symbicort fda label health workforce. For example, loan repayment in exchange for a commitment to serve in a medically underserved area of California is a quick way to improve access to primary care, behavioral health, and dentistry in those areas. Improving the diversity of the workforce, however, requires support for a diverse array of college students to succeed in California’s health professional symbicort fda label training programs. Ultimately, underserved rural and urban areas are more likely to retain health professionals who are from those areas, and interventions that seek to engage those professionals will likely have the greatest impact.

Read the symbicort fda label report here. For more information on the report or on health workforce challenges in California, please contact Todd Kohlhepp.Despite the important mission of adult education to provide adults with the competencies they need to succeed in the workforce and achieve economic self-sufficiency, policymakers and practitioners have limited evidence on effective strategies for improving adult learners’ outcomes. The Workforce Innovation and symbicort fda label Opportunity Act (WIOA) Title II, the key federal investment helping adults acquire important skills and credentials to succeed in the workplace, encourages adult education programs to use evidence-based strategies to improve services and participant success. A new review of existing research, authored by staff at Mathematica for the Institute of Education Sciences at the U.S.

Department of symbicort fda label Education, identifies some promising strategies and a need for more rigorous studies to guide decision making around successful strategies for adult learners. The available evidence provides limited support for the use of particular adult education strategies over others, although bridge classes and integrated education and training programs offer some promise. The authors also note opportunities for the field symbicort fda label to prioritize research investments to increase the evidence base. Namely, under WIOA, Title II requires adult education programs to collect data on skill gains, educational progress, employment, and earnings for program participants.

These data offer opportunities to symbicort fda label examine adult education strategies that might improve these learner outcomes. The emphasis in WIOA on longer term educational attainment and labor market outcomes also provides opportunities for research on strategies with an increased focus on improving adult learner transitions to postsecondary education or to better jobs and higher earnings, outcomes for which reliable data sources exist.“This systematic review provides some guidance for the field to make progress on its goals of helping adult learners obtain the competencies they need to be productive workers, family members, and citizens,” noted project director Alina Martinez. This research can help policymakers and local providers target their resources to help adult learners achieve higher earnings and career success.“Read the IES snapshot..

There are not enough health workers in symbicort online usa California to meet the needs of the state’s increasingly diverse, growing, and aging population, and the situation is getting worse. In 2019, 39 percent of Californians identified as Latinx, but only 14 percent of medical school students and 6 percent of active patient care physicians in California were Latinx.Researchers from Mathematica, with support from the California Health Care Foundation, recently reviewed evidence from key health workforce policy interventions to determine their impact on access to health care, the diversity of the health workforce, and providers’ ability to deliver services in a language other than English (“language concordance”). The evidence review included academic literature and interviews symbicort online usa of key experts in the field. It focused on health professions that require an advanced degree, because it has been particularly challenging to improve access, diversity, and language concordance through these jobs.“There have been many public and private efforts in California to increase the number and diversity of health professionals, but they have not been sufficient to alleviate the crisis,” said Diane Rittenhouse, a senior fellow at Mathematica. €œIn a year with a symbicort online usa state budget surplus, this report reviews evidence and presents options for public investment to improve health care access and health workforce diversity.” Mathematica’s researchers concluded that a blended approach is necessary to achieve better health care access and improve the diversity of the health workforce.

For example, loan repayment in exchange for a commitment to serve in a medically underserved area of California is a quick way to improve access to primary care, behavioral health, and dentistry in those areas. Improving the diversity of the workforce, however, requires support for a diverse array of college students to succeed in symbicort online usa California’s health professional training programs. Ultimately, underserved rural and urban areas are more likely to retain health professionals who are from those areas, and interventions that seek to engage those professionals will likely have the greatest impact. Read the report symbicort online usa here. For more information on the report or on health workforce challenges in California, please contact Todd Kohlhepp.Despite the important mission of adult education to provide adults with the competencies they need to succeed in the workforce and achieve economic self-sufficiency, policymakers and practitioners have limited evidence on effective strategies for improving adult learners’ outcomes.

The Workforce Innovation and Opportunity Act (WIOA) Title II, the key federal investment helping adults acquire important skills and credentials to succeed in the workplace, encourages adult education programs to use evidence-based strategies to improve services symbicort online usa and participant success. A new review of existing research, authored by staff at Mathematica for the Institute of Education Sciences at the U.S. Department of Education, identifies some promising strategies and a need for more rigorous studies to guide decision making around successful strategies for adult symbicort online usa learners. The available evidence provides limited support for the use of particular adult education strategies over others, although bridge classes and integrated education and training programs offer some promise. The authors also note opportunities for the field to prioritize research investments to symbicort online usa increase the evidence base.

Namely, under WIOA, Title II requires adult education programs to collect data on skill gains, educational progress, employment, and earnings for program participants. These data offer opportunities to examine adult education strategies that might improve symbicort online usa these learner outcomes. The emphasis in WIOA on longer term educational attainment and labor market outcomes also provides opportunities for research on strategies with an increased focus on improving adult learner transitions to postsecondary education or to better jobs and higher earnings, outcomes for which reliable data sources exist.“This systematic review provides some guidance for the field to make progress on its goals of helping adult learners obtain the competencies they need to be productive workers, family members, and citizens,” noted project director Alina Martinez. This research can help policymakers and local providers target their resources to help adult learners achieve higher earnings and career success.“Read the IES snapshot..

What is symbicort

NYS announced the 2020 Income and Resource levels in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates ) and levels based on the Federal Poverty Level are in GIS 20 MA/02 – 2020 Federal Poverty Levels Here is the 2020 HRA Income and Resources Level Chart Non-MAGI - 2020 Disabled, 65+ or Blind what is symbicort ("DAB" or SSI-Related) and have Medicare MAGI (2020) (<. 65, Does not have Medicare)(OR has Medicare and has dependent child <. 18 or <. 19 in what is symbicort school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care.

See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All what is symbicort of the attachments with the various levels are posted here. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. Which household size applies?. The rules are what is symbicort complicated.

See rules here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act what is symbicort changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &.

Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do what is symbicort not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R. § 435.4. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies < what is symbicort. Age 1, 154% FPL for children age 1 - 19.

CAUTION. What is counted as what is symbicort income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and what is symbicort bad changes.

GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD what is symbicort. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see.

ALSO SEE 2018 Manual on Lump Sums and Impact what is symbicort on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid. Here are what is symbicort the 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size.

These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else what is symbicort -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts what is symbicort to explain the new MAGI budgeting, including how to determine the Household Size.

See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st what is symbicort "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p.

573, what is symbicort NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because what is symbicort they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL).

Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless what is symbicort Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income. This category has now been subsumed what is symbicort under the new MAGI adult group whose limit is now raised to 138% FPL.

Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, what is symbicort they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange. PAST INCOME &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order.

These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings what is symbicort Programs and other public health programs in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care. The special income standard for housing expenses helps pay for housing expenses what is symbicort to help certain nursing home or adult home residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes.

GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to what is symbicort Reduce Spend-down, including this Special Income Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll what is symbicort in, or remain enrolled in, an MLTC plan.

Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding the special income standard may what is symbicort be directed to DOH at 518-474-8887. Who is eligible for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC.

How much is the what is symbicort allowance?. The rates vary by region and change yearly. Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan what is symbicort Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05.

2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!.

HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it. The procedures in NYC are explained in this Troubleshooting guide. NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard.

GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy. References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard.

19 in school) 138% FPL*** Children < symbicort online usa Where to get female viagra. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF).

All of symbicort online usa the attachments with the various levels are posted here. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. Which household size applies?.

The rules are complicated symbicort online usa. See rules here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels.

Box 10 on page 3 are symbicort online usa the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &.

Nursing Homes and Box 8 symbicort online usa has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R. § 435.4.

Certain populations have symbicort online usa an even higher income limit - 224% FPL for pregnant women and babies <. Age 1, 154% FPL for children age 1 - 19. CAUTION.

What is counted as income may not symbicort online usa be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI).

There are good symbicort online usa changes and bad changes. GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income.

BAD symbicort online usa. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see.

ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 symbicort online usa may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid.

Here are the symbicort online usa 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article.

Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this symbicort online usa is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp.

8-10 of the PDF, This PowerPoint by NYLAG on symbicort online usa MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient.

Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the symbicort online usa 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p.

573, NYS symbicort online usa GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The following programs symbicort online usa were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household.

It was sometimes known as symbicort online usa "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income.

This category has symbicort online usa now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL.

For applicants between 138%-150% FPL, they will be eligible for a new program symbicort online usa where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange. PAST INCOME &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order.

These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, symbicort online usa MBI-WPD, Medicare Savings Programs and other public health programs in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care.

The special income standard for housing expenses helps pay for housing expenses to symbicort online usa help certain nursing home or adult home residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust.

KNOW YOUR RIGHTS - FACT SHEET on THREE ways to symbicort online usa Reduce Spend-down, including this Special Income Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify.

"Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from symbicort online usa a nursing home and enroll in, or remain enrolled in, an MLTC plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community.

Questions regarding the special income standard may be directed to DOH at symbicort online usa 518-474-8887. Who is eligible for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC.

How much is the allowance?. The rates vary by region and change yearly. Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St.

Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS.

2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo.

Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!. HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard.

See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it. The procedures in NYC are explained in this Troubleshooting guide. NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard.

GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy.

References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept. 28, 2018 - this finally implements the most recent Special Terms &.

Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan.

How many inhalations in symbicort

About Insight Insight provides an in-depth look at how many inhalations in symbicort health care anonymous issues in and affecting California.Have a story suggestion?. Let us know how many inhalations in symbicort. This story was produced in partnership with PolitiFact. This story can be republished for free (details). President Donald Trump accepted the Republican Party’s nomination for president in a 70-minute speech from the South Lawn of how many inhalations in symbicort the White House on Thursday night.Speaking to a friendly crowd that didn’t appear to be observing social distancing conventions, and with few participants wearing masks, he touched on a range of topics, including many related to the anti inflammatory drugs symbicort and health care in general.Throughout, the partisan crowd applauded and chanted “Four more years!.

€ And, even as the nation’s anti inflammatory drugs death toll exceeded 180,000, Trump was upbeat. €œIn recent months, our nation and the entire planet has been struck by a new and powerful invisible how many inhalations in symbicort enemy,” he said. €œLike those brave Americans before us, we are meeting this challenge.”At the end of the event, there were fireworks.Our partners at PolitiFact did an in-depth fact check on Trump’s entire acceptance speech. Here are the highlights related to the administration’s anti inflammatory drugs how many inhalations in symbicort response and other health policy issues:“We developed, from scratch, the largest and most advanced testing system in the world.” This is partially right, but it needs context.It’s accurate that the U.S.

Developed its anti inflammatory drugs testing system from scratch, because the government didn’t accept the World Health Organization’s testing recipe. But whether the system is the “largest” or “most advanced” is how many inhalations in symbicort subject to debate.The U.S. Has tested how many inhalations in symbicort more individuals than any other country. But experts told us a more meaningful metric would be the percentage of positive tests out of all tests, indicating that not only sick people were getting tested.

Another useful metric would be the percentage of the how many inhalations in symbicort population that has been tested. The U.S. Is one of the most populous countries but has how many inhalations in symbicort tested a lower percentage of its population than other countries. Don't Miss A Story Subscribe to California Healthline’s free Weekly Edition newsletter.

The U.S how many inhalations in symbicort. Was also slower than other countries in rolling out tests and amping up testing capacity. Even now, many states are experiencing delays in reporting test results to positive individuals.As for “the most advanced,” Trump may be referring to new testing investments and systems, like how many inhalations in symbicort Abbott’s recently announced $5, 15-minute rapid antigen test, which the company says will be about the size of a credit card, needs no instrumentation and comes with a phone app through which people can view their results. But Trump’s comment makes it sound as if these testing systems are already in how many inhalations in symbicort place when they haven’t been distributed to the public.“The United States has among the lowest [anti inflammatory drugs] case fatality rates of any major country in the world.

The European Union’s case fatality rate is nearly three times higher than ours.”The case fatality rate measures the known number of cases against the known number of deaths. The European Union has a rate that’s about 2½ times greater than the United States.But the source of that data, Oxford University’s Our World in Data project, reports that “during an outbreak of how many inhalations in symbicort a symbicort, the case fatality rate is a poor measure of the mortality risk of the disease.”A better way to measure the threat of the symbicort, experts say, is to look at the number of deaths per 100,000 residents. Viewed that way, the U.S. Has the 10th-highest death rate in the world.“We will produce a treatment before the end of the year, or maybe how many inhalations in symbicort even sooner.”It’s far from guaranteed that a anti-inflammatories treatment will be ready before the end of the year.While researchers are making rapid strides, it’s not yet known precisely when the treatment will be available to the public, which is what’s most important.

Six treatments are in the third phase of testing, which involves thousands of patients. Like earlier phases, this one looks how many inhalations in symbicort at the safety of a treatment but also examines its effectiveness and collects more data on side effects. Results of the third phase will be submitted to the Food and Drug Administration for approval.The government website Operation Warp Speed seems less optimistic than Trump, announcing it “aims to deliver 300 million doses of a safe, effective treatment for anti inflammatory drugs by January 2021.”And federal health officials and other experts have generally predicted a treatment will be available in early 2021. Federal committees how many inhalations in symbicort are working on recommendations for treatment distribution, including which groups should get it first.

€œFrom everything we’ve seen now — in the how many inhalations in symbicort animal data, as well as the human data — we feel cautiously optimistic that we will have a treatment by the end of this year and as we go into 2021,” said Dr. Anthony Fauci, the nation’s top infectious diseases expert. €œI don’t think it’s dreaming.”“Last month, I took how many inhalations in symbicort on Big Pharma. You think that is easy?.

I signed orders that how many inhalations in symbicort would massively lower the cost of your prescription drugs.”Quite misleading. Trump signed four executive orders on July 24 aimed at lowering prescription drug prices. But those orders haven’t taken how many inhalations in symbicort effect yet — the text of one hasn’t even been made publicly available — and experts told us that, if implemented, the measures would be unlikely to result in significant drug price reductions for the majority of Americans.“We will always and very strongly protect patients with preexisting conditions, and that is a pledge from the entire Republican Party.”Trump’s pledge is undermined by his efforts to overturn the Affordable Care Act, the only law that guarantees people with preexisting conditions both receive health coverage and do not have to pay more for it than others do. In 2017, Trump supported congressional efforts to repeal the ACA.

The Trump administration is now backing GOP-led efforts to how many inhalations in symbicort overturn the ACA through a court case. And Trump has also expanded short-term health plans that don’t have to comply with the ACA.“Joe Biden recently raised his hand on the debate stage and promised he was going to give it away, your health care dollars to illegal immigrants, which is going to bring a massive number of immigrants into our country.”This is misleading. During a June 2019 Democratic primary debate, candidates were asked how many inhalations in symbicort. €œRaise your hand if your government plan would provide coverage for undocumented immigrants.” All candidates on stage, including how many inhalations in symbicort Biden, raised their hands.

They were not asked if that coverage would be free or subsidized.Biden supports extending health care access to all immigrants, regardless of immigration status. A task force recommended that he allow immigrants who are in the country illegally to buy health how many inhalations in symbicort insurance, without federal subsidies.“Joe Biden claims he has empathy for the vulnerable, yet the party he leads supports the extreme late-term abortion of defenseless babies right up to the moment of birth.”This mischaracterizes the Democratic Party’s stance on abortion and Biden’s position.Biden has said he would codify the Supreme Court’s ruling in Roe v. Wade and related precedents. This would how many inhalations in symbicort generally limit abortions to the first 20 to 24 weeks of gestation.

States are allowed under court rulings to ban abortion after the point at which a fetus can sustain life, usually considered to be between 24 and 28 weeks from the mother’s last menstrual period — and 43 states do. But the rulings require states to make exceptions “to preserve the life or health of the mother.” Late-term abortions are very rare, about 1%.The Democratic Party platform holds that “every woman should have access to quality reproductive health care services, including safe and legal abortion — regardless of where she lives, how much money she makes, or how she is insured.” It does not address late-term abortion.PolitiFact’s Daniel Funke, Jon Greenberg, Louis Jacobson, Noah Y how many inhalations in symbicort. Kim, Bill McCarthy, Samantha Putterman, Amy Sherman, Miriam Valverde and KHN reporter Victoria Knight contributed to this report. This story was produced by Kaiser Health News, an editorially independent program how many inhalations in symbicort of the Kaiser Family Foundation.

Related Topics Elections Health Industry Insight Pharmaceuticals Public how many inhalations in symbicort Health The Health Law Abortion anti inflammatory drugs Immigrants KHN &. PolitiFact HealthCheck Preexisting Conditions Trump Administration treatmentsAbout Insight Insight provides an in-depth look at health care issues in and affecting California.Have a story suggestion?. Let how many inhalations in symbicort us know. This story also ran on CNN. This story can be republished for free (details). Flu season will look different this year, as the country grapples with a anti-inflammatories symbicort that has killed more than 172,000 people.

Many Americans are reluctant to visit a doctor’s office and public health officials worry people will shy away from being how many inhalations in symbicort immunized.Although sometimes incorrectly regarded as just another bad cold, flu also kills tens of thousands of people in the U.S. Each year, with the very young, the elderly and those with underlying conditions the most vulnerable. When coupled with the effects of anti inflammatory drugs, public health experts say it’s more important than ever to get a flu shot.If enough of how many inhalations in symbicort the U.S. Population gets vaccinated — more than the 45% who did last flu season — it could help head off a nightmare scenario in the coming winter of hospitals stuffed with both anti inflammatory drugs patients and those suffering from severe effects of influenza.Aside from the potential burden on hospitals, there’s the possibility people could get both symbicortes — and “no one knows what happens if you get influenza and anti inflammatory drugs [simultaneously] because it’s never happened before,” Dr.

Rachel Levine, Pennsylvania’s secretary of health, told reporters this month.In response, manufacturers are producing more how many inhalations in symbicort treatment supply this year, between 194 million and 198 million doses, or about 20 million more than they distributed last season, according to the Centers for Disease Control and Prevention. Email how many inhalations in symbicort Sign-Up Subscribe to California Healthline’s free Daily Edition. As flu season approaches, here are some answers to a few common questions:Q. When should I get my how many inhalations in symbicort flu shot?.

Advertising has already begun, and some pharmacies and clinics have their supplies now. But, because the effectiveness of the treatment can wane over time, the CDC recommends against a shot in August.Many pharmacies and clinics will start immunizations how many inhalations in symbicort in early September. Generally, influenza symbicortes start circulating in mid- to late October but become more widespread later, in the winter. It takes about two weeks how many inhalations in symbicort after getting a shot for antibodies — which circulate in the blood and thwart s — to build up.

€œYoung, healthy people can begin getting their flu shots in September, and elderly people and other vulnerable populations can begin in October,” said Dr. Steve Miller, chief clinical officer for insurer how many inhalations in symbicort Cigna.The CDC has recommended that people “get a flu treatment by the end of October,” but noted it’s not too late to get one after that because shots “can still be beneficial and vaccination should be offered throughout the flu season.”Even so, some experts say not to wait too long this year — not only because of anti inflammatory drugs, but also in case a shortage develops because of overwhelming demand.Q. What are the reasons I should roll up my sleeve for this?. Get a shot because it protects you from catching the flu how many inhalations in symbicort and spreading it to others, which may help lessen the burden on hospitals and medical staffs.And there’s another message that may resonate in this strange time.“It gives people a sense that there are some things you can control,” said Eduardo Sanchez, chief medical officer for prevention at the American Heart Association.While a flu shot won’t prevent anti inflammatory drugs, he said, getting one could help your doctors differentiate between the diseases if you develop any symptoms — fever, cough, sore throat — they share.And even though flu shots won’t prevent all cases of the flu, getting vaccinated can lessen the severity if you do fall ill, he said.You cannot get influenza from having a flu treatment.All eligible people, especially essential workers, those with underlying conditions and those at higher risk — including very young children and pregnant women — should seek protection, the CDC said.

It recommends how many inhalations in symbicort that children over 6 months old get vaccinated.Q. What do we know about the effectiveness of this year’s treatment?. Flu treatments — which must be developed anew each year because influenza how many inhalations in symbicort symbicortes mutate — range in effectiveness annually, depending on how well they match the circulating symbicort. Last year’s formulation was estimated to be about 45% effective in preventing the flu overall, with about a 55% effectiveness in children.

The treatments how many inhalations in symbicort available in the U.S. This year are aimed at preventing at least three strains of the symbicort, and most cover four.It isn’t yet known how well this year’s supply will match the strains that will circulate in the U.S. Early indications from the Southern Hemisphere, which goes through its flu season how many inhalations in symbicort during our summer, are encouraging. There, people practiced social distancing, wore masks and got vaccinated in greater numbers this year — and global flu levels are lower than expected.

Experts caution, how many inhalations in symbicort however, not to count on a similarly mild season in the U.S., in part because masking and social distancing efforts vary widely.Q. What are insurance plans how many inhalations in symbicort and health systems doing differently this year?. Insurers and health systems contacted by KHN say they will follow CDC guidelines, which call for limiting and spacing out the number of people waiting in lines and vaccination areas. Some are setting appointments for flu shots to help manage the flow.Health Fitness Concepts, a company that works with UnitedHealth Group and other businesses to set up flu shot clinics in the Northeast, said it is “encouraging smaller, more frequent events to support social distancing” and “requiring all forms to be completed and shirtsleeves rolled up before entering the flu shot area.” Everyone will be required to wear masks.Also, nationally, some physician groups contracted with UnitedHealth will set up tent areas so shots can be given outdoors, a spokesperson said.Kaiser Permanente plans drive-thru vaccinations at some how many inhalations in symbicort of its medical facilities and is testing touch-free screening and check-in procedures at some locations.

(KHN is not affiliated with Kaiser Permanente.)Geisinger Health, a regional health provider in Pennsylvania and New Jersey, said it, too, would have outdoor flu vaccination programs at its facilities.Additionally, “Geisinger is making it mandatory for all employees to receive the flu treatment this year,” said Mark Shelly, the system’s director of prevention and control. €œBy taking this step, we hope to convey to our neighbors the importance of the how many inhalations in symbicort flu treatment for everyone.”Q. Usually I get a flu shot at work. Will that be an option how many inhalations in symbicort this year?.

Aiming to avoid risky indoor gatherings, many employers are reluctant to sponsor the on-site flu clinics they’ve offered in years past. And with so many people continuing to work from home, there’s less need to bring flu shots to employees on how many inhalations in symbicort the job. Instead, many employers are encouraging workers to get shots from their primary care doctors, at pharmacies or in other community settings. Insurance will generally cover the cost of the treatment.Some employers are considering offering vouchers for flu shots to their uninsured workers or those who don’t participate in the company plan, said Julie Stone, managing director for health and benefits at Willis Towers Watson, a consulting firm.

The vouchers could allow workers to get the shot at a particular lab at no cost, for example.Some employers are starting to think about how they might use their parking lots for administering drive-thru flu shots, said Dr. David Zieg, clinical services leader for benefits consultant Mercer.Although federal law allows employers to require employees to get flu shots, that step is typically taken only by health care facilities and some universities where people live and work closely together, Zieg said.Q. What are pharmacies doing to encourage people to get flu shots?. Some pharmacies are making an extra push to get out into the community to offer flu shots.Walgreens, which has nearly 9,100 pharmacies nationwide, is continuing a partnership begun in 2015 with community organizations, churches and employers that has offered about 150,000 off-site and mobile flu clinics to date.The program places a special emphasis on working with vulnerable populations and in underserved areas, said Dr.

Kevin Ban, chief medical officer for the drugstore chain.Walgreens began offering flu shots in mid-August and is encouraging people not to delay getting vaccinated.Both Walgreens and CVS are encouraging people to schedule appointments and do paperwork online this year to minimize time spent in the stores.At CVS MinuteClinic locations, once patients have checked in for their flu shot, they must wait outside or in their car, since the indoor waiting areas are now closed.“We don’t have tons of arrows in our quiver against anti inflammatory drugs,” Walgreens’ Ban said. €œTaking pressure off the health care system by providing treatments in advance is one thing we can do.” This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Julie Appleby. jappleby@kff.org, @julie_appleby Related Topics Insight Insurance Public Health anti inflammatory drugs Insurers treatments.

About Insight Insight provides an in-depth symbicort online usa look at health care issues in and affecting California.Have a http://nl.keimfarben.de/where-can-i-buy-seroquel-over-the-counter-usa story suggestion?. Let us know symbicort online usa. This story was produced in partnership with PolitiFact. This story can be republished for free (details). President Donald Trump accepted the Republican Party’s nomination for president in a 70-minute speech from the South Lawn of the White House on Thursday night.Speaking to a friendly crowd that didn’t appear to be observing social distancing conventions, and with few participants symbicort online usa wearing masks, he touched on a range of topics, including many related to the anti inflammatory drugs symbicort and health care in general.Throughout, the partisan crowd applauded and chanted “Four more years!.

€ And, even as the nation’s anti inflammatory drugs death toll exceeded 180,000, Trump was upbeat. €œIn recent months, our nation and the entire planet has been struck by a new and powerful invisible enemy,” he symbicort online usa said. €œLike those brave Americans before us, we are meeting this challenge.”At the end of the event, there were fireworks.Our partners at PolitiFact did an in-depth fact check on Trump’s entire acceptance speech. Here are the highlights related to the administration’s anti inflammatory drugs response and other health policy issues:“We developed, from scratch, the largest and most advanced testing system in the world.” This is partially right, but symbicort online usa it needs context.It’s accurate that the U.S.

Developed its anti inflammatory drugs testing system from scratch, because the government didn’t accept the World Health Organization’s testing recipe. But whether the system is the “largest” or “most advanced” symbicort online usa is subject to debate.The U.S. Has tested symbicort online usa more individuals than any other country. But experts told us a more meaningful metric would be the percentage of positive tests out of all tests, indicating that not only sick people were getting tested.

Another useful symbicort online usa metric would be the percentage of the population that has been tested. The U.S. Is one of the most populous countries but has tested a symbicort online usa lower percentage of its population than other countries. Don't Miss A Story Subscribe to California Healthline’s free Weekly Edition newsletter.

The symbicort online usa U.S. Was also slower than other countries in rolling out tests and amping up testing capacity. Even now, many states are experiencing delays in reporting test results to positive individuals.As for “the most advanced,” Trump may be referring to new testing investments and systems, like Abbott’s recently announced $5, 15-minute rapid antigen test, which the company says will be about symbicort online usa the size of a credit card, needs no instrumentation and comes with a phone app through which people can view their results. But Trump’s comment makes it sound as if these testing systems are already in place when they haven’t been distributed symbicort online usa to the public.“The United States has among the lowest [anti inflammatory drugs] case fatality rates of any major country in the world.

The European Union’s case fatality rate is nearly three times higher than ours.”The case fatality rate measures the known number of cases against the known number of deaths. The European Union has a rate that’s about 2½ times greater than the United States.But the source of that data, Oxford University’s Our World in Data project, reports that “during an outbreak of a symbicort, the case fatality rate is a poor measure of the mortality risk of the disease.”A better way to measure the threat of the symbicort, experts say, is symbicort online usa to look at the number of deaths per 100,000 residents. Viewed that way, the U.S. Has the 10th-highest death rate in the world.“We will produce a treatment before symbicort online usa the end of the year, or maybe even sooner.”It’s far from guaranteed that a anti-inflammatories treatment will be ready before the end of the year.While researchers are making rapid strides, it’s not yet known precisely when the treatment will be available to the public, which is what’s most important.

Six treatments are in the third phase of testing, which involves thousands of patients. Like earlier phases, this one looks at the safety of a treatment but also examines its effectiveness and collects more data symbicort online usa on side effects. Results of the third phase will be submitted to the Food and Drug Administration for approval.The government website Operation Warp Speed seems less optimistic than Trump, announcing it “aims to deliver 300 million doses of a safe, effective treatment for anti inflammatory drugs by January 2021.”And federal health officials and other experts have generally predicted a treatment will be available in early 2021. Federal committees are working on recommendations for treatment distribution, including which symbicort online usa groups should get it first.

€œFrom everything we’ve seen now symbicort online usa — in the animal data, as well as the human data — we feel cautiously optimistic that we will have a treatment by the end of this year and as we go into 2021,” said Dr. Anthony Fauci, the nation’s top infectious diseases expert. €œI don’t think symbicort online usa it’s dreaming.”“Last month, I took on Big Pharma. You think that is easy?.

I signed orders that would massively lower the cost of symbicort online usa your prescription drugs.”Quite misleading. Trump signed four executive orders on July 24 aimed at lowering prescription drug prices. But those orders haven’t taken effect yet — the text of one hasn’t symbicort online usa even been made publicly available — and experts told us that, if implemented, the measures would be unlikely to result in significant drug price reductions for the majority of Americans.“We will always and very strongly protect patients with preexisting conditions, and that is a pledge from the entire Republican Party.”Trump’s pledge is undermined by his efforts to overturn the Affordable Care Act, the only law that guarantees people with preexisting conditions both receive health coverage and do not have to pay more for it than others do. In 2017, Trump supported congressional efforts to repeal the ACA.

The Trump administration is now backing GOP-led efforts to overturn the ACA through a court case symbicort online usa. And Trump has also expanded short-term health plans that don’t have to comply with the ACA.“Joe Biden recently raised his hand on the debate stage and promised he was going to give it away, your health care dollars to illegal immigrants, which is going to bring a massive number of immigrants into our country.”This is misleading. During a June 2019 Democratic primary debate, candidates were asked symbicort online usa. €œRaise your hand if your government plan would provide coverage for undocumented immigrants.” All candidates on stage, including Biden, raised their symbicort online usa hands.

They were not asked if that coverage would be free or subsidized.Biden supports extending health care access to all immigrants, regardless of immigration status. A task force recommended that he allow immigrants who are in the country illegally to buy health insurance, without federal subsidies.“Joe Biden claims he has empathy for the vulnerable, yet the party he leads supports the extreme late-term abortion of defenseless babies right up to symbicort online usa the moment of birth.”This mischaracterizes the Democratic Party’s stance on abortion and Biden’s position.Biden has said he would codify the Supreme Court’s ruling in Roe v. Wade and related precedents. This would generally limit abortions to the first 20 to 24 weeks of symbicort online usa gestation.

States are allowed under court rulings to ban abortion after the point at which a fetus can sustain life, usually considered to be between 24 and 28 weeks from the mother’s last menstrual period — and 43 states do. But the rulings symbicort online usa require states to make exceptions “to preserve the life or health of the mother.” Late-term abortions are very rare, about 1%.The Democratic Party platform holds that “every woman should have access to quality reproductive health care services, including safe and legal abortion — regardless of where she lives, how much money she makes, or how she is insured.” It does not address late-term abortion.PolitiFact’s Daniel Funke, Jon Greenberg, Louis Jacobson, Noah Y. Kim, Bill McCarthy, Samantha Putterman, Amy Sherman, Miriam Valverde and KHN reporter Victoria Knight contributed to this report. This story was produced by Kaiser Health News, an editorially independent program symbicort online usa of the Kaiser Family Foundation.

Related Topics Elections Health Industry Insight Pharmaceuticals Public Health The Health Law symbicort online usa Abortion anti inflammatory drugs Immigrants KHN &. PolitiFact HealthCheck Preexisting Conditions Trump Administration treatmentsAbout Insight Insight provides an in-depth look at health care issues in and affecting California.Have a story suggestion?. Let us know symbicort online usa. This story also ran on CNN. This story can be republished for free (details). Flu season will look different this year, as the country grapples with a anti-inflammatories symbicort that has killed more than 172,000 people.

Many Americans are reluctant to visit a doctor’s office and public health officials worry people will shy away from being immunized.Although sometimes incorrectly regarded as just another bad cold, flu also symbicort online usa kills tens of thousands of people in the U.S. Each year, with the very young, the elderly and those with underlying conditions the most vulnerable. When coupled with the symbicort online usa effects of anti inflammatory drugs, public health experts say it’s more important than ever to get a flu shot.If enough of the U.S. Population gets vaccinated — more than the 45% who did last flu season — it could help head off a nightmare scenario in the coming winter of hospitals stuffed with both anti inflammatory drugs patients and those suffering from severe effects of influenza.Aside from the potential burden on hospitals, there’s the possibility people could get both symbicortes — and “no one knows what happens if you get influenza and anti inflammatory drugs [simultaneously] because it’s never happened before,” Dr.

Rachel Levine, symbicort online usa Pennsylvania’s secretary of health, told reporters this month.In response, manufacturers are producing more treatment supply this year, between 194 million and 198 million doses, or about 20 million more than they distributed last season, according to the Centers for Disease Control and Prevention. Email Sign-Up Subscribe to California Healthline’s free symbicort online usa Daily Edition. As flu season approaches, here are some answers to a few common questions:Q. When should I get my symbicort online usa flu shot?.

Advertising has already begun, and some pharmacies and clinics have their supplies now. But, because the effectiveness of the treatment can wane over time, the CDC recommends against a shot in August.Many pharmacies and clinics will symbicort online usa start immunizations in early September. Generally, influenza symbicortes start circulating in mid- to late October but become more widespread later, in the winter. It takes about two weeks symbicort online usa after getting a shot for antibodies — which circulate in the blood and thwart s — to build up.

€œYoung, healthy people can begin getting their flu shots in September, and elderly people and other vulnerable populations can begin in October,” said Dr. Steve Miller, chief clinical officer for insurer Cigna.The CDC has recommended that people “get a flu treatment symbicort online usa by the end of October,” but noted it’s not too late to get one after that because shots “can still be beneficial and vaccination should be offered throughout the flu season.”Even so, some experts say not to wait too long this year — not only because of anti inflammatory drugs, but also in case a shortage develops because of overwhelming demand.Q. What are the reasons I should roll up my sleeve for this?. Get a shot because it protects you from catching the flu and spreading it to others, which may help lessen the burden on hospitals and medical staffs.And there’s another message that may resonate in this strange time.“It gives people a sense that there are some things you can control,” said Eduardo Sanchez, chief medical officer for prevention at the American Heart Association.While a flu shot won’t prevent anti inflammatory drugs, he said, getting one symbicort online usa could help your doctors differentiate between the diseases if you develop any symptoms — fever, cough, sore throat — they share.And even though flu shots won’t prevent all cases of the flu, getting vaccinated can lessen the severity if you do fall ill, he said.You cannot get influenza from having a flu treatment.All eligible people, especially essential workers, those with underlying conditions and those at higher risk — including very young children and pregnant women — should seek protection, the CDC said.

It recommends that children over 6 months symbicort online usa old get vaccinated.Q. What do we know about the effectiveness of this year’s treatment?. Flu treatments symbicort online usa — which must be developed anew each year because influenza symbicortes mutate — range in effectiveness annually, depending on how well they match the circulating symbicort. Last year’s formulation was estimated to be about 45% effective in preventing the flu overall, with about a 55% effectiveness in children.

The treatments available in the symbicort online usa U.S. This year are aimed at preventing at least three strains of the symbicort, and most cover four.It isn’t yet known how well this year’s supply will match the strains that will circulate in the U.S. Early indications from the Southern Hemisphere, which goes through its symbicort online usa flu season during our summer, are encouraging. There, people practiced social distancing, wore masks and got vaccinated in greater numbers this year — and global flu levels are lower than expected.

Experts caution, however, not to count symbicort online usa on a similarly mild season in the U.S., in part because masking and social distancing efforts vary widely.Q. What are insurance plans and health systems symbicort online usa doing differently this year?. Insurers and health systems contacted by KHN say they will follow CDC guidelines, which call for limiting and spacing out the number of people waiting in lines and vaccination areas. Some are setting appointments for flu shots to help manage the flow.Health Fitness Concepts, a company that works with UnitedHealth Group and other businesses to set up symbicort online usa flu shot clinics in the Northeast, said it is “encouraging smaller, more frequent events to support social distancing” and “requiring all forms to be completed and shirtsleeves rolled up before entering the flu shot area.” Everyone will be required to wear masks.Also, nationally, some physician groups contracted with UnitedHealth will set up tent areas so shots can be given outdoors, a spokesperson said.Kaiser Permanente plans drive-thru vaccinations at some of its medical facilities and is testing touch-free screening and check-in procedures at some locations.

(KHN is not affiliated with Kaiser Permanente.)Geisinger Health, a regional health provider in Pennsylvania and New Jersey, said it, too, would have outdoor flu vaccination programs at its facilities.Additionally, “Geisinger is making it mandatory for all employees to receive the flu treatment this year,” said Mark Shelly, the system’s director of prevention and control. €œBy taking this step, we hope to symbicort online usa convey to our neighbors the importance of the flu treatment for everyone.”Q. Usually I get a flu shot at work. Will that be an option this symbicort online usa year?.

Aiming to avoid risky indoor gatherings, many employers are reluctant to sponsor the on-site flu clinics they’ve offered in years past. And with so many people continuing to work from home, there’s less need to bring flu shots to employees on the symbicort online usa job. Instead, many employers are encouraging workers to get shots from symbicort online usa their primary care doctors, at pharmacies or in other community settings. Insurance will generally cover the cost of the treatment.Some employers are considering offering vouchers for flu shots to their uninsured workers or those who don’t participate in the company plan, said Julie Stone, managing director for health and benefits at Willis Towers Watson, a consulting firm.

The vouchers could allow workers to get the shot at a particular lab at no cost, for example.Some employers are starting to think about how they might use their parking lots for symbicort online usa administering drive-thru flu shots, said Dr. David Zieg, clinical services leader for benefits consultant Mercer.Although federal law allows employers to require employees to get flu shots, that step is typically taken only by health care facilities and some universities where people live and work closely together, Zieg said.Q. What are pharmacies doing to encourage people to get flu shots? symbicort online usa. Some pharmacies are making an extra push to get out into the community to offer flu shots.Walgreens, which has nearly 9,100 pharmacies nationwide, is continuing a partnership begun in 2015 with community organizations, churches and employers that has offered about 150,000 off-site and mobile flu clinics to date.The program places a special emphasis on working with vulnerable populations and in underserved areas, said Dr.

Kevin Ban, chief medical officer for the drugstore chain.Walgreens began offering flu shots in mid-August and is encouraging people not to delay getting vaccinated.Both Walgreens and CVS are encouraging people to schedule appointments and do paperwork online this year to minimize time spent in the stores.At CVS MinuteClinic locations, once patients have checked in for their flu shot, they must wait outside or in their car, since the indoor waiting areas are now closed.“We don’t have tons of arrows in our quiver against anti inflammatory drugs,” Walgreens’ Ban said. €œTaking pressure off the health care system by providing treatments in advance is one thing we can do.” This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Julie Appleby. jappleby@kff.org, @julie_appleby Related Topics Insight Insurance Public Health anti inflammatory drugs Insurers treatments.

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