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Duddy C, Gadsby E, Hibberd V, Krska J, Wong G. What happens after an NHS Health Check? A survey and realist review. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-133. [PMID: 37830173 DOI: 10.3310/rgth4127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Background The National Health Service Health Check in England aims to provide adults aged 40 to 74 with an assessment of their risk of developing cardiovascular disease and to offer advice to help manage and reduce this risk. The programme is commissioned by local authorities and delivered by a range of providers in different settings, although primarily in general practices. This project focused on variation in the advice, onward referrals and prescriptions offered to attendees following their health check. Objectives (1) Map recent programme delivery across England via a survey of local authorities; (2) conduct a realist review to enable understanding of how the National Health Service Health Check programme works in different settings, for different groups; (3) provide recommendations to improve delivery. Design Survey of local authorities and realist review of the literature. Review methods Realist review is a theory-driven, interpretive approach to evidence synthesis that seeks to explain why, when and for whom outcomes occur. We gathered published research and grey literature (including local evaluation documents and conference materials) via searching and supplementary methods. Extracted data were synthesised using a realist logic of analysis to develop an understanding of important contexts that affect the delivery of National Health Service Health Checks, and underlying mechanisms that produce outcomes related to our project focus. Results Our findings highlight the variation in National Health Service Health Check delivery models across England. Commissioners, providers and attendees understand the programme's purpose in different ways. When understood primarily as an opportunity to screen for disease, responsibility for delivery and outcomes rests with primary care, and there is an emphasis on volume of checks delivered, gathering essential data and communicating risk. When understood as an opportunity to prompt and support behaviour change, more emphasis is placed on delivery of advice and referrals to 'lifestyle services'. Practical constraints limit what can be delivered within the programme's remit. Public health funding restricts delivery options and links with onward services, while providers may struggle to deliver effective checks when faced with competing priorities. Attendees' responses to the programme are affected by features of delivery models and the constraints they face within their own lives. Limitations Survey response rate lower than anticipated; review findings limited by the availability and quality of the literature. Conclusions and implications The purpose and remit of the National Health Service Health Check programme should be clarified, considering prevailing attitudes about its value (especially among providers) and what can be delivered within existing resources. Some variation in delivery is likely to be appropriate to meet local population needs, but lack of clarity for the programme contributes to a 'postcode lottery' effect in the support offered to attendees after a check. Our findings raise important questions about whether the programme itself and services that it may feed into are adequately resourced to achieve positive outcomes for attendees, and whether current delivery models may produce inequitable outcomes. Future work Policy-makers and commissioners should consider the implications of the findings of this project; future research should address the relative scarcity of studies focused on the end of the National Health Service Health Check pathway. Study registration PROSPERO registration CRD42020163822. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR129209).
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Erica Gadsby
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Vivienne Hibberd
- Public Involvement in Pharmacy Studies Group, Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Decision-Making Dilemmas within Integrated Care Service Networks: A Systematic Literature Review. Int J Integr Care 2022; 22:11. [DOI: 10.5334/ijic.6458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
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Duddy C, Gadsby E, Hibberd V, Krska J, Wong G. Understanding what happens to attendees after an NHS Health Check: a realist review. BMJ Open 2022; 12:e064237. [PMID: 36357002 PMCID: PMC9660666 DOI: 10.1136/bmjopen-2022-064237] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The NHS Health Check offers adults aged 40-74 an assessment of their risk of developing cardiovascular disease. Attendees should be offered appropriate clinical or behavioural interventions to help them to manage or reduce these risks. This project focused on understanding variation in the advice and support offered to Health Check attendees. DESIGN We conducted a realist review, assembling a diverse body of literature via database searches (MEDLINE, Embase, CINAHL, HMIC, Web of Science) and other search methods, and synthesised data extracted from documents using a realist logic of analysis. Our aim was to develop an understanding of contexts affecting delivery of the NHS Health Check and the underlying mechanisms producing outcomes related to the offer for attendees post-Check. RESULTS Our findings demonstrate differences in how NHS Health Check commissioners, providers and attendees understand the primary purpose of the programme. A focus on screening for disease can produce an emphasis on high-volume delivery in primary care. When delivery models are organised around behavioural approaches to risk reduction, more emphasis is placed on advice, and referrals to 'lifestyle services'. However, constrained funding and competing priorities for providers limit what can be delivered within the programme's remit. Attendees' experiences and responses to the programme are affected by how the programme is delivered, and by the difficulty of incorporating its outputs into their lives. CONCLUSIONS The remit of the NHS Health Check should be reviewed with consideration of what can be effectively delivered within existing resources. Variation in delivery may be appropriate to meet local needs, but differences in how the programme's primary purpose is understood contribute to a 'postcode lottery' in post-Check advice and support. Our findings underline existing concerns that the programme may generate inequitable outcomes and raise questions about whether it can deliver positive outcomes for the majority of attendees. TRIAL REGISTRATION NUMBER PROSPERO CRD42020163822.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Erica Gadsby
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Vivienne Hibberd
- Public Involvement in Pharmacy Studies Group, University of Greenwich Medway School of Pharmacy, Chatham, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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Díaz-Castro L, Ramírez-Rojas MG, Cabello-Rangel H, Sánchez-Osorio E, Velázquez-Posada M. The Analytical Framework of Governance in Health Policies in the Face of Health Emergencies: A Systematic Review. Front Public Health 2022; 10:628791. [PMID: 35812499 PMCID: PMC9263350 DOI: 10.3389/fpubh.2022.628791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
The Governance Analytical Framework (MAG) defines governance as a social fact, endowed with analyzable and interpretable characteristics, through what it calls observable constitutive elements of governance: the problem, the actors, the social norms, the process of decision-making and scope or nodal points; in the sense that each society develops its modes of governance, its decision-making or conflict resolution systems among its members, its norms, and institutions. In this perspective, the purpose of this article was to carry out a systematic review of the scientific literature to understand the role of governance in health policies in health emergencies, such as that caused by the SARS-CoV-2. The systematic review was designed based on the methodology proposed in the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) Declaration. The literature search was carried out in six databases: Psychology and Behavioral Sciences, APA-PsycInfo, MEDLINE, eBook Collection (EBSCOhost), PubMED, and MedicLatina, published in the last 5 years. Fifteen articles that met quality and evidence criteria were analyzed. The governance approach alluding to the health emergency problem in health policies was the most addressed by the authors (80%), followed by a description of the actors (40%), the process of decision-making spaces (33%), and ultimately, social norms or rules with 13%. Formulating a coherent set of global health policies within a large-scale global governance framework is mostly absent. Although the countries adopt international approaches, it is a process differentiated by the social, economic, and political contexts between countries, affecting heterogeneous health outcomes over the pandemic.
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Affiliation(s)
- Lina Díaz-Castro
- Direction of Epidemiological and Psychosocial Research, National Institute of Psychiatry Ramon de la Fuente Muñiz (INPRFM), Mexico City, Mexico
| | - María Guadalupe Ramírez-Rojas
- Department of Medical Anthropology, National Council of Science and Technology (CONACYT), Center for Research and Higher Studies in Social Anthropology (CIESAS-Sureste), Chiapas, Mexico
- *Correspondence: María Guadalupe Ramírez-Rojas
| | - Héctor Cabello-Rangel
- Research Department, Psychiatric Hospital Fray Bernardino Álvarez, Mexico City, Mexico
| | - Ever Sánchez-Osorio
- Center and Assistance in Technology and Design of Jalisco State (CIATEJ), Jalisco, Mexico
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Monaghan K, Cos T. Integrating physical and mental healthcare: Facilitators and barriers to success. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211050615. [PMID: 36204502 PMCID: PMC9413608 DOI: 10.1177/23992026211050615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Effective and appropriate provision of mental healthcare has long been a
struggle globally, resulting in significant disparity between prevalence of
mental illness and access to care. One attempt to address such disparity was
the Patient Protection and Affordable Care Act (PPACA), 2010, mandate in the
United States to integrate physical and mental healthcare in Federally
Qualified Health Centers (FQHCs). The notion of integration is attractive,
as it has demonstrated the potential to improve both access to mental
healthcare and healthcare outcomes. However, while the PPACA mandate set
this requirement for FQHCs, no clear process as to how these centers should
achieve successful integration was identified. Methods: This research employed case study methods to examine the implementation of
this policy in two FQHCs in New England. Data were obtained from in-depth
interviews with leadership, management, and frontline staff at two case
study sites. Results: Study findings include multiple definitions of and approaches for integrating
physical and mental healthcare, mental healthcare being subsumed into,
rather than integrated with, the medical model and multiple facilitators of
and barriers to integration. Conclusion: This study asked questions about what integration means, how it occurs, and
what factors facilitate or pose barriers to integration. Integration is
facilitated by co-location of providers within the same department, a warm
hand-off, collaborative collegial relationships, strong leadership support,
and a shared electronic health record. However, interdisciplinary conflict,
power differentials, job insecurity, communication challenges, and the
subsumption of mental health into the medical model pose barriers to
successful integration.
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Affiliation(s)
| | - Travis Cos
- School of Arts and Sciences, La Salle University, Philadelphia, PA, USA
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Rayment J, Sidhu M, Wright P, Brown P, Greenfield S, Jeffreys S, Gale N. Collaboration for Impact: Co-creating a Workforce Development Toolkit Using an Arts-based Approach. Int J Integr Care 2020; 20:11. [PMID: 32565761 PMCID: PMC7292144 DOI: 10.5334/ijic.5377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 05/13/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The identification, communication and management of health risk is a core task of Community Health Workers who operate at the boundaries of community and primary care, often through not-for-profit community interest companies. However, there are few opportunities or resources for workforce development. Publicly funded researchers have an obligation to be useful to the public and furthermore, university funding is increasingly contingent on demonstrating the social impact of academic research. Collaborative work with participants and other stakeholders can have reciprocal benefits to all but may be daunting to some researchers, unused to such approaches. METHODS This case study is an account of the co-creation of a (freely accessible) workforce development toolkit, as part of a collaboration between academics, community interest companies, patients and services users and arts practitioners. RESULTS Our collaborative group produced three short films, fictionalising encounters between Community Health Workers and their clients. These were used within a series of five discussion-led workshops with facilitator guidance to explore issues generated by the films. Two collaborating community-based, not-for-profit organisations piloted the toolkit before its launch. CONCLUSION We aim to encourage other academics to maximise the impact of their own research through collaborative projects with those outside of academia, including research participants and to consider the potential value of arts-based approaches to explore and facilitate reflection on complex tasks and tensions that make up daily work practices. Whilst publication of findings from such projects may be commonplace, accounts of the process are unusual. This detailed account highlights some of the benefits and challenges involved.
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Affiliation(s)
- Juliet Rayment
- Centre for Maternal and Child Health Research, City, University of London, GB
| | - Manbinder Sidhu
- Health Services Management Centre, University of Birmingham, GB
| | | | | | - Sheila Greenfield
- Medical Sociology, Institute of Applied Health Research, University of Birmingham, GB
| | | | - Nicola Gale
- Health Sociology and Policy, Health Services Management Centre, University of Birmingham, GB
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Nunes J, Lotta G. Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil's community health workers. Soc Sci Med 2019; 242:112551. [PMID: 31622914 PMCID: PMC6853157 DOI: 10.1016/j.socscimed.2019.112551] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 08/29/2019] [Accepted: 09/12/2019] [Indexed: 01/04/2023]
Abstract
This article explores the mobilization of power by health workers during policy implementation, showing how in a context of discretion and resource scarcity they can reproduce inequalities in access to health services. The argument innovates theoretically by supplementing the ‘street-level bureaucracy’ literature, which emphasizes frontline worker discretion, with a conceptualization of power as domination encompassing the shaping of behavior, the constitution of subjects and the reproduction of inequality. Empirically, the article focuses on Brazilian community health workers (agentes comunitários desaúde, CHWs). CHWs are a neglected but highly important segment of the health workforce that traditionally functions as a link between the health system and disadvantaged groups. The article examines how Brazilian CHWs act as street-level bureaucrats mobilizing power in their interactions with users. They operate within a severely under-resourced public health system, the Sistema Único de Saúde, which places constraints upon their action and forces them to make allocation decisions with little training and support. The article highlights the ways in which inequalities in access to health services are reproduced (inadvertently or not) through the practices, discursive styles and classifications of CHWs. Methodologically, the paper is based on ethnography with 24 CHWs and interviews with 77 other CHWs in Brazil. Develops a novel framework for analysing health worker discretion and power. Supplements the street-level bureaucracy approach with the concept of domination. Explores the mobilization of power by Brazilian community health workers. Shows how policy implementation can reproduce inequality in access to healthcare.
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Affiliation(s)
- João Nunes
- Department of Politics, University of York, Heslington, York, YO10 5DD, UK.
| | - Gabriela Lotta
- Department of Public Management, Getúlio Vargas Foundation, Av Nove de Julho, 2029, São Paulo, Brazil.
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Gale NK, Sidhu MS. Risk work or resilience work? A qualitative study with community health workers negotiating the tensions between biomedical and community-based forms of health promotion in the United Kingdom. PLoS One 2019; 14:e0220109. [PMID: 31356605 PMCID: PMC6662997 DOI: 10.1371/journal.pone.0220109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 07/09/2019] [Indexed: 12/02/2022] Open
Abstract
Emplaced health promotion interventions, delivered by community health workers are increasingly being used internationally. However, the application of epidemiological risk knowledge to individuals within such communities is not straightforward and creates tensions for community health workers who are part of the communities that they are serving. Situated qualitative interview data were co-produced with community health workers employed in a superdiverse, deprived, post-industrial region of the United Kingdom, using photo-voice methods, to develop an account of how they made sense of the challenges of their work. The analysis draws on and develops theories of risk work and resilience work, which draw on practice theory. The key findings were that, first, being a critical insider enabled community health workers to make sense of the diverse constraints on health and lifestyles within their community. Second, they understood their own public health role as limited by operating within this context, so they articulated their occupational identity as focused on supporting clients to make small but sustainable changes to their own and their families’ lifestyles. Third, the uncertainties of translating population based risk information to individual clients were (at least partially) resolved at an embodied level, with the community health workers identifying as accessible and trusted role models for the value of changed lifestyles. The article is important for policy and practice as it provides a critique of a rapidly evolving new mode of delivery of public health services, and insights on the development of this new public health workforce.
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Affiliation(s)
- Nicola K. Gale
- Health Services Management Centre, School of Social Policy, College of Social Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Manbinder S. Sidhu
- Health Services Management Centre, School of Social Policy, College of Social Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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Hrynick TA, Barasa V, Benschop J, Cleaveland S, Crump JA, Davis M, Mariki B, Mmbaga BT, Mtui-Malamsha N, Prinsen G, Sharp J, Sindiyo E, Swai ES, Thomas KM, Zadoks R, Waldman L. Street-level diplomacy and local enforcement for meat safety in northern Tanzania: knowledge, pragmatism and trust. BMC Public Health 2019; 19:863. [PMID: 31269927 PMCID: PMC6610827 DOI: 10.1186/s12889-019-7067-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/29/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND With increasing demand for red meat in Tanzania comes heightened potential for zoonotic infections in animals and humans that disproportionately affect poor communities. A range of frontline government employees work to protect public health, providing services for people engaged in animal-based livelihoods (livestock owners and butchers), and enforcing meat safety and food premises standards. In contrast to literature which emphasises the inadequacy of extension support and food safety policy implementation in low- and middle-income countries, this paper foregrounds the 'street-level diplomacy' deployed by frontline actors operating in challenging contexts. METHODS This research is based on semi-structured interviews with 61 government employees, including livestock extension officers/meat inspectors and health officers, across 10 randomly-selected rural and urban wards. RESULTS Frontline actors combined formal and informal strategies including the leveraging of formal policy texts and relationships with other state employees, remaining flexible and recognising that poverty constrained people's ability to comply with health regulations. They emphasised the need to work with livestock keepers and butchers to build their knowledge to self-regulate and to work collaboratively to ensure meat safety. Remaining adaptive and being hesitant to act punitively unless absolutely necessary cultivated trust and positive relations, making those engaged in animal-based livelihoods more open to learning from and cooperating with extension officers and inspectors. This may result in higher levels of meat safety than might be the case if frontline actors stringently enforced regulations. CONCLUSION The current tendency to view frontline actors' partial enforcement of meat safety regulations as a failure obscures the creative and proactive ways in which they seek to ensure meat safety in a context of limited resources. Their application of 'street-level diplomacy' enables them to be sensitive to local socio-economic realities, to respect local social norms and expectations and to build support for health safety interventions when necessary. More explicitly acknowledging the role of trust and positive state-society relations and the diplomatic skills deployed by frontline actors as a formal part of their inspection duties offers new perspectives and enhanced understandings on the complicated nature of their work and what might be done to support them.
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Affiliation(s)
- T A Hrynick
- Institute of Development Studies, University of Sussex, Brighton, UK
| | - V Barasa
- Institute of Development Studies, University of Sussex, Brighton, UK
| | - J Benschop
- mEpiLab, School of Veterinary Science, Massey University, Palmerston, New Zealand
| | - S Cleaveland
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - J A Crump
- Centre for International Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| | - M Davis
- Paul G. Allen School for Global Animal Health, College of Veterinary Medicine, Washington State University, Pullman, USA
| | - B Mariki
- Tanzania Chamber of Commerce - Kilimanjaro, Moshi, Tanzania
| | - B T Mmbaga
- Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - N Mtui-Malamsha
- Ministry of Livestock and Fisheries Development, Dodoma, Tanzania
| | - G Prinsen
- School of People, Environment and Planning, Massey University, Palmerston North, New Zealand
| | - J Sharp
- School of Geographical and Earth Sciences, University of Glasgow, Glasgow, UK
| | - E Sindiyo
- Mwanga District Council Department of Livestock and Fisheries, Mwanga, Tanzania
| | - E S Swai
- Ministry of Livestock and Fisheries Development, Dodoma, Tanzania
| | - K M Thomas
- Centre for International Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - R Zadoks
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - L Waldman
- Institute of Development Studies, University of Sussex, Brighton, UK.
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Brown P, Gale N. Developing a sociology of risk work in client-facing contexts: an editorial. HEALTH RISK & SOCIETY 2018. [DOI: 10.1080/13698575.2018.1445072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Patrick Brown
- Department of Sociology, University of Amsterdam, The Netherlands, Amsterdam
| | - Nicola Gale
- HSMC, School of Social Policy, University of Birmingham, Birmingham, UK
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