"You don't get side effects from social prescribing"-A qualitative study exploring community pharmacists' attitudes to social prescribing.

OBJECTIVES: Social prescribing is an approach that enables the referral of patients to non-clinical support and places a focus on holistic care. This study explored views of community pharmacists regarding social prescribing in pharmacies. STUDY DESIGN: A qualitative phenomenological approach was used. METHODS: A convenience sample of eleven community pharmacists from Northern England were recruited via social media (Twitter, Facebook) and took part in a semi-structured, one-to-one qualitative interviews that asked about their knowledge of social prescribing, the advantages of community pharmacist involvement and any barriers they predicted to its implementation. Interviews were transcribed verbatim and thematically analysed. RESULTS: The sample included largely male pharmacists (63.3%) with less than five years' experience (45.5%) and included pharmacists working as employees (63.6%), locums (27.3%) and owners (9%) in both chain (36%) and independent stores (54.5%). The main findings indicate an enthusiasm for but limited understanding of social prescribing. Factors which appeared to influence involvement were training requirements and time available to complete an additional service in busy pharmacies. Opportunities centred on the broader pharmacy team's role to optimise health outcomes. CONCLUSIONS: The findings indicate pharmacists may be an underused resource due to a poor understanding of the full scale and scope of social prescribing beyond health promotion, lifestyle interventions. Further work is needed to explore the transferability of the findings to the broader pharmacy workforce to understand how social prescribing can be positioned within pharmacy practice.

The well-being and work-related stress of senior school leaders in Wales and Northern Ireland during COVID-19 "educational leadership crisis": A cross-sectional descriptive study.

The COVID-19 pandemic caused far-reaching societal changes, including significant educational impacts affecting over 1.6 billion pupils and 100 million education practitioners globally. Senior school leaders were at the forefront and were exposed to particularly high demands during a period of "crisis leadership". This occupation were already reporting high work-related stress and large numbers leaving the profession preceding COVID-19. This cross-sectional descriptive study through the international COVID-Health Literacy network aimed to examine the well-being and work-related stress of senior school leaders (n = 323) in Wales (n = 172) and Northern Ireland (n = 151) during COVID-19 (2021-2022). Findings suggest that senior school leaders reported high workloads (54.22±11.30 hours/week), low well-being (65.2% n = 202, mean WHO-5 40.85±21.57), depressive symptoms (WHO-5 34.8% n = 108) and high work-related stress (PSS-10: 29.91±4.92). High exhaustion (BAT: high/very high 89.0% n = 285) and specific psychosomatic complaints (experiencing muscle pain 48.2% n = 151) were also reported, and females had statistically higher outcomes in these areas. School leaders were engaging in self-endangering working behaviours; 74.7% (n = 239) gave up leisure activities in favour of work and 63.4% (n = 202) sacrificed sufficient sleep, which was statistically higher for females. These findings are concerning given that the UK is currently experiencing a "crisis" in educational leadership against a backdrop of pandemic-related pressures. Senior leaders' high attrition rates further exacerbate this, proving costly to educational systems and placing additional financial and other pressures on educational settings and policy response. This has implications for senior leaders and pupil-level outcomes including health, well-being and educational attainment, requiring urgent tailored and targeted support from the education and health sectors. This is particularly pertinent for Wales and Northern Ireland as devolved nations in the UK, who are both implementing or contemplating major education system level reforms, including new statutory national curricula, requiring significant leadership, engagement and ownership from the education profession.

Supported self-management for all with musculoskeletal pain: an inclusive approach to intervention development: the EASIER study.

BACKGROUND: Supported self-management interventions for patients with musculoskeletal (MSK) conditions may not adequately support those with limited health literacy, leading to inequalities in care and variable outcomes. The aim of this study was to develop a model for inclusive supported self-management intervention(s) for MSK pain that take account of health literacy. METHODS: A mixed methods study with four work-packages was conducted: work package 1: secondary analysis of existing data to identify potential targets for intervention; work package 2: evidence synthesis to assess effective components of self-management interventions taking into account health literacy; work package 3: views of community members and healthcare professionals (HCPs) on essential components; work package 4: triangulation of findings and an online modified Delphi approach to reach consensus on key components of a logic model. FINDINGS: Findings identified targets for intervention as self-efficacy, illness perceptions, and pain catastrophizing. A range of intervention components were identified (e.g. information in diverse formats offered at specific times, action planning and visual demonstrations of exercise). Support should be multi-professional using a combination of delivery modes (e.g. remote, face-to-face). CONCLUSIONS: This research has developed a patient-centred model for a multi-disciplinary, multi-modal approach to supported self-management for patients with MSK pain and varying levels of health literacy. The model is evidence-based and acceptable to both patients and HCPs, with potential for significant impact on the management of MSK pain and for improving patient health outcomes. Further work is needed to establish its efficacy.

Improving alcohol health literacy and reducing alcohol consumption: recommendations for Germany.

BACKGROUND: Although the detrimental health effects of alcohol are well established, consumption levels are high in many high-income countries such as Germany. Improving alcohol health literacy presents an integrated approach to alcohol prevention and an important complement to alcohol policy. Our aim was to identify and prioritize measures to enhance alcohol health literacy and hence to reduce alcohol consumption, using Germany as an example. METHODS: A series of recommendations for improving alcohol health literacy were derived from a review of the literature and subsequently rated by five experts. Recommendations were rated according to their likely impact on enhancing (a) alcohol health literacy and (b) reducing alcohol consumption. Inter-rater agreement was assessed using a two-way intra-class correlation coefficient (ICC). RESULTS: Eleven recommendations were established for three areas of action: (1) education and information, (2) health care system, and (3) alcohol control policy. Education and information measures were rated high to increase alcohol health literacy but low to their impact on alcohol consumption, while this pattern was reversed for alcohol control policies. The ratings showed good agreement (ICC: 0.85-0.88). CONCLUSIONS: Improving alcohol health literacy and reducing alcohol consumption should be considered complementary and become part of a comprehensive alcohol strategy to curb the health, social, and economic burden of alcohol.

Improving access to primary care and annual health checks for people who have a learning disability: a multistakeholder qualitative study.

OBJECTIVES: To investigate key stakeholders' views on how to improve access to primary care in general practice settings for people with learning disabilities (or intellectual disabilities). Further to explore how inequalities and barriers in specific areas including annual health checks might be addressed. DESIGN: A qualitative study design was used with data collected during focus groups, interviews and open-response surveys; data analysis was thematic and informed by stakeholder consultation. Processes to facilitate quality included triangulation of stakeholder perspectives, triangulation of data collection methods and checking interpretation of findings with participants. SETTING: UK regional services including learning disability organisations, primary care general practitioner (GP) clinical practice networks and supported housing organisations. PARTICIPANTS: Sixteen people participated in the study: four people with learning disabilities participated in a focus group; four relatives completed an interview or survey; eight GPs, practice nurses and supported housing managers participated in interviews. RESULTS: Five overarching themes describing approaches to improve primary care access for people with learning disabilities were identified including: prioritisation, proactivity, innovation and improvement, personalisation and prevention and follow-up. Definitions of themes were described and illustrated with quotes. Ten recommendations informed by the thematic analysis, stakeholder consultation, research and primary care guidance were codeveloped with people with learning disabilities. CONCLUSIONS: All stakeholders identified problems, with primary care interfaces being misaligned with the needs of people with learning disabilities. The recommendations informed by all stakeholders can be used to guide development of service provision to better meet the needs of people with learning disabilities in primary care. Future research should explore professionals' understanding of reasonable adjustments.

Impact of Training and Municipal Support on Primary Health Care-Based Measurement of Alcohol Consumption in Three Latin American Countries: 5-Month Outcome Results of the Quasi-experimental Randomized SCALA Trial.

PURPOSE: We aimed to test the effects of providing municipal support and training to primary health care providers compared to both training alone and to care as usual on the proportion of adult patients having their alcohol consumption measured. METHODS: We undertook a quasi-experimental study reporting on a 5-month implementation period in 58 primary health care centres from municipal areas within Bogotá (Colombia), Mexico City (Mexico), and Lima (Peru). Within the municipal areas, units were randomized to four arms: (1) care as usual (control); (2) training alone; (3) training and municipal support, designed specifically for the study, using a less intensive clinical and training package; and (4) training and municipal support, designed specifically for the study, using a more intense clinical and training package. The primary outcome was the cumulative proportion of consulting adult patients out of the population registered within the centre whose alcohol consumption was measured (coverage). RESULTS: The combination of municipal support and training did not result in higher coverage than training alone (incidence rate ratio (IRR) = 1.0, 95% CI = 0.6 to 0.8). Training alone resulted in higher coverage than no training (IRR = 9.8, 95% CI = 4.1 to 24.7). Coverage did not differ by intensity of the clinical and training package (coefficient = 0.8, 95% CI 0.4 to 1.5). CONCLUSIONS: Training of providers is key to increasing coverage of alcohol measurement amongst primary health care patients. Although municipal support provided no added value, it is too early to conclude this finding, since full implementation was shortened due to COVID-19 restrictions. TRIAL REGISTRATION: Clinical Trials.gov ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599.

A systematic review and thematic synthesis to identify factors that influence pharmacists' involvement in asthma care services: An identity crisis.

Background: Asthma is a common chronic disease worldwide affecting an estimated 300 million people. Pharmacists can play key roles to support optimal health outcomes for patients with asthma. Goffman's Dramaturgical Theory was used in this review to critically examine the literature describing the role of pharmacists in asthma services. Objectives: The aim of this review is to identify factors that influence the role of pharmacists in asthma care services. Methods: A systematic literature search was conducted of seven electronic databases including: CINAHL, Midline (Ovid), PubMed, Scopus, Web of science, Embase and PsycInfo.). The search was not restricted by language or date of publication. Studies were screened according to inclusion criteria which included much relate to pharmacists, asthma services and include qualitative findings. Data was extracted and thematically synthesised to create demographic, descriptive and analytical findings. Results: Eighteen studies were included. The majority of studies were conducted in high income countries, with most of the studies conducted in Australia (n = 10). Semi-structured interview was used as a method for data collection in most studies (n = 11). Evidence indicated pharmacists engaged in asthma services positively and wanted to expand their roles in patient care. However, literature reported patients' attitudes and health-system factors such as remuneration, as well as inter-professional collaboration and expected low levels of knowledge and skills of pharmacists were barriers to implementation of pharmacy-led asthma care. Analytical findings suggest that pharmacists' involvement in asthma care services were influenced by patients' and healthcare professionals' expectations which were juxtaposed with pharmacists' own self-perceived identity. Conclusions: This review demonstrates pharmacists self-identified as being capable and equipped with appropriate knowledge and skills, however the expectations of patients and other healthcare professionals prohibited their involvement in delivering asthma care services.

The Evidence-Based Development of an Intervention to Improve Clinical Health Literacy Practice.

Low health literacy is an issue with high prevalence in the UK and internationally. It has a social gradient with higher prevalence in lower social groups and is linked with higher rates of long-term health conditions, lower self-rated health, and greater difficulty self-managing long-term health conditions. Improved medical services and practitioner awareness of a patient's health literacy can help to address these issues. An intervention was developed to improve General Practitioner and Practice Nurse health literacy skills and practice. A feasibility study was undertaken to examine and improve the elements of the intervention. The intervention had two parts: educating primary care doctors and nurses about identifying and enhancing health literacy (patient capacity to get hold of, understand and apply information for health) to improve their health literacy practice, and implementation of on-screen 'pop-up' notifications that alerted General Practitioners (GPs) and nurses when seeing a patient at risk of low health literacy. Rapid reviews of the literature were undertaken to optimise the intervention. Four General Practices were recruited, and the intervention was then applied to doctors and nurses through training followed by alerts via the practice clinical IT system. After the intervention, focus groups were held with participating practitioners and a patient and carer group to further develop the intervention. The rapid literature reviews identified (i) key elements for effectiveness of doctors and nurse training including multi-component training, role-play, learner reflection, and identification of barriers to changing practice and (ii) key elements for effectiveness of alerts on clinical computer systems including 'stand-alone' notification, automatically generated and prominent display of advice, linkage with practitioner education, and use of notifications within a targeted environment. The findings from the post-hoc focus groups indicated that practitioner awareness and skills had improved as a result of the training and that the clinical alerts reminded them to incorporate this into their clinical practice. Suggested improvements to the training included more information on health literacy and how the clinical alerts were generated, and more practical role playing including initiating discussions on health literacy with patients. It was suggested that the wording of the clinical alert be improved to emphasise its purpose in improving practitioner skills. The feasibility study improved the intervention, increasing its potential usefulness and acceptability in clinical practice. Future studies will explore the impact on clinical care through a pilot and a randomised controlled trial.

Shaping Alcohol Health Literacy: A Systematic Concept Analysis and Review.

BACKGROUND: This study uses an innovative methodology to understand the implications of applying the emerging concept of health literacy to other contexts using the example of alcohol. METHODS: An evolutionary concept analysis combined with the principles and standards of the systematic review process enables a rigorous analysis of the conceptual representation of alcohol health literacy. KEY RESULTS: Alcohol health literacy includes a wide range of attributes that encompass many different health literacies beyond simply the capacity to understand alcohol-related harms and use that information in decision-making. Alcohol health literacy empowers people to understand alcohol marketing and messages and how alcohol information is distributed through social networks. It is an outcome of media-related alcohol education, and its consequences include health action skills and realistic expectancies of alcohol. DISCUSSION: The focus on health literacy, which emphasizes not only individual skills but also draws attention to the social determinants of alcohol use and how alcohol health literacy is shaped by social networks and interactions, provides important lessons for alcohol health promotion interventions. Health literacy when applied to alcohol includes many different domains and the innovative method used here provides a framework to develop interventions that build health literacy in different contexts. [HLRP: Health Literacy Research and Practice. 2020;4(1):e3-e20.].

Health literacy among Malawian HIV-positive youth: a qualitative needs assessment and conceptualization.

Despite growing evidence of the significance of health literacy in managing and coping with acquired immune deficiency syndrome (HIV), it is not yet an integrated part of HIV/AIDS-related health promotion research and practice in Africa. This article contributes to addressing the gap in research on health literacy and HIV in Sub-Saharan Africa. We aimed to assess health literacy-related needs of young people living with HIV (YPLHIV) and adapt existing health literacy frameworks to the context of HIV/AIDS in Malawi. We used focus group discussions to collect data from a sample of the membership of the national association of YPLHIV. Twenty-four HIV-positive youth (18-29 years) participated in focus group discussions. Participants came from three regions of Malawi. Additionally, we conducted three in-depth interviews with key informants. We used a thematic framework approach to analyse data in MAXQDA. We contextualized definitions of four dimensions of health literacy: functional, interactive, critical and distributed health literacy, which we used as an a priori analytical framework. To further contextualize the framework, we revised it iteratively throughout the analysis process. We identified the need for comprehensive information about HIV and sexual reproductive health, skills to interact with healthcare providers and navigate the health system, and skills to appraise information from different sources, among others. The identified needs were translated into nine action recommendations for the national association of YPLHIV, and with relevance within the wider HIV sector in Malawi and beyond. We found that the dimensions in our analytical framework operate on the individual, system and public policy levels.

Health Literacy in Context.

Health literacy has been defined and conceptualized in multiple ways, but almost all definitions have similar core elements describing the personal skills that enable individuals to obtain, understand, and use information to make decisions and take actions that will have an impact on their health. [...].

Developing and Applying Geographical Synthetic Estimates of Health Literacy in GP Clinical Systems.

Background: Low health literacy is associated with poorer health. Research has shown that predictive models of health literacy can be developed; however, key variables may be missing from systems where predictive models might be applied, such as health service data. This paper describes an approach to developing predictive health literacy models using variables common to both "source" health literacy data and "target" systems such as health services. Methods: A multilevel synthetic estimation was undertaken on a national (England) dataset containing health literacy, socio-demographic data and geographical (Lower Super Output Area: LSOA) indicators. Predictive models, using variables commonly present in health service data, were produced. An algorithm was written to pilot the calculations in a Family Physician Clinical System in one inner-city area. The minimum data required were age, sex and ethnicity; other missing data were imputed using model values. Results: There are 32,845 LSOAs in England, with a population aged 16 to 65 years of 34,329,091. The mean proportion of the national population below the health literacy threshold in LSOAs was 61.87% (SD 12.26). The algorithm was run on the 275,706 adult working-age people in Lambeth, South London. The algorithm could be calculated for 228,610 people (82.92%). When compared with people for whom there were sufficient data to calculate the risk score, people with insufficient data were more likely to be older, male, and living in a deprived area, although the strength of these associations was weak. Conclusions: Logistic regression using key socio-demographic data and area of residence can produce predictive models to calculate individual- and area-level risk of low health literacy, but requires high levels of ethnicity recording. While the models produced will be specific to the settings in which they are developed, it is likely that the method can be applied wherever relevant health literacy data are available. Further work is required to assess the feasibility, accuracy and acceptability of the method. If feasible, accurate and acceptable, this method could identify people requiring additional resources and support in areas such as medical practice.

Progress in Implementing National Policies and Strategies for Health Literacy-What Have We Learned so Far?

Health literacy has been a prominent issue on the agenda of the World Health Organization (WHO) for almost two decades. WHO recently established a strong global mandate for public policy action on health literacy by positioning it as one of three key pillars for achieving sustainable development and health equity in the Shanghai Declaration on Health Promotion. Several countries have national health literacy policies, with many others expected to develop them in the immediate future. It is, therefore, timely to examine current policy approaches to health literacy. The purpose of this study was to analyze a selection of existing policy documents for their strengths, limitations and themes, and offer observations about their potential to improve health literacy and health outcomes. In doing so our intention is to offer lessons and advice from early adopters that will have usefulness for future policy development and implementation. We selected six policies for review; Australia, Austria, China, New Zealand, Scotland, and the United States. We used a set of criteria to guide a systematic analysis of policy documents for their context, intended target audiences, objectives, proposed actions and interventions, evidence of financial investment and intentions to monitor outcomes. We observed a number of common features that provide helpful signposting for future policy development in other countries. All represent a response to perceived deficiencies in the quality of patient communication and patient engagement. Most present health literacy as a universal challenge, with some also identifying groups who are of higher priority. They all recognize the importance of professional education in improving the quality of communication, and most recognize that the health literacy responsiveness of the health system needs to be improved. However, there was significant variability in linking resources to specific strategies and actions, as well as in the systems for monitoring progress and accountability for progress. This variability reflects important contextual differences between countries and health systems. However, this lack of specificity will likely have an impact on the priority given to improving health literacy and on the long-term sustainability of defined actions to improve health literacy in populations.

Relationships between health literacy, motivation and diet and physical activity in people with type 2 diabetes participating in peer-led support groups.

AIMS: To investigate associations between health literacy (HL) and diet and physical activity, and motivation and diet and physical activity in Danish people with type 2 diabetes. METHODS: We used a cross-sectional design including 194 individuals with type 2 diabetes participating in peer-led support groups provided by the Danish Diabetes Association between January-December 2015. The participants completed a questionnaire at the first meeting including; The Summary of Diabetes Self-Care Activities (SDSCA) measure, The Treatment Self-Regulation Questionnaire (TSRQ) (Self-Determination Theory) measuring type of motivation, and two HL scales: The HLS-EU-Q16, and the Diabetes Health Literacy scale (Ishikawa, H). Data were analyzed using linear regression models adjusting for age, gender, educational level, diabetes duration, motivation and HL. RESULTS: The adjusted ß (95%CI) showed that autonomous motivation and functional HL were associated with following recommended diet: autonomous motivation; 0.43 (0.06; 0.80) and functional HL; 0.52 (0.02; 1.00). Autonomous motivation was related to following physical activity recommendations; ß (95%CI) 0.56 (0.16; 0.96). CONCLUSIONS: This study indicates that, for people with type 2 diabetes, functional HL and autonomous motivation may be important drivers for following diet recommendations, and autonomous motivation may be the most important factor for following recommendations regarding physical activity. These concepts may therefore be highly relevant to address in interventions to people with type 2 diabetes. Different interventions are suggested.

Health literacy of hospital patients using a linguistically validated Croatian version of the Newest Vital Sign screening test (NVS-HR).

The Newest Vital Sign (NVS) is a simple, quick and accurate screening test for health literacy (HL). It has been validated for different languages but, to date, not for the Croatian language. The aim of this study was to develop a linguistically validated Croatian version of the NVS and to use it at a later stage in a pilot study of health literacy assessment of hospital patients in Croatia. A full linguistic validation procedure was applied, including forward and backward translation, expert panel review, cognitive interview with 10 respondents from general population, and full involvement in the procedure of one of the screening test developers, the lead author of the NVS-UK version. HL testing on 100 hospital patients (55% women, median age 63.5 years) revealed 58% of patients had less than adequate HL level (scores less than 4), and mean NVS total score was 3.34. A positive significant association was observed between HL and educational level (p = 0.002). A high percentage of patients (92%) did not object to being tested for HL by their primary care physician or in hospital, and 99% of patients would recommend HL testing among patients in general. The respondents' positive views on HL testing and mean completion time of 4 minutes indicate that the Croatian version of the NVS (NVS-HR) could be recommended for use in both clinical and research settings in Croatia.

Health literacy is associated with health behaviour and self-reported health: A large population-based study in individuals with cardiovascular disease.

Background Health literacy may constitute a modifiable determinant of health behaviour and affect cardiovascular disease prevention. This study investigates the associations between health literacy and health behaviour as well as health status. Design A cross-sectional study on a population-based sample of people with acute myocardial infarction, angina pectoris or stroke ( N = 3116). Methods Health literacy was assessed using two dimensions from the Health Literacy Questionnaire: 'understanding health information' and 'engaging with healthcare providers'. Health behaviour included physical activity, dietary habits, smoking, alcohol consumption and body mass index. Health status was examined using Short Form Health Survey 12 version 2 (four-week recall) (physical and mental components). We used regression analyses to examine the associations. Results 'Understanding health information' was inversely associated with physical inactivity (odds ratio (OR) 0.48 (0.39;0.59), unhealthy diet (OR 0.64 (0.47;0.88)), underweight (OR 0.43 (0.21;0.89)) and obesity (OR 0.79 (0.63;0.99)). 'Engaging with healthcare providers' was inversely associated with physical inactivity (OR 0.64 (0.53;0.77)), less than healthy diet (OR 0.79 (0.64;0.96)) and daily smoking (OR 0.81 (0.66;1.0)). An increase in 'understanding health information' as well as 'engaging with healthcare providers' was associated with an increase in both physical and mental health status. Conclusions The findings suggest that aspects of health literacy are associated with health status and health behaviour in cardiovascular patients and should be considered in interventions regarding cardiovascular disease prevention.

The health literacy dyad: the contribution of future GPs in England.

BACKGROUND: Health literacy studies have primarily focused on the cognitive and social skills of individuals needed to gain access to, understand, and use health information. This area of study is undergoing a paradigm shift with increased attention being paid to the skills of practitioners and an examination of their contribution to the link between literacy and health outcomes. The aim of this study was to describe the health literacy related competencies of General Practice (GP) trainees who will soon be responsible for the clinical encounter. METHODS: A cross-sectional survey of a convenience sample of 206 GP trainees was conducted online. Univariate and bivariate analysis methods were used to describe GP trainees' health literacy-related competencies. RESULTS: GP trainees overestimated the numeracy and literacy levels of the English population and did not regard the improvement of patient health literacy as a GP responsibility. GP trainees rated their general communication skills highly but the skills that are important for patients in health decision-making such as coaching skills, explaining risk and using visual aids to clarify were rated low. CONCLUSION: This study demonstrates that health literacy is insufficiently addressed in the undergraduate and postgraduate medical education of GPs to enable them to fulfil the core competence which is part of building an effective partnership with patients.

Towards an understanding of the relationship of functional literacy and numeracy to geographical health inequalities.

The relative contributions of functional literacy and functional numeracy to health disparities remain poorly understood in developed world contexts. We seek to unpack their distinctive contributions and to examine how these contributions are framed by place-based deprivation and rurality. We present a multilevel logistic analysis of the 2011 Skills for Life Survey (SfLS), a representative governmental survey of adults aged 16-65 in England. Outcome measures were self-assessed health status and the presence of self-reported long-term health conditions. Exposure variables were functional literacy (FL) and functional numeracy (FN). Age, sex, individual socio-economic status, ethnicity, whether English was a first language, non-UK birthplaces, housing tenure and geography were included as potential confounders and mediators. Geography was measured as area-based deprivation and urban/rural status. FL and FN were both independently associated with self-assessed health status, though the association attenuated after taking account of confounders and mediators. For long-term conditions, the association with FN remained significant following inclusion of confounders and mediators whilst FL attenuated to non-significance. Rurality did not influence these associations. Area deprivation was a significant factor in attenuating the association between FL and self-assessed health status. Policy makers and health professionals will need to be aware of the distinctive impact of FN as well as FL when combating health inequalities, promoting health and managing long-term conditions.